Congress DID Repeal Outpatient Therapy Caps Despite Lack of Information on Medicare.gov

The Bipartisan Budget Act of 2018 became law on February 9, 2018. The Act repealed the Medicare outpatient therapy caps, which functioned as a barrier to care for those receiving outpatient therapy services. Section 50202 of the Act, “Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy,” states that the repeal of the therapy caps is retroactive.[1] This means that therapy caps have been removed for all physical therapy, occupational therapy, and speech-language pathology services provided “after December 31, 2017.”[2]

To date, the Centers for Medicare & Medicaid Services (CMS) has not updated the relevant CMS.Gov or Medicare.Gov webpages to account for the repeal of outpatient therapy caps. However, CMS did issue a special edition Medicare Learning Network (MLN) Connects newsletter to highlight the key aspects of the Act dealing with the repeal. The newsletter emphasizes that “Medicare claims are no longer subject to the therapy caps (one for occupational therapy services and another for physical therapy and speech-language pathology combined).”[3]

Thus, Medicare beneficiaries and providers are no longer required to seek additional coverage beyond a set dollar amount through the former “exceptions process.” However, claims above the former cap threshold must still “include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.” [4]

Together with the Settlement Agreement in Jimmo v. Sebelius, No. 11-cv-17 (D. VT), Medicare beneficiaries should now be able to continue receiving outpatient therapy to improve or maintain their current conditions, or to slow or prevent the further deterioration of their conditions, without having to overcome arbitrary payment caps as barriers to care.

• To read the Bipartisan Budget Act of 2018, please visit: https://www.gpo.gov/fdsys/pkg/BILLS-115hr1892enr/pdf/BILLS-115hr1892enr.pdf
• To read CMS’s Medicare Learning Network Connects newsletter, please visit: https://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers/Downloads/Medicare-Expired-Legislative-Provisions-Extended.pdf
• To read the Center for Medicare Advocacy’s Self-Help Packet for Outpatient Therapy Denials, Including “Improvement Standard” Denials, please visit: https://www.medicareadvocacy.org/self-help-packet-for-outpatient-therapy-denials/
• For more information on the Jimmo Settlement Agreement, please visit: https://www.medicareadvocacy.org/medicare-info/improvement-standard/

Medicare beneficiaries who are told they cannot continue therapy because they have reached a therapy cap should direct their physicians and therapists, or any Medicare contractors reviewing their claim, to the repeal language in the Bipartisan Budget Act of 2018 and the MLN Connects newsletter.  

D. Valanejad, March 1, 2018