Does Medicare Cover Physical Therapy?

Medicare helps beneficiaries manage healthcare needs, including physical therapy. Understanding how Medicare covers physical therapy is important for individuals seeking to restore function, reduce pain, or prevent disability. While Medicare can cover physical therapy, specific conditions and requirements must be met for eligibility. The type of Medicare plan and the setting where therapy is received influence coverage and financial support.

Which Parts of Medicare Cover Physical Therapy

Medicare’s structure divides physical therapy coverage based on the care setting.

Medicare Part A, or Hospital Insurance, covers physical therapy received during an inpatient stay. This includes services in a skilled nursing facility (SNF) after a qualifying hospital stay or within an inpatient rehabilitation facility. Part A also covers physical therapy through Medicare-certified home health agencies if a beneficiary is homebound and requires intermittent skilled care.

Medicare Part B, or Medical Insurance, primarily covers outpatient physical therapy services. This includes therapy received in a physical therapist’s office, a hospital outpatient department, a private practice, or even in some home settings if the Part A home health criteria are not met. Part B is the most common avenue for physical therapy coverage, addressing a wide range of needs from injury recovery to chronic condition management. It focuses on medically necessary services aimed at improving or maintaining a beneficiary’s physical function.

Medicare Advantage Plans (Part C) are offered by private insurance companies approved by Medicare. These plans must cover at least all services included in Original Medicare (Parts A and B), including physical therapy. While providing comparable coverage, Medicare Advantage Plans can have different rules, costs, and network restrictions. Beneficiaries should consult their specific plan documents to understand their physical therapy benefits, including any prior authorization requirements or preferred provider networks.

Eligibility Requirements for Coverage

For Medicare to cover physical therapy services, specific conditions and documentation requirements must be met. Physical therapy must be medically necessary, as determined by a doctor or other qualified practitioner. This means the therapy is needed to restore function, improve a condition, or slow a decline in health that impacts daily activities. Services must be specific, safe, and effective treatments for the patient’s condition.

A doctor’s order or referral is required before initiating physical therapy services. This order establishes medical necessity and directs the physical therapist to provide specific interventions. The referral ensures that the therapy aligns with the overall medical treatment plan supervised by the patient’s physician. Without a proper physician’s order, Medicare may not cover the physical therapy services provided.

Physical therapy services also require a personalized plan of care. This written plan, developed by the treating physical therapist, outlines the patient’s goals, types of therapy, and anticipated frequency and duration. A doctor must review and approve this plan, affirming its medical necessity and appropriateness for the patient’s condition. Additionally, services must be provided by a Medicare-certified physical therapist or under their direct supervision, ensuring the quality and professional standards of care.

Understanding Your Costs and Coverage Limits

When receiving outpatient physical therapy under Medicare Part B, beneficiaries face financial responsibilities. After meeting the annual Part B deductible, which is a fixed amount each year, Medicare generally pays 80% of the Medicare-approved amount for covered services. The beneficiary is responsible for the remaining 20% coinsurance. For example, if a therapy session’s Medicare-approved amount is $100, Medicare pays $80, and the beneficiary pays $20 after the deductible is met.

For physical therapy covered under Medicare Part A, such as in a skilled nursing facility (SNF), different cost-sharing rules apply. For SNF stays, Medicare covers the first 20 days at no cost. A daily coinsurance amount applies for days 21 through 100. This coinsurance amount is a set daily rate, and the beneficiary is responsible for paying it for each day within that period. After day 100, Medicare generally ceases to cover SNF care, and the beneficiary becomes responsible for all costs.

Medicare no longer imposes a financial cap on physical therapy expenses if services are medically necessary. However, “thresholds” exist for incurred expenses. If total outpatient physical therapy expenses exceed a certain dollar amount in a calendar year, claims may be subject to a targeted medical review. This review helps ensure that services beyond the threshold remain medically necessary and are provided appropriately. Beneficiaries with Medicare Advantage Plans may have different cost-sharing, including varying deductibles, copayments, or coinsurance, depending on their plan.

Accessing Covered Physical Therapy Services

Accessing covered physical therapy services often begins with discussing needs with a primary care physician, who can provide a referral or order. This initial step ensures that the therapy aligns with your overall medical treatment plan.

Finding a Medicare-certified physical therapist or facility is important for coverage. Beneficiaries can use Medicare’s online “Find a Doctor” tool or ask their physician for recommendations. This ensures the chosen provider is enrolled in Medicare and can bill for services. Verifying participation status before treatment can prevent unexpected out-of-pocket costs.

During the initial visit, the physical therapist assesses the patient’s condition and functional limitations. Based on this, a personalized plan of care is developed, outlining goals, interventions, and expected duration. This plan must be approved by the referring physician. Ongoing therapy sessions follow this plan, with regular re-assessments to track progress and adjust treatment. The physical therapy provider typically submits claims directly to Medicare. After processing, the beneficiary receives an “Explanation of Benefits” (EOB) document, which details the services billed, the amounts Medicare paid, and any remaining patient responsibility.