OPTM Therapy | Medicare FAQ
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Medicare FAQ

Medicare Limits on Therapy Services


Important: This information only applies if you have Original Medicare. If you have a Medicare Advantage Plan (like an HMO or PPO), check with your plan for information about your plan’s coverage rules on therapy services.

 

Medicare limits how much it pays for your medically necessary outpatient therapy services in one calendar year. These limits are called “therapy caps” or “therapy cap”

 


What are the outpatient therapy cap limits for 2015?

 

$1,940 for physical therapy (PT) and speech-language pathology (SLP) services

 

$1,940 for occupational therapy (OT) services

 

After 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 for the therapy services.

 

The Part B deductible is $147 for 2014. Medicare will pay its share for therapy services until the total amount 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.


 

Can I get an exception to the therapy cap limits?

 

You may qualify for an exception to the therapy cap limits (which would allow Medicare to pay for services after you reach the therapy cap limits) if you get medically necessary PT, SLP, and/or OT services over the $1,920 therapy cap limit. See the next page for


What can I do if I need services that will go above the outpatient therapy cap?

 

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

  • Indicate on your Medicare claim that your therapy services are medically reasonable and necessary

  • A Medicare contractor will review for medical necessity if your services are more than $3,700.

 

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.


 What can I do if I need services that will go above the outpatient therapy cap limits?

 

Your therapist must give you a written notice, called an “Advance Beneficiary Notice of Noncoverage” (ABN), before providing services that aren’t medically reasonable and necessary. 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 Starting January 1, 2014, the outpatient therapy cap limits apply to therapy services you get in a CAH. Your therapist will need to determine if you qualify for an exception to the therapy limits you get in a CAH.


How can I find out if my therapy services will go above the therapy cap limits?

 

  • Ask your therapist. They will have the most up-to-date information.

  • Visit MyMedicare.gov to track your claims for therapy services. 

  • Check your “Medicare Summary Notice” (MSN). 


Where can I get more information?

 

Call your State Health Insurance Assistance Program (SHIP) to get free personalized health insurance counseling. To get the phone number for your state, visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.