Home Advocacy Act Now to Fix Medicare Therapy Caps on Your Services

Act Now to Fix Medicare Therapy Caps on Your Services

by Jeffrey Regan
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Medicare Part B written on piece of paper on top of stack of $100 bills

 As of Jan. 1, Medicare Part B recipients may receive no more than $2,010 in combined physical and speech-language therapy services in 2018, with no exceptions process in place for medically necessary services.

Congress failed to take action before adjourning last year on repealing or replacing therapy caps—the statutory ceiling on how much outpatient occupational, physical and speech-language therapy each beneficiary is allowed per year. For the past 20 years, a moratorium or an exceptions process has allowed speech-language pathologists to provide medically necessary services above the cap by using the –KX modifier on claim forms.

Hospital outpatient departments are exempt from the hard cap, but speech-language pathology services provided in all other outpatient settings are included. To receive services beyond the cap, Medicare beneficiaries may seek care in hospital outpatient departments, or pay out-of-pocket for additional medically necessary care. However, there is no guarantee that Congress will decide to cover those services retroactively when it deals with the therapy caps, as it has in previous years.

ASHA is urging Congress to address the therapy caps as soon as possible, and supports a bipartisan and bicameral policy agreement struck last year to repeal the therapy caps permanently. This agreement would provide stability to the delivery of all therapy services and ensure that Medicare beneficiaries have access to the care they need.

The therapy caps, along with other Medicare provisions, are in political limbo as Congress works to develop a longer-term solution to fund the federal government in 2018. The resolution that funds the federal government expires Jan. 19, and congressional leaders have indicated a desire to attach therapy cap legislation to a long-term spending bill. ASHA supports attaching therapy cap legislation to a long-term spending bill, or passing it separately with other Medicare provisions that Congress would act on as soon as possible.

ASHA has also asked the Centers for Medicare and Medicaid Services (CMS) to publish guidance for providers. CMS has regulatory mechanisms that could temporarily mitigate or lessen the impact of a hard cap. For example, CMS could delay processing claims for two or three weeks while Congress seeks to pass a long-term solution. ASHA will inform members of any guidance that CMS may release.

ASHA needs your voice on the therapy caps! Please consider taking action today to contact your elected officials, and request that they actively support fixing the therapy caps under Medicare Part B as soon as possible. Thank you for your advocacy.

Jeffrey P. Regan, MA, is ASHA’s director of government relations and public policy. jregan@asha.org

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Tracie East January 18, 2018 - 3:11 pm

Where are you finding that outpatient hospital based rehab is exempt? I’m not finding there clearly spelled out anywhere.

Jeffrey Regan January 19, 2018 - 10:10 am

Posted by Shelley D. Hutchins on behalf of Jeffrey Regan:

Hi, Tracie:

Thank you for your note, and the question: where are you finding that outpatient hospital based rehab is exempt? I’m not finding there clearly spelled out anywhere.

Hospital outpatient departments or clinics were not originally included under the therapy cap when it was first enacted into law in 1997 as part of the Balanced Budget Act. Given that Congress failed to repeal the hard cap at the end of December 31, 2017, or create/extend any new exceptions process, the hard cap is in place as originally written in 1997.

CMS has also detailed the outpatient hospital department exemption on their website here:

These are the Part B outpatient therapy settings and providers to which the hard cap applies:
• Speech-language-pathologist private practices
• Offices of physicians and certain non-physician practitioners
• Part B skilled nursing facilities
• Home health agencies (visits provided on an outpatient basis)
• Rehabilitation agencies (also known as outpatient rehabilitation facilities)
• Comprehensive outpatient rehabilitation facilities
• Critical access hospitals (CAHs)
I have copied my Medicare policy colleague, Sarah Warren, on this response. Please reach out to Sarah if you have any additional questions.

Thank you!

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