Now that the exceptions process for Medicare’s therapy cap has expired, therapy patients and providers are wondering what’s next. Medicare’s annual maximum allowance for outpatient rehab is absurdly low. A patient receiving both physical and speech therapy can reach the limit in just one month.
Background
In 1997, Medicare instituted a cap on how much they’d pay for outpatient rehabilitation services per year. Until December 31, 2017, the law included a 2-tiered exceptions process to allow more coverage if Medicare found the services “reasonable and necessary.” As of today, Congress has not extended the exceptions process, nor have they repealed the cap altogether. This could theoretically cost patients thousands of dollars in out-of-pocket therapy costs over 2018.
What you should know
Earlier this week, CMS announced that it is holding medically necessary claims exceeding the cap for 20 days. They are not denying such claims outright, in the hopes that something will change in the meantime. If Congress takes no action, the cap will become a “hard cap” — and patients will be responsible for all outpatient therapy above the limit for the rest of the year.
Keep in mind that if you are receiving sub-acute care under Medicare Part A, the cap does not apply. Your inpatient rehabilitation stay covers your required therapies as part of your treatment plan.
If you think the therapy cap may affect you, speak with your therapist to find out more.
