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 Government Open, but Therapy Caps Await Further Congressional Action

Much remains unsettled for the long term and post-acute care (LT/PAC) profession in terms of when and if Congress takes action on therapy caps. Even as the Senate and House reached a deal on Jan. 22 to keep the federal government open until a new Feb. 8 deadline for a budget plan to be in place, that legislation did not include a measure supported by LT/PAC providers to eliminate therapy caps.

Medicare extenders, the measures that address therapy caps, may however be included in a longer-term budget deal required by the new deadline set to expire in three weeks, LT/PAC industry sources say. In the past, Congress has retroactively permitted the Centers for Medicare & Medicaid Services (CMS) to pay providers for therapy services that exceed the cap threshold, they add.

The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) is urging lawmakers to enact a permanent repeal of the caps, and concurrently is seeking answers from CMS on how providers should manage therapy caps since they have been active from Jan. 1, 2018.

For skilled nursing facilities (SNFs), the fact caps being are in place is a major issue. Long-stay SNF residents in the Medicare program often have mobility deficits and multiple chronic conditions. This typically puts them at higher risk for further deterioration without skilled therapy services to restore or maintain function in areas like mobility, self-care, swallowing, and communication.

Many residents with these chronic conditions could hit their annual cap limits within weeks of starting therapy. An AHCA analysis of Medicare claims from 2015 indicate that 286,000 (37 percent) of the association’s residents receiving physical therapy (PT)/speech-language pathology (SLP) services surpass the cap, while 161,000 (31 percent) surpass the occupational therapy (OT) cap.

Without Congressional action on eliminating therapy caps, SNF residents who require extensive therapy will see efforts to restore or maintain their function and quality of life endangered, AHCA 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.

Since Jan. 1, 2018, Medicare will only cover $2,010 of PT/SLP services combined, and $2,010 of OT services per year. 
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