Utah · Medicare · Physical therapy, the $2,480 line and what a course of visits costs
Does Medicare Cover Physical Therapy in Utah? (2026 Costs)
Yes. Medicare Part B pays 80% of medically necessary outpatient physical, occupational and speech therapy after the deductible, with no cap on visits or dollars in a year; therapy at home, in a nursing facility after a hospital stay, and in a rehabilitation hospital is covered under separate rules. The $2,480 figure you may have heard is a documentation threshold, not a limit. Here is the whole picture for a Utah retiree: the rules in each setting, what an evaluation and a treatment visit actually cost Utahns in CMS's own 2024 claims file, why Utah uses more physical therapy than almost any state and how fast that is growing, which counties use it most, where the 1,132 Medicare-enrolled therapists are, what happens when you stop improving, and how a Medigap policy or a Medicare Advantage plan handles each visit.
The bottom line
- Outpatient physical therapy is a Part B benefit at 20% after the $283 deductible, with no annual limit. Medicare.gov: “There's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.” A doctor, nurse practitioner, clinical nurse specialist or physician assistant must certify the plan of care. Occupational therapy and speech-language pathology work the same way. Physical therapy by telehealth is covered through December 31, 2027.
- A visit costs about $19 at 2024 Utah averages. An evaluation was $94.78 in Medicare-approved charges ($18.96 at 20%) and a typical hour of four 15-minute units $93.64 ($18.73). An evaluation plus 12 visits is $1,218.46: $243.69 if the deductible is met, $470.09 if it is not. Medigap Plan G pays all of the 20%.
- The $2,480 “cap” is not a cap. The therapy caps were repealed in 2018. Above $2,480 of approved charges for physical and speech therapy combined in 2026 (a separate $2,480 for occupational therapy), the therapist adds a KX modifier attesting the care is still necessary and keeps billing; above $3,000 a claim can be selected for review. $2,480 is about an evaluation and 25 visits at Utah averages.
- Utah uses physical therapy more than the nation and the gap is widening. 32,544 Utahns in Original Medicare had outpatient physical or occupational therapy in 2025, 12.2% of fee-for-service beneficiaries against 9.72% nationally (1.26 times the national rate), up from 7.27% in 2020; the number of Utah therapy providers billing Medicare went from 425 to 1,040 in five years. On the 2024 claims file, 15.86% of Utahns with Part B had therapeutic exercise against 10.86% nationally, 1.46 times the national rate. Summit, Wasatch, Washington and Cache counties use it most.
- Not improving is not a reason to stop. Medicare covers therapy to maintain function or slow decline when a therapist's skill is needed; CMS's Jimmo settlement says coverage “does not turn on the presence or absence of a beneficiary's potential for improvement.” 1,066 of Utah's 1,132 Medicare-enrolled private-practice physical therapists (94%) accept assignment, and they are listed in 101 Utah towns including Moab, Blanding, Vernal, Price, Richfield and Kanab. In Medicare Advantage, expect a per-visit copay, a network and, often, prior authorization.
Physical therapy is the Medicare benefit most Utah retirees will use that is not a test or a pill. It follows the knee and hip replacements Utah does more of than any state, the falls that send Utahns to the emergency room, the back and shoulder that stiffen in the seventies, the stroke and the Parkinson's, and, increasingly, nothing at all but a doctor's wish to keep a patient walking. Medicare.gov's description is broad: physical therapy “helps to restore or improve physical movement in your body after an injury, illness, or surgery. You can also get this therapy to help improve or maintain your current function, or slow your rate of decline.” Part B pays for it as an outpatient service, at the same 20% after the deductible as a doctor's visit, when a physician or other qualified practitioner certifies that you need it, and there is no limit on how much it will pay in a year.
That last sentence surprises people, because for twenty years there was a limit. The Balanced Budget Act of 1997 capped outpatient physical and speech therapy together, and occupational therapy separately, at a dollar figure that started at $1,500 and was indexed up each year; Congress suspended the caps, let them lapse, created an exceptions process, and finally, in the Bipartisan Budget Act of 2018, repealed them, keeping the old cap amounts only as thresholds above which a therapist must attest, with a two-letter modifier on the claim, that the therapy is still medically necessary. The other thing that changed is what counts as necessary. For years Medicare contractors denied therapy once a patient stopped improving, under what came to be called the Improvement Standard; a 2013 class-action settlement, Jimmo v. Sebelius, made CMS rewrite its manuals to say coverage “does not turn on the presence or absence of a beneficiary's potential for improvement from the therapy, but rather on the beneficiary's need for skilled care.” Both changes matter more in Utah than most places, because Utah uses outpatient therapy at a rate well above the nation's and rising fast. We take the rules, the costs and the Utah numbers in turn.
What does Medicare cover for physical therapy, and in which settings?
Where you get therapy decides which part of Medicare pays and what you owe. The rules below are quoted from Medicare.gov's coverage pages for each setting and from CMS's Therapy Services page. In every setting, the therapy must be “medically necessary,” a qualified clinician must certify the plan of care, and the therapist must be Medicare-enrolled. “Assignment” means the provider accepts the Medicare-approved amount as payment in full.
| Setting | Which part pays | Conditions | What you pay in 2026 (provider accepts assignment) |
|---|---|---|---|
| Outpatient physical therapy: a private practice, a hospital outpatient clinic, a rehabilitation agency, a nursing home's outpatient department, or your home when you are not under the home health benefit | Part B | Plan of care certified by a doctor, nurse practitioner, clinical nurse specialist or physician assistant; reviewed and recertified at least every 90 days; therapy must require a therapist's skill | 20% of the Medicare-approved amount after the $283 Part B deductible; no limit on the number of visits or dollars in a year; above $2,480 of approved charges (physical and speech therapy combined) the therapist adds the KX modifier and billing continues |
| Outpatient occupational therapy (dressing, bathing, cooking, hand and arm function) | Part B | Same certification | 20% after the deductible; its own separate $2,480 KX threshold |
| Outpatient speech-language pathology (speech, language, cognition, swallowing) | Part B | Same certification | 20% after the deductible; shares the physical therapy KX threshold |
| Physical therapy by telehealth | Part B | Covered from anywhere in the U.S., including your home, through December 31, 2027; the therapist must be enrolled and able to deliver the service remotely | 20% after the deductible, the same as in person |
| Therapy at home under the home health benefit | Part A or Part B | You are homebound, need part-time skilled care (physical therapy counts), a doctor has a face-to-face visit and certifies the plan, and the agency is Medicare-certified | $0 for the therapy visits; 20% only for any durable medical equipment the agency supplies |
| Therapy in a skilled nursing facility | Part A | A medically necessary inpatient hospital stay of at least three days first (observation days do not count), admission generally within 30 days of leaving the hospital, and a daily need for skilled nursing or therapy | $0 for days 1 to 20 after the $1,736 Part A deductible (if not already paid for the hospital stay); $217 a day for days 21 to 100; all costs after day 100 of a benefit period |
| Inpatient rehabilitation hospital or unit | Part A (hospital) and Part B (doctors) | Your condition requires intensive rehabilitation, physician supervision and coordinated care | $1,736 Part A deductible for days 1 to 60 of a benefit period, then daily copays; 20% of doctors' fees |
| Not covered | Exercise that does not require a therapist's skill (a home program you can do on your own, a gym membership, a fitness class), massage or other services by someone who is not a Medicare-enrolled therapist, and personal or custodial care when it is the only care you need. Some Medicare Advantage plans add a fitness benefit; Original Medicare does not | ||
Sources: Medicare.gov, Physical therapy services; Occupational therapy services; Speech-language pathology services; Telehealth; Home health services; Skilled nursing facility care; Inpatient rehabilitation care; CMS, Therapy Services (KX modifier thresholds, CY 2026); CMS, 2026 Medicare Parts A & B Premiums and Deductibles — medicare.gov (PT), medicare.gov (home health), medicare.gov (SNF), cms.gov, cms.gov (2026 amounts).
Three practical points. First, the certification requirement is Medicare's, not Utah's: Utah law lets you see a physical therapist without a referral, but Medicare will not pay unless a physician, nurse practitioner, clinical nurse specialist or physician assistant signs the plan of care the therapist writes, which most clinics arrange by faxing it to your doctor after the first visit. Second, the home health route is the one that costs nothing, and after a joint replacement or a hospital stay it is the usual first stop; when you can leave the house without difficulty, the benefit ends and outpatient therapy at 20% begins. Our home health guide covers the homebound rule. Third, the three-day inpatient rule for a nursing facility catches people every week: a night in a hospital bed under observation status does not count, and a Utah patient discharged to a nursing home for rehabilitation after two observation days is paying the whole bill unless a Medicare Advantage plan or an accountable care organization has waived the rule.
What do you pay for physical therapy with Medicare in 2026?
Therapy is billed in pieces. The first visit is an evaluation, priced at one of three complexity levels that, in practice, pay almost the same amount. Each later visit is a set of 15-minute units of whatever the therapist did: therapeutic exercise, manual therapy, balance work, walking training, “therapeutic activities” (lifting, reaching, stairs), and sometimes a modality such as electrical stimulation, which is priced as a whole rather than by the quarter hour. Medicare pays the first unit of the day in full and reduces the practice-expense part of each later unit by half, so the second, third and fourth units are cheaper than the first. The figures below are what Medicare approved, on average, on every claim billed by a Utah therapist in 2024, with the reduction already in them.
Sources: CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024, Utah rows for 97162, 97110, 97140 and 97530; CMS, Therapy Services (thresholds) — data.cms.gov, cms.gov.
| Service (code) | 2024 Utah average Medicare-approved amount | Your share in 2026, Original Medicare, deductible met |
|---|---|---|
| Physical therapy evaluation, low complexity (97161) | $92.89 | $18.58 |
| Physical therapy evaluation, moderate complexity (97162) | $94.78 | $18.96 |
| Physical therapy evaluation, high complexity (97163) | $93.85 | $18.77 |
| Physical therapy re-evaluation (97164) | $64.95 | $12.99 |
| Therapeutic exercise, each 15 minutes (97110), per unit | $22.06 (therapists submitted $54.05 on average) | $4.41 |
| Neuromuscular re-education (balance), each 15 minutes (97112), per unit | $26.30 | $5.26 |
| Gait (walking) training, each 15 minutes (97116), per unit | $21.00 | $4.20 |
| Manual therapy, each 15 minutes (97140), per unit | $19.69 | $3.94 |
| Therapeutic activities, each 15 minutes (97530), per unit | $29.83 | $5.97 |
| Self-care and home management training, each 15 minutes (97535), per unit | $24.20 | $4.84 |
| Group therapy (97150), per session | $13.12 | $2.62 |
| Electrical stimulation, unattended (G0283), per session | $8.39 | $1.68 |
| Typical treatment visit: 97110 × 2 + 97140 + 97530 | $93.64 | $18.73 |
| Same visit furnished in whole or part by a physical therapist assistant (CQ modifier, paid at 85%) | $79.59 | $15.92 |
| Occupational therapy evaluation (all three levels) (97165-97167) | $95.37 (moderate complexity) | $19.07 |
| Speech, language or swallowing treatment, individual (92507), per session / Speech sound and language evaluation (92523) | $70.81 / $214.22 | $14.16 / $42.84 |
Averages across all Utah claims for each code in 2024. Not price quotes: a hospital outpatient therapy department bills under the hospital and is not in this file, and a non-participating therapist may charge up to 15% above the approved amount. Since January 1, 2022, Medicare pays 85% of the fee for services furnished in whole or in part by a physical or occupational therapist assistant, and your 20% is 20% of the reduced amount. Sources as above.
Two things follow from the arithmetic. The first is that therapy is cheap per visit and expensive per course: $19 is less than most specialist copays, but a twice-a-week schedule for six weeks is 12 of them, and a knee replacement can run to twenty or more. The second is that the deductible lands on the first visits of the year. A Utah retiree who starts therapy in January with nothing yet applied to the $283 deductible pays the first $283 of approved charges in full, about the evaluation and the first two visits, and 20% after that; one who starts in October, after a year of doctor's visits, pays $19 from the first visit. With a Medigap policy both pay the deductible once and nothing per visit.
Is there still a Medicare therapy cap, and what is the $2,480 KX threshold?
There is no cap. CMS's Therapy Services page puts it in one sentence: section 50202 of the Bipartisan Budget Act of 2018 “repeals application of the Medicare outpatient therapy caps and its exceptions process while adding limitations to ensure payment for appropriate therapy services.” The limitations are two numbers. The first is the KX modifier threshold, which the law set at the old cap amounts and indexes each year by the Medicare Economic Index: for 2026 it is $2,480 of Medicare-approved charges for physical therapy and speech-language pathology combined, and a separate $2,480 for occupational therapy. Once your year's charges pass that line, every claim must carry the KX modifier, which is the therapist's attestation “that services are medically necessary as justified by appropriate documentation in the medical record”; CMS's page is blunt that “claims for services over the KX modifier threshold amounts without the KX modifier are denied.” The second number is the targeted medical review threshold, $3,000 for each of the two categories, fixed by law through 2027 and indexed from 2028. Above it, a claim can be pulled for review, but CMS explains that “not all claims exceeding the MR threshold amount are subject to review as they once were”; the reviews target providers with unusual billing patterns, not patients.
What this means for you is mostly nothing, and occasionally a form. The threshold counts the Medicare-approved amount, Medicare's 80% and your 20% together, across every outpatient therapy provider you see in the calendar year, so a spring course for a shoulder and a fall course for a knee add up. At 2024 Utah averages, $2,480 is an evaluation and about 25 treatment visits, so a single course rarely gets there and a year with a joint replacement plus a fall can. When it does, a therapist who believes you still need skilled care simply adds the modifier and continues, at the same 20% to you. A therapist who does not believe Medicare will pay (because the care has become maintenance you could do yourself, or because the documentation is thin) must give you an Advance Beneficiary Notice before the visits, telling you Medicare may deny them and you may have to pay; if you are billed for therapy above the threshold without having signed that notice, the liability rules on CMS's page protect you, and the provider, not you, absorbs the denial. There is no form to file and no exception to request. If a clinic tells you that you have “used up your Medicare therapy,” it is describing its own paperwork, not your benefit, and the right response is to ask whether the therapist believes the care is still medically necessary.
Does Medicare cover physical therapy if you are not improving?
Yes, when a therapist's skill is still needed. For years the practical answer was no: Medicare contractors denied therapy, home health and nursing facility claims once a patient had “plateaued,” and CMS's manuals could be read to support it. In Jimmo v. Sebelius, a class of beneficiaries with chronic and progressive conditions challenged that practice, and in January 2013 a federal court approved a settlement under which CMS rewrote the Medicare Benefit Policy Manual chapters on skilled nursing facility, home health and outpatient therapy coverage. CMS's fact sheet on the settlement states the clarified rule: coverage of therapy “does not turn on the presence or absence of a beneficiary's potential for improvement from the therapy, but rather on the beneficiary's need for skilled care,” and “when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.” Medicare.gov's physical therapy page now carries the same idea in plain words: therapy “to help improve or maintain your current function, or slow your rate of decline.”
The settlement did not expand what is covered; CMS was careful to say so, and the boundary is the word skilled. A maintenance program is covered when it must be carried out by a therapist because of its complexity or the patient's condition: a person with Parkinson's whose gait training has to be adjusted visit by visit, a stroke survivor whose spasticity makes unsupervised exercise unsafe. It is not covered when the program could safely be done by you, a spouse or an aide, which is the normal end of a course of therapy for a healed knee. In that case Medicare still covers the therapist's visits to design the program, teach it, and periodically reassess and adjust it, just not the repetitions in between. For a Utah retiree with a progressive condition, the practical use of Jimmo is a sentence to your therapist and your doctor: the plan of care should say that skilled therapy is needed to maintain function or slow decline, and why. A denial that says only “no improvement expected” is appealable, and our appeals guide explains the steps; CMS's Jimmo page and its FAQs are the citations to attach.
How many Utahns on Medicare get physical therapy, and how does Utah compare?
More than the nation, and more every year. CMS's Market Saturation file, which counts every Original Medicare beneficiary living in a state with an outpatient physical or occupational therapy claim, puts Utah at 32,544 people in 2025, 12.2% of fee-for-service beneficiaries, against 9.72% nationally (3,839,619 of 39,522,162), 1.26 times the national rate. Medicare paid $29,206,613 for it in Utah, about $897 per person against $1,117 nationally, so Utahns go to therapy more often but each course costs Medicare less. The growth is the striking part: in 2020 the figure was 16,980 people and 7.27%, so the count has risen 92% in five years while Utah's Original Medicare population shrank as people moved to Medicare Advantage, and the number of Utah providers billing Medicare for therapy for more than ten beneficiaries went from 425 to 1,040. Part of that is Utah's joint-replacement rate, the highest in the nation, and part is supply: more than twice as many Utah therapy practices bill Medicare today as did in 2020, most of them along the Wasatch Front and in Washington County.
| Service (code) | Utah beneficiaries, 2024 | Share of Utah Part B (Original Medicare) | Share, U.S. | Utah ÷ U.S. | Utah units of service |
|---|---|---|---|---|---|
| Physical therapy evaluation, all three levels (97161–97163) | 30,000 | 16.35% | 10.92% | 1.50 | — |
| Therapeutic exercise, each 15 minutes (97110) | 29,100 | 15.86% | 10.86% | 1.46 | 529,992 (18.2 per person; U.S. 21.1) |
| Manual therapy, each 15 minutes (97140) | 20,962 | 11.42% | 7.80% | 1.46 | 246,586 |
| Neuromuscular re-education (balance), each 15 minutes (97112) | 18,705 | 10.19% | 7.86% | 1.30 | 244,073 |
| Therapeutic activities, each 15 minutes (97530) | 18,186 | 9.91% | 8.13% | 1.22 | 279,191 |
| Electrical stimulation, unattended (G0283) | 9,248 | 5.04% | 1.85% | 2.72 | — |
| Self-care and home management training, each 15 minutes (97535) | 5,412 | 2.95% | 2.23% | 1.32 | — |
| Gait (walking) training, each 15 minutes (97116) | 3,151 | 1.72% | 1.30% | 1.32 | 36,307 |
| Group therapy (97150) | 587 | 0.32% | 1.20% | 0.27 | — |
| Occupational therapy evaluation (all three levels) (97165-97167) | 2,278 | 1.24% | 1.22% | 1.02 | — |
| Speech, language or swallowing treatment, individual (92507) | 523 | 0.29% | 0.20% | 1.39 | — |
Distinct Original Medicare beneficiaries with each service billed by a Utah therapist or practice in 2024, office rows (a person can appear under more than one code, and the evaluation row counts a person once per evaluation level); hospital-based therapy departments bill on institutional claims and are not included, so the Utah figures understate total use. Shares are of all people with Part B in Original Medicare, Utah 183,494 and U.S. 27,982,142. Source: CMS, Medicare Physician & Other Practitioners — by Geography and Service, 2024; CMS, Medicare Monthly Enrollment.
Share of people with Part B in Original Medicare who had each service billed in 2024; Utah bars solid, national bars lighter; bars scaled to the largest value. Source: CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024.
The claims file tells the same story from the therapist's side. 29,100 Utahns in Original Medicare had therapeutic exercise billed by a Utah therapist in 2024, 15.86% of everyone with Part B in Original Medicare against 10.86% nationally, 1.46 times the national rate, and the share has climbed every year: 11.13% in 2022, 14.18% in 2023, 15.86% in 2024, a 32% rise in the count in two years while the denominator fell. Utah therapists billed physical therapy evaluations for 30,000 people in 2024, up from 20,309 in 2022 and 24,572 in 2023. Utah runs above the nation on every physical therapy code, highest on the hands-on and functional ones (manual therapy 1.46 times, therapeutic activities 1.22 times, electrical stimulation 2.72 times), about even on occupational therapy (1.02), and above on speech therapy (1.39). The one figure that runs the other way is intensity: a Utah patient averaged 18.2 units of therapeutic exercise in the year against 21.1 nationally, so Utah's pattern is more people in shorter courses. That is consistent with a state whose therapy is driven by elective orthopedics, where a course has a natural end, rather than by chronic illness, where it does not.
Which Utah counties use physical therapy most, and where is mobility hardest?
The county table pairs two measures: the share of Original Medicare beneficiaries in each county who had outpatient physical or occupational therapy in 2025, and the CDC's estimate of how many adults in the county have a mobility disability (serious difficulty walking or climbing stairs). They do not line up, and the mismatch is the point. 21 of Utah's 29 counties use therapy above the national rate, and the leaders are the ski and retirement counties: Summit (21.2%), Wasatch (20.86%), Washington (16.9%, with 4,604 people, the most outside Salt Lake County) and Cache (16.07%), all with mobility disability at or below the national 13.5%. The counties where walking is hardest use therapy least: Piute (20.3% with a mobility disability, 10.59% in therapy), San Juan (19.7%, 11.27%), Carbon (15.4%, 7.04%), Duchesne (13.3%, 4.7%) and Kane (14.2%, 6.32%). Juab (2.66%) and Beaver (4.49%) are lowest in the state. The Wasatch Front's big counties sit near the national rate: Salt Lake 10.66%, Davis 10.72%, Weber 11.67%, Utah County 13.19%.
| County | PT/OT users, 2025 | Share of Original Medicare | Billing providers | Adults with mobility disability, 2023 | County | PT/OT users, 2025 | Share of Original Medicare | Billing providers | Adults with mobility disability, 2023 |
|---|---|---|---|---|---|---|---|---|---|
| Summit | 1,165 | 21.20% | 51 | 9.3% | Davis | 2,966 | 10.72% | 109 | 9.1% |
| Wasatch | 762 | 20.86% | 27 | 9.8% | Salt Lake | 9,064 | 10.66% | 385 | 10.6% |
| Rich | 69 | 19.83% | 1 | 14.0% | Piute | 36 | 10.59% | 2 | 20.3% |
| Washington | 4,604 | 16.90% | 93 | 13.4% | Garfield | 109 | 10.33% | 1 | 14.0% |
| Cache | 1,286 | 16.07% | 57 | 9.3% | Wayne | 59 | 10.28% | 1 | 15.8% |
| Iron | 1,021 | 14.95% | 24 | 12.0% | Daggett | 28 | 10.18% | 0 | 16.5% |
| Morgan | 161 | 14.07% | 2 | 9.3% | Emery | 154 | 9.32% | 2 | 14.0% |
| Sevier | 403 | 13.68% | 9 | 13.2% | Uintah | 288 | 8.36% | 5 | 13.5% |
| Millard | 275 | 13.51% | 6 | 14.6% | Tooele | 460 | 7.77% | 18 | 10.6% |
| Utah | 4,825 | 13.19% | 183 | 7.9% | Carbon | 234 | 7.04% | 4 | 15.4% |
| Sanpete | 439 | 13.01% | 11 | 12.9% | Kane | 124 | 6.32% | 2 | 14.2% |
| Grand | 264 | 12.52% | 4 | 13.7% | Duchesne | 108 | 4.70% | 2 | 13.3% |
| Weber | 2,733 | 11.67% | 106 | 11.2% | Beaver | 52 | 4.49% | 1 | 11.7% |
| San Juan | 266 | 11.27% | 5 | 19.7% | Juab | 35 | 2.66% | 0 | 11.4% |
| Box Elder | 554 | 10.80% | 17 | 11.5% |
Original Medicare beneficiaries living in the county with any outpatient physical or occupational therapy claim in 2025, as a share of fee-for-service beneficiaries, sorted highest to lowest; “billing providers” = providers with paid therapy claims for more than ten beneficiaries living in the county, wherever the provider is located, so a county can show 0 providers and dozens of users. United States: 9.72%. Mobility disability is the CDC PLACES crude estimate for all adults 18 and older, 2023 (United States 13.5%); 11 Utah counties are above it. Sources: CMS, Market Saturation & Utilization State-County, 2025 — data.cms.gov; CDC, PLACES county data, 2025 release — data.cdc.gov.
Two cautions on reading it. The CDC figure is for all adults, not Medicare beneficiaries, and rural counties with older populations and more physical work will read higher on it regardless of care; and the therapy figure counts Original Medicare only, so in a county where most retirees are in Medicare Advantage it describes a minority. With those in mind, the pattern still says something useful to a Utah retiree in Carbon, San Juan, Duchesne or Kane County: the benefit is there, it costs the same $19 a visit as it does in Park City, and the distance to a therapist is shorter than you might think, which is the next section.
Where can a Utah retiree find a physical therapist who takes Medicare?
Nearly everywhere, which makes physical therapy different from the specialist care we have written about. CMS's clinician file lists 1,132 physical therapists in private practice with a Utah practice location, and 1,066 of them, 94%, accept assignment; the other 66 are non-participating and may charge up to 15% more than the approved amount. It also lists 153 occupational therapists (130 accepting assignment, 85%) and 75 speech-language pathologists (64 accepting assignment). In 2024, 1,029 Utah therapists and practices billed Medicare for therapeutic exercise, up from 650 in 2022. The file lists only clinicians who bill in their own name; the therapy departments of Utah's hospitals and their outpatient clinics, which are a large share of the state's capacity, bill under the hospital and do not appear, so the real count is higher.
| Area | Private-practice physical therapists, by practice location (Oct. 2026) |
|---|---|
| Salt Lake County (Salt Lake City, Murray, Sandy, Draper, South Jordan, Taylorsville, West Jordan, Riverton) | 564 |
| Utah County (Lehi, Provo, American Fork, Orem, Saratoga Springs, Spanish Fork, Eagle Mountain) | 228 |
| Davis County (Layton, Bountiful, Clearfield, Kaysville, Farmington) | 118 |
| Weber and Morgan counties (Ogden, Roy, South Ogden, Farr West, North Ogden) | 97 |
| Washington County (St. George, Hurricane, Washington, Ivins, Enterprise) | 85 |
| Cache and Box Elder counties (Logan, Providence, North Logan, Tremonton, Brigham City) | 79 |
| Summit and Wasatch counties (Park City, Heber City, Midway, Kamas, Coalville) | 56 |
| Sanpete, Sevier, Millard, Juab and Wayne counties (Mt. Pleasant, Ephraim, Richfield, Delta, Fillmore, Bicknell) | 36 |
| Tooele County (Tooele, Grantsville) | 21 |
| Iron County (Cedar City, Parowan) | 19 |
| Grand and San Juan counties (Moab, Blanding, Monticello, Montezuma Creek) | 10 |
| Uintah Basin (Vernal, Roosevelt) | 7 |
| Kane, Garfield and Rich counties (Kanab, Panguitch, Garden City) | 6 |
| Carbon and Emery counties (Price, Castle Dale, Green River) | 5 |
Clinicians with a Utah practice location whose primary specialty is physical therapist in private practice, counted once per clinician in each city where a location is listed, so a therapist with offices in two towns appears in both and the area figures add to more than 1,132; a listed address is not a measure of how often the clinician is there. Source: CMS, Doctors and Clinicians National Downloadable File, retrieved October 9, 2026 — data.cms.gov.
Set that beside the urology and gastroenterology maps and the difference is plain. Moab has five listed physical therapists and no urologist; Blanding three; Vernal five; Price three; Richfield six; Kanab and Panguitch two each; Monticello, Castle Dale, Green River, Bicknell and Montezuma Creek one each. The one gap in the private-practice list is the Uintah Basin and Castle Country relative to their population, where the hospital departments in Vernal, Roosevelt and Price carry more of the load. For the rest of Utah the question is not whether a therapist is within reach but which one. In Original Medicare the choice is yours and any enrolled therapist in the state is covered at the same 20%; in a Medicare Advantage HMO it is the plan's network, and a clinic that is two blocks away but out of network is, for the plan's purposes, not there.
How do Medicare Advantage and Medigap each handle physical therapy?
More than half of Utah's Medicare population, 269,226 of 490,235 people in June 2026 (54.9%), is in a Medicare Advantage plan. Medicare.gov's rule is that these plans must cover everything Original Medicare covers, so outpatient therapy is covered with no annual cap and the Jimmo maintenance standard applies to them too. The differences are in the mechanics. Instead of 20%, most plans charge a flat copay per therapy visit, which for a short course can cost about the same as Original Medicare and for a long one can cost more or less depending on the amount; read the Evidence of Coverage line for “outpatient rehabilitation services” or “physical therapy,” and the separate line for the home health benefit, which some plans charge for. HMO plans generally require a referral, and many plans require prior authorization for therapy, sometimes in blocks of visits, so a plan may approve eight and ask the therapist to justify the next eight; the KX threshold itself does not apply to plan claims. Skilled nursing facility stays after a hospitalization are the place where Medicare Advantage and therapy collide hardest: plans may waive the three-day rule, which helps, and may also charge daily copays from day one and review the stay for continued need, which is where many of the appeals we see arise. Some plans add a fitness benefit, a gym membership or class program that Original Medicare does not have, which is useful after a course of therapy ends.
In Original Medicare with a Medigap policy, each visit is the Medicare amount described above and the policy pays your share. Plan G pays the 20% on every evaluation and visit, the $217 daily copay for days 21 to 100 of a skilled nursing stay, the Part A deductible for a hospital or rehabilitation admission, and any excess charge from a non-participating therapist, leaving you the $283 Part B deductible once a year. Plan N pays the same except that it does not cover excess charges and adds a copay of up to $20 on some office visits; whether a therapy visit triggers that copay depends on how the insurer treats therapy claims, so ask before you buy. Our Plan G vs. Plan N guide works through the difference and the Medigap vs. Medicare Advantage guide covers the bigger choice. For a Utah retiree with a progressive condition who expects therapy to be a standing part of the year, the absence of per-visit copays, networks and authorizations is a real part of the Medigap argument; for one who expects a course after the occasional injury, $19 a visit is a modest sum either way.
A Washington County example: a fall in January
Consider a 71-year-old retired schoolteacher in St. George, in Original Medicare without a Medigap policy, who slips on an icy step in early January and bruises her hip and shoulder. Nothing is broken, but two weeks later she is still stiff and unsteady, and her doctor refers her for physical therapy. The clinic does a moderate-complexity evaluation, sends the plan of care to her doctor for signature, and schedules her twice a week for six weeks: an hour each visit of exercise, hands-on work on the shoulder, and practice on stairs and getting up from a chair. Nothing has yet been applied to her $283 Part B deductible for the year.
| Step | Visits | Medicare-approved amount | Your share in 2026 (Original Medicare, no Medigap) |
|---|---|---|---|
| Physical therapy evaluation, moderate complexity (97162) | 1 | $94.78 | 20% after the deductible |
| Treatment visits: two units of therapeutic exercise (97110), one of manual therapy (97140), one of therapeutic activities (97530), $93.64 each | 12 | $1,123.68 | 20% after the deductible |
| Total | 13 | $1,218.46 | $470.09: the $283 deductible plus 20% of the remaining $935.46; $243.69 if the deductible had already been met. Medicare pays $748.37 |
Illustrative; averages across all Utah claims for each code in 2024, not a price quote. Sources: CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024; CMS, 2026 Medicare Parts A & B Premiums and Deductibles.
Her year's therapy charges are $1,218.46, well under the $2,480 KX threshold, so no modifier and no notice are involved. If she had fallen again in September and needed another course, the second would have carried her past $2,480 around its twelfth visit; her therapist would have added the KX modifier and nothing about her bill would have changed. With Plan G she owes the $283 deductible and nothing else; with Plan N the same, plus whatever office-visit copay the insurer applies to therapy. In a Medicare Advantage plan she owes the plan's per-visit therapy copay times 13, with no deductible, which could be less or more than $470.09 depending on the amount, and the plan may have authorized the course in two blocks. Had the fall broken her hip, the sequence would have been different: surgery, two or three inpatient days, then either home health therapy at $0 or a skilled nursing stay at $0 for 20 days and $217 a day after, then outpatient therapy at 20%. Our 100-day skilled nursing guide covers that path.
What should a Utah retiree on Medicare actually do?
- Ask for the referral, and make sure the plan of care gets signed. Utah lets you walk into a physical therapy clinic without one, but Medicare pays only on a plan of care certified by a physician, nurse practitioner, clinical nurse specialist or physician assistant. Most clinics handle the signature; confirm it happened before the third visit, because an unsigned plan is the commonest reason a therapy claim is denied.
- Confirm the therapist is Medicare-enrolled and accepts assignment. 94% of Utah's private-practice physical therapists do, and every hospital department does; a cash-only clinic or a wellness studio with a therapist on staff is not covered at all. Medicare.gov's Care Compare lists enrolled clinicians by town.
- Know what a visit costs you. About $19 at Utah averages once the deductible is met, $19 for the evaluation, and the first $283 of the year's Part B charges in full. Ask the clinic how many units it typically bills per visit; a four-unit hour is normal, and a bill with six or seven units for a 45-minute visit is worth a question.
- Ignore anyone who says you have “used up” your therapy. There is no cap. The $2,480 figure is a point at which the therapist attests the care is still necessary and continues. If a clinic wants to stop at the threshold, ask whether the therapist believes you still need skilled care; if yes, the modifier is the clinic's job, not yours.
- If you have a progressive condition, say “maintain” and “Jimmo” out loud. Therapy to maintain function or slow decline is covered when it takes a therapist's skill. Ask your doctor and therapist to write the plan of care that way, and if a denial says only that you are not improving, appeal it with CMS's Jimmo fact sheet attached.
- After a hospital stay, ask “inpatient or observation?” before you accept a nursing-facility bed. Three inpatient days make the rehabilitation stay a Part A benefit at $0 for 20 days; observation days make it your bill. Home health therapy, at $0, is the alternative if you are homebound.
- If you are in Medicare Advantage, get the authorization and stay in network. Ask how many visits were approved and when the therapist must request more, and ask whether home health and skilled nursing carry copays under your plan. Our HMO vs. PPO guide explains why a PPO's out-of-network option can matter for therapy in a small town.
- Use the home program. The part of therapy Medicare does not pay for, the repetitions between visits, is the part that decides whether the course works. A therapist can also prescribe a walker or cane, which Medicare covers as equipment, and can re-evaluate you at $13 if things change.
We help Utah retirees understand what their Medicare coverage pays for, including how Medigap and Medicare Advantage each handle therapy visits, skilled nursing stays and the home health benefit, and how it fits with long-term care protection and retirement income. Plain English, no pressure. Education, not advice. We do not offer every plan available in your area.
Talk to a planner →Frequently asked questions
Does Medicare cover physical therapy?
Yes. Medicare Part B covers medically necessary outpatient physical therapy, occupational therapy and speech-language pathology when a doctor, nurse practitioner, clinical nurse specialist or physician assistant certifies the plan of care, and Medicare.gov states plainly that there is no limit on how much Medicare pays for medically necessary outpatient therapy in a calendar year. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026. Therapy at home under the home health benefit, in a skilled nursing facility after a three-day inpatient stay, and in an inpatient rehabilitation hospital is covered too, each under its own rules and cost-sharing. Medicare covers therapy to improve function and also to maintain function or slow decline; since the 2013 Jimmo settlement, coverage cannot be denied just because you are not expected to improve.
How much does physical therapy cost with Medicare in Utah in 2026?
At 2024 Utah average Medicare-approved amounts, an initial physical therapy evaluation was $94.78 and a typical hour-long treatment visit of four 15-minute units (two of therapeutic exercise at $22.06, one of manual therapy at $19.69 and one of therapeutic activities at $29.83) was $93.64, so your 20% is about $18.96 for the evaluation and $18.73 per visit once the $283 Part B deductible is met. A course of one evaluation and twelve visits is $1,218.46 in approved charges: $243.69 at 20%, or $470.09 if the deductible has not been met for the year. Medigap Plan G pays the 20% in full. In Medicare Advantage you pay the plan's per-visit copay instead, and the plan may require prior authorization or a referral.
Is there a cap on Medicare physical therapy visits in 2026?
No. The therapy caps created in 1997 were repealed by the Bipartisan Budget Act of 2018. What remains is a paperwork threshold: once your physical therapy and speech-language pathology charges together pass $2,480 of Medicare-approved amounts in 2026 (a separate $2,480 for occupational therapy), the therapist must add a KX modifier to each claim confirming that the care is still medically necessary and documented, and claims above the line without it are denied. Above $3,000 a claim can be selected for targeted medical review, though most are not. At 2024 Utah averages $2,480 is roughly an evaluation plus 25 treatment visits, so a single course of therapy rarely reaches it; a year with two injuries or a long recovery can.
Will Medicare pay for physical therapy if I am not getting better?
Yes, if you still need a therapist's skill. Medicare.gov's physical therapy page says the benefit covers therapy to improve or maintain your current function, or slow your rate of decline. CMS's Jimmo v. Sebelius settlement fact sheet states that coverage of therapy does not turn on the presence or absence of a beneficiary's potential for improvement from the therapy, but rather on the beneficiary's need for skilled care, and that a claim cannot be denied based on the absence of potential for improvement. The limit is skill, not progress: once a safe exercise program could be carried out by you, a family member or an aide without a therapist, Medicare stops paying for therapist visits, though a therapist can still be covered to design and periodically adjust the program.
How many Utahns on Medicare use physical therapy, and how does Utah compare?
More than almost anywhere. CMS's Market Saturation file counts 32,544 Utahns in Original Medicare with an outpatient physical or occupational therapy claim in 2025, 12.20% of fee-for-service beneficiaries against 9.72% nationally, 1.26 times the national rate, and the Utah count has nearly doubled since 2020 (16,980 and 7.27%). The 2024 claims file shows 29,100 Utahns in Original Medicare with therapeutic exercise billed by a Utah therapist, 15.86% of everyone with Part B in Original Medicare against 10.86% nationally, 1.46 times the national rate, and Utah evaluations rose from 20,309 in 2022 to 30,000 in 2024. Summit, Wasatch, Washington and Cache counties use therapy most; Juab, Beaver, Duchesne, Kane and Carbon counties least.
Where can a Utah retiree find a physical therapist who takes Medicare?
Almost everywhere in the state. CMS's clinician file lists 1,132 physical therapists in private practice with a Utah practice location, and 1,066 of them (94%) accept assignment, meaning they take the Medicare-approved amount as payment in full; the other 66 may charge up to 15% more. They are listed in 101 Utah towns, including Moab, Blanding, Monticello, Vernal, Roosevelt, Price, Castle Dale, Green River, Richfield, Delta, Fillmore, Bicknell, Kanab, Panguitch and Garden City, places that have no urologist or gastroenterologist. Hospital outpatient therapy departments, which bill under the hospital, add to that list but are not counted individually. Utah also lists 153 occupational therapists and 75 speech-language pathologists in private practice. In Medicare Advantage, use the plan's network directory, because an out-of-network therapist may not be covered.
Sources
- Medicare.gov — Physical therapy services (Part B covers medically necessary outpatient physical therapy to “restore or improve physical movement” or “improve or maintain your current function, or slow your rate of decline”; certification by a doctor, nurse practitioner, clinical nurse specialist or physician assistant; 20% after the Part B deductible; “there's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year”): medicare.gov — physical therapy; Occupational therapy services: medicare.gov — occupational therapy; Speech-language pathology services: medicare.gov — speech-language pathology
- Medicare.gov — Telehealth (through December 31, 2027, Medicare covers telehealth services from anywhere in the U.S., including your home; 20% after the deductible): medicare.gov — telehealth; Home health services (physical, occupational and speech therapy at home; “you pay nothing for covered services”; homebound and part-time skilled care conditions): medicare.gov — home health; Skilled nursing facility care (three-day qualifying inpatient stay; 2026: $0 for days 1–20 after the $1,736 deductible, $217 a day for days 21–100; therapy “to improve or maintain your current condition, or to prevent or delay it from getting worse”): medicare.gov — SNF care; Inpatient rehabilitation care (2026: $1,736 deductible for days 1–60): medicare.gov — inpatient rehabilitation
- CMS — Therapy Services, “Implementation of the Bipartisan Budget Act of 2018,” revised February 2026 (section 50202 repeals the therapy caps and exceptions process; KX modifier threshold $2,480 for CY 2026 for PT and SLP combined and $2,480 for OT, indexed by the Medicare Economic Index; claims over the threshold without the KX modifier are denied; targeted medical review threshold $3,000 through 2027; section 53107 payment at 85% for services furnished in whole or part by PTAs and OTAs with the CQ/CO modifiers since January 1, 2022; multiple procedure payment reduction of 50% on the practice expense of second and later therapy services on the same day; section 6209 of the Consolidated Appropriations Act, 2026 extending telehealth by PTs, OTs and SLPs through December 31, 2027; limitation of liability and ABN rules): cms.gov — therapy services
- CMS — Jimmo Settlement (settlement approved January 24, 2013; manual revisions under Change Request 8458 to the Medicare Benefit Policy Manual chapters 7, 8 and 15; FAQs) and the Jimmo v. Sebelius Settlement Agreement Fact Sheet (coverage “does not turn on the presence or absence of a beneficiary's potential for improvement from the therapy, but rather on the beneficiary's need for skilled care”; “coverage cannot be denied based on the absence of potential for improvement or restoration”; not an expansion of coverage): cms.gov — Jimmo settlement, cms.gov — fact sheet (PDF)
- CMS — 2026 Medicare Parts A & B Premiums and Deductibles, November 14, 2025 (Part B premium $202.90; Part B deductible $283; Part A deductible $1,736; skilled nursing facility coinsurance $217 a day for days 21–100): cms.gov — 2026 premiums and deductibles
- Medicare.gov — Does your provider accept Medicare as full payment? (assignment; non-participating providers; the 15% limiting charge): medicare.gov — assignment; Compare Original Medicare & Medicare Advantage (plans must cover all Part A and Part B services; networks and referrals): medicare.gov — compare
- CMS — Medicare Physician & Other Practitioners — by Geography and Service, calendar years 2022, 2023 and 2024 (Utah and National rows for 97161–97164, 97110, 97112, 97116, 97140, 97530, 97535, 97150, G0283, 97165–97167, 92507 and 92523; beneficiaries, units of service, billing therapists, average submitted, approved and paid amounts): data.cms.gov — physicians by geography and service
- CMS — Market Saturation & Utilization State-County, type of service “Physical & Occupational Therapy,” reference periods 2020 through 2025 (Utah 2025: 32,544 users, 12.2% of fee-for-service beneficiaries, 1,040 providers, $29,206,612.83 paid; Utah 2020: 16,980, 7.27%, 425 providers; nation 2025: 3,839,619 of 39,522,162, 9.72%, 95,124 providers; all 29 Utah counties) and its methodology (providers counted when they have paid claims for more than ten beneficiaries in the county): data.cms.gov — market saturation, data.cms.gov — methodology
- CMS — Medicare Monthly Enrollment (people with Part B in Original Medicare: Utah 197,316 in 2022, 188,838 in 2023, 183,494 in 2024; U.S. 27,982,142 in 2024; June 2026: 490,235 Utah beneficiaries, 269,226 in Medicare Advantage): data.cms.gov — monthly enrollment
- CMS — Doctors and Clinicians National Downloadable File, retrieved October 9, 2026 (1,132 Utah physical therapists in private practice, 1,066 accepting assignment; 153 occupational therapists, 130 accepting assignment; 75 speech-language pathologists, 64 accepting assignment): data.cms.gov — doctors and clinicians
- CDC — PLACES: Local Data for Better Health, County Data, 2025 release (measure MOBILITY, crude prevalence of mobility disability among adults 18 and older, 2023 BRFSS; all 29 Utah counties and the United States, 13.5%): data.cdc.gov — PLACES county data
- Utah Insurance Department — Medicare consumer page (Utah SHIP (877) 424-4640): insurance.utah.gov
About this article. Written by the Utah Retirement Income Data Desk and reviewed by Brian Penner, Retirement income & long-term care planner. Educational only — not medical, financial, or legal advice, and not a recommendation of any specific plan, provider, clinic, facility or treatment; whether you need therapy, what kind, and for how long is a decision for you, your doctor and your therapist. Coverage rules and cost-sharing are quoted from Medicare.gov and CMS as of October 9, 2026; the Utah and national beneficiary counts, shares, units and average amounts are our own tabulation of the CMS Physician & Other Practitioners, Market Saturation & Utilization, Doctors and Clinicians and Medicare Monthly Enrollment public use files, which count Original Medicare claims only, attribute each claim to the state of the billing therapist or practice (or, in the Market Saturation file, the county where the beneficiary lives), exclude hospital-based therapy departments from the clinician-level counts, and are revised by CMS periodically; a person can appear under more than one billing code; the mobility-disability figures are CDC survey estimates for all adults with the limitations noted on their source page; the clinician counts are the CMS file as retrieved on that date. Average Medicare-approved amounts are averages across all claims and are not price quotes; the “typical visit” is an illustration of one common combination of units; Medicare Advantage copay and authorization descriptions are general and vary by plan; the example household is illustrative. What you will owe depends on your coverage, your therapist, the setting, how many units are billed, whether each provider accepts assignment or is in your plan's network, and whether your deductible has been met; confirm with your plan, your provider, or 1-800-MEDICARE before you act. Utah Retirement Income is a licensed independent insurance agency (NPN 16493717) and is not a government agency; we are not connected with or endorsed by Medicare, the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the Social Security Administration, or any government program, and nothing here should be read as an endorsement by them. 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 State Health Insurance Assistance Program — in Utah, the Utah SHIP at (877) 424-4640 — to get information on all of your options. A $0-premium Medicare Advantage plan is not free; you still pay the Part B premium ($202.90 a month in 2026 for most people) and the plan's cost-sharing. Long-term care insurance and annuity guarantees depend on the claims-paying ability of the issuing company, with no promise of savings. If you call or text us, you consent to be contacted at the number you provide about your options; message and data rates may apply, and you can opt out at any time by replying STOP.