Many of us have loved ones who’ve heard those dreaded words “Medicare won’t approve any more physical therapy (or occupational therapy or speech therapy) for you this year” – or have been told the same thing ourselves.  Whether recovering from a stroke, heart attack, serious fall or myriad other conditions, few things are more frustrating for convalescing seniors than being informed they have hit a coverage limit in the midst of medically necessary therapy.

Congress imposed caps on outpatient therapies for Medicare Part B beneficiaries in 1997 as part of the Balanced Budget Act.  Since then, the National Committee and other Medicare advocates have been shouting from the rooftops that therapy caps are bad policy.

Realizing the hardship these caps would cause patients, subsequent Congresses enacted - and continually renewed – an exceptions process for exceeding the caps.  Under this process, beneficiaries could get coverage for therapy beyond the caps until they hit a higher threshold (currently $3700 per year), after which Medicare would manually review every claim before deciding whether to pay.  

However, the current Congress failed to extend the exceptions process, meaning that as of January 1st, all Medicare beneficiaries are subject to a hard, annual cap of $1,980 on physical therapy – and the same for occupational therapy.

In a letter to Congress, the Legislative Council of Aging Organizations (of which the National Committee is a member) says the therapy caps are random – and harmful.

“These arbitrary caps are aimed at federal cost-savings rather than providing clinically appropriate service and disproportionately impact the most vulnerable Medicare beneficiaries who require ongoing therapy services.” – LCAO letter to Congress

Christina Metzler, Chief Public Affairs Officer at the American Occupational Therapy Association (AOTA), says Congress has left the Medicare community in the lurch by failing to at least renew the exceptions process:

“Consumers and practitioners are in a very difficult spot right now.  While few people will hit the cap right away, if you have a severe injury or are just getting out of the hospital, your outpatient visits are going to start piling up.” – Christina Metzler, AOTA, 1/5/18

The Centers for Medicare and Medicaid Services (CMS) has issued zero guidance for providers or patients on how to handle the situation, opening the door for potential confusion and denial of proper care.

Ironically, there already is a bipartisan solution to this problem.  Last fall, Republicans and Democrats on key Senate and House committees agreed on a policy to make the exceptions process permanent – and less onerous for patients and providers.

As Metzler describes it, the bipartisan policy would result in:

*Elimination of therapy caps

*A nimbler process for obtaining coverage beyond cost thresholds

*Greater clarity for beneficiaries and providers

“The benefit of this approach is that there are no caps.  Instead, we’d have a new and different methodology for documenting and reviewing therapy claims. Patients would be assured of a permanent policy, and we wouldn’t be in a situation of confusion where beneficiaries and providers are in the dark.”  - Christina Metzler, AOTA, 1/5/18

The National Committee, AOTA, and other advocacy groups are calling on Congress to attach the bipartisan measure to pending legislation without delay.  Some Hill-watchers believe that reauthorization of the Children’s Health Insurance Program (CHIP) funding is the most likely vehicle.  (Congress would have to act on CHIP by January 19th before some states run out of money for children’s health insurance.)

“Anything less than a permanent fix that finally allows patients to receive medically necessary therapies without interruption or financial worry would be a disservice to everyone who relies on Medicare.” - National Committee president and CEO Max Richtman, 1/8/18