Dear Marci,
I have been receiving outpatient physical therapy for a while now, and my condition is not improving. I am worried about reaching a therapy cap or losing coverage for not meeting an improvement standard. How can I troubleshoot potential coverage issues with my physical therapist?
-Venita (Mobile, AL)
Dear Venita,
Medicare Part B covers outpatient therapy, including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT). Previously, there was a limit, 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 your therapy is medically necessary. This is not a therapy cap, but it does require your provider to take action before Medicare will cover continued care.
In 2020, Original Medicare covers up to:
- $2,080 for PT and SPL before requiring your provider to indicate that your care is medically necessary .
- And, $2,080 for OT before requiring your provider to indicate that your care is medically necessary.
If your provider has questions about how to bill Medicare for more therapy, let them know they should contact the Medicare Administrative Contractor (MAC) for their state.
Medicare pays for up to 80% of the Medicare-approved amount. This means Original Medicare covers up to $1,664 (80% of $2,080) before your provider is required to confirm that your outpatient therapy services are medically necessary. If Medicare denies coverage because it finds your care is not medically necessary, you can appeal.
It is also important to know that Medicare will cover your physical therapy even if your condition is not improving. Medicare covers skilled nursing facility, home health, and outpatient therapy careregardless of whether your condition is temporary or chronic, or whether your condition is improving or not, as long as the care is medically necessary for another reason. This was clarified in the settlement of a class action lawsuit, Jimmo v. Sebelius. The settlement agreement explained that an improvement standard cannot be the only test applied when Medicare is determining coverage of claims that require skilled care, such as skilled therapy. Medicare covers services that are needed to:
- Help maintain ability to function
- Help regain or improve your function
- Prevent or slow the worsening of your condition
In other words, your coverage of skilled therapy cannot end solely because your condition is not improving. If your therapy is being denied or ending just because you are not improving, you should file an appeal.
-Marci