Editorial: Congress Must Extend
Exceptions to Medicare Therapy Cap

 

Effective January 1, 2010, people with Medicare face a $1,860 cap on the amount of physical and speech therapy they can receive during the year, as well as a separate $1,860 cap on occupational therapy. The cap does not extend to services provided in hospitals. Settings impacted by the therapy caps include private practice, rehabilitation agencies, skilled nursing facilities, comprehensive outpatient rehabilitation facilities, physician offices, and Part B home health agency services.

The therapy caps limit treatment for older adults and people with disabilities who need extensive therapy as they recover from a stroke or other acute episode, or suffer from chronic conditions such as Parkinson’s disease or multiple sclerosis.

Both the House and Senate health reform bills would have extended an exceptions policy that allows Medicare to pay for medically necessary therapy above the $1,860 cap. But with health reform stalled—at least temporarily—it is urgent for Congress to find another legislative vehicle to pass an extension of the exceptions policy. Without prompt action by Congress, people who need extensive therapy may soon see their therapy interrupted, resulting in real harm to their ability to function or recover from an injury.

Most members of Congress are aware of the urgency of acting now to prevent a 21 percent Medicare pay cut to doctors from taking effect on March 1. The therapy cap issue, however, has received relatively little attention.

Background

The therapy caps were imposed by the Balanced Budget Act of 1997. However, the Deficit Reduction Act of 2005 directed CMS to create a clinically-based exception process to the therapy caps for expenses incurred during calendar year (CY) 2006. Since 2006, Congress has repeatedly extended the exception process.  Most recently, the Medicare Improvements for Patients and Providers Act of 2008 extended the exception process through December 31, 2009.  Unless Congress repeals the therapy caps or further extends the exception process, the therapy caps (without the exception process) take effect on January 1, 2010.

The Senate health care reform bill, titled the Patient Protection and Affordable Care Act, would apparently extend the exceptions process through December 31, 2010. In contrast, the House health care reform bill, titled the Affordable Health Care for America Act (H.R.3962), appears that it would extend the exceptions process through December 31, 2011.

-From “Congress Must Extend Exceptions to Medicare Therapy Cap”, Asclepios, February 4, 2010 • Volume 10, Issue 5, Medicare Rights Center Advocacy, February 04, 2010 . Additional information from American Speech-Language-Hearing Association http://www.asha.org/advocacy/federal/cap/, retrieved 2/5/10

2/10