Medicare Therapy Cap

Under the Balanced Budget Act (BBA) of 1997 Congress placed an annual cap on rehabilitation services under Medicare. As part of the Deficit Reduction Act (DRA) in 2006, Congress passed legislation implementing the therapy caps but authorizing the Centers for Medicare and Medicaid Services (CMS) to create and employ an exceptions process to permit medically necessary physical therapy, occupational therapy, and speech language pathology services above cap. Since enacting the BBA, Congress has long recognized the cap's potential harmful effect on Medicare beneficiaries and has acted several times to prevent implementation of a hard cap.

On January 1, 2013, Congress passed the American Taxpayer Relief Act of 2012 which extended the Medicare therapy cap exceptions process until December 31, 2013. The automatic exceptions process applies when patients reach the $1,900 threshold and the manual medical review process will continue at the $3,700 threshold. Hospital outpatient settings will continue to be included under the therapy cap with the exceptions process in 2013.

Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA), and Senators Ben Cardin (D-MD) and Susan Collins (R-ME) introduced the Medicare Access to Rehabilitation Services Act (HR 713/S 367) in both chambers on February 14, 2013. HR 713 and S 367 would permanently repeal the $1,900 therapy "cap" imposed on physical therapy, occupational therapy, and speech-language pathology services. With discussion of reform of the sustainable growth rate (SGR) ramping up, APTA is calling on Congress to also address permanent repeal of the therapy cap in 2013.

How to Take Action

APTA Members: Go to APTA's Legislative Action Center, click "Take Action" under "Stop the Medicare Therapy Cap & Prevent SGR Payment Cuts," and follow the instructions. If you have time, please personalize the e-mail and tell Congress how the cap impacts your patients.

Nonmember PTs/PTAs and Patients: E-mail your legislators using our Patient Action Center. Simply enter your zip code and click "Go!"

Current Cosponsors

• HR 1546
• S 829

Inform Your Patients

• Consumer Handout: What Patients Need to Know (.pdf)
• Consumer Handout: You Can Make a Difference (.pdf)
• Consumer Handout: Patient Petition (.pdf)

Payment Information & Resources

• Medicare Coding & Billing

  The Medicare Coding & Billing page includes information on October 1 changes, frequently asked questions, a medical manual review complaint form, and more.

Background

• APTA Official Statement to House: Medicare Therapy Cap in Rural Settings (.pdf) - 6/13/12
• Podcast: 2012 Medicare Therapy Cap Update - 2/23/12
• President Signs Legislation Inclusive of Medicare Payment Cut Reprieve and Therapy Cap Exceptions Process Extension - 2/23/12
• Therapy Cap Coalition Urges Congress to Protect Services (.pdf) - 2/14/12
• Medicare Therapy Cap Coalition: Letter to Conference Committee Members (.pdf) - 1/27/12
• Podcast: 2012 Therapy Cap Short Term Extension Update - 1/12/12
• Ways and Means Testimony: Expiring Medicare Provider Payment Policies (.pdf) - 9/21/11
• Position Paper: Medicare Therapy Cap (.pdf)
• History of Medicare Therapy Caps

Additional Resources

• 2011 Impact: General Background and Information
• Supporting Organizations

• Last Updated: 2/15/2013
• Contact: therapycap@apta.org
• = Members Only