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. firstname.lastname@example.org