Information for our Medicare Patients

A Little History

For the past several years, Medicare patients have been subject to arbitrary monetary caps on the costs of their outpatient physical therapy services. To make matters more confusing, every year, Congress has increased the cap amount while at the same time has attempted through legislation to repeal the cap. In 2009, Congress once again introduced legislation to permanently rid Medicare beneficiaries of the cap.

Hereford Physical Therapy & Sports Medicine actively lobbies the Congress and the Senate to pass legislation that would allow seniors to receive outpatient physical therapy at the facility of their choice for as long as their therapist and treating physician deem necessary.

Medicare Limits on Therapy Services

Medicare limits how much it will pay for medically necessary outpatient physical therapy, speech language pathology and occupational therapy. For 2009 the limit for physical therapy and speech language pathology is $1840 and for occupational therapy $1840.

What Does This Means to You?

After you have paid your annual deductible for Medicare Part B, Medicare will pay for 80% of the therapy cost, and you, the patient will pay the remaining 20%. Many patients have secondary insurance that will pay all or a portion of that remaining 20% not paid by Medicare. Medicare will continue to pay for therapy services until the $1840 cap limit is reached.

You may be eligible for an exception to the cap limits if services are medically necessary. This will allow Medicare to continue to pay for services after you had reached the cap. Your therapist can let you know if your medical condition qualifies for the cap exception.

What Happens if I Do Not Meet the Exception Criteria?

Medicare beneficiaries that do not meet the exception criteria and are still in need of therapy services may continue their therapy at an outpatient hospital facility. Hospital based outpatient therapy facilities are exempt from the cap.

How Will I Know if I have Reach the Cap?

Hereford Physical Therapy & Sports Medicine billing staff actively tracks patients’ Medicare payments and cap balances. Patients also receive Medicare Summary Notices, that is, statements that Medicare sends you when it pays a provider, so that you can track the amount of cap you have remaining. You can also visit Medicare’s website at www.MyMedicare.gov. This website is Medicare’s secure online service for assessing your personal Medicare information.

HPT will do everything possible to keep patients aware of their cap status but we strongly urge that patients keep track of it themselves as well.

Note: This information only applies if you have Original Medicare. If you get your Medicare health care through a Medicare Advantage Plan, like and HMO or PPO, check with your specific plan information about individual coverage rules.

If you have any additional questions or concerns about your Medicare coverage, please contact our office to speak with our billing department. We are happy to assist you.

Information for our Medicare Patients

Medicare Physical Therapy Cap Update (01/07/09)

Medicare Physical Therapy Cap Update (01/16/07)

Medicare Physical Therapy Cap Update (01/06/06)

Medicare Physical Therapy Cap Update (10/10/05)

Medicare Physical Therapy Cap Update (3/29/05)

Medicare Physical Therapy Cap Update (12/08/03)

Medicare Physical Therapy Cap Update (11/25/03)

Medicare Physical Therapy Cap Update (10/3/03)

Medicare Physical Therapy Cap Update (7/23/03)

Medicare Physical Therapy Cap Update (7/2/03)