PERFORMAX Physical Therapy

Patient Name: ______________________________ Date Notice Given: ____________

2010 EXPLANATION OF MEDICARE BENEFITS

for Physical/Speech Therapy or Occupational Therapy

Per Section 4541 (c) of the Balance Budget Act (BBA), Medicare has an annual limit for all outpatient
rehabilitation services (with the exception of outpatient departments of a hospital). The annual limit for
Physical Therapy & Speech-Lanuage Therapy [combined] or Occupational Therapy is $1860/each. If a
Medicare patient has already paid their annual $155 Medicare Part B deductible, the maximum amount
payable for Physical/Speech Therapy or Occupational Therapy by Medicare is $1,488 (80% of $1860).

If you have not met your Medicare deductible, you will be responsible for paying the
deductible ($155) PLUS the 20% Medicare co-insurance ($372 [20% of $1860] personally, or
by other insurance benefits you may have.

Patients are responsible for knowing their Medicare and private insurance benefits. Performax Physical
therapy does not verify Medicare secondary insurance benefits.

THERE ARE NO EXEMPTIONS TO THE $1860 CAP EFFECTIVE 1/1/2010. (May be subject to change)
We will try to inform you when you are close to reaching your Medicare cap. However, you are responsible
for 100% of the costs of therapy services above the therapy limit of $1,860 for either Physical/Speech
Therapy or Occupational Therapy. We are required by law to bill Medicare for all services on a given date of
service even if some of the charges might exceed the $1,860 limit. If you choose to continue treatment after
exhausting your Medicare benefits, you will be asked to sign the Medicare Advanced Beneficiary Notice
(ABN) form stating that you understand you are receiving service for which Medicare will not pay. If
necessary, appropriate care above the $1,860 limit can be obtained at a hospital outpatient therapy
department.
o Medicare does not pay for all of your health care costs. Some of the items/services Medicare does
not pay are: Iontophoresis, orthotics, canes or walkers, gym balls, splints, wellness classes, etc.
o You will be notified in advance of the items/services Medicare does not pay for. If you agree to receive
an item or service Medicare does not pay, you will be personally responsible for payment.

As with other denial of benefit determinations, you (the beneficiary) can appeal Medicare’s denial of benefits
as set forth in 42 CFR Part 405, Sub-part G.

Additional Medicare beneficiary information can be obtained by calling 1-800-MEDICARE and/or by visiting
www.trailblazerhealth.com.

1. Are you currently receiving therapy or help in your home (such as bathing, cooking, nursing)? ____________
2. Have you recently been discharged from a home health program? __________ Date of Discharge __________
3. Have you had PT or OT at another clinic this calendar year? ____ If yes, name of clinic: _________________
4. Have you had Speech/Language therapy this calendar year? _____ If yes, name of clinic: _________________
5. Medicare will not cover maintenance/wellness services, even if ordered by your physician ________ (INITIAL)

In order to process your claims, Medicare requires us to fax a Plan of Care to your physician every 10 visits (or 30 days)
for his or her signature and return. Medicare does not accept a prescription for physical or occupational therapy as a
plan of care. If your physician fails to sign and return your Plan of Care after two attempts on our part, we will ask for
your assistance. If we still do not receive your physician-signed Plan of Care, Medicare can deny your claim, forcing us
to transfer your account to self-pay.

Patient’s Signature:____________________________________ Date:_____________

(Authorized Signature)
REV 12/09