Medicare Part B has a $147 deductible for the 2015 calendar year, which must be paid before therapy services are covered. After your deductible has been met, Medicare covers 80% of your therapy services. Medicare also has a cap of $1940 for the 2015 calendar year toward your physical therapy and speech language therapy services combined. It will pay up to an additional $1940 for Occupational Therapy which is a separate benefit. Since Medicare pays for 80% of the allowed $1940, that means $388 is not covered by Medicare. If you have a secondary insurance, the coinsurance may cover part or all of this cost. Please visit www.medicare.gov for more information.
Some people who think they “have Medicare” as their primary carrier, actually have a Medicare Advantage or Medicare Part C plan. This means that the services are covered by an independent insurance company, contracted by Medicare. We must be in-network with that carrier in order for our services to be covered. The therapy benefits usually require prior authorization, which we will obtain. The Medicare Advantage plans usually carry a copay for all therapy visits. The copays vary, depending on your particular plan, and we make every effort to verify your copay prior to the start of services. However, we encourage you to contact your insurance carrier for questions about your benefits and patient responsibilities.
We accept assignment for most major plans and will contact your carrier prior to the start of services to verify your therapy benefits. The coverage widely varies between plans.
Most people with Medicaid now have “managed” Medicaid plans. These plans require pre-authorization from a case manager, which we will obtain for you. The benefits may vary depending on which plan you have. Some people may still have traditional Medicaid plans, which may cover up to 20 visits per benefit year, or a “waiver”, which may cover more than 20 visits per year. We will obtain any necessary authorizations.
Special Information About The Empire Plan:
We are out of network providers with the Empire Plan, which will usually cover a nominal amount as coinsurance. However, the insurance company will send the payment to you. You are responsible for forwarding payment and a copy of the Explanation on Benefits to us. You can endorse the insurance check and mail it to us, or you may deposit the check and write us a personal check for this amount. We do not have any control over the insurance company mailing you the payment. We also do not have access to this plan’s database to know which dates of services are being paid. Therefore, we need a copy of the insurance statement from you to properly credit your account
We verify all insurance benefits prior to starting services. In most cases, we make every attempt to bill your insurance directly for services. You will also be notified if there is a copay for services prior to starting. The explanations above do not in any way guarantee payment. It is important that you understand your insurance benefits. Please contact your carriers directly for specific questions regarding your benefits. These explanations are for general guidance only and coverage is determined only by your insurance carrier, and is subject to change at any time.