What is a Medicare Therapy Cap?
I have Original Medicare and I get physical therapy on a routine basis. My therapist said that I may reach the therapy cap in a few months and that Medicare may not pay for my therapy after I reach the cap. What is a therapy cap?
A therapy cap is a limit placed on the amount of outpatient physical therapy, speech-language pathology, and occupational therapy that Medicare will cover in a given year. This means that Medicare will cover medically necessary therapy up to the therapy cap amount in a particular year. After you have reached the cap, Medicare may not pay for additional therapy, unless your therapist or doctor feels that additional therapy is medically necessary.
Note that you may be affected by the therapy cap if you get therapy in an outpatient setting, such as a clinic or medical office. In addition, therapy caps apply to you if you get your Medicare benefits through Original Medicare, the traditional Medicare program administered by the federal government. Medicare Advantage plans, also known as Medicare private health plans, may apply caps or limits on your therapy benefits, but are not required to do so. If you have a Medicare Advantage plan, contact your plan directly to learn how your plan covers therapy.
Therapy caps change each year. In 2014, the therapy cap is $1,920, meaning that you can get $1,920 worth of combined physical therapy and speech-language pathology services or $1,920 worth of occupational therapy from outpatient health care providers. Note that physical therapy and speech-language pathology services are combined to meet the therapy cap, while occupational therapy services are counted separately to meet the cap.
If you are approaching the therapy cap and you need more therapy, talk to your therapist or doctor. Medicare can make an exception to the therapy cap and cover therapy you receive beyond the cap if your therapist or doctor tells Medicare that additional therapy is medically necessary.
Remember, if Medicare does not pay for the therapy that you need, you have the right to file an appeal. If you have any questions or need assistance with reviewing and changing your current coverage, please call the Sussex County Department of Human Services, Division of Senior Services, at 973-579-0555 ext. 1221 to speak to a SHIP counselor or email firstname.lastname@example.org.