What Medicare Part B Covers for Physical Therapy

Medicare Part B 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 as medically necessary treatment for an injury, illness, or surgery. The therapy must take place in an outpatient setting — a hospital outpatient department, a rehabilitation facility, or a therapist's private office. Part B does not cover physical therapy you arrange on your own without a doctor's referral, and it does not cover therapy purely for fitness, wellness, or prevention.

You pay 20 percent of the cost after you meet your annual Part B deductible (which changes each year). The therapist must be enrolled in Medicare and accept Medicare payment. If you see an out-of-network therapist, your costs will be higher, and you may owe the full bill.

Key Takeaways

Your doctor must order physical therapy as treatment for a medical condition; you cannot refer yourself and have Medicare pay.
Medicare Part B covers the cost after your deductible, but you pay 20 percent of what Medicare allows, and visit limits explore.
The therapist must be enrolled in Medicare; using an out-of-network provider means you pay more or the full cost.
Medicare sets an annual dollar limit on what it will pay for physical therapy combined with occupational therapy, though your doctor can request an exception.

When Part B will pay for physical therapy

Part B covers physical therapy when it is ordered by your doctor as treatment for a specific medical condition. Common reasons include recovery from surgery (hip replacement, knee surgery, stroke), injury (broken bone, torn ligament), or illness (arthritis, Parkinson's disease, heart disease). The therapy must be aimed at restoring function or managing a medical problem, not maintaining fitness or preventing future injury.

Your doctor does not have to be a specialist — your primary care doctor can order it. The therapist will need a written order from your doctor that describes your condition and what the therapy is meant to treat. Without this order, Medicare will not pay, and you will owe the full bill.

The therapy must take place in an outpatient setting. This includes a hospital outpatient department, a rehabilitation facility, a skilled nursing facility (if you are there for another covered reason), or a therapist's private office. If you are an inpatient in a hospital or nursing home, physical therapy is covered under the inpatient benefit, not Part B.

How much Medicare Part B pays

After you meet your annual Part B deductible, Medicare pays 80 percent of the cost and you pay 20 percent. The amount Medicare pays is based on what it considers the standard fee for that service in your area — called the "allowed amount." If your therapist charges more than the allowed amount, you may owe the difference on top of your 20 percent.

Medicare sets an annual dollar limit on combined physical therapy and occupational therapy services. This limit changes each year. Once you reach the limit, Medicare stops paying unless your doctor requests and receives an exception. Your therapist's office should track your spending toward this limit and tell you when you are approaching it.

If you have a Medigap or Medicare Advantage plan, your out-of-pocket costs may be lower. Medigap plans often cover the 20 percent coinsurance. Medicare Advantage plans have their own rules about copays and coinsurance, and some may have different visit limits. Check your plan documents or call your plan to understand your costs before you start therapy.

What you need before you start

You need a written order from your doctor. This order should describe your condition and what the physical therapy is meant to treat. Bring this order to your first appointment, along with your Medicare card. The therapist's office will verify your coverage and tell you what your out-of-pocket costs will be.

If you are seeing a therapist for the first time under Medicare, ask the office whether the therapist is enrolled in Medicare and accepts Medicare payment. If the therapist is out-of-network, you will pay more. Some out-of-network therapists will not bill Medicare at all and will ask you to pay the full cost upfront and submit the claim yourself.

Before you start, ask the therapist's office how many visits your doctor ordered and whether they expect you to reach Medicare's annual dollar limit. If you are close to the limit, ask whether your doctor can request an exception. This request is called a "therapy cap exception" or "medical review," and it allows Medicare to pay for additional visits if the therapy is medically necessary.

Visit limits and when they reset

Medicare does not set a limit on the number of visits you can have, but it does set an annual dollar limit on what it will pay for physical therapy combined with occupational therapy. This limit is the same whether you have one visit or fifty. Once you reach the dollar amount, Medicare stops paying unless your doctor requests an exception.

The calendar year runs from January 1 to December 31. Your limit resets on January 1. If you reach your limit in November, you can start fresh visits in January without paying out-of-pocket, as long as your doctor orders them again.

Your doctor can request an exception to the annual limit if the therapy is medically necessary and you have not yet received the full benefit of treatment. This request must come from your doctor, not from you or the therapist. The therapist's office can help your doctor submit the request, but the decision comes from Medicare.

What Part B does not cover

Medicare Part B does not cover physical therapy ordered for fitness, wellness, or prevention. This includes therapy to improve athletic performance, prevent injury in a healthy person, or maintain general strength and flexibility. If your doctor orders therapy for one of these reasons, Medicare will deny the claim and you will owe the full cost.

Part B does not cover therapy you arrange on your own without a doctor's order. Even if a therapist thinks you need treatment, Medicare will not pay unless your doctor has ordered it in writing.

Part B does not cover therapy from an unlicensed provider or from a provider who is not enrolled in Medicare. If you see someone who is not a licensed physical therapist or who does not accept Medicare, you will pay the full cost.

If your claim is denied

If Medicare denies your claim, the therapist's office will send you a notice called a "Remittance information" or "Explanation of Benefits." This notice will say why Medicare denied it — usually because there was no doctor's order, the order did not describe a medical condition, or you reached your annual dollar limit.

If you disagree with the denial, you have the right to appeal. You can ask your doctor to provide more information about why the therapy is medically necessary, or you can ask your doctor to request an exception to the annual limit. The therapist's office can help you understand what information Medicare needs to reconsider.

Frequently Asked Questions

Do I need a referral from my primary care doctor, or can any doctor order physical therapy?

Any doctor can order physical therapy — it does not have to be your primary care doctor. This includes specialists, urgent care doctors, and hospital doctors. The order must be in writing and describe your medical condition and what the therapy is meant to treat.

What if I want to see a physical therapist but my doctor has not ordered it?

You can ask your doctor to order it. Bring information about your condition and why you think therapy would help. If your doctor agrees it is medically necessary, they can write an order. If your doctor does not think it is necessary, Medicare will not pay if you see a therapist anyway.

Does Medicare Part B cover telehealth physical therapy?

Yes, Medicare Part B covers physical therapy delivered by video if the therapist is enrolled in Medicare and your doctor has ordered it. You pay the same 20 percent coinsurance as in-person therapy, and the visit counts toward your annual dollar limit.

What happens if I reach my annual dollar limit in the middle of treatment?

Medicare stops paying once you reach the limit. You can either pay out-of-pocket for additional visits, or your doctor can request an exception. If your doctor requests an exception and Medicare approves it, Medicare will resume paying for visits that meet the medical necessity standard.

If I have a Medicare Advantage plan, does it cover physical therapy the same way?

Medicare Advantage plans must cover at least what Original Medicare covers, but they can have different rules about copays, coinsurance, visit limits, and which therapists you can see. Check your plan documents or call your plan to understand your specific coverage before you start therapy.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.