Does Medicaid Cover Physical Therapy? State Rules, Visit Limits and Kids' Coverage

If you are hurting after an injury or surgery and the card in your wallet says Medicaid, physical therapy is often covered, but not everywhere in the same way. Medicaid is run by each state, and how you got your Medicaid can matter as much as where you live. Here is how to work out where you stand.

Physical therapy is an optional benefit, but most states include it

Federal law splits Medicaid services into ones every state must cover and ones each state may choose to add. Physical therapy is on the optional list. Most states include it for adults in some form, but they set their own rules: how many visits, whether you need approval first, and whether there is a small copay.

That is why a friend's experience in another state may not match yours. The rules that count are the ones in the state that issued your card.

How you qualified for Medicaid can change your benefits

In states that expanded Medicaid to more low-income adults, people in that expansion group are usually enrolled in what Medicaid calls an Alternative Benefit Plan. These plans must include the same ten broad essential health benefit categories as marketplace insurance, and one of those categories is rehabilitative services, the group physical therapy belongs to. Visit limits and approval rules can still apply.

If you qualified another way, for example through pregnancy, disability or age, your benefits may follow your state's standard Medicaid package instead. Your member handbook will say which one you have.

Where the therapy happens can matter

Therapy at a private physical therapy clinic, at a hospital outpatient department, or at home through a home health agency can be billed under different Medicaid benefits, each with its own limits. If one route is capped or not covered in your state, ask whether another one is.

Children and teens get broader coverage

For members under 21, Medicaid's EPSDT benefit requires states to cover medically necessary care, including physical therapy, even if the state limits or doesn't cover it for adults. A visit cap that applies to adults can often be exceeded for a child when a provider documents the need.

If you also have Medicare

If you have both, Medicare usually pays first. According to Medicare.gov, Part B covers medically necessary outpatient physical therapy, and you normally pay 20% of the Medicare-approved amount after the Part B deductible. Depending on your Medicaid category, Medicaid may help with that share.

What to check on your plan

• Is outpatient physical therapy covered for adults in your state and plan?
• Which Medicaid health plan are you in, and is the therapist in its network?
• Is the clinic enrolled with your state Medicaid program?
• Do you need a doctor's order, a referral or prior approval?
• Is there a yearly visit limit, and is it shared with occupational or speech therapy?
• Is there a copay per visit?

Call the member services number on the back of your card and ask these questions word for word.

If physical therapy isn't covered or you hit the limit

Ask your doctor or therapist to request more visits; many plans approve extra sessions when progress is documented. If a request is denied, you have the right to appeal, and the denial letter explains how. Hospital-based clinics and community health centers may offer sliding-scale fees, and a therapist can teach you a home exercise program to continue on your own.

Ready to look? Find physical therapy near you that accepts Medicaid. Tell us your plan and ZIP code and we'll match you with a clinic; the clinic checks your benefits before your first visit.

Sources

• Medicaid.gov: Mandatory and optional Medicaid benefits
• MACPAC: EPSDT in Medicaid
• Medicare.gov: Physical therapy services