A long awaited permanent fix to the Medicare Physical Therapy cap has been achieved! If you are not familiar with the cap, and the concerns related to it, here is some background information. Previously, Medicare beneficiaries had an annual “soft” cap at $1,980 for Speech-Language Pathology and Physical Therapy services, and a separate $1,980 cap for Occupational Therapy. If you reached this “soft” cap you were still eligible for services, with an exemption, up to the “hard” cap at $3,700 , and at that point therapy would most likely not be covered.
Through bipartisan support, and a 20 year effort from the American Physical Therapy Association (APTA), the “hard” cap has been removed. The new benefits are below:
-“Soft” cap of $2,010. At which point PT will require justification of services as medically necessary. This is taken care of by your PT and Physician.
-A threshold of $3,000 has been set at which point Medicare can do medical review. Although, Medicare will not be receiving any additional funding or seek to expand their review process.
-$3,000 will not trigger an automatic review. The reviews will be targeted at claims that appear abnormal; presence of denials, abnormal billing, etc…
The previous cap was not a concern for most patients, but those with serious injuries or diagnosis often felt threatened with the cap hanging over them. Providers were often forced to inform their most vulnerable patients that Medicare would be no longer be covering their services. So, with the new legislation, and threat of “hard” cap removed patients and providers can focus on whats most important and that’s a return to a healthy and happy life.