Medicare Advantage pulmonary rehab should be covered when it is medically necessary and Original Medicare covers it, because Medicare.gov says plans must cover all medically necessary services that Original Medicare covers. How you get that care can differ by plan, since plans can have provider networks, referral rules, prior authorization and different out-of-pocket costs. We did not find a Medicare.gov page that addresses pulmonary rehab in Medicare Advantage plans specifically, so this page explains the general rules and the questions to ask your plan.
What does Medicare.gov say about Medicare Advantage coverage?
Medicare.gov says that Medicare Advantage plans must cover all medically necessary services that Original Medicare covers. (Medicare.gov, Compare Original Medicare and Medicare Advantage) A CMS booklet on Medicare Advantage plans repeats the rule and adds that plans may also include extra benefits, such as vision, hearing or dental. (CMS, Understanding Medicare Advantage plans)
How does Original Medicare cover pulmonary rehab?
Medicare.gov says Part B covers pulmonary rehab for moderate to very severe COPD, in a doctor’s office or a hospital outpatient setting. (Medicare.gov, Pulmonary rehabilitation programs) Federal rules require a referral from the physician treating the chronic respiratory disease and limit coverage to two 1-hour sessions per day, for up to 36 sessions over up to 36 weeks, with an option for an additional 36 sessions that the Medicare Administrative Contractor approves. (42 CFR 410.47) Our page on does Medicare cover pulmonary rehab goes into more detail.
How can Medicare Advantage plans differ?
Medicare.gov and CMS describe several ways plans can differ from Original Medicare. (Medicare.gov, Compare Original Medicare and Medicare Advantage; CMS, Understanding Medicare Advantage plans)
- Networks. You may need to use doctors and other providers who are in the plan’s network and service area for non-emergency care. CMS says HMOs generally require network providers for non-emergency care, while PPOs let you go out of network, usually at a higher cost.
- Referrals. You may need a referral to see a specialist, and some plans, such as HMOs, may require one.
- Prior authorization. You may need approval from your plan before it covers certain services or items.
- Costs. Plans may have different out-of-pocket costs for certain services.
What should you ask your plan?
Your plan’s Evidence of Coverage is a yearly notice that describes what the plan covers and what you pay, and CMS says plans send it by October 15. (CMS, Understanding Medicare Advantage plans) You can also call your plan, or call 1-800-MEDICARE at 1-800-633-4227 for help. (Medicare.gov, Talk to someone) Questions to ask:
- Does my plan cover pulmonary rehab, and for which conditions?
- Do I need a referral, and from whom?
- Do I need prior authorization before I start?
- Which pulmonary rehab programs are in my network, and are virtual programs covered?
- How many sessions are covered, and what will I pay for each one?
- Can you point me to the page in my Evidence of Coverage that explains this?
For Original Medicare costs, see how much pulmonary rehab costs with Medicare. For what CMS says about rehab by video, see does Medicare cover telehealth pulmonary rehab.
Where Bloom fits in
Bloom Medical Group provides one-on-one virtual pulmonary rehab by video with a licensed respiratory therapist or clinical exercise physiologist, and accepts Original Medicare Part B in New Jersey and California. If you have a Medicare Advantage plan, call Bloom at 1-866-972-8228 with your plan details and ask about coverage. A referral from your own doctor is needed to start.
Frequently asked questions
Medicare.gov says plans must cover all medically necessary services that Original Medicare covers, and Original Medicare covers pulmonary rehab for moderate to very severe COPD. We did not find a Medicare.gov page about pulmonary rehab in Medicare Advantage specifically, so check your plan’s Evidence of Coverage or call the plan.
You may. Medicare.gov says you may need a referral to see a specialist and may need approval from your plan before it covers certain services. Ask your plan about pulmonary rehab.
We could not find a Medicare.gov page that answers this. Ask your plan whether virtual programs are in its network and covered, and what you would pay.
Medicare.gov says plans may have different out-of-pocket costs for certain services. Your plan’s Evidence of Coverage describes what it covers and what you pay.
You can call 1-800-MEDICARE at 1-800-633-4227, or visit Medicare.gov/plan-compare to compare plans.
Bloom accepts Original Medicare Part B in New Jersey and California. For questions about a Medicare Advantage plan, call 1-866-972-8228.
Next step
Not sure whether rehab fits you? Take our free 2 minute lung health assessment.
Ready to find out if you qualify? Call Bloom Medical Group at 1-866-972-8228 or fill in the see if you qualify form. One-on-one virtual pulmonary rehab with licensed respiratory therapists and clinical exercise physiologists, billed to commercial insurance, and to Original Medicare Part B in New Jersey and California. Read how virtual pulmonary rehab at Bloom works.
This article is for education only and is not medical advice. Talk with your doctor about what is right for you.
