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Does Medicare Cover Occupational Therapy?

Just the Essentials…

  • Occupational therapy helps you adapt to changes caused by health conditions and aging, allowing you to continue doing the things you love.

  • Occupational therapy is covered under Original Medicare, provided it is deemed medically necessary.

  • A Medicare Advantage plan may offer additional occupational therapy services and equipment that Original Medicare does not offer.

What is occupational therapy?

Do you have a health condition that makes it difficult to continue doing what you love? Occupational therapy can help you regain ability lost due to a health condition or slow a general decline in ability. Unlike physical therapy, occupational therapy focuses on improving quality of life in general rather than restoring your ability to move. 

Occupation, in this case, does not necessarily refer to a job or career. Instead, it refers to the various tasks that occupy our daily lives: this can include work but also includes things like hobbies, eating and drinking, bathing, dressing oneself, and moving about your living space. 

An occupational therapist can prescribe assistive devices like canes, walkers, and wheelchairs. They can also teach you techniques for performing tasks at varying levels of physical ability, like bathing, cooking, and dressing. They can also help you rearrange your home to prevent falls, ease movement, and can help address cognitive issues like misplacing items or forgetting to take medications.

Why might I need occupational therapy?

There are a variety of conditions that may lead your doctor to prescribe occupational therapy, though these are some of the most prominent.

  • Adapting to the amputation of a limb

  • Arthritis and carpal tunnel

  • Brain injury due to trauma or stroke

  • Dementia, including Alzheimer’s

  • Depression, anxiety, and similar conditions

  • Heart attack complications

  • Hip or knee replacement

  • Multiple sclerosis

  • Parkinson’s

Children receiving Medicare due to a disability may also be prescribed occupational therapy for the following conditions:

  • Attention Deficit Hyperactivity Disorder (ADHD)

  • Autism Spectrum Disorder (ASD)

  • Cerebral Palsy

  • Down’s Syndrome

  • Muscular Dystrophy

  • Sensory Processing Disorder

  • Spina Bifida

These treatments will involve a combination of practical training to help you adapt to your circumstances and psychological therapy to help you cope with the difficulties these conditions can bring.

Occupational therapy is often performed in an outpatient facility. However, occupational therapists may also go to environments you frequent, such as your home or office, to observe your routine and help you adapt to any challenges your condition may cause. If you are hospitalized for a condition that will require occupational therapy, you may also receive treatment during your stay.

Does Medicare pay for occupational therapy?

Occupational therapy is covered by both Original Medicare and Medicare Advantage. However, the pre-requisites for coverage vary depending on your specific plan. 

Depending on where it is received, occupational therapy can fall under either Medicare Part A or Part B.

If you receive occupational therapy as part of a stay in a hospital or skilled nursing facility, it falls under Medicare Part A. After meeting the Part A deductible, this is completely covered, provided you’ve spent at least two days in the facility. This treatment is subject to the same limitations as Part A coverage, meaning Medicare will only cover a limited number of days before cost-sharing.

If you receive occupational therapy at home or on an outpatient basis, it is covered by Medicare Part B. There is no limit on how much Medicare will pay for these services, but you are responsible for 20 percent of the approved cost.

Your occupational therapy must be considered medically necessary and must fall within Medicare guidelines to qualify for coverage. This means that you must have a formal diagnosis from your primary care physician, indicating that you have a condition inhibiting your day-to-day functioning. Your doctor may prescribe you services that Medicare might not cover, either due to being too frequent or not being on the Medicare-approved list. You’ll be informed of this before you commit to any treatment plan.

Medicare Advantage plans must cover everything Original Medicare does but may offer additional benefits depending on your plan. For instance, they may offer relaxed pre-requisites or cover a more comprehensive range of services. They might also cover equipment that Original Medicare doesn’t, like stairlifts and walk-in tubs. Medicare therapy coverage depends on your specific plan, and you may be required to stay in-network to receive your benefits. 

Our licensed insurance agents can help you find a Medicare Advantage plan that fits your needs. Call us today at (800) 950-0608 to begin your search. 

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