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Vol. 13, Issue 7 • April 7, 2014

What is a therapy cap?

Dear Marci,

I have Original Medicare and I get physical therapy on a routine basis. My therapist said that I may reach the therapy cap in a few months and that Medicare may not pay for my therapy after I reach the cap. What is a therapy cap?

– Bernard (Cincinnati, OH)

Dear Bernard,

A therapy cap is a limit placed on the amount of outpatient physical therapy, speech-language pathology, and occupational therapy that Medicare will cover in a given year. This means that Medicare will cover medically necessary therapy up to the therapy cap amount in a particular year. After you have reached the cap, Medicare may not pay for additional therapy, unless your therapist or doctor feels that additional therapy is medically necessary.

Note that you may be affected by the therapy cap if you get therapy in an outpatient setting, such as a clinic or medical office. In addition, therapy caps apply to you if you get your Medicare benefits through Original Medicare, the traditional Medicare program administered by the federal government. Medicare Advantage plans, also known as Medicare private health plans, may apply caps or limits on your therapy benefits, but are not required to do so. If you have a Medicare Advantage plan, contact your plan directly to learn how your plan covers therapy.

Therapy caps change each year. In 2014, the therapy cap is $1,920, meaning that you can get $1,920 worth of combined physical therapy and speech-language pathology services or $1,920 worth of occupational therapy from outpatient health care providers. Note that physical therapy and speech-language pathology services are combined to meet the therapy cap, while occupational therapy services are counted separately to meet the cap.

If you are approaching the therapy cap and you need more therapy, talk to your therapist or doctor. Medicare can make an exception to the therapy cap and cover therapy you receive beyond the cap if your therapist or doctor tells Medicare that additional therapy is medically necessary.

Remember, if Medicare does not pay for therapy that you need, you have the right to file an appeal. Click here for more information on Medicare coverage of outpatient therapy. Click here for information on how to file an Original Medicare appeal.


Health Tip

For many people, memory loss can be very frustrating. While there is no guaranteed way to prevent memory loss, the Mayo Clinic offers some simple tips on sharpening your memory:

  • Engage in mentally stimulating activities, like crossword puzzles. Mentally stimulating activities can help keep your brain in shape in the same way that physical exercise keeps your body in shape.

  • Sleep well. Sleep plays an important role in helping you retain and consolidate your memories. Most adults need about seven to eight hours of sleep each day.

  • Eat a healthy diet. A healthy diet can be as good for your brain, as it is for the rest of your body.

  • Socialize with friends and/or loved ones. Social interaction can help ward off depression and stress, both of which can contribute to memory loss.

Click here for the entire list of Mayo Clinic tips on improving your memory.

Need to Know

Medicare Rights University, a comprehensive online training curriculum for professionals, provides a guided learning experience complete with a self-assessment tool, in-depth and user-friendly Medicare content, quizzes to test your knowledge, and downloadable materials.

This unique resource provides professionals with a clear path to learning Medicare through a Core Curriculum—four levels of Medicare instruction designed to build on information learned as you progress through each level. Medicare Rights University also offers a Special Topics section which provides an in-depth look at subjects not covered in the Core Curriculum, such as Medicare’s coverage of durable medical equipment and Medicare from a policy perspective.

Check out Medicare Rights University today by going online and visiting www.medicarerightsuniversity.org.

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