Access to Therapy Services Threatened if Congress Fails to Act

Heather Parsons

On January 1st, 2018, a cap on Medicare outpatient therapy services will go into effect if Congress fails to act. Absent Congressional action, no beneficiary will be able to receive Medicare Part B therapy services once they reach a cap of $2,010 for occupational therapy services and a cap of $2,010 for physical therapy and speech language pathology services combined.

We need your help! Tell Congress they must act now to protect access to therapy services. Please call your elected representatives today and tell them to stop the therapy cap once and for all.

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At the end of October, the three Congressional Committees with jurisdiction over Medicare outpatient therapy service released a bi-partisan framework to repeal the therapy cap once and for all. With the cap repealed, this framework would put into place measures to assure appropriate utilization, including the use of the KX modifier to certify medical necessity and a continuation of the current system of targeted review of claims over a $3,000 threshold. This framework achieves multiple goals: (1) ensuring access to necessary therapy services for all beneficiaries, (2) providing appropriate oversight of therapy utilization, and (3) ending the threat of a hard cap on therapy services forever. But Congress needs to take the step of passing this framework into law.

The cap on Part B therapy services was put into place 20 years ago in the Balanced Budget Act of 1997. Since that time, Congress has rarely let the cap go into effect, passing moratoria (a temporary “pause” on the cap) or a temporary exceptions process (which allows a pathway to care). But at the end of each of these patches, Congress has had to act to once again keep the cap from going into place.

The current patch expires on December 31, 2017. At that time more than a million beneficiaries are at risk of losing access to outpatient Medicare therapy services. While roughly 15% of Medicare beneficiaries received therapy services over the cap in 2015, more than 50% of spending of Part B services occurred over the cap. The beneficiaries who need these services represent the most vulnerable people receiving Medicare, including those who have had a stroke or have conditions such as Parkinson’s disease, multiple sclerosis, or ALS.

Read the letter from the Therapy Cap Coalition to Congressional Leadership, calling on them to act before the end of the year.