Stop cap measures.

Congress weighs proposals to amend therapy limits

WHILE LONG TERM CARE PROVIDERS HAVE BEEN eager to see the annual cap on Medicare outpatient rehab services repealed, a dose of political reality has left them willing to accept a modification to the financial limit on therapies. Effective January 1, 1999, the Balanced Budget Act of 1997 imposed a $1,500 cap on physical therapy and speech and language pathology services combined and a separate $1,500 cap on occupational therapy provided in nonhospital outpatient settings, including SNFs.

The current legislative forerunner is Senator Charles Grassley's (R-Iowa) proposal to allow exceptions to the therapy cap (S 472). The bill continues to garner industry and congressional support. The measure would grant additional therapy services to Medicare beneficiaries who met criteria established by the bill--for example, a person diagnosed with a second condition requiring therapy in the same calendar year. In addition, beneficiaries facing hospitalization without the extra outpatient care would be exempt from the benefit limitation. The bill also directs the Secretary of Health and Human Services (HHS) to recommend alternatives to the annual cap.

As of press time in early May, Representatives Benjamin Cardin (D-Md.), Richard Burr (R-N.C.), and Frank Pallone Jr. (D-N.J.) were expected to introduce companion legislation to S 472 in the House at any time.

Representative Bill Thomas (R-Calif.) is also considering introducing a $160 million, five-year plan that would allow separate $1,500 limits for physical therapy and speech and language pathology services, in addition to the currently allowed $1,500 limit on occupational therapy. Thomas is also contemplating a plan where Medicare patients could transfer unused benefits to other patients in need of services exceeding the limit.

In mid-April, Representative Jo Ann Emerson (R-Mo.) introduced legislation to repeal the annual cap. The Reinstatement of the Medicare Rehabilitation Benefit Act of 1999 (HR 1385) would also require the HHS Secretary to implement a new payment method for outpatient therapies based on a beneficiary's diagnostic category, functional status, and prior use of services in outpatient and inpatient settings.

The American Association of Homes and Services for the Aging supports elimination of the cap, but objects to the Emerson bill's unique "robbing Peter to pay Paul" approach. "The legislation offsets the cost of the repeal through other cuts to Medicare," says Barbara Gay, director of congressional affairs for AAHSA, adding that it remains unclear where the cuts would occur.