The CAP is an alternative to the ASP (buy and bill) methodology for acquiring certain Part B drugs which are administered incident to a physician's services.
What is the Medicare therapy cap?
Nov 02, 2005 · The CAP program was established through an interim final rule issued on July 6, 2005 by the Centers for Medicare & Medicaid Services (CMS). In order to improve overall access to drugs furnished under Part B and to increase interest in the program, certain aspects of the CAP were revised in two rules issued today.
What happened to the Medicare competitive Acquisition Program (CAP)?
Prior to 2018, Medicare enforced a ‘therapy cap’ for any beneficiary receiving physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) services. Ultimately, a patient was only able to receive treatment until a set amount, after which the services would not be eligible for reimbursement by Medicare.
What is cap for supplemental insurance companies?
The CAP and its pathologist Contractor Advisory Committee (CAC) representatives advocate for fair reimbursement policies at the local Medicare level. By reviewing and commenting on pathology-related Local Coverage Determinations (LCDs) and policy changes before they are implemented, the CAP helps ensure that all pathologists are appropriately reimbursed for …
What does Medicare savings program pay for?
Therapy services: Medicare limits the amount of coverage you can get as an outpatient for physical or occupational therapy and speech-language pathology in any given year. In 2014 the limits are $1,920 for occupational therapy and $1,920 for physical therapy and speech-language pathology combined.
Current CAP Activity
Information about 2008 CAP claims submission deadlines and instructions about what to do with unused CAP drugs are posted on the Information for Physicians and Approved CAP Vendor pages.
September 18, 2008 Ask the Contractor Teleconference (ACT) PowerPoint Presentation
On September 18, 2008, CMS hosted an ACT for CAP physicians to discuss the postponement of the CAP for 2009 and to assist participating CAP physicians in planning for the transition out of the program. The ACT was moderated by Noridian Administrative Services (NAS), the CAP Designated Carrier.
2009 CAP Postponement
On September 10, 2008, the Centers for Medicare & Medicaid Services (CMS) announced the postponement of the 2009 Medicare Part B Competitive Acquisition Program (CAP). The program will continue through December 31, 2008.
The LCD Process and CAC Representatives
The CAP and its pathologist Contractor Advisory Committee (CAC) representatives advocate for fair reimbursement policies at the local Medicare level.
Medicare LCD Reform
The CMS announced in October 2018 the revision of Chapter 13 of Medicare’s Program Integrity Manual, which addresses LCDs. The revisions, the first changes to the manual since 2015, are in response to legislative requirements and comments from stakeholders, like the CAP.
When is NC Medicaid CAP/DA?
During the month of June 2019 , NC Medicaid Long-Term Services and Supports held a Community Alternatives Program for Disabled Adults (CAP/DA) Home- and Community-Based Services (HCBS) waiver orientation and educational training for CAP/DA HCBS providers.
When does the 1915 C waiver expire?
The 1915 (c) Home and Community-Based Services Waiver for the Community Alternatives Program for Disabled Adults (CAP/DA) is scheduled to expire on Sept. 30, 2018. The NC Division of Medical Assistance (DMA) must submit a waiver renewal application to the Centers for Medicare and Medicaid Services (CMS) no later than June 1, 2018, ...
What is a disabled adult?
A disabled adults 18 years old and older. An individual who is determined to require a level of institutional care under the State Medicaid Plan. An individual who needs at least one or more CAP/DA home-and community-based services based on a reasonable indication of need assessment that must be coordinated by a CAP/DA case manager.
What is a personal assistant?
Independently recruiting, hiring, supervising, and firing (when necessary) an employee (personal assistant); Independently setting a pay rate for an employee (personal assistant); and. Assigning work tasks for the employee (personal assistant) based on medical and functional needs.
How To Find Services In My Area
You can locate a HICAP office in your area by selecting your county on the Find Services in My County page of this website or by calling 1-800-434-0222.
Program Data
For past and current program data visit the CDA COVID-19 Response Data Dashboard and the Data and Reports sections of the website.
How to review a claim?
Factors used to select claims for review may include the following: 1 The provider has had a high claims denial percentage for therapy services or is less compliant with applicable requirements. 2 The provider has a pattern of billing for therapy services that is aberrant compared with peers, or otherwise has questionable billing practices for services, such as billing medically unlikely units of services within a single day. 3 The provider is newly enrolled or has not previously furnished therapy services. 4 The services are furnished to treat targeted types of medical conditions. 5 The provider is part of group that includes another provider identified by the above factors.
What is the KX modifier threshold for BBA?
Along with the KX modifier threshold, the BBA of 2018 retains the targeted medical review process that was established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). For 2018 through 2028, the targeted medical review threshold is $3,000 for PT and SLP services, and $3,000 for OT services. (After 2028, the threshold will be indexed annually by the MEI.) As the name implies, targeted medical review means that not all claims exceeding the therapy threshold amount are subject to review.
What does KX mean in a claim?
Add the KX modifier to claim lines to indicate that you are attesting that services at and above the therapy thresholds are medically necessary , and that documentation in the patient's medical record justifies the services. This includes documentation that patients, based on their condition, require continued skilled therapy—ie, therapy beyond the amount payable under the threshold to achieve their prior functional status or maximum expected functional status within a reasonable amount of time.
How long does a hospice have to be in cap year?
In this situation, the initial cap calculations for newly certified hospices must cover a period of at least 12 months but less than 24 months.
When do hospices have to file a cap?
Hospices are required to file a self-determined cap no earlier than 3 months after, and no later than 5 months after the end of the hospice cap year, September 30. The earliest a hospice may file its self-determined cap is December 31, and the latest is February 28 of each year.
How long does it take for CGS to review self-determined cap?
Hospices will receive a letter from CGS to confirm receipt of the filed self-determined aggregate cap calculation within 45 days of receipt.
When was the sequestration order issued?
The sequestration order, first issued on March 1, 2013, has been extended for services with dates of service or dates of discharge April 1, 2013 until further notice. For information about how sequestration amounts are handled pertaining to the hospice cap calculation, refer to the " Sequestration – Impact on Hospice Aggregate Cap Calculations " article. Please note that this article references dates based on the 2013 cap year; however the information applies to other cap years.
What Is Cap/Da?
- A Medicaid Home and Community-Based Services (HCBS) program authorized under section1915(c) of the Social Security Act and complies with 42 CFR § 440.180, Home and Community-Based Waiver Services. This waiver program provides a cost-effective alternative to institutionalization for a Medicaid beneficiary who is medically fragile and at risk for ins...
Who Is Eligible For Cap/Da?
- A disabled adults 18 years old and older.
- An individual who is determined to require a level of institutional care under the State Medicaid Plan.
- An individual who needs at least one or more CAP/DA home-and community-based services based on a reasonable indication of need assessment that must be coordinated by a CAP/D…
- A disabled adults 18 years old and older.
- An individual who is determined to require a level of institutional care under the State Medicaid Plan.
- An individual who needs at least one or more CAP/DA home-and community-based services based on a reasonable indication of need assessment that must be coordinated by a CAP/DA case manager.
What Home- and Community-Based Services Are Approved in The CAP/DA Waiver?
- Adult day health;
- CAP In-home aide;
- Equipment, modification and technology;
- Meal preparation and delivery;
What Is Consumer Directed Services?
- Consumer-direction is a service delivery model that allows a CAP/DA Medicaid beneficiary or designated representative to act in the role of employer of record to direct their personal care services by: 1. Freely choosing who will provide care to meet medical and functional needs; 2. Independently recruiting, hiring, supervising, and firing (when necessary) an employee (personal …
How to Make A CAP/DA Referral?
- Contact a local CAP/DA case management entity in the county of residenceof the applicant to request a CAP/DA referral. If you are a CAP/DA case management entity or a qualified home- and community-based provider, a referral can be completed in the e-CAP system. 1. Quick Facts A referral may also be made by calling 919-855-4340 or faxing the completed referral formto 919-…
Special Announcements
Covid-19 Management
- SPECIAL BULLETIN COVID-19 #55: NC Medicaid Receives Approval for Expanded Flexibilities for Home and Community-Based Services
- SPECIAL BULLETIN COVID-19 #134: Clarification of COVID-19 Temporary Rate Increases and Clinical Policy Changes
- SPECIAL BULLETIN COVID-19 #93: Targeted Rate Increase, Additional Hours and Associate…
- SPECIAL BULLETIN COVID-19 #55: NC Medicaid Receives Approval for Expanded Flexibilities for Home and Community-Based Services
- SPECIAL BULLETIN COVID-19 #134: Clarification of COVID-19 Temporary Rate Increases and Clinical Policy Changes
- SPECIAL BULLETIN COVID-19 #93: Targeted Rate Increase, Additional Hours and Associated Reporting Requirements for In-Home Personal Care Services (PCS) Providers under State Plan PCS and CAP/C and C...
Contact Information
- NC Medicaid Clinical Section Phone: 919-855-4340 Fax: 919-715-0052 Email: medicaid.capda@dhhs.nc.gov