January 2013 Medicare began putting a limit (cap) on therapy services. This limit is $3700 for an auto exceptions diagnosis and $1940 if there is not an auto exception diagnosis available. This amount is combined for physical therapy and speech language pathology and a separate $3700/$1940 amount for occupational therapy. The number of therapy visits then translates to approximately 37 or 19 visits respectively per year for each limit.
If your therapy visits exceed the Medicare limit, then you have 1 of 3 options:
- You agree to your therapy visits and you agree to pay out of pocket as you receive services. You can then appeal to Medicare by following the directions on a Medicare Summary Notice. If Medicare does pay, then you will be reimbursed by CAPTA less co-pays or deductibles.
- You can choose to continue with therapy and pay out of pocket. Medicare will not be billed and you cannot appeal.
- You can choose to discontinue therapy and not appeal Medicare.
If you have a secondary insurance, sometimes it will cover beyond the Medicare limit, but not always.
If you have questions on the Medicare cap, you can call: 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048)