Does Insurance Cover Physical Therapy?

Physical therapy can help you regain or improve movement in your body after you’ve been through surgery, injury, or illness. A physical therapist (PT) can provide treatments and exercises to help you manage your movement or reduce pain.

Most health insurance policies, including Medicare, will cover some of the costs of physical therapy when deemed medically necessary. But plans vary in what they cover and the amount of coverage they offer.

Here’s what you need to know to get insurance to cover as much of your physical therapy as possible

How health insurance works with physical therapy

In most cases, insurers — including private insurance companies and Medicare — will help pay for physical therapy that’s considered “medically necessary.”^[1]

How your healthcare plan defines “medically necessary” can affect which services it covers. To adhere to Medicare’s definition of medically necessary, services must meet the following criteria:

• Provided by a qualified clinician, such as a physical therapist or supervised physical therapist assistant^[2]

• Treatment requires a level of expertise acquired through specialized training

• Service is accepted under the standard of medical practice and considered effective for the patient’s condition

• Reasonable frequency and duration of the service

• Documentation that shows treatment is resulting in progress

It’s up to your doctor or healthcare provider to determine if physical therapy is a medical necessity for your treatment.

Rules can vary between insurance plans for things like which physical therapist you can see, how many sessions you can attend, and if you need a referral or approval before you can receive care. For instance, if you have Medicare, you’ll have to find a clinician that accepts Medicare, and there’s no limit to how many physical therapy sessions you can attend in a year.

But some insurers will require you to use one of their contracted physical therapists, and there may be limits to how many PT visits you can have within a period of time. Some insurance companies also require authorization for members of certain plans.

While some insurance plans permit self-referral, known as “direct access,” others require a provider referral.

Some larger private insurance companies don’t require a referral, and Medicare allows direct access once your physician has created a treatment plan.

Finally, plans vary based on the:

• 

  Deductible

  This is the out-of-pocket cost you’ll pay before your insurance provides coverage. For example, the deductible for Medicare Part B (Medical Insurance) is $240 per year before Medicare starts to pay.^[3]

• 

  Co-insurance

  This is a percentage of the cost that you pay for each appointment after you’ve met your deductible. Medicare typically requires you to pay 20% for each covered service once you’ve paid your deductible.

• 

  Copay

  A copay is a fixed amount that you have to pay per session, sometimes starting before you’ve met your deductible.

How to figure out whether your health insurance covers physical therapy

Calling your insurer and asking if it covers physical therapy is the easiest way to confirm coverage and ask questions about the details of your insurance. Many insurers also have online portals where you can log on to see details about your plan.

You can learn more about your plan by asking:

• Do I need a referral? Before covering a PT appointment, some insurers might require a referral from a primary care provider.

• Can I choose my physical therapist? Some insurers might cover PT sessions from in-network providers but not cover, or have different coverage, for PTs who are out of network.

• How much is my deductible, co-insurance, or copay? Check how much you have to pay for your deductible, co-insurance, or copay.

• Will insurance cover the cost of equipment? Your physical therapist might recommend equipment, such as weights or resistance bands, to aid in your physical therapy. You can check with your insurer to see if it’ll cover equipment or supplies.

• Are there limits to my coverage? While some plans may have no limits for PT services in a calendar year, others might have restrictions on the number of sessions or the amount of time you can get physical therapy.

Evaluating the coverage scope: HMO vs. PPO

A health maintenance organization (HMO) is a type of health plan that limits coverage to providers within the HMO network. It typically won’t cover out-of-network providers unless it’s an emergency.

A preferred provider organization (PPO) also has a group of in-network providers, and you’ll generally pay less if you use one. But unlike an HMO, it’s possible to use a PT outside of the network — though you should expect to pay more.

Medicare and physical therapy coverage 

Medicare Part A (hospital insurance) covers eligible physical therapy if you’re “homebound.” This means you have trouble leaving your home without help or your doctor recommends that you don’t leave due to your condition.

Medicare Part B (medical insurance) helps pay for physical therapy that’s deemed “medically necessary.” After you meet your deductible of $240 per year, you’re responsible for paying 20% going forward, while Medicare pays the remaining 80%. If you have Medicare Supplement Insurance, known as Medigap, you can use it to cover the 20% gap.

Reducing the costs of physical therapy

If you’re looking for ways to reduce the costs of physical therapy, consider the following tips:

• Use secondary coverage. Medicare will typically cover 80% of your claim, and you’ll have to pay the other 20%. If you have secondary insurance, you can check if it’ll cover the remaining amount.

• Reduce appointment frequency. Talk to your PT to see if it’s reasonable to reduce the frequency of your appointments. See if you can do things at home to maintain your progress.

• Use an in-network provider. Seeing a provider that’s within your insurance company’s network is typically cheaper than an out-of-network provider.

• Check out the payment assistance program. If you need help with your insurance premiums, you can check out the Medicare Savings Program. In some cases, the program can help pay your Part B deductibles, co-insurance, and copayments.

• Be disciplined. If you don’t commit to doing your physical therapy exercises outside of your session, it’ll slow your progress. By doing the rehabilitation, you can try to progress faster and finish physical therapy sooner.

Insurance and physical therapy FAQs