Medicare's payment for physical therapy varies by setting and your plan type

Medicare does not set a single dollar amount per visit. Instead, it pays based on the specific therapy code used, the setting where you receive care (outpatient clinic, hospital, home, or skilled nursing facility), and whether you have Original Medicare or a Medicare Advantage plan. A physical therapy visit in an outpatient clinic might be reimbursed at one rate, while the same therapy in your home is reimbursed at a different rate.

Original Medicare (Part A and Part B) typically reimburses between $50 and $150 per visit for outpatient physical therapy, though the exact amount depends on the procedure code, your geographic location, and the complexity of your treatment. Medicare Advantage plans set their own payment rates and cost-sharing rules, so your out-of-pocket cost can differ significantly from someone with Original Medicare.

What matters most to you as a patient is not what Medicare pays the provider, but what you owe. That depends on your deductible status, whether you have met your annual out-of-pocket maximum, and the specific terms of your plan.

Key Takeaways

  • Original Medicare covers physical therapy with a $20 to $50 copay per visit after you meet your Part B deductible, with no visit limit as long as the therapy is medically necessary.
  • Medicare Advantage plans vary widely — some charge $0 to $75 per visit, and some limit the number of visits per year, so you must check your plan documents.
  • The amount Medicare pays the provider is not the same as what you pay; Medicare's payment is based on procedure codes and your location, while your cost depends on your plan type and deductible status.
  • Physical therapy in a skilled nursing facility, hospital outpatient department, or your home may have different payment rules and cost-sharing than a private clinic.
  • You should ask your physical therapy clinic to verify your coverage and estimate your cost before your first visit, because payment rules change based on where you receive care.

How Original Medicare pays for outpatient physical therapy

If you have Original Medicare (Part B), physical therapy at an outpatient clinic is covered after you meet your annual Part B deductible, which is $240 in 2024. Once you have met the deductible, you typically pay 20% of what Medicare approves, and Medicare pays 80%.

The amount Medicare approves depends on a fee schedule that varies by location. In rural areas, the approved amount may be lower than in urban areas. Medicare also updates these amounts each year, so the payment in 2024 is different from 2023. Your physical therapy clinic should be able to tell you the approved amount for your specific procedure code and zip code.

Original Medicare does not limit the number of physical therapy visits per year, as long as your doctor orders the therapy and the therapist documents that it is medically necessary. However, Medicare may deny payment if it determines the therapy is not progressing or is no longer needed.

Medicare Advantage plans and physical therapy costs

Medicare Advantage plans (Part C) are run by private insurance companies and set their own rules for physical therapy coverage. Some plans cover physical therapy with no copay; others charge $25 to $75 per visit. Many Advantage plans limit the number of visits per year — commonly 20 to 30 visits — though some plans have no limit.

Your plan documents (called the Summary of Benefits and Coverage) list the copay amount and any visit limits. You can find this document on your plan's website or by calling the plan's customer service number, which is on your insurance card. If you cannot find the information, call 1-800-MEDICARE and ask them to look up your specific plan's physical therapy coverage.

Some Medicare Advantage plans waive the copay for physical therapy ordered by your primary care doctor but charge a copay if you go to a therapist without a referral. Check whether your plan requires a referral before you schedule.

Physical therapy in different settings and what Medicare pays

The setting where you receive physical therapy affects how much Medicare pays and what you owe. The main settings are outpatient clinics (private therapy offices or hospital-based clinics), skilled nursing facilities, hospital outpatient departments, and your home.

Outpatient clinics: This is the most common setting. Original Medicare pays the clinic based on the approved amount for your area, and you pay 20% after your deductible. Medicare Advantage plans vary.

Skilled nursing facilities: If you are admitted to a skilled nursing facility after a hospital stay, physical therapy is usually included in your daily facility charge. You pay a copay (up to $194.50 per day in 2024 for days 1–20, and up to $389 per day for days 21–100 under Original Medicare). Medicare Advantage plans have different cost-sharing.

Hospital outpatient departments: Physical therapy at a hospital's outpatient clinic may have a higher copay than a private clinic because hospitals bill under a different payment system. You may owe 20% of a higher approved amount.

Home health: If your doctor orders physical therapy as part of home health services, Medicare Part A covers it with no copay after you meet your Part A deductible. You must be homebound and receiving skilled nursing or another may have access to service for home health to be covered.

Your out-of-pocket costs and how to estimate them

Your actual cost per visit depends on three things: whether you have met your annual deductible, your plan's copay or coinsurance rate, and whether you have reached your out-of-pocket maximum.

If you have Original Medicare and have not met your $240 Part B deductible, you pay the full approved amount for your first few visits until the deductible is satisfied. After that, you pay 20% of the approved amount per visit. If the approved amount is $100, you pay $20 per visit. If it is $75, you pay $15 per visit.

Once you have paid $2,430 out of pocket in 2024 (the Part B out-of-pocket maximum), Medicare covers 100% of approved charges for the rest of the year. This means your copay drops to $0 after you reach this limit.

Medicare Advantage plans have their own out-of-pocket maximums, which are often lower than Original Medicare's. Once you reach your plan's maximum, the plan covers 100% of in-network services for the rest of the year.

What to ask your physical therapy clinic before your first visit

Call your physical therapy clinic and ask them to verify your coverage. Provide your Medicare card number and the type of plan you have (Original Medicare or the name of your Advantage plan). Ask them to tell you:

  • The copay or coinsurance amount per visit
  • Whether there is a limit on the number of visits per year
  • Whether your plan requires a referral from your doctor
  • Whether the clinic is in-network with your plan (if you have an Advantage plan)
  • An estimate of your total cost for the course of therapy your doctor has ordered

The clinic should also verify that your doctor's order for physical therapy is on file and that Medicare will cover it as medically necessary. If the clinic cannot answer these questions, ask them to contact your insurance company on your behalf, or call your plan directly.

When Medicare denies payment for physical therapy

Medicare may deny payment if the therapy is not medically necessary, if you have exceeded your visit limit (under some Advantage plans), or if the therapy is not progressing. Your physical therapist should document your progress at each visit and communicate with your doctor if Medicare may deny future visits.

If Medicare or your Advantage plan denies a claim, you will receive a notice called an Explanation of Benefits (EOB). The EOB explains why the claim was denied and tells you how to appeal. You have the right to appeal any denial, and you can ask your physical therapy clinic or your doctor to help you with the appeal.

If you believe the denial is incorrect, contact your plan's customer service number (on your insurance card) or call 1-800-MEDICARE to ask about the appeal process. Keep copies of all bills, receipts, and correspondence with your insurance company.

Frequently Asked Questions

Do I need a referral from my doctor to get physical therapy covered by Medicare?

Original Medicare does not require a referral, but your doctor must order the therapy and document that it is medically necessary. Medicare Advantage plans vary — some require a referral, others do not. Check your plan documents or call your plan's customer service to confirm.

What happens if I go to a physical therapist who is not in my Medicare Advantage network?

If you use an out-of-network provider, you will typically pay more out of pocket, and your plan may not cover the visit at all. Some Advantage plans cover out-of-network care at a higher copay, but this varies. Call your plan before seeing an out-of-network therapist to understand your cost.

Can I get more physical therapy visits if my doctor says I need them?

Under Original Medicare, there is no annual visit limit as long as the therapy is medically necessary and progressing. Medicare Advantage plans often have limits (commonly 20 to 30 visits per year), though some plans have no limit. If you need more visits than your plan allows, ask your doctor to appeal to your plan or to request an exception.

Does Medicare cover physical therapy for prevention or fitness?

No. Medicare covers physical therapy only when it is ordered by a doctor to treat a specific medical condition or injury. Therapy for general fitness, wellness, or prevention is not covered.

What should I do if I receive a bill I think Medicare should have paid?

Contact your physical therapy clinic first and ask them to resubmit the claim or explain why it was denied. If the clinic cannot resolve it, call your insurance company's customer service number (on your card) or call 1-800-MEDICARE. Ask for an Explanation of Benefits and keep it for your records.