Of high importance to the therapy community, President Bush signed the FY 2006 Budget Reconciliation into law on February 8, 2006. As you probably remember, this legislation offers a one-year fix to the therapy cap by creating a process whereby those in need of medically necessary procedures surpassing the limit of $1740 per year, are able to gain exceptions to the cap.

The Centers for Medicare and Medicaid Services (CMS) has issued a fact sheet for those patients who wish to apply for the therapy cap exception. The exceptions process allows for two types of exceptions for medically necessary services:  

• Automatic Exceptions.    Automatic exceptions for certain conditions or complexities are allowed without a written request.  A request to the contractor for an exception is not required when services related to these conditions and complexities are appropriately provided and documented.  It is anticipated that the majority of beneficiaries who require services in excess of the caps will qualify for automatic exceptions.
  
• Manual Exceptions.    Manual exceptions require submission of a written request by the beneficiary or provider and medical review by the contractor responsible for processing the claims.  If the patient does not have a condition or complexity that allows automatic exception, but is believed to require medically necessary services exceeding the caps--the provider/supplier or beneficiary may fax a letter requesting up to 15 treatment days of service beyond the cap.  A treatment day is a day on which one or more services are provided.  The request must include certain documentation, including a justification for the request.  Contractors will make a decision on the number of treatment days they determine are medically necessary within 10 business days.  These requests for cap exceptions should be submitted prior to the date the cap is expected to be surpassed to avoid placing the beneficiary at risk of incurring the costs of treatment if the request is denied.

For more information about applying for the therapy cap exception, please see the CMS fact sheet here: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1782

On the executive front, President Bush used his State of the Union address on January 31 to present his legislative goals for the year. Although healthcare reform played a minor role in his address, the President’s FY 2007 budget recommendations and recent US tour pushing heath savings accounts (HSAs) indicate that healthcare is indeed a priority. Moreover, Bush participated in the U.S. Department of Health and Human Services’ panel discussion on healthcare initiatives, further indicating that health care reform will be a major focus of legislation in 2006. For more information on the President’s goals for health care reform this year, please visit the White House website here: http://www.whitehouse.gov/infocus/healthcare/