Your Medicare Coverage
Is my test, item, or service covered?
Physical therapy/occupational therapy/speech-language pathology services
How often is it covered?
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 2015 are:
- $1,940 for physical therapy (PT) and speech-language pathology (SLP) services combined
- $1,940 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
- 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 2015 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 $1,940 therapy cap limits. Your therapist must give you a written notice, called an "Advance Beneficiary Notice of Noncoverage" (ABN), before providing generally covered therapy services that aren't medically reasonable and necessary for you at the time. 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.
Starting January 1, 2014, the outpatient therapy cap limits apply to therapy services you get in a critical access hospital (CAH). Your therapist will need to determine if you qualify for an exception to the therapy cap limits for services you get in a CAH.
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.
To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service.
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.