If a qualified healthcare provider considers treatment medically necessary, Medicare will usually cover it.
If you have an injury, disease, or just had surgery, your doctor may suggest or prescribe physical therapy to help provide pain relief and/or prevent further impairments, injury or functional limitations.
Outpatient therapy, which includes physical therapy, speech-language pathology, and occupational therapy, is covered under Original Medicare Part B. Medicare Part A may also cover some or all of the costs of physical therapy under certain circumstances (outlined below).
Therapy may include instruction, stretching, soft tissue or joint mobilization, equipment use or muscle strengthening exercises. However, not all costs for therapy services will be covered by Original Medicare.
Medicare Physical Therapy Guidelines
In order for your physical therapy to be covered, it must be deemed medically necessary by your doctor. Medically necessary means it is needed to help diagnose or treat a condition or illness, maintain your current condition, or slow further deterioration or functional limitations.
Physical therapy services must be received from a qualifying physical therapist or doctor and will be covered either under Part A or Part B.
Part A, which is your hospital insurance, may cover physical therapy services at an inpatient rehabilitation facility when they are considered medically necessary after hospitalization. It may also cover therapy at a skilled nursing facility after a qualifying hospitalization lasting at least three days.
Medicare Part B, your medical insurance, will cover medically necessary physical therapy, including diagnosis and treatment. These services will be covered at:
- Your doctor’s office
- Hospital outpatient departments
- Outpatient rehabilitation facilities
- Skilled nursing facilities if you’re being treated as an outpatient
- At home
Unlike Part A coverage, Part B does not require you to have had a prior hospitalization in order for physical therapy to be covered.
Typically, your physical therapist will document evaluations of your condition and progress to continue to prove the services are medically necessary. This may include:
An evaluation and assessment of your condition and diagnosis
The types of physical therapy you’ll receive
A plan of care, including:
- Your short and long-term goals for physical therapy
- How many sessions you will have per day or week, and how many you will need total
- Duration of sessions and what will happen at each
After a certain number of sessions, your doctor and physical therapist will reevaluate your treatment plan and determine whether or not you should continue physical therapy. However, Medicare does not require you demonstrate improvement in order to continue to receive coverage. Your doctor just has to determine it is medically necessary to treat, maintain, or prevent deterioration of your condition.
Is Physical Therapy Covered at Home?
If you are receiving at-home physical therapy services, they may be 100 percent covered by either Medicare Part A or B depending on whether or not:
- You are under a doctor’s care, and physical therapy is part of your care plan
- You are certified home-bound by your physician
- The physical therapy treatments are performed by a qualified physical therapist
- The home health agency providing the physical therapy services is certified by Medicare
- Your doctor expects you to improve due to physical therapy
Is There a Limit on Physical Therapy with Medicare?
As of 2018, there is no longer a therapy cap, or limit, for how much Medicare will pay for your physical therapy services each calendar year.
Medicare will also monitor and review to ensure your therapy sessions are helping your condition and following your treatment plan. If upon review Medicare determines your doctor hasn’t given enough information or the physical therapy is no longer medically necessary, they may decide not to cover additional sessions.
If this happens, or if your therapist believes you need therapy that is not covered by Medicare, your provider or therapist will provide you with an Advance Beneficiary Notice of Noncoverage (ABN), and you can either end your therapy or continue and pay 100 percent out-of-pocket.
How Much Will Physical Therapy Cost?
As long as the physical therapy is medically necessary and takes place at a participating provider, Medicare Part B typically covers 80 percent of the cost after you reach your deductible ($226 in 2023). This is the case if your therapy happens at the hospital, outpatient center, or your doctor’s office. You’d then be responsible for paying the remaining 20 percent.
The actual cost of your physical therapy depends on:
- Your insurance
- The type of physical therapy you need
- How many sessions are involved with your treatment
- How much your physical therapist charges
- Where you live
- The type of facility you’re receiving services at
You may also have a copay in some cases, so talk with your physical therapist and contact Medicare to understand exactly how much your treatment will cost. Again, if the physical therapy is not considered medically necessary, you are responsible for 100 percent of the cost.
If you need any durable medical equipment (DME) as part of your therapy, such as a walker or cane, that may also be covered by Medicare up to 80 percent.
Is Physical Therapy Covered by Medicaid?
With Medicaid coverage, federal law requires states to provide certain mandatory benefits, and gives states the ability to choose whether or not they cover additional optional benefits.
While mandatory services include inpatient and outpatient hospital services, physician services, labs and x-ray services, and some home health services, physical therapy is an optional benefit. This means your state may or may not cover physical therapy services.
Even if your state does cover physical therapy, you may have an additional required copay or limitations on service, such as:
- Only a certain number of visits are covered per year
- Services must take place in certain locations, such as in home or your doctor’s office
- A maximum cost for outpatient services
- Prior authorization required
Do Medicare Advantage (MA) Plans Cover Physical Therapy?
Physical therapy coverage depends on your specific MA plan. While MA plans must provide at least the same coverage as Original Medicare, they may also offer additional benefits not covered by Medicare, including increased physical therapy coverage.
There may also be limitations, such as being required to get your physical therapy at specific practices or within your covered network.
To understand your physical therapy coverage, benefits, and cost, contact your plan.
Does Medicare Cover Other Types of Therapy?
In addition to physical therapy, Medicare also covers speech therapy and occupational therapy.
- Speech therapy, or speech-language pathology, helps treat speech and voice challenges. This may include help finding the right word, using proper voice volume, and creating meaningful sentences.
- Occupational therapy helps you improve (or regain) skills you need for everyday activities. This may include eating, bathing, getting dressed, etc. It may also include social skills or skills necessary for employment.
What Part B Covers
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