Medicare cap on therapies OK'd

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Medicare cap on therapies OK'd

By Diane C. Lade, South Florida Sun-Sentinel
September 30, 2003

Seniors on Medicare increasingly are being forced to make tough decisions as their out-of-pocket medical expenses continue to rise. Now they'll face one more: whether to drive to the nearest hospital for rehabilitative therapies they might need, pay for it themselves or do without.

On Monday, a federal district court judge in Washington , D.C. , turned back a legal attempt by consumer advocates to block a cap on Medicare reimbursements for speech, occupational and physical therapies. The federal government now can place a $1,590 annual limit on physical and speech therapies, with a separate $1,590 annual limit for occupational therapy, beginning with care received Sept. 1.

That means Merle Marram, 67, already has received all of her Medicare-covered visits from her therapist this year. The Lake Worth retiree, who suffers from lupus, had a knee replacement in June and was getting three at-home treatments weekly.

Marram said she had no idea she had reached the limit on her benefit until her therapist called her last week, telling her the next day's session would be the last covered. Now she has a choice of going to a local hospital for treatments, as hospital-based therapies are not included in the cap, or paying out of her pocket.

"I guess I'll just have to see how it goes," said Marram, who must use a cane. She has trouble driving, so it might be difficult for her to use a hospital program.

But her sympathy is for seniors who are dealing with strokes or Parkinson's disease, as they often need intense therapy just to be able to talk or walk across a room. "This is going to kill them," she said.

Robert M. Hayes, president of the Medicare Rights Center , thinks Congress eventually will repeal the therapy limit, which surfaced as part of the 1997 Balanced Budget Act. The center, along with Easter Seals and the American Parkinson Disease Association, brought the lawsuit against the federal government.

House and Senate conferees working on the Medicare bill that addresses prescription drug coverage already had agreed to include language again delaying the cap until 2005. Federal legislators in both houses have said they would sponsor legislation repealing the cap permanently, Hayes said.

But the prescription drug coverage bill is moving slowly, and Congress doesn't want to introduce stand-alone Medicare legislation while it's still in the works, Hayes said. "How many people will lose their chance at mobility, or never come back from a stroke, while the congressional leadership sits on its hands?" Hayes asked.

Congress approved a series of moratoriums over four years, delaying the cap's implementation but never repealing it outright. But Congress took no action this year, and therapy limits were to begin July 1.

Medicare Rights and the other consumer groups then sued, saying that the Centers for Medicare and Medicaid Services could not impose the limits without first notifying Medicare's 40 million elderly and disabled beneficiaries. The parties reached a settlement, delaying the implementation to Sept. 1 with the federal government agreeing to contact 90 percent of Medicare recipients.

Federal Judge Emmet Sullivan ruled Monday that Medicare had kept its end of the deal. However, he did say individual beneficiaries could challenge coverage denials if they weren't notified of the cap, according to Hayes.

Bill Shearouse, a partner in Alternative Rehab of West Palm Beach, and other therapy providers have created the American Rehab Foundation in order to challenge the cap. Shearouse, whose clients included Marram, said the foundation is considering suing the federal government on the grounds it has discriminated against small businesses by not capping therapy reimbursements for hospitals and their outpatient clinics.

"Providers are upset about what this is doing to our patients," Shearouse said.