Advocacy Continues on Medicare Caps With No Guidance From CMS, Implementation Date Uncertain Policy Analysis
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Policy Analysis  |   December 01, 2002
Advocacy Continues on Medicare Caps
Author Notes
  • Ingrida Lusis, is ASHA’s director of health care regulatory advocacy.
    Ingrida Lusis, is ASHA’s director of health care regulatory advocacy.×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   December 01, 2002
Advocacy Continues on Medicare Caps
The ASHA Leader, December 2002, Vol. 7, 1-15. doi:10.1044/leader.PA.07232002.1
The ASHA Leader, December 2002, Vol. 7, 1-15. doi:10.1044/leader.PA.07232002.1
On Jan. 1, the Centers for Medicare and Medicaid Services (CMS) will reinstate the $1,500 caps on all Medicare Part B outpatient rehabilitation services because of Congress’ failure to act upon Medicare legislation before adjournment of the session.
Despite intense lobbying by ASHA and other organizations, Congress postponed consideration of Medicare legislation that would extend the current moratorium on Part B caps on speech-language pathology, physical therapy, and occupational therapy services.
The caps could significantly restrict beneficiary access to care, and speech-language pathologists should begin working with their facility administration to ensure that patients will continue to receive appropriate levels of services next year.
Awaiting Guidance
To date, CMS has not issued instructions to its contractors on how to implement the caps. It is anticipated that CMS will not issue new regulations, but instead will rely on the 1998 policies that were in place prior to the moratorium, which is in its third year. If this occurs, CMS will be re-implementing a provider cap of $1,500 worth of combined speech-language pathology and physical therapy services to each beneficiary, and an additional $1,500 in occupational therapy. And, again, providers will be required to track the amount of care they provide to each beneficiary. This is despite the fact that the enacting legislation as part of the Balanced Budget Act of 1997 stipulated a beneficiary cap for therapy services. As in 1998, it is unclear if CMS has the systems in place to allow for an accurate accountability of care. The Medicare Part B cap includes the 20% coinsurance required of the beneficiary as well as the Medicare payment as part of the $1,500.
ASHA will provide instructions by mail, e-mail, and on its Web site as soon as CMS issues the 2003 therapy cap implementation instructions. Carriers and fiscal intermediaries will have 60 days from that date to implement the caps.
By law, the therapy caps go back into effect Jan. 1, even though CMS has yet to provide guidance to intermediaries and carriers. SLPs are advised to begin recording their visits as of Jan. 1, however, because CMS may instruct contractors to retroactively enforce the caps. SLPs should advise their Medicare patients that, effective Jan. 1, there will be a financial limit on Medicare Part B outpatient rehabilitation services. Once the $1,500 cap is exceeded, the beneficiary will either be expected to pay out-of-pocket or seek services at a hospital outpatient clinic, where the care would continue to be covered.
Congress Fails to Act
During the 107th Congress in 2002, ASHA was successful in including legislative language to extend the moratorium for an additional two years in both the House-passed Medicare legislation (H.R. 4954) and in the Senate Medicare legislation (S. 3018) that became mired in a partisan fight over prescription drug coverage for Medicare beneficiaries. ASHA’s lobbyists have worked through December to ensure that congressional leaders and current cosponsors of the bills will support further extending the proposed moratorium when Congress returns to Capitol Hill on Jan. 11. All SLPs are urged to contact their senators and representatives to urge an extension of the moratorium. Contact your members of Congress.
Delay Requested
During the congressional adjournment, ASHA has worked with key members of Congress to submit a request to CMS Administrator Tom Scully, asking that he delay the caps’ implementation. ASHA believes that CMS has the authority to delay implementation of the caps because the agency failed to advise both beneficiaries and providers of the reinstatement of the caps. CMS is required by law to notify beneficiaries and providers concerning changes in its benefits and coverage policies.
For more information regarding ASHA’s legislative efforts, contact Reed Franklin by e-mail at rfranklin@asha.org. Questions regarding the regulatory implementation of the therapy caps should be directed to Ingrida Lusis at ilusis@asha.org or Mark Kander at mkander@asha.org. For questions about the impact on clinical service delivery, contact Janet Brown at jbrown@asha.org.
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FROM THIS ISSUE
December 2002
Volume 7, Issue 23