By Jon Costa
The Medicare Minute for June, 2014 provided by the Medicare Rights Center and the State Health Insurance Assistance Program, is entitled “Physical, Occupational, and Speech Therapy.”
Understanding how Med -icare covers outpatient physical, occupational, and speech therapy will help ensure you have access to the services you need to be as healthy as possible.
Understand how to qualify for physical, occupational, and speech therapy.
Medicare covers therapy services that help you regain your ability to function, help prevent your health from worsening, or slow worsening symptoms. As long as you meet the following criteria, Medicare should cover your outpatient therapy whether or not your condition is temporary or chronic:
You need the technical skills of a trained therapist to provide safe and effective treatment.
Your doctor or therapist sets up the plan of treatment before you get care;
Your doctor regularly reviews your plan of treatment to see if changes are needed.
Understand which location is best for you to receive your therapy.
You may receive your outpatient physical, occupational, and speech therapy in a variety of locations.
If you qualify for therapy, you could receive it from an outpatient hospital facility, rehabilitation agency, Comprehensive Outpatient Rehabilitation Facility (CORF), or public health agency. You may also get services from a privately practicing, Medicare-approved therapist in his or her office or in your home. Talk to your doctor to figure out which location is best for you.
Understand how outpatient therapy costs and caps work.
If you have Original Medicare, Medicare Part B generally covers approximately 80 percent of the Medicare-approved amount for each outpatient therapy service. You will be responsible for the remaining 20 percent. Remember that you have to meet the annual Medicare Part B deductible each year ($147 in 2014). If you have a Medicare Advantage plan, you can receive the same amount of therapy coverage as under Original Medicare, but your plan may have different therapy costs.
You should note that Original Medicare does have therapy caps. This means that when the cost of your therapy reaches a certain amount, Original Medicare may stop covering your therapy.
In 2014, the therapy cap for physical and speech therapy combined is $1,920 spent by you and Medicare together. There is a separate $1,920 cap for occupational therapy. Medicare Advantage plans may choose to have these caps, but they are not required to do so. Contact your plan if you are unsure about its therapy coverage rules.
Keep in mind that after you’ve reached the cap, Medicare will continue to pay its portion for our therapy if your doctor indicates that you need more therapy and certifies that it is still medically necessary. If you need a lot of care after you have reached the therapy cap, your doctor may need to get a special approval from Medicare for your therapy to continue. Also, speak to your therapist if you are concerned about needing Medicare coverage for therapy services above the cap. You may appeal if Medicare denies you therapy coverage above the cap. If your appeal is unsuccessful and you continue to go to the therapist, you may have to pay for care out-of-pocket.