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by ASHA Advocacy category: Cause
The Medicare cap on outpatient rehabilitation therapy services was originally instituted under the Balanced Budget Act of 1997 as a combined cap on speech-language pathology (SLP) and physical therapy (PT) services, as well as a separate cap on occupational therapy (OT) services to Medicare beneficiaries.
The original $1,500 cap on Part B Medicare therapy services was intended as a cost control mechanism, but has not proved effective in saving Medicare money. Instead, the sickest of Medicare patients were being denied needed care. Congress has recognized that a financial limitation on therapy is detrimental to Medicare patients and through the years placed numerous moratoriums on its implementation.
In 2015, President Obama signed the Medicare Access and CHIP Reauthorization Act into law. The law directs the Centers for Medicare and Medicaid Services (CMS) to continue to allow exceptions to therapy caps for medically necessary services provided through December 31, 2017. The therapy cap exceptions process requires reauthorization annually and historically been achieved within payment, tax, or fiscal related legislation.
Under the Cap, Medicare beneficiaries that suffer from speech language disorders due to life events such as stroke, head injury, Alzheimer's, Parkinson's, and more, risk being denied therapy and/or forced to pay out of pocket for services to help them regain their ability to communicate effectively.
While a cap exception process has been in place for several years, this offers only a short-term fix for a long-term problem.
Congress and CMS must continue to engage with stakeholders to develop a long‐term solution that ensures access to outpatient therapy services in a cost effective and clinically appropriate manner.
The American Speech-Language-Hearing Association (ASHA) is the national professional, scientific, and credentialing association for 191,500 members and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students.