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. Medicare law no longer limits how much Medicare pays for your medically necessary outpatient therapy services in one calendar year. However, your therapist will need to add information to your therapy claims and your medical record if your therapy services reach these amounts in 2018:
- $2,010 for physical therapy (PT) and speech-language pathology (SLP) services combined
- $2,010 for occupational therapy (OT) services
Once your therapy services reach these amounts, your therapist will need to add a special code to your therapy claim. By adding this code, your therapist confirms that:
- Your therapy services are reasonable and necessary
- Your medical record includes information to explain why the services are medically necessary
A Medicare contractor may also review your medical records to be sure your therapy services were medically necessary. This review may happen if your therapy services reach these amounts in 2018:
- $3,000 for PT and SLP services combined
- $3,000 for OT services
Your therapist or therapy provider must give you a written notice before providing providing services that aren't medically necessary. This includes therapy services that are generally covered but aren't medically reasonable and necessary for you at the time. This notice is called an "Advance Beneficiary Notice of Noncoverage" (ABN). The ABN lets you choose whether or not you want the therapy services. If you choose to get the medically unnecessary services, you agree to pay for them.
All people with Part B are covered as long as the services are medically reasonable and necessary.
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 test, item, or service will cost, talk to your doctor or 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
- 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. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
- Get more information about therapy caps
- Medicare & You: National Physical Therapy Month (video)