Do You Need a Referral for Physical Therapy with Medicare?

If you’re recovering from surgery, managing a chronic condition, or looking to regain strength and mobility, physical therapy (PT) can be a vital part of your recovery. But if you’re on Medicare, a common question arises: Do you need a referral for Medicare to start physical therapy?

The short answer: it depends on your Medicare coverage type and where you’re receiving care. This guide will break down the rules for Original Medicare and Medicare Advantage, explain plan of care requirements, and help you avoid surprises when accessing PT services.

Understanding Medicare Coverage for PT Services

Physical therapy is a form of rehabilitative care aimed at restoring movement, relieving pain, and improving physical function. It’s commonly prescribed after surgery, injury, or to manage chronic conditions.

Here’s how Medicare covers physical therapy:

• Original Medicare (Part B) typically covers outpatient physical therapy, including services at a clinic, therapist’s office, or sometimes in your home.
• Medicare Advantage (Part C) plans are offered by private health insurance companies and cover all services that Original Medicare does—but often with different access requirements, such as needing a referral.

Knowing which type of plan you have is key to understanding your access to physical therapy.

Referral Requirements Under Original Medicare

If you have Original Medicare, the good news is that you do not need a referral from a doctor to start outpatient physical therapy.

However, Medicare Part B does require a “plan of care”:

• It must be created by your physical therapist and signed by a physician or qualified provider.
• It should include a diagnosis, treatment goals, frequency, and expected duration of therapy.
• You must be under the care of a physician, meaning a doctor monitors your condition and progress—though not necessarily with frequent visits.

This requirement is based on Medicare regulations, not your state’s direct access laws.

When Medicare Advantage Plans May Require a Referral

If you’re enrolled in a Medicare Advantage plan, the rules may be different. These plans are managed by private health insurance companies, and many do require a doctor’s referral or prior authorization to begin PT.

This might involve:

• Getting a referral from your primary care doctor.
• Submitting for pre-authorization from your insurance company.
• Using in-network physical therapists to receive full coverage.

Each plan is different. Your Medicare Advantage plan may cover outpatient PT, but only after your primary care doctor writes a referral and the insurer approves it. Always check with your insurance provider to confirm your plan’s requirements.

State Access Laws vs. Medicare Rules

Many states have direct access laws, which allow patients to see a physical therapist without a referral. However, these laws do not override Medicare’s rules.

Here’s the key difference:

• State access laws determine what’s legally allowed.
• Medicare rules determine what’s covered and reimbursed.

Even in a direct access state, Original Medicare still requires a plan of care. And many Medicare Advantage plans require a referral, regardless of local access laws.

Common Scenarios for Medicare Patients

To better understand how this applies in real life, here are some examples:

1. Original Medicare Patient

You recently had knee surgery and want to start physical therapy. You don’t need a referral, but your PT provider must develop a plan of care and get it signed by your doctor before starting treatment.

2. Medicare Advantage Member

You’re recovering from a fall and want therapy. Your plan may require:

• A referral from your primary care doctor.
• Prior authorization from your insurer.
• Treatment from an in-network provider.

3. Recently Discharged from Hospital

You’re sent home after a hospital stay with a recommendation for outpatient PT. If you have Original Medicare, a doctor must approve a plan of care. If you have Medicare Advantage, your discharge team may help with the referral and authorization process.

How to Ensure Coverage for Physical Therapy Services

Here are steps to take to ensure your physical therapy is covered under Medicare:

• Talk to your doctor about your condition and need for PT.
• Ensure a plan of care is written and signed by an authorized provider.
• Ask if your Medicare Advantage plan requires a referral or pre-authorization.
• Confirm that your PT provider accepts Medicare or is in-network for Advantage plans.
• Keep copies of all paperwork, including referrals, approvals, and treatment plans.

When in doubt, always call your plan provider or Medicare to double-check your coverage.

Frequently Asked Questions (FAQs)

Do I need a doctor’s referral for Medicare to cover physical therapy?

Not with Original Medicare. However, you do need a doctor-signed plan of care. Many Medicare Advantage plans require a referral.

What’s the difference between a referral and a plan of care?

A referral is a recommendation from your doctor to see a specialist. A plan of care outlines your treatment and must be signed by a doctor to get Medicare approval.

Does Medicare Advantage always require a referral for PT?

Not always, but many plans do. Requirements vary by provider, so check your specific plan.

Can I see a physical therapist without a doctor’s order?

You might be able to legally, depending on your state—but Medicare rules still apply, and you may need a referral or plan of care for coverage.

What should I ask my insurance provider about PT access?

• Do I need a referral to see a PT?
• Is pre-authorization required?
• Are there in-network providers I must use?
• Will you cover physical therapy services for my condition?

Need Help Understanding Your Medicare Coverage for PT?

Navigating Medicare requirements can be tricky. Whether you’re unsure about referrals, plan requirements, or how to start, we can guide you.

Schedule a free Medicare coverage review.

Let’s make sure you’re covered and confident before your first therapy session.