Reminder: Medicare limits on outpatient therapies

In 2010, the Medicare benefit for outpatient physical therapy and speech-language pathology services (combined) is limited to $1860 per year. There is a separate yearly benefit limit of $1860 for outpatient occupational therapy.  (The therapy limit is based on the allowed amount which includes what the member pays and what Priority Health Medicare pays.)

Priority Health Medicare pays for occupational, physical, and speech therapy based on the copay or coinsurance listed in the Evidence of Coverage as long as it is medically necessary, but only up to the yearly benefit limit of $1860. After a member has reached the $1860 cap, the member will be responsible for 100% of the charge, unless the member has other insurance coverage.

There is no limit if a member goes to a hospital outpatient therapy department. People who occupy a Medicare-certified bed in a skilled nursing facility are limited to the cap amounts and cannot receive additional covered outpatient hospital therapy while in the certified bed.

Exceptions may be allowed under limited circumstances. 

See your Evidence of Coverage or call Customer Service for more details.