Does Medicare cover PT, OT and speech therapy?

Yes. If you have Medicare, Part B covers medically necessary outpatient physical therapy, occupational therapy and speech-language pathology with no yearly limit on what Medicare pays; in 2026 you pay 20 percent of the approved amount after a $283 deductible. This guide is for adults with Medicare and the family members helping them.⁠^1,2

Does Medicare cover physical, occupational and speech therapy?

Yes. Part B helps pay for medically necessary outpatient physical therapy, occupational therapy and speech-language pathology, and Medicare.gov says there is no limit on how much Medicare pays for them in a calendar year.⁠^1,3,4 Medically necessary means needed to diagnose or treat an illness, injury, condition, disease or its symptoms, and meeting accepted standards of medicine.⁠¹ For all three, your doctor or another provider, such as a nurse practitioner, clinical nurse specialist or physician assistant, must certify that you need the care.⁠^1,3,4

Coverage follows the service, not the clinic. General exercise for fitness and flexibility, and activities for diversion or motivation, are not therapy for Medicare purposes even when a therapist leads them; CMS gives a Tai Chi class offered by a physical therapist as an example of a service Medicare would never cover.⁠^8,15

What does Medicare say each of the three therapies is for?

Medicare.gov describes each discipline in its own terms:⁠^1,3,4

• Physical therapy helps restore or improve physical movement after an injury, illness or surgery.⁠¹
• Occupational therapy helps you perform activities of daily living, like dressing or bathing.⁠³
• Speech-language pathology evaluates and treats speech and language skills, including cognitive and swallowing skills.⁠⁴

All three can also aim to maintain function or slow decline.⁠^1,3,4 Each works from its own plan of care: a physical therapist may not treat you under an occupational therapist’s plan, though both may treat the same condition on the same day within their own scope.⁠⁵ Our guides to physical therapy, occupational therapy and speech therapy for adults explain what each treats.

Can people under 65 use Medicare to pay for therapy?

Yes. Medicare covers people 65 or older, and people can qualify earlier with a disability, End-Stage Renal Disease or ALS.⁠¹⁶ The therapy coverage pages set no separate rules by age, but if you are under 65 you might not be able to buy a Medigap policy, or may pay more for one.⁠^1,17 For a child’s therapy, see does insurance cover therapy for kids.

What do you pay for outpatient therapy under Medicare Part B in 2026?

You pay the first $283 of Part B costs in 2026, then usually 20 percent of the Medicare-approved amount for each visit, as long as the clinic accepts assignment, plus the Part B premium of $202.90 a month or more depending on income.⁠² The approved amount is what Original Medicare sets for the service; Medicare pays its share and you pay yours.⁠¹ Original Medicare has no yearly out-of-pocket limit unless you have supplemental coverage such as Medigap, and what you owe also depends on other insurance, the type of facility and where you get care.⁠^1,2 For costs outside Medicare, see physical therapy cost with and without insurance and occupational therapy costs for adults.

Does a Medigap policy pay the 20 percent therapy coinsurance?

Most do: Plans A, B, C, D, F, G, M and N pay the Part B coinsurance in full, Plan K pays 50 percent and Plan L 75 percent.⁠¹⁸ Plan N can leave a copayment of up to $20 for some office visits, so ask whether therapy counts, and only Plans C and F pay the Part B deductible, which not everyone can buy.⁠¹⁸ Medigap works only with Original Medicare; your six-month Medigap Open Enrollment Period starts the first month you have Part B and are 65 or older, and afterward a policy may cost more or be unavailable.⁠¹⁹

Does Medicaid pick up therapy costs for people with both programs?

It can. Medicare enrollees with limited income and resources may get help with premiums and out-of-pocket costs from Medicaid, and services covered by both programs are paid by Medicare first, with Medicaid filling in the difference up to the state’s payment limit.⁠²⁰ In the Qualified Medicare Beneficiary (QMB) program, Medicare providers are not allowed to bill you for covered services, including deductibles and coinsurance; the 2026 federal limits for one person are $1,350 a month in income and $9,950 in resources, you may still qualify in your state above them, and you apply through your state.⁠²¹ Show your Medicare card and your Medicaid or QMB card at every visit.⁠²¹

Do you need a doctor’s referral for Medicare to pay for therapy?

No. Medicare’s manual says there is no Medicare requirement for an order, and payment depends on a certified plan of care rather than an order, though an order in your record helps show that you need therapy and are under a doctor’s care.⁠⁵ The regulation adds that none of its references to an order or referral may be read as requiring one for outpatient physical therapy, occupational therapy or speech-language pathology.⁠⁶ A Medicare Advantage plan may still require a referral, so check before the first visit.⁠¹⁰

What is a therapy plan of care, and who has to sign it?

A plan of care is the written treatment plan your therapist and doctor sign. A physician, nurse practitioner, clinical nurse specialist, physician assistant, or the therapist who treats you writes it before treatment begins, setting out the diagnosis, goals, and the type, amount, frequency and duration of therapy.⁠²² When a therapist writes it, a physician or one of those practitioners who knows your case certifies that you need the therapy and are under the care of a physician or one of those practitioners.⁠⁶ No signature is needed when your record holds a written order or referral from one of them and the therapist documents sending them the plan within 30 days of the evaluation.⁠⁶

A certification covers the plan’s length or 90 days from the first treatment, whichever is shorter; it is on time if signed within 30 days of the first treatment, counting the evaluation, and recertification is required at least every 90 days.⁠^5,6

What happens if your doctor never signs the plan of care?

The answer depends on where you are treated. Medicare accepts a late certification that gives a reason, and its manual says needed therapy is not meant to be stopped because a signature is late.⁠⁵ If none is ever produced, the claim can be denied: in a therapist’s or doctor’s office you are then liable, while a hospital or other provider billing under a Medicare provider agreement may not charge you.⁠⁵ Ask the clinic to tell you when the signed plan is back.

Is there a yearly cap on Medicare therapy in 2026?

No. The Bipartisan Budget Act of 2018 repealed the outpatient therapy caps; what remains are dollar thresholds that trigger documentation and review, not limits on coverage.⁠⁷

What does the KX modifier threshold mean for your therapy?

It means the clinic confirms on each claim above it that your therapy is medically necessary and documented. For 2026 the threshold is $2,480 for physical therapy and speech-language pathology combined and $2,480 for occupational therapy; claims above it without the KX modifier are denied, and claims above $3,000 in either group can be picked for targeted medical review.⁠⁷ The count is the year’s outpatient therapy at the Medicare-allowed amount, including your deductible and coinsurance.⁠²³

Neither amount moves the cost to you. Medicare covers therapy above both when it is medically reasonable and necessary, and if a claim is denied because the clinic left off the KX modifier, the clinic is liable unless it gave you a valid Advance Beneficiary Notice.⁠⁸ A provider cannot give you that notice only because your therapy expenses have reached a certain amount.⁠²⁴ If a clinic says you have “used up” Medicare therapy, ask whether it means the threshold, a review, a medical necessity decision or a Medicare Advantage plan rule.

Does Medicare cover therapy when you are no longer improving?

Yes, when you still need a therapist’s skills. CMS’s page on the 2013 Jimmo settlement says coverage of skilled therapy in outpatient therapy, home health and skilled nursing facilities does not turn on your potential for improvement but on your need for skilled care, including care to maintain function or slow decline.⁠⁹

The test is skill, not progress. Medicare covers a therapist designing a maintenance program, teaching you or a caregiver to do it, and reassessing it; when you or a helper can safely carry it out, the routine sessions are not covered.⁠¹⁵ A diagnosis cannot be the only reason a service is called skilled or unskilled, and improvement can occur even with a chronic, progressive or terminal condition.⁠¹⁵ The therapy must still be reasonable and necessary.⁠⁹

What can you say when a therapist says you have plateaued?

Ask whether therapy is ending because you no longer need a therapist’s skills or only because progress has slowed, since slower progress alone is not the Medicare test.⁠⁹

How does Medicare Advantage cover physical, occupational and speech therapy?

A Medicare Advantage plan must cover all medically necessary services Original Medicare covers, so therapy is covered, but the plan sets its own costs and may require network clinics, referrals and prior authorization.⁠¹⁰ It must follow Original Medicare’s coverage rules, base medical necessity decisions on them and on your history, your physician’s recommendations and your clinical notes, and may not deny a basic benefit on other criteria except published internal criteria where Medicare’s are not fully set.⁠²⁵

Before therapy starts, you, your representative or the clinic can ask the plan for an organization determination, its coverage decision.⁠²⁶ If a plan provider sends you to a clinic without getting one, Medicare.gov calls it plan-directed care, and in most cases you pay no more than the usual cost sharing.⁠¹¹

Can a Medicare Advantage plan require prior authorization for therapy?

Yes, within limits. A plan may use prior authorization only to confirm a diagnosis or other medical criteria, or to check that a basic benefit is medically necessary under the standards the regulation sets for plans; once it approves a service, it cannot later deny it for lack of medical necessity, and can reopen the approval only for good cause or fraud.⁠²⁷ The approval must last as long as medically necessary to avoid disruptions, and a new member in the middle of a course of therapy gets at least 90 days without reauthorization, even out of network.⁠²⁸ A standard request is decided within 14 days, or 7 days for a request under the plan’s prior authorization rules from 2026, and you or a physician can ask for an expedited decision when waiting could seriously jeopardize your health or ability to regain maximum function.⁠^29,30

Where can you get therapy under Medicare, and how does each setting pay?

Medicare pays for therapy in four main settings, each with its own rules: outpatient Part B, home health, a skilled nursing facility and an inpatient rehabilitation facility.⁠^12,13,24,31

When a private practice treats you at home under Part B, Medicare pays the same amount as for a clinic visit and nothing for the therapist’s travel; if you are on a home health plan of care, home therapy falls under home health instead.⁠^24,32 The in-home therapy guide compares the home routes.

When does Medicare home health cover therapy at home?

When you are homebound, need part-time or intermittent skilled care, and a doctor or other provider has seen you in person and ordered it from a Medicare-certified agency.⁠¹² Homebound means leaving home is not recommended for your condition or needs help such as a walker, wheelchair or another person, and you normally cannot leave without a lot of effort; medical appointments, short trips such as religious services, and adult day care do not end it.⁠¹² Occupational therapy must first be ordered with nursing, physical therapy or speech therapy, then can continue alone.⁠¹² Covered visits cost nothing and are unlimited if you qualify.⁠¹²

How many skilled nursing facility days does Medicare cover?

Up to 100 days each benefit period, after an inpatient hospital stay of at least 3 days in a row, not counting the discharge day or time under observation.⁠¹³ You generally enter within 30 days of leaving the hospital and need daily skilled care, such as therapy, to improve or maintain your condition.⁠¹³ In 2026 you pay $0 a day for days 1–20 after the $1,736 deductible, $217 a day for days 21–100, then all costs; a Medicare Advantage plan may charge copayments during the first 20 days and may waive the 3-day stay.⁠¹³ Medigap Plans C, D, F, G, M and N pay that coinsurance in full.⁠¹⁸

Who qualifies for an inpatient rehabilitation facility stay?

Someone whose provider certifies a need for intensive rehabilitation, continued medical supervision and coordinated care.⁠³¹ At admission you should need therapy from more than one discipline, one of them physical or occupational therapy, and be able to take part in an intensive program, generally at least 3 hours a day at least 5 days a week.⁠³³ In 2026 you pay the $1,736 deductible, unless already paid in the same benefit period, then $0 a day for days 1–60, $434 a day for days 61–90, and $868 a day for days 91–150 while you use your 60 lifetime reserve days.⁠³¹ The hospital’s discharge team arranges this care; DrSensory lists therapy clinics, not inpatient rehabilitation facilities.

Does Medicare cover physical, occupational or speech therapy by telehealth?

Yes, through December 31, 2027. CMS’s telehealth FAQ, updated in October 2026, says physical therapists, occupational therapists, speech-language pathologists and audiologists may furnish Medicare telehealth until then, to patients anywhere in the United States, including at home, with audio-only visits at home allowed too.⁠^7,14,34 From January 1, 2028, the FAQ says these professions can no longer furnish Medicare telehealth.⁠¹⁴ The current date comes from section 6209 of the Consolidated Appropriations Act, 2026, so confirm the rule for your date of service.⁠⁷

You pay 20 percent after the deductible, usually the same as in person, and Medicare Advantage plans may offer more telehealth benefits.⁠³⁴ Whether your therapy works well by video is a separate question for the therapist.

What is an Advance Beneficiary Notice, and should you sign one?

An Advance Beneficiary Notice of Noncoverage (ABN) is the written notice a provider gives you before a service when it expects Original Medicare to deny payment, so you can decide whether to take on the cost.⁠^35,36 A therapy clinic must tell you that your services are not medically necessary before giving you one.⁠²⁴ It offers three options, and the clinic must not choose for you:⁠³⁶

1. Option 1: you get the service and Medicare is billed; if Medicare does not pay, you owe the bill but can appeal.⁠³⁶
2. Option 2: you get the service and pay, Medicare is not billed, and you cannot appeal.⁠³⁶
3. Option 3: you do not get the service and owe nothing.⁠³⁶

Signing means you accept you may owe the bill, not that Medicare has decided; if you believe the therapy is necessary, Option 1 keeps your appeal rights.⁠³⁶ The clinic must review it with you, answer questions and give you a copy if you ask; if you have both Medicare and Medicaid, you should be told to check Option 1, and you cannot be billed until both programs decide.⁠³⁶

How do you appeal a Medicare therapy denial?

Follow the notice you received, because the route depends on whether you have Original Medicare or a Medicare Advantage plan. You can appeal a refusal to cover or pay for a service, or a decision to stop one you think you still need; a family member or friend can act as your appointed representative.⁠³⁷ Ask your provider for records that strengthen the appeal: for therapy, the plan of care, progress notes and a letter on why you need a therapist’s skills.⁠³⁷

What are the five levels of appeal in Original Medicare?

Each decision letter explains the next step.⁠³⁸

1. Redetermination: file by the date on your Medicare Summary Notice, 120 days from receiving it under the regulation; a decision generally comes within 60 days.⁠^38,39
2. Reconsideration by a Qualified Independent Contractor: within 180 days.⁠³⁸
3. Office of Medicare Hearings and Appeals: within 60 days, if at least $200 is at stake in 2026.⁠³⁸
4. Medicare Appeals Council: within 60 days.⁠³⁸
5. Federal district court: within 60 days, if at least $1,960 is at stake in 2026.⁠³⁸

How do Medicare Advantage therapy appeals and deadlines work?

They start with the plan’s organization determination, which includes refusing therapy or cutting short an approved course; a medical necessity denial must be reviewed first by a physician or other qualified professional.⁠²⁶ Ask the plan for a reconsideration within 65 days of the date on the denial notice; your doctor can ask for a service you have not had yet.⁠^11,40 The plan decides within 30 days for a service, 60 for a payment, or 72 hours when waiting could seriously jeopardize your health, and a denial goes automatically to an Independent Review Entity.⁠¹¹

What if your home health or nursing facility therapy is ending?

Ask for a fast appeal. You should get a Notice of Medicare Non-Coverage at least 2 days before covered skilled nursing facility, home health or comprehensive outpatient rehabilitation facility services end; contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) on the notice by noon the day before the end date.⁠⁴¹ It decides by close of business the day after it has the information; if services end, you do not pay for those before the end date, but may for those after.⁠⁴¹

What should you ask a therapy clinic before your first Medicare visit?

Ask whether the clinic bills your exact coverage, who sends your plan of care to your doctor, and what you can expect to owe. Original Medicare lets you use any provider that takes Medicare, but you may pay more if it does not accept assignment.⁠¹⁰

When you are ready to look, the DrSensory directory is free for families and lists occupational, physical and speech therapy clinics for children and adults by location. It lists clinics, not individual therapists, does not verify clinical quality and does not rank clinics by payment, so confirm Medicare coverage with the clinic itself; a message you send through DrSensory is read by the clinic in its portal. Your local SHIP offers free one-on-one Medicare counseling.⁠⁴²

Sources

1. Centers for Medicare & Medicaid Services (Medicare.gov). Physical therapy services (Your Medicare coverage). Checked October 24, 2026.
   Show the passageHide the passage

   “Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy, if you’re eligible”; “Physical therapy helps to restore or improve physical movement in your body after an injury, illness, or surgery. You can also get this therapy to help improve or maintain your current function, 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 that you need it.”; “After 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.” The page’s glossary defines medically necessary as “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine” and the Medicare-approved amount as “The payment amount that Original Medicare sets for a covered service or item. When your provider accepts assignment, Medicare pays its share and you pay your share of that amount.” What you owe depends on “Other insurance you may have”, “How much your doctor charges”, “If your doctor accepts assignment”, “The type of facility” and “Where you get your test, item, or service”.
2. Centers for Medicare & Medicaid Services (Medicare.gov). Costs (what you pay in 2026). Checked October 24, 2026.
   Show the passageHide the passage

   Part B: premium “$202.90 each month (or higher depending on your income)”; deductible “$283 before Original Medicare starts to pay. You pay this deductible once each year.”; coinsurance “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’).” Part A: deductible “$1,736 for each inpatient hospital benefit period, before Original Medicare starts to pay”; skilled nursing facility stay “Days 1-20: $0 each day after you pay the Part A deductible”, “Days 21-100: $217 each day”, “Days 101 and beyond: You pay all costs.” “There’s no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage, like a Medicare Supplement Insurance (Medigap) policy or join a Medicare Advantage Plan (Part C).”
3. Centers for Medicare & Medicaid Services (Medicare.gov). Occupational therapy services (Your Medicare coverage). Checked October 24, 2026.
   Show the passageHide the passage

   “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.”
4. Centers for Medicare & Medicaid Services (Medicare.gov). Speech-language pathology services (Your Medicare coverage). Checked October 24, 2026.
   Show the passageHide the passage

   “Medicare Part B (Medical Insurance) covers medically necessary outpatient speech-language pathology services if you’re eligible”; “Speech-language pathology services provide evaluation and treatment to regain and strengthen speech and language skills. This includes cognitive and swallowing skills, or therapy to improve or maintain current function or slow 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 speech-language pathology services in one calendar year.”
5. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; sections 220.1.1, 220.1.2 and 220.1.3, care of a physician or NPP, plans of care, and certification and recertification). Checked October 24, 2026.
   Show the passageHide the passage

   220.1.1: “Although there is no Medicare requirement for an order, when documented in the medical record, an order provides evidence that the patient both needs therapy services and is under the care of a physician.”; “Payment is dependent on the certification of the plan of care rather than the order”. 220.1.2: “There shall be different plans of care for each type of therapy discipline.”; “a physical therapist may not provide services under an occupational therapist plan of care. However, both may be treating the patient for the same condition at different times in the same day for goals consistent with their own scope of practice.”; “The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.” 220.1.3: the certification covers “the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less. The initial treatment includes the evaluation that resulted in the plan.”; “Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation).”; “Physicians/NPPs may require that the patient make a physician/NPP visit for an examination if, in the professional’s judgment, the visit is needed prior to certifying the plan”; “Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay.”; “It is not intended that needed therapy be stopped or denied when certification is delayed.”; “In the case of a service furnished under a provider agreement as described in 42CFR489.21, the provider is precluded from charging the beneficiary for services denied as a result of missing certification. However, if the service is provided by a supplier (in the office of the physician/NPP, or therapist) a technical denial due to absence of a certification results in beneficiary liability. For that reason, it is recommended that the patient be made aware of the need for certification and the consequences of its absence.”; “If an appropriate certification is later produced, the denial shall be overturned.”
6. Code of Federal Regulations. 42 CFR § 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (text as published in the eCFR). Checked October 24, 2026.
   Show the passageHide the passage

   Paragraph (c), outpatient physical therapy, occupational therapy and speech-language pathology: the certification states that “The individual needs, or needed, physical therapy, occupational therapy, or speech-language pathology services”, that “The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant” and that they were furnished under a plan meeting § 410.61; “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.”; (c)(5): where “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”; “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.”
7. Centers for Medicare & Medicaid Services. Therapy Services (page last modified March 10, 2026). Checked October 24, 2026.
   Show the passageHide the passage

   “Section 50202 of the BBA of 2018 repeals application of the Medicare outpatient therapy caps and its exceptions process”; 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. Just as with the incurred expenses for the therapy cap amounts, there is one amount for PT and SLP services combined and a separate amount for OT services.”; “Claims for services over the KX modifier threshold amounts without the KX modifier are denied. 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.”; for PT and OT services furnished in whole or in part by PTAs and OTAs, “Payment for these services is at 85 percent of the otherwise applicable PFS payment amount/rate for the service”; the 2026 update reflects “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”.
8. Centers for Medicare & Medicaid Services. Outpatient Therapy Services and Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 (frequently asked questions, August 2018, linked from CMS’s Therapy Services page). Checked October 24, 2026.
   Show the passageHide the passage

   “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.”; “No, Medicare covers therapy services above the −KX modifier thresholds for which the therapist or therapy provider attests are medically reasonable and necessary.”; “No, Medicare covers therapy services above the $3,000 MR thresholds that are medically reasonable and necessary.”; “An ABN is not needed for services that Medicare would never cover.”, with the example of a patient who “opted to pay out-of-pocket for Tai Chi classes her PT offers as part of her Wellness Programs”.
9. Centers for Medicare & Medicaid Services. Jimmo Settlement (Important Message About the Jimmo Settlement). Checked October 24, 2026.
   Show the passageHide the passage

   The Jimmo Settlement Agreement (January 2013) “clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met)”; “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.”; coverage “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”; “The Jimmo Settlement Agreement does not alter or supersede any other applicable coverage requirements beyond those involving the need for skilled care, such as Medicare’s overall requirement that covered services must be reasonable and necessary to diagnose or treat the beneficiary’s condition”.
10. Centers for Medicare & Medicaid Services (Medicare.gov). Compare Original Medicare & Medicare Advantage (side-by-side comparison). Checked October 24, 2026.
    Show the passageHide the passage

    Original Medicare: “You can use any doctor or hospital that takes Medicare, anywhere in the U.S. You may pay more if your doctor doesn’t accept assignment.”; “In most cases you don’t need a referral to see a specialist.”; “In most cases, you don’t need approval (prior authorization) for Original Medicare to cover your services or supplies”; “You can choose to buy Medigap to help pay your out-of-pocket costs that Medicare doesn’t cover (like your 20% coinsurance).” Medicare Advantage: “You may need to use doctors and other providers who are in the plan’s network and service area (for non-emergency care). Some plans offer non-emergency coverage out of network, but it may cost more.”; “You may need to get a referral to see a specialist.”; “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.”; “Plans have a yearly limit on what you pay for covered Medicare services”; “You can’t buy Medigap to cover your out-of-pocket costs.”
11. Centers for Medicare & Medicaid Services (Medicare.gov). Appeals in Medicare health plans (Medicare Advantage appeals). Checked October 24, 2026.
    Show the passageHide the passage

    “Coverage decisions in a Medicare Advantage Plan are called ‘Organization Determinations.’”; “If a plan provider refers you for a covered service or to a provider outside the network, but doesn’t get an organization determination in advance, this is called ‘plan directed care.’ In most cases, you won’t have to pay more than the plan’s usual cost sharing.”; “If your appeal is for a service you haven’t gotten yet, your doctor can ask for a reconsideration on your behalf (and must notify you about it).”; “You, your representative, or your doctor or healthcare provider must file an appeal within 65 days from the date on the initial denial notice sent by your plan.”; “The plan must give you its decision within 72 hours if it determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.”; standard process “Pre-service appeal: 30 days”, “Payment appeal: 60 days”; “If the plan decides against you (fully or partially), your appeal is automatically sent to level 2.”; level 3 “For 2026, the minimum dollar amount is $200”; level 5 “For 2026, the minimum dollar amount is $1,960.”
12. Centers for Medicare & Medicaid Services (Medicare.gov). Home health services (Your Medicare coverage). Checked October 24, 2026.
    Show the passageHide the passage

    Covered services include “Physical therapy, occupational therapy, and speech-language pathology services (if you meet certain conditions)”; “You must need part-time or intermittent skilled services and you’re ‘homebound’”: “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” and “You’re normally unable to leave your home and leaving takes a lot of effort.”; “You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.”; “a doctor or health care provider (like a nurse practitioner) must see you in person and confirm you need home health care. They must also order your care, and a Medicare-certified home health agency must provide it.”; “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”; “You pay nothing for covered home health services.”; 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 “should give you a notice called the ‘Advance Beneficiary Notice (ABN)’ before giving you services and supplies that Medicare doesn’t cover”; Medicare Advantage members “check with your plan for more information about your home health benefits”; “If you qualify, you can get unlimited home health visits.”
13. Centers for Medicare & Medicaid Services (Medicare.gov). Skilled nursing facility care (Your Medicare coverage). Checked October 24, 2026.
    Show the passageHide the passage

    Covered services include physical therapy, occupational therapy and speech-language pathology “if needed to meet your health goal”; a “qualifying inpatient hospital stay” is “a prior medically necessary inpatient hospital stay of at least 3 days in a row (starting the day you were admitted as an inpatient, but not including the day you leave the hospital)”, and “Time you spend at the hospital under observation or in the emergency room before you’re admitted doesn’t count”; “Medicare Advantage Plans may also waive the 3-day minimum inpatient hospital stay.”; you must “enter the SNF within a short time (generally 30 days) of leaving the hospital” and need “daily skilled care (like intravenous fluids/medications or physical therapy)” for “An ongoing condition that was also treated during your qualifying inpatient hospital stay” or “A new condition that started while you were getting SNF care for the ongoing condition”, “to improve or maintain your current condition, or to prevent or delay it from getting worse.”; 2026 costs: “Days 1–20: You pay $0 each day after you pay the $1,736 deductible. You don’t have to pay the Part A deductible for skilled nursing facility care if you already paid it for care you got in a hospital during the same benefit period.”; “If you’re in a Medicare Advantage Plan, you may be charged copayments during the first 20 days.”; “Days 21–100: You pay $217 each day.”; “Days 101 and beyond: You pay all costs.”; “Part A limits SNF coverage to 100 days in each benefit period.”
14. Centers for Medicare & Medicaid Services. Telehealth FAQ (updated October 8, 2026; listed on CMS’s Telehealth page as updated October 9, 2026). Checked October 24, 2026.
    Show the passageHide the passage

    “Through December 31, 2027, beneficiaries can receive Medicare telehealth services anywhere in the United States and territories. Starting January 1, 2028, except for behavioral health services, beneficiaries will generally need to be in a medical facility and in a rural area to receive Medicare telehealth services.”; “Through December 31, 2027, an extended range of practitioners may bill for Medicare telehealth services. Starting January 1, 2028, physical therapists, occupational therapists, speech-language pathologists, and audiologists can no longer furnish Medicare Telehealth services.”; “Under current law, beneficiaries may continue to receive audio-only telehealth services in their homes through December 31, 2027.”
15. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; section 220.2, Reasonable and Necessary Outpatient Rehabilitation Therapy Services, subsections A to D). Checked October 24, 2026.
    Show the passageHide the passage

    “Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”; “services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes”; “Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.”; “a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled”; rehabilitative skilled procedures include “Evaluations and reevaluations”; “Rehabilitative therapy may be needed, and improvement in a patient’s condition may occur, even when a chronic, progressive, degenerative, or terminal condition exists.”; maintenance programs: “If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered. If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered. If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.”; “A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided.”
16. Centers for Medicare & Medicaid Services (Medicare.gov). Get started with Medicare (eligibility). “Medicare is health insurance for people 65 or older who meet citizenship or residency requirements. You may be eligible to get Medicare earlier if you have a disability, End-Stage Renal Disease (ESRD), or ALS (also called Lou Gehrig’s disease).” Checked October 24, 2026.
17. Centers for Medicare & Medicaid Services (Medicare.gov). Your coverage options (Original Medicare, Medicare Advantage and Medigap). Checked October 24, 2026.
    Show the passageHide the passage

    “If you’re under 65, you might not be able to buy a Medigap policy, or you may have to pay more.”; “Contact your local State Health Insurance Assistance Program (SHIP) to get free personalized health insurance counseling. SHIPs aren’t connected to any insurance company or health plan.”
18. Centers for Medicare & Medicaid Services (Medicare.gov). Compare Medigap plan benefits (the plan chart, 2026). Checked October 24, 2026.
    Show the passageHide the passage

    In the chart’s row “Part B coinsurance or copayment”, Plans A, B, C, D, F, G, M and N are marked as covering 100% of the benefit, Plan K “50%” and Plan L “75%”; in the row “Part B deductible” only Plans C and F are marked as covering it; in the row “Skilled nursing facility care coinsurance” Plans C, D, F, G, M and N are marked as covering it, Plan K “50%”, Plan L “75%”, and Plans A and B are marked as not covering it. “The Medigap policy will only pay your coinsurance after you’ve paid the deductible (unless the Medigap policy also covers your deductible).”; “Not everyone can buy Medigap Plan C & Plan F. Your eligibility depends on when you first became eligible for Medicare.”; “Plan N pays 100% of the costs of Part B coinsurance. You must pay a copayment of up to $20 for some office visits and up to $50 for emergency room visits when you aren’t admitted as an inpatient.”
19. Centers for Medicare & Medicaid Services (Medicare.gov). Get Medigap basics (Medicare Supplement Insurance). Checked October 24, 2026.
    Show the passageHide the passage

    “You can only buy Medigap if you have Original Medicare.”; “You get a 6 month ‘Medigap Open Enrollment’ period, which starts the first month you have Medicare Part B and you’re 65 or older. During this time, you can enroll in any Medigap policy and the insurance company can’t deny you coverage due to pre-existing health problems. After this period, you may not be able to buy a Medigap policy, or it may cost more.”; “policies with the same letter offer the same basic benefits no matter where you live or which insurance company you buy the policy from”; “In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way.”
20. Medicaid.gov (Centers for Medicare & Medicaid Services). Seniors & Medicare and Medicaid Enrollees (eligibility policy). Checked October 24, 2026.
    Show the passageHide the passage

    “Medicare enrollees who have limited income and resources may get help paying for their premiums and out-of-pocket medical expenses from Medicaid (e.g. MSPs, QMBs, SLBs, and QIs).”; “Services covered by both programs are first paid by Medicare with Medicaid filling in the difference up to the state’s payment limit.”
21. Centers for Medicare & Medicaid Services (Medicare.gov). Medicare Savings Programs (help from your state, 2026 limits). Checked October 24, 2026.
    Show the passageHide the passage

    “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.”; Qualified Medicare Beneficiary (QMB) Program: “Helps pay for: Part A premiums (if you don’t have premium-free Part A); Part B premiums, deductibles, coinsurance, and copayments (for services and items Medicare covers).”, with 2026 limits for an individual of $1,350 monthly income and $9,950 in resources; “You may still qualify for these programs in your state even if your income or resources are higher than the federal limits listed.”; “Medicare providers aren’t allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments.”; “You may get a bill for a small Medicaid copayment, if one applies.”; “Show both your Medicare card and Medicaid card (or QMB card) each time you get care.”
22. Code of Federal Regulations. 42 CFR § 410.61, Plan of treatment requirements for outpatient rehabilitation services (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    “The plan is established before treatment is begun by one of the following: (1) A physician. (2) A physical therapist who furnishes the physical therapy services. (3) A speech-language pathologist who furnishes the speech-language pathology services. (4) An occupational therapist who furnishes the occupational therapy services. (5) A nurse practitioner, a clinical nurse specialist, or a physician assistant.”; “The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.”
23. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04, Rev. 11129; sections 10.2.A and 10.4.A, on the former financial limitation and on institutional claims). Checked October 24, 2026.
    Show the passageHide the passage

    “The limits were based on incurred expenses and included applicable deductible and coinsurance.”; the system applies the financial limitation “using the lesser of the MPFS allowed amount (before adjustment for beneficiary liability) or the amount charged.”; “Since the limitations apply to outpatient services, they do not apply to skilled nursing facility (SNF) residents in a covered Part A stay”.
24. Centers for Medicare & Medicaid Services (Medicare.gov). Medicare Coverage of Outpatient Occupational Therapy, Physical Therapy, and Speech-language Pathology Services (fact sheet, CMS Product No. 10988, October 2026). Checked October 24, 2026.
    Show the passageHide the passage

    “This information only applies if you have Original Medicare.”; “If the therapy services you’re getting aren’t medically necessary, your therapy provider can only charge you for them if they give you a written notice before you get the services. This notice is called an ‘Advance Beneficiary Notice of Noncoverage (ABN).’”; “Your therapy provider must tell you that your services aren’t medically necessary before giving you an ABN. They can’t give you an ABN only because your therapy expenses have reached a certain amount.”; places to get these services include “Offices of privately practicing therapists”, “Medical offices”, “Outpatient hospital departments”, “Rehabilitation facilities (sometimes called ‘other rehabilitation facilities’)”, “Comprehensive outpatient rehabilitation facilities”, “Skilled nursing facilities (when Medicare Part A (Hospital Insurance) doesn’t apply)” and “At home, from certain therapy providers, like privately practicing therapists and certain home health agencies (Note: If you’re getting therapy as part of a Medicare home health plan of care, Medicare covers it under the home health benefit instead.)”
25. Code of Federal Regulations. 42 CFR § 422.101, Requirements relating to basic benefits (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    Each MA organization must “Provide coverage of, by furnishing, arranging for, or making payment for, all services that are covered by Part A and Part B of Medicare”; must comply with “CMS’s national coverage determinations” and “General coverage and benefit conditions included in Traditional Medicare laws”, including “requirements for payment of Skilled Nursing Facility (SNF) Care, Home Health Services under 42 CFR part 409, and Inpatient Rehabilitation Facilities (IRF) at 42 CFR 412.622(a)(3)”; MA organizations “may create publicly accessible internal coverage criteria” when “coverage criteria are not fully established”; medical necessity determinations must be based on coverage criteria in paragraphs (b) and (c) and the organization “may not deny coverage for basic benefits based on coverage criteria not specified in paragraph (b) or (c) of this section”, on “Whether the provision of items or services is reasonable and necessary”, and on “The enrollee’s medical history (for example, diagnoses, conditions, functional status), physician recommendations, and clinical notes.”
26. Code of Federal Regulations. 42 CFR § 422.566, Organization determinations (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    An organization determination includes “The MA organization’s refusal, pre- or post-service or in connection with a decision made concurrently with an enrollee’s receipt of services, to provide or pay for services, in whole or in part, including the type or level of services” and “Reduction, or premature discontinuation, of a previously authorized ongoing course of treatment.”; it can be requested by “The enrollee (including his or her representative)” or “Any provider that furnishes, or intends to furnish, services to the enrollee”; a partially or fully adverse medical necessity decision “must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the services at issue”.
27. Code of Federal Regulations. 42 CFR § 422.138, Prior authorization (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    Prior authorization processes “may only be used for one or more the following purposes: (1) To confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service; or (2) For basic benefits, to ensure an item or service is medically necessary based on standards specified in § 422.101(c)(1)”; once a plan approves a covered item or service through prior authorization, “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”, citing the reopening rules, “or if there is reliable evidence of fraud or similar fault”.
28. Code of Federal Regulations. 42 CFR § 422.112, Access to services (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    A coordinated care plan “may specify the networks of providers from whom enrollees may obtain services if the MA organization ensures that all covered services, including supplemental services contracted for by (or on behalf of) the Medicare enrollee, are available and accessible under the plan”; for enrollees undergoing an active course of treatment, “Approval of a prior authorization request for a course of treatment must be valid for as long as medically necessary to avoid disruptions in care”, and plans must provide “A minimum 90-day transition period for any active course(s) of treatment when an enrollee has enrolled in an MA plan after starting a course of treatment, even if the service is furnished by an out-of-network provider. This includes enrollees new to a plan and enrollees new to Medicare.”
29. Code of Federal Regulations. 42 CFR § 422.568, Standard timeframes and notice requirements for organization determinations (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    The plan must decide a request for a service “as expeditiously as the enrollee’s health condition requires but no later than either of the following: (i) For a service or item not subject to the prior authorization rules in § 422.122, 14 calendar days after receiving the request for the standard organization determination. (ii) Beginning on or after January 1, 2026, for a service or item subject to the prior authorization rules in § 422.122, 7 calendar days after receiving the request”; “The MA organization may extend the timeframe by up to 14 calendar days” in stated circumstances.
30. Code of Federal Regulations. 42 CFR § 422.570, Expediting certain organization determinations (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    “An enrollee or a physician (regardless of whether the physician is affiliated with the MA organization) may request that an MA organization expedite an organization determination”; the plan must expedite an enrollee’s request “if it determines that applying the standard timeframe for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.”
31. Centers for Medicare & Medicaid Services (Medicare.gov). Inpatient rehabilitation care (Your Medicare coverage). Checked October 24, 2026.
    Show the passageHide the passage

    “Inpatient rehabilitation can help if you’re recovering from a serious surgery, illness, or injury and need an intensive rehabilitation therapy program, physician supervision, and coordinated care”; covered care includes “Rehabilitation services, including physical therapy, occupational therapy, and speech-language pathology”; “Your health care provider must certify that you have a medical condition requiring intensive rehabilitation, continued medical supervision, and coordinated care from your providers.”; 2026: “Days 1-60: After you pay the $1,736 deductible you pay $0 each day.”, “Days 61-90: You pay $434 each day.”; “Days 91-150: You pay $868 each day while using your 60 lifetime reserve days.”; no deductible is charged if one was already charged within the same benefit period, for example if “You’re transferred to an inpatient rehabilitation facility directly from an acute care hospital.”
32. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; section 220.1.4, Requirement That Services Be Furnished on an Outpatient Basis). Checked October 24, 2026.
    Show the passageHide the passage

    “Therapy services are payable when furnished in the home at the same physician fee schedule payment rates as in other outpatient settings. Additional expenses incurred by providers of outpatient therapy due to travel to the beneficiary are not covered.”
33. Code of Federal Regulations. 42 CFR § 412.622, Basis of payment (inpatient rehabilitation facilities) (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    IRF coverage criteria at admission: the patient “requires the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy), one of which must be physical or occupational therapy”; the intensive program “generally consists of at least 3 hours of therapy (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics therapy) per day at least 5 days per week. In certain well-documented cases, this intensive rehabilitation therapy program might instead consist of at least 15 hours of intensive rehabilitation therapy per week.”; the rehabilitation physician “must conduct face-to-face visits with the patient at least 3 days per week throughout the patient’s stay”.
34. Centers for Medicare & Medicaid Services (Medicare.gov). Telehealth (Your Medicare coverage). Checked October 24, 2026.
    Show the passageHide the passage

    “Through December 31, 2027, Medicare covers telehealth services that you can get from anywhere in the U.S., including your home.”; the examples listed include “Speech therapy”; “Medicare Advantage Plans and some providers in Original Medicare may offer more telehealth benefits than the basic coverage in Original Medicare.”; “After you meet the Part B deductible, you pay 20% of the Medicare-approved amount for your doctor or other health care provider’s services.”; “For most telehealth services, you’ll pay the same amount that you would if you got the services in person.”
35. Centers for Medicare & Medicaid Services. FFS ABN (Beneficiary Notices Initiative, page last modified July 17, 2026). Checked October 24, 2026.
    Show the passageHide the passage

    “The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances.”; “Skilled nursing facilities (SNFs) issue the ABN to transfer potential financial liability for items/services expected to be denied under Medicare Part B only.”
36. Centers for Medicare & Medicaid Services. Form Instructions, Advance Beneficiary Notice of Non-coverage (ABN) (OMB Approval Number 0938-0566). Checked October 24, 2026.
    Show the passageHide the passage

    Notifiers must “Review the ABN with the patient or their representative and answer any questions before it’s signed”, “Deliver the ABN far enough in advance that the patient or representative has time to consider the options and make an informed choice” and “Give a copy to the patient or representative, if requested”; “ABNs are never required in emergency situations.”; Option 1: “I want the item, test, service or care listed above, and I want Medicare to be billed for an official decision on payment, which I’ll get on a Medicare Summary Notice (MSN). You can ask to be paid now. I understand that if Medicare doesn’t pay, I’m responsible to pay, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you’ll refund any payments I made to you, minus co-pays or deductibles.”; Option 2: “I want the item, test, service or care listed above, but don’t bill Medicare. You can ask to be paid now and I’m responsible to pay. I understand I can’t appeal, since Medicare isn’t billed.”; Option 3: “I don’t want the item, test, service or care listed above. I understand I’m not responsible for payment and I can’t appeal to see if Medicare would pay.”; “the notifier must not decide for the patient which of the 3 options to select”; “Dually eligible patients must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication.”; “Providers must not bill the patient until adjudication by both Medicare and Medicaid”.
37. Centers for Medicare & Medicaid Services (Medicare.gov). Filing an appeal (Claims, appeals and complaints). Checked October 24, 2026.
    Show the passageHide the passage

    “Before you start an appeal, you can ask your provider or supplier for any information to make your appeal stronger.”; you can file an appeal if Medicare or your plan refuses to “Cover a health care service, supply, item, or drug you think Medicare should cover” or “Pay for a health care service, supply, item, or drug you already got”, or if it “stops providing or paying for all or part of a health care service, supply, item, or drug you think you still need”; SHIPs give “free, personalized health insurance counseling”; “If you have a trusted family member or friend helping you with a complaint, you can appoint them as a representative.”; “You also have the right to a fast appeal if you think your Medicare-covered services are ending too soon. This includes services you get from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice.”
38. Centers for Medicare & Medicaid Services (Medicare.gov). Appeals in Original Medicare (the five levels). Checked October 24, 2026.
    Show the passageHide the passage

    “There are 5 levels of appeal.”; Level 1: “You must file your appeal by the date in the MSN. If you miss the deadline for appealing, you may still file an appeal and get a decision if you can show good cause”; “You’ll generally get a decision from the Medicare Administrative Contractor (MAC) within 60 days after they get your appeal.”; an appeal includes, if you have appointed a representative, a copy of the “Appointment of Representative” form “or any written instrument that has the required elements”; “You have 180 days after you get the MAC’s decision letter or an MSN to ask for a level 2 appeal, called a ‘Reconsideration’ by a Qualified Independent Contractor (QIC).”; “The QIC will send you a decision within 60 days after the QIC gets your appeal request.”; “you have 60 days from the date of the QIC’s decision to ask for a level 3 appeal”; “For 2026, the minimum dollar amount is $200.”; “You have 60 days after you get the decision to move to appeals level 4, by asking for a review by the Medicare Appeals Council”; level 5, judicial review: “For 2026, the minimum dollar amount is $1,960.”; “You have 60 days after you get the Appeals Council’s decision to ask for judicial review by a federal district court.”
39. Code of Federal Regulations. 42 CFR § 405.942, Time frame for filing a request for a redetermination (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    “any request for redetermination must be filed within 120 calendar days from the date a party receives the notice of the initial determination”; “the date of receipt of the initial determination will be presumed to be 5 calendar days after the date of the notice of initial determination, unless there is evidence to the contrary”; the contractor may extend the time frame if “a party shows good cause”.
40. Code of Federal Regulations. 42 CFR § 422.582, Request for a standard reconsideration (text as published in the eCFR). Checked October 24, 2026.
    Show the passageHide the passage

    “a request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice”; “The date of receipt of the organization determination is presumed to be 5 calendar days after the date of the written organization determination, unless there is evidence to the contrary.”; a physician who is treating the enrollee may ask “upon providing notice to the enrollee”; “If a party or physician acting on behalf of an enrollee shows good cause, the MA organization may extend the timeframe”.
41. Centers for Medicare & Medicaid Services (Medicare.gov). Fast appeals (when services end too soon). Checked October 24, 2026.
    Show the passageHide the passage

    Fast appeals cover services ending from a hospital, “Skilled nursing facility (SNF)”, “Home health agency (HHA)”, “Comprehensive outpatient rehabilitation facility (CORF)” and hospice; “In other settings: You should get a notice called ‘Notice of Medicare Non-Coverage’ at least 2 days before covered services end. If you don’t get this notice, ask for it.”; “Follow the instructions on the ‘Notice of Medicare Non-Coverage’ no later than noon the day before the termination date listed on the notice.”; an independent reviewer “called a Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO), will decide if your covered services should continue”; the provider then gives you a “Detailed Explanation of Non-Coverage”; in other settings the BFCC-QIO decides “By close of business the day after it gets the information it needs to make a decision”; “If they decide your services should end: You won’t be responsible for paying for any SNF, HHA, CORF, or hospice services provided before the coverage end date on the ‘Notice of Medicare Non-Coverage.’ If you continue to get services after the coverage end date, you may have to pay for those services.”; “If you miss the deadline for requesting a fast appeal from the BFCC-QIO, you can request a fast reconsideration from your plan, but services will only be covered if there’s a decision issued in your favor.”
42. SHIP National Technical Assistance Center (supported by the Administration for Community Living, HHS). State Health Insurance Assistance Program (SHIP) (home page). Checked October 24, 2026.
    Show the passageHide the passage

    “Local, one-on-one Medicare counseling from your local SHIP at no cost to you.”; “SHIP counselors can help you compare costs, review coverage, check provider networks, understand your options, and make informed decisions during Open Enrollment. Counseling is confidential and personalized to your needs.”; “Your local SHIP will provide you in depth, one-on-one insurance counseling and assistance with Medicare.”
43. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; section 40.4, Definition of Physician/Practitioner, in the rules on private contracts and opting out). Checked October 24, 2026.
    Show the passageHide the passage

    The practitioners who may opt out are listed as “Physician assistant; Nurse practitioner; Clinical nurse specialist; Certified registered nurse anesthetist; Certified nurse midwife; Clinical psychologist; Clinical social worker; Registered dietitian; or Nutrition Professional”; “Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not within the opt out law’s definition of either a ‘physician’ or ‘practitioner’.”

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.