How Medicare Covers In-Home Physical Therapy (Without the Surprise Bills)

Money shouldn’t be a barrier to healing. Yet so many seniors avoid starting physical therapy because they’re terrified of surprise bills, confusing coverage rules, and out-of-pocket costs that seem unpredictable.

The good news? Medicare has a straightforward path to covering in-home physical therapy. And when you know how it works, the surprises disappear.

This guide walks you through exactly how Medicare pays for in-home therapy, what you’re responsible for, and why choosing a transparent, Medicare-experienced provider (like Care To You Health) protects you from billing stress.

The Bottom Line First: Yes, Medicare Covers In-Home PT

Medicare Part B covers physical therapy, occupational therapy, and speech-language pathology services delivered in your home — exactly as it covers clinic-based therapy.​

There are no additional costs for choosing in-home therapy over clinic-based care. Medicare’s coverage is the same. Your out-of-pocket responsibility is the same.

But there are important details that determine how much you pay. Let’s break them down.

How Medicare Part B Coverage Works (The Simple Version)

Think of Medicare Part B coverage like this: Medicare pays 80%, you pay 20% (after you meet your annual deductible).

Step 1: Meet Your Annual Deductible

In 2025, the Medicare Part B annual deductible is $257. This is a one-time amount you pay per calendar year before Medicare starts paying anything.​

Example: Your first physical therapy session costs $150. You owe $150 out-of-pocket toward your deductible. Your second session (also $150) starts paying toward the deductible — now you’ve met it. Your third session, Medicare begins covering 80%.

Step 2: Medicare Pays 80%, You Pay 20% Coinsurance

Once your deductible is met, Medicare covers 80% of the approved amount for therapy services. You pay the remaining 20% as coinsurance.​

Example: A typical in-home PT session costs around $150–$200. If Medicare approves $160 for your visit, Medicare pays $128 (80%), and you pay $32 (20%).

Step 3: Medicare Advantage Plans May Vary Slightly

If you have Medicare Advantage (Part C) instead of Original Medicare (Part A + B), coverage is at least the same — but may be better. Some Medicare Advantage plans have zero copayment or coinsurance for therapy, depending on your specific plan.​

What to do: Call your Medicare Advantage plan to confirm your exact out-of-pocket costs before starting therapy.

The Therapy Threshold: What It Is and Why It Doesn’t Scare You

You may have heard about Medicare’s “therapy cap.” Here’s the truth: there’s no hard limit on how many sessions Medicare will cover.​

What does exist is a therapy threshold — an annual monitoring point, not a barrier.

How It Works (2025)

For 2025, the therapy threshold amounts are:​

• $2,410 for Physical Therapy and Speech-Language Pathology combined
• $2,410 for Occupational Therapy

What this means: If your therapy bills exceed these amounts in a calendar year, your provider must document that therapy is medically necessary. If it is (which it usually is, when prescribed by your doctor or therapist), Medicare continues to cover it.​

You don’t stop getting therapy at $2,410. Your provider just includes extra documentation to confirm it’s still medically necessary.

Real-World Example

Maria, 76, needs PT after her knee surgery. Her sessions run $150 each. By mid-year, she’s had 20 sessions (total: $3,000), which exceeds the $2,410 threshold.

What happens? Her provider documents that continued therapy is medically necessary for her recovery. Medicare reviews it, agrees, and continues paying 80% of her sessions. Maria’s coverage doesn’t stop.

What Counts as “Medically Necessary”?

Medicare only covers therapy that your doctor certifies as medically necessary to treat an illness, injury, or surgery — or to manage a chronic condition.​

Therapy is typically considered medically necessary if:

• You’re recovering from surgery (knee replacement, hip surgery, cardiac surgery, etc.)
• You’re managing an acute injury or fall
• You’re recovering from a hospitalization or skilled nursing facility stay
• You have a chronic condition that requires ongoing therapeutic management (Parkinson’s disease, stroke recovery, arthritis, etc.)
• Your doctor or physical therapist determines you need therapy to safely restore function​

Therapy that Medicare won’t cover includes:

• Massage therapy for relaxation
• Fitness coaching or gym memberships
• Preventative “wellness” therapy (therapy before any medical event)​

Bottom line: If a licensed provider determines your therapy is medically necessary, Medicare covers it. The system trusts professional judgment, not arbitrary limits.

Your Out-of-Pocket Costs: The Real Numbers

Let’s get specific about what you actually pay.

Scenario 1: Original Medicare (Part A + B)

Your annual out-of-pocket costs for in-home PT:

Item	2025 Cost
Annual Part B Deductible	$257
Your Coinsurance (20% per visit)	Varies by session cost

Example: Assume PT sessions are $160 per session after your deductible:

• Session 1-2: $257 (deductible)
• Sessions 3–30 (28 sessions): $32 per session (20% coinsurance) = $896

Total out-of-pocket for 30 sessions: ~$1,153

What Medicare pays: ~$4,480 (80% of $5,600)

Scenario 2: Original Medicare + Supplemental Insurance

Many seniors purchase a Medigap (supplemental) policy that covers coinsurance (the 20% you normally pay).

If your Medigap covers coinsurance: You may pay little to nothing out-of-pocket after your annual deductible. Some plans even cover the deductible.

Check your Medigap policy — many cover up to 80% of your coinsurance, dramatically reducing your costs.

Scenario 3: Medicare Advantage (Part C)

Medicare Advantage plans provide at least the same coverage as Original Medicare, often with better benefits.

Typical out-of-pocket:

• Some plans: $0 copayment for therapy
• Other plans: $15–$50 per session coinsurance
• Check your specific plan — each is different​

Scenario 4: If You Have Secondary Insurance (TRICARE, VA, etc.)

If you qualify for TRICARE, VA benefits, or other secondary coverage alongside Medicare, your secondary insurance may cover some or all of your Medicare coinsurance.

Check with both insurers to understand how they coordinate benefits.

No Referral Required (In California)

Here’s good news specific to California: You don’t need a doctor’s referral to start physical therapy under Medicare. California is a “direct access” state.​

This means you can contact Care To You Health directly, schedule an evaluation, and begin therapy — your licensed PT can evaluate and treat you without a physician referral.

However, your PT may recommend that you see your primary care doctor to:

• Ensure therapy fits your overall health picture
• Get medical certification that therapy is medically necessary (required for billing)
• Rule out other medical concerns

Bottom line: No unnecessary gatekeeping. You can access therapy directly.

How to Verify Your Coverage (Before Your First Visit)

Don’t start therapy wondering what you’ll owe. Verify your benefits in advance.

Step 1: Call Medicare or Your Plan

• Original Medicare: Call 1-800-MEDICARE
• Medicare Advantage: Call your plan’s customer service number (on the back of your card)

Ask:

• “Am I eligible for physical therapy benefits?”
• “What’s my deductible status for 2025?”
• “What’s my coinsurance percentage for outpatient therapy?”
• “Do I have secondary coverage that applies?”

Step 2: Contact Care To You Health

Our team verifies your benefits and can often tell you your exact out-of-pocket costs before your first visit. We work with Medicare daily and know how to navigate coverage.

Have your Medicare card ready when you call.

Step 3: Request a Cost Estimate

Before beginning therapy, ask Care To You Health for an estimate of your out-of-pocket costs based on your coverage. Transparency prevents surprises.

What Triggers Surprise Bills (And How We Prevent Them)

Surprise bills happen when:

1. You didn’t know therapy wasn’t covered (e.g., preventative wellness care)
2. Your provider didn’t verify your coverage before treatment
3. You were billed by an out-of-network provider (rare with Medicare, but possible)
4. Services weren’t coded correctly for insurance billing

At Care To You Health, we prevent these by:

• Verifying your Medicare coverage and benefits before your first visit
• Being transparent about what Medicare covers and what you’re responsible for
• Billing Medicare correctly the first time
• Communicating your estimated out-of-pocket costs upfront
• Not surprising you with unexpected bills

Medicare Advantage vs. Original Medicare: Which Covers More?

Both cover in-home therapy. Here’s how they compare:

Factor	Original Medicare (Part A + B)	Medicare Advantage (Part C)
In-Home PT Coverage	Yes, through Part B	Yes, at least equal to Part B
Annual Deductible	$257 (2025)	Varies by plan; often $0–$200
Coinsurance	20% (after deductible)	Often $0–$50 per visit
Therapy Limits	Threshold ($2,410) with medical necessity	Usually same, sometimes better
Supplemental Coverage	Can purchase Medigap	Built-in, may cover coinsurance
Out-of-Network Risk	Lower (Medicare sets rates)	Higher (depends on plan)

Bottom line: Medicare Advantage often has lower out-of-pocket costs, but verify your specific plan before starting therapy.

The Paperwork Behind the Scenes (So You Don’t Have to Worry)

When you receive in-home therapy, here’s what happens with Medicare billing:

1. We verify your coverage before your first visit
2. We deliver therapy and document everything (medical necessity, progress, treatment plan)
3. We bill Medicare using the correct codes and your session information
4. Medicare reviews the claim and pays us 80% of the approved amount
5. You receive a bill for your 20% coinsurance (or nothing, if supplemental insurance covers it)
6. We follow up if there are any billing issues

You don’t handle any of this. We manage Medicare billing; you focus on recovery.

What If You’re Under 65 (Group Health Insurance)?

Medicare doesn’t apply to you, but the good news: most commercial insurance plans cover in-home physical therapy.

Check with your insurance plan about:

• Whether referral is required
• Your deductible and copayment structure
• Annual or per-visit limits
• In-network vs. out-of-network provider status

Care To You Health works with many commercial insurance plans. Let us verify your benefits.

Self-Pay Options (If You Choose to Bypass Insurance)

Some patients prefer to self-pay to maintain privacy or because their deductible is high early in the year.

Self-pay rates for in-home therapy typically range from $125–$200 per session, depending on the provider and location.

Comparison:

• With Medicare: You pay $257 deductible + 20% coinsurance per session ($30–$40 typically) = relatively low cost
• Self-pay: You pay full session cost ($150–$200) = higher upfront, but no insurance involvement

Recommendation: Use Medicare benefits if eligible. The coverage is designed for you.

Common Questions About Medicare and In-Home PT

“Will therapy cost more if it’s in my home?”
No. Medicare covers in-home therapy the same as clinic-based therapy — same rates, same coverage. No premium for convenience.​

“Can I get in-home therapy if I’m not homebound?”
Yes. You don’t need to be homebound to receive in-home PT under Medicare Part B. Care To You Health serves patients who simply prefer home-based therapy for convenience and personalization.​

“What if my doctor didn’t refer me to therapy?”
In California, you can self-refer (direct access). However, Medicare will ask for medical certification that therapy is medically necessary. Your PT can work with you and your doctor to ensure proper documentation.

“Does Medicare cover travel time to get to my home?”
No, but that’s irrelevant — your therapist comes to you, so there’s no travel time to cover. One of the hidden benefits of in-home therapy.

“What if I stop therapy mid-year? Can I restart later?”
Yes. Your deductible and threshold amounts reset each calendar year (January 1). If you restart therapy in July, you’ll have a fresh deductible for that year.

“Can my spouse or family member attend sessions?”
Yes, and it’s encouraged. Medicare covers your therapy; family participation doesn’t add cost and often improves outcomes.

“What happens if I use all my therapy coverage by September?”
With the threshold system, you don’t “use up” coverage. If therapy remains medically necessary, Medicare continues covering it. Your provider documents the necessity, and coverage continues.

Red Flags: When to Ask Questions

Stop and ask for clarification if:

• A provider tells you there’s a hard limit on sessions and you can’t get more
• You’re charged for services that should be covered
• You don’t receive an estimate of out-of-pocket costs before starting
• A bill arrives that you weren’t expecting
• Insurance denies a claim and you’re told “that’s just how it is”

Good providers (like Care To You Health) welcome these questions and provide clear answers.

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The Bottom Line: Medicare + In-Home PT = Affordable Recovery

Medicare covers in-home physical therapy comprehensively and affordably. Your costs are predictable: a one-time annual deductible ($257 in 2025) plus 20% coinsurance per session (typically $30–$40).

There’s no premium for in-home convenience. No surprise bills. No hidden costs.

All you have to do is:

1. Verify your coverage before starting
2. Choose a provider experienced in Medicare billing
3. Show up and focus on recovery

Care To You Health handles the rest.

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Ready to Start? Here’s What’s Next

💳 Verify Your Medicare Coverage

📞 Schedule a Free Benefits Verification Call

Contact Care To You Health and we’ll verify your exact coverage and estimated out-of-pocket costs — no guessing, no surprises.

Connect Via Phone: 949-353-5509

📋 Download Your Medicare & In-Home PT Guide

Get a printable guide explaining coverage, costs, what to expect, and questions to ask your provider.