$1,740 Outpatient Therapy Caps – With No Exceptions – Are Scheduled to Take Effect Jan. 2007

WASHINGTON -- U.S. Rep. Benjamin L. Cardin has written to key committee House chairs with jurisdiction over the Medicare program urging passage of legislation to extend an “clinical exceptions” process through 2007 for patients who exceed statutory limits on outpatient rehabilitation therapy services.  Without congressional action, on Jan. 1, 2007 outpatient therapy services will be restricted to limits of $1,740 a year, with no exceptions allowed.

In 1997, Congress imposed a cap on physical therapy and speech-language pathology services and a separate cap on occupational therapy as a cost-saving measure. Congress has delayed implementation of the caps several times, but on Jan. 1, 2006 the caps went into effect.  In early 2006, Congress passed legislation requiring the Centers for Medicare and Medicaid Services (CMS) to establish an “exceptions process” for beneficiaries with more severe conditions that require additional services.

Under the current policy, since March 13, CMS has automatically granted “exceptions” to the therapy caps for certain conditions.  In addition, Medicare beneficiaries, or someone acting on their behalf, can apply for an “exception” to the therapy cap limit based on medical necessity.    

“While the exceptions process has not been perfect, once the glitches have been corrected, it can serve as a viable option to provide beneficiaries access to needed services.  There are fewer than 60 legislative days remaining this year, and prompt attention to this matter is required. By extending the exceptions process at least through 2007, seniors who have complex conditions will be able to get necessary care.  Congress still needs to work with the Administration to develop a long-term alternative to therapy caps,” said Rep. Cardin.

The letter to the Chairmen and Ranking Members of the Ways and Means and Energy and Commerce Committees was also headed by Reps. Phil English (R-PA) and Frank Pallone (D-NJ), and cosigned by a bipartisan group of 175 members.   Reps. Cardin, English, Pallone, and Rep. Roy Blunt (R-MO) are the sponsors of HR 916, legislation to repeal the caps entirely, which has 251 cosponsors.

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