Therapy cap
Encyclopedia
In 1997 Congress established per-person Medicare
spending limits, or therapy cap for nonhospital outpatient therapy, but responding to concerns that some people with Medicare need extensive services, it has since placed temporary moratoriums on the caps. The therapy cap is a combined $1,810 (USD) Medicare cap for physical therapy and speech language pathology, and a separate $1,810 cap for occupational therapy.
Medicare patients requiring rehabilitation from disabilities, car accidents, hip injuries, stroke, and other ailments would be limited to roughly two months worth of treatments at an outpatient therapy clinic. Any patients that exceed the cap, whether they are healed or not, would have to stop therapy, or pay for the therapy services out of their own pocket.
. Its purpose and effective result was to reduce Medicare spending by limiting outpatient therapy payments.
The original cap was $1,500 (USD). The effective date of the original $1,500 cap was January 1, 1999; however, there were several legal challenges to the therapy cap that temporarily halted its implementation. The moratorium was further extended by the passage of Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999
and Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.
In December 2006, Congress passed the Tax Relief and Health Care Act of 2006
which provided exemptions for the therapy cap and allowed patients with Parkinson's disease
and muscuskeletal disorders to continue treatments until the end of 2007.
Patients are able to received a waiver to cover services above the capped amount if their treatment is medically necessary. This waiver program expires June 30, 2008, however it is likely Congress will extend the program, as it has done in the past.
UPDATE: The Medicare Therapy Cap is $1870 for 2011.
and American Occupational Therapy Association have lobbied against therapy caps because the bill inadvertently restricted disabled seniors, stroke patients, and other severe cases from receiving therapy treatments.
Another controversy is the original bill combined physical therapy and speech therapy together allowing only a shared $1810 per calendar year for both therapy services. This was the result of the original bill not properly using commas. This error has yet to be corrected by congress, further limiting therapy services to outpatients.
have concluded through an independent study that the therapy caps are not meeting the needs of patients.
The Study and Report on Outpatient Therapy Utilization by the Centers for Medicare and Medicaid Services (CMS) released on September 2002 concluded that older patients require more therapy than what the cap allowed: “patients who are female, older, minorities, live in certain geographic regions, require the services of institutional providers and suffer from complex medical conditions are more likely to require more costly outpatient therapy services than the general outpatient therapy population.”
The American Heart Association
concluded that the Medicare caps are costing the government more money in the long run, especially to stroke patients. According to their study, arbitrary caps on rehabilitation therapies punish stroke patients who often undergo needed extensive rehabilitation programs. More than 5.4 million Americans, including 4.4 million people with Medicare, are living with the consequences of stroke. The failure to properly treat and rehabilitate stroke patients costs $21.8 billion annually in lost productivity and disability expenses.
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
spending limits, or therapy cap for nonhospital outpatient therapy, but responding to concerns that some people with Medicare need extensive services, it has since placed temporary moratoriums on the caps. The therapy cap is a combined $1,810 (USD) Medicare cap for physical therapy and speech language pathology, and a separate $1,810 cap for occupational therapy.
Medicare patients requiring rehabilitation from disabilities, car accidents, hip injuries, stroke, and other ailments would be limited to roughly two months worth of treatments at an outpatient therapy clinic. Any patients that exceed the cap, whether they are healed or not, would have to stop therapy, or pay for the therapy services out of their own pocket.
Purpose and History of Therapy Cap
The therapy cap was originally passed with the Balanced Budget Act of 1997Balanced Budget Act of 1997
The Balanced Budget Act of 1997, , was signed into law on August 5, 1997. It was an omnibus legislative package enacted using the budget reconciliation process and designed to balance the federal budget by 2002....
. Its purpose and effective result was to reduce Medicare spending by limiting outpatient therapy payments.
The original cap was $1,500 (USD). The effective date of the original $1,500 cap was January 1, 1999; however, there were several legal challenges to the therapy cap that temporarily halted its implementation. The moratorium was further extended by the passage of Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999
The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 is a federal law of the United States, enacted in 1999. The BBRA was first introduced into the House as H.R. 3075 on October 14, 1999 by Rep. William M. Thomas with 75 cosponsors...
and Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.
In December 2006, Congress passed the Tax Relief and Health Care Act of 2006
Tax Relief and Health Care Act of 2006
The Tax Relief and Health Care Act of 2006 , includes a package of tax extenders, provisions affecting health savings accounts and other provisions in the United States.-Extenders:...
which provided exemptions for the therapy cap and allowed patients with Parkinson's disease
Parkinson's disease
Parkinson's disease is a degenerative disorder of the central nervous system...
and muscuskeletal disorders to continue treatments until the end of 2007.
Patients are able to received a waiver to cover services above the capped amount if their treatment is medically necessary. This waiver program expires June 30, 2008, however it is likely Congress will extend the program, as it has done in the past.
UPDATE: The Medicare Therapy Cap is $1870 for 2011.
Controversy
Several medical associations and organizations including the American Physical Therapy AssociationAmerican Physical Therapy Association
A Historical PerspectivePhysical therapists formed their first professional association in 1921, called the American Women's Physical Therapeutic Association. Led by President Mary McMillan, an executive committee of elected officers governed the Association, which included 274 charter members...
and American Occupational Therapy Association have lobbied against therapy caps because the bill inadvertently restricted disabled seniors, stroke patients, and other severe cases from receiving therapy treatments.
Another controversy is the original bill combined physical therapy and speech therapy together allowing only a shared $1810 per calendar year for both therapy services. This was the result of the original bill not properly using commas. This error has yet to be corrected by congress, further limiting therapy services to outpatients.
Studies
The Government Accountability OfficeGovernment Accountability Office
The Government Accountability Office is the audit, evaluation, and investigative arm of the United States Congress. It is located in the legislative branch of the United States government.-History:...
have concluded through an independent study that the therapy caps are not meeting the needs of patients.
The Study and Report on Outpatient Therapy Utilization by the Centers for Medicare and Medicaid Services (CMS) released on September 2002 concluded that older patients require more therapy than what the cap allowed: “patients who are female, older, minorities, live in certain geographic regions, require the services of institutional providers and suffer from complex medical conditions are more likely to require more costly outpatient therapy services than the general outpatient therapy population.”
The American Heart Association
American Heart Association
The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas...
concluded that the Medicare caps are costing the government more money in the long run, especially to stroke patients. According to their study, arbitrary caps on rehabilitation therapies punish stroke patients who often undergo needed extensive rehabilitation programs. More than 5.4 million Americans, including 4.4 million people with Medicare, are living with the consequences of stroke. The failure to properly treat and rehabilitate stroke patients costs $21.8 billion annually in lost productivity and disability expenses.