HF4837

Purpose

• To change and expand how physical therapy (PT) is covered for children under Minnesota Medical Assistance (MA) and to adjust how PT services are billed when provided by physical therapy assistants (PTAs). The bill adds coverage for specialized maintenance therapy for people age 20 and under and sets new annual visit limits starting in 2027 (or earlier if federal approval arrives).

Main Provisions

• Coverage for physical therapy

  • MA continues to cover physical therapy and related services.
  • Specialized maintenance therapy is covered for recipients age 20 and under.

• Reimbursement for physical therapy assistants

  • When a PTA works under the direction of a PT who is on the premises, PTA services are reimbursed at the same rate as PT services.
  • When a PTA works under the direction of a PT who is not on the premises, PTA services are reimbursed at 65% of the PT rate.

• Current vs. future visit limits (transitions)

  • Until the new limits take effect, payment for PT and related services is limited to 14 visits per year unless an authorized greater number of visits is approved. This rule ends when the new limits (paragraph d) take effect.
  • Starting January 1, 2027 (or later if federal approval happens first), the annual visit limits become:
  • 30 visits per year for children following inpatient or outpatient hospital-based surgery.
  • 14 visits per year for all other MA recipients.
  • In both cases, exceeding these limits still requires prior authorization.

Implementation Details and Dates

• Effective date

  • The new visit limits apply on January 1, 2027, or sooner if federal approval is obtained.

• Transition rules

  • The current 14-visit cap is superseded for post-surgery cases by the 30-visit limit once the new effective date occurs.
  • The non-surgery cap remains 14 visits per year, subject to prior authorization if more visits are needed.

Significance and Expected Impact

• Access to PT after surgery

  • More visits (30 per year) may improve rehabilitation access for children recovering from hospital-based surgery.

• Consistency in PTA billing

  • Clear rules about when PTA services are paid at the same rate as PT versus at a reduced rate help providers bill appropriately.

• Administrative considerations

  • Prior authorization remains a tool for approving more than the annual limit when clinically justified.
  • The changes affect providers, families, and the state’s MA program, particularly around budgeting for PT services.

Who is Affected

• Children and youths eligible for Medical Assistance who receive physical therapy or related services.
• Physical therapists and physical therapy assistants who bill MA for these services.
• Hospitals and outpatient clinics providing PT services to MA recipients.

Relevant Terms

• medical assistance (MA)
• physical therapy (PT)
• physical therapy assistant (PTA)
• specialized maintenance therapy
• on the premises
• not on the premises / direction of the PT not on premises
• reimbursement rate
• 14 visits per year
• 30 visits per year
• prior authorization
• inpatient hospital-based surgery
• outpatient hospital-based surgery
• federal approval
• Minnesota Statutes 256B.0625 subdivision 8
• visits per year
• related services