Many feel that Medicare is the end all be all. Medicare will solve all of their problems as it relates to health and wealth in older age. However, there are a number of limits that occur with traditional Medicare coverage that you may not be aware of.
One of those said limits occurs due to the nature of prescription received from the physician. Medicare provided physical and occupational therapy will only cover the costs associated with therapy for a specific injury or illness.
As one ages, the tendency for aches and pains to flare up increases. One may wake up with a sore back on any given day and find relief knowing the have a scheduled therapy session in the afternoon. However, the therapy session is for a shoulder replacement that occurred four weeks ago, not lower back pain. Under Medicare guidelines the physical therapist, occupational therapist or therapy assistant cannot treat you for the lower back pain without a new prescription written by the physician. The therapy session must focus on what the prescription indicates, in this case a shoulder replacement.
Medicare provided therapy is can only be utilized for a specific injury or illness. The guidelines do not allow for a maintenance program to be established under Medicare coverage. Therefore, should an individual wish to continue their progress after discharge from therapy, they will have to do so with a private pay personal trainer.
In 2021 Medicare placed limits on the amount of coverage provided for physical and occupational therapy. The limit for 2021 stands at $2,110 for both physical and occupational therapy.
What does the limit mean?
Providers regularly bill Medicare for the services associated with the recovery process. Various billing codes will reimburse the providers differing amounts. Therefore once the limit of $2,110 is reached a patient is said to have reached their limit. This means the provider will now have to prove the services they are providing are medically necessary in order to be reimbursed by Medicare.
This is important towards the end of the recovery process. Physical and occupational therapies are designed to regain normal functioning, not necessarily optimal. They are also not designed as a maintenance tool. As the therapy caps are reached, and the recovery process comes to a close individuals will no longer require medically necessary therapy, rather a provider to help continue the progress already made.
All in all, Medicare provided therapy has its limits. The therapy is utilized only when it can be deemed medically necessary. The guidelines and caps are put in place to help individuals regain their function while also being fiscally efficient. Contrary to common belief, you cannot receive physical therapy as an ongoing service after the age of 65. Those wishing to continue or maintain their progress must seek out alternatives.