Therapy providers warn of coverage changes

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As Washington lawmakers continue to search for a budget deal, Flathead-area therapy providers are sounding the alarm on looming coverage changes for Medicare patients.

Without action by Congress, Medicare coverage for physical, occupational and speech therapy will harden into a strict limit with no exceptions — leaving many patients facing tough choices.

At stake is the process through which Medicare patients receive coverage for annual physical, occupational and speech therapy visits. The process has been confusing; since 1997, when Congress passed the Balanced Budget Act, Medicare coverage for therapy services has been capped at a certain amount per year.

But an exception allowed patients to exceed that limit when medically necessary, such as with stroke recovery, multiple procedures and managing degenerative diseases like Parkinson’s.

However, those medical exceptions expired on Dec. 31, 2017. Unless Congress votes to extend the exceptions on Feb. 8, coverage for all physical and speech therapy vists is capped at $2,010 per year, with a separate $2,010 for occupational therapy. That would cover about 20 visits annually, according to Ashley McGuire of Whitefish Therapy & Sports Center — enough visits for some, but too limited for patients with long-term therapy needs.

This could leave patients without the ability to pay for therapy in cash out in the cold, warned McGuire.

“As it stands now, patients would have to pay out-of-pocket,” she said.

McGuire also noted that since secondary insurance follows Medicare rules, even those with supplemental insurance will be forced to shoulder the cost — a burden too great for many patients. “Many people choose not to or will be unable to pay and will forego needed therapy services,” said McGuire.

Brian Miller, of Advanced Rehabilitation Services in Kalispell, put the issue in practical terms.

“Say a patient has rotator cuff surgery at the beginning of the year — that requires a lot of therapy to recover,” he said. “Then, at the end of the year, that same patient has to have knee surgery, but they’ve already reached their limit of therapy services.”

Without the exception to the cap, many Medicare patients are stuck in a bind between health care they can’t afford and therapy they can’t afford to lose. “If patients do not get these therapies, they will lose function,” Miller said.

The costs of physical therapy are already high, with co-pays of $45 a visit, said Stacy Dolan of North Valley Physical Therapy. With patients already budgeting visits to get through the year, area therapy providers are advocating pressure on Congress to repeal the hard cap.

“Are patients going to pay the lights and heat and pay the grocery bill and pay for physical therapy?” Dolan asked. “I don’t want people to have to make that choice.”

Though the cap won’t impact inpatient therapy services, it will apply to outpatient providers who, like Dolan at North Valley Hospital, work on a hospital’s campus.

The application of the cap and Medicare funding can be difficult to decipher, especially for patients, according to Jason Spring, interim CEO at North Valley Hospital. “The regulatory environment is complicated and frustrating and it impacts patient care in a way that patients don’t know whether they’ll be subject to the cap or not,” he told the Daily Inter Lake.

For McGuire and other therapy providers in the Flathead, this means educating patients in person and encouraging people to call or write senators to repeal the hard cap.

“A point that we’re really trying to stress is that there are a lot of people who may not yet be on Medicare who stand to be severely impacted if this cap is not repealed,” said McGuire. “This is a current issue but it is also about the future.”

For more information, visit the American Physical Therapy Association’s website at

Reporter Adrian Horton can be reached at or at 758-4439.

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