United Spinal Association believes people living with disabilities should get the outpatient therapy care they need to enjoy healthy and independent lifestyles without any caps on services.

The level of a cap on therapy services beginning in 2014 through 2017 is $1,920 for occupational therapy and a separate cap of $1,920 for physical therapy and speech-language-pathology services combined. Caps place arbitrary limits on access to medically necessary rehabilitation services for Medicare beneficiaries. There is a claims exceptions process in place that triggers a medical review when the beneficiary’s expenses reach $3,700.

Therapy cap amounts include Medicare payments to providers as well as beneficiary co-pays. In outpatient settings, Medicare will pay 80 percent of allowable charges and the consumer is responsible for the remaining 20 percent. The therapy cap applies to all Part B outpatient therapy settings and providers including: private practice, skilled nursing facilities, home health agencies, outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities and hospital outpatient departments.

Back in December 2013, Congress had 30 days to act to ensure individuals continue to receive critical outpatient therapy they depend on––including occupational therapy, physical therapy and/or speech-language pathology services. Thanks to United Spinal advocates for helping pass a 3-month extension through March 31, 2014.

The American Taxpayer relief Act was passed in January 1, 2013 which extended the exceptions process for one year through December 31, 2013 and congressional budget agreements at the end of 2013 extended the exceptions process through March 31, 2014.  The exceptions process means that supporting documentation can be submitted for an amount above the therapy cap amount.

An exceptions process was in place for the first three months of 2014 On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014.  This new law extends the exceptions process for outpatient therapy caps through March 31, 2015.

04/15/2015: The Senate passed the Medicare Access and CHIP Reauthorization Act (H.R. 2) legislation to repeal and reform the Sustainable Growth Rate (SGR) formula which adjusts how physicians are paid for Medicare services and includes an extension of the Medicare therapy cap exceptions process through December 31, 2017.

04/01/2014: On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014.  This new law extends the exceptions process for outpatient therapy caps through March 31, 2015.

2/6/14: Congress introduced legislation, SGR Repeal and Medicare Provider Payment Modernization Act, HR 4015, which provides for reform of physician payments but does not address eliminating the therapy cap or implement an extension of the therapy cap exceptions process. United Spinal and its grassroots network is advocating to ensure the cap on therapy services does not go into effect.

12/2013: Congress passed a 3-month extension to prevent cuts to Medicare and to continue an option for Medicare beneficiaries to go beyond the cap on therapy services, known as the exceptions process. That extension ends March 31st. Consumers could face a hard cap on outpatient therapy services after the current extension expires at the end of March. Thanks to United Spinal advocates for helping to pass the 3-month extension.

9/13-10/13: United Spinal and UsersFirst lead grassroots advocacy campaign in support of  Medicare Access to Rehabilitation Services Act (H.R. 713/S. 367).

9/10/13:  United Spinal signed onto a consumer stakeholder letter to Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner urging for better implementation of the therapy medical review process.

9/13: United Spinal, as part of the Therapy Cap Coalition, began the Fall Advocacy Campaign opposing caps on rehab therapy for Medicare beneficiaries.

06/13: United Spinal signed onto Congressional letters to House and Senate leadership in support of Medicare Access to Rehabilitation Services Act (H.R. 713/S. 367), legislation that would eliminate an arbitrary limit on outpatient rehabilitation services.

1/2/13: The American Taxpayer Relief Act (ATRA) of 2012 was passed by Congress on January 1, 2013 and signed into law by President Obama on January 2, 2013.  ATRA extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013.  Thank you to all our advocates in helping to educate your representatives on Capitol Hill.

12/12: United Spinal took the lead, along with other stakeholders, in collecting consumer stories from grassroots advocates about the impact of limits on rehab therapy services, distributed a press release opposing caps on therapy and urged Congress to get rid of the limit on therapy services.