What Is Medicare?

Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). The Medicare program covers U.S. citizens aged 65 or older who have been in the workforce as well as younger individuals with diabilities, end-stage renal disease, or amyotrophic lateral sclerosis (ALS). Medicare is designed to reduce health risks and therefore provides coverage to healthy individuals who currently have, or may develop, complex medical concerns that require medical intervention. 

As of September 2022, Medicare was providing coverage to over 65 million Americans. Generally, Medicare covers approximately 75% of its beneficiaries' healthcare costs, and about 70% of those beneficiaries fall between the ages of 65 and 85. All Medicare benefits are determined based on medical necessity.

What Is Medical Necessity?

Medical necessity classfies the kind of care being received as reasonable and necessary by the clinicians according to evidence-based clinical standards of care. The defintion of "reasonable and necessary" varies according to National Coverage Determinations (NCDs) and Local Coverage Determination (LCDs). Every provider is responsible for knowing the current NCDs and LCDs. 

In most cases, medical necessity is determined based on:

  • If the cost of treatment is reasonable considering the patient's chances of reaching their desired level of relief or functional improvement.
  • If the treatment will motigate the patient's risk of suffering an even worse outcome if their current condition is left untreated.

What Are The 4 Parts of Medicare?

The four parts of medicare are:

Part A: Often referred to as hospital insurance that covers inpatient care.

Part B: Known as medical insurance that covers outpatient care, testing, and preventative services.

Part C: Known as Medical Advantage, and is a plan that includes Part A, Part B, and typically Part D. It is an alternative to traditional Medicare and may offer extra benefits.

Part D: Provides prescriptuion drug coverage that helps pay for medications.

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Does Medicare Cover Physical Therapy?

Medicare covers physical therapy when:

  • It is considered reasonable and medically necessary
  • Your healthcare provider certifies that you need it
  • After meeting your Part B deductible, Medicare will pay 80% of your physical therapy costs

Physical therapy helps to improve or restore physical movement and function following an injury, surgery, or illness. Physical therapy may also be utilized to slow down deline or maintain or improve your current function. There is no limitation to how much Medicare pays for your medically necessary outpatient physical therapy services in one calendar year.