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When Does Medicare Coverage Come with Limits?

Copyright © 2014 AARP. All rights reserved.

For all the loose and cruelly inaccurate talk about “death panels” and “rationing” that still circulates in mass e-mails meant to exploit older people’s fears of being denied coverage, Medicare simply doesn’t — and can’t, by law — ration care like that. “Medical necessity” is what usually counts.

If you’ve had a hip replacement but fall again and need another, Medicare isn’t going to turn around and deny you coverage for the second one. If you’re fighting your third bout of pneumonia, Medicare isn’t going to shut you out of the hospital because of the first two episodes. If you’re in your 90s and have heart failure or cancer, Medicare isn’t going to refuse you treatment because you’re too old.

At the same time, Medicare has always placed limits on certain areas of coverage — and although Washington policy makers may regard these caps as reasonable attempts to rein in runaway costs and guard against fraud, the limits can adversely affect some patients.

So on the basis that forewarned is forearmed, take time to view a couple main areas where coverage comes with limits: stays in a skilled nursing facility and therapy services.

Limits on skilled nursing facility stays

If you need continuing skilled nursing care after you’ve been in the hospital and meet certain conditions, Medicare covers a stay in a skilled nursing facility — but it comes with limits. Beyond 100 days in each benefit period, you’d pay the full cost unless you have additional insurance.

Some or all of these costs may be covered if you have additional insurance coverage through Medicaid, employer health benefits, long-term care insurance, or Medigap supplementary insurance. Check your policy to find out. Most Medicare Advantage plans also limit coverage to 100 days in a benefit period.

Limits on therapy services

Medicare limits the amount of coverage you can get for therapy services in any given year as an outpatient or in a hospital outpatient department or emergency room. In 2013, the limits are $1,900 for occupational therapy and $1,900 for physical therapy and speech-language pathology combined.

These dollar limits are the total cost of the services received in a year — including what Medicare pays (80 percent of the Medicare-approved amount) and what you pay (20 percent). Medicare may continue to cover these services beyond the annual limits if you have a condition that requires ongoing therapy, such as extensive rehabilitation for stroke or heart disease.

To get this exception, your therapist must justify the need when she bills Medicare. If the total cost reaches $3,700 in a year, Medicare automatically reviews your case.

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