Occupational Therapy Detailed
Coverage: Conditions that must be met before Medicare will provide coverage, and limits to coverage.
Medicare helps pay for medically necessary outpatient physical and occupational therapy and speech pathology services when:
- Your doctor or therapist sets up the plan of treatment, and
- Your doctor periodically reviews the plan to see how long you will get therapy.
You can get these services as an outpatient of a participating hospital or skilled nursing facility, or from a participating home health agency, rehabilitation agency, or public health agency. Also, you can get services from a privately practicing, Medicare-approved physical or occupational therapist in his or her office or in your home. (Medicare may not pay for services given by privately practicing speech pathologists.)
CoPayment: The amount you need to pay.
You pay 20% of Medicare-approved amounts.
Medicare Part: The part of Medicare that pays for this service or supply.
Organization Name: The organization name that this coverage topic is associated with.
Carrier (Part B)
Important Notes: Details regarding important notes about the coverage.
You must pay an annual $100 deductible for Part B services and supplies before Medicare begins to pay its share. Actual amounts you must pay may be higher if a doctor, health care provider, or supplier does not accept assignment. From September 1, 2003 through December 7, 2003, there was a limit on the amount Medicare would pay for outpatient physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services. This limit was removed by the recent Medicare Prescription Drug Modernization Act of 2003.
Effective December 8, 2003, there is no limit to the amount of medically necessary outpatient PT, OT, or SLP services you may get. You can get these services from any Medicare-approved outpatient provider.
If you had any outpatient rehabilitation therapy from September 1, 2003 through December 7, 2003, the payment limit will apply to these services if claims are received during this period. For this period, the limits were $1,590 for PT and SLP combined and $1,590 for OT. Medicare paid up to 80% of the limits. This limit did not apply if you got these services in a hospital outpatient department, unless you were a resident of and occupied a Medicare-certified bed in a skilled nursing facility.
If you exceeded the maximum amount allowed for therapy services on or after September 1, 2003 through December 7, 2003, Medicare will not reimburse you for your therapy costs unless you had therapy at an outpatient hospital setting. Medicare will not reimburse any costs above the limits if you were a resident getting Part B services in the Medicare-certified part of a skilled nursing facility. However, if you continue to need therapy services, Medicare will resume covering your therapy services beginning December 8, 2003.