Does Healthfirst Cover Physical Therapy? Costs, Visits, and Authorization

Healthfirst does cover physical therapy, across every plan it offers in New York: Medicaid Managed Care, the Essential Plans, Child Health Plus, Medicare Advantage, the marketplace Leaf plans, and the Senior Health Partners managed long-term care plan. What you pay per visit ranges from $0 on Medicaid and most Essential Plans up to $45 on certain Leaf plans. The therapy has to be medically necessary and ordered by a licensed provider, and prior authorization is generally required before treatment begins.

What You’ll Pay Per Visit

Your copay depends entirely on which Healthfirst plan you carry.

For the marketplace Leaf plans, 2026 copays break down this way:5Healthfirst. Leaf Plans

  • Platinum Leaf and Platinum Leaf Premier: $35
  • Gold Leaf: $40 after deductible
  • Gold Leaf Premier: $45 after deductible
  • Gold Leaf Premier Plus: $45 for the first visit (no deductible), then $40 after deductible
  • Silver Leaf, Silver Leaf Premier, and Silver Leaf Premier Plus: $20

Copays and benefits can change each January 1, so check the current Summary of Benefits for your specific plan at healthfirst.org before you start a course of treatment.6Healthfirst. Summary of Benefits

How Many Visits You Can Get

As of January 1, 2021, Healthfirst removed all annual visit limits on physical therapy for Medicaid Managed Care (including HIV Special Needs Plans and Health and Recovery Plans), Senior Health Partners, Essential Plan 3, and Essential Plan 4. CompleteCare members were already uncapped because their therapy runs through Medicare.4Healthfirst Provider Portal. Removal of Service Limits Physical Therapy Occupational Therapy and Speech Therapy

For Leaf plans and other plan types, no fixed annual visit cap is specified, but every visit still has to meet the medical necessity standard to stay covered.

Getting Physical Therapy Approved

Healthfirst requires prior authorization for physical therapy. Since January 1, 2024, the insurer has handled those requests directly rather than through a delegated vendor. Your therapist submits the request through the Healthfirst Provider Portal or by fax.7Healthfirst Provider Portal. Prior Authorization Request Physical Occupational and Speech Therapies

You don’t necessarily need a doctor’s referral to start. New York’s direct access law lets a physical therapist evaluate and treat you for up to 10 visits or 30 days, whichever comes first, without a referral. You’ll sign a Notice of Advice form at the first visit. Once you hit that 10-visit or 30-day mark, a referring practitioner has to evaluate you before therapy continues.8Healthfirst Provider Portal. Outpatient Physical Therapy Continuation Request Requirements

Continuing Treatment Past the Initial Authorization

Rules that took effect October 1, 2025 require your therapist to submit a plan of care covering your diagnosis, date of onset, measurable goals, and the frequency and duration of treatment, signed by both the attending physician and the physical therapist. A physician or non-physician practitioner has to recertify that plan of care at least every 90 days, and the therapist must reevaluate you monthly and document progress.8Healthfirst Provider Portal. Outpatient Physical Therapy Continuation Request Requirements

The medical necessity standard Healthfirst applies is whether there is a “reasonable expectation that physical therapy will achieve measurable improvement in the patient’s condition in a reasonable and predictable period of time.” Therapy that is maintaining function rather than improving it can be harder to keep authorized under that standard.8Healthfirst Provider Portal. Outpatient Physical Therapy Continuation Request Requirements

If Healthfirst Denies Your Request

You have appeal rights, and the deadlines differ by plan.

Medicaid and Essential Plan members get at least 45 days from the Notice of Action to file an appeal, either orally or in writing. File within 10 days and you can request “aid continuing,” which keeps your therapy running while the appeal is pending. Standard appeals are decided within 30 calendar days; expedited appeals, used when a delay could harm your health, are decided within two to three business days. If Healthfirst upholds the denial, you can request a State Fair Hearing, or an External Appeal if the denial was based on medical necessity.9NY Health Access. Healthfirst Appeal and Grievance Process

Medicare Advantage members have 65 days from the denial notice to appeal. Standard decisions come within 30 days. An expedited decision, available within 72 hours, can be requested at 1-877-779-2959 or by fax at 1-646-313-4618.10Healthfirst. Medicare Coverage

Finding a Physical Therapist in Network

Staying in network is the single biggest factor in keeping your costs predictable. You can search for Healthfirst-contracted physical therapists through the New York State Provider and Health Plan Look-Up at pndslookup.health.ny.gov. The state recommends calling the provider to confirm they still accept your plan before you book: “you should still ask the provider if they accept your health plan and participate in your network before receiving health care services.”11New York State Department of Health. Provider and Health Plan Look-Up

Healthfirst’s service area is the five boroughs of New York City, Long Island, and Westchester, Orange, Rockland, and Sullivan counties.1Healthfirst. Medicaid Managed Care Plan

If You Go Out of Network

Specific out-of-network reimbursement rates aren’t detailed in Healthfirst’s published materials. New York’s surprise billing law and the federal No Surprises Act protect you when an out-of-network provider treats you at an in-network facility or when an in-network doctor formally refers you out, limiting your charges to normal in-network cost-sharing.12New York Department of Financial Services. Surprise Medical Bills13Centers for Medicare and Medicaid Services. No Surprises Understand Your Rights Against Surprise Medical Bills Those protections hinge on the circumstances of the visit, not the type of service. If you pick an out-of-network physical therapist on your own, you may owe the full billed amount. Call Member Services first.

Who To Call