Yes. Medicare Part B helps pay for medically necessary outpatient physical therapy: in 2026 you pay the $283 Part B deductible, then usually 20% of the Medicare-approved amount, and there is no yearly dollar cap. A doctor, nurse practitioner, clinical nurse specialist or physician assistant must certify that you need the therapy. Medicare pays only when the therapist bills it properly, so before you book near Carmel, ask the therapist’s office how it works with Medicare.
Last reviewed By the Monon Therapy Collective editorial team
- 2026 Part B deductible
- $283 a year
- Your share after it
- Usually 20% of the approved amount
- Yearly cap
- None for medically necessary therapy
- KX threshold (PT and speech combined)
- $2,480 in 2026
How does Original Medicare pay for outpatient physical therapy in 2026?
Outpatient physical therapy sits under Part B, Medicare’s medical insurance. CMS set the 2026 Part B deductible at $283, so the first $283 of approved Part B charges in the calendar year are yours, whether they come from a therapist, a doctor or a scan. After that, Medicare pays 80% of the approved amount for each therapy visit and you pay 20%.
Medicare.gov is explicit that there is no limit on how much Medicare pays for medically necessary outpatient therapy in one calendar year. The old annual therapy cap was repealed, which surprises many people who remember it. The 20% share is where a Medigap policy or other secondary coverage may help; the Medigap and physical therapy page explains how those plans fill the gap.
Medicare’s own fact sheet lists the offices of privately practising therapists among the places you can receive outpatient therapy, alongside hospital outpatient departments and rehabilitation agencies. The setting matters less than whether the individual therapist is enrolled with Medicare and bills it correctly.
Is the $2,480 KX threshold a limit on my therapy visits?
No. The KX threshold is a documentation checkpoint, not a cap. For 2026, CMS set it at $2,480 for physical therapy and speech-language pathology combined, with a separate $2,480 amount for occupational therapy. Once your approved charges pass that figure, the therapist adds the KX modifier to each claim, a billing code confirming the care is still medically necessary and that the records support it.
CMS also uses a $3,000 targeted medical review threshold, above which some claims may be selected for review. That review is about the therapist’s records, not a bill you have to answer. If you want the visit-count question answered in more depth, read whether Medicare limits physical therapy visits.
Why does Medicare need a doctor to sign my therapy plan when Indiana does not?
Indiana law and Medicare payment rules answer different questions. Indiana’s direct access law lets a physical therapist evaluate and treat you for up to 42 calendar days without a referral. Medicare, separately, will only pay when your doctor or another qualified provider (a nurse practitioner, clinical nurse specialist or physician assistant) certifies that you need the therapy.
In practice, the therapist evaluates you, writes a plan of care with goals and a visit frequency, and sends it to your provider for signature. You do not always need a separate appointment for that. More on the document itself is in what a physical therapy plan of care is.
When can a therapist ask a Medicare patient to sign an ABN?
An Advance Beneficiary Notice of Noncoverage, or ABN, is a written notice a therapist must give you before providing a service they expect Medicare will not pay for because it is not reasonable and necessary. It lets you decide whether to receive that service and pay the full cost yourself.
Medicare’s fact sheet adds two protections. The therapist must explain why the services are not medically necessary before handing you an ABN, and they cannot issue one simply because your therapy spending has reached a certain dollar amount. Reaching the KX threshold, on its own, is not a reason to start charging you privately.
What should a Medicare patient ask a therapist’s office before booking?
Ask whether the therapist is enrolled with Medicare and whether they accept assignment. The answer changes what you pay, as the table shows. Each therapist in the network is an independent practice that handles its own Medicare enrollment and billing, so this is a question for the therapist’s office, not the network.
When you complete the physical therapy questionnaire, tell the matching team you have Original Medicare. The team uses that to propose a therapist whose office works with Medicare where one is available, and tells you plainly if none is. If the plan you carry is a private Medicare plan instead, the Medicare Advantage page covers its different rules. Free, impartial Medicare counseling is available from Indiana SHIP at (800) 452-4800.
| Provider status | What Medicare.gov says it means for you |
|---|---|
| Participating (accepts assignment) | Charges only the Medicare deductible and coinsurance and usually waits for Medicare to pay first. |
| Non-participating | Can charge more than the approved amount, in many cases up to 15% above it, and may ask for payment up front. |
| Opted out of Medicare | Medicare pays nothing for that provider’s services, even covered ones; you pay under a private contract. |
Check before your first Medicare-billed visit
- The therapist is enrolled with Medicare and you know whether they accept assignment.
- Your doctor or qualified provider knows a plan of care is coming for signature.
- You know whether you have already met the $283 Part B deductible this year.
- Any secondary coverage (Medigap, a retiree plan, Medicaid) is on file with the therapist’s office.
If you think it is an emergency, call 911.
