Congress and Repeal of the Medicare Therapy Cap

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Congress and Repeal of the Medicare Therapy Cap

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Two weeks ago, the partial shutdown of the Federal Government was the culmination of long-standing disagreement between Congressional Democrats and Republicans about several key issues including: funding levels for defense and non-defense spending, the future of the Deferred Action for Childhood Arrivals (DACA) program, and funding for boarder security (including the boarder wall).  Other legislative issues were also caught up in this debate including the cap on Medicare outpatient services (also known as the “therapy cap”)*, the Children’s Health Insurance Program (CHIP), funding for Community Health Centers (FQHCs) to name a few.  While a long-term extension of CHIP was ultimately passed, these other issues (including the cap) still remain.

Last October, the three Congressional committees with responsibility for Medicare and the therapy cap (two in the House and one in the Senate) drafted a bi-partisan proposal to permanently repeal the therapy cap and replace it with a review process that would ensure therapy services were medically necessary and allow beneficiaries a guaranteed pathway to care.  The proposal was the next step after year's of lobbying by stakeholders and was aided by a report commissioned by  American Occupational Therapy Association (AOTA)  that demonstrated the average cost of therapy, per Medicare beneficiary, has decreased under a similar review process (see attached, below).

With this framework in place, AOTA, the American Physical Therapy Association (APTA), the American Speech-Language Hearing Association (ASHA), provider groups, and patient advocates were all hopeful that Congress would be able to repeal the cap once and for all by the end of 2017 (when the therapy cap was scheduled to go back into place).  However as time in 2017 was quickly running out, Congress spent the majority of time on tax reform, then passed a short-term funding for the federal government, CHIP, and FQHCs, and then went home.

Now, in February, some Medicare beneficiaries are hitting the cap and in danger of  losing access to therapy services. Congressional champions and key staff on the relevant Committees (who are essential to passing anything in Congress) remain committed to seeing the therapy cap ended once and for all.  But the when and how this will happen remain in question.

We have heard from the Speaker of the House, the House Majority Leader and others that the therapy cap will be addressed on February 8th as part of this next budget deal, but this result is far from certain. Everyday brings different intelligence about inclusion of a permanent repeal, and the larger forces that caused the last shut down are still in play.

 At AOTA we feel we are closer than we have ever been to a final repeal of the Medicare therapy cap. However, given the political climate, we are deeply concerned that those Medicare beneficiaries, who need therapy services now, will get caught up in the larger storm of current politics.  Congress needs to understand that they can’t forget about the therapy cap while they address other issues.  Dealing with the therapy cap must be a priority.  These beneficiaries must be a priority. Contact your Members of Congress now. Let them know they must #StoptheCap because #TherapyCantWait.

Other Therapy Cap Resources:

* For the past 20 years, a cap has existed on how much outpatient therapy a Medicare beneficiary can receive each year, regardless of medical necessity. Since the policy’s enactment, Congress has stopped this "hard cap" on services by implementing multiple, temporary moratorium and "exceptions processes” meaning beneficiaries have seldom been denied therapy service because of the cap.  Currently, for 2018, the therapy cap places a financial limit of $2,010 on occupational therapy services and a financial limit of $2,010 on physical therapy and speech-language pathology services combined. The therapy cap applies to all Medicare Part B providers of therapy services, except Hospital Outpatient Departments, but including Critical Access Hospitals.

Attachment: OT PT SLP - Therapy Cap Analysis - 03.10.2017.pdf
  • Today I read an article from ASHT stating that “negotiators included an offset that would reduce payment for therapy assistant (OTA and PTA) services beginning in 2022 to 85% of what is currently reimbursed.”  I am concerned that this does not really support OTAs in the long run. Couldn't this set a precedent for future regulations regarding services provided by OTAs. Did AOTA support this negotiated change? I really hope AOTA can provide some feedback so that their members (both OT and OTA) can come to informed opinions. As an OTA, I must admit that I am feeling a bit thrown under the bus. OT services, whether provided by OTs or by a collaborative OT/OTA intradisciplinary team, are of the same quality and outcome. Please explain how a discounted reimbursement rate will help OTAs in the workforce? Thank you.

  • Hi David - the provision caught us by surprise as well, we only found out it was under consideration when the large budget bill was released on Tuesday night.  No one discussed it with any of the therapy organizations and we certainly did not support it. Our current news articles on the therapy cap repeal  includes information on this and we have a separate article on the OTA provision alone.  Will link to those in the next comment (character limitations)

  • Most recent news article on therapy cap repeal: www.aota.org/.../Victory-in-Sight-Permanent-Repeal-Therapy-Cap-House-Budget-Bill-Vote.aspx

  • Article on OTA cuts: www.aota.org/.../Understanding-the-Proposal-to-Change-OTA-Payments.aspx  This was particularly disappointing given our recent victory in finally getting OTAs recognized as providers under Tricare.

  • Thanks Heather. Given this situation, what can AOTA do on behalf of OTA members? I just don't see how this is a good thing for OTAs. Will AOTA be voicing their concern? I need to trust that my professional organization is doing everything in its power to support me out there. I understand that politics involves negotiations and compromises. I just hope that AOTA will not remain silent when OTAs are being sacrificed.  In the article link you just posted, Amy Lamb states “We are in a time of changing payment systems and approaches. We must adapt in order to thrive, and at the same time challenge potentially harmful changes.”  (www.aota.org/.../Understanding-the-Proposal-to-Change-OTA-Payments.aspx)

    What does this mean? Is AOTA going to publicly "challenge" this threat?  Or is AOTA going to "adapt" by sacrificing the viability of OTAs for the sake or preserving OTs? This is a sincere question. I would really like a public response. Thank you.          

  • Hi David - to reiterate, the change in payment for OTA services is a proposal we first saw in relation to this most recent continuing resolution on Monday night.  AOTA immediately started an advocacy campaign to get the Senate to first conduct a study before implementing the cuts. We worked with APTA to propose changes to the language and let our congressional contacts know we objected to this provision. I want to be very clear that the advocacy and negotiations around the cap were NOT in any way linked to this. This is a separate proposal that was included in the continuing resolution.  

    It is clear our work  is not done. We will be fighting for how this is implemented, how the language is interpreted, how it can be prevented from damaging the future of OTAs.  We will work to protect rural or other areas that depend on OTA services.  There is a host of issues that AOTA will stand firmly behind the OTA community at one with the entire occupational therapy community. We will provide resources for you and everyone else to take action.