Cap on Medicare Outpatient Therapy Services Returned January 1; No Exceptions Process

January 2, 2018

ASHA members who provide outpatient therapy services to Medicare beneficiaries should track claims closely this month. The Medicare Part B outpatient therapy cap exceptions process expired at the end of 2017. A hard cap of $2,010 for combined physical therapy and speech-language pathology services went into effect on January 1, 2018. Without an exceptions process, Medicare beneficiaries who exceed the $2,010 therapy cap will be required to stop therapy or pay for continued services out-of-pocket. Hospital Outpatient Departments (HOPDs) are exempt from the cap, which will serve as a safety net provider for Medicare beneficiaries to continue to receive medically necessary therapy services above the cap. 

Background

Since Congress did not address the therapy cap before adjourning for the year, the hard cap was implemented on January 1, 2018. Annual dollar limits reset at the beginning of each year; therefore, the hard cap should have little impact on Medicare beneficiaries in the initial weeks of 2018. However, the cap becomes problematic for those receiving both physical therapy and speech-language pathology services early in the year. 

Congress is expected to consider the repeal of the therapy caps by January 19, 2018, as part of a larger budget process. ASHA is working with Congress and the Centers for Medicare & Medicaid Services to press for action on the cap. Congress applied the therapy cap and exemptions to HOPDs in 2012 for more consistent application of the manual medical review process to all claims exceeding $3,700, but that application was time limited to the duration of the exceptions process. The exemption of HOPDs returned January 1, 2018. 

More details will be available from ASHA as the situation evolves.

Questions?

Please contact Sarah Warren, ASHA’s director of health care regulatory advocacy, at swarren@asha.org.  


ASHA Corporate Partners