Does Insurance Pay for Physical Therapy?

In most cases, insurance will cover physical therapy. But the number of sessions may be limited, and you may have to demonstrate progress to continue.

Mark Steinbach
Written by
Mark Steinbach
Mark Steinbach
Written by
Mark Steinbach
Insurance Writer
Mark Steinbach is a writer based in Brooklyn, NY. In addition to his years of work as a copywriter, he is also a TV writer with a degree in English from Harvard University. When he isn't writing, he can be found playing tennis or doing crossword puzzles.
Evelyn Pimplaskar
Edited by
Evelyn Pimplaskar
Evelyn Pimplaskar
Edited by
Evelyn Pimplaskar
Editor-in-Chief, Director of Content
Evelyn Pimplaskar is Insurify’s director of content. With 30-plus years in content creation – including 10 years specializing in personal finance – Evelyn’s done everything from covering volatile local elections as a beat reporter to building fintech content libraries from the ground up.Prior to joining Insurify, she was editor-in-chief at Credible, where she launched and developed the lending marketplace’s media partnership’s content initiative, and managed the restructuring of the editorial team to enhance content production efficiency. Formerly, as Credit Karma’s tax editor, Evelyn built a library of more than 300 educational articles on federal and state taxes, achieving triple-digit year-over-year growth in e-files from organic search.Her early career included work as a content marketer, vice president and managing officer of a boutique public relations agency, chief copy editor for 14 weekly Forbes publications, reporting for large and mid-sized daily newspapers, and freelancing for the Associated Press.Evelyn is passionate about creating personal finance content that distills complex topics into relatable, easy-to-understand stories. She believes great content helps empower readers with the information they need to make important personal finance decisions.

Updated December 21, 2022

Reading time: 6 minutes

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Most health insurance plans cover the cost of physical therapy in some form. Physical therapists work closely with patients to help them recover from injury, regain strength after surgery, and manage certain conditions. It’s no wonder physical therapy is a key part of many patients’ healthcare plans.

Health plans differ in how much physical therapy they’ll cover, how much your plan will pay, and how much you’ll have to pay out of your own pocket.

Does insurance cover physical therapy?

In almost all cases, physical therapy will be covered by insurance if the services are deemed “medically necessary.” Generally, major healthcare providers consider physical therapy to be medically necessary if it:

  • Has been prescribed by a physician

  • Improves the patient’s functioning in a reasonable period of time

  • Outlines attainable, quantifiable goals for the patient

  • Requires the skills of a licensed, trained physical therapist (as opposed to another type of medical specialist)

For instance, a patient may receive physical therapy to regain function after a stroke, slow physical deterioration due to illness, or improve motor function after surgery. In all these cases, physical therapy likely would be considered medically necessary.

Physical therapy isn’t considered medically necessary if:

  • The patient’s condition isn’t expected to improve in response to therapy

  • The patient can gradually regain function without therapeutic services

  • Treatment will not lead to medical improvement

For example, if a patient received physical therapy to return to a sport, such treatment is not considered a medical necessity. Additionally, if a physician expects a patient to regain function as a natural part of the healing process, physical therapy will not be considered medically necessary.

Coverage for assistive equipment or specialty PT procedures may vary based on your insurance plan. For more details on what’s covered in your plan, reach out to your insurance provider directly. You can also discuss coverage with your physical therapist, as they’re often well-versed in coverage options.

Learn More: How to Compare Medicare Advantage and Get the Best Plan

Will employer-sponsored health plans cover physical therapy?

In the majority of cases, employer-sponsored health plans cover physical therapy. It’s important to find a therapist in your insurance network, which will reduce your out-of-pocket costs. Visit your insurance company’s website, which often includes a database of in-network healthcare providers.

Read your policy carefully to determine how many sessions are covered in a calendar year. For example, Kaiser Permanente limits physical therapy coverage to 40 sessions per year.[1] If you need more sessions, you’ll need a letter from your physical therapist outlining the need for further services, which can help certify additional coverage.

Does Medicare cover physical therapy?

Medicare Part B covers outpatient rehabilitation, which includes physical therapy. To qualify for coverage, a physician or non-physician practitioner must certify the physical therapy treatment as medically necessary.[2] To prove medical necessity, documentation must outline how physical therapy will improve the patient’s physical functioning or slow physical deterioration.

Medicare guidelines state that the duration of these services must be reasonable. Your physical therapist will perform an initial evaluation to determine the amount and frequency of therapy sessions. Medicare recipients will still have to pay the annual Part B deductible, which was $233 in 2022.

Will Obamacare cover physical therapy?

Rehabilitative and habilitative healthcare are covered under the Affordable Care Act, which means at least part of your physical therapy will be paid if you have a plan from the Health Insurance Marketplace.[3] Depending on the state you’re enrolled in, the number of physical therapy sessions that are covered in a year may be capped.

Check Out: What Is the Affordable Care Act?

Does Medicaid cover physical therapy?

Medicaid covers physical therapy in 41 states, according to a Kaiser Family Foundation survey of all state Medicaid directors. In states where Medicaid covers physical therapy, 25 have limitations on services.[4]

Keep in Mind: If a state considers a type of healthcare service to be an “optional benefit,” it may still be covered. However, there may be stricter eligibility requirements or fewer sessions covered. Contact your state Medicaid agency for more information.

How does physical therapy coverage work?

Insurance coverage for physical therapy functions similarly to coverage for other medical needs. To understand how much you’ll owe for your physical therapy services, here are a few terms to familiarize yourself with:

  • Deductible: This is the amount you pay out of pocket before insurance starts covering your expenses. So you may have to pay for a few of your physical therapy sessions in full before insurance coverage kicks in.[5]

  • Copay: This is the amount you pay on a per-session basis. The amount is determined by your insurance plan and doesn’t change from session to session.

  • Co-insurance: After you’ve met your deductible, this is the portion of costs you’re responsible for. If your co-insurance is 20%, this means you pay 20% of the costs associated with physical therapy, then insurance covers the rest.

  • Out-of-pocket maximum: When you hit this amount in a year, your insurance plan will pay 100% of covered costs going forward, until the new plan year.

If you work with a therapist who isn’t in your network, you’ll end up paying more out of pocket. Receiving a referral from your primary care physician is a good way to find physical therapists in your network.

Learn More: What’s the Difference Between Deductible and Out-of-Pocket in Health Insurance?

How much does physical therapy cost with insurance coverage?

To help understand how physical therapy benefits work, let’s look at an example of a summary of insurance benefits in a specific state.

Let’s say you’re a Massachusetts resident who receives Blue Cross Blue Shield insurance through your employer.[6] After a fall, you receive knee surgery that will require an initial 10 sessions of outpatient physical therapy.

Your deductible is $2,500, which you already reached due to the medical expenses associated with your knee surgery. If you work with an out-of-network physical therapist, your cost is 20% of the bill, while insurance will cover the rest. If you work with an in-network physical therapist, you’ll simply pay a $45 copay for each session.

You decide it’s a good idea to stay in your insurance network — and end up paying $450 total for your 10 physical therapy sessions.

Learn More: What Is a PPO and How Does It Work?

How much does physical therapy cost without insurance?

Without insurance, you’ll pay full price for each session. This price will vary based on the specific services you receive and the duration of the treatment. Fortunately, some physical therapy providers are willing to negotiate with patients who don’t have insurance, or even offer discounts for certain bundles of sessions.

What to do if your insurance won’t cover physical therapy

An insurer might decline coverage of physical therapy for several reasons. First, make sure there wasn’t a billing error or eligibility issue. Reaching out to your physical therapist’s office or your insurer is a good first step to make sure there hasn’t been a clerical error.

If your coverage was denied because the treatment was deemed medically unnecessary, consider filing an appeal. Federal law gives you 180 days to appeal your claim denial. Then, contact your PT’s office or your physician to request documentation that proves treatment was medically necessary.

Physical therapy and insurance FAQs

Determining what your insurance covers isn’t always easy, so it’s natural to have questions. Here are the answers to a few commonly asked questions.

  • All 50 states and the District of Columbia allow physical therapists to evaluate patients and provide some treatment without requiring patients to first get a referral from a physician.[7] Still, some states impose limits on this access, which you can learn more about from this map, courtesy of the American Physical Therapy Association.

  • An insurance company can deny coverage if it doesn’t deem physical therapy medically necessary. Physical therapy for preventative care or elective procedures might fall under this umbrella. If so, you can try a cash-based physical therapy practice that works around insurance constraints to provide affordable care.

  • Physical therapy sessions are often 30 to 90 minutes and occur two to three times per week. You’ll work with your doctor or physical therapists to determine how many sessions you need. Insurance companies typically require progress reports from your PT at regular intervals (often every 10 sessions) to make sure the treatment is having the desired effect.

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Sources

  1. Kaiser Permanente. "Summary of Benefits and Coverage." Accessed December 19, 2022
  2. Centers for Medicare & Medicaid Services. "Complying with Outpatient Rehabilitation Therapy Documentation Requirements." Accessed December 19, 2022
  3. HealthCare.gov. "What Marketplace health insurance plans cover." Accessed December 19, 2022
  4. Kaiser Family Foundation. "Medicaid Benefits Database Notes and Methods." Accessed December 19, 2022
  5. HealthCare.gov. "Glossary: Deductible." Accessed December 19, 2022
  6. Blue Cross and Blue Shield of Massachusetts HMO Blue Inc.. "Schedule of Benefits." Accessed December 19, 2022
  7. American Physical Therapy Association. "Direct Access Advocacy." Accessed December 19, 2022
Mark Steinbach
Written by
Mark Steinbach
Linkedin

Insurance Writer

Mark Steinbach is a writer based in Brooklyn, NY. In addition to his years of work as a copywriter, he is also a TV writer with a degree in English from Harvard University. When he isn't writing, he can be found playing tennis or doing crossword puzzles.

Learn More
Evelyn Pimplaskar
Edited by
Evelyn Pimplaskar
Linkedin

Editor-in-Chief, Director of Content

Evelyn Pimplaskar
Edited by
Evelyn Pimplaskar
Editor-in-Chief, Director of Content
Evelyn Pimplaskar is Insurify’s director of content. With 30-plus years in content creation – including 10 years specializing in personal finance – Evelyn’s done everything from covering volatile local elections as a beat reporter to building fintech content libraries from the ground up.Prior to joining Insurify, she was editor-in-chief at Credible, where she launched and developed the lending marketplace’s media partnership’s content initiative, and managed the restructuring of the editorial team to enhance content production efficiency. Formerly, as Credit Karma’s tax editor, Evelyn built a library of more than 300 educational articles on federal and state taxes, achieving triple-digit year-over-year growth in e-files from organic search.Her early career included work as a content marketer, vice president and managing officer of a boutique public relations agency, chief copy editor for 14 weekly Forbes publications, reporting for large and mid-sized daily newspapers, and freelancing for the Associated Press.Evelyn is passionate about creating personal finance content that distills complex topics into relatable, easy-to-understand stories. She believes great content helps empower readers with the information they need to make important personal finance decisions.