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Physical Therapy benefits under Medicare & Medicaid

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Medicare and Medicaid provide Physical Therapy benefits that many of my patients don’t fully understand.  Both Medicare and Medicaid have what is called a Physical Therapy cap.   Just like private insurance that people get as a benefit from their employer or purchase individually, Physical Therapy benefits are limited.   For Medicaid the cap is 25 Physical Therapy visits per year.  Medicare requires that the patient pay a $155 deductible, then they pay 80% of Physical Therapy services  up to a cap of $1860.  For my patients, a Medicare cap of $1860 would provide them with approximately 22 treatments per year.  For my average patient and compared to many private plans, I find these limitations quite generous.

Medicare is interested in prevention.  They now have a program where they ask providers to target specific measures.  For PT, one of the measures is falls prevention.  Medicare recommends that adults over the age of 65 who have fallen once in the past year with an injury or fallen twice in the past year without an injury be screened by a Physical Therapist for falls risks.  This usually consists of testing a patient’s hip and knee strength and looking at their balance.  There are often little things such as declining hip strength that can be addressed in 4-6 visits with a large emphasis on home program and can make a huge difference in falls risks.  It is so much easier to help people with strength and balance if they seek help when they first notice a problem vs. waiting until they break a hip!!

Medicare also is interested in women who have urinary incontinence.  As I have written previously, women who are racing to the bathroom are at risk for falls, and with increasing age this could be a fracture risk.  I work with many women who have urinary incontinence teaching them to improve the strength of the pelvic floor muscles allowing them to eliminate their urinary incontinence.  Medicare feels this is so important that they will purchase a $450 Electric Stimulation machine for those women who are doing their home program correctly but are still incontinent after 4 weeks.  That’s how important continence is to Medicare!

Mary Boyd, MS, PT is the owner of Mountain View Physical Therapy.  She can be reached at 290-5575 for questions or on the web at

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