Is there still an annual cap on Medicare physical therapy?

No, the hard annual cap was eliminated permanently by the Bipartisan Budget Act of 2018. Medicare now uses a tiered KX modifier threshold (approximately $2,410 in 2026 for combined PT and speech therapy, with a separate threshold for occupational therapy). Care above the threshold continues with documentation requirements; care above approximately $3,000+ may trigger Medicare audits. There's no absolute dollar limit on medically necessary therapy.

Does Medicare cover maintenance physical therapy for chronic conditions?

Yes. The Jimmo v. Sebelius settlement clarified that Medicare covers skilled maintenance therapy — care needed to maintain a patient's condition or prevent decline, not just care expected to improve the patient. Conditions like Parkinson's, MS, post-stroke deficits, and chronic neuromuscular disorders all qualify for maintenance therapy when skilled care is needed. If Medicare denies coverage for lack of expected improvement, your provider can cite Jimmo in the appeal.

Does Medicare cover physical therapy in my home?

Yes, under the home health benefit, if you're homebound (leaving home requires considerable effort and is medically inadvisable) and need skilled care. Home health PT is covered 100% with no deductible or copay when you meet criteria. The threshold for 'homebound' is somewhat strict — temporary mobility limitations after surgery often qualify; permanent mild mobility limitations may not. Your physician determines homebound status and refers you to a Medicare-certified home health agency.

Do I need a referral for physical therapy on Medicare?

Original Medicare typically doesn't require a formal referral, but you do need a physician's order/prescription for PT. The order documents medical necessity and authorizes the therapist to evaluate and treat. Medicare Advantage plans often require formal referrals from your primary care physician before PT, plus prior authorization in some cases.

How many PT visits will Medicare cover?

Original Medicare doesn't have a fixed visit limit — care continues as long as it's medically necessary, with KX modifier and audit thresholds adding documentation requirements at higher cost levels. Medicare Advantage plans may have visit limits or require prior authorization for continued care beyond a certain number. If you need extensive PT (post-surgical, stroke recovery, chronic condition), Original Medicare + Medigap often provides more flexibility than MA plans with visit caps.

Can I see a PT directly without going through my doctor first?

Ohio is a 'direct access' state for physical therapy — meaning patients can see a PT for evaluation and some treatments without a physician referral. However, Medicare requires a physician's order for PT coverage. Even though Ohio allows direct access for state law purposes, Medicare won't pay for your PT without a physician order. Most PT clinics will help you obtain the order from your primary care physician.

Does Medicare Cover Physical Therapy in Ohio? (2026)

On this page

When Medicare covers physical therapy
Outpatient PT vs in-home PT
The KX modifier threshold (formerly the cap)
Medicare Advantage PT coverage rules
Cost-sharing and Medigap
Finding a Medicare PT provider in Ohio
Common questions

When Medicare covers physical therapy

Medicare covers physical therapy when three criteria are met:

Ordered by a physician — your doctor must determine PT is medically necessary and prescribe it.
Provided by a Medicare-certified therapist — licensed physical therapist, occupational therapist, or speech-language pathologist working in a Medicare-approved setting.
Reasonable and necessary — the care must be expected to improve your condition, maintain your condition, or prevent further deterioration. Medicare doesn't require expected improvement (the "Jimmo settlement" clarified that maintenance therapy is covered when skilled care is needed).

Common PT covered conditions: post-surgical rehabilitation (joint replacement, cardiac surgery, stroke recovery), arthritis management, vestibular disorders, fall prevention, Parkinson's-related therapy, back/neck pain, and many others.

Outpatient PT vs in-home PT

Medicare covers PT in three main settings:

Outpatient PT clinic — most common. You travel to a clinic or hospital outpatient department. Covered under Part B at 80% after the deductible.
Home health PT — covered under Medicare's home health benefit when you're homebound (leaving home requires considerable effort and is medically inadvisable) and need skilled care. Covered 100% with no deductible or copay when you meet home health criteria.
Skilled nursing facility (SNF) PT — included in your SNF stay coverage, subject to the 100-day SNF benefit limits.

The eligibility rules for home health PT are stricter than outpatient. Most Medicare beneficiaries access PT through outpatient clinics — convenient if you can travel, cost-effective for Medicare, and broadly accessible across Ohio.

The KX modifier threshold (formerly the cap)

From 1997 to 2017, Medicare had a hard annual cap on PT spending (with various exception processes). The Bipartisan Budget Act of 2018 eliminated the hard cap permanently. Instead, Medicare now uses a tiered system:

Threshold 1 (approximately $2,410 in 2026 for combined PT + SLP): Once costs exceed this amount, your provider must add a KX modifier to subsequent claims, certifying that continued care is medically necessary. Care continues, but with documentation requirements.
Threshold 2 (approximately $3,000+ for targeted medical review): Costs above this level may trigger Medicare audits and prepayment medical review. Your provider may need to submit additional documentation to support continued care.
Occupational therapy has its own separate threshold, typically the same dollar amount as the PT+SLP combined.

The practical effect: medically necessary PT continues regardless of cost, but documentation becomes more important as costs increase. Your therapist's office handles the KX modifier and audit responses; you generally don't need to take action beyond continuing to attend therapy sessions.

The Jimmo settlement: maintenance therapy is covered

Before 2013, Medicare contractors often denied PT coverage if a patient wasn't expected to 'improve.' The Jimmo v. Sebelius settlement clarified that Medicare covers skilled maintenance therapy — care needed to maintain a patient's condition or prevent decline, even without expected improvement. If you have a chronic condition like Parkinson's, MS, or stroke deficits, this matters significantly. If Medicare denies your PT for lack of expected improvement, your provider can cite Jimmo in the appeal.

Medicare Advantage PT coverage rules

Medicare Advantage plans must cover physical therapy at least as well as Original Medicare, but plan-specific rules apply:

Prior authorization — many MA plans require prior auth before PT visits begin or after a certain number of visits. Your PT provider's office typically handles this.
Network restrictions — MA plans require you to use in-network PT providers (except for emergencies). Verify your PT provider is in-network before starting care.
Copays per visit — MA plans typically charge $20-$50 per PT visit (instead of Original Medicare's 20% coinsurance). The copay structure can be either more or less expensive than Original Medicare + Medigap depending on the number of visits.
Visit limits — some MA plans cap PT at a specific number of visits per year. Beyond the cap, the plan may deny continued care without further appeal.

If you anticipate significant PT needs (post-surgical rehab, chronic condition management), comparing MA plans by their PT coverage and copay structure matters. A plan with lower premium but higher PT copays may cost more if you need 20+ visits annually.

For Original Medicare PT in 2026:

Annual Part B deductible: $283 (applies to PT same as other Part B services).
20% coinsurance: after the deductible, you pay 20% of the Medicare-approved amount for each PT session.
Medigap covers the 20%: All Medigap plans except Plan A and high-deductible plans cover the 20% Part B coinsurance, leaving you with no out-of-pocket cost per PT visit.

For Medicare Advantage PT in 2026:

Plan-specific copay: typically $20-$50 per visit.
Counts toward MOOP: PT costs apply to your plan's Maximum Out-of-Pocket limit ($9,250 maximum in 2026 for in-network care).
No annual deductible for most MA plans, but some plans have separate medical or therapy deductibles.

Ohio Medicare beneficiary needing PT — comparing plans?A licensed Ohio Medicare agent can compare PT cost-sharing across Medicare Advantage plans and Original Medicare + Medigap for your specific anticipated needs. No cost to you.

Find a Medicare Agent in Ohio

Finding a Medicare PT provider in Ohio

Most physical therapy practices in Ohio accept Medicare. To find one:

Medicare's Provider Compare tool at medicare.gov/care-compare lets you search PT providers by ZIP code with quality ratings and Medicare acceptance.
Hospital-affiliated PT — major Ohio hospital systems (Cleveland Clinic, OSU Wexner, UH, Mercy Health, Summa Health, Premier Health, ProMedica) all operate outpatient PT clinics that accept Medicare.
Independent PT practices — common across Ohio. Confirm Medicare acceptance and (if you have MA) network participation before starting care.
Home health agencies for home-based PT — your physician's office can recommend Medicare-certified home health agencies in your area.