Medicare Advantage plans cover outpatient physical therapy, but the plan, not Original Medicare, sets your copays and decides which providers you can use and whether you need a referral or prior approval. HMO plans generally require you to stay in the plan’s network and usually need a referral for specialists, while PPO plans let you go out of network at a higher cost. The matching team asks for your plan name and tells you honestly whether a therapist in the network works with it; the therapist’s office verifies benefits before a first visit.
Last reviewed By the Monon Therapy Collective editorial team
- Who sets your cost
- Your plan, once a year on January 1
- HMO
- Network only, referral usually needed
- PPO
- Out of network allowed, usually at higher cost
- Approval rule
- A prior approval must last as long as the treatment is medically necessary
How is physical therapy different on Medicare Advantage than on Original Medicare?
The rules come from your plan. Medicare Advantage plans are offered by Medicare-approved private companies that must follow Medicare’s rules, but each plan sets its own premiums, deductibles and charges for services, and Medicare.gov notes those amounts can be different from Original Medicare’s.
On Original Medicare you pay the Part B deductible and 20% of the approved amount for therapy, as the page on Medicare coverage for physical therapy explains. On an Advantage plan you might instead pay a flat copay per visit, a coinsurance percentage, or a mix, and the plan’s yearly out-of-pocket limit caps what you spend on covered medical services.
Do I need a referral for physical therapy on a Medicare Advantage HMO?
Often, yes. Medicare.gov says that in most cases you need a referral to see a specialist in an HMO plan, and that you generally must use doctors, other providers and hospitals in the plan’s network except for emergencies and urgent care. Many HMOs treat physical therapy as a service that needs a referral from your primary care provider.
This is separate from Indiana’s 42-day direct access rule. The law may allow a therapist to treat you without a referral, but an HMO that requires one can decline to pay. Ask member services before you book.
Can I use an out-of-network physical therapist on a Medicare Advantage PPO?
Usually, at a higher cost. Medicare.gov explains that PPO members can use out-of-network providers for covered services if those providers participate in Medicare or accept assignment, but will usually pay more, and that PPOs do not require referrals to specialists.
Call the plan first to confirm the out-of-network cost for therapy and whether prior approval still applies. Some HMO plans with a point-of-service option allow limited out-of-network care, too.
How does prior approval work for therapy in an Advantage plan?
Many plans require approval before a course of therapy, often in blocks of visits. Under the federal rule CMS finalized for Medicare Advantage in 2024, an approval for a course of treatment must stay valid for as long as the care is medically reasonable and necessary, so the plan cannot keep demanding fresh approvals for that same treatment.
The same rule gives you a transition period of at least 90 days if you switch to a new Advantage plan in the middle of treatment: the new plan cannot require prior authorization for that active course of care during those days. The general idea of prior authorization for physical therapy is explained in its own answer.
What should I ask my Medicare Advantage plan before booking?
Ask five things, and write down the answers with the date and the name of the person you spoke to. The matching team asks about your plan when you complete the questionnaire, and the therapist’s office runs its own benefits check before a first visit.
- What is my copay or coinsurance for an outpatient physical therapy visit?
- Does this plan require a referral from my primary care provider before therapy starts?
- Is prior approval required, and how many visits are approved at a time?
- Is the therapist I am considering in the plan’s network, and what does out of network cost?
- How much of my yearly out-of-pocket limit have I used?
