Memorandum in Opposition S.2809-A/A.4009-A, Part H, Section 27
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Memorandum in Opposition

S.2809-A/A.4009-A, Part H, Section 27

Budget Proposal to Cap Physical, Occupational and Speech Therapy to 20 visits in a 12 month period


The New York Physical Therapy Association (“NYPTA”), which represents the interests of 12,000 physical therapists, physical therapist assistants and physical therapy students in New York, respectfully opposes the above referenced proposal which would restrict access to therapy services by imposing an arbitrary cap on number of visits regardless of the medical necessity of the services.

Medicaid enrollees suffering from major medical conditions which require significant therapy services will be hardest hit by the proposal - stroke victims, individuals experiencing a traumatic brain injury and individuals recovering from a major orthopedic event such as a total joint replacement. For each of these medical conditions, 20 visits in 12 months will likely be an inadequate level of care. For example, a stroke victim discharged home and ordered to receive PT, OT and speech, three times a week, will only be eligible for a little over 2 weeks of care. As a result, the proposal will produce poor outcomes such as re-injury, re-hospitalization and increased institutional placements. The proposal may also delay discharges from acute care and sub-acute facilities. All events that will impose far greater costs on the Medicaid system than any savings attributable to the visit limits.

The proposal is also entirely unnecessary. Under the proposals adopted by the Medicaid Design Team, the State will enroll the entire Medicaid population into managed care over a three year period. Managed care will review therapy services and deny coverage for services that are not medically necessary, ruling out any unnecessary care. If the patient or their health care provider believes that the services are needed, the denial of care can be appealed through the appeals processes afforded by the managed care patient bill of rights. Under the budget proposal, the Medicaid enrollee is afforded no relief from the cap regardless of the necessity of the care. Indeed, a similar cap for Medicare Part B contains an exceptions process similar to the managed care bill of right’s appeals process.

NYPTA opposes arbitrary therapy caps as inartful attempts to restrict access to care regardless of the necessity of the care. At the very least, any cap should have a built in appeals process to protect the enrollee and ensure that unnecessary re-injuries or institutionalizations occur. That the above referenced proposal fails to provide for an exceptions process makes it a particularly pernicious proposal.

For the above reasons, NYPTA requests that your opposition to the cap on outpatient therapy care.

posted 3/17/2011

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