Is Physical Therapy Covered by Medi-Cal?

Medi-Cal is California’s Medicaid program that provides basic health insurance to low-income individuals and families. One of the primary services that Medi-Cal covers is physical therapy. Physical therapy plays an important role in the recovery process for patients who have undergone surgery, sustained an injury, or have a chronic illness. However, there are specific conditions, guidelines, and restrictions that determine whether physical therapy is covered by Medi-Cal. Knowing the details can help ensure that you are getting the right care.

Physical Therapy Coverage Under Medi-Cal

If physical therapy is deemed medically necessary, it is typically covered by Medi-Cal. This means that the service must be necessary to improve or restore the individual’s physical function. In order to qualify for physical therapy under Medi-Cal, a health care provider must include it in your treatment plan. In many cases, Medi-Cal will cover physical therapy when it is part of a broader plan to treat an illness, rehabilitate an injury, or maintain or improve a patient’s ability to perform daily activities.

Eligibility Criteria

Medi-Cal physical therapy coverage is subject to certain eligibility criteria and eligibility requirements. To receive coverage for physical therapy, a physician must deem the treatment medically necessary. The patient’s health care provider must determine whether physical therapy is necessary to address a specific health condition, such as rehabilitating an injury, managing pain, improving mobility, or preventing further disability. Additionally, Medi-Cal typically only covers physical therapy performed by a licensed physical therapist. Therapists must practice medicine in their specialty and adhere to Medi-Cal standards. Services provided by unlicensed individuals or outside of a prescribed treatment plan are typically not covered.

Types of Physical Therapy Covered

Medi-Cal typically covers a wide range of physical therapy services, including rehabilitative physical therapy. This is a treatment that helps patients regain function after surgery, injury, or illness. Rehabilitation can help improve movement, strength, and coordination. Preventive physical therapy may also be covered for people with medical conditions that could lead to further disability or complications. For example, physical therapy can be used to maintain body function and prevent health conditions from getting worse. In addition, Medi-Cal covers therapeutic exercises designed to improve mobility, strength, and flexibility, especially if prescribed by a physician. Manual therapy techniques, such as joint mobilization or soft-tissue massage, may be covered if they are deemed medically necessary to improve the patient’s condition. Other treatments, such as heat therapy, cold therapy, ultrasound therapy, or electrical stimulation, may also be covered if they relieve pain and promote healing.

Limitations and Restrictions

Although Medi-Cal covers physical therapy, certain limitations and restrictions apply. Medi-Cal may limit the amount of physical therapy you receive in a given period, depending on the nature of the treatment and the patient’s condition. Medi-Cal typically covers physical therapy on an individual basis, with the number of sessions determined based on the medical necessity of the treatment. If additional treatment is needed beyond standard coverage, Medi-Cal may require a review or prior authorization. In some cases, Medi-Cal may authorize additional treatments if the patient is improving and continues to benefit from the treatment.

Special Consideration for Children and Seniors

For children, Medi-Cal typically covers physical therapy if it is needed because of developmental delays or other conditions that affect physical development. Seniors who need physical therapy because of age-related problems, such as osteoporosis or arthritis, may also be eligible for Medi-Cal coverage. In these cases, Medi-Cal typically covers physical therapy if it is part of a broader treatment plan designed to improve or maintain the individual’s functional independence.

Medi-Cal Managed Care Plans and Physical Therapy

It is important to note that many Medi-Cal beneficiaries are enrolled in a managed care plan, which may have specific rules regarding physical therapy coverage. Medi-Cal managed care plans work with a network of providers and may have different procedures for obtaining coverage. Once you are ready, you will be able to see a physical therapist within the program’s network.

Out-of-Network Providers and Non-Covered Services

Medi-Cal typically only covers physical therapy services provided by licensed and Medi-Cal-approved providers. If you go to a health insurer that is not in the approved network, you may have to pay for the services yourself. Medi-Cal typically does not cover care outside of the approved network, except in special circumstances. Additionally, some services may not be covered by Medi-Cal, such as physical therapy that is considered experimental or medically unnecessary. It is important to check your coverage with your provider and Medi-Cal to make sure that the specific physical therapy you receive is covered.

How to Get Physical Therapy Through Medi-Cal

To get physical therapy through Medi-Cal, you should first contact your primary care physician. Your physician will evaluate your condition and refer you for physical therapy if necessary. Once you have a referral, you can schedule an appointment with a Medi-Cal-approved physical therapist. If you are enrolled in a Medi-Cal managed care plan, you may need to follow that plan’s procedures to obtain referrals and receive treatment services.

Conclusion

Medi-Cal does cover physical therapy, but coverage is contingent upon medical necessity, a prescription from a healthcare provider, and compliance with Medi-Cal rules and restrictions. The program offers a wide range of physical therapy services, including rehabilitation exercises, manual therapy, and pain management techniques. However, it is important to be aware of any limitations on the number of sessions and any prior authorization requirements. If you are interested in receiving physical therapy through Medi-Cal, talk to your primary care physician to determine if you need treatment and follow the necessary steps to obtain coverage.