Medicare has cap for physical, speech, occupational therapies

My father is 66 and has always been an extreme athlete. Recently, he had a mishap water skiing. He broke his ankle and wrist; his orthopedic surgeon ordered physical therapy for his ankle. His ski hit his face; his reconstructive surgeon ordered speech therapy since he suffered muscle/nerve damage. Dad is improving but has a way to go for a full recovery. He just mentioned that there is a cap on the number of therapy sessions available under Medicare. What if he reaches this limit and still needs therapy?

I am sorry to hear about your father's mishap but pleased to hear he is on the mend. You are correct, Medicare has set annual "therapy caps" for physical therapy, speech therapy and occupational therapy.

For 2016, Medicare covers a combined total of $1,960 worth of physical therapy and speech therapy. Medicare covers an additional $1,960 of occupational therapy.

Since his doctors have ordered both physical therapy and speech therapy, your father is subject to the $1,960 annual therapy cap. It is possible that your father will achieve the therapy goals prior to the $1,960 limit. However, if he reaches his annual therapy limit and his doctors believe it is medically necessary for him to continue therapy, his doctors may request an "exception" to Medicare therapy limits. An exception will allow that additional therapy be covered.

Is there an annual open enrollment for Medigap plans? I have a Medigap plan and the premiums keep increasing every year. I want to find a similar plan at a lower premium.

Unlike Medicare Part D and the Medicare Advantage Plan, there is not an annual open enrollment for Medigap plans. The best time to consider a Medigap plan is when you are new to Medicare Part B. During the first six months that you have Medicare Part B, you have an initial enrollment period for Medigap plans.

Federal rules state that during that first six months that you are both age 65 (or older) and you have Medicare Part B, you may purchase any Medigap plan available in the state in which you live. Maryland law extends protections to people who are under age 65 and have Medicare due to a disability. Maryland allows the under 65 disabled person the right to some (not all) Medigap plans during the six months a person is new to Medicare Part B.

Outside your initial enrollment period for a Medigap, there are seven other specific times a person over age 65 could be sold a Medigap plan without the plan asking your health history. The booklet, "Choosing a Medigap Plan," is available by calling 1-800-MEDICARE or it may be view/downloaded by visiting www.medicare.gov. This booklet explains the initial enrollment period and the seven specified "guarantee issue" situations.

You state you currently have a Medigap plan. Medigap plans are automatically renewable, meaning a person will automatically maintain enrollment year after year as long as the person continues to make premium payments. You also mention the premium cost has increased for your Medigap. Over time, Medigap plans increase premium costs. You want to know if you can switch to a less costly plan. If you do not fall into the initial enrollment period or you do not meet one of the specific "guarantee issue" situations, your enrollment into another Medigap plan is up to the discretion of the new plan.

Bottom line: A new plan can ask your health status and a new plan is not required to sell you a policy. If you find a less costly Medigap plan, do not drop your current coverage until you are certain a new Medigap plan is willing to sell you a policy.

Amy Rubino is the director of the Senior Health Insurance Assistance Program and the Senior Medicare Patrol for the Anne Arundel County Department of Aging and Disabilities. You may contact either program at 410-222-4257 or [email protected].

Credit: Amy Rubino