Medicaid is a public health insurance program designed to provide medical assistance to eligible low-income adults, children, pregnant women, and people with disabilities. This program is administered as a partnership between the federal government and individual state governments, which results in variations in coverage details across the country. Physical therapy (PT) is an important service that Medicaid often covers when it is deemed medically necessary for a patient’s recovery or functional improvement. The goal of this coverage is to restore function lost due to injury or illness, or to help a patient maintain their current level of function. Specific rules and session limits depend entirely on how each state structures its benefits.
State-Specific Rules and Coverage Limits
Because Medicaid is not uniform across the United States, there is no single national answer for how many physical therapy sessions are covered. Each state operates its own program, determining the amount, duration, and scope of services provided. Therefore, specific session limits, annual caps, or dollar maximums for physical therapy depend entirely on the patient’s state of residence and their specific Medicaid plan, such as a State Plan or a waiver program.
Many state programs impose annual limits on the number of sessions an adult patient may receive. These limits often combine physical, occupational, and speech therapy visits into a single cap. For example, some states may limit coverage to 20 or 30 combined therapy visits per patient within a 12-month period, which is a common structure for outpatient rehabilitation services.
These limits can also be structured differently based on the specific Medicaid plan a person is enrolled in. Furthermore, some state programs may enforce a dollar-amount cap on the total cost of therapy services rather than a session count. Given this state-by-state variability, individuals must check their local Medicaid agency’s provider manual or contact their managed care organization directly to find the precise limits applicable to their coverage.
The Prior Authorization Requirement for Treatment
Even if a patient has not reached a session limit, physical therapy treatment almost always requires prior authorization. This process requires the therapist to submit documentation to the state or its contracted utilization management entity to prove the medical necessity of the proposed treatment plan. The documentation typically includes a detailed Plan of Care outlining specific, measurable, and achievable goals for the patient.
The primary criterion for authorization is that the service must be “medically necessary.” This means the treatment must be considered a specific and effective intervention for the patient’s condition under accepted standards of practice. For adults, many state programs limit coverage to care for an acute medical condition or an acute exacerbation of a chronic condition, where significant functional improvement is expected within a predictable timeframe.
The service must also be skilled, meaning it requires the expertise of a licensed physical therapist and could not be performed effectively by an untrained individual. Therapy services determined to be purely for maintenance, without an expectation of measurable functional progress, are generally not covered for adults unless allowed under a specific waiver program. Failure to submit the required prior authorization documentation before treatment begins or continues past an initial evaluation period can result in a denial of payment for the services rendered.
Covered Physical Therapy Settings and Services
Medicaid coverage depends heavily on the setting where services are delivered, as different settings use separate funding streams or regulatory rules. Outpatient physical therapy, typically provided in a clinic, is the most common form of coverage and is subject to state-specific session limits. Therapy provided in a skilled nursing facility (SNF) or during a home health episode may be covered under a bundled payment arrangement. This bundled payment affects how individual sessions are counted against a patient’s annual limit.
Coverage for Children (EPSDT)
Services for children and adolescents under age 21 are covered under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This federal requirement mandates that states cover any medically necessary service needed to correct or ameliorate a physical or mental condition. EPSDT often provides broader coverage and allows for more sessions than are available to adults. Additionally, physical therapy services delivered in a school setting are sometimes considered supplemental to other plan-covered therapy and may not count against a patient’s annual outpatient session maximum.
Rehabilitative vs. Habilitative Services
Coverage rules distinguish between rehabilitative and habilitative services. Rehabilitative therapy aims to restore function lost due to injury or illness. Habilitative therapy focuses on helping a patient keep, learn, or improve skills for daily living that they have not yet acquired at an age-appropriate level. Both types of therapy are generally covered by Medicaid, but the distinction can sometimes influence the authorization process and the specific session limits applied by a state.
Requesting Exceptions and Appealing Denials
Patients whose treatment requires more sessions than the state’s mandated limit, or whose initial request for authorization is denied, have the right to challenge that decision through a formal process. The first step often involves the physical therapist requesting an “exception to policy.” This requires submitting detailed clinical documentation demonstrating continued medical necessity, proving the patient is making significant, measurable progress, and that ceasing therapy would cause functional regression.
If an exception or authorization request is denied, the Medicaid enrollee can file a formal appeal, typically a State Fair Hearing. The denial notice details the reason for the denial, the policy used, and the patient’s appeal rights and deadlines. It is important to file the appeal request quickly. Patients who file within a short timeframe, often 10 days of the denial notice, may be entitled to receive “aid paid pending,” meaning their services continue until a final decision is reached on the appeal.
A successful appeal relies on a detailed statement from the treating physician or physical therapist explaining why the requested service is medically necessary and how it meets the state’s coverage criteria. The appeal process allows the patient and their representative to present evidence to an administrative law judge or hearing officer. Patients generally have a reasonable period of time, often up to 90 days from the notice date, to file their initial appeal request.