New Year- New Medicare Therapy Dollars!

What does the Medicare Therapy CAP mean to You?

Every year- Medicare beneficiaries are given new therapy dollars to be used for Physical, Occupational & Speech Therapy Services received in an outpatient setting. Physical Therapy is important for Medicare beneficiaries in their efforts to stay healthy and active, independent and pain free!

In 2018- Medicare eliminated the inflexible limit to the amount of therapy they will pay for in a calendar year- once termed the Therapy CAP. Instead they reinforced requirements of these services being “Medically Necessary” under the benefit.

In 2019- the Therapy CAP amount initially provide is $2040 for Physical and Speech Therapy combined and $2040 for Occupational Therapy. which is subject to a deductible of and then a 20% co-pay. This co-pay may be submitted to a Medicare recipient’s secondary plan or Medicaid if you are eligible.

Therapy Services that are “over the CAP” in any calendar year are still payable by Medicare if the therapy meets certain criteria of being “medically necessary”.

What types of Physical Therapy services does Medicare Part B (Outpatient) cover for me?

Rehabilitative Therapy: Your ability to function related to a …. “condition that has the potential to improve or is improving in response to [skilled] therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time. Improvement is demonstrated by specific measurements whenever possible.”

Maintenance Therapy: Your … “treatment by the therapist is necessary to maintain, prevent or slow further deterioration of your functional status and the services cannot be safely carried out by the by yourself or by a family member, another caregiver or unskilled personnel.”*

What does Skilled Therapy mean?

Therapy services must be considered “skilled” to be covered by Medicare.

Medicare describes skill as:

“The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can only be safely and effectively performed by a qualified clinician, or therapists supervising assistants.”*

* (see the National Government Services Outpatient Physical and Occupational Therapy Local Coverage Determination)

Talk to your Physical Therapist or Physician to determine if Physical Therapy is for you in 2019 to help you attain your goals of staying active, independent & pain free!



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