Medicare Advantage

Let’s Get Physical! PT Caps Removed for Medicare Enrollees

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Let’s Get Physical! PT Caps Removed for Medicare Enrollees

Medicare recipients and providers received some positive news with the Bipartisan Budget Act of 2018: no more caps on physical therapy services. Seniors can seek the physical therapy services that they need without concern that they’ll be left holding the full bill. Considering that physical therapy can improve health outcomes and reduce overall medical spending, a permanent removal of the hard spending cap has the potential to help many Americans with original Medicare and Medicare Advantage plans. 

Repeal of Medicare Therapy Caps

The Balanced Budget Act of 1997 set a spending cap on how much Medicare would pay for therapy services in one year. This was a hard cap. Any expenses above the set limit would be the responsibility of the enrollee. Since then, advocacy groups have fought for the repeal of this cap. Over the years, short-term exceptions and extensions have been enacted as partial fixes, but none have been permanent.

Without a permanent repeal in place, there’s always been the possibility that the hard cap could be enacted in full force. In fact, the last fix expired at the end of 2017, so this calendar year began with a firm $2,010 limit in place.

Congress passed a budget bill in February that included the permanent repeal of the hard cap on physical therapy for Medicare recipients. The change was retroactive to the beginning of 2018, and the new regulation will continue for Medicare 2019 and beyond.

Spending above $2,010 in one year still requires special coding. Providers need to denote that any claims above that soft cap are medically necessary. However, claims aren’t subject to targeted medical review until they reach the $3,000 threshold. Even then, not all claims are reviewed. This practice is supposed to be limited to claims from providers who have a history of filing questionable or excessive claims. Bottom line: the lift on therapy caps means more affordable alternatives to costly medical interventions.

Benefits of Physical Therapy for Seniors

Access to physical therapy through Medicare enrollment is certainly a positive thing for those in both traditional and Medicare Advantage plans. Therapy services have been shown to help older adults recover from injuries and reduce the chances of future accidents.

Physical therapists often provide support in response to chronic pain or medical conditions that limit mobility. Because therapy helps people keep moving and using their muscles, it can help improve outcomes for patients with things like:

  • Dementia
  • Arthritis
  • Vision impairments
  • Bone conditions
  • Malnutrition

This type of therapy is particularly beneficial after an injury. Getting hurt, especially in a fall, can keep older people from becoming active again for fear of a repeat injury. Over time, seniors might become lonely, isolated and even homebound due to fear. Physical therapy has the potential to reverse those tendencies. Therapy strengthens the parts of the body that were affected, lessening the chances of a repeat injury. It also boosts confidence so that you fret less about your body’s ability to handle everyday tasks and outings.

Cost Savings of Physical Therapy

Those who sign up for coverage during the 2019 Medicare open enrollment period, also known as the annual election period, will have access to physical therapy services without a hard cap. Although this could lead to higher Medicare spending on therapy services, it may decrease overall healthcare spending.

For chronic pain, physical therapy is a more cost-effective method of treatment than injections or surgery. During the initial treatment period, physical therapy has been shown to be 19 percent cheaper than injections and 75 percent less expensive than surgery.

The savings associated with physical therapy continue past the diagnosis and first interventions. Over the course of 12 months, using physical therapy as the primary procedure for lower back pain relief produces a savings of 18 percent compared to trying injections first. It also leads to a savings of 54 percent compared to immediately performing surgery.

Early intervention is key. Patients who begin physical therapy within two weeks of receiving a diagnosis incur fewer treatment costs over the long term. Since the hard cap on therapy services has been eliminated for those with Medicare coverage, you may now experience fewer delays in beginning physical therapy treatment.

Furthermore, prevention is often cheaper than a cure, and that certainly holds true in the case of physical therapy. After a single fall, seniors are at high risk of falling again. New falls lead to new injuries, which require additional – and often expensive – treatments. Undergoing physical therapy after the first incident can greatly reduce the chances that it will happen again. Proactively paying for therapy services is typically cheaper than covering the cost of care related to a fresh injury or the reaggravation of an old one. 

Additional Noninvasive Treatments to Improve Outcomes

Along with physical therapy, you might also benefit from additional noninvasive procedures as you get older. These might improve your overall well-being and reduce what you spend on healthcare.

Relaxation and stress relief via focused activities, for example, can complement a healthy lifestyle and good nutrition. These include tai chi, mindfulness practices and yoga. Whether you’re currently in good health or are trying to recover from an illness or injury, you can benefit from these activities, which are known to support mental health and strengthen physical health at the same time.

Acupuncture is a procedure that may help with chronic conditions like lower back pain. Although the exact mechanisms by which this practice helps aren’t yet understood, it does seem to make a difference for many people. Note that original Medicare doesn’t cover acupuncture, but a Medicare Advantage plan might.

Other noninvasive procedures that may be recommended for the treatment of chronic pain include low-level light therapy and biofeedback. More conservative methods include wearing supportive garments or braces.

As with acupuncture, original Medicare probably won’t cover any service that isn’t considered “medically necessary,” a blanket category under which many alternative forms of treatment fall. But Medicare Advantage, the private portion of Medicare, may cover these services along with dozens of others. When you’re deciding on a Medicare plan – whether you’re new to the program or updating your coverage for the new year – think about your healthcare needs and weigh the pros and cons carefully. Choose a plan that will cover the services you need, even if those services buck traditional medicine.

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