Stop Medicare Limits on Therapy, Groups Tell Congress

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By Mindy Yochelson

Medicare beneficiaries who need therapy after a stroke or for other health issues will be subject to caps or limits on their care unless Congress acts to prevent that by the end of the year.

A hold on the two therapy caps—for occupational therapy services and for physical therapy and speech-language-pathology combined—expires at the end of 2017.

Even a temporary moratorium on the limits until Congress can address the issue “would protect beneficiaries who might quickly exhaust their outpatient therapy benefit,” the two dozen groups, which make up the Therapy Cap Coalition, wrote to House and Senate leadership Dec. 15.

If enforcement of the caps begins Jan. 1, beneficiaries with high services needs could exceed them by the end of the month, Heather Parsons, chief associate officer of federal affairs for the American Occupational Therapy Association, told Bloomberg Law. Beneficiaries would then have to pay out-of-pocket, she said.

Caps Created in 1997

Congress 20 years ago created a cap or monetary limit system for outpatient therapies, except when received from a hospital outpatient department. The caps weren’t put into effect until 2006 when Congress established an exceptions process. This allows beneficiaries to be granted an exception to the caps and receive rehabilitation services deemed medically necessary.

Congress extended the exceptions process at the end of each year as part of a group of policies known as Medicare extenders that continue reimbursements for a host of providers.

But in 2015, the Medicare Access and CHIP Reauthorization Act extended the exceptions process for three years—through the end of 2017. MACRA also directed the Centers for Medicare & Medicaid Services to scrutinize exception requests through a manual medical review for claims over $3,700.

The caps remained on the books although the exception process allowed beneficiaries to continue to get services beyond the limit. Each cap will be $2,010 in 2018.

Deal Announced

In October, the bipartisan leaders of the House and Senate committees with Medicare jurisdiction announced an agreement, essentially making permanent the current system created by MACRA. The caps would be repealed but the targeted medical review threshold would be dropped from $3,700 to $3,000.

However, details on paying for the legislation and the timetable for introduction were never finalized.

The American Physical Therapy Association hasn’t seen the official score but has heard that repeal of the caps would cost $10 billion to $12 billion over 10 years, Michael Matlack, director of congressional affairs, told Bloomberg Law.

The therapy limit deal was one of several in a draft extenders package announced by the House Ways and Means Committee in November. Nothing further on the legislation has been revealed.

The committee didn’t respond to a request for comments.

Limited Timing

Tax reform “has sucked all the oxygen out” of other legislative endeavors, Matlack said. There’s very limited time until lawmakers leave for the year to consider a continuing resolution that could include the extenders, he said.

Even if the caps go into effect for just a few weeks in January, it would be difficult for therapists to ensure that their patients won’t receive an interruption of care, he said.

That’s why if offsets for a permanent repeal aren’t agreed upon by the end of the year, the coalition would at least want to see a short-term hold on the caps, Parsons said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

For More Information

The coalition letter is at

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