What are Medicare Therapy Caps?

medicare therapy caps limit recovery care

Medicare Part B covers medically necessary physical therapy and speech language pathology; however there is a cap on the amount covered for these services under Medicare.

For 2017, the therapy caps are:

  • $1,980 for physical therapy (PT) and speech language pathology services combined
  • $1,980 for occupational therapy (OT) services.

Legislation seeks to repeal therapy caps

Senator Ben Cardin (MD) has proposed repeal legislation, the Medicare Access to Rehabilitation Services Act, which would repeal the annual cap on Medicare rehab services. Margaret Danilovich, physical therapist and public health researcher at Northwestern University, argues that the therapy cap is costly in the long run to patients’ health. For example, someone with one or more chronic illnesses would need ongoing PT to maintain their health, prevent scar tissue from building up, and to be mobile.

Under the current therapy cap, the dollar amount covers about two months of therapy, which is not nearly enough in some cases, especially for those dealing with Parkinson’s, Alzheimer’s, stroke, or major injury recovery.

Exceptions process

There is an exceptions process if your services are deemed in writing as medically necessary. The exceptions process includes thresholds of:

  • $3,700 for PT and SLP combined
  • $3,700 for OT.

If your therapy extends beyond the caps or is not covered by Medicare, your therapist should provide you with an ABN, or Advance Beneficiary Notice of Noncoverage, which allows you to choose whether or not to get the services Medicare does not cover. You must pay for any services that are not covered.

Danilovich argues that investing in covering more therapy on the front end will prevent major problems such as broken bones and disease down the road. But legislators are hesitant to pass the repeal legislation due to the costs it could incur.

Some relief for those with chronic illness

Luckily, some rules regarding therapy caps have changed. Effective January 7, 2014, Medicare beneficiaries can no longer be denied coverage for PT, OT, or SLP simply due to lack of improvement – a decision that greatly benefits those with Parkinson’s, Alzheimer’s, and other chronic conditions. However the therapy caps are still in place for these patients.

Related Links

Reduce Medicare Costs with Physical Therapy

A Glossary of Medicare Terms

2017 Medicare Part B Overview

How to use Medicare for Home Health Services

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