Medicare has Limits on Therapy

By January 14, 2013 January 3rd, 2020 Making the Most of your Medicare

Many people on Medicare do not realize that Medicare caps the amount of therapy a person is eligible for in a given year.  Here is a link for the official document.  For 2013, Medicare will only approve:

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$1,900/year for physical therapy and speech therapy
$1,900/year for occupational therapy

Those are separate figures, meaning you could receive a total of $3,800 worth of services per year.

It is important to remember that this is the amount Medicare approves.  Medicare will only cover 80% of this amount.  If you have a supplement, it would pick up the 20% balance.  Because Medicare does not approve services above the $1,900 amount, any therapy provided would be paid out of pocket by the recipient.

This is not a new rule but is becoming more common as therapy is prescribed for a variety of illnesses.   Here are a few rules of thumb to keep in mind:

– These caps are annual limits that run from January 1st to December 31st
– There are appeal processes available for “medically necessary” therapy above the $1,900
– Most therapy people receive is for orthopedic issues (knee/hip replacement, rotator cuff surgery).

When you get this type of therapy, often in home or in an outpatient therapy facility, it may be a good idea to see if you can space your visits further apart to avoid running out of therapy mid stream.  You may also ask your therapist for literature on how to perform the exercises on your own at a gym or in your house, using the therapy appointments as “follow ups”, to measure range of motion or strength, and to learn new exercises.

Another common way people hit this limit is with rehab for chronic conditions.  The two most common are cardiac rehab and pulmonary rehab.  This type of therapy usually involves stamina training, disease specific exercises, and breathing strategies to use after a heart attack or lung episode.  Again, a good idea is to take the strategies provided in these meetings and follow them at a gym or in your home.

Therapy limits are also common on employer and individual health plans as well.  Regardless of you coverage, is important to keep these caps in mind when you are using PT or OT services in order to avoid an interruption in care.  I know from experience the frustration involved when your therapy runs out before you are 100%!

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