Does Medicare cover occupational therapy?

At times, injuries and illnesses are so severe that they hamper a person’s ability to function independently. A person who had a stroke may have difficulty feeding and dressing themselves. A recent amputee may be lost on how to operate their prosthetic. A person suffering from schizophrenia may feel disoriented and in need of activities to reduce their confusion. In all of these cases and more, occupational therapy can help.

Despite the name, occupational therapy doesn’t concern itself primarily with job or vocational training. Rather, occupational therapy is meant to diagnose and assist people in maintaining the daily living and work skills they need to remain independent. It can do this through:

  • teaching essential skills (like cooking, telephone use, and dressing)
  • reducing environmental barriers (like installing chair lifts on stairs)
  • finding activities that are both meaningful and useful to their client

Occupational therapy can be a valuable corollary to speech therapy, physical therapy, and psychological counseling, and is one of the types of services covered by Medicare.

Coverage restrictions

As with most Medicare services, there are restrictions to your coverage. Coverage for occupational therapy is available to anyone with Medical Part B or a Medicare Advantage Plan. As with speech therapy, there are “therapy caps” for your treatment. Once your occupational therapy costs exceed $1,960 (in 2016), your coverage will end. Costs that contribute to the therapy cap include your deductible, the amount Medicare pays for your service (about 80%), and the remaining 20% you or your insurance pays out of pocket.

You can ask your therapy provider to help you get an exception to the therapy cap limit for an extra $3,700 for occupational therapy. To do this, your therapist needs to document why continued treatment is medically necessary, and state the same on your Medicare claim.

Because Medicare requires occupational therapy to be medically necessary, they only cover therapies designed to help with daily living tasks. They do not cover therapy designed only to help with work skills or employment. However, many therapies designed by occupational therapists that assist in daily living also help people with their work skills, and Medicare will cover those treatments. For instance, therapies designed to improve balance and standing tolerance in someone with a recent hip replacement is a necessary skill for getting around the house or dressing. But if that person is also employed in a job that requires them to stand for long periods every day, the same therapy will help them in a work setting.

Medicare also specifies that they will not cover occupational therapy on the basis of psychiatric illness alone. If you are suffering from an undiagnosed mental illness, Medicare will deny coverage for occupational therapy until diagnosis. You will also be denied coverage if you’re diagnosed mental illness isn’t the direct cause of your need for occupational therapy. Be sure to speak with your therapist about your eligibility for coverage, and what treatments they offer that are covered by Medicare.

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