Original Medicare does not require a referral for physical therapy. You can call a physical therapist directly and schedule an evaluation without going through your primary care doctor first. What Medicare does require, before it will pay, is that a qualified provider certify the therapy as medically necessary and approve a written plan of care. If you’re in a Medicare Advantage plan, the rules can be stricter, so your plan documents are the place to confirm what applies to you.
Referral Versus Certification
A lot of the confusion comes from how private insurance works. Many HMOs and commercial plans gate access to specialists through a referral from your primary care physician. Original Medicare (Parts A and B) does not. You’re free to schedule an appointment with a physical therapist on your own.
Certification is different, and it’s the piece Medicare actually cares about. A physician, nurse practitioner, clinical nurse specialist, or physician assistant must certify that you need physical therapy before Medicare will cover it.1Medicare.gov. Physical Therapy Services A signed and dated order from one of these providers can satisfy the initial certification requirement, as long as it’s included in your medical record and the plan of care is sent to the ordering provider within 30 days of your first evaluation.2Centers for Medicare & Medicaid Services. Physical Therapist in Private Practice
The practical difference matters. A referral controls whether you can walk in the door; certification controls whether Medicare pays once you’re there. Your therapist’s office usually handles the certification paperwork, but it’s worth asking them to confirm it’s in place before your second or third visit so you don’t end up with an uncovered bill.
The Plan Of Care And Recertification
Medicare also requires a written plan of care before treatment begins. Federal regulations allow that plan to be established by a physician, the treating physical therapist, a nurse practitioner, clinical nurse specialist, or physician assistant.3eCFR. 42 CFR 410.61 – Plan of Treatment Requirements for Outpatient Rehabilitation Services The plan spells out your diagnosis, your goals, and the type, frequency, and duration of therapy sessions.
It isn’t a one-time document. The plan needs to be recertified at regular intervals, generally every 90 calendar days or whenever your condition changes significantly. If treatment continues past that window, the certifying provider has to review your progress and reauthorize services. Missed recertifications are one of the more common reasons claims get denied. If you’re in a longer course of therapy, ask whether the recertification is current.
Medicare Advantage Plans Can Add Requirements
Everything above applies to Original Medicare. If you’re enrolled in a Medicare Advantage plan (Part C), the picture can shift. Medicare Advantage plans must cover at least what Original Medicare covers, but they’re allowed to layer on administrative steps like prior authorization or a referral from your primary care physician before you can see a physical therapist.
Whether your plan requires either depends on the plan. Some waive referral requirements but still demand prior authorization for certain procedures. Others require both. CMS has proposed stricter limits on how Medicare Advantage plans use prior authorization, but as of 2026 most of those protections have not been finalized.4Centers for Medicare & Medicaid Services. Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program – Final Rule Check your plan’s Evidence of Coverage or call the member services number on your card before scheduling to avoid a surprise denial.
What You’ll Pay
Once you’ve met the annual Part B deductible of $283 in 2026, you pay 20% of the Medicare-approved amount for each physical therapy visit, and Medicare pays the remaining 80%.5Centers for Medicare & Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles On a session with an approved amount of $150, your share would be $30.
Medicare no longer caps outpatient therapy spending for the year, but there is a threshold that triggers more scrutiny. In 2026, once your combined spending on physical therapy and speech-language pathology services reaches $2,480, your provider must confirm that continued services are medically necessary by adding a KX modifier to each claim.6Centers for Medicare & Medicaid Services. Therapy Services You don’t have to do anything on your end, but claims above that threshold face a higher chance of being audited.
Assignment And Assistants
Your out-of-pocket cost also depends on whether your therapist accepts Medicare assignment. Providers who accept assignment agree to charge only the Medicare-approved amount, so your maximum cost is the 20% coinsurance plus any remaining deductible. Providers who don’t accept assignment can charge up to 15% above the approved amount, and that extra 15% comes out of your pocket.
If a physical therapist assistant (PTA) provides some or all of your treatment under the supervising therapist, Medicare pays the provider 85% of the normal rate.7Centers for Medicare & Medicaid Services. Reduced Payment for Physical Therapy and Occupational Therapy Services Furnished in Whole or In Part by a Physical Therapist Assistant or an Occupational Therapy Assistant Your 20% coinsurance is calculated on that reduced amount, so sessions involving a PTA cost you slightly less.
Medigap policies can cover some or all of the 20% coinsurance depending on the plan. Medicare Advantage plans typically use copays per visit instead of percentage coinsurance, with amounts that vary by plan.
If A Claim Is Denied
If your provider expects Medicare won’t cover a particular service, they’re required to give you an Advance Beneficiary Notice (ABN) before performing it. The ABN explains why coverage may be denied and lets you choose whether to proceed and accept financial responsibility.8Centers for Medicare & Medicaid Services. Advance Beneficiary Notice of Non-coverage Tutorial If a provider skips the ABN and the claim is later denied, the provider may absorb the cost rather than passing it to you.
When a claim is denied after services are provided, you have 120 days from the date you receive the denial notice to file a written appeal (a redetermination) with the Medicare contractor that processed the claim.9Centers for Medicare & Medicaid Services. First Level of Appeal – Redetermination by a Medicare Contractor There’s no minimum dollar amount. Include your name, Medicare number, dates of service, a clear explanation of why you disagree, and any supporting documentation from your therapist or physician. The contractor generally issues a decision within 60 days. Further levels of appeal are available if the first one goes against you, each with its own deadlines spelled out on your Medicare Summary Notice.