Part B coverage · Garfield County, Colorado · Plan year 2026

Does Medicare cover physical therapy? The 2026 rules, the $2,480 threshold, and what a course of rehab costs in Garfield County

A knee replacement in Glenwood Springs, a shoulder that will not lift in Rifle, a fall on the ice in New Castle — the recovery from each runs through the same Medicare benefit. Part B pays 80% of it, with no visit limit. The 20% it does not pay has no ceiling of its own, and a number your therapist watches — $2,480 in 2026 — is not the cap most people think it is.

Bemis Insurance Data Desk

Reviewed by Trinity Bemis, Licensed Insurance Broker & Medicare Specialist (NPN 21424070) · Published 2026-09-16

The short answer

Medicare Part B covers outpatient physical therapy that is medically necessary, in a therapist's office, a hospital outpatient department, a rehabilitation agency or your home, with no limit on the number of visits or on what Medicare pays in a year. You pay the Part B deductible ($283 in 2026) and then 20% of the Medicare-approved amount for every visit. Two things govern whether the care keeps getting paid: a plan of care that a physician or nurse practitioner certifies and recertifies, and a therapist who can document that the care is still reasonable and necessary.

The confusion in this benefit comes from its history. For twenty years Medicare had a hard annual dollar cap on therapy, and enough people remember it that "how many visits does Medicare allow" is still the first question. The cap is gone. What replaced it is a pair of dollar thresholds that change the therapist's paperwork, not your coverage. The number that actually matters to a Garfield County household is the 20% — because in a county where nearly three in four beneficiaries are on Original Medicare and no Medicare Advantage plan is open to the general public, that 20% is paid by you or by a Medigap policy, and by nothing else.

Sources: Medicare.gov — Physical therapy services (coverage) · Medicare.gov — Medicare costs (2026 premiums, deductibles and coinsurance) · CMS — Transmittal 13437 / CR 14252, 2026 Annual Update of Per-Beneficiary Threshold Amounts (October 30, 2025) · CMS MLN — Complying with Outpatient Rehabilitation Therapy Documentation Requirements (MLN905365, September 2025) · CMS — Medicare Monthly Enrollment (data.cms.gov), calendar year 2025. Plan year 2026.

What does Part B cover, and where?

Medicare.gov's coverage page puts it in one sentence: Part B "helps pay for medically necessary outpatient physical therapy." The same rule covers occupational therapy — relearning the tasks of daily living, from dressing to cooking — and speech-language pathology, which includes swallowing therapy after a stroke. All three are "outpatient rehabilitation therapy" in Medicare's vocabulary, and they share one set of rules.

Who can provide it, per Medicare's therapy fact sheet: physical therapists, occupational therapists and speech-language pathologists, and also physicians and practitioners such as nurse practitioners and physician assistants. Where you can get it is a longer list, and it matters in a county with two hospitals seventy miles apart:

• Offices of privately practicing therapists
• Medical offices
• Outpatient hospital departments, and critical access hospital outpatient departments
• Rehabilitation agencies (sometimes called "other rehabilitation facilities") and comprehensive outpatient rehabilitation facilities
• Skilled nursing facilities, when Part A does not apply — for example, after your covered Part A stay has ended
• At home, from certain therapy providers such as privately practicing therapists, if you are not under a home health plan of care

That last line is where two Medicare benefits touch. If you are homebound and need skilled care, therapy at home can instead come through the home health benefit, which in 2026 has no deductible and no coinsurance. A therapist who drives to your house under Part B is a different benefit with the 20% attached. If you are eligible for both, which door you go through changes your bill; ask.

One line the fact sheet leads with, and this article will repeat: this information only applies if you have Original Medicare. A Medicare Advantage plan must cover the same services, but sets its own cost sharing and can require prior authorization. We come back to that below.

Sources: Medicare.gov — Physical therapy services (coverage) · Medicare.gov — Occupational therapy services (coverage) · Medicare.gov — Medicare Coverage of Therapy Services (CMS Product No. 10988, November 2024). Retrieved September 2026.

What will I pay in 2026?

Three numbers, all from Medicare.gov's 2026 cost page. The standard Part B premium is $202.90 a month. The Part B deductible is $283 for the year. After the deductible, you pay 20% of the Medicare-approved amount for each covered service and Medicare pays 80%. The "Medicare-approved amount" is the fee-schedule price for the codes your therapist bills, most of them 15-minute timed units of exercise, manual therapy or gait training, plus an untimed evaluation at the start; it is not the clinic's sticker price.

What Original Medicare does not have is an out-of-pocket maximum. The 20% runs as long as the therapy does. Here is what that arithmetic looks like at four levels of approved charges, assuming therapy is the first Part B care you use in the year so the whole deductible lands on it, and assuming no Medigap policy:

Sources: Medicare.gov — Medicare costs (2026 premiums, deductibles and coinsurance) (2026 deductible and coinsurance) · CMS — Transmittal 13437 / CR 14252, 2026 Annual Update of Per-Beneficiary Threshold Amounts (October 30, 2025) (threshold amounts). The arithmetic is an illustration of the Original Medicare cost-sharing formula — $283 plus 20% of the remainder — not a quote from any provider; your actual approved amounts depend on the codes billed and on whether the deductible was already met by other care. Plan year 2026.

Three things to notice. First, the deductible is a one-time event per year, so if you already met it on a specialist visit in February, the therapy bill is simply 20% — at the $2,480 threshold, that is $496. Second, the 20% is of the approved amount. A therapist who accepts Medicare assignment agrees to that amount as payment in full and cannot bill you the difference to their own rate; nearly all do, but it is a question worth asking once. Third, if part of your visit is delivered by a physical therapist assistant rather than the therapist, Medicare has paid those minutes at 85% of the fee-schedule amount since January 1, 2022; your 20% is calculated on the reduced amount, so it is slightly smaller, not larger.

Medicare only pays for therapy that is "reasonable and necessary." If your therapist believes further visits would not be, they have to tell you and give you a written Advance Beneficiary Notice of Noncoverage before providing them; you can then choose to continue and pay the full cost yourself. The fact sheet adds a sentence that is the hinge of the next section: "They can't give you an ABN only because your therapy expenses have reached a certain amount."

What is the $2,480 threshold, and is it a cap?

It is not a cap. Here is the history in four sentences, because the history is the reason people still ask.

The Balanced Budget Act of 1997 put annual dollar limits — "therapy caps" — on outpatient physical and speech therapy combined, and separately on occupational therapy. For years Congress passed an "exceptions process" so people with real need could keep going, then let it lapse, then passed it again. Section 50202 of the Bipartisan Budget Act of 2018 repealed the caps outright. But the same section kept the old cap amounts alive as thresholds "above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record."

So each year CMS updates two numbers by the Medicare Economic Index. For 2026, per Transmittal 13437 dated October 30, 2025, effective January 1, 2026:

Sources: CMS — Transmittal 13437 / CR 14252, 2026 Annual Update of Per-Beneficiary Threshold Amounts (October 30, 2025) · CMS — Therapy Services (KX modifier thresholds, medical review threshold, PTA/OTA payment), page updated March 10, 2026. Plan year 2026.

What the thresholds count is the Medicare-approved amount of your therapy for the year — Medicare's 80% and your 20% together — across every setting, so a spring of physical therapy after a hip replacement and an autumn of speech therapy after a stroke accumulate in the same $2,480 bucket. Your therapist's billing software watches the running total. When you cross it, nothing changes in the treatment room; a two-letter code goes on the claim, and the record has to support it. The denial CMS describes is a denial of the claim for a missing modifier, a billing error the provider corrects and resubmits, not a denial of your care.

Where the threshold does touch you is indirectly. A therapist who knows your total is past $2,480 and heading for $3,000 is a therapist who is going to want the documentation to be strong — measurable goals, progress notes, a physician's recertification on file. That is the system working. If instead you are told Medicare "has run out" for the year, that is wrong, and the Advance Beneficiary Notice rule above is the sentence to quote. Denials of therapy claims, like any Part B denial, follow the standard appeal path.

Do I need a referral? The plan-of-care rules

Medicare does not have a referral requirement for outpatient therapy. It has something adjacent that people call a referral: a plan of care that a physician or non-physician practitioner must certify. CMS's September 2025 documentation fact sheet lists what Medicare needs before it pays: the plan is "established by a physician, NPP, or qualified therapist providing the services," it is "reviewed periodically by a physician or NPP," the certifying provider's name and NPI are on the claim, and the record supports medical necessity. Four rules govern the timing.

• Who writes it. The therapist who evaluates you can write the plan — diagnosis, goals, type and frequency of treatment, and how long it will run. Your doctor does not have to write it; they have to sign it.
• Initial certification: 30 calendar days. "The physician or NPP certifies the initial POC with a dated signature or verbal order within 30 calendar days from the first day of treatment, including evaluation." A verbal order must be signed within 14 calendar days.
• Certification period: up to 90 calendar days. A physician can certify for whatever duration they judge appropriate, to a maximum of 90 days. Then it must be recertified — "whenever a significant POC modification becomes evident, or at least every 90 calendar days after treatment starts."
• Progress reports: every 10 treatment days. The therapist must write a progress report "at least once every 10 treatment days" that justifies continued medical necessity, signed and dated.

A change that matters in a rural county took effect January 1, 2025. Under the 2025 physician fee schedule rule, if your doctor has not signed and returned the therapist's plan within 30 days, a signed and dated written order or referral from that doctor can substitute for the signature on the initial plan, provided the therapist can show the plan was delivered to the doctor within 30 days of the evaluation. CMS adopted it, in its own words, to "safeguard patient access to medically necessary therapy services, including those experiencing challenges accessing these services in rural and underserved areas." Translated: the therapy does not have to stop because a signature is sitting in a Glenwood Springs inbox, as long as an order exists. The exception does not apply to recertifications.

Practically, then: if you already have an order or referral from your doctor, bring it; it does double duty. If you do not, and the clinic will see you without one, the therapist evaluates you, writes the plan and sends it to your doctor for signature, and the 30-day clock starts at that first visit. Whether a given clinic will see you without a referral is its own policy and a matter of state licensing law, not a Medicare rule. Ask that question when you book, along with whether they accept Medicare assignment.

Sources: CMS MLN — Complying with Outpatient Rehabilitation Therapy Documentation Requirements (MLN905365, September 2025) · CMS — Medicare Benefit Policy Manual, Chapter 15, §220 (outpatient therapy plan of care, certification, progress reports) · CMS — Calendar Year 2025 Medicare Physician Fee Schedule Final Rule (fact sheet; therapy plan-of-care certification change). Retrieved September 2026.

How Medigap and Medicare Advantage change the number

Everything above is Original Medicare. The 20% lands differently depending on what, if anything, sits alongside it.

With a Medigap policy. Every standardized Medigap plan covers the Part B coinsurance. Medicare.gov's comparison chart shows Plan G paying 100% of it, which means a course of therapy costs you the $283 Part B deductible (Plan G does not cover that) and nothing per visit after it. Plan N also pays 100% of Part B coinsurance, with the exception Medicare.gov spells out: "You must pay a copayment of up to $20 for some office visits and up to $50 for emergency room visits when you aren't admitted as an inpatient." Whether a therapy visit is one of the "some office visits" depends on how it is billed, and different insurers apply it differently, so ask the insurer, not the clinic. High-deductible Plan G requires you to pay up to $2,950 in 2026 for Medicare-covered costs before it pays anything — which is to say, a full year of rehab at the $2,480 threshold would land almost entirely on you. Which of these is worth its premium is a personal calculation; a year with a joint replacement in it is exactly the year the answer changes. Our Medigap versus Medicare Advantage guide walks the trade-off.

With a Medicare Advantage plan. The plan must cover the same therapy but replaces the 20% with its own cost sharing, usually a flat copay per visit, inside an annual out-of-pocket maximum. Two features to read for in a plan's Evidence of Coverage: whether therapy requires prior authorization, and whether it is limited to in-network therapists. KFF's analysis of 2024 data found Medicare Advantage insurers made nearly 53 million prior authorization determinations that year; only 11.5% of denials were appealed, and 80.7% of those appeals were partially or fully overturned. Therapy is a common target of these reviews. Under Original Medicare there is no prior authorization for outpatient therapy at all — the plan of care is the gate.

The Garfield County fact that decides it. CMS's CY2026 Landscape file lists two Medicare Advantage plans for Garfield County, and both are Dual-Eligible Special Needs Plans for people who also have Medicaid; none are open to general enrollment. Neighboring Mesa County has 21. That means that for a Garfield County resident who is not dual-eligible, the choice for 2026 is Original Medicare with or without a Medigap policy — and the 20% on physical therapy is either covered by Medigap or paid by you. If you are shopping during the Annual Enrollment Period, October 15 – December 7, that is the comparison to make, and it is the reason this article spends its time on the 20% rather than on copays.

Sources: Medicare.gov — Compare Medigap plan benefits (Plan G, Plan N, high-deductible amounts for 2026) · CMS — Medicare Advantage / Part D Landscape files (plan premiums and benefits by county), CY2026 · KFF — Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024 · Medicare.gov — Medicare Coverage of Therapy Services (CMS Product No. 10988, November 2024). Medigap plan availability and premiums vary by insurer; we do not offer every plan available in your area. Plan year 2026.

Who this touches in Garfield County

In calendar year 2025, CMS counted 10,764 Medicare beneficiaries in Garfield County: 7,871 in Original Medicare and 2,894 in a Medicare Advantage or other Medicare health plan. Nearly three in four — 73% — are on Original Medicare, and they are the population for whom every number in this article is the actual number.

How much therapy a county uses is a health question. The CDC's PLACES estimates for Garfield County's 47,597 adults put arthritis at 24.0%, a mobility disability — serious difficulty walking or climbing stairs — at 11.3%, any disability at 28.1%, no leisure-time physical activity at 18.6%, obesity at 24.0%, stroke at 2.9% and COPD at 5.8%. On most of these measures only Pitkin County scores lower. The chart shows arthritis, the condition behind the most therapy referrals, across all six:

Source: CDC PLACES — Local Data for Better Health, County Data, 2025 release. Model-based crude prevalence of arthritis among adults 18 and older, 2023 BRFSS data year. Percentages are of all adults, not of Medicare beneficiaries; arthritis prevalence rises steeply with age.

Source: CDC PLACES — Local Data for Better Health, County Data, 2025 release, crude prevalence among adults, 2025 release. Mobility disability is "serious difficulty walking or climbing stairs."

Where the therapists are is the other half. We searched the federal NPI registry on September 16, 2026 for active physical therapist NPIs by practice city. Roughly 83 list a Garfield County city, concentrated at the two ends of the county:

Source: CMS — NPPES NPI Registry (National Plan and Provider Enumeration System), searched September 16, 2026; taxonomy "Physical Therapist," Colorado, active NPIs, by practice city. An NPI record does not mean the therapist is enrolled in Medicare, accepts assignment, or is taking new patients; some individuals work for the organizations also listed, and some records reflect a mailing rather than treatment address. Basalt, just over the Eagle County line, adds 18 more.

Two observations. First, Rifle's 18 therapist NPIs include only one organizational record, and Parachute, Silt and New Castle together have 11; a resident of the western end of the county will likely be driving to Rifle or Glenwood Springs three times a week for the length of a plan of care, and the length of a plan of care is measured in months. That is a reason to ask about a home-exercise-heavy plan with fewer supervised visits, which is a clinical conversation, and to ask whether you qualify for the home health benefit instead, which is a coverage one. Second, the Roaring Fork end of the county — Carbondale, Glenwood Springs, and Basalt across the line — is dense with sports-medicine and performance practices. Under Original Medicare any of them that accepts Medicare is available to you with no network to check; under a Medicare Advantage plan, if you had one, the network would be the first question.

Sources: CMS — Medicare Monthly Enrollment (data.cms.gov), calendar year 2025 annual county figures · CDC PLACES — Local Data for Better Health, County Data, 2025 release · CMS — NPPES NPI Registry (National Plan and Provider Enumeration System).

Seven things to settle before the first visit

1. Ask whether the clinic accepts Medicare assignment. If yes, the Medicare-approved amount is payment in full and your share is 20% of it. If they are not enrolled in Medicare at all, Medicare pays nothing.
2. Bring any order or referral your doctor already wrote. Since January 1, 2025 a signed written order can stand in for the plan-of-care signature if the doctor is slow to return it. It also tells the clinic which therapy is wanted.
3. Ask where you stand on the Part B deductible. If the $283 is already met this year, the first therapy bill is 20%, not the whole approved amount. Your Medicare Summary Notice or your Medicare.gov account shows it.
4. Know what pays your 20%. Medigap Plan G: all of it. Plan N: all of it except possibly a $20 office-visit copay — ask the insurer. High-deductible G: nothing until $2,950. Nothing alongside Original Medicare: you.
5. Ask what the plan of care says. How many visits a week, for how long, and what the goals are. The certification runs up to 90 days; if you are still going at day 91, someone needed to have recertified it.
6. If you hear "Medicare only allows" a number of visits, ask what rule that is. There is no visit limit. The $2,480 threshold changes the therapist's billing code, not your coverage. An Advance Beneficiary Notice has to be about medical necessity, not a dollar total.
7. If you are homebound, ask about the home health benefit before Part B therapy. Covered home health has no deductible and no coinsurance in 2026. The rules are strict — see our home health guide — but if you qualify, the 20% disappears.

One more, for anyone who will need equipment along the way: a walker, a knee scooter or a hospital bed prescribed during rehab is a separate Part B benefit with its own 20%, its own rental rules and its own supplier questions. Our durable medical equipment guide covers them, and the hospital and skilled nursing guide covers the rehab that happens before you get home.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options. Bemis Insurance is a licensed independent insurance agency. Not connected with or endorsed by the United States government or the federal Medicare program. This is education, not advice — confirm plans, costs, and eligibility with a licensed agent or Medicare.gov. Figures above are for plan year 2026 and are drawn from the sources listed; the cost illustrations apply Medicare's published formula and are not quotes.

Sources

• Medicare.gov — Physical therapy services (coverage)
• Medicare.gov — Occupational therapy services (coverage)
• Medicare.gov — Medicare Coverage of Therapy Services (CMS Product No. 10988, November 2024)
• Medicare.gov — Medicare costs (2026 premiums, deductibles and coinsurance)
• CMS — Transmittal 13437 / CR 14252, 2026 Annual Update of Per-Beneficiary Threshold Amounts (October 30, 2025)
• CMS — Therapy Services (KX modifier thresholds, medical review threshold, PTA/OTA payment)
• CMS MLN — Complying with Outpatient Rehabilitation Therapy Documentation Requirements (MLN905365, September 2025)
• CMS — Medicare Benefit Policy Manual, Chapter 15, §220 (outpatient therapy plan of care, certification, progress reports)
• CMS — Calendar Year 2025 Medicare Physician Fee Schedule Final Rule (fact sheet; therapy plan-of-care certification change)
• Medicare.gov — Compare Medigap plan benefits (Plan G, Plan N, high-deductible amounts for 2026)
• CMS — Medicare Advantage / Part D Landscape files (plan premiums and benefits by county), CY2026
• KFF — Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024
• CMS — Medicare Monthly Enrollment (data.cms.gov)
• CDC PLACES — Local Data for Better Health, County Data, 2025 release
• CMS — NPPES NPI Registry (National Plan and Provider Enumeration System)
• Medicare.gov — Find health & drug plans
• Medicare & You 2026 (official handbook)
• Colorado Division of Insurance — Senior health care and Medicare (SHIP)
• SHIP National Technical Assistance Center — find your local SHIP