How Medicare Covers Physical Therapy

Medicare physical therapy coverage helps millions of older adults regain strength, mobility, and independence after surgery, injury, or illness. Physical therapy is one of the most commonly used Medicare outpatient services. It is often needed after a hip replacement, a stroke, a fall, or a flare of chronic back pain.

Many beneficiaries still believe Medicare limits the number of visits each year. That has not been true since 2018. Understanding how medicare physical therapy works across Part A, Part B, and Medicare Advantage can save families money and stress. It also helps patients avoid surprise bills and coverage denials when they need care most.

How Medicare Physical Therapy Is Covered Under Parts A and B

Medicare covers physical therapy in several settings. The part of Medicare that pays depends on where you get care. Part A covers therapy you receive as a hospital inpatient. It also covers therapy in a skilled nursing facility (SNF) after a qualifying hospital stay of at least three days. In addition, Part A helps pay for therapy in an inpatient rehabilitation facility.

Part B covers outpatient physical therapy. This includes care in a therapist’s private practice, a hospital outpatient department, or a rehab clinic. It can also include therapy delivered in your home through Part B. After you meet the annual Part B deductible, you typically pay 20% of the Medicare-approved amount. Medicare pays the other 80%.

Home health therapy works differently. If you are homebound and need skilled care, Medicare covers home health physical therapy at no cost to you. There is no coinsurance or deductible for approved home health services. As a result, home health can be the lowest-cost option for people who qualify. A doctor or other allowed practitioner must certify that you are homebound and need intermittent skilled care.

Eligibility Rules, Caps, and What Medicare Requires

To get medicare physical therapy covered, the care must be medically necessary. A qualified therapist must provide it or closely supervise it. Your doctor, nurse practitioner, or physician assistant must also certify a written plan of care. That plan lists your diagnosis, goals, and the type and frequency of treatment. It must be recertified at least every 90 days.

Many people still ask about the “therapy cap.” The Bipartisan Budget Act of 2018 permanently repealed hard caps on outpatient therapy. In their place, CMS uses a yearly spending threshold. Physical therapy and speech-language pathology share one combined threshold. Occupational therapy has its own separate threshold. CMS updates these amounts each year.

When your care passes the threshold, your therapist adds a “KX modifier” to claims. That modifier confirms the care is still medically necessary. Medicare then keeps paying. However, once combined spending reaches a higher level, claims may face targeted medical review. Under current law, that review level is $3,000 per year through 2027.

Another key rule comes from the 2013 Jimmo v. Sebelius settlement. Medicare cannot deny therapy just because you are not improving. Skilled therapy to maintain your condition or slow decline can be covered. For example, a person with Parkinson’s disease may qualify for ongoing therapy to preserve walking ability.

Medicare Advantage, Medigap, and Your Out-of-Pocket Costs

Medicare Advantage plans must cover everything Original Medicare covers. That includes medicare physical therapy in every setting listed above. However, the rules and costs can look very different. Most plans from UnitedHealthcare, Humana, Aetna, Cigna, and Blue Cross charge a fixed copay per outpatient visit. These copays vary by plan and by state.

Prior authorization is common in Medicare Advantage. Many plans require approval before therapy begins or after a set number of visits. In addition, most HMO plans limit you to in-network therapists. Since 2024, CMS rules require Medicare Advantage plans to follow Original Medicare coverage criteria. Plans also must keep an approved prior authorization valid for the full course of treatment. New enrollees get a 90-day transition period for ongoing care.

Visit copays can add up fast. Someone recovering from a knee replacement may attend two or three sessions a week for two months. That can mean 20 visits or more. As a result, a plan with a high per-visit copay may cost more than expected. Check your plan’s Evidence of Coverage before starting treatment.

If you have Original Medicare, a Medigap policy can help. Medigap plans from companies like Mutual of Omaha, AARP/UnitedHealthcare, and Aetna typically pay some or all of your 20% coinsurance. Plan G, for example, covers the full Part B coinsurance after the Part B deductible. That makes long therapy courses far more predictable.

Steps to Take Before and During Therapy

A few simple steps can protect you from denials and surprise costs. Start by confirming your therapist accepts Medicare assignment. Providers who accept assignment agree to the Medicare-approved amount as full payment. You can search for participating therapists using the Care Compare tool on Medicare.gov.

Next, ask for a copy of your plan of care. Make sure your goals are clearly written and measurable. Good documentation is your best defense if a claim is questioned. If you are in a Medicare Advantage plan, call the plan first. Ask whether prior authorization is needed and how many visits are approved.

Watch for an Advance Beneficiary Notice of Noncoverage (ABN). Outpatient providers may give you this form if they think Medicare will not pay. Read it carefully before signing. Signing means you agree to pay if Medicare denies the claim. You still have the right to ask the provider to submit the claim to Medicare.

If therapy is cut short, you can appeal. In a skilled nursing facility or home health setting, you should receive a Notice of Medicare Non-Coverage at least two days before services end. You can request a fast appeal through your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). In most cases, you must request it by noon of the day before services end.

Finally, get free help when you need it. Your State Health Insurance Assistance Program (SHIP) offers unbiased Medicare counseling at no charge. SHIP counselors can review your plan, explain denials, and help you file appeals. You can also call 1-800-MEDICARE for claims questions.

Frequently Asked Questions

Is there a limit on medicare physical therapy visits per year?

No, there is no hard limit on visits. Congress repealed the therapy cap in 2018. However, once spending passes a yearly threshold, your therapist must confirm the care is medically necessary. Claims may also face review above $3,000.

Do I need a doctor’s referral for physical therapy under Medicare?

Many states let you see a physical therapist directly for an evaluation. Even so, Medicare requires a doctor or other qualified practitioner to certify your plan of care. Typically, your therapist will send the plan to your doctor for signature.

Does Medicare cover physical therapy at home?

Yes, if you qualify for the home health benefit. You must be homebound and need skilled care on a part-time basis. Approved home health medicare physical therapy costs you nothing. Outpatient therapists can also treat you at home under Part B, with standard 20% coinsurance.

Will Medicare stop paying if I stop improving?

Not necessarily. The Jimmo v. Sebelius settlement confirmed that improvement is not required. Medicare covers skilled therapy needed to maintain function or slow decline. For instance, a stroke survivor may qualify for maintenance therapy to prevent falls.

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Official Sources & Resources

For verified information on Medicare regulations and consumer protection:

• Medicare.gov (Official Site): medicare.gov
• CMS (Centers for Medicare & Medicaid Services): cms.gov
• NAIC (National Association of Insurance Commissioners): naic.org
• KFF Medicare Research: kff.org/medicare
• Social Security Administration: ssa.gov

Content last reviewed October 2026. If you notice any outdated information, please contact us.

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