Lifting Therapy Caps Is really a Load Off Medicare Patients' Shoulders


Physical therapy helps Leon Beers, 73, get out of bed in the morning and move his home using his walker. Other treatment strengthens his throat muscles in order to communicate and swallow food, said his sister Karen Morse. But in mid-January, his home healthcare agency told Morse it could no longer provide these services while he had used all his therapy benefits allowed under Medicare for that year.

Beers, a retired railroad engineer who lives outside Sacramento, Calif., has a type of Parkinson’s disease. The treatments slow its destructive progress and “he'll need it throughout his life,” Morse said.

But within recent change in federal law, people who qualify for Medicare’s therapy services will no longer lose them simply because they used an excessive amount of.

“It's a good idea,” said Beers. “It can help me get back to walking.”

The federal budget agreement Congress approved recently removes annual caps on how much Medicare pays for physical, occupational or speech therapy and streamlines the medical review process. It applies to individuals traditional Medicare as well as individuals with private Medicare Advantage policies.

As of Jan. 1, Medicare beneficiaries qualify for therapy indefinitely so long as their doctor – or perhaps in some states, physician assistant, clinical nurse specialist or nurse practitioner – confirms their requirement for therapy and they continue to meet other requirements. The Centers for Medicare & Medicaid Services (CMS) last month notified health care providers concerning the change.

And within 2021 court settlement, they won’t lose coverage since they have a chronic disease that does not get better.

“Put the above things together and it implies that when the care is ordered by a doctor which is medically necessary to have a skilled person provide the services to keep the patient's condition, prevent or slow decline, there isn't a random limit how long or how much Medicare covers that,” said Judith Stein, executive director from the Center for Medicare Advocacy.

But don’t be surprised if the Medicare website doesn't mention the modification. Info on the website will be revised “as soon as possible,” said a spokesman, who declined to become identified. However, information from the 800-Medicare helpline continues to be updated.

Until then, patients can refer to the CMS update posted last month for providers.

Lifting the therapy caps is among the important changes Congress designed for the 59 million people signed up for Medicare. Here are two others:

Shrinking The 'Doughnut Hole'

Beneficiaries have long complained about a coverage gap, the so-called doughnut hole, in Medicare drug plans. That’s once the initial coverage phase ends – this year, that occurs following the beneficiaries as well as their insurers have paid $3,750 for covered drugs. When it happens, a patient’s share of prescription costs shoots up. This year, when individuals hit this stage, they are accountable for paying as much as 35 % of brand-name drug costs.

When beneficiaries' total yearly drug expenses reach a certain amount ($5,000 this season), they enter the catastrophic coverage stage and pay just Five percent of the costs. But studies have shown that less than 10 percent of beneficiaries spend enough to reach that last stage.

Beers relied on Medicare for physical therapy along with other types of therapy to assist slow the progression of his Parkinson’s disease. (Bert Johnson for KHN)

The Affordable Care Act had called for a person's doughnut hole share to become narrowed to 25 % by 2021, however the budget deal moved up that adjustment to 2021.

Much from the drug cost will be shouldered by pharmaceutical companies. And those payments by drugmakers will also count as money paid by patients, which will help them progress towards the catastrophic level more quickly, said Caroline Pearson, senior v . p . at Avalere Health, a research firm.

The deal could have an added attraction. “Premiums will come down because the drug plans are not being required to cover around they used to,” Pearson added.

Lower premiums will also save money for that government since it will spend less on subsidies for low-income beneficiaries.

Expanding Medicare Advantage Benefits

Another important change allows private Medicare Advantage plans in 2021 to offer special benefits to members who've a chronic illness and meet other criteria.

Currently, these private insurance plans, which limit members to a network of providers, treat all members the same.

But under the budget law, benefits targeting individuals with chronic diseases do not have to be primarily health-related and want only have a “reasonable expectation” of improving health. Some examples that CMS has suggested include devices and services that assist individuals with disabilities, minimize the outcome of health problems or avoid er visits.

This wider range of benefits might help people remain at home, improve their quality of life and lower unnecessary medical expenses. “We’re really excited the law is doing what plans have noted for a long time,” said Mark Hamelburg, senior vice president of federal programs at America’s Medical health insurance Plans, an industry association.

But the alterations will affect only those beneficiaries signed up for these private plans, in regards to a third from the Medicare population. “We wish to see some of these innovations happen in the standard Medicare program as well, to ensure that all beneficiaries could reap these benefits,” said Lindsey Copeland, federal policy director in the Medicare Rights Center.