Congress Rescinded Outpatient Therapy Caps Despite Lack of Information on Medicare.gov

The Bipartisan Budget Act became law on February 9, 2018. The Bipartisan Budget Act of 2018 revoked the Medicare outpatient therapy caps which served as a barrier to care for people receiving outpatient therapy services. Referring to Section 50202 of the Act, the repeal of the therapy caps is retroactive.

 

This means that therapy limits have been eliminated for physical therapy, occupational therapy, and speech-language pathology services rendered after December 31, 2017. Claims that are above the previous cap threshold must include documentation to support the medical necessity of the services rendered. In addition, documentation must be available upon request.

 

Surprisingly, the Centers for Medicare & Medicaid Services (CMS) has not revealed the repeal of outpatient therapy caps on both CMS.Gov and Medicare.Gov webpages. CMS featured a special edition in the Medicare Learning Network (MLN) linking the newsletter to accentuate the important characteristics of the Act pertaining to the repeal.

Jimmo v. Sebelius

The Settlement Agreement in Jimmo v. Sebelius, No. 11-cv-17 (D. VT) ensures that Medicare beneficiaries will be able to continue receiving outpatient therapy to improve or maintain their current conditions, or to slow or halt the further deterioration of their conditions, without having to overcome arbitrary payment caps as barriers to care.

 

In May of 2018, the Jimmo Settlement Center attorneys had a meeting with CMS officials. The Center emphasized the overwhelming need for improved implementation in home health, skilled nursing facilities, and outpatient therapy. The officials expressed a desire to collaborate with the Center to provide additional education.

 

Upon request, the Center submitted educational materials for CMS with the expectation that they would be released in August of 2018. However, no actions to improve Jimmo implementation since the May of 2018 meeting have been initiated. The Center encourages Medicare beneficiaries and their families to continue appealing unfair Improvement Standard denials.

Resources

For additional information about the Jimmo Settlement Agreement and helpful resources, please see the Center for Medicare Advocacy’s Improvement Standard and Jimmo News webpage.

 

The repeal language in the Bipartisan Budget Act of 2018 may be helpful to Medicare beneficiaries who are told they cannot continue therapy because they have reached a therapy cap.

 

Also, Medicare beneficiaries should consult with their doctors and therapists, or any Medicare contractors who are reviewing their claim. The Bipartisan Budget Act of 2018 will shed more light on this topic.

 

Another useful resource is The Center for Medicare Advocacy’s Self-Help Packet for Outpatient Therapy Denials, including “Improvement Standard” Denials.

 

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