How Medicare Pays for Physical Therapy
Part B covers outpatient physical therapy when your doctor or other health care provider, including a nurse practitioner, clinical nurse specialist, or physician assistant, certifies that you need it and it is medically necessary. You pay 20 percent of the approved amount after the $283 Part B deductible in 2026. Congress eliminated the old hard therapy caps back in 2018, so there is no longer a dollar limit on how much therapy Medicare will pay for in a year. Today there is only a documentation threshold. Once your combined physical therapy and speech language pathology charges pass $2,480 in 2026, your therapist adds a billing code attesting that continued care is medically necessary. Claims above $3,000 can face targeted medical review. Neither of these numbers is a coverage limit, and therapy continues as long as it is justified and properly documented by your provider. Medicare also covers physical therapy delivered during a covered home health care episode or a skilled nursing facility stay, so the benefit follows you across different care settings rather than applying only to a therapist's office. Your share changes with the setting, though. According to Medicare.gov, you pay nothing for physical therapy delivered as part of a covered home health episode, and only durable medical equipment carries the 20 percent share. In a skilled nursing facility after a qualifying inpatient hospital stay of at least 3 days in a row, you pay $0 per day for days 1 through 20 after the $1,736 Part A deductible and $217 per day for days 21 through 100 in 2026. The 20 percent coinsurance applies to outpatient therapy under Part B. Medicare Advantage plans must cover the same physical therapy services as Original Medicare, since federal law requires them to match Part B benefits. However, these plans usually charge a fixed copay per visit instead of the 20 percent coinsurance, and some require prior authorization before therapy begins. That means two plans covering the identical service can leave you with very different total costs depending on visit copays and any authorization delays.
Original Medicare vs Medicare Advantage
Under Original Medicare, physical therapy is covered at 20 percent coinsurance after the $283 Part B deductible in 2026, with no annual cap and no prior authorization requirement. Under Medicare Advantage, the plan must cover the same medically necessary therapy, but it typically replaces coinsurance with a fixed copay for each visit. Many Medicare Advantage plans also require prior authorization before therapy starts or continues, which can add a step your therapist's office has to manage. If you need frequent, ongoing therapy, the per visit copay structure of Medicare Advantage can add up differently than Original Medicare's percentage based cost sharing, so it is worth comparing both against your expected number of visits. This difference matters most for people expecting many visits over several months, since a fixed copay repeated week after week can end up costing more or less than the 20 percent share, depending on your plan's specific copay amount and the total number of visits your therapy plan requires.
Your Protections When a Medicare Advantage Plan Requires Prior Authorization
Prior authorization is the main tool a Medicare Advantage plan uses to manage therapy, but federal rules limit how it can be applied. In the CMS final rule known as CMS-4201-F, Medicare Advantage plans must follow the same national coverage determinations, local coverage determinations and general coverage conditions that apply in Traditional Medicare, so a plan cannot use a narrower definition of medically necessary physical therapy than Original Medicare does. Once a plan approves a course of treatment, CMS requires that approval to stay valid for as long as the care remains medically reasonable and necessary, a rule written to avoid disruptions partway through recovery. If you switch to a different Medicare Advantage plan while therapy is underway, the new plan may not require prior authorization for that active course of treatment during a transition period of at least 90 days. Each plan must also have a utilization management committee that reviews its policies every year. Keep your plan of care and any approval letters, and if you are weighing a plan change in the middle of treatment, call Lara Goulson at (818) 472-5484 to talk through the timing.
Ask About Your Therapy Costs
If you expect ongoing therapy, for example after a joint replacement or a fall, a licensed agent can compare the per visit therapy copays and prior authorization rules across the Medicare Advantage plans available where you live. She can also walk through whether staying on Original Medicare paired with a Medigap plan would lower your total out of pocket cost over a long course of treatment, so you are not caught off guard partway through recovery.
Call (818) 472-5484 to compare how your plan handles physical therapy costs.
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