As the New Year approaches, there are changes afoot for many insurance plans. It is common for insurance plans to ‘roll over’ at the beginning of the calendar year. This typically means that a new set of benefits is available to each plan holder. It may also mean that there are updates to plan attributes such as deductibles, co-insurance, and pre-authorization requirements. As a health-care consumer, it is important to know what to expect from your insurance coverage in the New Year. It is Symmetry’s recommendation to take a look at the physical therapy benefits for your individual policy for 2018, so that you can make appropriate plans for how to most effectively utilize your benefits through the year.
The New Year will bring changes to all types of insurance plans. Symmetry has been specifically following the development of changes pertaining to Medicare, which as a large federal policy will affect healthcare benefits for 55 million Americans. We think it is important that our clients are aware of some important information with regard to Medicare coverage for physical therapy. Below is a summary of what is currently occurring.
- The 2018 Medicare benefit for the combination of Physical Therapy and Speech Therapy is set at $2010. Depending on what types of treatment are being administered in any given office visit, this allowance might cover somewhere between 10 and 20 therapy sessions.
- Traditionally over the last decade, there has been an ‘Exceptions Process’ in place that allows additional therapy services to be covered beyond the stated benefit ‘cap’. When a patient qualifies for additional services, treatment providers have typically been able to continue to bill Medicare, as long as services are coded with a ‘modifier’ designating that continued care is appropriate. This exceptions process DOES NOT EXIST for 2018.
- The United States Congress has been discussing modifications to Medicare benefits for Physical Therapy / Speech Therapy for the last several months. Until recently, it was expected that Congress would enact changes that would eliminate a specific dollar limit to the quantity of therapy that could be eligible for coverage. This would have been a good thing for health care consumers – particularly those that have multiple or complicated medical conditions that require ongoing or intermittent therapy.
- Congress has now gone on recess without passing legislation that included the Medicare provisions being discussed. The adjournment also occurred without the passing of any extension to previous temporary fixes to Medicare policy rules.
- Congress will not return until mid-January. Thus, further action on Medicare will not occur for at least several weeks. How quickly the issue is brought back to the table or put up for a vote remains to be seen.
So what does this mean for patients with Medicare insurance? In short, it means that at the moment, there is only guaranteed coverage for Physical Therapy & Speech Therapy until the services billed total $2010. Patients will be responsible for any therapy expenses over this amount unless or until Congress acts on planned modifications to the Medicare billing process. While it is likely and expected that some type of corrective action will occur fairly early in the year, the specifics are currently uncertain.
Symmetry is continuing to monitor Congressional action regarding Medicare and is actively involved in the process of lobbying for changes to Medicare coverage that allow patients to adequately access and utilize physical therapy / speech therapy services. We will be passing along updated information as it becomes available. In the meantime, we want you to be aware of what is taking place in Congress.
We are in agreement with our professional organization and many other health care providers that the situation that Congress’ inaction on Medicare issues has produced is a terrible scenario for Americans that rely on access to rehabilitation services to maintain their health and daily function. The uncertainty of beginning the year without knowing that sufficient medical coverage for therapy is available is at best inconvenient and at worst a significant issue for health care consumers.
If you would like to read more about this issue, please check out this post from Physical Therapy in Motion. If you would like to reach out to your specific U. S. Congressional representatives to tell them about how Medicare coverage affects you personally, and to urge them to take action on this issue, check out this website for contact information.
If you have specific questions about how your individual insurance coverage will work for you in 2018, we encourage you to contact your insurance plan’s customer service representatives and/or your plan’s written or electronic coverage and benefits summaries. Contact information is typically printed directly on your insurance cards. We hope to be able to provide an update on the Medicare therapy benefits situation in Symmetry’s newsletter in January. Watch this space for further information…