You can get many therapies with Medicare, including outpatient and inpatient services like physical therapy, occupational therapy, speech-language pathology, and mental health counseling. Each is covered under different parts and rules.
Medicare Part B commonly pays for outpatient therapies and mental health visits. Parts A and D help with inpatient care and medications; limits, provider rules, and costs vary.
If you want help navigating coverage, The Modern Medicare Agency makes it simple. Our licensed agents are real people you can speak with one-on-one, who match Medicare plans to your needs without adding extra fees.
Overview of Medicare-Covered Therapies
Medicare pays for many types of therapy when they are medically necessary and provided by eligible professionals. You will see which services count as therapy, who qualifies, and which Medicare part usually pays for each service.
What Is Considered Therapy Under Medicare
Medicare defines therapy as services that help restore or improve function after injury, illness, or a health decline. This includes physical therapy (PT) to rebuild strength and mobility, occupational therapy (OT) to help with daily tasks, and speech-language pathology (SLP) to address communication or swallowing problems.
Mental health counseling and psychotherapy are also covered when provided in an approved setting. Therapy must be part of a treatment plan signed by a qualified provider.
Medicare looks for clear medical need, measurable goals, and progress toward those goals. Services meant mainly for convenience, general fitness, or social reasons are not covered.
Eligibility Criteria for Coverage
You qualify for therapy coverage if you have Medicare Part A or Part B and the services are deemed medically necessary. Medical necessity means a licensed clinician documents that therapy is required to treat or prevent a specific condition and that it is reasonable and safe.
Your provider must create and review a plan of care with goals and periodic progress notes. Providers must be Medicare-enrolled and operate within acceptable settings — hospitals, outpatient clinics, skilled nursing facilities, or home health when eligible.
You may owe deductibles, coinsurance, or co-pays depending on your plan and the Medicare part that pays for the service.
Medicare Parts and Relevant Coverage
Part A covers inpatient therapy services during a hospital stay or in a skilled nursing facility when you meet the qualifying conditions. Part A also covers some home health therapy if you are homebound and need intermittent skilled care.
Part B covers outpatient therapy including PT, OT, SLP, and outpatient mental health counseling when ordered by a doctor. You typically pay 20% coinsurance after the Part B deductible.
Part D covers prescription drugs related to mental health or other therapy needs, as long as the medicine is on your plan’s formulary. If you use Medicare Advantage, benefits may differ.
Physical Therapy Coverage
Medicare pays for physical therapy when it treats a medical issue that affects your ability to function. Coverage depends on who provides care, where you get it, and whether your provider documents ongoing medical need.
Medically Necessary Physical Therapy
Medicare covers physical therapy that your doctor or qualified provider says is medically necessary. This means therapy must treat an illness, injury, or condition that limits your ability to move, function, or perform daily tasks.
Your provider must create a treatment plan, document progress, and periodically review the plan to show therapy remains needed. You need a physician or eligible practitioner to certify the need and refer you when required.
Medicare does not pay for therapy that is mainly for general fitness, convenience, or social reasons. If your therapist or doctor cannot show skilled care is needed, Medicare may deny payment.
Settings Where Physical Therapy Is Covered
Medicare covers physical therapy in many places: outpatient clinics, hospitals, skilled nursing facilities, and at home through home health services. For outpatient PT, Part B pays when a doctor certifies the need and the therapist provides skilled services.
Inpatient therapy in hospitals and rehab units is covered under Part A when you meet admission and care criteria. Home health physical therapy is covered if a doctor orders home health services and you are homebound.
Skilled nursing facility therapy is covered under Part A if you qualify for a covered stay. Always check whether your provider accepts Medicare assignment to limit your out-of-pocket costs.
Limits and Caps on Coverage
Medicare does not have a single nationwide dollar cap on therapy, but it uses rules and medical review to limit coverage to necessary, skilled therapy. Part B requires you to meet the annual deductible and pay a coinsurance percentage for outpatient therapy.
Medicare may require documentation of progress and medical necessity to continue paying for ongoing services. If Medicare questions the need for continued therapy, it may suspend payments until additional records justify care.
You can appeal denials if you disagree. Work with your provider and a licensed agent from The Modern Medicare Agency to understand likely costs, document care properly, and choose a plan that fits your needs and budget.
Occupational Therapy Under Medicare
Medicare pays for occupational therapy when it helps you regain or improve daily living skills after injury, illness, or due to a chronic condition. Coverage rules depend on where you get care, who provides it, and whether a doctor orders and reviews the treatment.
Conditions Treated With Occupational Therapy
Occupational therapy focuses on tasks you do every day. Common reasons Medicare covers OT include stroke recovery, joint replacement rehab, traumatic brain injury, arthritis that limits hand function, and balance or fall-risk issues.
Therapists work on dressing, bathing, eating, cooking, using adaptive tools, and home safety. They also address cognitive problems that affect memory, planning, or attention if those issues limit daily tasks.
Therapists document specific goals, such as increasing grip strength to button a shirt or improving standing balance to transfer safely. Medicare looks for measurable progress toward those goals.
If your condition clearly affects daily independence and the therapy is reasonable and necessary, Medicare is likely to cover it.
Eligibility Requirements for Occupational Therapy
A doctor or other authorized provider must order and periodically review your occupational therapy. Medicare requires that OT be “medically necessary” — meaning it treats or manages a diagnosed condition and is expected to help you function better.
The therapist must be a Medicare-qualified practitioner working in an approved setting or under proper supervision. You must meet plan cost rules: Part A covers inpatient therapy during a hospital or skilled nursing stay, while Part B covers outpatient therapy after you meet the Part B deductible and pay the coinsurance.
Keep clear records of diagnoses, treatment plans, and progress notes to support continued coverage.
Outpatient vs. Inpatient Occupational Therapy
Inpatient OT under Medicare Part A applies when you are in a hospital or skilled nursing facility. Coverage follows facility rules and case management.
Therapy must be part of a documented plan of care and tied to a skilled need during your stay. Outpatient OT under Part B covers therapy you get in clinics, doctor offices, or outpatient rehab centers.
You need a physician’s order and periodic reviews. Part B pays 80% of the Medicare-approved amount after the deductible; you’re responsible for the remaining 20% unless a Medicare Advantage plan covers more.
Speech-Language Pathology Services
You can get Medicare coverage for speech-language pathology when services are medically necessary and ordered by a qualified provider. Coverage covers evaluation, treatment, and certain swallowing (dysphagia) therapies, but some limits and rules apply.
Covered Speech Therapy Services
Medicare Part B covers outpatient speech-language pathology that treats communication or swallowing disorders. This includes diagnostic evaluations, individual and group therapy, and treatment plans created by a licensed speech-language pathologist (SLP).
Therapy must be medically necessary, documented in your medical record, and ordered by a physician or qualified practitioner. Medicare pays 80% of the Medicare-approved amount after you meet the Part B deductible; you pay the remaining 20% unless supplemental coverage reduces your cost.
If you have a Medicare Advantage plan, check your plan rules and network requirements, because plans may handle prior authorization and provider choice differently.
Qualifying Diagnoses for Speech Therapy
Medicare covers speech therapy for a variety of diagnoses that affect communication or swallowing. Common qualifying conditions include stroke-related aphasia, traumatic brain injury, Parkinson’s disease, dementia with communication impairment, and dysphagia from neurological or structural causes.
Coverage focuses on treating loss of function rather than elective or educational goals. Your clinician must document functional deficits, measurable therapy goals, and progress toward those goals.
If therapy restores or improves medically necessary functions, Medicare is more likely to cover continued services. Keep clear records and physician orders to support coverage.
Coverage Restrictions and Exclusions
Medicare does not cover services that are not reasonable and necessary. Purely educational, vocational, or maintenance therapy without expected improvement may be denied.
Services performed by unrecognized providers, such as speech-language pathology assistants billed to Medicare as independent therapists, are typically excluded unless a supervising qualified SLP provides and documents the skilled portion. Medicare also requires proper coding and documentation; missing orders, insufficient progress notes, or incorrect billing codes can lead to denials.
Mental Health Therapy Coverage
Medicare helps pay for many common mental health services you may need, including therapy visits, hospital stays for psychiatric care, and telehealth sessions. You’ll see what types of providers, settings, and costs matter most so you can plan care and expenses.
Outpatient Psychotherapy and Counseling
Medicare Part B covers outpatient mental health services like individual therapy, group therapy, and psychiatric evaluations. Covered providers include psychiatrists, clinical psychologists, clinical social workers, and certain other licensed mental health professionals.
You pay 20% of the Medicare-approved amount after meeting the Part B deductible, and the plan pays the rest. Sessions that support treatment for anxiety, depression, grief, or other conditions usually qualify when a licensed provider documents medical necessity.
You can use Medicare to see providers in offices, community mental health centers, or some clinics. If you have a Medicare Advantage plan, check whether you need prior authorization or must use in-network therapists to keep costs lower.
Inpatient Psychiatric Services
Medicare Part A covers inpatient psychiatric care when you require hospital admission for acute psychiatric conditions. Coverage includes room and board, nursing care, lab tests, medication, and therapy provided during your stay.
You must meet hospital admission rules, and Medicare applies Part A cost-sharing: a daily coinsurance for longer stays after the benefit period deductible. If the hospital stay transitions you to a specialized psychiatric hospital, Medicare still covers eligible services but rules about benefit periods and eligible days can change.
Documented medical necessity and physician orders are key to approval. Ask your care team and The Modern Medicare Agency’s licensed agents about how inpatient costs and length-of-stay rules apply to your plan.
Coverage of Telehealth Mental Health Services
Medicare covers many mental health telehealth visits under Part B when you connect with an eligible provider by video or, in some cases, by audio-only phone. Covered services include psychotherapy, medication management, psychiatric diagnostic interviews, and certain therapy follow-ups.
You generally pay 20% of the Medicare-approved amount after the Part B deductible. Telehealth rules can vary by provider type and your plan.
Some services must be “incident to” a provider’s ongoing treatment plan. If you enroll in a Medicare Advantage plan, check whether the plan offers additional telehealth benefits or lower cost-sharing.
The Modern Medicare Agency’s licensed agents can help you find plans that cover telehealth visits you need and explain any prior authorization or network rules.
Cardiac and Pulmonary Rehabilitation Therapies
Medicare covers supervised rehab programs that help you recover after heart events or manage chronic lung disease. Coverage includes structured exercise, education, and monitoring when you meet specific medical and documentation rules.
Cardiac Rehabilitation Programs
Medicare covers cardiac rehabilitation when a physician documents a qualifying diagnosis and an individualized treatment plan. Qualifying diagnoses commonly include recent heart attack, certain types of heart surgery, percutaneous coronary intervention, and stable angina.
Your plan must be physician-prescribed and include monitored exercise, risk-factor modification (like blood pressure and cholesterol counseling), psychosocial assessment, and outcome measurements. Coverage limits apply: Medicare Part B generally covers up to 36 sessions over a set period, with possible additional sessions if criteria are met.
You may pay the Part B coinsurance and any deductible. The program must be supervised by qualified medical staff and follow the rules in 42 CFR 410.49 to qualify for payment.
Pulmonary Rehabilitation Eligibility
Medicare Part B covers pulmonary rehabilitation for people with chronic, disabling lung disease that impairs daily activities, such as COPD and chronic bronchitis, when ordered by a physician. Your physician must document that pulmonary rehab is medically necessary and create an individualized treatment plan.
The program typically includes exercise training, breathing techniques, education on lung disease management, and psychosocial support. Like cardiac rehab, pulmonary rehab requires supervision by qualified clinicians and regular outcome assessments.
Coverage usually limits the number of sessions and may require periodic reassessment to continue therapy. You pay the standard Part B coinsurance and deductible unless your plan says otherwise.
Alternative and Complementary Therapies
Medicare covers a few specific non‑traditional treatments but leaves many others to private plans or out‑of‑pocket payment. Know which services qualify, what limits apply, and when you may need a referral or prior authorization.
Coverage of Acupuncture
Medicare Part B covers acupuncture only for chronic low back pain when other treatments haven’t worked. Coverage applies to a set number of sessions and requires a treating physician to order and document medical necessity.
You’ll typically pay 20% of the Medicare-approved amount after meeting the Part B deductible, unless you have supplemental coverage that reduces your cost. Medicare Advantage plans may offer broader acupuncture benefits, but benefits vary by plan.
Always check plan details for session limits, provider networks, and prior‑authorization rules. Your Modern Medicare Agency licensed agent can review local plan options and confirm whether acupuncture visits are included and what your expected copay will be.
Medicare Stance on Chiropractic Care
Medicare Part B covers manual manipulation of the spine when medically necessary to correct a subluxation that affects function. Coverage does not extend to general chiropractic services like x-rays, massage, or acupuncture performed by the chiropractor unless those services meet Medicare rules and are separately covered.
You pay 20% of the Medicare-approved amount for covered chiropractic manipulation after the Part B deductible, unless supplemental coverage applies. Medicare Advantage plans may add extra chiropractic benefits or limit provider choice.
The Modern Medicare Agency’s licensed agents will compare plans for you, explain which chiropractic services a plan covers, and help find providers in your area who accept Medicare.
Therapy Coverage Limitations and Exceptions
Medicare covers many medically necessary therapy services but has rules that affect how much and under what conditions services get paid. You need to watch for limits tied to yearly thresholds and check if your plan changes rules or costs.
Annual Therapy Thresholds
Medicare Part B no longer sets a hard cap on outpatient physical, occupational, or speech therapy sessions, but it does use a financial threshold that triggers extra review. When your billed therapy charges reach that threshold, providers must document that the services remain medically necessary.
If the provider fails to use the required KX modifier or supply supporting records, Medicare can deny payment and the provider may not bill you. You still pay standard cost sharing: typically 20% of Medicare-approved amounts after the Part B deductible.
Inpatient therapy follows Part A rules, so different limits and cost responsibilities can apply. Keep copies of therapy plans, physician orders, and progress notes to avoid coverage denials.
Medicare Advantage Plan Variations
If you have a Medicare Advantage plan, your therapy coverage can differ from Original Medicare. Plans may require prior authorization, use a smaller provider network, or set visit limits for certain therapies.
You might face different copays or require referrals from a primary care provider. Always read your plan’s Evidence of Coverage and call your plan to confirm rules before starting therapy.
For help comparing options, The Modern Medicare Agency offers licensed agents who talk with you one-on-one, review plan details, and find Medicare packages that match your needs without extra fees. Their agents can check provider networks and authorization rules so you avoid surprise charges.
How to Access and Appeal Therapy Coverage
Start by getting a written order from your doctor or authorized provider for the therapy. Medicare Part B covers outpatient therapies when they are medically necessary and periodically reviewed.
Keep copies of orders, progress notes, and bills. Check your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) for any denials or limited payments.
If you disagree with a decision, you can request a redetermination. Act quickly—appeal deadlines are short, usually 60–120 days from the decision date.
Follow these steps when appealing:
- Request the written decision and reason for denial.
- Gather supporting records: therapy notes, doctor letters, and test results.
- File the appeal level required and meet deadlines.
You can get help from licensed agents at The Modern Medicare Agency. Our agents talk with you one-on-one to explain coverage details and find plans that match your needs.
They help you prepare paperwork and can guide you through appeal steps without hidden fees. If your appeal moves to a hearing, consider having an agent help you prepare medical evidence and questions.
Keep phone logs and copies of everything you send. Persistence and clear documentation raise your chances of a successful appeal.
