Does Medicare Cover Maintenance Physical Therapy?

Medicare is a federal health insurance program for Americans, primarily those aged 65 or older. A common question among beneficiaries concerns its coverage for physical therapy, especially for ongoing, long-term conditions known as “maintenance therapy.” Understanding Medicare’s approach to such therapy is important for individuals seeking to maintain physical function or slow the progression of a chronic illness. This article clarifies how Medicare addresses these services, outlining specific coverage criteria and financial considerations.

Defining Maintenance Physical Therapy

Maintenance physical therapy refers to services designed to prevent a condition’s deterioration, maintain current function, or slow decline, rather than to improve or restore function. This therapy differs from rehabilitative therapy, which aims to help a patient regain lost abilities after injury or illness. Examples include exercises to prevent muscle atrophy in a chronic neurological condition or gait training to preserve mobility in an ongoing balance disorder.

Medicare’s stance on maintenance therapy was clarified through the “Jimmo v. Sebelius” settlement. This ruling established that Medicare coverage for therapy services, including physical therapy, cannot be denied solely because a patient’s condition is chronic, stable, or not expected to improve. The determining factor for coverage is the “skilled” nature of the service, meaning it requires the expertise of a licensed physical therapist.

Medicare’s Coverage of Physical Therapy

Medicare provides coverage for physical therapy services through various parts, depending on the setting. Original Medicare, which includes Part A and Part B, is a primary source. Medicare Part A, known as Hospital Insurance, generally covers physical therapy received as part of an inpatient hospital stay, in a skilled nursing facility (SNF) after a qualifying hospital stay, or through home health care. For SNF and home health, maintenance therapy can be covered if it is part of a skilled plan of care.

Medicare Part B, or Medical Insurance, is the main component covering outpatient physical therapy services. This includes therapy provided in a doctor’s office, an outpatient clinic, or in the home if the patient qualifies for home health services.

Medicare Advantage Plans, also known as Part C, are offered by private companies approved by Medicare. These plans must cover at least the same services as Original Medicare (Parts A and B), including medically necessary physical therapy. However, Medicare Advantage plans may have different rules regarding costs, networks, and prior authorization requirements.

Meeting Medicare’s Coverage Requirements

For Medicare to cover physical therapy, including maintenance therapy, specific conditions and documentation requirements must be met. A core requirement is “medical necessity,” meaning the services must be reasonable and necessary to diagnose or treat an illness, injury, or to maintain function and prevent deterioration. Services must be provided by a licensed and Medicare-certified physical therapist or by a physical therapist assistant under appropriate supervision.

A physician or other qualified practitioner, such as a nurse practitioner or physician assistant, must order the physical therapy. Following this order, a comprehensive plan of care must be developed by the physical therapist and certified by the referring physician. This plan should detail the diagnosis, the type of therapy, the frequency and duration of sessions, and specific goals.

Regular review and re-certification of the plan of care by the physician are necessary to ensure continued medical necessity, typically every 90 days. Thorough documentation by the physical therapist is also important. This documentation must demonstrate the skilled nature of the services provided, justify the ongoing medical necessity, and record the patient’s response to therapy, including maintenance of function or prevention of decline.

Patient Financial Responsibilities

Patients receiving physical therapy under Medicare have out-of-pocket costs that vary based on their coverage. For therapy covered under Medicare Part A, such as in an inpatient hospital or skilled nursing facility (SNF) stay, deductibles and coinsurance apply based on the length of stay. For instance, in an SNF, Medicare covers the first 20 days fully after a qualifying hospital stay, but a daily copayment is required for days 21-100. Home health physical therapy services generally have no out-of-pocket costs.

For outpatient physical therapy covered by Medicare Part B, patients are responsible for an annual deductible, which is $257 for 2025. After meeting this, Medicare typically pays 80% of the approved amount, and the patient pays the remaining 20% coinsurance. While there are no longer traditional “caps” on therapy expenses, Medicare requires physical therapists to confirm medical necessity when costs exceed $2,410 for physical therapy and speech-language pathology services combined in 2025.

Medicare Advantage Plans (Part C) have varying cost-sharing structures, including deductibles, copayments, or coinsurance for therapy visits. Patients with these plans should review their specific plan documents for details on out-of-pocket costs and network requirements. Medigap policies, also known as Medicare Supplement Insurance, can help cover Part A and Part B out-of-pocket costs, including deductibles and coinsurance. Providers who accept Medicare assignment cannot charge beneficiaries more than the Medicare-approved amount.