Medicare covers physical therapy, but only under specific conditions and with limits on how many visits you can have

Medicare Part B pays for physical therapy when a doctor orders it to treat a medical condition or injury — not for general fitness or wellness. The therapy must be medically necessary, meaning it aims to restore function you have lost or improve a condition that is preventing you from doing daily activities. Medicare will cover the cost of the therapist's services, but you will pay a copay of 20% of the approved amount after you meet your Part B deductible.

The catch is that Medicare sets an annual limit on how much it will spend on physical therapy combined with occupational therapy and speech-language pathology services. That limit changes each year. You also cannot straightforward decide you need physical therapy — a doctor must refer you, and the therapist must document that the treatment is helping you improve.

Key Takeaways

  • A doctor must order physical therapy for a medical condition; Medicare does not cover therapy for general fitness or prevention.
  • You pay 20% of the Medicare-approved amount after meeting your Part B deductible, and the therapist's office will bill Medicare directly.
  • Medicare sets an annual spending limit on physical therapy combined with occupational therapy and speech-language pathology, though you can request an exception if your doctor says you need more visits.
  • The therapist must show that your condition is improving; if progress stops, Medicare may stop paying even if you have visits remaining.
  • Therapy must take place in a Medicare-approved setting such as a hospital outpatient department, rehabilitation facility, or private practice clinic.

When Medicare will and will not pay for physical therapy

Medicare covers physical therapy when you have a condition that has caused you to lose physical function and a doctor believes therapy can help you regain it. Common reasons Medicare approves therapy include recovery from a stroke, hip or knee replacement, a broken bone, or a fall that has left you unable to walk safely. Therapy after surgery or hospitalization is frequently covered.

Medicare will not pay for physical therapy ordered only to prevent injury or maintain fitness, even if your doctor thinks it would be good for you. Therapy for chronic pain without a specific injury or condition is also typically not covered. If you want therapy for general wellness, balance training to prevent falls, or exercise coaching, you would need to pay out of pocket or check whether your supplemental insurance or Medicare Advantage plan covers it.

How much Medicare pays and what you owe

After you meet your Part B deductible for the year, Medicare pays 80% of the approved amount for each physical therapy visit, and you pay 20%. The approved amount is set by Medicare, not by what the therapist charges. If a therapist charges more than Medicare's approved amount, they can bill you for the difference only if they are not a Medicare provider — most therapists who treat Medicare patients are, so the bill stops at your 20% copay.

The annual spending limit for physical therapy combined with occupational therapy and speech-language pathology services is set by Medicare each year. Once you reach that limit, Medicare stops paying unless your doctor submits a request for an exception and Medicare approves it. Your therapist's office can tell you how many visits you have used and how close you are to the limit.

The annual visit limit and exceptions

Medicare sets a cap on the total number of visits or total dollars spent on physical therapy, occupational therapy, and speech-language pathology services in a calendar year. This limit applies whether you receive therapy in one setting or spread across multiple providers. The exact limit varies by year and by whether you are in an outpatient setting or a hospital.

If your doctor believes you need more therapy than the limit allows, they can request an exception from Medicare. This is called a "therapy cap exception" or "manual therapy cap exception." Your therapist's office usually handles this paperwork. Medicare reviews the request and your medical records to decide whether the additional visits are medically necessary. The request must show that you are still improving and that stopping therapy would harm your recovery. Approval is not may provide, but many exceptions are granted when the medical case is strong.

Where you can receive physical therapy under Medicare

Medicare covers physical therapy in several settings: a hospital outpatient department, a skilled nursing facility (if you are a resident), a rehabilitation facility, a home health agency (if you are homebound), or an outpatient physical therapy clinic. The therapist must be a licensed physical therapist or a physical therapist assistant working under a therapist's supervision, and the facility must be Medicare-approved.

If you receive therapy in your home because you cannot leave without help, Medicare may cover it under the home health benefit instead of the outpatient therapy benefit. Home health therapy has different rules and limits. Ask your doctor or the home health agency whether your situation qualifies.

What happens if you reach the visit limit

When you approach the annual limit, your therapist's office should notify you. At that point, you have a few options. You can stop therapy, continue paying out of pocket for additional visits, or ask your doctor to request an exception from Medicare. If your doctor submits an exception request, Medicare will review it, and you should know the decision within a few weeks. During that time, you can continue therapy, but you may be responsible for the cost if Medicare denies the exception.

If Medicare denies the exception and you want to continue therapy, you can appeal the decision. Your doctor or therapist can help you file an appeal, which involves submitting additional medical evidence that the therapy is still helping you improve. Some people also check whether their supplemental insurance or Medicare Advantage plan covers therapy beyond the Medicare limit.

Medicare Advantage and supplemental insurance coverage

If you have a Medicare Advantage plan instead of Original Medicare, your coverage for physical therapy may be different. Some Medicare Advantage plans cover more visits than Original Medicare allows, and some have lower copays. You should check your plan's coverage details or call the plan to ask about physical therapy limits before you start treatment.

If you have a Medigap (supplemental insurance) policy, it typically does not cover physical therapy beyond what Original Medicare covers, because Medigap policies are designed to cover the copays and deductibles that Medicare leaves unpaid, not to expand benefits. However, some Medicare Advantage plans do offer additional therapy visits, so it is worth asking.

Questions to ask your doctor and therapist

Before you start physical therapy, ask your doctor whether Medicare will cover it for your condition and whether they believe you will need more visits than the annual limit allows. Ask your therapist's office to explain the copay amount, how many visits they expect to schedule, and whether they will track your progress toward the annual limit. Request that they notify you when you are close to the limit so you are not surprised by a bill.

If your therapy is not improving your condition after several weeks, ask your therapist and doctor whether continuing makes sense. Medicare requires that therapy show measurable progress; if it does not, Medicare may deny payment even if you have visits left. Knowing this upfront helps you and your therapist decide together whether the treatment plan is working.

Frequently Asked Questions

Do I need a referral from my doctor to start physical therapy?

Yes. Medicare requires that a doctor order physical therapy and document that it is medically necessary for your condition. You cannot start therapy on your own and have Medicare pay for it. The referral can come from your primary care doctor, a specialist, or a hospital discharge planner.

What if my physical therapist is not a Medicare provider?

If your therapist does not accept Medicare, you can still receive therapy, but you will likely pay the full cost upfront and then submit a claim to Medicare yourself. Medicare may reimburse you for part of the cost if the therapy was medically necessary, but you will not know the amount until after you pay. It is easier to use a Medicare-approved provider so the billing is handled directly.

Can I continue physical therapy after I reach the annual limit?

You can continue paying out of pocket, or your doctor can request an exception from Medicare if you still need therapy and are making progress. Medicare reviews exception requests and approves many of them when the medical evidence supports continued treatment. Without an exception, Medicare will not pay once the limit is reached.

Does Medicare cover physical therapy for arthritis or chronic pain?

Medicare covers physical therapy for arthritis or chronic pain only if there is a specific injury or condition causing it — for example, therapy after a knee replacement or a rotator cuff repair. Therapy ordered only to manage ongoing arthritis pain without a recent injury is usually not covered. Ask your doctor whether your situation qualifies.

What is the difference between physical therapy and occupational therapy under Medicare?

Physical therapy focuses on movement, strength, and walking. Occupational therapy focuses on daily living skills like dressing, bathing, and cooking. Both count toward the same annual spending limit, so if you receive both types of therapy, the visits are combined when calculating whether you have reached the limit.