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Ask Ms. Medicare

Are There Limits on Medicare Coverage?

Therapy services: Medicare limits the amount of coverage you can get as an outpatient for physical or occupational therapy and speech-language pathology in any given year. In 2014 the limits are $1,920 for occupational therapy and $1,920 for physical therapy and speech-language pathology combined. These dollar limits are the total cost of the services received in a year—including what Medicare pays, what you pay (20 percent of the Medicare-approved amount) and your Part B annual deductible ($147 in 2014) if this applies. Here are exceptions:

•  Medicare may continue to cover these services, beyond the annual limits, if you have a condition that requires ongoing therapy, such as extensive rehabilitation for stroke and heart disease. To get this exception, your therapist must justify the need when he or she bills Medicare.

• There are no limits on medically necessary therapy that you get at a hospital outpatient department or emergency room.

If your therapy exceeds the limits, and you don’t qualify for an exception, you can continue to get Medicare coverage if you’re able to switch to hospital outpatient or emergency services. Otherwise, you’re responsible for the full cost for the rest of the year.

For more information see Medicare’s guidance on therapy caps.

Note:  The idea that, as a result of the Affordable Care Act (aka “ObamaCare), Medicare will stop covering needed surgeries and other services for people over a certain age (such as 70) has been widely circulated in mass emails.  Don’t believe them. They’re not true. They’re intended to scare older Americans into believing that the ACA will ration their care.  (And you can easily check out their veracity by entering a key phrase from them into a search engine and reading how various fact-checking sites have refuted their claims.) Apart from the limitations listed above, Medicare covers services strictly on the basis of medical necessity—regardless of age. 

Patricia Barry is a senior editor for AARP Integrated Media and the author of “Medicare For Dummies” (Wiley/AARP, October 2013).

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