Does Medicare Pay for Physical Therapy in a Nursing Home?

Medicare coverage for physical therapy, especially in facilities commonly called “nursing homes,” can be complex. Medicare’s benefits depend on the specific type of facility and the medical services provided. This distinction is crucial, as coverage for physical therapy is specific to certain settings and conditions, not general long-term care.

Medicare Coverage for Skilled Nursing Facility Stays

Medicare generally covers physical therapy when provided in a Skilled Nursing Facility (SNF). An SNF is a specific type of facility distinct from a general nursing home offering custodial or long-term care. SNFs provide specialized medical care and rehabilitation services for individuals needing high medical attention after a hospital stay. These facilities are designed for temporary stays, focusing on recovery and rehabilitation.

To qualify for Medicare Part A coverage for an SNF stay, a person must first have a “qualifying inpatient hospital stay” of at least three consecutive days. Admission to the Medicare-certified SNF must occur within 30 days of leaving the hospital.

A physician must determine that daily skilled care is medically necessary for the patient’s condition. This skilled care involves services performed by, or under the supervision of, skilled nursing or therapy staff, such as registered nurses or physical therapists. The need for skilled services, which may include intravenous fluids, wound care, or physical therapy, drives coverage, not simply a diagnosis. The care provided must aim to improve, maintain, or slow the decline of a patient’s condition.

Physical Therapy Services Covered in an SNF

Physical therapy within a Medicare-covered Skilled Nursing Facility (SNF) must be medically necessary and prescribed by a physician. These services are part of a comprehensive care plan to help patients regain movement, reduce pain, and improve functional abilities. The therapy must be specific, safe, and effective for the patient’s condition, with an expectation of improvement, maintenance of function, or prevention of further decline.

Physical therapists develop individualized care plans based on a patient’s needs and goals. Common physical therapy interventions include gait training, therapeutic exercises, and modalities like heat or cold therapy. These services must meet the criteria for “skilled care” and be provided by qualified professionals. Medicare does not impose an arbitrary limit on the amount of therapy an individual can receive in an SNF as long as it remains medically necessary.

Medicare Part B covers outpatient physical therapy services in settings like a doctor’s office or outpatient clinic. Part B can also apply if a person is in an SNF as an outpatient, not under a Part A covered stay. Physical therapy provided during a Medicare Part A SNF stay encompasses a broader range of services and is integral to the rehabilitation process.

Costs and Coverage Limits

Medicare Part A coverage for a Skilled Nursing Facility (SNF) stay, including physical therapy, is defined by a “benefit period.” A benefit period begins the day a person is admitted as an inpatient to a hospital or SNF. It ends when they have not received inpatient hospital care or skilled care in an SNF for 60 consecutive days. There is no limit to the number of benefit periods an individual can have, but each new benefit period requires payment of a new Part A deductible.

For each benefit period, Medicare Part A covers the full cost of an SNF stay, including physical therapy, for the first 20 days. During this initial period, beneficiaries pay nothing in coinsurance. For days 21 through 100 of the SNF stay within a benefit period, a daily coinsurance amount applies, which is the beneficiary’s responsibility. After day 100 in an SNF within a single benefit period, Medicare does not cover additional costs, and the individual becomes responsible for all charges.

The Part A deductible for a hospital stay must be met before SNF coverage begins, as the SNF stay typically follows a qualifying hospital admission. This deductible applies per benefit period, not annually. These costs cover the entire SNF stay, including room and board, skilled nursing care, and rehabilitative services like physical therapy, provided the SNF stay meets all Medicare criteria.

Understanding Your Medicare Statement and Appeals

Beneficiaries receiving Medicare-covered services, including physical therapy in a Skilled Nursing Facility (SNF), receive a Medicare Summary Notice (MSN). This statement is mailed every few months and details all services and supplies billed to Medicare. The MSN is not a bill, but it shows what Medicare paid and the maximum amount the beneficiary may owe. Reviewing the MSN helps ensure accuracy and identify any billing discrepancies or coverage denials.

Upon receiving an MSN, compare it with personal records and receipts to verify that all listed services were received. If there are discrepancies or if coverage for an SNF stay or specific physical therapy services is denied, beneficiaries have the right to appeal Medicare’s decision. The MSN provides instructions on how to initiate this appeal process.

The initial step in an appeal involves contacting the healthcare provider to ensure correct information was submitted to Medicare. If the issue remains unresolved, a formal redetermination request can be submitted. Adhering to strict deadlines for submitting appeals is crucial, and maintaining thorough records of all medical care, communications, and documents related to the SNF stay and physical therapy is highly recommended throughout the process.