Physical therapy cost with and without insurance

This guide is for adults paying for outpatient physical therapy, and for parents checking a child’s costs. With insurance, your share depends on the plan’s allowed amount and its deductible, copay or coinsurance; without insurance, it is the clinic’s self-pay rate. Medicare’s 2026 national amount for a PT evaluation is $97.86, and a clinic’s own price can differ.⁠¹

How much does a physical therapy visit cost in 2026?

There is no single price, because clinics set their own charges and self-pay rates and each insurer pays its own allowed amount, but Medicare publishes what it pays for each billing code. CMS’s Physician Fee Schedule look-up tool shows the 2026 amounts, adjusted for the area where care is given.⁠¹

The three treatment codes are timed codes, billed in 15-minute units, while a PT evaluation code is billed as one unit, at most once a day by the same clinic.⁠⁴ The figures are the tool’s 2026 Non-QPP Rates; it shows a second set because a different conversion factor applies to clinicians who qualify as Alternative Payment Model participants.⁠¹

Read the table with three points in mind:

• In 2026 Medicare lists the same amount for a low-, moderate- or high-complexity PT evaluation, so the tier on your claim does not change Medicare’s figure.⁠¹
• The figures are the total Medicare allows, not your share: under Original Medicare you pay 20 percent of the lower of the actual charge or the fee schedule amount once the Part B deductible is met.⁠¹¹
• They are Medicare’s numbers only. A commercial plan pays its own allowed amount, and a clinic sets its own cash price.

What is the difference between a charge, an allowed amount and a cash price?

They are three different numbers, and the one you owe depends on how the visit is paid. The charge is what the clinic bills. HealthCare.gov defines the allowed amount as the maximum a plan pays for a covered service, also called the negotiated rate or payment allowance, and warns that if a provider charges more, you may have to pay the difference.⁠² Billing you that difference is balance billing, and a preferred provider, one with a contract with your plan, may not balance bill you for covered services.⁠^12,13

The cash price is the rate a clinic sets for people who pay it directly. Federal good faith estimate rules call it the expected charge: “the cash pay rate or rate established by a provider or facility for an uninsured (or self-pay) individual, reflecting any discounts for such individuals”.⁠³ A cash price can be higher or lower than your share under insurance, so compare the two for the same plan of care before choosing.

Why can two physical therapy visits cost different amounts?

Because a physical therapy bill is built from codes, and the codes, their units and the place of care change from visit to visit. The first visit is usually an evaluation, billed with one of the three PT evaluation codes, which Medicare allows only under a physical therapy plan of care and no more than once per clinic per day.⁠⁴ Later visits are billed with treatment codes, many of them timed, so a 30-minute visit and a 55-minute visit can carry different numbers of units.⁠⁴ A re-evaluation, when your therapist reassesses your progress against the plan, has its own code and amount.⁠¹

Two Medicare payment rules also change the amount on a claim. When several therapy services are given the same day, Medicare reduces the practice-expense part of the second and later services by 50 percent.⁠⁷ When a physical therapist assistant provides all or part of a service, Medicare pays 85 percent of its usual payment; CMS’s claims manual takes that reduction from the amount Medicare pays, not from the allowed amount, and your 20 percent coinsurance is figured on the allowed amount.⁠^7,11

Ask the clinic to translate any answer you cannot turn into an expected amount you would pay.

How does Medicare’s 8-minute rule turn minutes into billed units?

Medicare converts the day’s timed treatment minutes into 15-minute units on a fixed chart. A single service given for less than 8 minutes is not billed; one unit covers 8 to 22 minutes, two units 23 to 37, three units 38 to 52, and four units 53 to 67.⁠⁴ When several timed services are given in one day, the total minutes set the number of units. The manual’s own example: 33 minutes of therapeutic exercise and 7 minutes of manual therapy, 40 timed minutes in all, are billed as 3 units, 2 of exercise and 1 of manual therapy.⁠⁴

This is Medicare’s rule for Medicare claims; ask your plan how it counts units if it is not Medicare. Under Medicare, the total timed minutes must be documented, so if a claim shows more units than the time you remember, ask the clinic to explain the minutes behind it.⁠⁴

Does a hospital outpatient clinic charge a facility fee for PT?

It depends on the payer, so ask before the first visit. Under Original Medicare, outpatient therapy furnished by a hospital is paid on the same Physician Fee Schedule as other settings, and your coinsurance is 20 percent of the lower of the actual charge or the fee schedule amount.⁠¹¹ Critical access hospitals and hospitals in Maryland are paid under different rules.⁠¹¹ Medicare.gov lists the type of facility and where you get care among the things that change what you owe.⁠⁵

Commercial and Medicare Advantage plans write their own rules for hospital-based clinics. A clinic’s name does not tell you how it bills, so look up both the outpatient hospital and the rehabilitation benefits in your plan documents, and ask the clinic and the plan which one applies and what you pay under it.

How do you estimate your physical therapy cost with insurance?

Start from your plan’s own terms, then fit the clinic’s codes to them. These are HealthCare.gov’s definitions of the words on your plan documents:

• Deductible: “The amount you pay for covered health care services before your insurance plan starts to pay.”⁠¹⁴
• Copayment: “A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible.”⁠¹⁵
• Coinsurance: “The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.”⁠¹⁶
• Out-of-pocket maximum: “The most you have to pay for covered services in a plan year.” It does not count premiums, services the plan does not cover, out-of-network care, or charges above the allowed amount.⁠¹⁷
• In-network: your plan’s network is “the facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.”⁠¹⁸
• Out-of-network: a non-preferred provider is “a provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider.”⁠¹³

For Marketplace plans in 2026, the out-of-pocket limit is no more than $10,600 for an individual or $21,200 for a family.⁠¹⁷ Marketplace plans must cover rehabilitative and habilitative services and devices as one of the ten essential health benefits, though what each category includes varies with state requirements.⁠¹⁹

1. Confirm the exact plan, clinic and location. Ask about your exact plan, not only the insurer’s name, and give the plan the clinic’s name and address; a referral from your doctor does not make a clinic in-network.
2. Find your deductible status. If the deductible applies and is not met, you pay the full allowed amount for the visit until it is.⁠¹⁶ Some plans pay certain services before the deductible, so check yours.⁠¹⁴
3. Find the cost share after the deductible. Is it a copayment per visit or coinsurance on the allowed amount? Copayments can vary for different services within the same plan, so ask about outpatient rehabilitation by name.⁠¹⁵
4. Ask about approvals and limits. Ask whether physical therapy needs preauthorization, how many visits an approval covers, and whether visit limits are shared with occupational or speech therapy.
5. Ask the clinic for the codes and an estimate. Ask which codes it expects to bill and how many units a visit usually runs.
6. Track your spending against the out-of-pocket maximum. Out-of-network care does not count toward it.⁠¹⁷

Why did you owe more than your copay for physical therapy?

Usually because the deductible had not been met, because the plan charges coinsurance for therapy rather than a copay, or because more was billed than you expected. Before the deductible is met, you pay the full allowed amount for the visit, not the copay.⁠¹⁵ Other possible reasons are an evaluation and treatment billed on the same day, a separate bill from a hospital, a clinic outside your network, a service your plan does not cover, and a plain claim error.

Compare three documents line by line: the clinic’s itemized bill, your plan’s explanation of benefits for the claim, and your plan’s Summary of Benefits and Coverage, the plain summary of costs and coverage you can request from your insurer.⁠²⁰ If the codes, dates or units differ from what happened at the visit, ask the clinic’s billing office to explain or correct them before you pay.

What do preauthorization and visit limits mean for PT coverage?

Both are ways a plan controls how much therapy it pays for, and missing either can leave you with the bill. HealthCare.gov defines preauthorization as the plan’s decision that a service or treatment plan is medically necessary, and adds that it is not a promise the plan covers the cost.⁠²¹ Ask who requests it, how many visits and which dates it covers, and what happens when it runs out.

Visit limits are written in the plan documents. Look for the rehabilitation or outpatient therapy benefit, then ask the plan whether the limit is per year or per condition, and whether physical, occupational and speech therapy share it. A clinic can have an opening on its calendar while your approval is still pending; ask whether the visit waits for the approval.

Do you need a doctor’s referral to see a physical therapist?

Not always: every state allows some form of direct access to a physical therapist, but the limits vary, and your plan may need a referral before it pays. The American Physical Therapy Association reports that all 50 states, the District of Columbia and the U.S. Virgin Islands provide some form of direct access to physical therapists, with provisions and limitations that differ by jurisdiction; its data is current as of July 2025.⁠⁸ State practice law and plan payment rules are separate questions. HealthCare.gov notes that in many HMOs you need a referral before seeing anyone except your primary care doctor, and that without one the plan may not pay.⁠⁹

Public programs have their own rules:

• Medicare does not require a doctor’s order or referral for outpatient physical therapy.⁠²² It does require a plan of care, the written treatment plan your therapist sets, stating the type, amount, frequency and duration of therapy with your diagnosis and goals.⁠²³
• Certification: a physician, nurse practitioner, clinical nurse specialist or physician assistant signs the plan of care; if you came with a written order or referral from one of them, sending them the plan within 30 days of the evaluation can take the place of that signature.⁠²²
• Recertification: the plan of care must be recertified at least every 90 days by a physician, nurse practitioner, clinical nurse specialist or physician assistant.⁠²²
• Medicaid defines physical therapy as services “prescribed by a physician or other licensed practitioner of the healing arts” and provided by or under the direction of a qualified physical therapist.⁠²⁴

Ask two questions before the first visit: the clinic, whether it can see you without a referral in your state; and your plan, whether it pays without one.

What does physical therapy cost with Original Medicare in 2026?

You pay the Part B deductible, $283 in 2026, and then 20 percent of the Medicare-approved amount for medically necessary outpatient physical therapy.⁠^5,6 At the national amount, 20 percent of a $97.86 evaluation is $19.57; if the deductible is not yet met, the evaluation counts toward it.⁠^1,11

Medicare covers physical therapy to maintain your function or slow a decline, not only to improve it.⁠⁵ The Jimmo settlement of January 2013 confirmed that coverage does not depend on your potential for improvement but on your need for skilled care.⁠²⁵ Original Medicare has no yearly limit on what you pay out of pocket unless you have supplemental coverage such as a Medigap policy, so a long course of therapy adds up.⁠⁶

If you were thinking of paying privately instead, ask how the clinic handles Medicare first. Medicare’s opt-out and private-contract rules apply to physicians and a defined list of practitioners, and physical therapists are not among them.⁠²⁶ The guide to Medicare therapy coverage covers home health and inpatient rehabilitation alongside outpatient care.

What is Medicare’s KX threshold for physical therapy in 2026?

It is $2,480 a year for physical therapy and speech-language pathology combined, with a separate $2,480 for occupational therapy.⁠⁷ It is not a cap: the Bipartisan Budget Act of 2018 repealed the old therapy caps. Above the threshold, your clinic adds the KX modifier to confirm that the care is medically necessary and documented in your record, and claims over the threshold without it are denied.⁠⁷

Because physical therapy and speech therapy share one threshold, a year with both reaches it sooner. Do not read the threshold as a number of visits you are allowed; ask your therapist how your documentation supports the care you need.

If a clinic thinks Medicare may not pay for a service, it may give you an Advance Beneficiary Notice of Non-coverage, which lists the services, an estimate of their cost and the reasons.⁠²⁷ An ABN is not an official denial, and you can appeal if a claim is submitted and Medicare denies it.⁠²⁷

How does Medicare Advantage change what you pay for PT?

A Medicare Advantage plan must cover every service Part B covers, including outpatient physical therapy, and follow Medicare’s national coverage decisions and general coverage conditions, but it sets its own costs.⁠²⁸ Medicare.gov states that premiums, deductibles, copayments and coinsurance vary by plan, and that each plan has a yearly out-of-pocket limit after which it pays 100 percent of covered services.⁠⁶

If your plan uses prior authorization, federal rules limit it to confirming diagnoses or medical criteria and checking medical necessity, and a plan that approves a service through prior authorization may not later deny it for lack of medical necessity.⁠²⁹ Ask your plan for the per-visit copayment or coinsurance for outpatient rehabilitation, whether the clinic is in network, and how many visits each approval covers.

Does Medicaid cover physical therapy for adults?

It depends on your state. Medicaid.gov lists physical therapy among the optional benefits a state may add to its Medicaid plan, so whether an adult is covered, and on what terms, depends on the state’s plan.⁠³⁰ Adults covered through Medicaid expansion receive an Alternative Benefit Plan, which must include rehabilitative and habilitative services among its essential health benefits.⁠^30,31

Children are covered differently. Under the Early and Periodic Screening, Diagnostic, and Treatment benefit, states must provide medically necessary services coverable under federal Medicaid to enrolled children under 21, whether or not the state plan covers them for adults.⁠³² Ask your state Medicaid agency or Medicaid plan which clinics take Medicaid, what needs prior approval, and whether a copayment applies.

How much does physical therapy cost without insurance?

It costs whatever the clinic sets as its self-pay rate, so ask for it in writing: the evaluation price, the follow-up price, how long each appointment lasts and what it includes, and whether a re-evaluation or equipment costs extra. A cash rate may include a discount, but it is not automatically lower than what you would pay through insurance, so compare the two for the whole plan of care.⁠³

Before buying a package of prepaid visits, ask about cancellation and refund terms, whether unused visits expire, and what happens if your therapist changes the plan. A package price should not decide how many visits you need; your plan of care does.

When does a PT clinic have to give you a good faith estimate?

When you have no coverage for the service, or you have a group health plan, individual or group insurance, or a federal employees’ plan but choose not to have the claim sent to it.⁠³ Any discussion or question about cost counts as a request, and the clinic must give the estimate in writing, on paper or electronically, no later than 3 business days after you ask.⁠³

Physical therapy is recurring care, and the rule fits it: a clinic may give one estimate for recurring visits if it states the expected timeframe, frequency and total number of visits, for no more than 12 months.⁠³ If the plan of care changes, ask for a new estimate. The self-pay option in the rule is written for commercial and federal employees’ plans; it does not list Medicare or Medicaid, so if you have either, ask the clinic how it bills.

Can you dispute a PT bill that is far above the estimate?

Yes, if you received a good faith estimate and the bill from that clinic is at least $400 more than the estimate. That is the federal threshold for the patient-provider dispute resolution process, and you start it by notice to HHS within 120 calendar days of receiving the first bill, with an administrative fee.⁠¹⁰ Keep the estimate, the bill and your notes of every cost conversation together until the course of therapy is paid.

Can an HSA or FSA pay for physical therapy visits?

Usually, yes. IRS Publication 502 says you can include “amounts you pay for therapy received as medical treatment” in medical expenses.⁠³³ HSA distributions used for qualified medical expenses are not taxed, but expenses from before you opened the HSA do not qualify.⁠³⁴ A health FSA pays the expenses its plan specifies and cannot reimburse future or projected expenses in advance, so keep each receipt and submit it after the visit.⁠³⁴

Where can you get help with an unaffordable hospital PT bill?

Start with the hospital’s financial assistance policy if your therapy was at a tax-exempt, nonprofit hospital. Federal tax law requires a tax-exempt hospital organization to have a written financial assistance policy covering emergency and other medically necessary care, offering free or discounted care to people who meet its criteria, and to publicize it widely.⁠³⁵ Ask the billing office for the application, and ask that the account be held while it is reviewed. For a private clinic, ask whether it offers a payment plan or a reduced rate, and get the terms in writing.

What questions get a real price from a physical therapy clinic?

Questions that name the service, the codes, your plan and the length of the course. Send them by email so you have the answers in writing.

If a clinic cannot quote an exact amount, ask what is known, what is still uncertain, and who can settle each uncertainty: the clinic’s billing office, your plan, or your therapist after the evaluation.

How do you plan the total cost of a course of physical therapy?

Multiply your expected share per visit by the number of visits in your plan of care, then add the evaluation, any re-evaluations and equipment. Under Medicare, your plan of care sets the type, amount, frequency and duration of therapy, so it is the place to find the number of visits.⁠²³ Group the rest of the cost into three lines:

1. Clinical charges: the evaluation, follow-up visits, re-evaluations, and any separate equipment or supplies.
2. Access costs: transportation, parking, time away from work, and childcare or a support person.
3. Uncertainty: network status not yet confirmed, an unmet deductible, a pending approval, or a plan of care likely to change.

Access costs are real even though they never appear on a medical bill. A nearby clinic with hours that fit your work can cost less in total than a lower-priced clinic that takes unpaid time off for every visit.

Ask your therapist when progress is reassessed and what would change the number of visits. Do not cut visits, change weight-bearing precautions, or replace prescribed rehabilitation with exercises found online to fit a budget; raise the cost with your therapist, who can tell you what each option means for your care.

Can a home exercise program lower the cost of physical therapy?

That is your therapist’s decision to make with you, not a substitute this guide can recommend. If your plan of care includes exercises at home, your therapist decides how they fit with supervised visits, and under Medicare any change to the plan is made in writing and signed by the therapist or another listed practitioner.⁠²³ Medicare covers skilled therapy for a maintenance program when a qualified therapist’s skills are needed to carry it out safely and effectively.⁠²⁵ If cost is the issue, say so, and ask what the plan of care would look like with fewer visits and what that would mean for your goals.

What should parents check differently about a child’s PT costs?

The price questions are the same, but a child can have routes to physical therapy that adults do not. Medicaid’s EPSDT benefit requires states to provide medically necessary services to enrolled children under 21 even when the state does not cover them for adults.⁠³² Early intervention for infants and toddlers and school-based therapy are separate programs with their own eligibility rules and purposes.

The pediatric physical therapy cost guide covers those routes and the questions to ask, the guide to insurance coverage of therapy for kids covers plan rules, and pediatric therapy without insurance lists lower-cost options. If your child is uninsured or self-pay, you can ask a clinic for a good faith estimate as the person authorized under state law to consent for your child.⁠³

How do you find a physical therapy clinic you can afford?

Shortlist clinics near you, then put the same price questions to each. DrSensory is a free directory families use to find occupational, physical and speech therapy clinics for children and adults, filterable by location; you can go straight to physical therapy clinics. It lists clinics rather than individual therapists, it does not rank clinics by payment or verify clinical quality, and a message you send through it is read by the clinic in its own portal. Confirm insurance, ages seen, specialties, availability and accessibility with each clinic directly.

For what therapy involves, see the adult orthopedic, neurologic and older-adult sections. For occupational therapy, see adult occupational therapy cost; if no in-network clinic fits, see adult therapy without insurance.

Sources

1. Centers for Medicare & Medicaid Services. Search the Physician Fee Schedule (PFS Look-up Tool, year 2026, Non-QPP Rates, Pricing Information; the tool reads “Data Updated: 10/01/2026”). 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.” QPP Price Indicator note: “Effective January 1, 2026, a differential conversion factor will apply to services furnished by an eligible clinician who qualifies as a Qualifying Alternative Payment Model (APM) Participant for the applicable year.” Non-facility price for the National Payment Amount (locality 0000000), Manhattan (locality 1320201) and Arkansas (locality 0710213), in that order: 97161 “Pt eval low complex 20 min” $97.86, $108.82, $91.20; 97162 “Pt eval mod complex 30 min” $97.86, $108.82, $91.20; 97163 “Pt eval high complex 45 min” $97.86, $108.82, $91.20; 97164 “Pt re-eval est plan care” $67.47, $75.40, $62.36; 97110 “Therapeutic exercises” $29.06, $32.43, $26.97; 97140 “Manual therapy 1/> regions” $27.72, $30.95, $25.72; 97530 “Therapeutic activities” $35.07, $39.45, $32.08. The facility price equals the non-facility price for each of these codes in each locality; conversion factor 33.4009.
2. HealthCare.gov. Allowed amount (glossary). “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.
3. 45 CFR §149.610, Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals. Checked October 24, 2026.
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   (a)(1): the section covers good faith estimates “for uninsured (or self-pay) individuals (or their authorized representatives), upon request or upon scheduling an item or service”; (a)(2)(xiii): an uninsured (or self-pay) individual is one who has no benefits for the item or service under a group health plan, individual or group coverage from an insurer, a Federal health care program (as defined in section 1128B(f) of the Social Security Act) or a federal employees’ plan under chapter 89 of title 5, United States Code; or one who has benefits under a group health plan, individual or group coverage from an insurer, or a chapter 89 plan “but who does not seek to have a claim for such item or service submitted to such plan or coverage”; (a)(2)(v): expected charge means “the cash pay rate or rate established by a provider or facility for an uninsured (or self-pay) individual, reflecting any discounts for such individuals”; (a)(2)(i): an authorized representative is “an individual authorized under State law to provide consent on behalf of the uninsured (or self-pay) individual”; (b)(1)(iv): providers “shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate”; (b)(1)(vi)(C): “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.”; (e)(1): “A good faith estimate must be provided in written form either on paper or electronically”; (b)(1)(x): a provider “may issue a single good faith estimate for recurring primary items or services”, which must include “the expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)” and “must not exceed 12 months”. Text as published in the eCFR, current through October 22, 2026.
4. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5: Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04), §20.2, Reporting of Service Units With HCPCS (Rev. 3670). Checked October 24, 2026.
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   “When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (‘untimed’ HCPCS), the provider enters ‘1’ in the field labeled units.”; “When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes.”; “1 unit: ≥ 8 minutes through 22 minutes; 2 units: ≥ 23 minutes through 37 minutes; 3 units: ≥ 38 minutes through 52 minutes; 4 units: ≥ 53 minutes through 67 minutes”; “When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed.”; “the total number of timed minutes must be documented”; Example 3: “33 minutes of therapeutic exercise (97110), 7 minutes of manual therapy (97140), 40 Total timed minutes”; “Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140.” “The codes that are allowed one unit for ‘Allowed Units’ in the chart below may be billed no more than once per provider, per discipline, per date of service, per patient.” The section’s chart allows 97161, 97162, 97163 (“Evaluation of physical therapy”) and 97164 (“Re-evaluation of physical therapy”) 1 unit under a PT plan of care and 0 units under an OT or SLP plan of care.
5. Medicare.gov. Physical therapy services. Checked October 24, 2026.
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   “Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy, if you’re eligible”; “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 amounts you could owe depend 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”.
6. Medicare.gov. Medicare costs (What you pay in 2026). Checked October 24, 2026.
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   Part B 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’)”; Original Medicare out-of-pocket limit: “There’s no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage”, such as a Medigap policy, “or join a Medicare Advantage Plan (Part C).”; Medicare Advantage: premiums and other costs “Varies by plan”, and the out-of-pocket limit “Varies by plan. Once you pay the plan’s limit, the plan pays 100% of your covered health services for the rest of the calendar year.”
7. Centers for Medicare & Medicaid Services. Therapy Services (page last modified March 10, 2026). Checked October 24, 2026.
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   Section 50202 of the Bipartisan Budget Act of 2018 “repeals application of the Medicare outpatient therapy caps”; the former cap amounts are kept “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”; “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 law “continues to provide limitation of liability protections to beneficiaries receiving outpatient therapy services when services are denied for certain reasons, including failure to include a necessary KX modifier”; “Medicare applies a MPPR to the practice expense component of certain ‘always therapy’ services. Since April 1, 2013, the MPPR rate is 50 percent for both practitioner/office and institutional settings. It applies to the second and subsequent therapy services provided to a patient on the same day.”; for PT and OT services furnished in whole or in part by assistants, “Payment for these services is at 85 percent of the otherwise applicable PFS payment amount/rate for the service, effective January 1, 2022”; section 6209 of the Consolidated Appropriations Act, 2026 “extended the ability of PTs, OTs, and SLPs to furnish Telehealth Services”, including telephone assessment and management services, “through December 31, 2027”.
8. American Physical Therapy Association. Levels of Patient Access to Physical Therapists Services in the U.S. (resource dated September 4, 2024). Checked October 24, 2026.
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   “While all 50 states, the District of Columbia and the U.S. Virgin Islands, provide some form of direct access to physical therapist services, the specific provisions and limitations differ across jurisdictions.”; “Please note that the data below is current as of July 2025.”
9. HealthCare.gov. Referral (glossary). Checked October 24, 2026.
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   “A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.”
10. 45 CFR §149.620, Requirements for the patient-provider dispute resolution process. Checked October 24, 2026.
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    (a)(2)(ii): “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.”; (c)(1): the individual may start the process by a notice to HHS “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”, and “must submit an administrative fee”. Text as published in the eCFR, current through October 22, 2026.
11. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5: Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04). Checked October 24, 2026.
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    §10 (Rev. 3454): the Medicare Physician Fee Schedule (MPFS) “became the method of payment for outpatient therapy services furnished by”, among others, “Hospitals (to outpatients and inpatients who are not in a covered Part A stay)”; “The Medicare allowed charge for the services is the lower of the actual charge or the MPFS amount. The Medicare payment for the services is 80 percent of the allowed charge after the Part B deductible is met. 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.” §20.1 (Rev. 11129): claims with the CQ or CO modifier for services furnished in whole or in part by a PTA or OTA “are paid at an amount equal to 85 percent of the otherwise applicable Part B payment that’s based on the MPFS”; “This reduction is taken from the paid amount, i.e., the actual amount paid not the MPFS allowed amount.”
12. HealthCare.gov. Balance billing (glossary). “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.
13. HealthCare.gov. Non-preferred provider (glossary). “A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider.” Checked October 24, 2026.
14. HealthCare.gov. Deductible (glossary). “The amount you pay for covered health care services before your insurance plan starts to pay.”; “Many plans pay for certain services, like a checkup or disease management programs, before you’ve met your deductible. Check your plan details.” Checked October 24, 2026.
15. HealthCare.gov. Copayment (glossary). “A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible.”; “If you haven’t met your deductible: You pay $100, the full allowable amount for the visit.”; “Copayments (sometimes called ‘copays’) can vary for different services within the same plan”. Checked October 24, 2026.
16. HealthCare.gov. Coinsurance (glossary). “The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.”; “If you’ve paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest. If you haven’t met your deductible: You pay the full allowed amount, $100.” Checked October 24, 2026.
17. HealthCare.gov. Out-of-pocket maximum/limit (glossary). 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 limit does not include premiums, “Anything you spend for services your plan doesn’t cover”, “Out-of-network care and services” or “Costs above the allowed amount for a service that a provider may charge”. For a Marketplace plan in 2026: “No more than $10,600 for an individual or $21,200 for a family”.
18. HealthCare.gov. Network (glossary). “The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.” Checked October 24, 2026.
19. HealthCare.gov. What Marketplace health insurance plans cover. Checked October 24, 2026.
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    “All plans offered in the Marketplace cover these 10 essential health benefits”, including “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.”
20. HealthCare.gov. Summary of Benefits and Coverage (SBC) (glossary). “An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans.”; you get it “when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.” Checked October 24, 2026.
21. HealthCare.gov. Preauthorization (glossary). “A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.”; “Preauthorization isn’t a promise your health insurance or plan will cover the cost.” Checked October 24, 2026.
22. 42 CFR §424.24, Requirements for medical and other health services furnished by providers under Medicare Part B. Checked October 24, 2026.
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    (c)(1): the certification states that “The individual needs, or needed, physical therapy, occupational therapy, or speech-language pathology services”, that they were furnished while the individual was “under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant”, and “under a plan of treatment that meets the requirements of § 410.61”; (c)(3)(ii): if the plan 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)”; (c)(4)(i): “Recertification is required at least every 90 days.”; (c)(4)(iii): “The physician, nurse practitioner, clinical nurse specialist, or physician assistant who reviews the plan must recertify the plan by signing the medical record.”; (c)(5): when the plan is established by the therapist “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”; and “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.” Text as published in the eCFR, current through October 22, 2026.
23. 42 CFR §410.61, Plan of treatment requirements for outpatient rehabilitation services. Checked October 24, 2026.
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    (a): services “must be furnished under a written plan of treatment”; (b): “The plan is established before treatment is begun” by a physician, the physical therapist who furnishes the physical therapy services, or another listed practitioner; (c): “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.”; (d): “Any changes in the plan—(1) Are made in writing and signed by” the physician, the therapist who furnishes the services, or another listed practitioner. Text as published in the eCFR, current through October 22, 2026.
24. 42 CFR §440.110, Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Medicaid). Checked October 24, 2026.
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    (a)(1): “Physical therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified physical therapist.” Text as published in the eCFR, current through October 22, 2026.
25. Centers for Medicare & Medicaid Services. Jimmo Settlement. Checked October 24, 2026.
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    The January 2013 settlement agreement “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.”
26. 42 CFR §405.400, Definitions (Medicare opting out and private contracts). Checked October 24, 2026.
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    “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”; physical therapists are not listed, and the section’s definition of physician does not include them. Text as published in the eCFR, current through October 22, 2026.
27. Medicare.gov. Your Protections. Checked October 24, 2026.
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    “If you have Original Medicare, your doctor, other health care provider, or supplier may give you a written notice if they think Medicare won’t pay for the items or services you’ll get. This notice is called an ‘Advance Beneficiary Notice of Non-coverage,’ or ABN.”; “The ABN lists the items or services that your doctor or health care provider expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay.”; “Remember, an ABN isn’t an official denial of coverage by Medicare. You have the right to file an appeal if a claim is submitted and Medicare denies payment.”
28. 42 CFR §422.101, Requirements relating to basic benefits (Medicare Advantage). Checked October 24, 2026.
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    Each MA organization must “(a) Provide coverage of, by furnishing, arranging for, or making payment for, all services that are covered by Part A and Part B of Medicare” and “(b) Comply with—(1) CMS’s national coverage determinations; (2) General coverage and benefit conditions included in Traditional Medicare laws, unless superseded by laws applicable to MA plans.” Text as published in the eCFR, current through October 22, 2026.
29. 42 CFR §422.138, Prior authorization (Medicare Advantage). Checked October 24, 2026.
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    (b): prior authorization processes for coordinated care plans “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”; (c): if the plan approved a covered item or service through prior authorization, “it may not deny coverage later on the basis of lack of medical necessity”. Text as published in the eCFR, current through October 22, 2026.
30. Medicaid.gov. Mandatory & Optional Medicaid Benefits. “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.” The optional benefits listed include “Physical therapy (1905(a)(11), 42 CFR 440.110(a))”; “The ABP is mandatory for the Medicaid expansion population.” Checked October 24, 2026.
31. 42 CFR §440.347, Essential health benefits (Medicaid). (a): “Alternative Benefit Plans must contain essential health benefits coverage, including benefits in each of the following ten categories”, among them “(7) Rehabilitative and habilitative services and devices”. Text as published in the eCFR, current through October 22, 2026. Checked October 24, 2026.
32. Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment. Checked October 24, 2026.
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    The benefit “provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan.”
33. Internal Revenue Service. Publication 502, Medical and Dental Expenses (for use in preparing 2025 returns). Therapy: “You can include in medical expenses amounts you pay for therapy received as medical treatment.” Checked October 24, 2026.
34. Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans. Checked October 24, 2026.
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    “Distributions from an HSA that are used to pay qualified medical expenses aren’t taxed.”; “For HSA purposes, expenses incurred before you establish your HSA aren’t qualified medical expenses.”; “Reimbursements from an FSA that are used to pay qualified medical expenses aren’t taxed.”; for a health FSA, “Qualified medical expenses are those specified in the plan that would generally qualify for the medical and dental expenses deduction.”; “The FSA can’t make advance reimbursements of future or projected expenses.”
35. Internal Revenue Service. Financial Assistance Policies (FAPs). Checked October 24, 2026.
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    “Section 501(r)(4) of the Internal Revenue Code (IRC) requires a tax-exempt hospital organization to establish a written financial assistance policy (FAP).”; “Financial assistance includes free or discounted health services provided to persons who meet the organization’s criteria for financial assistance and are unable to pay for all or a portion of the services.”; the FAP must “Apply to all emergency and other medically necessary care provided by the hospital facility” and be “widely publicized”.

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.