Ever wonder why you may be getting bills for your physical therapy even though you’re covered by Medicare? You may not know, and you’re certainly not alone, that Medicare puts limits on what they pay for your physical therapy. Specifically, we’re talking about outpatient physical therapy versus inpatient therapy which would involve admittance into a skilled nursing facility.
Medicare Limits Your Physical Therapy (Sort of)
Yes, Medicare does limit or cap what they will pay in a calendar year for your outpatient physical therapy; however, you can have an exception granted that will increase the coverage. This increase is not unlimited of course and also has a cap as well. Here are the limits for 2017:
- Occupational Therapy (OT) – $1,980
- Physical Therapy (PT) or Speech Language Pathology (SLP) – $1,980
These therapy caps or therapy cap limits are your initial limits to what Medicare will pay without needing to qualify for an exception. You’ll also see that the limits are broken up into both physical therapy and occupational therapy, so if you’re needing both you will receive more care before hitting that limit.
What If Additional Physical Therapy Is Needed?
Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), you are able to seek additional coverage through Medicare for physical therapy that is deemed medically necessary and reasonable. This is continued in 2017 to allow you to get physical therapy care that is needed. The limits for this exception in 2016 and 2017 are:
- Occupational Therapy (OT) – $3,700
- Physical Therapy (PT) or Speech Language Pathology (SLP) – $3,700
This almost doubles the amount of coverage that Medicare limits you to when receiving outpatient physical therapy. Of course, they don’t just automatically give this extra coverage to you. The provider has to deem it to be medically necessary and reasonable. A Medicare contractor has the ability to go back and review you claims to make sure that they are medically reasonable and necessary. Also, if the care that you are given is not going to meet the medically necessary and reasonable requirement, the provider must notify you so you can make the decision knowing that it won’t be paid for by Medicare. They do this by written notice, also known as a Advance Beneficiary Notice of NonCoverage (ABN). This protects you from receiving care that is not going to be paid for by Medicare.
Of course, with Medicare Part B coverage only, they are not paying all of the costs associated with the physical therapy anyway. You still will have to pay the annual deductible and coinsurance which is 20% under Medicare Part B. Other factors that can affect how much you pay will be how much the provider charges, where the services are received, whether or not the provider accepts assignment, and of course any other insurance that you may have.
This “extra” coverage provided through MACRA, is not guaranteed beyond this year 2017. We currently don’t know if it will be available to you next year or beyond so now may be the time to consider having that procedure or at least looking at the best time to have the procedure that will require outpatient physical or occupational therapy.