Medicare Physical Therapy Coverage: Limits, Costs and Your Rights

Original Medicare has no yearly dollar cap on outpatient physical therapy. Congress repealed the old therapy cap in 2018. What replaced it is a threshold: once your physical therapy and speech therapy together pass $2,480 in Medicare-approved charges in 2026 ($2,540 in 2027), your therapist has to add a "KX" code to each claim confirming the care is medically necessary and documented. That's a paperwork line, not a stopping point.

A lot of people still hear "Medicare only pays while you're improving" or "you've used up your visits." Neither is how the rules read. Below is how Part B covers outpatient PT, what you pay, how coverage works at home and in a skilled nursing facility, what the Advance Beneficiary Notice means, and what changes if you're in a Medicare Advantage plan. There's a Florida section at the end on direct access to a physical therapist and where to get free help.

Source: Medicare.gov, Physical therapy services; CMS, Therapy Services; CY 2027 Physician Fee Schedule final rule, 91 FR 71186; CMS, 2026 Part B deductible.

What Part B covers

Medicare.gov puts it in one line: Part B "helps pay for medically necessary outpatient physical therapy." Outpatient means you aren't admitted: a private PT clinic, a hospital outpatient department, a doctor's office, or a physical therapist in private practice who treats you in your home.

The purpose can be to restore movement after an injury, illness or surgery. It can also be to "improve or maintain your current function, or slow your rate of decline." Keep that second half in mind; it comes up again below.

Under federal rules (42 CFR 410.60), the therapy has to be done by a qualified physical therapist or a physical therapist assistant the therapist supervises, while you're under a doctor's care, and under a written plan. The test that matters most is in CMS's Benefit Policy Manual: the services have to be reasonable, effective treatment for your condition that need a therapist's skill. If a family member or aide could safely do the same exercises with you, Medicare treats that as unskilled care and won't pay for it.

One more thing the manual spells out: therapy for weakness that would clear up by itself, like being a little unsteady after a few days in bed following surgery, isn't considered reasonable and necessary. That's one of the more common reasons a therapist will tell you Medicare won't cover more visits.

The plan of care and certification

Every Medicare PT episode runs on a written plan of care. Per 42 CFR 410.61, it's set up before treatment starts, by your doctor, a nurse practitioner, clinical nurse specialist or physician assistant, or the physical therapist who treats you. It lists your diagnosis, your goals, and the type, amount, frequency and duration of therapy.

Then a physician or one of those practitioners certifies it. Here's how the timing works under 42 CFR 424.24(c) and the manual:

Source: 42 CFR 424.24(c); Medicare Benefit Policy Manual, ch. 15, sec. 220.1.3.

Note the last line of the federal rule: nothing in it "shall be construed to require an order or referral" for outpatient therapy. Medicare doesn't make you get a referral before your first visit. It does require a certified plan, and if the paperwork never gets signed, the claim can be denied. If you start without a doctor's referral, ask the clinic how they'll get the plan certified.

The KX threshold: 2024 to 2027

Until 2018, Medicare had hard therapy caps with an exceptions process. Section 50202 of the Bipartisan Budget Act of 2018, signed February 9, 2018, repealed them. CMS kept the old cap amounts as thresholds. Above the threshold, the therapist adds the KX modifier, which is an attestation that the services are reasonable and necessary and that the medical record backs that up. A claim above the threshold without the KX modifier gets denied.

There's one amount for physical therapy and speech-language pathology combined, and a separate amount for occupational therapy. So if you get speech therapy after a stroke as well as PT, both count toward the same threshold. The amount rises each year with the Medicare Economic Index (MEI), rounded to the nearest $10.

$0$1,000$2,000$3,000

$2,330

$2,410

$2,480

$2,540

2024202520262027

Source: CY 2024, CY 2025, CY 2026 and CY 2027 Physician Fee Schedule final rules (Federal Register); CMS, Therapy Services.

Show the numbers

	Threshold
2024	$2,330
2025	$2,410
2026	$2,480
2027	$2,540

For 2027, CMS took the 2026 amount of $2,480, multiplied by the final MEI increase of 2.6%, and rounded to get $2,540. That's in the CY 2027 Physician Fee Schedule final rule, published in the Federal Register on November 9, 2026, and it applies to services starting January 1, 2027.

The second number is $3,000, the targeted medical review threshold. It's been $3,000 since 2018, stays there through 2027, and starts rising with the MEI in 2028. "Targeted" is the key word. Not every claim over $3,000 gets reviewed. CMS focuses on providers with high denial rates, unusual billing patterns, or who are newly enrolled, among other factors. A review is aimed at the provider's documentation. It isn't a bill to you.

Source: CMS, Outpatient Therapy Services and ABN FAQs (August 2018), Q1, Q4, Q5.

The improvement myth and Jimmo

For years, some providers and Medicare contractors acted as if therapy was covered only while a patient kept improving. A lawsuit, Jimmo v. Sebelius, ended in a settlement the court approved on January 24, 2013. CMS's Jimmo page says the settlement may change practice for those who "may have erroneously believed" coverage depended on expected improvement.

The standard CMS restated: coverage in outpatient therapy, home health and skilled nursing facilities "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."

In practice, under the Benefit Policy Manual, section 220.2, Medicare covers:

• A therapist designing a maintenance program for you, when it takes a therapist's skill to design it.
• Teaching you or a caregiver how to do the program.
• Periodic reassessments, when they need a therapist.
• Ongoing skilled maintenance therapy when your condition makes the exercises complex enough, or your medical complications risky enough, that a therapist has to do them.

CMS's example of covered maintenance work is a patient with Parkinson's disease near the end of a rehab course: the therapist setting up a maintenance program and teaching the patient or family to carry it out may be covered therapy.

What isn't covered: carrying out a maintenance routine you can safely do alone or with a family member, caregiver or aide.

If you're told "you've plateaued, so Medicare stops paying," ask the therapist whether you still need skilled care to keep your function or slow decline. If the answer is yes and they still won't bill Medicare, you can ask them to submit the claim anyway (Option 1 on an ABN, below) so you keep your appeal rights. Mention Jimmo by name. CMS tells beneficiaries with questions about it to call 1-800-MEDICARE.

What you pay

Outpatient PT is a regular Part B service. You pay the Part B deductible first ($283 in 2026), then 20% of the Medicare-approved amount for each visit. CMS hasn't announced the 2027 Part B deductible as of November 14, 2026, so I won't guess at it; the math below works the same way once it's out.

The Medicare-approved amount for a visit depends on which services the therapist bills, where in Florida the clinic is, and the setting. Medicare.gov also lists your other insurance and whether the provider accepts assignment. Ask the clinic for an estimate before you start.

Source: Medicare.gov, Physical therapy services; CMS, 2026 Part B deductible. The $120-per-visit figure is a round hypothetical for illustration, not a CMS payment rate.

Example (hypothetical): Say you're in Sarasota after a knee replacement and your clinic's Medicare-approved amount averages $120 a visit. Twelve visits come to $1,440. If PT is your first Part B bill of the year, the first $283 is yours, then 20% of the remaining $1,157, which is $231.40. Total: $514.40. If you'd already met the deductible, you'd owe $288.

Stretch that to 24 visits and the total is $2,880. That's over the $2,480 KX threshold, so somewhere around visit 21 the clinic starts adding the KX modifier. Your cost doesn't jump. You keep paying 20%, and it's still under the $3,000 review threshold.

A Medigap policy picks up some or all of that 20%, depending on the plan letter; per Medicare.gov's comparison chart, Plans K and L pay 50% and 75% of Part B coinsurance. Our Florida Medicare Supplement page explains how the letters differ. One more billing detail: when a physical therapist assistant does more than a small part of a service, the claim carries a "CQ" modifier and Medicare pays the clinic 85% of the normal rate. That's a provider payment rule. It doesn't limit how much therapy you can get.

Home health, skilled nursing and hospital settings

Where you get therapy changes which part of Medicare pays and what you owe. This is where people get surprised most often, in both directions.

Source: Medicare.gov, Home health services; Medicare.gov, Skilled nursing facility care; 42 CFR 410.60(b); CMS, 2026 Medicare Parts A and B amounts. SNF days 1 to 20 are $0 after the Part A deductible ($1,736 in 2026) if it wasn't already paid for the hospital stay in the same benefit period.

Home health. If you're homebound, meaning leaving home isn't recommended or you need help to leave, and leaving takes a lot of effort, PT through a Medicare-certified home health agency costs you nothing for the covered services. You'd still pay 20% for medical equipment. Our guide to Medicare home health coverage walks through the homebound test.

Skilled nursing facility. After a qualifying inpatient stay of at least 3 days in a row (observation days don't count), Part A covers daily skilled therapy in a SNF. Coinsurance starts on day 21. Our skilled nursing facility guide has the full cost math. Jimmo applies here too: a SNF can't end coverage just because you stopped improving if you still need daily skilled care.

Home health agencies and SNFs have to give you a Notice of Medicare Non-Coverage no later than 2 days before covered services end; for home health visits more than 2 days apart, it comes no later than the next-to-last visit (42 CFR 405.1200). You can ask the Quality Improvement Organization for a fast review by noon of the day after you get it (42 CFR 405.1202).

The ABN, and how to appeal

An Advance Beneficiary Notice of Noncoverage (form CMS-R-131) is how a provider in Original Medicare tells you, before treatment, that it expects Medicare to deny payment. Per CMS, therapy above the threshold that the therapist doesn't consider medically necessary, and other care that isn't medically necessary, are situations that call for one. CMS's therapy FAQ gives a typical case: you've met all the goals in your plan and want to keep coming once a week anyway.

The form gives you three choices. Read them carefully, because two of them give up your appeal rights.

Source: CMS, ABN form instructions (CMS-R-131); CMS therapy ABN FAQ, Q2.

A provider can't hand out ABNs to everyone as a routine form, and an ABN given after a course of treatment has started can't make you liable for visits before it. If you think the therapy is still necessary, Option 1 is the one that keeps the door open. An ABN also isn't needed for things Medicare never covers; CMS's example is a wellness class the clinic runs after you're discharged.

If Medicare denies the claim, here's the path in Original Medicare. Our Medicare appeal process guide covers all five levels.

Source: Medicare.gov, Appeals in Original Medicare; 42 CFR 405.942.

Ask your therapist and doctor for their notes before you file. Documentation of why you need a therapist's skill, whether to improve or to keep you from declining, is what wins these.

Medicare Advantage

A Medicare Advantage plan has to cover everything Part B covers, and it has to follow Original Medicare's coverage rules and national coverage decisions (42 CFR 422.101). Maintenance therapy under the Jimmo standard is part of that. What can differ is the process and what you pay.

• Prior authorization. A plan can require approval before PT starts or before more visits. Federal rules limit what that approval can be used for: confirming the diagnosis and medical necessity (42 CFR 422.138). Once a plan approves a service, it can't later deny it as not medically necessary except for good cause or fraud.
• Decision time. Since January 1, 2026, a standard decision on a prior authorization request is due within 7 calendar days (42 CFR 422.568). If waiting could seriously harm your health, ask for an expedited decision.
• Course of treatment. An approval for a course of treatment has to last as long as it's medically necessary, and if you join a plan mid-treatment, you get at least a 90-day transition period (42 CFR 422.112).
• Cost sharing and network. Your copays or coinsurance and which therapists you can use come from the plan's own rules. Check the Evidence of Coverage.

If a plan denies therapy, you have appeal rights there too, with different deadlines than Original Medicare. The appeal guide linked above covers both.

Florida: direct access and SHINE

Florida lets you see a physical therapist without a referral first. Under s. 486.021(11)(a), Florida Statutes, a PT can carry out a treatment plan the PT wrote. If treatment has to go past 30 days for a condition no practitioner of record has assessed, the PT has to have one review and sign the plan. Practitioners of record include medical and osteopathic doctors, chiropractors, podiatrists and dentists in active practice. The PT also has to refer you out if your condition falls outside physical therapy.

How that fits with Medicare: state law decides whether a PT can treat you. Medicare decides whether it pays, and Medicare still wants a plan of care certified by a physician, nurse practitioner, clinical nurse specialist or physician assistant, as described above. So in Florida you can walk into a PT clinic in Tampa or Fort Lauderdale on your own, but the clinic still needs your doctor's sign-off on the plan for Medicare to keep paying. Clinics usually arrange this; ask anyway.

Free help. SHINE (Serving Health Insurance Needs of Elders), run by the Florida Department of Elder Affairs with the local Area Agencies on Aging, gives free, unbiased Medicare counseling. Call 1-800-963-5337 (TTY 1-800-955-8770) or use the online request form. A counselor can help you read a Medicare Summary Notice, decide on an ABN option, or start an appeal. Our SHINE guide explains how to get an appointment, and our Florida Medicare page covers how Parts A, B, C and D fit together.

FAQ

How many physical therapy visits does Medicare cover per year?

Original Medicare has no visit limit and no yearly dollar cap on medically necessary outpatient physical therapy. Above $2,480 in 2026 ($2,540 in 2027) for physical and speech therapy combined, the therapist adds a KX modifier confirming the care is medically necessary.

Does Medicare cover physical therapy if I'm not improving?

Yes, if you need a therapist's skill. Under the Jimmo settlement, coverage depends on your need for skilled care, not on your potential for improvement, so skilled therapy to maintain function or slow decline can be covered.

How much does Medicare pay for physical therapy?

Under Original Medicare, after the Part B deductible ($283 in 2026) you pay 20% of the Medicare-approved amount. Covered PT from a home health agency costs you nothing.

Do I need a doctor's referral for physical therapy under Medicare?

Medicare doesn't require a referral before your first visit, but a physician, nurse practitioner, clinical nurse specialist or physician assistant must certify your plan of care. Florida law lets you see a physical therapist directly, with a practitioner of record signing the plan if treatment goes past 30 days for a condition no practitioner of record has assessed.

What is the Medicare therapy threshold for 2027?

CMS set the 2027 KX modifier threshold at $2,540 for physical therapy and speech-language pathology combined, and a separate $2,540 for occupational therapy. The targeted medical review threshold stays at $3,000.

Federal Medicare rules, Florida law and your own plan or policy documents control what's covered and what you pay. Confirm your situation with Medicare, SHINE or a licensed agent, and talk to an attorney about legal questions.

Sources

1. Medicare.gov: Physical therapy services
2. Medicare.gov: Home health services
3. Medicare.gov: Skilled nursing facility (SNF) care
4. Medicare.gov: Appeals in Original Medicare
5. Medicare.gov: Compare Medigap plan benefits
6. CMS: Therapy Services (KX modifier thresholds, PTA payment differential)
7. CMS: Outpatient Therapy Services and ABN FAQs (August 2018)
8. CMS MLN006266: Medicare Advance Written Notices of Non-coverage (May 2025)
9. CMS: ABN form instructions (CMS-R-131)
10. CMS: Jimmo Settlement
11. CMS: Medicare Benefit Policy Manual, chapter 15 (sections 220 and 230)
12. Federal Register: CY 2027 Physician Fee Schedule final rule (Nov. 9, 2026)
13. Federal Register: CY 2026 Physician Fee Schedule final rule (Nov. 5, 2025)
14. Federal Register: CY 2025 Physician Fee Schedule final rule (Dec. 9, 2024)
15. Federal Register: CY 2024 Physician Fee Schedule final rule (Nov. 16, 2023)
16. CMS: 2026 Medicare Parts A and B premiums and deductibles
17. eCFR: 42 CFR 410.60, Outpatient physical therapy services: conditions
18. eCFR: 42 CFR 410.61, Plan of treatment requirements
19. eCFR: 42 CFR 424.24, Requirements for medical and other health services
20. eCFR: 42 CFR 405.942, Time frame for filing a redetermination
21. eCFR: 42 CFR 405.1200, Notifying beneficiaries of provider service terminations
22. eCFR: 42 CFR 405.1202, Expedited determination procedures
23. eCFR: 42 CFR 422.101, Requirements relating to basic benefits
24. eCFR: 42 CFR 422.112, Access to services
25. eCFR: 42 CFR 422.138, Prior authorization
26. eCFR: 42 CFR 422.568, Standard timeframes for organization determinations
27. Florida Statutes s. 486.021, Definitions (practice of physical therapy)
28. SHINE (Florida Department of Elder Affairs)
29. SHINE: Contact Us