• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer
  • Donate Now
  • Sign Up

Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

  • Eligibility/Enrollment
  • Coverage/Appeals
    • Medicare Costs (2020 & 2021)
    • Self Help Materials – Toolkits & More
  • Topics
    • Basic Introduction to Medicare
    • COVID-19 and Medicare
    • Medicare Costs (2020 & 2021)
    • Home Health Care
    • Improvement Standard and Jimmo News
    • Nursing Home / Skilled Nursing Facility Care
    • Outpatient Observation Status
    • Part B
    • Part D / Prescription Drug Benefits
    • Medicare for People Under 65
    • Medicare “Reform”
    • All Other Topics
    • Resources
      • Infographics
  • Publications
    • CMA Alerts
    • Fact Sheets & Issue Briefs
    • Infographics
    • The Medicare Handbook
    • SNF Enforcement Newsletter
    • Elder Justice Newsletter
    • Medicare Facts & Fiction
    • Articles by Topic
  • Litigation
    • Litigation News
    • Cases
    • Litigation Archive
    • Amicus Curiae Activities
  • Newsroom
    • Press Releases
    • Editorials & Letters to the Editor
    • CMA Comments, Responses, and Letters
    • Medicare Facts & Fiction
    • CMA in the News
  • About Us
    • Mission Statement
    • CMA FAQs
    • Personnel & Boards
    • The Center for Medicare Advocacy Founder’s Circle
    • Connecticut Dually Eligible Appeals Project
    • Ossen Medicare Outreach, Education and Advocacy Project
    • National Medicare Advocates Alliance
    • National Voices of Medicare Summit
    • CMA Webinars
    • Products & Services
    • Testimonials
    • Career, Fellowship & Internship Opportunities
    • Contact Us
  • Support Our Work
    • Donate Now
    • Join the Center for Medicare Advocacy Founder’s Circle
    • Take Action
    • Share Your Health Care Story
    • Tell Congress to Protect Our Care
    • Listen to Medicare & Health Care Stories
    • Sign Up

Congress Repeals Medicare Outpatient Therapy Caps, Strengthening the Jimmo Settlement Agreement

February 14, 2018

Print Friendly, PDF & Email

On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law by the President. The budget act includes a “health extenders” package that, among other changes, permanently repeals annual Medicare payment limits (or caps) on outpatient physical, speech, and occupational therapy services.[1] Pursuant to the Balanced Budget Act of 1997, Medicare Part B outpatient therapy has been subject to payment caps that required therapists to seek “exceptions” in order to continue providing care to Medicare beneficiaries once those caps were reached. Medicare beneficiaries were often left with uncertainty as Congress frequently wrestled with extending the exceptions process over the last twenty years, as was the case this year when the exceptions process expired on December 31, 2017.

Although the 2018 budget act repeals outpatient therapy caps, it still requires providers to continue using a modifier code when submitting claims above $2,100 annually for the purposes of “indicating that such services are medically necessary as justified by appropriate documentation in the medical record involved.”[2] The budget act also provides the Centers for Medicare & Medicaid Services (CMS) with five million dollars a year for nationwide targeted medical reviews of claims that surpass $3,000. However, the American Physical Therapy Association (APTA) clarifies that “[c]laims that go above $3,000 will not automatically be subject to targeted medical review. Instead, only a percentage of providers who meet certain criteria will be targeted, such as those who have had a high claims denial percentage or have aberrant billing patterns compared with their peers.”[3] Further, the American Occupational Therapy Association (AOTA) notes, “the therapy cap will never again put beneficiaries at risk for being denied essential occupational therapy services.”[4]

The repeal of the therapy caps bolsters the implementation of the court-approved settlement agreement in Jimmo v. Sebelius, No. 11-cv-17 (D. VT), also known as the “Improvement Standard” case. The Jimmo Settlement – reached by the Center for Medicare Advocacy and Vermont Legal Aid with CMS – required CMS to confirm that “[s]killed care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”[5] Although the Jimmo Settlement protects all Medicare beneficiaries who need ongoing maintenance therapy services, including those with chronic conditions, beneficiaries still faced the annual therapy caps.

The Jimmo Settlement, along with the repeal of the outpatient therapy caps, confirms that beneficiaries in need of ongoing therapy should no longer need to worry about these arbitrary barriers to care.

  • To read more about the Jimmo Settlement Agreement, please visit: https://www.medicareadvocacy.org/medicare-info/improvement-standard/.
  • To read the Bipartisan Budget Act of 2018, please visit: https://www.congress.gov/bill/115th-congress/house-bill/1892/text.

D. Valanejad, February 14 2018

 


[1] Bipartisan Budget Act of 2018, H.R. 1892, 115th Cong. 50202 (2018) (to be codified at 42 U.S.C. § 1395l(g)).  
[2] Id.
[3] A Permanent Fix to the Therapy Cap: Improved Access for Medicare Patients Comes With Pending APTA-Opposed Cut to PTA Payment, PT In Motion, APTA (Feb. 9, 2018), http://www.apta.org/PTinMotion/News/2018/02/09/TherapyCapRepeal/.
[4] Amy Lamb, Therapy Cap Repealed After 20 Years: Message from AOTA President, AOTA (Feb. 9, 2018), https://www.aota.org/Advocacy-Policy/Congressional-Affairs/Legislative-Issues-Update/2018/therapy-cap-repealed-signed-into-law-aota-president-message.aspx?promo_name=stopped-the-cap&promo_creative=Advocacy-Policy&promo_position=hero.
[5] CMS Transmittal 179, Pub 100-02, 1/14/2014, available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf. 

 

 

Filed Under: Article Tagged With: alert, Jimmo-practice-tip, Medicare Part B, The Improvement Standard, Weekly Alert

Primary Sidebar

Easy Access to Understanding Medicare

The Center for Medicare Advocacy produces a range of informative materials on Medicare-related topics. Check them out:

  • Medicare Basics
  • CMA Alerts
  • CMA Webinars
  • Connecticut Info & Projects
  • Health Care Stories
  • Se habla Español

Sign Up for CMA Alerts

Jimmo v. Sebelius

Medicare covers skilled care to maintain or slow decline as well as to improve.

Improvement Isn’t Required. It’s the law!

Read more.

Latest Tweets

  • Our statement with @CANHR_CA and the Michigan Elder Justice Initiative recommends key issues of the Nursing Home Re… https://t.co/9nSwt3tAwT, Jan 15
@CMAorg

Footer

Stay Connected:

  • Contact Us
  • Sitemap
  • Products & Services
  • Copyright/Privacy

© 2021 · Center for Medicare Advocacy