Medicare and Outpatient Therapy in 2026, in Plain English
Short version: Original Medicare Part B helps pay for medically necessary outpatient physical therapy and occupational therapy, and there is no yearly limit on how much it will pay when the care is medically necessary. After you meet the 2026 Part B deductible of $283, you pay 20% of the Medicare-approved amount for each visit. Medicare Advantage plans cover the same benefit but set their own copays, networks and approval rules.
Two thirds of the people we treat are 65 or older, so these are the questions our front desk answers every single day. This guide puts the answers in one place. It is general information, and your own costs depend on your plan, so we still check your benefits before your first visit.
What you pay under Original Medicare
Part B is the piece of Original Medicare that covers outpatient care. For therapy it works in two steps. First comes the yearly deductible, $283 in 2026. Until you have paid that much toward Part B services of any kind, Medicare does not start paying its share. Plenty of patients have already met it by the time they reach us, because a doctor visit or an imaging study earlier in the year counts toward it.
After that, Medicare pays 80% of the Medicare-approved amount and you are responsible for the other 20%, called coinsurance. If you carry a Medicare Supplement (Medigap) plan, it may pay some or all of that 20%, depending on which plan you have. Secondary coverage through a former employer can work the same way. Bring every card you have to the first visit and we will sort out which pays first.
Is there a cap on therapy visits?
No. Medicare used to impose a hard dollar cap on outpatient therapy each year, and many people still remember it. Congress removed that cap in 2018. What remains is a checkpoint, not a ceiling.
Once your physical therapy charges for the year pass $2,480, the clinic adds a code called the KX modifier to your claims. It tells Medicare your therapist has documented why continued care is medically necessary. Occupational therapy has its own separate $2,480 threshold for 2026. A second, higher figure of $3,000 can trigger a targeted medical review, where Medicare looks more closely at the documentation. Neither number means your therapy has to stop. What matters is that the care is medically necessary and the notes show it, which is our job, not yours.
| Question | Original Medicare (Part B) | Medicare Advantage (Part C) |
|---|---|---|
| What you pay per visit | 20% of the Medicare-approved amount, after the $283 deductible | A copay or coinsurance set by your plan |
| Yearly limit on therapy | None, when care is medically necessary | None on the benefit itself, though plans may limit visits per approval |
| Approval before you start | Generally no prior authorization | Often required; we request it for you |
| Choice of clinic | Any provider that accepts Medicare | Usually the plan's network |
| Yearly out-of-pocket maximum | None, unless you add a Medigap plan | Yes, set by the plan |
Do I have to keep improving for Medicare to keep paying?
No, and this one surprises people. For years, some Medicare claims were denied because a patient had stopped getting better, a rule of thumb known as the improvement standard. A 2013 court settlement, Jimmo v. Sebelius, made CMS restate that no improvement standard applies. What Medicare looks at is whether you need the skills of a therapist, not whether you are still gaining ground.
Medicare's own description of covered physical therapy says it can help you improve, maintain your current function, or slow your rate of decline. That matters for someone living with Parkinson's disease, multiple sclerosis, arthritis or the after-effects of a stroke, where holding steady is a real achievement. If a skilled program is what keeps you walking safely or dressing yourself, that can qualify. Your therapist documents why the skilled care is needed, and that documentation is what Medicare reviews.
The flip side is also true. Once a home program you can do safely on your own will keep your progress, skilled therapy is no longer the right tool, and we will tell you so plainly.
When formal therapy ends
Discharge is not the finish line. The most common way people lose what they gained is stopping cold: no exercise, back to the chair. Every patient leaves with a written home exercise program, and patients who want more structure can move into our on-site wellness gym, training with a team that already knows their history. The gym is a separate program from Medicare-covered therapy and does not take insurance, so the front desk will explain how it works and what it costs before you sign up.
Why your doctor signs your plan of care
Medicare requires your doctor, or another qualified provider such as a nurse practitioner or physician assistant, to certify that you need therapy. In practice that means signing the plan of care your therapist writes after your evaluation: your goals, the treatment, how often you will come and for how long. We send it to your doctor and follow up until it comes back signed, so it does not become one more errand on your list.
That is also why the first visit matters so much. The initial evaluation takes about an hour, measures where you are today, and sets goals specific enough to show progress. Those measurements are what keep the documentation strong if your care runs past the KX threshold.
What a CORF is, and what it means for you
First Rehabilitation of North Palm Beach is a Comprehensive Outpatient Rehabilitation Facility, or CORF. That is a Medicare certification, not a marketing phrase. CMS defines a CORF as a facility that provides coordinated outpatient diagnostic, therapeutic and restorative services at a single fixed location, with physician consultation and review of the plan of treatment among its required core services.
For a patient, the practical meaning is coordination. Physical therapy, occupational therapy and certified hand therapy happen in the same building, under one plan, with the same team reading the same notes. A patient recovering from a stroke might need a physical therapist for walking and balance, an occupational therapist for dressing and cooking, and a certified hand therapist for a weak, closed hand. Here, those three people work down the hall from each other.
If you have a Medicare Advantage plan
We accept Medicare Advantage plans, including HMO and PPO plans from carriers such as Humana and Aetna. The benefit is the same medically necessary therapy, but the rules come from the plan. Many require prior authorization, approve a set number of visits at a time, and ask for progress notes before approving more. Your cost is usually a copay per visit rather than 20%.
None of that should land on you. When you call, we verify your plan, request any authorization it needs and tell you your copay before you arrive. If your plan approves visits in blocks, we track the count and request more before you run out, so your therapy does not stall halfway through.
Five questions to ask before your first visit
- Have I met my Part B deductible for this year?
- Do I have a Medigap or secondary plan that covers the 20%?
- If I have Medicare Advantage, does my plan need prior authorization for therapy?
- Does my plan require a physician referral, or can I start with an evaluation?
- Will one clinic be able to handle physical, occupational and hand therapy if I need more than one?
Our front desk can answer the first four for you with one phone call to 561-624-4263. The fifth one we can answer now: yes.
Sources
- Medicare.gov, Physical therapy services: Part B coverage, the 20% coinsurance, physician certification, and no yearly limit on medically necessary outpatient therapy.
- Federal Register, November 19, 2025: the 2026 Part B deductible of $283.
- CMS, Therapy Services: the 2026 KX modifier thresholds of $2,480 and the $3,000 targeted medical review threshold.
- CMS, Comprehensive Outpatient Rehabilitation Facilities: the CORF definition and core services.
- CMS, Jimmo Settlement: the maintenance coverage standard for skilled therapy, and the end of the improvement standard.
This guide is general information, not medical, legal or insurance advice. Figures are for 2026 and change each January. Your costs depend on your plan, which we verify before your first visit.