How Much Does Occupational Therapy Cost for Adults?

This guide is for adults paying for occupational therapy and the family helping them. No single price fits every visit. In 2026, Medicare’s national amount for an OT evaluation is $100.54, and with Original Medicare you usually pay 20 percent of it after the $283 Part B deductible. Private plans and self-pay rates differ, so get each in writing.⁠^1,2

What decides how much adult occupational therapy costs?

Four things set the price of adult OT: the service you need, where you get it, where you live, and who pays. AOTA describes occupational therapy as focusing on “the things you want and need to do in your daily life,” and lists help with activities of daily living such as bathing and dressing, adaptive equipment, caregiver and family training, returning to work, techniques for memory and executive functioning, and falls prevention and home safety.⁠¹⁴

Start by describing the task that has become hard, not by asking for “an OT session.” “I need to use my hand at work again” or “My mother can no longer get in and out of the bath safely” tells a clinic which service you need, whether it offers it for adults, and what it charges. A clinic known for children’s sensory services may not see adults at all, so ask first. Therapy for adults covers OT, PT and speech therapy by condition, and ADHD in adults and the sensory guide for adults cover attention and sensory concerns.

Then work out who pays: the same visit costs you a different amount under Original Medicare, a Medicare Advantage plan, an employer or Marketplace plan, Medicaid, or your own money. This guide covers adults only; for a child, read what pediatric occupational therapy costs.

What happens at an adult OT evaluation, and why is it priced separately?

The evaluation is the first, longer appointment, where the therapist learns what you want to do and what is getting in the way, and it is billed as its own service. AOTA says OT services typically include “an evaluation made just for you,” which it calls your occupational profile, then “an intervention plan that is unique to you” and an outcomes evaluation to check that your goals are being met.⁠¹⁴

Medicare’s look-up tool lists three OT evaluation codes by complexity, labeled low (30 minutes), moderate (45 minutes) and high (60 minutes), and a fourth for re-evaluating an established plan of care. In 2026 the three levels carry the same Medicare amount, so under Original Medicare your 20 percent share is the same whichever level is billed.⁠^1,3

Which charges should you ask a clinic to list before you start?

Ask for every charge that could apply to your care, separately and in writing, because a single “session rate” can leave out the evaluation, equipment and fees.

Splints deserve their own question. AOTA’s 2026 coding list includes a code for orthotic management and training, billed in 15-minute units, and points to other codes OT practitioners use “to report fabrication, fitting, or provision of orthoses,” so a custom splint can appear on the bill as more than one line.⁠¹⁵

How are adult OT treatment visits billed, by the visit or by the unit?

Many OT treatment services are billed in 15-minute units, so a visit’s price depends on how many minutes of each service you receive. AOTA’s coding list describes therapeutic exercise (97110), therapeutic activities (97530) and self-care and home management training (97535) as billed “each 15 minutes.”⁠¹⁵ Medicare’s claims manual gives the example of 60 minutes of occupational therapy under 97530, reported as four units, and says a code not defined by a set time is reported as one unit.⁠¹⁶

Medicare counts minutes with a fixed chart: a single timed service needs at least 8 minutes to be billed as one unit, 23 minutes for two and 38 minutes for three.⁠¹⁶ Other payers set their own rules, and AOTA notes that not all codes are accepted by all payers, so ask each clinic how long a visit lasts and compare prices for the same length.⁠¹⁵

What does Medicare pay for adult OT evaluations and visits in 2026?

Medicare’s 2026 Physician Fee Schedule sets an amount for each therapy code, adjusted for where the clinic is. CMS built its look-up tool so people can find each code’s payment amount “so you can calculate the patient coinsurance amount,” and it adjusts the amounts “to reflect the variation in practice costs from area to area.”⁠¹⁷ The table shows the tool’s 2026 amounts for one evaluation or one 15-minute unit, nationally and in two of Medicare’s payment localities.⁠¹

Read the table with these limits in mind:

• These are Medicare-approved amounts, not what you pay: with Original Medicare your share is usually 20 percent of them after the deductible.⁠³
• They are not a clinic’s self-pay price or a private plan’s allowed amount; each of those is its own number.
• A visit can be approved for less than the sum of its units. When more than one unit or service is billed on the same day, Medicare pays the practice-expense part of each after the first at 50 percent, and it pays 85 percent for OT furnished in whole or in part by an occupational therapy assistant.⁠^5,16
• The table uses the tool’s default non-QPP rates; it also lists slightly higher QPP rates (for 97165, $101.04 nationally), and it shows the same amount for the facility and non-facility setting for each of these codes.⁠¹

To look up your own area, open CMS’s Physician Fee Schedule look-up tool, choose 2026, enter the code and pick your locality.

How much do you pay for occupational therapy with Original Medicare?

With Original Medicare, you pay the Part B deductible, $283 in 2026, once a year, and then usually 20 percent of the Medicare-approved amount for each covered visit.⁠^2,3 Part B “helps pay for medically necessary outpatient occupational therapy if your doctor or other health care provider certifies you need it,” and you can get it “to help improve or maintain your current capabilities, or slow your rate of decline.”⁠³

The certification is for your plan of care, the written treatment plan your occupational therapist sets. You must be under the care of a physician, nurse practitioner, clinical nurse specialist or physician assistant, who certifies the plan as soon as possible after it is set and recertifies it at least every 90 days.⁠⁴ If your doctor wrote an order or referral and the therapist sends the plan to that doctor within 30 days of the evaluation, no separate signature is needed, and the rule says nothing in it requires an order or referral for OT.⁠⁴ Before the first visit, ask the clinic whether it has what it needs from your doctor.

Your clinic accepts Medicare’s amount as full payment. For outpatient therapy paid under the fee schedule, Medicare’s claims manual says “Assignment is mandatory,” sets the approved amount at the lower of the clinic’s actual charge or the fee schedule amount, and figures your coinsurance as 20 percent of that lower figure.⁠¹⁶

Other coverage can pay part or all of your share. A Medicare Supplement Insurance (Medigap) policy can help pay costs such as your 20 percent coinsurance, and your state’s Medicare Savings Programs may pay Part B deductibles and coinsurance for people with limited income and resources.⁠^8,18 In the Qualified Medicare Beneficiary (QMB) program, “Medicare providers aren’t allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments,” and Medicare.gov says to apply through your state even if you doubt you qualify.⁠¹⁸

What does the KX modifier threshold mean for your OT bill?

It is a checkpoint, not a cap. Medicare.gov says “There’s no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.”⁠³ The 2018 law that repealed the old therapy caps kept the former cap amounts as thresholds; above them, a claim must carry the KX modifier, a code the clinic adds to confirm the care is medically necessary and documented. For 2026 the threshold is $2,480 for OT, counted separately from a combined $2,480 for physical therapy and speech-language pathology.⁠⁵

Passing the threshold changes little for you while the care is still needed: CMS’s guidance says Medicare covers medically necessary therapy above it, and you remain responsible for your usual coinsurance and deductible.⁠⁶ If a clinic leaves off the KX modifier and Medicare denies the claim for that reason, the clinic bears the cost unless it gave you a valid Advance Beneficiary Notice of Noncoverage (ABN) beforehand.⁠⁶ At $3,000 of OT, Medicare may review claims, though not every claim above that amount is reviewed.⁠⁵ If you also need physical therapy, the physical therapy cost guide covers its side of the bill.

Does Medicare keep paying for OT if you are not improving?

Yes, as long as you still need a therapist’s skills. CMS’s Jimmo settlement page says coverage of skilled therapy in the outpatient, home health and skilled nursing settings “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”⁠¹⁹ A maintenance program is covered when an individualized assessment shows that a qualified therapist’s skills are needed to carry it out safely and effectively.⁠¹⁹

This matters for conditions that progress, such as those in the neurologic therapy guide. If you are told Medicare stops paying because you have stopped improving, ask for the reason in writing.

Can you pay a clinic in cash instead of billing Medicare?

Usually not for care Medicare covers, so tell the clinic you have Medicare before you agree to any cash price. Medicare’s private-contract rule, which lets some clinicians opt out of Medicare and bill patients directly, applies to physicians and a list of named practitioners, and occupational therapists are not on that list.⁠²⁰

The exception is care Medicare does not consider medically necessary, such as visits you want after reaching your goals. A clinic that intends to collect from you for that care must give you an ABN first, and one option on the notice is to pay with no claim sent to Medicare.⁠⁶ The good faith estimate rule for self-pay patients does not apply to care Medicare covers: someone with benefits for the service under a federal health care program, such as Medicare, does not count as uninsured or self-pay.⁠¹¹

How does Medicare Advantage change what adult OT costs?

A Medicare Advantage plan covers the same OT, but on its own terms for cost, network and approval. Federal rules require each plan to cover all services that Part A and Part B cover, and Medicare.gov says “Plans must cover all medically necessary services that Original Medicare covers.”⁠^7,8

What differs is the rest. Out-of-pocket costs vary by plan; you may need to use providers in the plan’s network; you may need the plan’s approval, called prior authorization, before it covers certain services; and plans have a yearly limit on what you pay for covered services, which Original Medicare does not. You cannot buy a Medigap policy to cover these costs.⁠⁸ Once a plan approves your OT through prior authorization, federal rules bar it from later denying that approved care for lack of medical necessity, except for good cause or reliable evidence of fraud.⁠²¹ Keep the approval letter or reference number.

Use the plan questions below before booking. For Medicare’s rules across OT, PT and speech therapy in more depth, read Medicare coverage for therapy.

What does adult OT cost with employer or Marketplace insurance?

With a private plan, your cost depends on the plan’s allowed amount for each service and on how your deductible, copayment or coinsurance apply to it. HealthCare.gov defines the terms this way:

• Deductible: “The amount you pay for covered health care services before your insurance plan starts to pay.”⁠²²
• Copayment: “A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible.”⁠²³
• Coinsurance: “The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.”⁠²⁴
• Out-of-pocket maximum: “The most you have to pay for covered services in a plan year.”⁠²⁵
• Network: “The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.”⁠²⁶
• In-network coinsurance: “The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan.”⁠²⁷

The out-of-pocket maximum leaves out your premiums, services the plan does not cover, out-of-network care, and charges above the allowed amount, so OT from an out-of-network clinic can cost more than the maximum suggests.⁠²⁵

Check the network for your exact plan: “We take that insurance” can mean a clinic bills the company, not that it is in your plan’s network. Note the date, time, name and title of the person you speak to and the reference number; HealthCare.gov advises keeping notes like these in case you need to appeal.⁠²⁸ A benefits quote is not a promise to pay: HealthCare.gov says that even a preauthorization, the plan’s decision that a service is medically necessary, is not a promise that the plan covers the cost.⁠²⁹

What is the difference between a plan’s allowed amount and a clinic’s fee?

The allowed amount is what your plan pays for a service; the clinic’s fee is what the clinic charges, and your share is figured from the allowed amount. HealthCare.gov defines the allowed amount as the most a plan pays for a covered service, also called a negotiated rate, and says that if your provider charges more, “you may have to pay the difference.”⁠⁹ That difference is balance billing, and “A preferred provider may not balance bill you for covered services.”⁠³⁰

So the price on a clinic’s website is not the number to multiply by your coinsurance: ask the plan for its allowed amount for the codes the clinic expects to bill, then apply your deductible and copayment or coinsurance. Out of network, you may owe your out-of-network share plus the difference between the clinic’s charge and the allowed amount.⁠^9,25

Are rehabilitative and habilitative OT covered by Marketplace plans?

Yes, as a category: every plan sold on the Marketplace covers “Rehabilitative and habilitative services and devices” among its 10 essential health benefits, though the specific services can vary with your state’s requirements.⁠¹⁰ Rehabilitative services help you “keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled”; habilitative services help you “keep, learn, or improve skills and functioning for daily living.” Both definitions name occupational therapy.⁠^31,32

A plan that provides essential health benefits may not set habilitative limits less favorable than its rehabilitative ones, and, for plan years beginning on or after January 1, 2017, may not combine the two into one limit.⁠³³ It can still limit visits, so ask how many OT visits your plan covers a year and whether physical or speech therapy shares that count. An employer plan not sold on the Marketplace follows its own plan documents; read its summary of benefits and coverage, then ask.

How does the setting change an adult OT bill?

Where you get OT can change both the price and the rules that apply, most of all under Medicare. Medicare.gov lists “The type of facility” and “Where you get your test, item, or service” among the things that decide what you owe.⁠³

Does a hospital outpatient department charge more for adult OT?

Under Original Medicare, generally not for the therapy itself: the claims manual says hospitals are paid for outpatient therapy under the Physician Fee Schedule, at the nonfacility rate, with coinsurance figured the same way. Critical access hospitals are paid on a reasonable-cost basis instead, and Maryland hospitals under that state’s all-payer model.⁠¹⁶

Private plans set their own rules, so if the clinic is part of a hospital, ask your plan whether that changes what you pay. A hospital must also post its standard charges online, free and without an account, including its discounted cash price and the charges it has negotiated with each plan.⁠³⁵

How does Medicare’s home health benefit pay for OT at home?

If you qualify, Medicare’s home health benefit covers OT at home with nothing to pay for covered services. You must need part-time or intermittent skilled care and be homebound: “You’re normally unable to leave your home and leaving takes a lot of effort,” and leaving isn’t recommended or needs help.⁠¹³ OT cannot open the benefit on its own: your doctor or other provider must first order it along with nursing care, physical therapy or speech-language pathology, and after that “you can keep getting occupational therapy on its own.”⁠¹³ The agency should tell you beforehand, verbally and in writing, about anything Medicare does not cover and what you would owe.⁠¹³ For a parent or partner finding daily life at home harder, the guide to staying independent at home covers what helps.

What if you pay for adult occupational therapy yourself?

Ask for the evaluation fee and the treatment fee separately, and ask for a written good faith estimate, which federal rules require a clinic to give you if you are uninsured or choose not to use your private insurance. The rule covers people with no coverage for the service and people with employer, individual or federal employee coverage who do not want a claim filed.⁠¹¹

The estimate is due within 3 business days of your request; within 1 business day of booking when you book at least 3 business days ahead; and within 3 business days of booking when you book at least 10 business days ahead.⁠¹¹ A clinic must treat any question about cost as a request, and CMS says you don’t need to use the words “good faith” to ask.⁠^11,36

For a series of visits, a clinic may issue one estimate that states the expected frequency and number of visits, covering no more than 12 months. The estimate lists expected charges with their service codes, and it is not a contract: it does not oblige you to get care there.⁠¹¹ Keep it. If the clinic’s bill is at least $400 more than its estimate, you can start a patient-provider dispute, postmarked within 120 calendar days of receiving the first bill with those charges.⁠^12,36

If the total is too much, ask about a payment plan, and read adult therapy without insurance for other routes. Medicaid may be one: Medicaid.gov lists occupational therapy as an optional benefit each state may choose to add, so ask your state Medicaid agency what it covers for adults.⁠³⁷

Can you use an HSA or FSA to pay for occupational therapy?

Generally yes, when the therapy is medical treatment. IRS Publication 502 says you can include in medical expenses “amounts you pay for therapy received as medical treatment.”⁠³⁸ Publication 969 says health savings account distributions are tax free when they pay qualified medical expenses incurred after the account is set up, and that a health FSA’s qualified expenses are those in the plan that would generally qualify for the medical expense deduction.⁠³⁹ Keep itemized receipts.

How do you compare the cost of a whole course of OT?

Compare the likely cost of the whole course, the evaluation plus the visits your plan of care calls for, rather than the price of one visit. The number of visits comes from the evaluation and later re-checks, so a clinic can price each visit before it can estimate a total. A lower fee per visit does not mean a lower total, and a higher fee does not prove better care.

What should you ask a clinic and your plan before you book?

Ask the clinic for its prices in writing, ask your plan how it pays, and put the answers side by side. Send health details only through the clinic’s private channels, never in a public review or comment.

Then fill in a comparison for each clinic. Leave a line blank until someone gives you the answer, and never record a guess about what insurance pays as if it were confirmed.

Where can you find an adult occupational therapy clinic?

You can search DrSensory, a free directory people use to find occupational, physical and speech therapy clinics for children and adults by location. It lists clinics, not individual therapists. It does not verify clinical quality, rank clinics by payment, or sell your inquiry as a lead, and if you message a clinic through its listing, the clinic reads it in its own portal.

Search the directory or go straight to occupational therapy clinics. A listing is a starting point: confirm with each clinic that it treats adults with your concern, that it is in network for your plan or quotes a self-pay price, and how soon it can see you, then send it the estimate request above.

Sources

1. Centers for Medicare & Medicaid Services. Search the Physician Fee Schedule (PFS Look-up Tool, “Data Updated: 10/01/2026”; searched for year 2026, the default Non-QPP Rates, Pricing Information, with National Payment Amount and with Specific Locality 0710213 ARKANSAS and 1320201 MANHATTAN). Checked October 24, 2026.
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   “Use this search to view adjusted pricing amounts that reflect variations in pricing costs from area to area.” Non-facility price shown for each code, national / ARKANSAS / MANHATTAN: 97165 “Ot eval low complex 30 min” $100.54 / $93.50 / $111.92; 97166 “Ot eval mod complex 45 min” $100.54 / $93.50 / $111.92; 97167 “Ot eval high complex 60 min” $100.54 / $93.50 / $111.92; 97168 “Ot re-eval est plan care” $68.47 / $63.22 / $76.56; 97110 “Therapeutic exercises” $29.06 / $26.97 / $32.43; 97530 “Therapeutic activities” $35.07 / $32.08 / $39.45; 97535 “Self care mngment training” $32.40 / $29.84 / $36.32. For each of these codes the facility price shown equals the non-facility price; the national non-QPP conversion factor shown is 33.4009. With QPP Rates selected, 97165 shows $101.04 nationally (conversion factor 33.5675).
2. Medicare.gov. Medicare costs (Part B costs, “What you pay in 2026”). Checked October 24, 2026.
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   “$283 before Original Medicare starts to pay. You pay this deductible once each year.”; “Usually 20% of the cost for each Medicare-covered service or item after you’ve paid your deductible (and as long as your doctor or health care provider accepts the Medicare-approved amount as full payment — called ‘accepting assignment’).”; “$0 for covered home health care services.”.
3. Medicare.gov. Occupational therapy services (coverage page). Checked October 24, 2026.
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   “Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient occupational therapy if your doctor or other health care provider certifies you need it”; “Therapy to help you perform activities of daily living (like dressing or bathing). You can get this therapy to help improve or maintain your current capabilities, or slow your rate of decline.”; “Your doctor or other health care provider (including a nurse practitioner, clinical nurse specialist, or physician assistant) must certify you need this care.”; “After you meet the Part B deductible, you pay 20% of the Medicare-approved amount for these services when they’re medically necessary.”; “There’s no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.”; “Specific amounts you could owe depend on:”; “The type of facility”; “Where you get your test, item, or service”.
4. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (regulation; eCFR text up to date as of October 22, 2026; §424.24(c), outpatient physical therapy, occupational therapy, and speech-language pathology services). Checked October 24, 2026.
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   “The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant.”; “The initial certification must be obtained as soon as possible after the plan is established.”; “If the plan of treatment is established by a physical therapist, occupational therapist, or speech-language pathologist, the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case, except as specified in paragraph (c)(5) of this section.”; “Recertification is required at least every 90 days.”; “If the plan of treatment is established by a physical therapist, occupational therapist, or speech-language pathologist, and there is a written order or referral from the individual’s physician, nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS) in the patient’s record and the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation, the certification does not need to be signed by a physician, NP, CNS, or PA who has knowledge of the case.”; “No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.”.
5. Centers for Medicare & Medicaid Services. Therapy Services (web page last modified March 10, 2026; its Bipartisan Budget Act section last revised in February 2026 for the CY 2026 thresholds). Checked October 24, 2026.
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   “Section 50202 of the BBA of 2018 repeals application of the Medicare outpatient therapy caps and its exceptions process while adding limitations to ensure payment for appropriate therapy services.”; “the law preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.”; “there is one amount for PT and SLP services combined and a separate amount for OT services.”; “For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined, and $2,480 for OT services.”; “the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services.”; “The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were.”; “Payment for these services is at 85 percent of the otherwise applicable PFS payment amount/rate for the service, effective January 1, 2022.”; “Medicare applies a MPPR to the practice expense component of certain ‘always therapy’ services.”; “It applies to the second and subsequent therapy services provided to a patient on the same day.”; “section 6209 of the Consolidated Appropriations Act, 2026 that extended the ability of PTs, OTs, and SLPs to furnish Telehealth Services, including the telephone assessment and management services (codes 98966 – 98968) through December 31, 2027”.
6. Centers for Medicare & Medicaid Services. Outpatient Therapy Services and Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 (FAQ document, August 2018, linked from the current Therapy Services page; its dollar thresholds are those of 2018). Checked October 24, 2026.
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   “Under section §1833(g)(8), the therapist or therapy provider is financially liable for the cost of therapy services provided to a beneficiary above the threshold amount when Medicare denies payment for failure to use the −KX modifier to indicate that the services are medically necessary as justified by documentation in the medical record.”; “In order for the therapist or therapy provider to transfer liability to the beneficiary, s/he must issue a valid ABN, Form CMS-R-131.”; “Therapists and therapy providers that intend to collect from beneficiaries directly are required to issue the ABN to original (fee-for–service) Medicare beneficiaries prior to providing therapy that is or may be denied as not medically reasonable and necessary regardless of the amount of incurred expenses.”; “You have reached your therapy goals and have been discharged from your Medicare PT episode of care. You may elect to pay for services that Medicare doesn’t consider medically reasonable and necessary.”; “If the beneficiary selects option 2, s/he agrees to pay for the services and no claim is submitted.”; “No, Medicare covers therapy services above the −KX modifier thresholds for which the therapist or therapy provider attests are medically reasonable and necessary.”; “The beneficiary would be liable for applicable co-pays and deductible for these covered therapy services.”.
7. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 422.101, Requirements relating to basic benefits (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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   “each MA organization must meet the following requirements:”; “Provide coverage of, by furnishing, arranging for, or making payment for, all services that are covered by Part A and Part B of Medicare (if the enrollee is entitled to benefits under both parts) or by Medicare Part B (if entitled only under Part B) and that are available to beneficiaries residing in the plan’s service area.”.
8. Medicare.gov. Compare Original Medicare & Medicare Advantage (side-by-side comparison page). Checked October 24, 2026.
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   “You may need to use doctors and other providers who are in the plan’s network and service area (for non-emergency care).”; “Out-of-pocket costs vary. Plans may have different out-of-pocket costs for certain services.”; “Plans have a yearly limit on what you pay for covered Medicare services (which may include different limits for in-network and out-of-network services).”; “There’s no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage (like Medicare Supplement Insurance (Medigap)) or other insurance (like Medicaid, employer, retiree, or union coverage).”; “You can choose to buy Medigap to help pay your out-of-pocket costs that Medicare doesn’t cover (like your 20% coinsurance).”; “You can’t buy Medigap to cover your out-of-pocket costs.”; “Plans must cover all medically necessary services that Original Medicare covers.”; “You may need to get approval (prior authorization) from your plan before it covers certain services or supplies.”.
9. HealthCare.gov (Centers for Medicare & Medicaid Services). Allowed amount (glossary entry). “The maximum amount a plan will pay for a covered health care service.”; “May also be called ‘eligible expense,’ ‘payment allowance,’ or ‘negotiated rate.’”; “If your provider charges more than the plan’s allowed amount, you may have to pay the difference.”. Checked October 24, 2026.
10. HealthCare.gov (Centers for Medicare & Medicaid Services). What Marketplace health insurance plans cover (coverage page). Checked October 24, 2026.
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    “All plans offered in the Marketplace cover these 10 essential health benefits:”; “Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)”; “Specific services covered in each broad benefit category can vary based on your state’s requirements.”.
11. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 149.610, Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    “for uninsured (or self-pay) individuals (or their authorized representatives), upon request or upon scheduling an item or service.”; “Authorized representative means an individual authorized under State law to provide consent on behalf of the uninsured (or self-pay) individual”; “Health care provider (provider) means a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable State law”; an uninsured (or self-pay) individual is, under paragraph (a)(2)(xiii)(A), “An individual who does not have benefits for an item or service under a group health plan,” followed by group or individual coverage from an insurer and then “Federal health care program (as defined in section 1128B(f) of the Social Security Act), or a health benefits plan under chapter 89 of title 5, United States Code; or” and, under (a)(2)(xiii)(B), which lists no federal health care program, “An individual who has benefits for such item or service under a group health plan,” followed by individual or group coverage from an insurer and then “or a health benefits plan under chapter 89 of title 5, United States Code but who does not seek to have a claim for such item or service submitted to such plan or coverage.”; “Convening providers and convening facilities shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate;”; “When a primary item or service is scheduled at least 3 business days before the date the item or service is scheduled to be furnished: Not later than 1 business day after the date of scheduling;”; “When a primary item or service is scheduled at least 10 business days before such item or service is scheduled to be furnished: Not later than 3 business days after the date of scheduling; or”; “When a good faith estimate is requested by an uninsured (or self-pay) individual: Not later than 3 business days after the date of the request.”; “A convening provider or convening facility may issue a single good faith estimate for recurring primary items or services if the following requirements are met”; “the expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)”; “The scope of a good faith estimate for recurring primary items or services must not exceed 12 months.”; “Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;”; “the information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate;”; “A disclaimer that the good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.”.
12. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 149.620, Requirements for the patient-provider dispute resolution process for uninsured (or self-pay) individuals (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    “Substantially in excess means, with respect to the total billed charges by a provider or facility, an amount that is at least $400 more than the total amount of expected charges listed on the good faith estimate for the provider or facility.”; “postmarked within 120 calendar days of receiving the initial bill containing charges for the item or service that is substantially in excess of the expected charges in the good faith estimate.”.
13. Medicare.gov. Home health services (coverage page). Checked October 24, 2026.
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    “You must need part-time or intermittent skilled services and you’re ‘homebound,’ which means you must meet both of these conditions:”; “Leaving your home isn’t recommended because of your condition or you have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury.”; “You’re normally unable to leave your home and leaving takes a lot of effort.”; “If you need occupational therapy, your doctor or health care provider must first order it along with nursing care, physical therapy, or speech-language pathology. After that you can keep getting occupational therapy on its own, even if you no longer need the other services.”; “You pay nothing for covered home health services.”; “Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you (both verbally and in writing) if Medicare won’t pay for any items or services they give you, and how much you’ll have to pay for them.”.
14. American Occupational Therapy Association. What is occupational therapy? (consumer page). Checked October 24, 2026.
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    “Occupational therapists and occupational therapy assistants focus on the things you want and need to do in your daily life.”; “an evaluation made just for you that lets us know your history, life experiences, and your interests. We call this your occupational profile”; “an intervention plan that is unique to you to improve your ability to perform daily activities and reach your goals,”; “and an outcomes evaluation to make sure that the goals you set with your occupational therapy practitioner are being met.”; “Activities of daily living (such as bathing, dressing, and eating)”; “Adaptive equipment (such as shower chairs, or equipment to make daily tasks easier)”; “Caregiver and family training”; “Returning to work, school, and leisure activities”; “Techniques to aid in memory, concentration, and executive functioning (e.g., planning and prioritizing, functional cognition)”; “Falls prevention and home safety and accessibility”.
15. American Occupational Therapy Association. 2026 Frequently Used CPT and HCPCS Codes for Occupational Therapy (AOTA coding list; code descriptors © 2026 American Medical Association). Checked October 24, 2026.
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    “The following CPT® and HCPCS G codes are frequently used by occupational therapy practitioners (OTPs) to report skilled services.”; “Not all codes are accepted by all payers.”; “97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility”; “97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes”; “97535 Self-care/home management training (e.g., activities of daily living [ADLs] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment), direct one-on-one contact, each 15 minutes”; “97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes”; “For other HCPCS codes commonly used by OT practitioners to report fabrication, fitting, or provision of orthoses, please see AOTA’s SELECTED HCPCS LEVEL II CODES list.”.
16. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04; sections 10, 10.7, 20.2). Checked October 24, 2026.
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    “Effective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for outpatient therapy services furnished by:”; “Hospitals (to outpatients and inpatients who are not in a covered Part A stay);”; “Assignment is mandatory.”; “The Medicare allowed charge for the services is the lower of the actual charge or the MPFS amount.”; “Coinsurance is made at 20 percent of the lower of the actual charge or the MPFS amount.”; “The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs) or hospitals in Maryland. CAHs are to be paid on a reasonable cost basis. Maryland hospitals are paid under the Maryland All-Payer Model.”; “Contractors pay the nonfacility rate on institutional claims for services performed in the provider’s facility.”; “the MPPR applies to multiple units as well as multiple procedures.”; “For subsequent units and procedures with dates of service on or after April 1, 2013, furnished to the same patient on the same day, full payment is made for work and malpractice and 50 percent payment is made for the PE for services submitted on either professional or institutional claims.”; “the procedure is not defined by a specific timeframe (‘untimed’ HCPCS), the provider enters ‘1’ in the field labeled units.”; “EXAMPLE: A beneficiary received a total of 60 minutes of occupational therapy, e.g., HCPCS ‘timed’ code 97530 which is defined in 15 minute units, on a given date of service. The provider would then report 4 units of 97530.”; “1 unit: ≥ 8 minutes through 22 minutes”; “2 units: ≥ 23 minutes through 37 minutes”; “3 units: ≥ 38 minutes through 52 minutes”.
17. Centers for Medicare & Medicaid Services. PFS Look-up Tool Overview (page last modified February 9, 2026). Checked October 24, 2026.
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    “The PFS Look-Up Tool helps you find Medicare payment amounts for each code so you can calculate the patient coinsurance amount.”; “We adjust the PFS pricing amounts to reflect the variation in practice costs from area to area.”; “For the official and definitive CMS PFS payment files, contact your MAC.”.
18. Medicare.gov. Medicare Savings Programs (help with costs page). Checked October 24, 2026.
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    “If you qualify, Medicare Savings Programs might also pay your Part A and Part B deductibles, coinsurance, and copayments.”; “You’ll apply for Medicare Savings Programs through your state.”; “Even if you don’t think you qualify, you should still apply.”; “In most cases, your income and resources must be below a certain limit to qualify for a Medicare Savings Program”; “Medicare providers aren’t allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments.”.
19. Centers for Medicare & Medicaid Services. Jimmo Settlement (web page on the January 2013 Jimmo v. Sebelius settlement agreement). Checked October 24, 2026.
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    “coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient Therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”; “Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (‘skilled care’) are necessary for the performance of a safe and effective maintenance program.”.
20. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 405.400, Definitions (opting out of Medicare and private contracts) (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    “Opt-out means the status of meeting the conditions specified in § 405.410.”; “Physician means a doctor of medicine; doctor of osteopathy; doctor of dental surgery or of dental medicine; doctor of podiatric medicine; or doctor of optometry”; “Practitioner means a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical psychologist, clinical social worker, marriage and family therapist, mental health counselor, registered dietitian or nutrition professional, who is currently legally authorized to practice in that capacity by each State in which he or she furnishes services to patients or clients.”.
21. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 422.138, Prior authorization (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    “When a coordinated care plan, as specified in § 422.4(a)(iii) (including MSA network plans), uses prior authorization processes in connection with basic benefits or supplemental benefits, the MA organization must comply with the requirements in this section.”; “If the MA organization approved the furnishing of a covered item or service through a prior authorization or pre-service determination of coverage or payment, or a concurrent determination made during the enrollee’s receipt of inpatient or outpatient services, it may not deny coverage later on the basis of lack of medical necessity and may not reopen such a decision for any reason except for good cause (as provided at § 405.986 of this chapter and § 422.616) or if there is reliable evidence of fraud or similar fault per the reopening provisions at § 422.616.”.
22. HealthCare.gov (Centers for Medicare & Medicaid Services). Deductible (glossary entry). “The amount you pay for covered health care services before your insurance plan starts to pay.”; “With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.”. Checked October 24, 2026.
23. HealthCare.gov (Centers for Medicare & Medicaid Services). Copayment (glossary entry). “A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible.”. Checked October 24, 2026.
24. HealthCare.gov (Centers for Medicare & Medicaid Services). Coinsurance (glossary entry). “The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.”. Checked October 24, 2026.
25. HealthCare.gov (Centers for Medicare & Medicaid Services). Out-of-pocket maximum/limit (glossary entry). Checked October 24, 2026.
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    “The most you have to pay for covered services in a plan year.”; “After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.”; “The out-of-pocket limit doesn’t include:”; “Your monthly premiums”; “Anything you spend for services your plan doesn’t cover”; “Out-of-network care and services”; “Costs above the allowed amount for a service that a provider may charge”.
26. HealthCare.gov (Centers for Medicare & Medicaid Services). Network (glossary entry). “The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.”. Checked October 24, 2026.
27. HealthCare.gov (Centers for Medicare & Medicaid Services). In-network coinsurance (glossary entry). “The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan.”; “In-network coinsurance usually costs you less than out-of-network coinsurance.”. Checked October 24, 2026.
28. HealthCare.gov (Centers for Medicare & Medicaid Services). Internal appeals (appealing a health plan decision). Checked October 24, 2026.
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    “Submit any additional information that you want the insurer to consider, such as a letter from the doctor.”; “You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.”; “If your insurance company still denies your claim, you can file for an external review.”; “Notes and dates from any phone conversations you have with your insurance company or your doctor that relate to your appeal. Include the day, time, name, and title of the person you talked to and details about the conversation.”.
29. HealthCare.gov (Centers for Medicare & Medicaid Services). Preauthorization (glossary entry). “A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.”; “Preauthorization isn’t a promise your health insurance or plan will cover the cost.”. Checked October 24, 2026.
30. HealthCare.gov (Centers for Medicare & Medicaid Services). Balance billing (glossary entry). “When a provider bills you for the difference between the provider’s charge and the allowed amount.”; “A preferred provider may not balance bill you for covered services.”. Checked October 24, 2026.
31. HealthCare.gov (Centers for Medicare & Medicaid Services). Rehabilitative/Rehabilitation services (glossary entry). Checked October 24, 2026.
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    “Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.”.
32. HealthCare.gov (Centers for Medicare & Medicaid Services). Habilitative/Habilitation services (glossary entry). “Health care services that help you keep, learn, or improve skills and functioning for daily living.”; “These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”. Checked October 24, 2026.
33. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 156.115, Provision of EHB (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    “Provision of EHB means that a health plan provides benefits that”; “Do not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices; and”; “For plan years beginning on or after January 1, 2017, do not impose combined limits on habilitative and rehabilitative services and devices.”.
34. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 410.59, Outpatient occupational therapy services: Conditions (regulation; eCFR text up to date as of October 22, 2026; §410.59(c), occupational therapists in private practice). Checked October 24, 2026.
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    “Bill Medicare only for services furnished in his or her private practice office space, or in the patient’s home.”; “A patient’s home does not include any institution that is a hospital, an CAH, or a SNF.”.
35. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 180.50, Requirements for making public hospital standard charges for all items and services (regulation; eCFR text up to date as of October 22, 2026). Checked October 24, 2026.
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    “A hospital must establish, update, and make public a list of all standard charges for all items and services online in the form and manner specified in this section.”; “Each type of standard charge as defined at § 180.20 (gross charge, discounted cash price, payer-specific negotiated charge, de-identified minimum negotiated charge, and de-identified maximum negotiated charge)”; “Payer and plan names”; “Free of charge;”; “Without having to establish a user account or password;”.
36. Centers for Medicare & Medicaid Services. Know your medical bill rights when not using insurance (No Surprises Act consumer page, last modified October 5, 2026). Checked October 24, 2026.
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    “This applies when you don’t have insurance, or are choosing not to use it.”; “You don’t need to use the specific term ‘Good Faith’ to request an estimate.”; “You can dispute a bill if one of your providers or facilities charged at least $400 more than their estimate.”; “You have to start a dispute within 120 days (about 4 months) of getting your initial bill.”.
37. Centers for Medicare & Medicaid Services (Medicaid.gov). Mandatory & Optional Medicaid Benefits (benefits page). “States are required to provide all mandatory benefits under federal law. States may provide optional benefits if they choose to add them through the state plan process.”; “Optional Benefits”; “Occupational therapy (1905(a)(11), 42 CFR 440.110(b))”. Checked October 24, 2026.
38. Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses (for use in preparing 2025 returns). “You can include in medical expenses amounts you pay for therapy received as medical treatment.”. Checked October 24, 2026.
39. Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans (for use in preparing 2025 returns; the HSA distributions and FSA sections). Checked October 24, 2026.
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    “You can receive tax-free distributions from your HSA to pay or be reimbursed for qualified medical expenses you incur after you establish the HSA.”; “Health FSAs are employer-established benefit plans.”; “Qualified medical expenses are those specified in the plan that would generally qualify for the medical and dental expenses deduction.”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider about your individual situation.