Medicare Therapy Caps
What are the Medicare Therapy Caps?
The Balanced Budget Act of 1997 created limits, or caps, on the amount of outpatient physical (PT), occupational (OT), and speech-language therapy (SLT) a Medicare beneficiary can receive each calendar year. Beginning in 1997, Congress voted several times to keep the caps from going into effect. However, on January 1, 2006, Congress allowed the therapy caps to take effect. The caps for 2014 are $1,920 – one cap for PT/SLT combined and a separate cap for OT - and once it is reached, beneficiaries who require additional services in the calendar year are responsible for 100% of the cost. In addition to the caps, a manual medical review is required once a beneficiary hits $3,700 (for PT/SLT combined and OT). For more information on manual medical review, click here.
Exceptions to the Medicare Therapy Caps
To mitigate the impact of the therapy caps on Medicare beneficiaries who need therapy services beyond the cap, in 2006, Congress created an exceptions process for services deemed medically necessary. Unfortunately, the exceptions process is temporary and must be reauthorized by Congress every year. In March 2014, Congress passed, and the president signed, a one-year extension of the therapy caps exceptions process.
This year, for the first time, there was significant movement in Congress to remove the therapy caps altogether. While it is disappointing Congress could not come to an agreement to permanently repeal the therapy caps this year, PAN will continue to push for a permanent repeal of the therapy caps as we believe it is the best way to ensure people with Parkinson’s have access to medically necessary physical, occupational, and speech-language therapy services.
- PAN One-Pager on Medicare Therapy Caps (Also includes information about the Improvement Standard)
- Medicare Therapy Resource to Share with Your Physical Therapist and Other Providers
- Medicare Therapy Caps: What You Need to Know
- Frequently Asked Questions: Outpatient Therapy Claims
- Webinar: Medicare Coverage of Therapy Services
- Take Action
- Affordable Care Act
- Congressional Caucus
- Data Collection on PD
- Department of Defense
- Food and Drug Administration
- National Institutes of Health
- Social Security Disability
- Veterans Affairs
- Other Initiatives