Physical therapy (PT) is a recognized treatment for managing chronic conditions like arthritis, which causes joint pain, stiffness, and reduced mobility. The goal of PT is to reduce discomfort and improve or maintain physical function, allowing individuals to perform daily activities more easily. Medicare generally covers physical therapy services when they are deemed medically necessary for treating conditions such as arthritis.
Medicare Part B Rules for Outpatient Physical Therapy
Coverage for outpatient physical therapy for arthritis primarily falls under Medicare Part B (Medical Insurance). For Part B to cover these services, the treatment must be “medically necessary,” meaning the therapy is required to diagnose or treat the medical condition. This includes services that aim to improve the patient’s condition, maintain function, or slow the rate of physical decline.
The services provided must be skilled, meaning they are complex enough to be safely and effectively performed or supervised only by a qualified physical therapist. General exercise programs that can be performed by an unskilled person are not covered under Part B. A physician or other authorized health care provider (such as a nurse practitioner or physician assistant) must certify that the patient needs these skilled services.
While a formal referral is not always necessary, the physical therapist must establish a Certified Plan of Care (POC). This plan details the goals, type of services, and expected duration of the therapy. The POC must be reviewed and signed by a physician or other certifying provider who oversees the patient’s care.
The services can be provided in various outpatient settings. These include a physical therapist’s private office, an outpatient hospital department, a rehabilitation agency, or in the patient’s home under certain circumstances. Medicare continues to cover medically necessary therapy as long as the skilled documentation supports the need for ongoing care.
Patient Costs and Financial Responsibilities
Patients covered by Medicare Part B still have financial responsibilities. The first step is meeting the annual Part B deductible, which is $257 for 2025. Medicare coverage for outpatient services begins only after the patient has paid this deductible amount out-of-pocket.
After the deductible is met, the patient is responsible for a coinsurance payment for each service. The standard coinsurance for Part B services, including physical therapy, is 20% of the Medicare-approved amount. Medicare pays the remaining 80% of the approved cost. This 20% coinsurance can accumulate, especially for individuals with chronic conditions like arthritis requiring long-term therapy.
The mandatory cap on outpatient therapy services was eliminated in 2018, meaning there is no arbitrary limit on the number of sessions Medicare covers annually. However, financial thresholds ensure continued medical necessity documentation. For 2025, when the combined cost of physical therapy and speech-language pathology services reaches $2,410, the provider must confirm the therapy is still medically necessary by adding a special modifier to the claim.
An additional threshold of \(3,000 for combined services may trigger a targeted medical review of the patient’s claim. These thresholds are not a cap on coverage but a mechanism to ensure high-use services are appropriately documented as skilled and necessary. Patients may also purchase a Medigap plan, which can help cover out-of-pocket costs like the Part B deductible and coinsurance payments.
Physical Therapy Coverage in Other Medicare Settings
Medicare Part A (Inpatient and SNF)
Physical therapy may be covered under Medicare Part A when the setting is an inpatient facility. Part A covers PT as part of a medically necessary stay in an acute care hospital or during a covered stay in a Skilled Nursing Facility (SNF). Coverage for an SNF stay requires the patient to have had a qualifying hospital stay of at least three consecutive days prior to admission.
In an SNF, Part A covers the entire cost of the first 20 days of care, including rehabilitation services. From days 21 through 100, the patient is responsible for a daily coinsurance payment (\)209.50 per day in 2025). Coverage ends after 100 days, and the patient must pay all costs unless they have other insurance.
Medicare Advantage (Part C)
Medicare Advantage plans (Part C) are offered by private insurance companies approved by Medicare. These plans must provide at least the same level of coverage as Original Medicare (Parts A and B), meaning they cover medically necessary physical therapy for arthritis. Part C plans often have different cost-sharing rules, such as copayments for therapy visits instead of the 20% coinsurance required by Part B.
These private plans may require beneficiaries to receive care from providers within a specific network. They frequently mandate prior authorization before a course of physical therapy can begin. Prior authorization helps the plan ensure the services are appropriate and medically necessary, but this process can sometimes delay treatment. Patients must compare the specific terms of a Part C plan, as out-of-pocket costs and administrative requirements can vary significantly.