Medicare therapy caps

 Important: This information applies to all Priority Health Medicare Advantage Plans. In 2018, Congress eliminated the limits on how much Medicare pays for therapy services in one calendar year (also called "therapy caps" or "therapy cap limits").  However, for Priority Health to pay for your services, the law requires therapists or therapy providers to confirm that therapy services are medically reasonable and necessary when they reach certain amounts each calendar year.

What should therapy providers do?

Therapists or therapy providers will need to add information to the therapy claims and medical records if a member’s therapy services reach these amounts as of Jan. 1, 2021 and going forward based on the Medicare allowed amount:

  • $2,110 for physical therapy (PT) and speech-language pathology (SLP) services combined
  • $2,110 for occupational therapy (OT) services

It is the provider's responsibility to track therapy services that reach these amounts, and upon reaching these amounts will need to add the KX modifier to the member’s therapy claims. By adding this modifier, the therapist or therapy provider confirms that:

  • Therapy services are reasonable and necessary
  • Medical records include information to explain why the services are medically necessary

In December 2020, we made changes to the Medicare outpatient therapy claims process to improve provider satisfaction. Providers are no longer required to submit medical records for Medicare outpatient therapy claims that meet or exceed the Medicare outpatient therapy threshold. The process will still require the KX modifier as a confirmation that services are medically necessary. Instead of submitting medical records with claims, we'll notify providers if chosen for the review.