Eli's Rehab Report

Published on Wed May 19, 2010 PDF

Rehab gets a piece of the essential benefits package pie.

Listening to the healthcare reform buzz and wondering how it affects you? Discover the direct links in the Patient Protection and Affordable Care Act (PPACA) to the therapy world, including good news for OTs, claims filing tweaks, and a growing list of open-ended questions worth tracking as the Centers for Medicare & Medicaid Services begins writing its detailed regulations for PPACA.

Best news: The PPACA established an essential benefits package for which Americans of all ages will be eligible (which takes effect Jan. 1, 2014). And rehabilitative services are included under the essential benefits package.

Even better, the essential benefits package includes devices, as well as habilitative services, points out Ingrida Lusis, director of federal and political advocacy for the American Speech-Language Hearing Association.

That's a big victory in particular for speech and occupational therapy. "Habilitation is particularly important for children and adults with developmental disabilities, autism spectrum disorders and many other chronic conditions," says Tim Nanof, federal affairs manager for the American Occupational Therapy Association.

Normally, insurance denies claims for habilitative services, so "the inclusion of this new requirement for private insurance to cover both rehabilitation and habilitation should be a big benefit," Nanof continues.

Another perk: The PPACA disallows excluding coverage due to pre-existing conditions, Lusis points out.

You now have one year to submit claims. In the past, Medicare Part B providers had 15 months or more to submit their claims to Medicare, but section 6404 of the new legislation requires you to submit your claims "one calendar year after the date of services" for service provided on or after Jan. 1, 2010.

Caveat: The legislation states that "the Secretary may specify exceptions to the 1 calendar year period" but does not yet indicate what types of situations might qualify for exceptions.

And speaking of exceptions ... Section 3103 of the PPACA extends the therapy cap exceptions process for outpatient therapy caps. The current outpatient therapy cap is $1,860 for physical therapy and speech language pathology services combined, and a separate $1,860 limit for occupational therapy services provided in a calendar year.

A downside: "We were not happy that reform didn't include a repeal of the flawed sustainable growth rate," says Kelly Lavin, director of federal government affairs for the American Physical Therapy Association. (See the related story in the News Briefs section for more information.) "We were also not happy about the Medicare market basket cuts to such settings as SNFs, home health, etc.," she adds.

The PPACA explicitly lists occupational therapy in all relevant workforce sections of the bill (P.L. 111-148), Nanof cheers. These inclusions will help address the growing demand for occupational therapists, he says. (See related story in the News Briefs section.)

Workforce provisions will provide opportunities for program expansion and funding streams for occupational therapy education and training, Nanof says. "Expansion in the area of prevention, particularly under Medicare, could be an area of growth opportunity for occupational therapy as the provision is fleshed out in the regulatory process."

Plus: OTs may see opportunities to explore home modifications, lifestyle supports, and other interventions not typically covered by health insurance under the newly created Community Living Assistance Supports and Services (CLASS) program, Nanof points out. This program will provide for community-based supportive services for people with disabilities and/or functional impairments.

Right now, the news from the healthcare legislation is quite broad, and the devil is in the details. "So much depends on what will happen in regulations," Lusis points out. "And there are always little caveats."

"This is a multi-year process with many unknowns at this point," Lavin agrees. "Currently most provisions could either be an opportunity or a concern, depending on how the Secretary [of Health and Human Services] creates programs."

Example: The following parts of PPACA may be good for PTs or may negatively impact PTs, Lavin says:

• The role of the PT in new models of care;
• The impact of new payment methodologies on physical therapy across the continuum;
• Prevention initiatives;
• Limited progress on physician self-referral; and
• The creation of an Independent Payment Advisory Commission.