PHYSICAL THERAPY; MEDICARE; ELDERLY;

ELDERLY;

Federal laws/regulations;

You asked if there is or will be a $ 1,500 cap on physical therapy services for elderly people. You indicated that you thought the cap went into effect on July 1, 2003.

We believe you are referring to coverage limits under the Medicare program.

There is not currently an annual cap on physical therapy services in the Medicare program but one is scheduled to go into effect on September 1. Congress imposed the cap back in 1997 but subsequently delayed it. The Centers for Medicare and Medicaid Services delayed it further through August 31, 2003.

In 1997, Congress imposed a yearly beneficiary limit of $ 1,500 for outpatient rehabilitation services, which included separate $ 1,500 limits for occupational and physical therapy, including speech-language pathology services (Section 4541(c) of the Balanced Budget Act of 1997). The limits do not apply to services furnished directly or under arrangement by a hospital to an outpatient, or to a hospital inpatient who is not covered by a Medicare Part A stay. The limit is based on incurred expenses and includes the $ 100 Part B deductible and coinsurance (the 20% that beneficiaries must pay). The budget act called for the limit to be indexed to reflect inflation, bringing it to $ 1,590 in 2003.

These limits were in effect only in 1999. Congress passed the Balanced Budget Refinement Act of 1999 and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2002, which placed two- and one-year moratoriums, respectively, on the cap, delaying it until January 2003. After a major push by the advocates, CMS delayed implementation until July 1, 2003. Most recently, CMS again delayed, until September 1, imposition of the cap. In its Program Memorandum dated July 3, 2003, CMS announced the delay retroactive to July 1, citing issues that had arisen in federal litigation.

There is currently a movement underway to repeal the cap altogether. S. 569 and H. R. 1125 would remove the caps. The House version has 205 sponsors, including Connecticut Rep. Robert Simmons.

RC: ro