Original Medicare, Part A and Part B, doesn’t generally cover gym memberships or exercise programs. However, there are a few exceptions, and you may also be able to get coverage through a Medicare Advantage plan or Medicare Supplement plan.
Medicare coverage of exercise programs for peripheral artery disease
According to the Centers for Medicare & Medicaid Services (CMS), peripheral artery disease (PAD) is a condition that results from plaque accumulating and eventually blocking the arteries in your lower body, resulting in leg pain while walking or exercising. Exercise is a common initial treatment, and the Medicare program now generally covers exercise programs for beneficiaries with symptomatic peripheral artery disease.
Medicare may cover up to 36 sessions of supervised exercise therapy (SET) over 12 weeks. The exercise program must meet the following criteria:
- The sessions are between 30 to 60 minutes long, targeting PAD patients with leg pain or cramping due to blocked arteries.
- It takes place in a doctor’s office or a hospital outpatient setting.
- It is directly supervised by a doctor, nurse practitioner, or physician assistant who has life support training.
- It is conducted by support staff trained in running exercise programs for PAD patients.
To be eligible, the doctor who is treating you for PAD must refer you for the program in a face-to-face office visit. During this time, your physician will give you more information on how to reduce your risk for peripheral artery disease. In some cases, Medicare may cover the exercise program for an extra 36 sessions, but your doctor will need to give you a second referral.
Medicare coverage of exercise programs for cardiac rehabilitation
Medicare Part B covers cardiac rehabilitation programs in either a hospital outpatient setting or a doctor’s office for beneficiaries who meet certain criteria. Cardiac rehabilitation programs are not simply exercise programs, but also include educational and counseling components. Intensive cardiac rehabilitation programs are also available, which are similar in format, but at a higher intensity.
To qualify for a cardiac rehabilitation program, your doctor must order the exercise program, and you must have had at least one of the following cardiac conditions:
- A heart attack in the last year
- Heart valve replacement or repair
- Heart transplant or heart-lung transplant
- Coronary artery bypass procedure
- Current stable angina pectoris (chest pain)
- Chronic heart failure (must be in stable condition)
- Coronary angioplasty
- Coronary stent
Eligibility for the intensive cardiac rehabilitation program also requires a doctor referral and one of the above conditions (except for chronic heart failure, which is only a qualifying condition for the regular cardiac rehabilitation program).
You’re responsible for cost sharing, including the Part B deductible and either a 20% coinsurance if the exercise program takes place in a doctor’s office, or a copayment if it takes place in a hospital outpatient setting.
Medicare Advantage and Medicare Supplement coverage of exercise programs
Although Original Medicare coverage of exercise programs is limited, some Medicare Advantage plans may cover wellness programs, such as SilverSneakers, as an extra benefit. Coverage varies by plan, so check with the specific Medicare Advantage plan if you’re interested in coverage for exercise programs.
In addition, some Medicare Supplement (Medigap) plans may cover gym memberships as an optional rider. Since plan availability may vary from state to state, you’ll need to check with the private insurance companies in your specific zip code.
Are you interested in finding Medicare Advantage plans or Medicare Supplement plans that may cover wellness or exercise programs? I can show you plan options, if you like. To set up a phone appointment to discuss your Medicare needs or to receive a personalized email with plan information, click on the Get Quotes button to get started.