Medicare Part B covers outpatient therapy, including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT). Previously, there were limits, also known as the therapy cap, how much outpatient therapy Original Medicare covered annually. However, in 2018, the therapy cap was removed.
Original Medicare covers outpatient therapy at 80% of the Medicare-approved amount. When you receive services from a participating provider, you pay a 20% coinsurance after you meet your Part B deductible ($183 in 2018).
If your total therapy costs reach a certain amount, Medicare requires your provider to confirm that your therapy is medically necessary. In 2018, Original Medicare covers up to:
- $2,010 for PT and SPL before requiring your provider to indicate that your care is medically necessary
- And, $2,010 for OT before requiring your provider to indicate that your care is medically necessary
Remember, Medicare pays for up to 80% of the Medicare-approved amount. This means Original Medicare covers up to $1,608 (80% of $2,010) before your provider is required to confirm that your outpatient therapy services are medically necessary. If Medicare denies coverage because it finds your care is not medically necessary, you can appeal.
Keep in mind that outpatient therapy includes therapy received:
- At therapists’ or doctors’ offices
- At Comprehensive Outpatient Rehabilitation Facilities (CORFs)
- At skilled nursing facilities (SNFs), when you are there as an outpatient or are otherwise ineligible for a Medicare-covered stay
- And, at home through therapists connected with home health agencies, when you are ineligible for Medicare’s home health benefit
Medicare’s coverage rules for outpatient therapy do not apply if you are receiving therapy as part of a Medicare-covered SNF stay or if you are receiving Medicare-covered home health care.