Understanding Medicare and Medicaid physical therapy coverage

Before diving into what Medicare and Medicaid cover for physical therapy (PT), it is important to understand your options. Many people do not realize that they may already have access to physical therapy through their employer, union, or health plan, often at no out-of-pocket cost.

Many people who qualify for Medicare or Medicaid may also have other health benefits through an employer, union, retiree plan, or family member’s coverage. These secondary plans can include digital musculoskeletal (MSK) programs like Sword Thrive at little or no cost. Checking all available coverage options, including through a spouse or family member’s plan, ensures you do not miss care that could already be included for you.

Whether you rely on Medicare, Medicaid, or another insurer, this guide explains what coverage typically includes and how to make the most of your benefits.

Common questions about Medicare and Medicaid PT coverage

Understanding how physical therapy coverage works under Medicare and Medicaid can be confusing. The rules vary between programs, and terms like “medical necessity” or “visit thresholds” often leave people unsure of what they’re entitled to. Let's tackle some of the most important questions so you know how each program covers physical therapy, what you might pay out of pocket, and how to find options that make care easier to access.

Does Medicare cover physical therapy?

Yes. Medicare Part B covers outpatient physical therapy when it is medically necessary. You typically pay 20 percent of the cost after your deductible.¹

How much does Medicare pay for physical therapy per visit?

After meeting your deductible, Medicare pays 80 percent of the approved amount and you are responsible for the remaining 20 percent unless you have supplemental coverage.¹

How many physical therapy sessions does Medicare cover?

There is no strict limit. As long as therapy is medically necessary and progress is documented, Medicare continues to cover care. Once therapy costs exceed a threshold, your provider must submit additional documentation for review.

Does Medicaid cover physical therapy?

In most states, yes. Medicaid often covers PT but benefits vary. Some states limit annual visits or require prior authorization. Check with your state Medicaid office for details.

What are the best PT options if you are on Medicare or Medicaid?

If your plan allows, digital PT solutions like Sword Thrive offer accessible, consistent, and engaging care from home. You can avoid travel and start recovery faster. Always ask your provider or plan if digital options are included.

If you have both Medicare or Medicaid and access to another plan, for example through your employer, your union, or your spouse’s employer, that plan may already include Sword Thrive. Many dependents or retirees discover they have coverage they were not aware of. It is always worth checking your eligibility with both your public and private plans to see if Sword is included at no out-of-pocket cost.

Why Medicare and Medicaid physical therapy coverage matters

Musculoskeletal (MSK) conditions are among the leading causes of pain and disability for older adults and low-income populations. An estimated 39 percent of Medicare beneficiaries report chronic MSK pain, most commonly in the back, knees, and hips.³ These conditions reduce independence, increase fall risk, and often lead to costly surgeries or long-term disability.

Traditional physical therapy is essential for managing pain, preventing surgery, and improving mobility, but navigating access through Medicare or Medicaid can be slow and complex. Long appointment wait times, transportation issues, and provider shortages, especially in rural areas, often limit access. An average wait time of 17.6 days to see an orthopedic specialist further delays care for many beneficiaries.⁴ Understanding what these programs cover and how to find care helps ensure equitable, cost-effective treatment.

What Medicare covers for physical therapy

Medicare Part B covers medically necessary outpatient PT services, including rehabilitation after surgery or injury and chronic pain management.¹

After meeting the annual Part B deductible, beneficiaries typically pay 20 percent coinsurance. There is no longer an annual therapy cap. However, when therapy costs exceed a specific threshold, your provider must add documentation to justify continued treatment.¹

Remember to check if you or a family member has coverage for Sword digital care within an employee benefits package or health plan. You might be eligible for Sword Thrive's expert at-home digital physical therapy at no additional cost to you.

Medicare Part A vs. Part B coverage

• Part A (Hospital Insurance): Covers PT if you are an inpatient in a hospital or skilled nursing facility.¹
• Part B (Medical Insurance): Covers outpatient PT in a clinic or at home when medically necessary.¹

Home Health PT under MedicareIf you are homebound and qualify for home health care, PT can be provided at home as part of your home health services. Your doctor must certify the need for home health and approve periodic re-evaluations.¹

Eligible services include:

• Initial evaluation and treatment plan
• Therapeutic exercise and functional training
• Manual therapy
• Gait training and re-evaluation as needed

What Medicaid covers and how it varies by state

Medicaid is administered by each state, which means PT benefits vary widely. While PT is an optional benefit under federal law, most states include it in some form.²

Coverage can involve visit caps, prior authorization requirements, or limits based on diagnosis. For example:

• Some states cover unlimited PT visits for certain conditions.²
• Others limit visits per year or require physician sign-off after a set number of sessions.²

Low-income adults, children, and people with disabilities often rely on Medicaid for MSK care. Dual-eligible individuals, those who qualify for both Medicare and Medicaid, may face extra paperwork or provider restrictions.²

Because rules differ, it is essential to confirm your state’s coverage. Visit your relevant Medicaid.gov state directory or contact your local Medicaid office for specific PT limits and provider listings.

Common barriers with traditional Medicare and Medicaid PT

Accessing PT under traditional programs is not always easy. Many members experience:

• Long wait times for appointments
• Shortages of local providers, especially in rural areas
• Transportation issues for in-person visits
• Complex prior authorization or eligibility checks
• Language barriers and limited digital support

These challenges delay care and lower adherence. Pain often worsens, leading to avoidable emergency visits or surgeries. Nearly half of adults with MSK pain report delaying or skipping care due to cost or access barriers.⁵ In the United States, the average wait time to see an orthopedic specialist exceeds 17 days, and in some regions it is more than a month.⁶

How Sword improves access and affordability

Sword Health offers a modern alternative. Through its digital PT program, Sword Thrive, members can receive care virtually and remove many common barriers faced by Medicare or Medicaid-adjacent populations. Members receive one-to-one guidance from licensed Clinical Specialists and complete sessions with the help of Sword's revolutionary AI technology. You receive a Thrive kit that includes motion-tracking sensors to guide your movement and provide feedback in real-time.

Care happens at home using a Digital Therapist device that provides real-time feedback. Sessions can be scheduled any time, and 42 percent occur outside business hours.⁶ Twenty-seven percent of members live in high-SDI areas where access is typically limited.⁶ Sword begins care in an average of just 6.3 days.⁶

What sets Sword Thrive apart

• No travel or time off work required
• Real-time feedback that increases adherence
• Care accessible on any device, in multiple languages
• Evidence-based outcomes validated in peer-reviewed studies⁷

For many members, including those with union, employer, or retiree plans, Sword Thrive is available at no out-of-pocket cost.

Check to see if you are covered for Thrive

Sword Thrive is not billed directly through Medicare or Medicaid, but many members who have those programs also qualify through another plan such as a retiree benefit, union coverage, or a spouse’s employer-sponsored plan. If that secondary coverage includes Sword, members can typically access care at no additional cost. Many people on Medicare or Medicaid also have access to employer or family health benefits that include Sword Thrive at no cost. Check your eligibility now to see if you or a dependent family member already have coverage.

Practical tips for Medicare and Medicaid members

• Talk to your primary care provider about symptoms and request a PT referral.
• Ask if home health PT is appropriate and covered by Medicare.
• If you have Medicaid, check your state website for coverage details.
• If you are dual eligible, coordinate with both programs to understand your full benefits.
• Ask about digital or home-based PT options.
• Check whether you, your spouse, or another family member already have Sword Thrive coverage through an employer, union, or retiree health plan. Even if you are enrolled in Medicare or Medicaid, you may still be listed as a dependent on another plan that includes Sword Thrive at no cost.

Sword partners with employers, unions, and health plans to deliver proactive, cost-effective MSK care that reduces high-cost claims and improves outcomes, especially for retirees or part-time staff who might not use traditional care due to access issues. Check your eligibility today.