How Many Therapy Sessions Does Medicare Pay For?

Medicare plays a role in providing health coverage for millions of individuals. This federal program assists people aged 65 or older, and some younger individuals with specific disabilities or health conditions. Understanding Medicare’s coverage of therapy services is important for beneficiaries.

Types of Therapy Covered

Medicare covers several categories of therapy services. Mental health therapy encompasses a range of services aimed at improving emotional and psychological well-being. This includes individual psychotherapy, group counseling, and family counseling. Psychiatric evaluations and medication management are also covered, provided by licensed professionals such as psychiatrists, clinical psychologists, and social workers.

Physical therapy (PT) focuses on restoring or improving physical movement and function. This therapy helps individuals recover from injuries, illnesses, or surgeries, and maintain physical abilities or slow decline. Occupational therapy (OT) assists individuals in regaining skills necessary for daily living and work activities, often incorporating adaptive equipment to enhance independence.

Speech-language pathology (SLP) addresses conditions that affect speech, language, and swallowing. These therapies help individuals who have experienced strokes, injuries, or other illnesses impacting their communication or eating abilities. All these therapy types are covered when deemed medically necessary and provided by qualified healthcare professionals.

Medicare Parts and Therapy Coverage

The specific Medicare part that covers therapy services depends on whether the care is provided in an inpatient or outpatient setting. Original Medicare Part A, known as Hospital Insurance, primarily covers inpatient therapy. This includes therapy received during a stay in a hospital or a skilled nursing facility (SNF) following a qualifying hospital stay. For mental health care in a psychiatric hospital, Part A has a lifetime limit of 190 days, though there is no such limit for mental health care in a general hospital.

Medicare Part B, or Medical Insurance, covers the majority of outpatient therapy services. This includes mental health counseling, physical therapy, occupational therapy, and speech-language pathology when provided in settings like a doctor’s office, clinic, or hospital outpatient department. Part B also covers certain home health therapy services for eligible individuals.

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans must provide at least the same level of coverage as Original Medicare Parts A and B, including therapy services. However, Medicare Advantage plans may have different rules regarding provider networks, referral requirements, and out-of-pocket costs. Medicare Part D, which covers prescription drugs, does not cover therapy sessions themselves, though it may cover medications prescribed as part of mental health treatment.

Understanding Coverage Limits and Patient Costs

For most outpatient therapy services under Medicare Part B, there are no hard numerical limits on the number of sessions Medicare will cover. The concept of “therapy caps,” which previously limited annual payments, was eliminated in 2018. Instead, coverage is primarily determined by whether the services are considered medically necessary for the diagnosis or treatment of a condition. A physician or therapist must certify that the therapy is reasonable and necessary, which can include maintaining a patient’s function or slowing their decline, not solely improving their condition.

While there are no hard caps, Medicare does employ financial thresholds that trigger additional documentation requirements. For 2025, if the total costs for physical therapy and speech-language pathology services combined, or for occupational therapy services alone, exceed $2,410, providers must indicate with a “KX modifier” that the services continue to be medically necessary. Claims exceeding $3,000 for these services may also be subject to targeted medical reviews to ensure appropriateness of care.

Beneficiaries also have financial responsibilities for therapy services. For Medicare Part B, after meeting the annual deductible, which is $257 in 2025, beneficiaries typically pay 20% of the Medicare-approved amount for services. This 20% is known as coinsurance. If a provider does not accept Medicare assignment, they may charge more than the Medicare-approved amount, leading to potential excess charges for the beneficiary. Medicare Advantage plans may have different cost-sharing structures, such as varying copayments, coinsurance rates, or out-of-pocket maximums, and some plans may not require beneficiaries to meet the Part B deductible for in-network services.

Accessing Therapy Services Through Medicare

To access Medicare-covered therapy services, a physician’s referral or order is required. This referral helps establish the medical necessity for the therapy and guides the initial course of treatment. The medical record should contain documentation of this referral to substantiate coverage.

Beneficiaries should find therapists and providers who are Medicare-approved and accept Medicare assignment to ensure coverage and limit out-of-pocket expenses. A comprehensive plan of care (POC) must be developed by the therapist, outlining the diagnoses, long-term treatment goals, and the type, amount, frequency, and duration of services. This plan must be certified by a physician before therapy begins and periodically recertified, typically every 90 days, to confirm the ongoing need for services.

For beneficiaries enrolled in Medicare Advantage Plans, prior authorization may be required before beginning therapy services. This step ensures that the services align with the plan’s specific guidelines and network requirements. Throughout the course of therapy, detailed documentation, including daily treatment notes and progress reports, is essential for demonstrating medical necessity and supporting claims during potential audits. If a provider anticipates that services may not be covered by Medicare because they are not medically necessary, they are required to issue an Advance Beneficiary Notice of Noncoverage (ABN), allowing the beneficiary to decide whether to proceed with the services and incur the full cost.