Does health insurance cover physical therapy?
Physical therapy falls under rehabilitative and habilitative services, one of the ACA's ten essential health benefits, so most plans cover medically necessary PT — subject to a referral in some plans and annual visit limits.
What flips the answer
- Covered when
The physical therapy is medically necessary, in-network, and within the plan's covered visit limits.
- Not covered when
You've exhausted the plan's annual cap on covered PT visits.
- Not covered when
The plan required a referral or prior authorization that wasn't obtained before starting.
- Not covered when
The therapist is out-of-network on a plan with no out-of-network benefit.
Physical therapy is part of rehabilitative and habilitative services, a required essential health benefit on ACA marketplace plans and most employer plans. Plans generally cover PT that's medically necessary to recover function after injury, surgery, or illness, or to maintain function with a chronic condition.
Coverage comes with common conditions. Many plans cap the number of covered PT visits per year, apply your copay or coinsurance to each visit, and — especially on HMO plans — require a physician referral or prior authorization before therapy begins.
Network status drives your cost. In-network physical therapists are billed at your plan's standard rate; out-of-network PT may carry a much higher share or no benefit at all on HMO and EPO plans. Once you hit the plan's annual visit cap, additional sessions are typically out of pocket.
That's the general answer. Yours is written in your actual policy.
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