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Medicare limits on therapy payments set to begin

By Diane C. Lade

The Sun-Sentinel, August 25, 2003

Despite a lawsuit and four years of reprieves, it appears the cap on Medicare payouts for physical, occupational and speech therapies finally will go into effect on Sept. 1.

From that day forward, seniors will be limited to $1,590 annually for physical and speech therapies combined, with a separate $1,590 cap for occupational therapy. In 2003, the limit would apply only to services received during the last four months of the year, but the limit would be in effect for all 12 months of 2004.

Health policy advocates, as well as therapists working with the elderly, say these ceilings will be devastating for patients recovering from strokes and other debilitating illnesses. The new restrictions would allow about 15 visits a year.

Brian Caits, an occupational therapist who owns BCOT Assessment and Services in Cooper City, thinks his clients may be forced to hold off on getting treatments they need for fear they'll hit the ceiling before the year's end.

"They may break a leg in March but won't get help learning to walk again because they're afraid if they have a heart attack later in the year, they won't be eligible," said Caits.

The limits would not apply to therapy received in a hospital or a hospital-based outpatient clinic, but the American Physical Therapy Association points out that some seniors live far away from such facilities or can't travel at all. The change also could cause problems for nursing homes, with some residents having to go to the hospital for treatments they used to be able to receive at the home.

The rehabilitative therapy cap has been on again-off again since it was first included in the 1997 Balanced Budget Act as a cost-cutting measure. Congress passed a one-year moratorium in 1999 to keep the new limits from being enacted, and the freeze since has been extended three additional times.

There are two chances now for yet another delay, although it probably won't happen before Sept. 1.

For one, the House version of the Medicare Prescription Drug and Improvement Act includes a provision that would put a one-year moratorium on instituting the cap beginning Jan. 1, 2004. Dave Mason, vice president of government affairs for the physical therapy association, anticipates the Senate will go along.

But Congress is in recess until early September and once an act is drafted, it must pass both houses before becoming law.

"Getting Medicare legislation to move this year is not as easy as it sounds," Mason said. "We are trying to keep our members engaged in the debate while telling them they may have to live with this."

The second shot at bringing down the cap comes out of a lawsuit filed this summer against the federal government by three consumer groups: the Medicare Rights Center, Easter Seals and American Parkinson Disease Association. The suit, heard in the U.S. District Court in Washington, D.C., argued that the limits could not be imposed without first telling Medicare's 40 million beneficiaries.

In a settlement agreement, the Centers for Medicare and Medicaid Services agreed to move the implementation date from July 1 to Sept. 1, and promised that at least 90 percent of Medicare clients would get a printed notice of the change along with their benefit statements in July. Law requires Medicare to tell recipients if their benefits are being changed or cut.

"We have some concerns that those 90 percent didn't get that notice," said Edo Banach, Medicare Rights Center's deputy general counsel.

The consumer coalition and Medicare are due back in court on Sept. 15, to give the judge an update. "If it turns out individuals weren't notified, we'll seek whatever legal remedies are available," Banach said.