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 December 2013, Congress passed, and the president signed, a three-month extension of the therapy caps exceptions process.
In years past, Congress has passed year-long extensions of the exceptions process. However, this year is different – for the first time, there is significant movement in Congress to remove the therapy caps altogether. There is currently a bill in the Senate that would repeal the therapy caps and replace them with a system that would allow for more targeted reviews of therapy use instead of the current arbitrary monetary caps. Because Congress did not have time to pass the full repeal before the expiration of the exceptions process, they passed the three-month extension to allow for more time for agreement in the New Year. Click here for more information on Medicare therapy caps repeal .
PAN is thrilled that a permanent repeal of the Medicare therapy caps could be within reach for the first time in nearly 20 years. In addition to working with Congress on their latest therapy caps proposal, PAN also endorsed the Medicare Access to Rehabilitation Services Act of 2013  (H.R. 713/S. 367), which would remove the caps altogether. We are committed to making access to medically necessary physical, occupational, and speech-language therapy a reality for people with Parkinson’s.