Medi-Cal, California’s Medicaid program, provides comprehensive health coverage for millions of residents, including therapeutic services. Medi-Cal covers physical therapy (PT) when the service is determined to be medically necessary for the recipient. This benefit is intended to help beneficiaries recover from injury, manage chronic conditions, and restore or maintain functional ability. Accessing this treatment requires navigating specific rules concerning eligibility, authorization, and the type of Medi-Cal plan an individual possesses.
Eligibility and Medical Necessity
Physical therapy coverage is directly tied to medical necessity, meaning the treatment must be reasonable and required to address a specific medical condition. For an adult recipient, services must be necessary to protect life, prevent a significant illness or disability, or alleviate severe pain. This definition ensures that coverage focuses on acute rehabilitation and symptom management rather than general wellness or maintenance.
The process begins with a written prescription from a licensed practitioner, such as a physician, dentist, or podiatrist. This prescription must be specific, detailing the exact services, modalities, frequency, and expected duration of the therapy. Simply writing “physical therapy” is insufficient; the documentation must establish a clear link between the diagnosis and the therapeutic goals.
For Medi-Cal recipients under the age of 21, the standard is broader due to the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate. Under EPSDT, physical therapy is covered if it is needed to correct or ameliorate a defect or condition. This means treatment that sustains, maintains, or improves a child’s current health condition is covered. This allows for services that prevent a condition from worsening or help achieve age-appropriate growth and development.
Treatment is expected to produce significant, measurable improvement, or be necessary to establish an effective maintenance program in connection with a specific disease state. Services that are primarily for the convenience of the patient or provider, or those that do not require the specific skills of a licensed physical therapist, are not considered medically necessary. The prescribing practitioner must provide sufficient documentation to support the medical necessity criteria for the entire duration of the requested treatment plan.
Coverage Limits and Prior Authorization
The amount of physical therapy covered is controlled through the requirement for Prior Authorization (PA), which involves specific limits on the number of treatments allowed per request. For recipients enrolled in the Fee-for-Service (FFS) delivery system, all physical therapy services require an authorization request, known as a Treatment Authorization Request (TAR). Coverage must be approved by the state’s Department of Health Care Services (DHCS) before services are rendered.
Authorizations for physical therapy in the FFS system are limited to services necessary to prevent or substantially reduce an anticipated hospital stay, continue a plan initiated during a hospital stay, or serve as a component of post-hospital care. A single authorization request is not granted for more than 30 treatments and is valid for a maximum of 120 days. Exceeding these administrative limits requires the provider to submit a new TAR with updated clinical documentation demonstrating the continued necessity of the treatment.
Prior Authorization is the administrative mechanism used to ensure that the continued services meet the medical necessity standard. The provider submits detailed clinical notes and the treatment plan to the payer—either the state or a managed care plan—for review. If the request for continued therapy is denied, the recipient has the right to appeal the decision through a Medi-Cal Fair Hearing process.
Navigating the Medi-Cal Delivery System
Physical therapy access is determined by which of the two main Medi-Cal delivery systems the recipient is enrolled in: Managed Care or Fee-for-Service. The vast majority of Medi-Cal recipients are enrolled in a Managed Care Plan (MCP). In this system, a specific health plan is responsible for coordinating all care, including physical therapy.
For those in a Managed Care Plan, the specific rules for prior authorization, provider networks, and administrative processes are set by the individual health plan. While the MCP must provide the same scope of benefits as the state’s FFS program, the procedures for obtaining authorization and the network of available therapists will vary by plan. Recipients must use physical therapists who are contracted with their specific Managed Care Plan to ensure coverage.
A smaller population of recipients, including those who are dually eligible for both Medi-Cal and Medicare, are often enrolled in the Fee-for-Service (FFS) system. In this structure, the state’s DHCS directly administers the benefits and handles the Treatment Authorization Requests. FFS recipients can access any provider who accepts Medi-Cal, which may offer a wider choice of specialists, though the administrative burden of the TAR process remains consistent.
Recipients choose or are assigned a Managed Care Plan upon enrollment, but they can contact the appropriate resources for assistance in understanding their plan and making informed choices. Understanding whether one is in an MCP or FFS system is the first step, as it dictates the network of providers and the specific authorization rules that apply to physical therapy services.