Medicare Limits on Therapy Services


Medicare Limits on Therapy Services

Important: This information only applies if you have Original Medicare. If you have a Medicare Advantage Plan (like an HMO or PPO), check with your plan for information about your plan’s coverage rules on therapy services.

Medicare limits how much it pays for your medically necessary outpatient therapy services in one calendar year. These limits are called “therapy caps” or “therapy cap limits.”

What are the outpatient therapy cap limits for 2013?

• $1,900 for physical therapy (PT) and speech-language pathology (SLP) services combined
• $1,900 for occupational therapy (OT) services

After you pay your yearly deductible for Medicare Part B (Medical Insurance), Medicare pays its share (80%), and you pay your share (20%) of the cost for the therapy services. The Part B deductible is $147 for 2013. Medicare will pay its share for therapy services until the total amount paid by both you and Medicare reaches either one of the therapy cap limits. Amounts paid by you may include costs like the deductible and coinsurance.

Can I get an exception to the therapy cap limits?

You may qualify for an exception to the therapy cap limits (which would allow Medicare to pay for services after you reach the therapy cap limits) if you get medically necessary PT, SLP, and/or OT services over the $1,900 therapy cap limit. See the next page for more information.

Who can give me outpatient therapy services?

You can get outpatient therapy from any of these health care professionals:
• Physical therapists
• Speech-language pathologists
• Occupational therapists
Doctors and other health care professionals (like nurse practitioners, clinical nurse specialists, and physician assistants) may also offer PT, SLP, and OT services.

Where can I get outpatient therapy services?

• Offices of privately practicing therapists
• Many medical offices
• Outpatient hospital departments, including those of critical access hospitals
• Rehabilitation agencies (sometimes called outpatient rehabilitation facilities)
• Comprehensive outpatient rehabilitation facilities (CORFs)
• Skilled nursing facilities (SNFs) for outpatients or residents who aren’t in Medicare-certified parts of the facility
• At home, from certain therapy providers, like privately practicing therapists and certain home health agencies (if you aren’t under a home health plan of care)

What can I do if I need services that will go above the outpatient therapy cap limits?

You may qualify to get an exception to the therapy cap limits so that Medicare will continue to pay its share for your therapy services after you reach the therapy cap limits. Your therapist must document your need for medically reasonable and necessary services in your medical record and must indicate on your Medicare claim for services above the therapy cap limit that your therapy services are medically reasonable and necessary.

A Medicare contractor will review your medical records to check for medical necessity if you get outpatient therapy services in 2013 higher than these amounts:
• $3,700 for PT and SLP combined
• $3,700 for OT

In general, if your therapist provides documentation that your services were medically reasonable and necessary, you won’t have to pay for costs above the $1,900 therapy cap limits. Your therapist must give you a written notice, called an “Advance Beneficiary Notice of Noncoverage” (ABN), before providing services that aren’t medically reasonable and necessary. Medicare doesn’t pay for therapy services that aren’t medically reasonable and necessary. The ABN lets you choose whether or not you want the therapy services. If you choose to get the services, you agree to pay for them if Medicare doesn’t pay. If you get therapy services that aren’t medically reasonable and necessary and Medicare doesn’t pay for them, you won’t have to pay for the services unless an ABN was given to you beforehand.

Note: If you’re getting therapy services in a critical access hospital, your therapist won’t have to take these extra steps for you to get an exception to the therapy cap limits.

How can I find out if my therapy services will go above the therapy cap limits?

• Ask your therapist. Your therapist will have the most up-to-date information and can check if your services will go above these limits.
• Visit MyMedicare.gov to track your claims for therapy services. This website is Medicare’s secure online service for accessing your personal Medicare information.
• Check your “Medicare Summary Notice” (MSN). This is the notice you get in the mail (usually every 3 months) that lists the services you had and the amount you may be billed.

Where can I get more information?

Call your State Health Insurance Assistance Program (SHIP) to get free personalized health insurance counseling. To get the phone number for your state, visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048