Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical and occupational therapy, and speech-language pathology services. There are limits on these services when you get them from most outpatient providers. These limits are called “therapy caps” or “therapy cap limits.”
The therapy cap limits for 2013 are:
• $1,900 for physical therapy (PT) and speech-language pathology (SLP) services combined
• $1,900 for occupational therapy (OT) services
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 that your outpatient 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.
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.
All people with Medicare are covered if Medicare finds that the services are medically reasonable and necessary. Medicare will pay its share for therapy services until the total amounts 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.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount, and the Part B deductible applies.