Video's trying to explain Medical Necessity
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Physical therapy/occupational therapy/speech-language pathology services
How often is it covered?
Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical and occupational therapy, and speech-language pathology services.
In 2018, Congress eliminated the limits on how much Medicare pays for therapy services in one calendar year (also called “therapy caps” or “therapy cap limits”). However, for Medicare to pay for your services, the law requires your therapist or therapy provider to confirm that your therapy services are medically reasonable and necessary when they reach certain amounts each calendar year.
Your therapist or therapy provider will need to add information to your therapy claims and your medical record if your therapy services reach these amounts in 2018:
- $2,010 for physical therapy (PT) and speech-language pathology (SLP) services combined
- $2,010 for occupational therapy (OT) services
If your therapy services reach these amounts, your therapist or therapy provider will need to add a special notation to your therapy claim. By adding this notation, your therapist confirms that:
- Your therapy services are reasonable and necessary
- Your medical record includes information to explain why the services are medically necessary
A Medicare contractor may review your medical records to be sure your therapy services were medically necessary. This review may happen if your therapy services reach these amounts in 2018:
- $3,000 for PT and SLP services combined
- $3,000 for OT services
Your therapist or therapy provider must give you a written notice before providing services that aren’t medically necessary. This includes therapy services that are generally covered but aren’t medically reasonable and necessary for you at the time. This notice is called an “Advance Beneficiary Notice of Noncoverage” (ABN). The ABN lets you choose whether or not you want the therapy services. If you choose to get the medically unnecessary services, you agree to pay for them.
All people with Part B are covered as long as the services are medically reasonable and necessary.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:
- Other insurance you may have
- How much your doctor charges
- Whether your doctor accepts assignment
- The type of facility
- Where you get your test, item, or service
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them. Copied from medicare.gov/pt-and-ot-and-speech-language-pathology pdf
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