How Much Physical Therapy Does Medicare Cover?

Physical therapy helps reduce pain, improve mobility, and restore physical function for various conditions, from injuries to chronic illnesses. It also aids in managing long-term conditions and preventing decline. Understanding Medicare’s coverage for these services is crucial for navigating healthcare. This article details Medicare’s provisions for physical therapy, including coverage, financial responsibilities, and access to services.

Medicare Parts Covering Physical Therapy

Medicare provides coverage for physical therapy services through different parts, depending on the setting where care is received. Original Medicare is composed of Part A and Part B, while Medicare Advantage plans encompass both. The setting of your physical therapy will determine which part of Medicare is primarily responsible for coverage.

Medicare Part A, known as Hospital Insurance, covers inpatient physical therapy services. This includes care received during a hospital stay or within a skilled nursing facility (SNF) following a qualifying inpatient hospital stay of at least three days. Part A typically covers the full cost for the first 20 days in a skilled nursing facility, after which a daily coinsurance applies for days 21 through 100. Additionally, Part A covers physical therapy provided by Medicare-certified home health agencies if an individual is considered homebound and requires skilled care.

Medicare Part B, or Medical Insurance, covers outpatient physical therapy services. These services can be provided in various settings, including outpatient clinics, private practices, hospital outpatient departments, and rehabilitation agencies. Part B also covers physical therapy furnished by home health agencies if Part A coverage is not applicable or has been exhausted. This broad coverage ensures access to therapy for individuals not requiring an inpatient stay.

Medicare Advantage Plans, designated as Part C, are offered by private companies approved by Medicare. These plans are required to cover at least the same services as Original Medicare Parts A and B, which includes physical therapy. However, Medicare Advantage plans may have different rules regarding costs, referrals, and network restrictions. It is advisable for beneficiaries to verify their specific plan’s details, including any requirements for using in-network providers or obtaining prior authorizations.

Financial Responsibilities and Coverage Thresholds

Medicare’s coverage for physical therapy is contingent upon the service being medically necessary. This means the therapy must be prescribed by a doctor or other qualified healthcare provider and be part of a comprehensive plan of care. The services must be reasonable and necessary for treating an illness or injury, restoring function, or preventing further decline.

Medicare does not require a patient’s condition to improve for physical therapy to be covered. Services aimed at maintaining function or preventing deterioration are also covered, provided they are medically necessary and require the skills of a qualified therapist.

Under Original Medicare, beneficiaries have certain financial responsibilities. For inpatient physical therapy covered by Part A, the deductible for 2025 is $1,676 per benefit period. For outpatient physical therapy covered by Part B, the annual deductible for 2025 is $257. After meeting the Part B deductible, Medicare typically pays 80% of the Medicare-approved amount for services, leaving the beneficiary responsible for the remaining 20% coinsurance. Medicare Advantage plans may have different copayments or cost-sharing structures, so beneficiaries should consult their specific plan documents.

While the former “therapy cap” was eliminated, Medicare still uses threshold amounts for outpatient therapy services. For 2025, the threshold amount is $2,410 for combined physical therapy and speech-language pathology services, and a separate $2,410 for occupational therapy services. Once these amounts are reached, providers must confirm that the services remain medically necessary by applying a specific modifier (KX) to claims. Services exceeding these thresholds may be subject to targeted medical review to ensure ongoing medical necessity, with a higher threshold of $3,000 for targeted medical review for both therapy categories.

Accessing Covered Physical Therapy Services

Obtaining covered physical therapy services generally begins with a referral or prescription from a doctor or other healthcare provider. While direct access laws exist in many areas allowing initial evaluation without a referral, Medicare typically requires a physician-approved plan of care for ongoing coverage. This plan outlines the specific therapy goals and interventions, ensuring services align with medical necessity.

When seeking a physical therapist, find one who accepts Medicare. The official Medicare.gov website’s “Find & Compare Providers” tool can help locate approved therapists. Confirm the therapist accepts Medicare assignment, meaning they agree to accept Medicare’s approved amount as full payment, charging only the deductible and coinsurance. If enrolled in a Medicare Advantage plan, verify the provider is within the plan’s network.

During the course of treatment, an initial evaluation will be conducted to assess the patient’s condition and develop an individualized plan of care. This plan, which must be approved by the doctor, guides the therapy sessions. Throughout the therapy, the therapist will document progress and make adjustments to the plan as needed.

After receiving services, beneficiaries will receive an Explanation of Benefits (EOB) statement from Medicare or their Medicare Advantage plan. Reviewing this statement helps understand covered services, the amount Medicare paid, and any remaining financial responsibility. This document provides a detailed breakdown of charges and payments, aiding in tracking out-of-pocket costs.