How Many Days of Therapy Does Medicare Pay For?

Medicare, the federal health insurance program, helps millions of Americans, including those aged 65 or older and certain younger individuals with disabilities, access necessary healthcare services. Therapy services often form an important part of recovery, rehabilitation, and health maintenance for many beneficiaries. Understanding Medicare coverage for these services can be complex, as it involves various parts of the program with distinct rules and limitations.

Medicare Coverage for Therapy Types

Medicare’s structure divides coverage for therapy services across different parts, depending on the setting and type of care received.

Medicare Part A primarily covers therapy services provided in an inpatient setting, such as a Skilled Nursing Facility (SNF) following a qualifying hospital stay. It also extends to certain home health care services, including therapy, when specific conditions are met.

Medicare Part B covers outpatient therapy services, including physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP). Part B also covers outpatient mental health therapy, such as individual and group counseling sessions. These services are provided by licensed therapists in various outpatient settings, including clinics, private practices, doctor’s offices, and hospital outpatient departments.

Medicare Part C offers an alternative to Original Medicare (Parts A and B). These plans are provided by private companies approved by Medicare and are required to cover at least the same services as Original Medicare. However, Medicare Advantage plans may have different rules, costs, and network restrictions for therapy services, requiring beneficiaries to check their specific plan details.

Specific Coverage Details and Limits

The extent of Medicare therapy coverage often depends on the specific setting and the medical necessity of the services.

For therapy received in a Skilled Nursing Facility (SNF) under Medicare Part A, coverage is available for up to 100 days per benefit period. To qualify, a beneficiary must have had a prior medically necessary inpatient hospital stay of at least three consecutive days. The SNF admission must occur within 30 days of leaving the hospital.

During a SNF stay, Medicare Part A provides full coverage for the first 20 days within a benefit period. For days 21 through 100, a daily co-insurance of $209.50 per day in 2025 is required. After day 100 in a benefit period, the beneficiary is responsible for all costs. Coverage for SNF therapy is contingent upon the services being “skilled” and medically necessary.

For outpatient therapy services covered by Medicare Part B, there are no specific day or visit limits, as long as the services are considered medically necessary. For 2025, there are financial thresholds: $2,410 for combined physical therapy and speech-language pathology services, and $2,410 for occupational therapy. If costs exceed these amounts, providers must confirm medical necessity, and services above $3,000 for PT/SLP and OT combined may trigger a targeted medical review process.

Home health therapy is covered if a beneficiary is homebound and requires skilled care on an intermittent basis. There are no specific day limits for home health therapy, with coverage based on a doctor’s order and a medically necessary plan of care. 24-hour-a-day care or homemaker services are not covered.

Outpatient mental health therapy is covered under Medicare Part B without specific day limits, provided the services are medically necessary. For inpatient mental health services in a freestanding psychiatric hospital, Medicare Part A has a lifetime limit of 190 days. There is no such lifetime limit for inpatient mental health care received in a general hospital.

Accessing Therapy and Managing Costs

Obtaining Medicare coverage for therapy services begins with a medical professional’s involvement. A doctor’s order or referral is required for therapy services to be covered by Medicare. Following the referral, a comprehensive evaluation and a personalized plan of care must be developed by the therapist and approved by the doctor, outlining treatment goals and duration.

Medical necessity is continuously assessed throughout the course of therapy. For continued coverage, services must demonstrate progress or be necessary to maintain function or prevent deterioration. If services are no longer considered medically necessary, providers are required to issue an Advance Beneficiary Notice of Noncoverage (ABN).

Beneficiaries also have financial responsibilities for therapy services. For Skilled Nursing Facility care under Part A, after the first 20 days of a benefit period, a daily co-insurance applies for days 21-100. For outpatient therapy under Part B, beneficiaries must first meet the annual Part B deductible, which is $257 in 2025. After the deductible is satisfied, beneficiaries pay a 20% coinsurance of the Medicare-approved amount for the services.

Medicare Advantage (Part C) plans may have different cost-sharing structures, including varying co-pays, deductibles, or network restrictions for therapy services. It is important for beneficiaries enrolled in these plans to consult their specific plan documents for details on out-of-pocket costs and provider networks. Supplemental insurance, such as Medigap policies or employer/union retiree coverage, can assist in covering out-of-pocket expenses like deductibles and coinsurance, reducing the financial burden on the beneficiary.

Appealing Denied Therapy Coverage

If Medicare denies coverage for therapy services, beneficiaries have the right to appeal the decision. Denials often occur if services are deemed not medically necessary, not skilled, or if the care is no longer expected to improve or maintain the patient’s condition.

The Medicare appeals process consists of five levels. The first level is a Redetermination by the Medicare Administrative Contractor (MAC). If the beneficiary disagrees with this outcome, they can proceed to a Reconsideration by a Qualified Independent Contractor (QIC) at the second level.

Further appeals can be made to an Administrative Law Judge (ALJ) hearing at the third level, followed by a review by the Medicare Appeals Council (MAC) at the fourth level. The final level of appeal is Judicial Review in Federal District Court. Beneficiaries should keep detailed records, gather supporting documentation such as medical records and doctor’s notes, and adhere to specific appeal deadlines for each level. Resources like the State Health Insurance Assistance Program (SHIP) can provide free counseling and assistance with the appeals process.