I have Original Medicare. My doctor told me I will need to have a large amount of outpatient physical and occupational therapy. My friend who used to get physical therapy said that Medicare only covers a certain amount. Is this true? What does Medicare cover?
-Nadine (Denver, CO)
Dear Nadine,
Medicare Part B covers outpatient therapy, including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT). If you meet Medicare’s eligibility requirements, Medicare covers therapy on a temporary basis to improve or restore your ability to function, or on an ongoing basis to prevent you from getting worse. Medicare should cover your outpatient therapy regardless of whether your condition is temporary or chronic. You are eligible for Medicare coverage of therapy services if:
You need skilled therapy services, and the services are considered safe and effective treatment for you
Medicare defines skilled care as care that must be performed by a skilled professional, or under their supervision
Your doctor or therapist creates a plan of care before you start receiving services
Your doctor or therapist regularly reviews the plan of care and makes changes as needed.
Original Medicare covers outpatient therapy at 80% of the Medicare-approved amount. When you receive services from a participating provider, you are responsible for a 20% coinsurance after you meet your Part B deductible ($183 in 2018).
Previously, there were limits, also known as the therapy cap, on how much outpatient therapy Original Medicare covered annually. However, in 2018, the therapy cap was removed. If your total therapy costs reach a certain amount, Medicare requires your provider to confirm that you therapy is medically necessary. In 2018, Original Medicare covers up to:
$2,010 for PT and SPL before requiring your provider to indicate that your care is medically necessary
And, $2,010 for OT before requiring your provider to indicate that your care is medically necessary.
Remember, Medicare pays for up to 80% of the Medicare-approved amount. This means Original Medicare covers up to $1,608 (80% of $2,010) before your provider is required to confirm that your outpatient therapy services are medically necessary. If Medicare denies coverage because it finds that your care is not medically necessary, you can appeal.
Keep in mind that outpatient therapy includes therapy received: