Marci’s Medicare Answers: therapy caps, dental care and Medicare Savings Program

Dear Marci,

My mother has Original Medicare and has been receiving therapy from a speech-language pathologist on a regular basis. She recently received a notice from her therapist that mentioned a $1,920 therapy cap. What is a therapy cap?

—Vlad

Dear Vlad,

A therapy cap is a limit placed on the amount of physical therapy, occupational therapy, and speech-language pathology that Medicare will cover in a given year. Therapy caps only apply if your mother gets her Medicare benefits through Original Medicare, the traditional Medicare program administered by the federal government. Medicare Advantage plans, also known as Medicare private health plans, may apply therapy caps, but are not required to do so.

In 2014, the therapy cap is $1,920, meaning that your mother can get up to $1,920 worth of combined physical therapy and speech-language pathology services or up to $1,920 worth of occupational therapy from outpatient health care providers. Note that physical therapy and speech-language pathology services are combined to meet the therapy cap. In contrast, occupational therapy is counted by itself when determining the therapy cap.

If your mother reaches the $1,920 therapy cap in 2014, Medicare may make an exception to the therapy cap limit and continue to cover her therapy services. In order for this to occur, her speech-language pathologist or therapist must indicate your mother’s continuing need for therapy in her medical record. He/she must also indicate that the therapy services provided to your mother are medically reasonable and necessary when submitting claims for additional therapy costs above the therapy cap to Medicare.

If your mother reaches the $1,920 therapy cap in 2014 and her therapist feels that additional therapy above the therapy cap is not medically necessary, he/she should give your mother a notice called an “Advance Beneficiary Notice,” before providing her with therapy services. This notice warns people with Original Medicare that Medicare will likely not pay for the service in question. If your mother still wants to receive the continued therapy, she can check the option on the notice that requires the therapist to provide additional therapy and then submit the medical claim for the therapy to Medicare. If Medicare ends up denying coverage for the additional therapy, your mother can still file an appeal.

It may be helpful for your mother to talk to her speech-language pathologist or therapist about the therapy cap. Note that you can go online and visit http://www.medicare.gov/coverage/pt-and-ot-and-speech-language-pathology.html to learn more about therapy caps.

—Marci

Dear Marci,

Does Medicare ever cover dental care?

—Betsey

Dear Betsey,

For the most part, Medicare does not cover dental care by law. In general, Medicare does not cover routine dental care or dental care that you need primarily for the health of your teeth. For example, Medicare will generally not cover routine checkups or cleaning.

However, Medicare will pay for dental services in very limited circumstances if the services are required to protect your general health or if you need dental care in order for a Medicare-covered health service to be successful. For example, Medicare will pay for dental services if:

You have a disease like oral cancer that involves the jaw and you need dental services for radiation treatment;
You need dental splints and wiring as a result of jaw surgery; or
You need surgery to treat jaw or face fractures.
Note that while Medicare may pay for initial dental services for the reasons mentioned above, Medicare will not pay for any follow-up dental care after the underlying health condition has been treated. For example, if Medicare paid for a tooth extraction as part of a procedure to repair a facial injury you had, Medicare will not pay for any other dental care you need in the future due to the loss of your tooth.

Keep in mind that some Medicare Advantage plans may cover limited dental care, depending on the plan’s specific benefits. If you get your Medicare benefits through a Medicare Advantage plan, contact your plan to see what dental services may be covered.

—Marci

Dear Marci,

I cannot afford to pay the $104.90 Medicare Part B premium each month. I was told by a social worker that while I do not qualify for Medicaid, I should apply for a Medicare Savings Program. What is a Medicare Savings Program?

—Roman

Dear Roman,

A Medicare Savings Program (MSP) is an assistance program that can help pay your Medicare costs if you have limited finances. MSPs can help pay your Medicare Part B premium, which is the amount you pay each month to have Medicare medical insurance. It may also pay other Medicare costs, depending on your income.

To qualify for an MSP, you must have Medicare Part A, the part of Medicare that covers most inpatient and hospital care, and meet your state’s income and asset eligibility guidelines. MSP eligibility limits vary by state, so you should contact your State Health Insurance Assistance Program (SHIP) or local Medicaid office to find out whether you qualify for an MSP.

—Marci

Marci’s Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare.