Medicare Beneficiaries Might Have to Pay Thousands More for Therapy

Millions of Medicare beneficiaries who need physical, speech or occupational therapy to help them recover from strokes or deal with chronic illnesses will have to pay thousands of dollars more for that care unless Congress acts soon.

For two decades, Medicare has capped how much it will pay for physical, speech and occupational therapy. But ever since the limits were imposed, Congress has passed an automatic exception that allows Medicare to pay for care beyond the caps when the treatments are deemed medically necessary.

The latest exception expired Dec. 31, which means the caps of $2,010 for physical and speech language therapy and $2,010 for occupational therapy are now being enforced. These services fall under Medicare Part B, which covers doctor visits and other outpatient services. When the exceptions were in place, Medicare beneficiaries paid only the 20 percent coinsurance that Part B requires.

Without the exceptions, Medicare beneficiaries must pay the entire therapy bill once they exceed the threshold. According to AARP, some beneficiaries with high-cost conditions could reach the annual caps in the coming weeks.

AARP is part of a coalition of provider, consumer and advocacy organizations urging Congress to repeal the therapy caps. “The caps prevent beneficiaries from receiving the rehabilitation care they need from therapists in a timely fashion,” Joyce Rogers, AARP senior vice president for government affairs, wrote in a December letter to Senate Finance Committee leaders. “Delaying or reducing care can diminish an individual’s independence in his or her home and community.” 

The caps apply to the therapy that Medicare covers whether delivered in a provider’s office, a patient’s home or an outpatient therapy center. It’s very common for someone who has had a stroke or a hip or other fracture to need intensive therapy to learn how to speak and walk again or feed themselves. Patients who suffer from conditions such as arthritis, Parkinson’s disease or multiple sclerosis also often need therapy to manage the tasks of everyday living.

According to a recent analysis commissioned by the American Occupational Therapy Association, nearly 6 million Medicare beneficiaries accessed outpatient therapy services in 2015. Of those, nearly 1 million required care that exceeded the combined cap on physical and speech therapy, while nearly 250,000 surpassed the occupational therapy threshold. 

Without rehabilitation care, more older Americans won’t be able to maintain their independence, making them more likely to move into a nursing home or face frequent and costly hospitalizations.

“The level of anxiety among patients, their families, caregivers and providers is definitely rising,” says Justin Elliott, vice president of government affairs for the American Physical Therapy Association. “Every day the caps are in place they’re going to potentially reach it and not get the care they need.”