As you probably already know, there is a Medicare Part B “Hard Cap” that went into effect 1/1/18 because Congress didn’t act to extend the exceptions process nor did they repeal the therapy caps altogether. As a result, residents receiving Part B therapy in 2018 will have a “Hard Cap” of $2,010 for Physical Therapy (PT)/Speech Therapy (ST) and a “Hard Cap” of $2,010 for Occupational Therapy (OT). The “Hard Cap” means that once the $2,010 amount is met for each cap, Medicare will no longer cover therapy services for the 2018 calendar year. Yep! That’s it! Medically necessary therapy services beyond the cap may be paid for privately by the patient/responsible party but this can only occur with a resident/responsible party signed ABN that is provided by the facility.
The ABN should be provided to the patient/responsible party any time when therapy is not medical necessary or not covered under Medicare. Once the $2,010 cap is met, Medicare will no longer cover therapy services for the calendar year. A few examples of when the ABN should be issued:
- The therapist determines that the therapy services no longer requires the skills of a therapist to treat the residents condition and therefore, the services are no longer medically necessary but the patient/responsible party would like therapy to continue
- Changes in frequency when the therapist determines that the less therapy is medically necessary but the patient/responsible party wants to continue at the same frequency. Example: 3x/wk. was originally provided and therapist will decrease frequency to 2x/wk. The ABN should be issued to the patient/responsible party for the 3rd
- Medicare doesn’t cover a particular therapy intervention(s) but the patient/responsible party wants that particular therapy intervention(s). The “Hard Cap” falls under this category.
Now that the “Hard Cap” is in place, the ABN form must be completely filled out according to the ABN instructions and it must be signed by the patient/responsible party in order for therapy services to continue beyond the $2,010 cap for PT/ST and $2,010 cap for OT. The patient/responsible party will need to check off their choice on the ABN and if they choose to continue therapy knowing Medicare will deny (the Medicare benefit only covers up to $2,010 for each cap), this will pass the financial liability on to the patient/responsible party. The most updated ABN form can be found on the CMS Website.
There is always a possibility that Congress will pass an exceptions process but that may not happen until March of 2018 if it happens at all. In the meantime, having a process in each facility is necessary to ensure tracking of Medicare Part B dollars spent and to ensure timely issuance of the ABN.