| Federal District Court Judge Emmet Sullivan
on Monday ruled that CMS can cap payments for outpatient therapy
for Medicare beneficiaries, the Wall Street Journal reports.
As a result of the decision, CMS between Sept. 1 and Dec. 31
will cap payments for outpatient physical therapy and speech-language
pathology at a combined $1,590 and also cap payments for occupational
therapy at $1,590. The caps will apply to the full year in 2004.
The caps apply to outpatient therapy administered at therapist
and physician offices, outpatient rehabilitation centers, nursing
facilities for outpatients and residents whose stays are not
covered by Medicare and in-home care from home health agencies
that are not covered by Medicare (Greene, Wall Street Journal,
9/29). The caps will not apply to outpatient therapy administered
at hospitals (Lade, Fort Lauderdale Sun-Sentinel, 9/30).
Case History
CMS imposed the caps as part of the 1997 Balanced Budget Act.
However, Congress passed two subsequent moratoriums on the caps,
and a complication with Medicare software delayed the planned
effective date for the caps to July 1 (Kaiser Daily Health Policy
Report, 7/10). On June 25, the Medicare Rights Center, the American
Parkinson Disease Association and Easter Seals filed a lawsuit
in U.S. District Court in Washington against HHS Secretary Tommy
Thompson and other federal officials over allegations that CMS
had not properly notified the 40 million Medicare Part B beneficiaries
affected by the caps before the effective date. On July 11,
HHS reached a partial settlement with the consumer groups under
which CMS delayed the effective date of the caps until Sept.
1 to provide adequate time to notify about 90% of affected Medicare
beneficiaries, but in court documents filed on Sept. 4, the
consumer groups alleged that CMS violated the settlement because
agency officials had only notified about 60% of beneficiaries
through notices sent in July and August. Sullivan on Monday
dismissed the claim because he said that CMS officials had not
guaranteed that they would notify a certain percentage of Medicare
beneficiaries affected by the caps (Wall Street Journal, 9/29).
However, Sullivan ruled that individual beneficiaries who did
not receive notification of the caps could challenge denials
of coverage (Fort Lauderdale Sun-Sentinel, 9/30).
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Submitted By: Susan
Dyson & David
Yoder |
