Open Letter to Occupational Therapy Assistants (OTAs) and OTA Students

Dear Occupational Therapy Assistants and Students:

Recent legislation to change Medicare Part B payment for occupational therapy assistants was included as a last minute addition to the Bipartisan Budget Act 2018 (BBA2018) passed in February. AOTA has concerns about this language and the impact on occupational therapy assistants and the profession as a whole. In summary, in 2020, all Medicare Part B providers must report with a modifier (yet to be determined) indicating whether an OT or an OTA provided services.

Beginning in 2022, these services provided by an OTA will be reimbursed at 85% of the typical payment rate. This change does not affect inpatient hospital payments, Part A skilled nursing facility (SNF) stays, home health, hospice, inpatient rehabilitation hospitals, or other providers covered under Part A of Medicare. Part A of Medicare primarily covers hospital and other facility services and is funded through tax dollars; everyone who pays into Medicare is eligible. Part B of Medicare covers outpatient services, including physicians, occupational therapy providers, and other professions and services; it is an optional health insurance that beneficiaries can choose to purchase. As AOTA develops strategies to address this policy change, this letter is intended to share what we see now as the potential consequences of the change and to affirm the continuing role of OTAs in Medicare and health care, as well as in other systems such as the aging network and schools.

Most importantly, occupational therapy assistants are still recognized by Medicare. BBA 2018 only makes a payment change for Part B services, and it does not change stated Centers for Medicare & Medicaid Services (CMS) policy that firmly supports the role of occupational therapy assistants in the provision of covered Medicare occupational therapy services. In Transmittal 88 of the Benefit Policy Manual published on June 30, 2006, CMS states:

“The services of OTAs used when providing covered therapy benefits are included as part of the covered service.”

This is still current; the BBA2018 did not change this policy. Thus, all Medicare providers—including hospitals, skilled nursing facilities, home health agencies, rehabilitation agencies, private practitioners, and others—are still able to provide occupational therapy services using the services of OTAs. AOTA has published a Frequently Asked Questions document that details what we know today regarding the current and future status of Medicare OTA reimbursement.

Rumors that providers are already letting OTAs go are not at this moment able to be verified. Furthermore, there is no reason to do so at this time as the payment change does not go into effect until 2022, and it does not impact many provider types. AOTA has had discussions with some providers and their response is that they will need to examine the potential business effects and develop possible strategies, such as shifting OTA caseloads to non-Part B clients, using OTAs more in non-Medicare services, etc. AOTA is also working to determine what impact this may have on  OTAs as well as  beneficiaries’ access to occupational therapy services. For instance, some geographic regions may be more dependent on OTA services; these must be identified, and solutions (such as waivers) to assure access to services must be designed.

The change is a payment change, reducing reimbursement for only Part B OTA services below the reimbursement level for services provided by an occupational therapist. The payment change reducing OTA-provided services by 15% is modeled after the Medicare payment distinction between physicians and nurse practitioners or physician assistants. The latter two are paid 15% less than physicians for providing the same services. OT payment without a differential has been an exception to the rule. But as noted above, there is no change to Medicare inclusion of OTAs as part of the delivery of covered occupational therapy, and there is no change to Medicare Part A.

The BBA2018 language came into the bill at the last minute; however, equal payment for OT and OTA services has been an issue for some time. Occupational therapy was subject to questions and scrutiny by CMS, Congress, and the American Medical Association (who is responsible for the CPT® codes and makes recommendations about the value to be paid for those codes) about this but no action was taken. Several years ago there was a move to make a similar cut but it was put off by AOTA advocacy which promoted a study of the issue. The cut was included in a bill in 2014 that was never brought to a vote or passed. Please note that providers have always been paid the same rate for OT and OTA services. There is and has been a variance in the pay of OTs and OTAs. Based on AOTA data, average OTA salaries are around $50,000, and OT salaries average around $75,000. However, some geographic areas have a much narrower gap. Further, in some locations there is a higher need for OTAs as there are overall shortages of occupational therapy practitioners. This is an area that AOTA is particularly concerned about, because the change may result in reduced services in areas of the country or particular settings where the economics may affect consumer access. Study of potential reduced access and of other effects of the payment change are being considered as part of the planning for AOTA’s response to this significant issue that will affect the entire profession. It was discussed at the February AOTA Board of Directors meeting, and an internal staff team is being put together to review the issue, AOTA’s positions, opportunities for advocacy, and methods to reach out to the OTA community to determine next steps.

There will be opportunities for AOTA and occupational therapy practitioners to influence the implementation of this new policy. CMS must interpret the law and make decisions on what services are subject to the 85% requirement. We will work to influence CMS as they interpret the legislative language. AOTA will also be working with Congress on possible changes to the language and how to prevent this policy from impacting consumer access. AOTA will keep you informed and let you know how you can weigh in. But OTA services as a recognized part of occupational therapy continues. Therefore OTA use is expected to continue. Furthermore, legislation was recently passed with AOTA advocacy to include OTAs as providers in Tricare programs for the military and their families to open another door for OTAs.

These BBA2018 changes were a surprise at this particular time and in this legislation, which included the therapy cap repeal, but were not completely unexpected based on marketplace actions in recent years. Some payers have changed the payment levels for OTAs with a 15% or more cut over the past several years; and some Medicaid programs and private insurance payers have imposed differences. Yet the OTA job market has remained steady. Please let AOTA know if you hear of such changes. Contact ASKFAD@aota.org.

There are daily changes in health care and multiple payment challenges on the horizon (such as skilled nursing facility and home health payments under Medicare, bundled payments, medical homes, and accountable care organizations). The overarching theme of all these changes is to promote value-based programs and payments. When payment is made for value, each profession and each practitioner must be sure to provide optimum services, to enfold quality into all therapy, to respond to individual needs, and to remain well informed in the research and evidence that proves the value of occupational therapy. Working together we will manage this change, alter it as we can, and survive as a community.

Sincerely,

Christina A. Metzler

AOTA Chief Public Affairs Officer