Medicare Open Enrollment is Almost Here!
October 15 – December 7, 2025
Now is the time to review your Medicare coverage and make sure your plan meets your needs—especially if physical therapy is an important part of your health care.
Physical therapy coverage can look very different depending on whether you choose Original Medicare, a Medicare Supplement (Medigap), or a Medicare Advantage plan. Here’s what you need to know:
1. Original Medicare (Parts A & B)
Physical Therapy Coverage:
✔ Outpatient physical therapy, occupational therapy, and speech therapy (must be medically necessary).
✔ You pay 20% of the Medicare-approved amount per visit after your deductible.
✔ At Alta, this will increase to about 35% since we don’t accept Medicare’s assigned fee schedule. That extra 15% is referred to as a limiting charge.
✔ At Alta, we require a physician’s referral for Medicare to ensure coverage
Pros:
- Nationwide coverage—see almost any provider that accepts Medicare
- Simple and predictable coverage.
Cons:
- No annual out-of-pocket maximum.
- Doesn’t cover extras like dental or fitness.
- Many people add a Supplement Plan to help with costs.
2. Medicare Supplement Plans (Medigap)
Physical Therapy Coverage:
✔ Covers the 20% coinsurance that Original Medicare doesn’t.
✔ Provides predictable costs for ongoing therapy.
Pros:
- Minimal out-of-pocket expenses.
- See any provider that accepts Medicare.
- Great for those who expect frequent therapy.
- Planning on getting a surgery are you?
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Many supplements will also cover Alta’s limiting charge.
Cons:
- Higher monthly premiums.
- Doesn’t include extras (dental, vision, fitness).
- Requires a separate Part D plan for prescriptions.
3. Medicare Advantage (Part C)
What these are:
Medicare Advantage plans are essentially insurance companies working as a middle man for Medicare. Medicare pays the insurance companies. Insurance companies would only do this if it was lucrative, and therefore companies are incentivized to restrict access.
Physical Therapy Coverage:
✔ Must cover at least the same therapy services as Medicare.
✔ May offer extra benefits like vision, dental, or SilverSneakers.
✔ Annual out-of-pocket limit for protection.
Pros:
- Lower or $0 monthly premiums.
- Extra perks (wellness, dental, vision).
- Out-of-pocket spending capped yearly.
Cons:
- Restricted provider networks.
- Alta doesn’t work with many Medicare Advantage programs
- Benefits may be misleading and unclear to yourselves and your providers
- May require prior authorization for therapy.
- Benefits vary by plan and location.
Quick Comparison:
| Plan Type | PT Coverage | Costs | Flexibility | Extras |
| Original Medicare | 80% covered, you pay 20% | Moderate | High (any Medicare provider) | None |
| Medigap + Medicare | Nearly all costs covered | Higher premiums | Very High | None |
| Advantage (Part C) | Similar to Medicare, with limits | Lower premiums, copays apply | Limited (networks) | Often includes dental, vision, fitness |
✅ Tip: If physical therapy is a regular part of your care, check your plan’s rules for:
- Visit limits
- Copays/coinsurance
- Prior authorization requirements