Does Original Medicare cover physical therapy?

Physical therapy can make a big difference in overall quality of life. No matter what type of exercise it includes.

Original Medicare helps pay for a variety of medical and hospital needs. Let’s take a look and see how Original Medicare and physical therapy work for health care needs.

Does Medicare pay for physical therapy? 

Yes, Medicare helps cover physical therapy. But a doctor or other health care provider (nurse practitioner, clinical nurse specialist, or physician assistant) must certify the member needs it.

Does Original Medicare Part A cover physical therapy? 

Original Medicare Part A does not cover outpatient or in-home physical therapy. It does help cover the costs of physical therapy received in hospitals, Medicare-approved skilled nursing facilities, and inpatient rehabilitation facilities. It will not cover physical therapy sessions after a hospital stay ends.

Does Original Medicare Part B cover physical therapy?

Yes, Original Medicare Part B does help cover outpatient physical therapy sessions. But a doctor or health care provider must certify it medically necessary. After the member meets the Part B deductible, they pay 20% of the Medicare-approved amount. There is no limit on the amount Medicare pays for medically necessary outpatient physical therapy in one calendar year.

Does Medicare Advantage (MA) cover physical therapy? 

Medicare Advantage, or Plan C, does cover physical therapy sessions. Out-of-pocket costs depend on which MA plan a person has. And where they get their physical therapy services and the circumstances of their condition.

The member must meet the same Original Medicare eligibility requirements to qualify for physical therapy services with an MA plan. It’s important individuals check with their plan to see what their coverage options are. And what to expect for out-of-pocket costs.

Medicare physical therapy guidelines  

Do I need a referral for physical therapy under Medicare?

Typically, Original Medicare does not require referrals for enrollees to access specialist services, including physical therapy. Those who have Original Medicare can use any doctor, hospital, or facility that takes Medicare, anywhere in the U.S. Therapists must ensure they are enrolled in Medicare for Medicare to cover their services.

Those enrolled in an MA plan can normally only use doctors and other providers who are in the plan’s network and service area. And depending on the MA plan, the member may need to get a referral to get physical therapy. The member’s health care provider must state physical therapy as medically necessary.

How many physical therapy sessions does Original Medicare cover? 

There’s no limit on the number of sessions Original Medicare Part B covers. Once the member pays the Part B deductible, Medicare helps to cover costs. The member is then responsible for 20% of the cost of the Medicare-approved amount.

Costs per physical therapy session with Medicare coverage depend on the following. 

• If enrollee has coverage other than Original Medicare.
• Amount charged by facility.
• Facility where member receives physical therapy.
• Whether or not member pays the deductible.

Does Medicare cover home physical therapy? 

Original Medicare does cover home services. But a physician must state it’s necessary. Patient must also be homebound for medical reasons to be eligible for full in-home physical therapy Medicare coverage. Below are eligibility requirements to receive Medicare coverage for home services (including physical therapy). 

• Be under a doctor’s care plan for services and treatments.
• Be homebound for medical reasons.
• Have physical therapy referrals from a doctor under their care plan. 

Medicare guidelines for physical therapy in skilled nursing 

Original Medicare Part A helps cover inpatient care in hospitals and skilled nursing facilities. Medicare Part A limits coverage to 100 days in a Medicare-approved skilled nursing facility in each benefit period. If treatment and services during time at a skilled nursing facility includes physical therapy sessions, Medicare covers it.

Does Medicare cover physical therapy for back pain? 

Original Medicare covers physical therapy sessions for back pain so long as the member’s doctor states it’s medically necessary.

Original Medicare (Part A and B) typically does not require referrals for members to access specialist services, including physical therapy. Medicare does cover services. And therapists must be enrolled in Medicare.

Medicare Advantage (MA) plans, offered by private insurance companies, may have referral requirements, especially for HMO and SNP enrollees. These requirements can vary between MA plans.

Medicare physical therapy cap  

Technically, there’s no Medicare cap for physical therapy as long as it’s medically necessary. And there’s no limit on the amount Medicare pays for outpatient services each year. There is a threshold for physical therapy coverage for Medicare that’s set at $2,330 for 2024. Physical therapists can go over the limit if treatment is medically necessary.

Original Medicare reimbursement for physical therapy 

Original Medicare covers 80% of the costs for physical therapy for the Medicare-approved amount. Once a member meets their deductible for their Medicare Part B, they’re responsible for 20% of the cost.