Almost every health plan sold in Texas pays for physical therapy. What nobody tells you is how much you will owe, and that answer sits in the fine print of your own policy. Here is how coverage works and how to check yours.
The short answer
Yes, in nearly every case. Medicare, Texas Medicaid, employer plans, Marketplace plans, auto accident claims and workers' compensation all pay for outpatient physical therapy when it is medically necessary. What changes from plan to plan is your cost per visit, your visit limit for the year, and whether someone has to approve the care first.
That matters more than the logo on your card. Two neighbors in Garland with the same Blue Cross plan can pay very different amounts for the same course of physical therapy, because one met her deductible in March and the other has not touched his.
Medicare
Medicare Part B covers outpatient physical therapy, and after the annual Part B deductible it pays 80 percent of the approved amount. The old hard cap on visits is gone. Medicare Advantage plans cover at least as much, but they run their own networks and often want prior authorization after a set number of visits, so bring that card and not only the red, white and blue one.
Texas Medicaid and CHIP
Texas Medicaid pays for physical therapy, and coverage for children through Texas Health Steps and CHIP is broader than it is for adults. Most managed care plans (Amerigroup, Superior HealthPlan, Molina, UnitedHealthcare Community Plan) want a physician order and prior authorization for a block of visits, then a renewal with progress notes. Copays are usually zero. We open the authorization the day we evaluate you.
Employer and Marketplace plans
Blue Cross Blue Shield of Texas, Aetna, Cigna, UnitedHealthcare and Humana all cover outpatient physical therapy. Your share comes down to four numbers, all printed on your summary of benefits.
- Copay: a flat fee per visit, commonly $20 to $75 in North Texas.
- Deductible: what you pay before the plan starts sharing costs. If yours is not met, expect the full contracted rate at first.
- Coinsurance: the percentage you owe after the deductible, usually 10 to 30 percent, until you hit your out-of-pocket maximum.
- Visit limit: often 20 to 60 therapy visits a year, sometimes shared with occupational and speech therapy.
Ask for the in-network contracted rate, not the list price. A visit billed at $180 can settle at your $45 copay, because that is the rate your insurer negotiated. Out of network, you can owe the difference.
Referrals and Texas direct access
Texas is a direct access state. A licensed physical therapist can evaluate you without a physician referral, and a qualified therapist can treat you for a set number of business days before one is required. That is why you can call a clinic yourself instead of waiting weeks for a doctor visit.
Your insurance runs on a separate rulebook. HMO plans and several Medicaid managed care plans will not pay without a referral on file. We can request one from your doctor, or you can get it from our general practice team in the same building. State law decides whether we can see you; your plan decides whether it pays.
How to verify your benefits in ten minutes
Call member services on the back of your card, ask these five questions, and write down the call reference number.
- Is outpatient physical therapy covered, and is this clinic in network?
- What is my copay or coinsurance per visit?
- How much of my deductible is left this year?
- How many therapy visits do I have, and are they shared with other therapies?
- Do I need a referral or prior authorization first?
Rather skip the phone tree? Send your plan details through our contact page and we verify it for you, usually the same business day, then tell you your expected cost per visit before you book.
What we bill directly at Rehoboth
At our Garland clinic on Peggy Lane we bill Medicare, Texas Medicaid, Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare and Humana directly. You pay your copay at the desk and we handle the claim, the authorization and the progress notes. We also take auto accident and workers' compensation cases. Details of a full course of care are on our physical therapy page.
No insurance, or a high deductible?
Ask for the self-pay rate: a flat price per visit with no surprise bill later. With a $5,000 deductible, self-pay often costs less than the contracted rate you would be paying anyway, and we will tell you which is cheaper.
Common questions
How much does physical therapy cost with insurance in Garland, TX?
Most insured patients in North Texas pay $20 to $75 per visit, or 10 to 30 percent coinsurance once the deductible is met. Before the deductible is met you pay the in-network contracted rate. We verify your benefits and give you the number before your first appointment.
Do I need a referral for physical therapy in Texas?
Not to be evaluated. Texas direct access lets a licensed physical therapist evaluate you, and a qualified therapist can begin treatment for a set number of business days, without a physician referral. Insurance is separate: HMO plans and several Medicaid managed care plans still require a referral on file before they pay, and we check that for you.
Does Medicare pay for physical therapy?
Yes. Medicare Part B covers medically necessary outpatient physical therapy. After the annual deductible, Medicare pays 80 percent of the approved amount and you or your supplement plan cover 20 percent. There is no hard visit cap; past an annual dollar threshold your therapist documents that care is still needed and coverage continues.
Find out what your plan covers
Do not let a billing question keep you in pain another month. Call (469) 555-0142 or book online and our front desk verifies your benefits before you arrive at 2241 Peggy Lane.