Medicare sets no lifetime dollar cap on therapy, but once your combined therapy charges pass $2,480 in 2026, one billing code decides whether Medicare pays. That code is the KX modifier: your therapist appends it to confirm the therapy is still medically necessary, as documented in your medical record, and Medicare denies claims above the threshold that are submitted without it. Outpatient physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) are covered under Medicare Part B when a doctor orders them and they are medically necessary; after the annual Part B deductible of $283, you pay 20% of the Medicare-approved amount for each session.,

What Medicare Part B covers

Medicare Part B covers three categories of outpatient therapy when a physician or other qualified practitioner orders the services and they are medically necessary:

  • Physical therapy (PT): evaluation and treatment for mobility, strength, pain, and functional limitations.
  • Occupational therapy (OT): evaluation and treatment to help you perform daily activities after illness, injury, or disability.
  • Speech-language pathology (SLP): evaluation and treatment for swallowing disorders, language difficulties, and voice and cognitive-communication problems.

Where you get therapy matters for cost: what you actually owe can depend on the type of facility, where the service is furnished, any other insurance you have, and whether the provider accepts assignment. Therapy at home from a Medicare-certified home health agency falls under Medicare's separate home health benefit, which has its own eligibility rules (see the FAQ below).

Medicare Advantage (Part C) plans must cover every medically necessary PT, OT, and SLP service that Original Medicare would cover. Individual plans may require prior authorization before certain therapy services, so check your plan's Evidence of Coverage before beginning a new course of treatment.

What Medicare therapy coverage costs in 2026

Part B covers outpatient therapy at 80% of the Medicare-approved amount once you meet the annual deductible. You pay the remaining 20% coinsurance, plus the $283 deductible if you have not yet met it for the year.

Cost element 2026 amount Notes
Part B annual deductible $283 An annual deductible; once you meet it, you don't owe it again that calendar year
Your share per covered visit 20% of Medicare-approved amount After the deductible; Medicare pays 80%
KX modifier threshold (PT + SLP combined) $2,480 Above this, the KX modifier is required on each claim
KX modifier threshold (OT) $2,480 Separate threshold, tracked independently from PT + SLP
Targeted medical review threshold $3,000 Separate amount for PT + SLP and for OT; $3,000 for any year before 2028, then MEI-indexed

A Medigap (Medicare Supplement) policy can pay some or all of that 20% coinsurance, depending on its plan letter; Plan G, for example, pays the Part B coinsurance., If you are in a Medicare Advantage plan, your plan's own cost-sharing applies instead, and its in-network Part A and Part B cost-sharing counts toward the plan's annual out-of-pocket maximum ($9,250 at most in 2026).

How the KX modifier threshold works

Before 2018, Medicare imposed hard annual dollar caps on outpatient therapy. The Bipartisan Budget Act of 2018 repealed those caps. In their place, Congress established a threshold and attestation system built on the KX modifier, a billing code a therapist appends to a claim to attest that services above a set dollar amount remain medically necessary.,

For 2026, the threshold is $2,480 for the combined total of PT and SLP services for a single beneficiary, and a separate $2,480 threshold applies to OT services. Medicare tracks spending independently for the PT-plus-SLP pool and the OT pool, so hitting the threshold in one pool does not affect the other.

Once your combined PT and SLP charges pass $2,480 in a calendar year, your treating therapist must add the KX modifier to every claim above that amount. The modifier is a formal attestation that:

  1. The therapist has assessed you and determined that continued therapy is medically necessary.
  2. That determination is documented in your medical record.

Medicare denies a claim above the threshold that arrives without the KX modifier. If your therapist omits the modifier on a claim above $2,480, that claim will not pay, even when the therapy itself is genuinely medically necessary. That denial does not automatically make you liable for the bill, though: you keep Medicare's limitation-of-liability protections, which have applied since January 1, 2013.

If you are approaching or have passed $2,480 in combined PT and SLP charges, confirm with your therapist that they are tracking your running total and will attach the KX modifier to each claim going forward. Ask to see that it is reflected on the Medicare Summary Notice you receive after each round of billing.

The targeted medical review threshold

The medical review threshold is $3,000 for 2026, and like the KX threshold it is applied separately: one $3,000 amount for PT and SLP combined, and another for OT, not a single pooled $3,000 across all your therapy. By statute it is $3,000 for any year before 2028; for 2028 it goes up by the percentage increase in the Medicare Economic Index (MEI), and each year after that is indexed by the MEI in turn, per CMS guidance on therapy services.

Crossing that amount does not by itself put your claims through review. In place of a manual review process, Medicare identifies and reviews services furnished by particular providers, using factors it considers appropriate: a provider's high claims-denial percentage, a billing pattern that looks aberrant next to peers, or a provider being newly enrolled. When a review does happen, a Medicare contractor may request documentation from the treating therapist to verify medical necessity before payment is approved.

Targeted review does not mean the therapy is denied. It means a Medicare contractor is more likely to audit a specific claim or request supporting records. The practical takeaway for patients is the same as with the KX threshold: make sure your therapist keeps thorough notes documenting medical necessity at each visit, and that the KX modifier is on every claim above $2,480.

There is no lifetime cap on medically necessary therapy

Medicare does not limit how much therapy it will pay for over your lifetime, as long as the therapy remains medically necessary. Medicare also sets no annual dollar cap. The old hard therapy caps were a source of real hardship for beneficiaries with chronic or degenerative conditions who needed ongoing therapy, and the 2018 repeal eliminated them.

What Medicare still requires is that each course of therapy be ordered by a physician or qualified practitioner and that the services remain medically necessary throughout treatment. If a physician determines that further therapy is not reasonable and necessary, coverage may end. Needing therapy to hold your ground is not that: Medicare says you can also get therapy to maintain your current function or slow your rate of decline, so being told you have "plateaued" is not, on its own, a reason coverage stops. And the dollar amount you spent in prior years has no bearing on whether coverage applies now.

Medicare Advantage and therapy coverage

Medicare Advantage plans must cover PT, OT, and SLP whenever those services would be covered by Original Medicare. Unlike Original Medicare, though, a plan may require prior authorization (plan approval) before it covers certain services, which can include therapy. Check your plan's rules before starting or continuing a course of treatment, so a missing approval does not hold up a claim for therapy you need.

As the Original Medicare vs. Medicare Advantage comparison explains, one key difference is that Medicare Advantage plans may require prior authorization for certain services, while Original Medicare generally does not. If you are in a Medicare Advantage plan and your therapy requests have been denied or limited, you have the right to appeal; ask your plan for its formal appeals process in writing.

To check your own spending against the threshold or confirm that a claim was processed with the KX modifier, review your Medicare Summary Notice or call Medicare's beneficiary helpline, 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). If the helpline cannot resolve the problem, you can ask the representative to refer your complaint to the Medicare Beneficiary Ombudsman.

Frequently Asked Questions

Does Medicare cover therapy at home?

Yes. If you are homebound, are under a plan of care from a doctor or allowed practitioner, need physical therapy, speech-language pathology, or continued occupational therapy, and get it from a Medicare-certified home health agency, Medicare covers it under the home health benefit. The KX modifier threshold and medical review rules described here apply to outpatient therapy; home health therapy follows the separate coverage rules of the home health benefit.

What happens if my therapist doesn't add the KX modifier?

Medicare denies a claim submitted without it once your combined PT and SLP charges are above $2,480, or your OT charges are above $2,480. That denial does not automatically make you liable, because you keep Medicare's limitation-of-liability protections. Contact the therapist's billing department to correct the claim and resubmit it with the KX modifier attached.

Does Medicare cover therapy for maintenance only, not improvement?

Yes. Under the Jimmo v. Sebelius Settlement, Medicare coverage of skilled therapy turns on your need for skilled care, not on your potential to improve. Therapy to maintain your current function or slow decline can be covered when an individualized assessment shows that a qualified therapist's skills are needed to carry out a safe and effective maintenance program. Medicare's other coverage rules, including that services be reasonable and necessary, still apply.

Is there a limit to how many visits Medicare covers per year?

Original Medicare sets no annual or lifetime dollar cap on medically necessary outpatient therapy; the KX modifier system replaced the old caps. As long as your physician orders the therapy and your therapist documents medical necessity, coverage can continue. Claims above $3,000 may be selected for targeted review, but that review is aimed at particular providers, chosen by factors such as a high claims-denial rate or unusual billing, not at your spending alone, and it is not a cap.

Learn More

MedicareIs there a limit on Medicare physical therapy?Medicare no longer caps outpatient physical therapy. There's no annual dollar limit on medically necessary PT; see how the 2026 KX threshold and costs work. MedicareDoes Medicare require you to improve to keep covering therapy?No, Medicare doesn't require you to be improving to cover skilled therapy or nursing. The Jimmo settlement means maintenance care counts too. Here's how. MedicareWho qualifies for Medicare home health careMedicare covers home health care when you meet four rules, and the homebound test surprises most families. Here is who qualifies and what it costs in 2026. MedicareWhat is Medicare? Parts A, B, C, and D explainedWhat is Medicare? A plain guide to Parts A, B, C, and D, who qualifies, 2026 costs, when to enroll, and what it doesn't cover, with help-paying options. MedicareWhat Medicare doesn't coverWhat Medicare doesn't cover, from long-term care to dental, vision, and hearing. Does Medicare cover long-term care? No, and here's where families turn instead. MedicareOriginal Medicare vs. Medicare Advantage: how to chooseCompare original Medicare vs Medicare Advantage on cost, networks, the $9,250 cap, and switching back. A neutral 2026 side-by-side to help you choose.

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The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.

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