Benefit Bulletin: May/June 2018

Benefit Bulletin: May/June 2018

Medicare Therapy Caps: A Long Battle for Patient Access

Madison West, Legislative Assistant

Mary Katherine was 90 when a stroke left her paralyzed on one side of her body and unable to speak.  It was 1996 and at the time Medicare had a cap on physical and speech therapy services, which only allowed for a limited number of therapy sessions to help Mary Katherine regain the ability to walk, feed herself, and speak.  The paltry coverage of therapy sessions from Medicare did not provide Mary Katherine with enough time or therapy to make much of an improvement in her physical health. Mary Katherine, who received a Social Security benefit of less than $250, couldn’t afford more therapy and never recovered her speech.  She remained paralyzed for the rest of her life, which she spent as a Medicaid patient in a nursing home.

Medicare’s therapy cap on rehabilitation services, such as physical, occupational and speech therapy, has a long and sordid history in Washington D.C.  The therapy cap sought to keep the Medicare budget under control but often hurt patients who need care after traumatic medical events.  In practice, this cap limits access to Medicare - covered rehabilitation services.  Patients are faced with either footing the bill for additional expensive care out of their own pocket or purchasing additional supplementary coverage if they can afford it.

Medicare first started covering rehabilitation services in 1972.  Just seven years later in 1979, Congress enacted a cap of $500 on outpatient therapy due to concerns that rehabilitation outpatient services would take over the Medicare budget. The cap – which was indexed to medical inflation – remained in place until the passage of the “Balanced Budget Act of 1997,” when a $1,500 cap was passed into law and set to take effect in 1999. However, President Clinton halted the implementation of the $1,500 cap, leaving services open to reimbursements by Medicare. Since 1999, several bills introduced in Congress sought to either repeal or keep the spending cap on rehabilitation services, with the cap drawing bipartisan criticism as being unfair to Medicare beneficiaries.

Only twice in the history of Medicare was the therapy cap actually implemented.  In 2003, the cap was set at $1,500 until the cap was once again halted from being implemented that same year.  Then earlier this year the cap briefly went into effect again.  Congressman Erik Paulsen (MN-3) introduced the Medicare Access to Rehabilitation Services Act of 2017, a bill that would repeal the therapy cap permanently.  This bill gained the bipartisan support of 240 cosponsors in the House of Representatives and TSCL was proud to endorse and build support for this piece of legislation.

In February of 2018, Congress took action and included a permanent repeal of the Medicare therapy cap in a two-year budget deal.  The Senior Citizens League is proud to have endorsed the repeal of the therapy cap from the time such a repeal was proposed legislation in the Congress.

In order to learn more about what services you are eligible for under Medicare, call 1-800-MEDICARE (1-800-633-4227), a State Health Insurance Assistance Program counselor at your Area Agency on Aging, or your Member of Congress.

Sources:  “History of Medicare Therapy Caps;” American Physical Therapy Association. January 2016.