Medicare covers occupational therapy services under certain conditions and following specific guidelines.
### Specific Rules and Coverage Limits for Medicare Part A and Part B for Occupational Therapy Services
Navigating the intricacies of Medicare coverage for occupational therapy (OT) can be a complex task, but understanding the key points can help individuals make informed decisions about their healthcare.
#### Medicare Part A
Medicare Part A generally covers inpatient care, including OT, when it is provided in a hospital, skilled nursing facility, or rehab center. However, it's crucial to note that OT must be deemed medically necessary by your doctor [1][2]. You pay the full cost of inpatient care until you reach your deductible, which is $1,676 in 2025. After this, Medicare covers most costs for the first 60 days of your stay [1]. Limited home health services are also covered under Part A, but these are typically covered under Part B unless part of a hospital discharge plan [2].
#### Medicare Part B
Medicare Part B covers outpatient care, including OT, as long as it is medically necessary and part of a doctor-approved care plan [2][3]. After meeting the annual deductible for Part B, you pay 20% of the approved costs for OT services [1]. Medicare pays the remaining 80% [1]. To receive home health services under Part B, your doctor must certify that you are homebound, meaning leaving your home requires considerable effort [2].
#### Key Points for Both Parts
Both Medicare Part A and Part B require OT to be medically necessary and part of a doctor-approved care plan to be covered [1][2]. For home health services under Part B, you must be homebound [2]. OT often includes improving a person's overall strength, measuring progress, and establishing a plan to maintain and support independence.
In 2025, the Part A deductible is $1,676 per benefit period. Medicare Part B covers 80% of medically necessary therapy received outside of the hospital on an outpatient basis, and the remaining 20% must be paid out of pocket after paying a $257 deductible. Medicare does not cover OT services that are not medically necessary [1].
For those with limited resources, assistance may be available from Medicaid or supplemental security income (SSI). If a person's doctor or therapist recommends OT more often than Medicare allows or for services not covered by Medicare, the person may have to pay some or all of the cost.
Private insurance companies administer Medicare Advantage (Part C) plans, but they must cover the same services as Original Medicare. A person can appeal Medicare's denial of coverage for a service within 120 days of receiving the Medicare Summary Notice (for Original Medicare) or through the private insurance company that administers the policy (for Medicare Advantage).
OT may help a person regain control of everyday activities, such as using cutlery, and finding the right adaptive equipment for independent living. OT helps people recover skills for everyday life and work following an injury, illness, or disability.
Those with Medigap plans will receive help to pay for some expenses associated with OT, such as Part A deductible, coinsurance, copayment, and Part B excess charges. SSI is a monthly benefit paid directly to a person's bank account and is not the same as Social Security retirement or disability benefits.
Medicare uses medical facts to determine the medical necessity of services. A person can help the appeals process by gathering information from their therapist and medical professional to support their case.
- Individuals seeking occupational therapy (OT) under Medicare should ensure that OT is deemed medically necessary by their doctor, as both Part A and Part B require OT to be part of a doctor-approved care plan to be covered.
- In 2025, while Medicare Part B covers 80% of medically necessary therapy received outside of the hospital on an outpatient basis, the remaining 20% must be paid out of pocket after meeting a $257 deductible.
- For those with limited resources, assistance may be available from Medicaid or supplemental security income (SSI), and if a person's doctor or therapist recommends OT more often than Medicare allows or for services not covered by Medicare, the person may have to pay some or all of the cost.
- OT may help individuals regain control of everyday activities, find the right adaptive equipment for independent living, and recover skills for everyday life and work following an injury, illness, or disability.
- The Medicare appeals process can be facilitated by gathering information from the therapist and medical professional to support the case, as Medicare uses medical facts to determine the medical necessity of services.
