[Congressional Record Volume 145, Number 30 (Thursday, February 25, 1999)]
[Senate]
[Pages S2017-S2021]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRASSLEY (for himself, Mr. Reid, Mr. Conrad, Mr. Hollings, 
        Mr. Johnson, Mr. Durbin, Ms. Collins, Mr. Daschle, and Mr. 
        Dorgan):
  S. 472. A bill to amend title XVIII of the Social Security Act to 
provide certain Medicare beneficiaries with an exemption to the 
financial limitations imposed on physical, speech-language pathology, 
and occupational therapy services under part B of the Medicare program, 
and for other purposes; to the Committee on Finance.


      The Medicare Rehabilitation benefit improvement act of 1999

  Mr. GRASSLEY. Mr. President, I rise today to introduce the Medicare 
Rehabilitation Benefit Improvement Act of

[[Page S2018]]

1999 with my colleague, Senator Reid. This legislation will enable 
seniors to receive medically necessary rehabilitative services based on 
their condition and health and not on arbitrary payment limits. We 
introduced similar legislation last Congress.
  The Balanced Budget Act (BBA) of 1997 is a very important 
accomplishment and one that I am proud to say I supported. However, in 
our rush to save the Medicare Trust Fund from bankruptcy, Congress 
neglected to thoroughly evaluate the impact the new payment limits on 
rehabilitative services would have on Medicare beneficiaries.
  The BBA included a $1500 cap on occupational, physical and speech-
language pathology therapy services received outside a hospital 
setting. This provision became effective January 1, 1999, and after 
just 31 days of implementation, an estimated one in four beneficiaries 
had exhausted half of their yearly benefit. According to a recent 
study, these limitations on services will harm almost 13 percent or 
750,000 of Medicare beneficiaries because these individuals will exceed 
the cap. While many seniors will not need services that would cause 
them to exceed the $1500 cap, others, like stroke victims and patients 
with Parkinson's disease, will likely need services beyond what the 
arbitrary caps will cover. Unfortunately, it is those beneficiaries who 
need rehabilitative care the most who will be penalized by being forced 
to pay the entire cost for these services outside of a hospital 
setting.
  The bill I am introducing would establish certain exceptions to the 
$1500 cap, for beneficiaries who have medical needs that require more 
intensive treatment than this benefit limit would allow. The Secretary 
of the Department of Health and Human Services would be required to 
implement the exceptions, and providers would be required to 
demonstrate medical necessity based on the criteria outlined in the 
bill. In essence, the bill attempts to accomplish the primary goal of 
the $1500 cap, budgetary savings, but without harming the Medicare 
beneficiary. Payment is based on the patient's condition and not on an 
arbitrary monetary amount. Help us provide access to services for those 
beneficiaries who will need these services or risk further 
complications, establish a system that makes sense, and still achieve 
the budget savings sought from the BBA without reducing Medicare 
benefits.
  Please join me and my colleagues in passing this legislation.
  Mr. President, I ask unanimous consent that the text of the bill and 
additional materials be printed in the Record.

                                 S. 472

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Medicare Rehabilitation 
     Benefit Improvement Act of 1999''.

     SEC. 2. PURPOSES.

       The purposes of this Act are as follows:
       (1) To provide certain medicare beneficiaries with an 
     exemption to the financial limitations imposed on physical, 
     speech-language pathology, and occupational therapy services 
     under section 1833(g) of the Social Security Act (42 U.S.C. 
     1395l(g)).
       (2) To direct the Secretary of Health and Human Services to 
     conduct a study on the implementation of such exemption and 
     to submit a report to Congress that includes recommendations 
     regarding alternatives to such financial limitations.

     SEC. 3. ESTABLISHMENT OF EXEMPTION TO CAP ON PHYSICAL, 
                   SPEECH-LANGUAGE PATHOLOGY, AND OCCUPATIONAL 
                   THERAPY SERVICES.

       (a) In General.--Section 1833(g) of the Social Security Act 
     (42 U.S.C. 1395l(g)) is amended by adding at the end the 
     following:
       ``(4)(A) The limitations in this subsection shall not apply 
     to an individual described in subparagraph (B).
       ``(B) An individual described in this subparagraph is an 
     individual that meets any of the following criteria:
       ``(i) The individual has received services described in 
     paragraph (1) or (3) in a calendar year and is subsequently 
     diagnosed with an illness, injury, or disability that 
     requires the provision in such year of additional such 
     services that are medically necessary.
       ``(ii) The individual has a diagnosis that requires the 
     provision of services described in paragraph (1) or (3) and 
     an additional diagnosis or incident that exacerbates the 
     individual's condition, thereby requiring the provision of 
     additional such services.
       ``(iii) The individual will require hospitalization if the 
     individual does not receive the services described in 
     paragraph (1) or (3).
       ``(iv) The individual meets other criteria that the 
     Secretary determines are appropriate.
       ``(C) Nothing in this paragraph shall be construed as 
     affecting any requirement for, or limitation on, payment 
     under this title (other than the financial limitation under 
     this subsection).
       ``(D) Any service that is covered under this title by 
     reason of this paragraph shall be subject to the same 
     reasonable and necessary requirement under section 1862(a)(1) 
     that is applicable to the services described in paragraph (1) 
     or (3) that are covered under this title without regard to 
     this paragraph.''.
       (b) Conforming Amendments.--Paragraphs (1) and (3) of 
     section 1833(g) of the Social Security Act (42 U.S.C. 
     1395l(g)) are each amended by striking ``In the case'' and 
     inserting ``Subject to paragraph (4), in the case''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to services provided on or after the date of 
     enactment of this Act.

     SEC. 4. STUDY AND REPORT TO CONGRESS.

       (a) Study.--The Secretary of Health and Human Services 
     shall conduct a study on the amendments to section 1833(g) of 
     the Social Security Act (42 U.S.C. 1395l(g)) made by section 
     3 of this Act, including a study of--
       (1) the number of medicare beneficiaries that receive 
     exemptions under paragraph (4) of such section (as added by 
     section 3);
       (2) the diagnoses of such beneficiaries;
       (3) the types of physical, speech-language pathology, and 
     occupational therapy services that are covered under the 
     medicare program because of such exemptions;
       (4) the settings in which such services are provided; and
       (5) the number of medicare beneficiaries that reach the 
     financial limitation under section 1833(g) of the Social 
     Security Act in a year (without regard to the amendments to 
     such section made by section 3 of this Act) and subsequently 
     receive physical, speech-language pathology, or occupational 
     therapy services in such year at an outpatient hospital 
     department.
       (b) Report.--Not later than 2 years after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services shall submit a detailed report to Congress on the 
     study conducted pursuant to paragraph (1), and shall include 
     in the report recommendations regarding alternatives to the 
     financial limitations on physical, speech-language pathology, 
     and occupational therapy services under section 1833(g) of 
     the Social Security Act and any other recommendations 
     determined appropriate by the Secretary. Such report shall be 
     included in the report required to be submitted to Congress 
     pursuant to section 4541(d)(2) of the Balanced Budget Act of 
     1997 (42 U.S.C. 1395l note).
                                  ____


    Medicare Rehabilitation Benefit Improvement Act of 1999--Summary

       This bill will provide certain Medicare beneficiaries with 
     an exemption based on medical necessity to the financial 
     limitation imposed on physical, speech-language pathology, 
     and occupational therapy services under part B of the 
     Medicare program. It will also direct the Secretary of Health 
     and Human Services (HHS) to conduct a study on the 
     implementation of such an exemption, and then submit a report 
     to Congress that includes recommendations regarding 
     alternatives to such financial limitations.
       The Balanced Budget Act (BBA) of 1997 imposed a $1500 cap 
     on all therapy effective January 1, 1999. There is a combined 
     $1500 cap for physical and speech-language pathology and a 
     separate $1500 cap on occupational therapy services received 
     outside a hospital setting. An estimated 750,000 
     beneficiaries will reach the cap this year. These patients 
     may be victims of stroke, brain-injury, or other serious 
     conditions requiring additional services.
       This bill establishes certain criteria in order for 
     Medicare beneficiaries to be eligible for an exemption from 
     the $1500 cap and allows the Secretary of HHS to establish 
     additional criteria if necessary. The criteria include:
       (1) the beneficiary must be diagnosed with an illness, 
     injury, or disability that requires additional physical, 
     speech-language pathology, or occupational therapy services 
     that are medically necessary in a calender year, or
       (2) the beneficiary has a diagnosis that requires such 
     therapy services and has an additional diagnosis or incident 
     that exacerbates his/her condition (ie: diabetes), which 
     would require more services, or
       (3) the beneficiary will require hospitalization if he/she 
     does not receive the necessary therapy services, or
       (4) the beneficiary meets other requirements determined by 
     the Secretary of HHS.
       The bill also requires the Secretary of HHS to conduct a 
     study and to report to Congress two years after the date of 
     enactment of this Act. This study will include:
       (1) the number of Medicare beneficiaries that receive 
     exemptions to the cap;
       (2) the diagnoses of the beneficiaries;
       (3) the types of therapy services that are covered due to 
     such exemptions;
       (4) the settings in which services are provided; and
       (5) the number of beneficiaries that reach the $1500 cap.
                                  ____

                                         American Speech-Language-


                                          Hearing Association,

                                 Rockville, MD, February 19, 1999.
     Hon. Charles E. Grassley,
     Chairman, U.S. Senate Special Committee on Aging, Washington, 
         DC
       Dear Chairman Grassley: The American Speech-Language-
     Hearing Association

[[Page S2019]]

     (ASHA) is pleased to support the ``Medicare Rehabilitation 
     Benefit Improvement Act of 1999.'' ASHA is the professional 
     and scientific organization of more than 96,000 speech-
     language pathologists, audiologists, and speech, language, 
     hearing scientists. Our members provide services in a number 
     of practice settings, including hospitals, clinics, private 
     practice, and home health agencies.
       There is a clear need for exemptions from the Medicare 
     financial limitations for beneficiaries receiving outpatient 
     rehabilitation services. Since the provision went into effect 
     on January 1, 1999, ASHA has received numerous calls and 
     letters of concern from our members regarding the problems 
     created by the financial limitation. Patients are actually 
     refusing medically necessary treatment for fear that they may 
     have a more acute episode or injury later in the year and 
     want to keep their $1500 ``banked'' for such a possibility. 
     Essentially, the cap's arbitrary limit is indirectly forcing 
     patients to inappropriately ration needed care that we 
     believe will ultimately cost the Medicare program more.
       A patient who requires both speech-language pathology 
     services and physical therapy services is placed in a true 
     dilemma. If the patient who has suffered a stroke chooses to 
     receive speech-language pathology services, the patient may 
     not have sufficient funding for physical therapy at the 
     conclusion of the speech-language pathology treatment. 
     Conversely, the patient who selects physical therapy may not 
     have adequate funding for the speech-language pathology 
     services. A third situation arises when the patient receives 
     both rehabilitation services concurrently and the programs 
     for both are inadequate because the financial limitation is 
     not sufficient for receipt of both health care services.
       I am enclosing a copy of a letter addressed to Congress 
     that ASHA received early this year from a family member whose 
     mother is receiving speech-language pathology services for a 
     swallowing disorder. Ms. Carol Eller McCaffrey of Lawrence, 
     Kansas, begins her letter with:
       ``I am the daughter of an 87-year-old woman whose brain 
     stem stroke left her unable to swallow or speak well and 
     weakened her right side, and whose quality of life will 
     suffer greatly with $1500 Medicare cap.
       ``The new cap will all but completely discontinue . . . 
     treatment thus requiring increased hydration through an 
     alternative feeding tube which we have left intact for these 
     emergencies. Taking away the very important . . . therapy 
     causes the need for more nursing care. Also, her quality of 
     life is `down the tubes' when mother is unable to eat and 
     drink comfortably.''
       This is but one example of the problems that arise because 
     of the arbitrary Medicare financial limitation. As 1999 
     progresses, there will undoubtedly be more examples of 
     difficulties caused by the cap unless legislation such as 
     yours can restore reasonable benefits in the program.
       The members of the American Speech-Language-Hearing 
     Association are committed to improving the health and safety 
     of those who suffer communication and related disorders. Your 
     legislation will make it possible for more Americans to 
     receive the care they need. ASHA commends you for your 
     efforts to seek a remedy to the cap that ensures patient 
     access to medically-needed services through the ``Medicare 
     Rehabilitation Benefit Improvement Act of 1999.''
           Sincerely,
                                                    Donna Geffner,
     President.
                                  ____

                                                  January 1, 1999.
       Honorable Congressional Leaders: I am not a professional in 
     the medical world nor am I very knowledgeable about the 
     logistics of medicare. I am the daughter of an 87 year old 
     woman whose brain stem stroke left her unable to swallow or 
     speak well and weakened her right side and whose quality of 
     life will suffer greatly with the $1500.00 medicare gap.
       With them help of our speech and physical therapists, 
     Mother has come a long way. Although she still doesn't speak 
     well, she eats normal food in the dining room with fellow 
     residents. Mother has a problem with thin liquids that causes 
     choking and probable aspiration. A new treatment called Deep 
     Pharyngeal Neuromuscular Stimulation (DPNS) is being taught; 
     our speech therapist has treated Mom with DPNS, resulting in 
     a 90% improvement. In my mother's case, the problem is that 
     several months after treatment, the benefits wear off. 
     Periodically, Mother needs another round of DPNS.
       The new cap will all but completely discontinue this 
     treatment thus requiring increased hydration through an 
     alternative feeding tube which we have left intact for these 
     emergencies. Taking away the very important DPNS therapy 
     causes the need for more nursing care. Also, her life quality 
     of life is ``down the tubes'' when mother is unable to eat 
     and drink comfortably.
       Mom also needs continual assertive physical therapy to keep 
     her strength up but the guidelines, even before the medical 
     cap, require a decrease in her function to qualify for 
     treatment. So, periodically, as Mother weakens, therapists 
     have to start over. This seems backwards to me. I thought 
     that as a nation, we were making great strides in the care of 
     our elderly and disabled. In my opinion, the recent medicare 
     cap is a huge backslide. Does the left hand of the government 
     know what the right hand is doing? And look who's suffering? 
     Obviously those making the rules have not had personal 
     experiences in this area.
       The paperwork for all medical personnel is already 
     overwhelming. Our professionals are spending more time with 
     paper than with patients! All this, I presume, to try and 
     thwart cheaters. I feel the cheaters are the minority and it 
     all comes down to punishing the patients.
       You are smart people. Come up with a reasonable way to deal 
     with this situation without losing sight of what is truly 
     important--the patients.
       Private pay is exorbitant--Have you checked? There is no 
     way normal families can take up where medicare leaves off.
       Please, rethink this decision to cap medicare part B 
     benefits. It is, after all, this particular generation who 
     have supported the US Government through thick and thin. 
     Don't let them down, visit nursing home/ care facilities. 
     Speak with hard working, caring therapists and the red, 
     white, and blue Americans who need your help. It is in your 
     own best interests * * * you'll be there yourself one day.
           Sincerely,
     Carol Eller McCaffrey.
                                  ____

                                                 American Physical


                                          Therapy Association,

                                Alexandria, VA, February 22, 1999.
     Hon. Charles Grassley,
     Chairman, Senate Special Committee on Aging, Washington, DC.
       Chairman Grassley: On behalf of the more than 74,000 
     members of the American Physical Therapy Association (APTA) 
     and the patients our members serve, I am writing to express 
     our strong support and appreciation for your leadership in 
     introducing the ``Medicare Rehabilitation Benefit Improvement 
     Act of 1999.''
       As you know, section 4541(c) of the Balanced Budget Act of 
     1997 imposes annual caps of $1,500 per beneficiary on all 
     outpatient rehabilitation services except those furnished in 
     a hospital outpatient department. The new law has been 
     interpreted to establish two separate limits--$1,500 cap for 
     physical therapy and speech-language pathology services and a 
     separate $1,500 cap for occupational therapy services. These 
     limits are effective for services rendered on or after 
     January 1, 1999.
       APTA maintains concern with the impact this limitation on 
     services will have on Medicare beneficiaries who require 
     physical therapy treatment. Senior citizens and disabled 
     citizens eligible for Medicare benefits suffering from a 
     range of conditions including stroke, hip fracture, 
     Parkinson's Disease, cerebral palsy and other serious 
     conditions that require extensive rehabilitation may not be 
     able to access the care they require to resume normal 
     activities of daily living due to the present limitation on 
     coverage. Enactment of your legislation provides the 
     Secretary of the U.S. Department of Health and Human Services 
     the authority to establish exceptions to the present $1,500 
     cap for patients with conditions that would likely exceed 
     such a limitation on coverage. APTA applauds the inclusion of 
     this provision.
       APTA maintains concern that the $1,500 cap is completely 
     arbitrary and bears no relation to the medical condition of 
     the patient nor the health outcomes of the rehabilitation 
     services. There exists absolutely no medical or empirical 
     justification for such a cap. The caps are by definition 
     completely insensitive to patients with chronic injuries and 
     illness or who have multiple episodes of care in a given 
     calendar year. Enactment of your legislation would provide 
     relief from the $1,500 annual cap for Medicare beneficiaries 
     who experience multiple episodes of care in a given calendar 
     year for services that are deemed medically necessary. APTA 
     applauds the inclusion of this provision.
       APTA maintains concern that the $1,500 cap dramatically 
     reduces Medicare beneficiaries' choice of care giver. Under 
     the present statute, beneficiaries who have exceeded their 
     cap in need of additional rehabilitation services are 
     restricted from receiving care from facilities other than 
     outpatient hospital departments. This restriction is a 
     notable step backward in Congress' efforts to expand access 
     to care, especially in rural and urban underserved 
     communities. Enactment of your legislation would better 
     ensure access to a wide range of community settings in which 
     Medicare beneficiaries could receive care, to include 
     rehabilitation agencies, Comprehensive Outpatient 
     Rehabilitation Facilities, and physical therapy private 
     practices. APTA applauds the inclusion of this provision.
       Lastly, APTA continues to object to the inclusion of 
     physical therapy and speech-language pathology under the same 
     $1,500 cap. Confusion has surrounded the interpretation of 
     how the $1,500 cap is to be applied. As the Medicare Policy 
     Advisory Committee (MedPAC) reported to Congress in its July 
     1998 report, 70 percent of outpatient therapy expenditures 
     under the program are for physical therapy services, while 21 
     percent are for occupational therapy, and 9 percent for 
     speech therapy. The combination of physical therapy and 
     speech therapy has no rational basis. Speech therapy is a 
     distinct and separate benefit provided under the Medicare 
     program and should not be included as a part of the physical 
     therapy benefit. While your legislation does not clarify this 
     issue, APTA is hopeful that Congress will address this issue 
     with common sense clarifications as it considers Medicare 
     revisions this year. APTA will continue to work with you to 
     achieve this end.

[[Page S2020]]

       Physical therapists across Iowa and the nation applaud your 
     leadership on this important issue. Passage of the Medicare 
     Rehabilitation Benefit Improvement Act of 1999 can ensure 
     that patients in need of outpatient physical therapy services 
     receive appropriate care in the setting of their choice 
     without the fear of exceeding their coverage. APTA stands 
     ready to assist you in any way to ensure that swift enactment 
     of this important legislation.
           Sincerely,
                                              Nancy Garland, Esq.,
     Director of Government Affairs.
                                  ____



                             American Health Care Association,

                                Washington, DC, February 24, 1999.
     Hon. Charles Grassley,
     Dirksen Senate Office Building,
     Washington, DC.
       Dear Senator Grassley: On behalf of the American Health 
     Care Association, long term care providers, and those for 
     whom we provide care, I'm writing you to commend you on your 
     leadership in introducing legislation designed to protect 
     America's most frail and elderly from the adverse effects of 
     arbitrary caps on certain medical services.
       One of the provisions contained in the 1997 Balanced Budget 
     Act (BBA) has the potential to harm senior citizens who rely 
     on Medicare for their health care needs. Congress changed 
     Medicare by imposing arbitrary annual limits of $1500 for 
     outpatient rehabilitation services. This includes a $1500 cap 
     on occupational therapy and a $1500 cap on physical therapy 
     and speech-language-pathology combined. Arbitrary caps do not 
     reflect the real rehabilitation needs of Medicare 
     beneficiaries and target the sickest and most vulnerable.
       Your efforts will protect senior citizens suffering from 
     common medical conditions such as stroke and hip fractures. 
     These seniors may not be able to obtain the rehabilitative 
     care they require to resume normal activities of daily living 
     because the $1500 limits are too low to pay for the services 
     which responsible medical practice deem necessary.
       Once again, thank you for taking the lead to redress the 
     problem posed by these arbitrary caps. On behalf of the 
     American Health Care Association, we commend you and stand 
     eager to assist you in your efforts.
           Sinceerely,
                                                    Bruce Yarwood,
     Legislative Counsel.
                                  ____

                                         The American Occupational


                                    Therapy Association, Inc.,

                                  Bethesda, MD, February 23, 1999.
     Hon. Charles Grassley,
     Chairman, Special Committee on Aging, U.S. Senate, 
         Washington, DC.
       Dear Chairman Grassley: On behalf of the 60,000 members of 
     the American Occupational Therapy Assn., I would like to 
     commend and thank you for your leadership in introducing the 
     Medicare Rehabilitation Benefit Improvement Act of 1999.
       The financial limitation on outpatient rehabilitation, 
     including occupational therapy, imposed by the Balanced 
     Budget Act of 1997 was, in AOTA's view, a misguided attempt 
     to constrain Medicare costs which is having a harmful effect 
     on patient care. The payment limitation interposes government 
     between a patient and a health care provider; it restricts 
     patient choice, and could have the unintended consequence of 
     exacerbating patient conditions causing Medicare cost 
     increases.
       Your bill will allow for patients such as those with 
     multiple injuries, illnesses or disabilities; those with more 
     than one incident of need in a year and, through the 
     Secretary's authority to establish criteria, those whose 
     diagnosis or condition requires extensive therapy to receive 
     the treatment which the Medicare coverage criteria guarantees 
     them.
       AOTA has been very concerned that individuals with 
     condition such as severe strokes, spinal card injury, 
     traumatic brain injury, extensive fractures, severe burns, or 
     diseases such as Parkinson's or multiple sclerosis will be 
     restricted in their access to needed occupational therapy 
     before the rehabilitation process is completed. Your bill 
     will allow for these and other individuals to have access to 
     appropriate care.
       Your efforts will move policy forward and establish some 
     necessary protections for Medicare beneficiaries. AOTA 
     appreciates your efforts to ameliorate the impacts of this 
     unwise policy.
       We look forward to working with you as the bill moves 
     through the legislative process. Please contact me if I can 
     be of further assistance.
           Sincerely,
                                             Christina A. Metzler,
     Director, Federal Affairs Department.
                                  ____

                                           National Association of


                                      Rehabilitation Agencies,

                                    Reston, VA, February 23, 1999.
     Charles E. Grassley,
     Chairman, Senate Special Committee on Aging, U.S. Senate, 
         Washington, DC.
       Dear Chairman Grassley: The National Association of 
     Rehabilitation Agencies (``NARA'') strongly endorses the 
     Medicare Rehabilitation Benefit Improvement Act of 1999 and 
     applauds your initiative in introducing this important 
     legislation. NARA represents over 225 Medicare-certified 
     rehabilitation agencies which provide physicial therapy, 
     speech-language pathology, and occupational therapy services 
     to hundreds of thousands of Medicare beneficiaries annually.
       The $1500 financial limitation on outpatient rehabilitation 
     services, as established by the Balanced Budget Act of 1997, 
     constitutes an arbitrary limit on the amount of services 
     which a Medicare enrollee may receive. The caps bear no 
     relation to the patient's medical need for rehabilitation 
     services nor the beneficial health outcomes which would flow 
     from the provision of such services. The most pernicious 
     aspect of the limitations is that they will deprive Medicare 
     patients who are most in need of rehabilitation--e.g. stroke 
     victims and those suffering from traumatic brain injury--of 
     the very care they require.
       You legislation is a workable and realistic solution to 
     many of the patient care and access problems caused by the 
     $1500 limitations. NARA's members are deeply appreciative of 
     the time and effort which you and your staff have expended in 
     developing the Medicare Rehabilitation Benefit Improvement 
     Act of 1999. NARA pledges to work with you to ensure that 
     this critical proposal becomes law.
           Sincerely,
                                                 Larry Fronheiser,
     President.
                                  ____

         Private Practice Section, American Physicial Therapy 
           Association,
                                Washington, DC, February 23, 1999.
     Charles E. Grassley,
     Chairman, Senate Special Committee on Aging, U.S. Senate, 
         Washington, DC.
       Dear Chairman Grassley: The Private Practice Section of the 
     American Physical Therapy Association has carefully reviewed 
     your proposed legislation, the Medicare Rehabilitation 
     Benefit Improvement Act of 1999, and is pleased to express 
     its support for this legislation.
       The membership of the Private Practice Section is comprised 
     of physical therapists in independent practice who, for many 
     years, have been subject to a financial limitation on the 
     amount which Medicare will pay for their services furnished 
     to any Medicare beneficiary. As a result, the Section's 
     members understand all too well the harmful effects which the 
     arbitrary $1500 caps will have on Medicare beneficiaries who 
     require outpatient rehabilitation services. Your proposal is 
     a sensible and practical approach to protecting those 
     patients.
       Your legislation is entirely consistent with the Private 
     Practice Section's goals and objectives for ensuring that 
     Medicare beneficiaries have access to all necessary 
     rehabilitation services. Accordingly, we are pleased to 
     proffer our commitment to help secure its enactment.
       That you for your leadership on this essential piece of 
     legislation.
           Sincerely,
                                                        Lisa Wade,
     Chief Executive Officer.
                                  ____

                                      National Association for the


                                    Support of Long Term Care,

                                Alexandria, VA, February 24, 1999.
     Hon. Charles E. Grassley,
     U.S. Senate,
     Washington, DC.
       Dear Mr. Chairman: On behalf of the National Association 
     for the Support of Long Term Care (NASL), we applaud your 
     leadership and your colleagues who have joined you in the 
     introduction of legislation entitled the ``Medicare 
     Rehabilitation Benefit Improvement Act of 1999.'' You have 
     developed a rational, good policy that will help 
     beneficiaries who would otherwise be limited in their 
     availability of rehabilitation services.
       The National Association for the Support of Long Term Care 
     (NASL) is an organization that represents over 150 providers 
     offering services in the long term care setting. We work 
     daily with patients who need rehabilitation services and this 
     limitation is hurting seniors access to services. There are 
     seniors in America who are already reaching the cap and they 
     need additional services that are medically necessary. These 
     are seniors who have had strokes. These are seniors who have 
     Parkinson's disease. These are seniors who have had hip 
     replacements and an additional illness. Senator Grassley, we 
     want to thank you for helping these patients get services 
     that are medically necessary.
       We are ready to help you share information about the 
     adverse effects of this cut in benefits that was enacted in 
     the BBA in 1997. We are certain that this was not the intent 
     of the law--and now that it is implemented, seniors will be 
     denied care. Your legislation will go a long way to ensure 
     that the most disadvantaged and ill seniors will get the care 
     that they need. The stroke patient that needs speech-language 
     pathology to learn how to swallow will get care. The 
     Parkinson's patient who is learning how to walk with an 
     exacerbating illness will get physical therapy in order to 
     improve.
       Again, we applaud your leadership and strongly support this 
     legislation. Please feel free to call on us for support and 
     help.
           Sincerely yours,
     Peter Clendenin.
                                  ____

                                                     Easter Seals,


                                     Office of Public Affairs,

                                Washington, DC, February 25, 1999.
     Hon. Charles E. Grassley,
     Chairman, Senate Special Committee on Aging, Washington, DC.
       Dear Mr. Chairman: Easter Seals is very pleased to support 
     the introduction of the ``Medicare Rehabilitation Benefit 
     Improvement Act of 1999.'' This legislation begins to 
     eliminate damaging limitations on needed

[[Page S2021]]

     therapy services for Medicare beneficiaries. Easter Seals is 
     committed to assisting you and your colleagues to improve and 
     enact this critical measure.
       Easter Seals is dedicated to assisting children and adults 
     with disabilities to live with equality, dignity, and 
     independence. Each year, Easter Seals 106-affiliate network 
     serves more than one million people nationally. Thousands of 
     Medicare beneficiaries and their families rely on Easter 
     Seals for community-based physical therapy, occupational 
     therapy, and speech-language pathology services. Without such 
     services, these beneficiaries would experience diminished 
     health, function, and quality of life.
       Current Medicare policy limiting payment for outpatient 
     medical rehabilitation services to $1,500 for occupational 
     therapy and $1,5000 for physical therapy and speech-language 
     pathology services combined is out-of-step with the real 
     medical needs of a significant share of Medicare 
     beneficiaries. It will cause beneficiaries with serious 
     medical needs resulting from illness, injury, and disability, 
     including stroke, traumatic brain injuries, total joint 
     replacement, and other serious conditions, to forfeit needed 
     care or seek such care in less cost-effective, often 
     inappropriate institutional settings.
       For many Easter Seals Medicare clients the impact of 
     current policy is devastating. One client's situation, if 
     constrained by a $1,500 cap, illustrates this point.
       Eighty-four-year old Richard H. lived independently with 
     his wife when, on February 27, 1997, he experienced a serious 
     stroke. Prior to the stroke he had high blood pressure, heart 
     disease, and diabetes. The stroke paralyzed his left side, 
     seriously impaired his vision, and left him very depressed.
       Physical therapy helped him learn to move independently and 
     to walk safely again. Occupational therapy retrained him in 
     the tasks of daily living, including preparing food, 
     toileting, and home safety. Speech and swallowing therapy 
     eliminated his choking on food, which presented a high risk 
     of aspiration pneumonia. This therapy, combined with much 
     determination and effort by Richard and his wife, has enabled 
     him to resume living independently at home.
       The doctors, therapists and family agree that without this 
     full course of medical rehabilitation, Richard would now be 
     helpless, severely depressed, and confined to a very 
     expensive nursing home for care. The current Medicare policy 
     limiting medical rehabilitation therapy services under the 
     $1,500 cap, with no exemptions, would have deprived Richard 
     of 62% of his needed rehabilitation treatment.
       Easter Seals believes that the ``Medicare Rehabilitation 
     Benefit Improvement Act of 1999'' is a necessary, timely, and 
     thoughtful approach to correcting serious problems for 
     Medicare beneficiaries requiring comprehensive services. 
     Easter Seals will work with you and your Senate colleagues to 
     refine this legislation, as appropriate, and promote its 
     enactment into law.
       Thank you very much for your commitment to assuring 
     Medicare beneficiaries the services that they need to live 
     healthy, productive lives.
           Sincerely,
                                                 Randall L. Rutta,
                             Vice President, Government Relations.

  Mr. REID. Mr. President, I rise in strong support of the ``Medicare 
Rehabilitation Benefit Improvement Act of 1999''. This legislation is 
designed to protect our sickest, most vulnerable seniors from the 
adverse effects of arbitrary limits on crucial rehabilitative services.
  The Balanced Budget Act of 1997 (BBA) created annual caps for two 
categories of therapy provided to beneficiaries under Medicare Part B: 
a $1500 annual cap on physical therapy and speech language combined; 
and a separate cap for occupational therapy. These arbitrary limits on 
rehabilitation therapy were hastily included in the BBA without the 
benefit of Congressional hearings or thorough review by the Health Care 
Financing Administration. As a result, the $1500 limits bear no 
relation to the medical condition of the patient, or the health 
outcomes of the rehabilitative services.
  The $1500 caps would create serious access and quality problems for 
Medicare's oldest and sickest beneficiaries. Senior citizens who suffer 
from common conditions such as stroke, hip fracture, and coronary 
artery disease, will not be able to obtain the rehabilitative services 
they need to resume normal activities of daily living. A stroke patient 
typically requires more than $3,000 in physical therapy alone. 
Rehabilitation therapy for a patient suffering from Multiple Sclerosis 
or ALS costs even more. Without access to outpatient therapy, patients 
must remain in institutional settings longer, be transferred to a 
higher cost hospital facility, or in some cases, just go without 
necessary services.
  Coverage for rehabilitative therapy should be based on medically 
necessary treatment, not arbitrary spending limits that ignore a 
patient's clinical needs. During the 105th Congress, I joined with 
Senator Grassley to introduce legislation that would correct this 
problem. The ``Medicare Rehabilitation Benefit Improvement Act of 
1999'' builds on our effort to ensure that all Medicare beneficiaries 
have access to the crucial therapy services they need.
  Our bill establishes criteria by which Medicare beneficiaries would 
be eligible for an exemption from the $1500 cap. According to our bill, 
any beneficiary who would require hospitalization if he did not receive 
the necessary therapy services would be allowed to exceed the cap. 
Beneficiaries suffering from a diagnosis that requires therapy services 
and has an additional diagnosis that exacerbates this condition would 
also be eligible for therapy services above the $1500 limit. In 
addition, any beneficiary that is diagnosed with an illness, injury, or 
disability that requires additional physical, speech-language 
pathology, or occupational therapy services that are medically 
necessary will receive the therapy services he or she requires. 
Finally, our bill gives the Department of Health and Human Services 
Secretary the flexibility to establish additional criteria if 
necessary.
  The $1500 therapy caps penalize our most frail and elderly citizens. 
Not only does allowing our seniors to have access to critical 
outpatient therapy services makes sense, it is the right thing to do. I 
urge you to join me in protecting Medicare's most vulnerable 
beneficiaries by supporting the ``Medicare Rehabilitation Benefit 
Improvement Act of 1999''.
                                 ______