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 Fate of Therapy Caps Awaits Congressional Action

The long term and post-acute care (LT/PAC) profession is taking a two-pronged approach as it awaits congressional action on therapy caps, industry sources tell Provider.

With the significant reimbursement issue in a state of limbo for the beginning of the new year, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) is urging lawmakers to enact a permanent repeal of the caps. At the same time, AHCA/NCAL is asking for federal regulatory guidance from the Centers for Medicare & Medicaid Services (CMS) for providers on what they should do on therapy caps since they are again in place from the start of 2018.

These sources say providers also should keep on the lookout for formal guidance from CMS and their Medicare Administrative Contractors on how to provide Medicare beneficiary notifications and submit claims while the therapy caps are in place.

Elimination of therapy caps has strong bipartisan support, with Republicans and Democrats in the appropriate House and Senate committees having agreed to a policy that would permanently repeal therapy caps. What is lacking right now is the legislative vehicle to put the policy in place, as well as a funding solution. While there is discussion the therapy cap repeal could be placed in must-do funding bills in January, or separate possible measures in February or March, there is no guarantee that will occur.

What is apparent, says Dan Ciolek, AHCA/NCAL associate vice president, therapy advocacy, is that without prompt congressional action hundreds of thousands of Medicare beneficiaries, including residents of skilled nursing and assisted living residences, will be hurt by the cap on their therapy services.

“Fortunately the caps only apply for services provided after Jan. 1, so care received in December and November don’t count, for instance,” says Ciolek. But without congressional action in the first part of the year, beneficiaries could start to hit cap levels as early as the end of January.

“As the year goes on, the number of people affected will grow significantly, and this also has financial and billing implications for providers on what they must do to inform beneficiaries and how to bill. None of those details has been released from CMS despite repeated contacts from AHCA and other organizations,” Ciolek says.

For skilled nursing facilities (SNFs) and assisted living residences (ALRs), the implications of the caps being in place are significant. Medicare beneficiaries that are long-stay SNF or ALR residents typically have mobility deficits and multiple chronic conditions. This often puts them at higher risk for further deterioration without periodic skilled therapy services to restore or maintain function in domains such as mobility, self-care, swallowing, and communication.

This means that many residents with complex and chronic conditions may reach their annual cap limits within weeks of starting therapy. For instance, an AHCA analysis of Medicare claims from 2015 indicates that 286,000 (37 percent) of beneficiaries receiving SNF physical therapy (PT)/speech-language pathology (SLP) services surpass the cap, while 161,000 (31 percent) surpass the occupational therapy (OT) cap.

Without congressional relief, the impact of the caps would be physically and financially devastating to those SNF residents who require extensive therapy to restore or maintain their function and quality of life, Ciolek says.

Therapy caps were first implemented in 1999 to limit the amount of PT, OT, and SLP services Medicare Part B would cover per year. Since 2006, an exceptions process was enacted allowing for medically necessary therapy services above the cap amounts; however, due to congressional inaction, the exceptions process provisions have ended.

Starting Jan. 1, 2018 (or until Congress acts), Medicare will only cover $2,010 of PT/SLP services combined and $2,010 of OT services per year. A Senate bill to repeal the caps (S 253) is currently co-sponsored by more than one-third (37) of senators, while a House bill (HR 807) is co-sponsored by a majority (229) of representatives.

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