Does Medicare Cover Occupational Therapy?
Medicare will cover occupational therapy if it is medically necessary that you receive it. Under Part A, Medicare could cover your treatments if you are an inpatient. Part B will cover 80 percent of the cost if you are an outpatient, leaving you with 20 percent after you have met your deductible.
What is Occupational Therapy?
Occupational therapy can rehabilitate you from an injury or medical condition to perform daily activities like bathing, getting dressed, eating or driving. The treatments can also slow the decline of your abilities in these areas.
- Pain rehabilitation
Occupational therapy is especially effective when dealing with stroke recovery. According to the American Occupational Therapy Association, stroke is one of the leading causes of adult disability in the United States. Rehabilitation through occupational therapy could help stroke victims continue to do daily activities or adapt them to whatever function they have left.
Occupational therapy and physical therapy are not the same things. While physical therapy focuses on your mobility and the function of a specific muscle or body part, occupational therapy is meant to help you complete activities and goals that are part of your everyday life.
Check with your doctor or healthcare provider about which type of therapy they are recommending.
Understanding Medicare Coverage of Occupational Therapy
Medicare covers occupational therapy if it is a medical necessity and ordered by your doctor or healthcare provider.
If you are an outpatient, then Medicare Part B will cover 80 percent of occupational therapy costs. You can still be considered an outpatient even if you receive treatment in a hospital or are hospitalized. Check with your doctor to learn your status as a patient.
If you are an inpatient and are staying in a hospital, skilled nursing facility or another similar environment, then Medicare Part A could also cover occupational therapy. However, you will have to pay your Part A deductible and any coinsurance before Medicare covers the rest of the cost.
You can receive occupational therapy in your home if it is part of home health care, which Medicare covers if you meet certain conditions.
Rules and Exclusions
Medicare covers services that are considered medically necessary. However, suppose you want occupational therapy for a non-medical purpose or even for a reason that is not considered essential to your health. In that case, Medicare will not help pay for it. Of course, your doctor may also recommend treatment, but that does not mean that Medicare will automatically cover it.
If your treatments are a medical necessity, then there are a few rules and exclusions to how Medicare will cover your occupational therapy.
Under the ”two-midnight rule,” Medicare Part A can be used to pay for services that you receive if you are expected to stay in the hospital through two midnights. However, Part A should not be used if your hospital stay is not expected to last that long.
Medicare Cap Removal
Until recently, there was a cap on how much money Medicare would spend covering your occupational therapy, physical therapy and similar services in a calendar year. That cap was removed in 2018, meaning your therapy will no longer be automatically cut off, allowing you to receive as much treatment as you need if it remains medically necessary.
Coverage through Medicare Advantage
Additional coverage for occupational therapy and similar services is also available through a Medicare Advantage plan. This plan is provided by private insurers and covers everything included in Original Medicare as well as additional benefits and coverage.
If you are interested in coverage beyond what Original Medicare offers for occupational therapy, learn more about what a Medicare Advantage plan could include.
10 Cited Research Articles
- University of Tennessee Health Science Center. (2021, May 12). What is OT? Retrieved from https://www.uthsc.edu/health-professions/occupational-therapy/about/what-is-ot.php
- U.S. Centers for Medicare & Medicaid Services. (2021, March 31). Therapy Services. Retrieved from https://www.cms.gov/Medicare/Billing/TherapyServices
- St. Catherine University. (2021, February 24). Occupational Therapy vs Physical Therapy: What’s the Difference? Retrieved from https://otaonline.stkate.edu/blog/occupational-therapy-vs-physical-therapy/
- U.S. Centers for Medicare & Medicaid Services. (2019, April). Outpatient Rehabilitation Therapy Services: Complying With Documentation Requirements. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OutptRehabTherapy-Booklet-MLN905365.pdf
- U.S. Centers for Medicare & Medicaid Services. (2015, October 30). Fact Sheet: Two-Midnight Rule. Retrieved from https://www.cms.gov/newsroom/fact-sheets/fact-sheet-two-midnight-rule-0
- American Occupational Therapy Association. (n.d.). Health and Wellness. Retrieved from https://www.aota.org/About-Occupational-Therapy/Professionals/HW.aspx
- American Occupational Therapy Association. (n.d.). The Role of Occupational Therapy in Stroke Rehabilitation. https://www.aota.org/About-Occupational-Therapy/Professionals/RDP/stroke.aspx
- Massachusetts College of Pharmacy and Health Sciences. (n.d.). OT vs PT: What’s the Difference? Retrieved from https://www.mcphs.edu/about-mcphs/news/occupational-therapy-versus-physical-therapy
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare costs at a glance. Retrieved from https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Occupational therapy. Retrieved from https://www.medicare.gov/coverage/occupational-therapy