Medicare Therapy Cap

By Kayla Caudle, Natalie Saber, & McKayla Burgess

For the past 20 years, due to wording in the Medicare portion of the Social Security Act, a Medicare cap has existed in the law. This cap would place a limit on how much an individual can be reimbursed for therapy each year.  The Medicare cap, however, has not been implemented since 1999 thanks to Congress making exemptions and placing moratoria on the cap.  The Medicare therapy cap is now a real danger, however, because the time limit on those exemptions have run out.  For 2017, the cap is $1,980 for speech-language pathology and physical therapy services, combined.  Even if medical professionals deem the services necessary, the therapy cap is still in place.  Ultimately, this cap could potentially prevent those who desperately need therapy from receiving services.  For example, individuals who have suffered a life-altering diagnosis, such as stroke, Alzheimer’s, or Parkinson’s disease may be denied therapy, or forced to pay out of pocket for services to regain their ability to communicate. Up until now, Congress has stopped this therapy cap by implementing temporary moratoria and exceptions processes.  In April of 2015, Congress passed the Medicare Access and Chip Reauthorization Act, which President Obama later signed into law.  This allowed exceptions to the therapy caps for medically necessary services, and individuals who required therapy services were able to receive it.  This was not a permanent fix, but is in effect until December 31st, 2017.  The Medicare Access to Rehabilitation Services Act of 2017 looks to permanently repeal the therapy cap by amending the Social Security Act.  Congress passing this act would mean that individuals who need therapy services would have access to them.  Since the cap has been stopped every year up until now, repealing this portion of the Social Security Cap would not come at any additional cost to the American people, but it would ensure them the services they need.

In 1972 a bill was passed in congress to include outpatient therapy services in Medicare coverage. Fast forward to 1997 when congress passed the Balanced Budget Act of 1997; this was the bill that introduced the $1500 outpatient therapy cap that is still in law to this day (though the cap has increased a bit), however, as of right now it is not in effect. The therapy cap actually did go into effect for a short period of time from January to November 1999. Congress saw that the cap was not effective, so they instituted a two year moratorium on the therapy cap to prevent it from going into effect. After that moratoriums and exceptions were passed every time the previous ones expired, but the cap was never repealed. Some people might wonder, “What if the cap is never repealed, and a moratorium or exception runs out and congress does not pass another one?” This actually did occur in 2002. For months people fought against the cap going into effect, but in 2003 the cap finally went fully into effect. The cap was only in effect from September to December 2003, so it did not get a chance to do much damage before another moratorium was passed. Lawmakers have attempted to repeal the cap, but with no luck so far.

​Most recently in 2015, an effort to repeal the cap was almost successful, but failed by two votes. Exceptions were extended until December 31st of this year, though. If the cap is not repealed by this date, or another moratorium not put into place, the cap will go into effect. There is a bill currently in congress to repeal the cap, as mentioned above, that is still gaining support.
 
Repealing the Medicare outpatient therapy cap is a vital piece of legislation that impacts the quality of healthcare. For 2017, Medicare has allotted only $1,980 worth of therapeutic services for speech-language pathology services and physical therapy services combined (ASHA, 2017). Not only does this fiscal limitation prove to be insufficient for our many severe patients suffering from speech, language, and swallowing/feeding deficits, it also does not take into account the severity of these diagnoses or the co-existing medical conditions of the patients, forcing them to continue to split their minute amount of fiscal resources allotted for their recovery between physical therapy and speech therapy. This cap may result in the premature termination of treatment for many patients when they are unable to pay out of pocket for the services that they need and deserve access to, hindering the recovery of a multitude of patients seeking the services of speech-language pathologists. It is the mission of healthcare providers to ensure quality and sufficient treatment to those in need, and it is the ethical responsibility of our government to ensure that these patients are provided with fair and adequate access to the medical services they are in need of.