Medicare Therapy Caps: What You Need to Know

The Parkinson’s Action Network (PAN) receives many inquiries on Medicare coverage of physical, occupational, and speech-language therapies. Many people with Parkinson’s need these therapy services to maintain quality of life, and that is why every year PAN works to ensure people with Parkinson’s can continue to receive these medically-necessary services.

We hope this additional information on Medicare therapy caps is helpful to those trying to navigate coverage. If you have specific questions, don’t hesitate to contact Catherine Pugh at cpugh@parkinsonsaction.org.

Background

In 1997, Congress created limits, or caps, on the amount of therapy services a Medicare beneficiary can receive each year. However, Congress voted every year until 2006 to keep the cap from going into effect. In 2006, the cap was allowed to go into effect, and thousands of people risked losing access to needed therapy services. To provide relief, Congress created an automatic exceptions process for medically-necessary therapy services. This exceptions process must be extended by Congress every year.

The cap is currently set at $1,900 and a manual medical review process is triggered at $3,700. If you receive medically-necessary therapies and are concerned that you may be denied coverage because of the cap, please speak with your healthcare provider about the exceptions process.

For a detailed, specific reference on how the exceptions process can and should be utilized, please see the full FAQ on the American Physical Therapy Association website.

People with Parkinson’s need access to physical, occupational, and speech-language therapies, and often utilize the exceptions process. In fact, a 2010 report published by the Centers for Medicare and Medicaid Services showed that nearly one-third of people with Parkinson’s utilizing therapy services exceeded the cap.

Current Efforts

Thanks to the advocacy of the Parkinson’s community, in coalition with other patient and provider advocacy groups, the exceptions process has been extended every year since 2006. This means that people with Parkinson’s and other conditions can continue to receive therapy services over the $1,900 cap.

With the exceptions process set to expire on December 31, PAN is working with the Therapy Cap Coalition to ensure the exceptions process will continue next year. Ultimately, PAN supports permanently removing the burdensome and arbitrary caps, and supports the Medicare Access to Rehabilitation Services Act of 2013 (HR 713/S 367), which would do just that