Does Medicare Require a Referral for Physical Therapy?

If you’re questioning, “does Medicare require a referral for physical therapy?”, rest assured, the process is more flexible than you might think. Medicare does not outright require a referral, but physician approval is essential to ensure coverage.

This article demystifies Medicare’s role in physical therapy for inpatient and outpatient services, direct access across different states, and strategic pointers for maneuvering through the coverage landscape.


Key Takeaways

  • Medicare covers both inpatient and outpatient physical therapy services under different parts (Part A for inpatient and Part B for outpatient), with outpatient services subject to an annual deductible and therapy caps requiring medical necessity confirmation.


  • While Medicare beneficiaries may have direct access to physical therapy services without a physician’s referral in certain states, Medicare requires physician involvement for care plans, including certifications and recertifications, to ensure coverage.


  • Medicare Advantage (Part C) and Medicare Supplement (Medigap) plans can offer alternative coverage options for physical therapy, potentially tailoring cost-sharing and network requirements to individual beneficiary needs.

Compare Plans in One Step!

Enter Zip Code



Medicare and Physical Therapy Referrals - The Basics

Medicare plays a significant role in covering physical therapy for many beneficiaries. Both inpatient and outpatient services fall under this coverage, with different parts of Medicare catering to each setting. Inpatient services, such as those provided in hospitals or skilled nursing facilities, are covered under Part A of Medicare. On the other hand, outpatient services typically fall under Part B. However, the physician’s involvement varies depending on the setting and state laws, adding a layer of complexity to the process.

Contrary to common belief, a physician’s referral isn’t always necessary for accessing physical therapy services.

Although Medicare doesn’t enforce a strict rule for patients to procure a physician’s prescription for physical therapy, it does insist on physician involvement. Physicians typically provide a physician’s referral for patients to undergo physical therapy and authorize up to 30 days of treatment at a time for continued coverage.

Medicare and Physical Therapy Referrals- The Basics

Inpatient Physical Therapy Coverage

Inpatient physical therapy, covered under Medicare Part A, is a critical part of the recovery process for many individuals. To be eligible for this coverage, a patient must have been admitted to the hospital as an inpatient for at least 3 days. Furthermore, a physician needs to confirm the need for specialized care to aid recovery from an illness, injury, or surgery.

This coverage encompasses rehabilitation services like physical therapy treatment, occupational therapy, and speech-language pathology services. Remember, coverage for inpatient rehabilitation care mandates at least a 3-day inpatient hospital stay and may extend to both inpatient and outpatient rehabilitation following surgery or for in-home care.

Medicare will pay for a rehab facility for up to 90 days per benefit period.


Outpatient Physical Therapy Coverage

On the other side of the coin, outpatient physical therapy services fall under Medicare Part B coverage. These services include occupational therapy and speech-language pathology, offering a comprehensive range of treatments for various conditions.

However, coverage for these services comes with its set of rules. Namely, an annual deductible of $226 applies, after which Medicare covers 80 percent of the approved amount for these services.

Additionally, there’s a cost threshold of $2,230 for combined physical therapy and speech-language pathology services, and a separate $2,230 threshold for occupational therapy. Once these thresholds are met, confirmation of medical necessity is required for continued coverage.

Direct Access to Physical Therapy: State Laws vs. Medicare Requirements

The complexity of navigating physical therapy increases when considering direct access – a term denoting a patient’s ability to directly seek treatment from physical therapists without a physician’s referral.


Do you need a referral for physical therapy in florida



It’s important to note that while all 50 states, the District of Columbia, and the U.S. Virgin Islands allow some form of direct access to receive physical therapy services, the degree of access can vary greatly due to different direct access laws.

As for Medicare, it stipulates that:


  • A physician’s signature must be obtained on the care plan within 30 days to facilitate unlimited direct access services.
  • Recertification, through a physician’s signature, is required whenever the plan of care is updated or every 90 days, whichever occurs first.
  • Failure to adhere to these guidelines can lead to the denial of payment by Medicare for the services rendered.


Direct Access States

In states permitting direct access, Medicare beneficiaries can opt to directly seek treatment from physical therapists without a physician’s referral.

However, if a direct access patient becomes eligible for Medicare during treatment, it is crucial to establish and certify a plan of care, possibly requiring an initial evaluation. The treatment must also comply with both the state practice act and Medicare’s guidelines.


Limited Direct Access States

Conversely, Limited Direct Access States impose more restrictive rules, frequently necessitating a physician’s referral before initiating Medicare-covered treatment.

These restrictions can include limitations on the types of services or patient populations that can be treated without a physician’s referral. Failure to secure a physician referral in these states can result in delays in receiving care, increased costs, and potential decline in functional outcomes.

Navigating Medicare Direct Access for Physical Therapy

The journey through Medicare direct access for physical therapy may seem overwhelming, but acquiring a good grasp of the process can significantly ease the process. This involves familiarizing oneself with:


  • Initial evaluations
  • Treatment plans
  • Billing
  • Documentation requirements


Medicare beneficiaries can undergo an initial evaluation directly by a physical therapist without a referral. Therapists can then create a personalized treatment plan for the patient without consulting a physician beforehand.


Medicare physical therapy referral guidelines



However, Medicare necessitates precise documentation, including a diagnosis or a description of the condition. This documentation is essential to accurately record and justify direct access services.


Initial Evaluations and Treatment Plans

An initial evaluation can be the first step in a patient’s physical therapy journey. Medicare patients can directly schedule this evaluation with a physical therapist to assess the suitability of physical therapy for their needs. This evaluation forms the basis for the development of a personalized plan of care (POC) for the patient.

Nevertheless, Medicare stipulates the following requirements for POC treatment:


  1. The initial evaluation should ascertain the necessity for the treatment.
  2. The treatment plan needs to be certified by a physician, PA, or NP with a dated signature or verbal order within 30 days post-evaluation.
  3. If the physical therapist determines that therapy is not suitable, a physician referral or signature on the evaluation is necessary for Medicare to cover the cost of the service.


Billing and Documentation Requirements

Billing and documentation are crucial aspects of navigating Medicare direct access for physical therapy. When billing for Medicare-covered physical therapy services, therapy providers must include the name and NPI number of the certifying physician or NPP in the ‘referring provider’ section of the claim form.


Physical therapy without referral near me



When it comes to documentation, Medicare requires the following:


  • The signed plan of care must be established before treatment commences, as outlined in the Medicare Benefit Policy Manual.
  • This plan must be recertified within 90 days or in case of a change in condition.
  • The plan must bear a dated signature by the physician or another authorized healthcare professional.

Compare plans and enroll online



Speak with a licensed insurance agent

TTY 711

Mon-Fri : 8am-9pm ET

compare medicare advantage plans

Medicare Advantage (Part C) and Physical Therapy Referrals

Also known as Part C, Medicare Advantage serves as an alternative to Original Medicare, offering coverage for physical therapy as well. However, the specifics of coverage and costs can vary from plan to plan. It’s also noteworthy that these plans often require patients to stay in-network for services.

Medicare Advantage plans offer at least the same physical therapy benefits as Original Medicare, but they differ in cost management, which can make Medicare Advantage a more cost-effective option for some beneficiaries.

Additionally, these plans may have varying coinsurance or copay requirements for physical therapy services. Despite this, there’s no imposed limit on the amount it pays for medically necessary outpatient therapy services in a calendar year.

Medicare Supplement Plans and Physical Therapy Costs

Also referred to as Medigap plans, Medicare Supplement plans are insurance policies tailored to help cover out-of-pocket expenses pertaining to healthcare, including physical therapy costs. These plans can be a smart choice for individuals who foresee needing physical therapy.

Once the deductible for Medicare Part B is fulfilled, Medicare covers physical therapy, with 80% of the expenses related to physical therapy being covered, leaving 20% to be paid by the patient.

However, depending on the specific plan, Medicare Supplement plans can help cover this remaining 20%, potentially resulting in comprehensive coverage. These plans typically cover physical therapy services that align with those covered by Medicare Part B, such as outpatient physical therapy. So, does Medicare cover physical therapy? Yes, it does, and it can be supplemented with additional plans for more comprehensive coverage. The services include:


  • rehabilitation services
  • therapeutic exercises
  • manual therapy
  • ultrasound therapy
  • electrical stimulation therapy


By enrolling in a Medicare Supplement plan, you can ensure that you have the financial support you need for your physical therapy treatments.

Non-Medicare Physical Therapy Services: Wellness and Self-Pay Options

Besides Medicare-covered physical therapy services, wellness programs are accessible to Medicare beneficiaries.

These services, not covered by Medicare, allow patients to avail them without necessitating a physician’s involvement. The payment for these services is collected directly from the patient, bypassing the need for Medicare involvement.


Will insurance cover physical therapy without a referral



Providers offering wellness services to Medicare beneficiaries need to clearly differentiate between Medicare’s definition of ‘wellness services’ and ‘physical therapy services’. Payment for wellness services that were never covered can be obtained directly from the Medicare patient without the necessity of an ABN.

Typical wellness programs offered to Medicare beneficiaries include:


  • Managing pain
  • Physical therapy
  • Exercise
  • Chiropractic care
  • Massage therapy
  • Annual wellness visits
  • Fitness programs
  • Nutrition counseling
  • Health coaching

Tips for Navigating Medicare Physical Therapy Coverage

While navigating Medicare physical therapy coverage may appear daunting, having the right knowledge can significantly simplify the process. Understanding how state practice acts impact physical therapy is crucial, as these acts dictate the extent of direct access available and are vital for ensuring adherence to Medicare regulations.

Plans of care play a crucial role in determining the eligibility of physical therapy services for coverage under Medicare. These plans must accurately represent the medically essential services recommended by a physician or other qualified healthcare professional in order to qualify for coverage.

When choosing between Medicare Advantage and Supplement plans, consider the specific coverage details, including the extent of coverage for physical therapy sessions, and choose a plan that best meets your physical therapy requirements.


In conclusion, understanding Medicare physical therapy coverage can be complex, but with the right knowledge, it becomes a lot more manageable.

Whether it’s understanding the basics of inpatient and outpatient coverage, navigating direct access, or choosing the right Medicare Advantage or Supplement plan, being informed can empower you to make decisions that best suit your healthcare needs.

Frequently Asked Questions



Do Medicare patients have direct access to physical therapy?

No, Medicare patients do not have direct access to physical therapy, as they need to be under the care of a physician and have a certified Plan of Care.


How many physical therapy sessions does Medicare allow in a year?

Medicare allows an unlimited number of physical therapy treatments within one calendar year as long as they are deemed medically necessary by your physician or physical therapist. This means there is no specific limit on the coverage for outpatient therapy services under Medicare.


Does Medicare require referrals?

No, Medicare Advantage plans, specifically HMOs, are the only ones that may require a referral; PPO and Original Medicare do not require referrals. Always check your specific plan benefits to confirm.


What is direct access in terms of physical therapy?

Direct access in physical therapy allows patients to seek treatment directly from physical therapists without a physician’s referral, with the extent of access varying by state laws.


How does Medicare Advantage cover physical therapy?

Medicare Advantage covers physical therapy, but the coverage and costs vary depending on the specific plan. It’s important to check if the therapy services need to be obtained from in-network providers.

call today for help



 ZRN Health & Financial Services, LLC, a Texas limited liability company

Find & Compare Plans Online 



Speak with a licensed insurance agent

TTY 711

Mon-Fri : 8am-9pm EST

Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.