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Using Medicare for SOL Physical Therapy

The following is everything you can expect if you are using medicare to cover the cost of your physical therapy at SOL.

Medicare Covers 80% of your visit cost, your secondary insurance may cover a portion of the rest.

If you have secondary insurance:

  1. We will bill your visit to medicare, and medicare will let us know the dollar amount they are covering.
  2. We will bill the remaining amount to your secondary insurance, and they will let us know what portion of that amount they will cover.
  3. Anything not covered by medicare and your secondary insurance will be billed to you.

Example: You have Medicare Part B, and AARP as a secondary insurance. We bill your visit to medicare, and they pay 80% of the visit.  We bill the remaining 20% to AARP, and they tell us that they are willing to cover 17%.  At this point, you will receive a bill equal to 3% of the total cost of your visit.

If you do not have secondary insurance, or if your secondary insurance is Medi-Cal or an HMO:

  1. You will be responsible for a $20 co-insurance payment at every visit.
  2. We will bill your visits to medicare, and medicare will let us know the dollar amount they are covering.
  3. Anything not covered by medicare will be billed to you, minus the $20 co-insurance provided at your visit.

Example: You have Medicare Part B. When you arrive for your visit, you pay your $20 co-insurance.  We bill your visit to medicare, and they pay 80% of the visit. You will receive a bill for the remaining 20%, minus the $20 already provided.

You can either receive 12 or 22 physical therapy visits per year.

Every person covered under medicare part b is entitled to a yearly dollar amount to cover outpatient physical therapy.  This dollar amount equals 12 physical therapy visits at SOL.

Some people covered by medicare have what is called an exception code. An exception code raises the yearly dollar limit to allow for an additional 10 visits.

By your fourth physical therapy appointment, we should know whether or not you have an exception code for your case.

Be Aware: If you received physical therapy services at another outpatient facility before coming to SOL, these visits will count toward your yearly total.

Certain treatment modalities are not covered by medicare, and will require payment at time of services.

Your physical therapist will never administer these modalities without first asking your permission.

After your allotted number of yearly visits, you can still see your physical therapist on a cash basis.

If you still require treatment after you’ve reached the dollar limit for the calendar year, you are more than welcome to continue seeing your physical therapist on a cash basis. Click here for our cash prices.

Be Aware: While we are able to work with your doctor to appeal to medicare to cover additional visits beyond the 12 or 22, these appeals very rarely result in approval.

When you switch from medicare to cash payments, the format of your visits will change.

Medicare regulations require us to treat patients utilizing medicare based on a certain set of rules and regulations. When you become a wellness patient with SOL, your follow-up visits will follow SOL’s standard model for care. For more information on how SOL’s standard follow-ups look, please click here.