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 2018 and going forward based on the Medicare allowed amount:

  • $2,040 for physical therapy (PT) and speech-language pathology (SLP) services combined
  • $2,040 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

Priority Health will review medical records to be sure therapy services were medically necessary. This review will happen if therapy services reach these amounts in 2018 through 2027:

  • $3,000 for PT and SLP services combined
  • $3,000 for OT services

For the most complete and updated information, go to the CMS website page explaining the dollar limits.

Effective Jan 1, 2018, when the member hits the $5,000 therapy cap, the provider should submit medical notes that support the reason for the additional rehab services with the claim. It is the provider responsibility to track the amount. If no notes are submitted, the claim will deny for medical records. Providers will not need to request a prior authorization because this service does not require an authorization according to the EOC.