Skip to content

Lifting Therapy Caps Is A Load Off Medicare Patients’ Shoulders

Leon Beers, a retired railroad engineer who lives near Sacramento, Calif., has a form of Parkinson’s disease. Caregiver Timothy Wehe helps him get outside using a walker. (Bert Johnson for KHN)

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

Beers, a retired railroad engineer who lives outside Sacramento, Calif., has a form of Parkinson’s disease. The treatments slow its destructive progress and “he will need it for the rest of his life,” Morse said.

But under a recent change in federal law, people who qualify for Medicare’s therapy services will no longer lose them because they used too much.

“It is a great idea,” said Beers. “It will help me get back to walking.”

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

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

And under a 2013 court settlement, they won’t lose coverage simply because they have a chronic disease that doesn’t get better.

“Put those two things together and it means that if the care is ordered by a doctor and it is medically necessary to have a skilled person provide the services to maintain the patient’s condition, prevent or slow decline, there is not an arbitrary limit on how long or how much Medicare will pay for that,” said Judith Stein, executive director of the Center for Medicare Advocacy.

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

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

Lifting the therapy caps is just one of the important changes Congress made for the 59 million people enrolled in 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 when the initial coverage phase ends — this year, that happens after the beneficiaries and their insurers have paid $3,750 for covered drugs. When it happens, a patient’s share of prescription costs shoots up. This year, when people hit this stage, they are responsible for paying up to 35 percent of brand-name drug costs.

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

Beers relied on Medicare for physical therapy and other forms of therapy to help slow the progression of his Parkinson’s disease. (Bert Johnson for KHN)

The Affordable Care Act had called for the patient’s doughnut hole share to be narrowed to 25 percent by 2020, but the budget deal moved up that adjustment to 2019.

Much of 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 to the catastrophic level more quickly, said Caroline Pearson, senior vice president 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 as much as they used to,” Pearson added.

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

Expanding Medicare Advantage Benefits

Another important change allows private Medicare Advantage plans in 2020 to offer special benefits to members who have 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 those with chronic diseases do not have to be primarily health-related and need have only a “reasonable expectation” of improving health. Some examples that CMS has suggested include devices and services that assist people with disabilities, minimize the impact of health problems or avoid emergency room visits.

This wider range of benefits might help people remain at home, increase their quality of life and reduce unnecessary medical expenses. “We’re really excited that the law is catching up with what plans have known for a long time,” said Mark Hamelburg, senior vice president of federal programs at America’s Health Insurance Plans, an industry association.

But the changes will affect only those beneficiaries enrolled in these private plans, about a third of the Medicare population. “We would like to see some of these innovations happen in the traditional Medicare program as well, so that all beneficiaries would be able to reap these benefits,” said Lindsey Copeland, federal policy director at the Medicare Rights Center.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Related Topics

Aging Cost and Quality Insight Medicare