Medicare Limits on Therapy Services
Medicare limits how much it covers for medically-necessary outpatient physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT).
What are the therapy limits for 2008?
• $1,810 for PT and SLP combined
• $1,810 for OTAfter you pay your yearly deductible for Medicare Part B (Medical Insurance), Medicare pays its share (80%) and you pay your share (20%) of the cost. The Part B deductible is$135 for 2008.
Medicare will keep paying its share until the total, including the deductible and copayments, reaches the therapy limit. You may qualify for an exception to the therapy limits (which would allow Medicare to pay for services above the limits) when the servicesare medically necessary.
The limits don’t apply to therapy services you get at hospital outpatient departments orhospital emergency rooms. There is no limit on Medicare payments for medically-necessaryoutpatient therapy services if you get them in a hospital outpatient department or hospitalemergency room.
The therapy limits apply to outpatient therapy you get from the following People:
• Doctors
• Physical therapists
• Occupational therapists
• Speech-language pathologists
• Nurse practitioners
• Clinical nurse specialists
• Physician assistants
Places
• Most medical offices
• Outpatient rehabilitation facilities/rehabilitationagencies
• Comprehensive outpatient rehabilitation facilities
• Skilled nursing facilities (SNFs) for outpatients orresidents who aren’t in Medicare-certified parts ofthe facility
• Home, from certain people who provide therapyservices
What can I do if I need services that will go above the therapy limits?
You or your therapist can ask for an exception if you have a condition that requires services that will go above the therapy limits. You don’t have to submit a written request to get an exception. Your therapist must keep information in your medical record to justify the need for services beyond the therapy limits.
If your condition is documented and your costs are above the therapy limits, your therapist’s billing office will add an explanation to the claim to justify your continuing need for services above the limits.
How do I find out if my therapy services will go above the limits?
If you get all your therapy in the same place, your therapist’s billing office will know if your services will go above these limits.
You can also check your Medicare Summary Notice. This is the notice you get in the mail (usually every 3 months)that lists the services you had and the amount you may be billed.
Where can I go for more information?
For free, personalized health insurance counseling, call your State Health Insurance Assistance Program (SHIP). To find the most current telephone number, visit www.medicare.gov on the web.
Under “Search Tools,” select “Find Helpful Phone Numbers and Websites.” Or, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.★