SF5018

Purpose

Update Minnesota Medical Assistance (Medicaid) coverage for physical therapy for children, clarify who can provide therapy, adjust payment rules for therapy assistants, and set new limits on the number of physical therapy visits per year. The changes aim to ensure access to necessary therapy while governing costs and supervision requirements.

Main provisions

• Coverage and applicable services
  • Medical Assistance continues to cover physical therapy and related services.
  • Specialized maintenance therapy remains covered for recipients age 20 and under.
• Physical therapy assistant (PTA) payment rules
  • If a PTA provides services under the direction of a physical therapist who is on the premises, the PTA’s services are reimbursed at the same rate as the physical therapist.
  • If a PTA provides services under a PT who is not on the premises, the reimbursement rate is 65% of the physical therapist rate.
• Visit limits before the new cap
  • Currently, payment for physical therapy and related services is limited to 14 visits per year unless more visits are authorized.
  • This existing cap is set to expire once the new rules take effect.
• New annual visit limits (effective date specified below)
  • Beginning on January 1, 2027, or when federal approval is received (whichever is later), the annual visit limits are:
  • 30 visits per year for children after inpatient or outpatient hospital-based surgery.
  • 14 visits per year for all other recipients.
  • Prior authorization can still be used to obtain a greater number of visits beyond these limits.

Significant changes to existing law

• Increases the annual visit limit from the prior general cap of 14 visits for most recipients to 30 visits for children following hospital-based surgery, with 14 visits still available for all other recipients, once the new effective date arrives.
• Establishes explicit separate limits based on whether the patient had surgery and on where supervision occurs for PTAs (on-premises vs off-premises).
• Adds or confirms coverage of specialized maintenance therapy for children 20 and under.
• Adds a trigger (effective date or federal approval) for when the new limits become binding, replacing the old 14-visit cap.

Effective date and implementation

• The new limits and rules take effect on January 1, 2027, or upon federal approval, whichever occurs later.
• The older 14-visit limit for non-surgery cases will be superseded for those cases once the new effective date arrives; prior authorization remains available to exceed limits in appropriate situations.

Practical impact

• Children who have had hospital-based surgery may receive up to 30 physical therapy visits per year under Medical Assistance, potentially improving recovery support.
• Other pediatric patients on Medical Assistance would still be limited to 14 visits per year unless authorized for more.
• Reimbursement structures for PTAs create clearer rules about when assistant services are reimbursed at the same rate as PTs and when a reduced rate applies if supervision is not on-site.

Relevant Terms - medical assistance - physical therapy - related services - specialized maintenance therapy - physical therapy assistant (PTA) - on the premises - under the direction of a physical therapist - reimbursement rate - 14 visits per year - prior authorization - 30 visits per year - inpatient hospital-based surgery - outpatient hospital-based surgery - Minnesota Statutes 256B.0625, subdivision 8 - recipients age 20 and under - effective date - federal approval