Medicare limits how much outpatient therapy it will cover, although coverage is allowed for medically necessary therapy over the cap, particularly for complex cases.
In 2013, Medicare will cover up to:
- $1,900 worth of physical therapy (PT) and speech-language pathology (SLP) combined; and another
- $1,900 worth of occupational therapy (OT).
After the annual Medicare Part B deductible is paid ($147 in 2013), Medicare will pay up to 80% of the Medicare-approved amount for each service (up to $1,520) and you will be responsible for the remainder. After the limit has been reached, you will have to pay the full cost of the services (100%).
If you are approaching the limit and need more therapy, your doctor can tell Medicare that it’s medically necessary for you to continue. If you need a lot of care after you have reached the therapy cap, your provider may need to get pre approval from Medicare for your care to continue.
Medicare is most likely to cover additional therapy if your case is medically complicated. If Medicare denies the claim, you can appeal through the regular Original Medicare appeals process.
The therapy limits apply to outpatient therapy received at:
- therapists' or physicians' offices;
- outpatient rehabilitation facilities;
- skilled nursing facilities (SNFs) for outpatients or residents who do not have Medicare-covered stays; and
- home, through therapists connected with home health agencies, when not part of a Medicare-covered home health benefit.