Does Medicare or Medicaid Pay for Physical Therapy in New York? MLTC, MAP, and MMC Explained

Physical therapy can help someone recover movement after surgery, walk more safely after a hospital stay, manage a long-term condition, or maintain function. In New York, the steps for getting therapy depend on which coverage pays for the medical visit and whether treatment will take place in a clinic or at home.

A person may have both Medicare and Medicaid, yet their Medicare plan and Medicaid long-term-care plan may be separate organizations. That distinction is especially important for members of a partially capitated Managed Long Term Care plan, commonly called MLTC.

This guide explains which plan to call, who generally pays, and what to do when therapy is delayed or an approval is running out.

First, identify every plan the person has

Before seeking physical therapy, gather all insurance cards and identify:

Medicare: Original Medicare or a Medicare Advantage plan, including a D-SNP.

Medicaid: Medicaid fee-for-service, a Medicaid Managed Care plan, a Health and Recovery Plan (HARP), or a long-term-care plan.

Long-term-care arrangement: MLTC Partial Capitation, Medicaid Advantage Plus (MAP), or PACE, if applicable.

MLTC Partial Capitation, MAP, and a standard Medicaid Managed Care plan are different products. An MLTC card does not necessarily replace a separate Medicare card. New York describes MAP as an arrangement for people with both Medicare and Medicaid, while partial-capitation MLTC covers a defined package of community-based long-term services. https://www.health.ny.gov/health_care/managed_care/mltc/partial_cap.htm and https://www.health.ny.gov/health_care/managed_care/mltc/map.htm

If you have MLTC Partial Capitation and Medicare

This is the situation most likely to cause a family to be sent between plans. Start by identifying the exact type of therapy being requested.

For physical therapy at a clinic

Medicare is generally the first coverage to check for Medicare-covered outpatient physical therapy. If the person has Original Medicare, ask the clinic whether it accepts Medicare. If the person has Medicare Advantage or a D-SNP, use that Medicare plan’s therapist network and ask about its referral and authorization rules.

Tell the MLTC care manager that therapy has been recommended, particularly if it affects the member’s ability to manage daily activities. But do not assume that an MLTC authorization for home care aides is the authorization a clinic needs to bill the separate Medicare plan. Medicare generally pays first for Medicare-covered services when a person also has Medicaid. https://www.medicare.gov/basics/costs/help/medicaid and https://www.medicare.gov/coverage/physical-therapy-services

What to say to the clinic: “This patient has Medicare and MLTC Medicaid. Please verify the Medicare therapy benefit first and tell us whether you can process any applicable secondary coverage.”

For therapy through a certified home health agency

Ask the clinician whether the patient qualifies for Medicare home health physical therapy. This benefit generally requires the person to be homebound, need qualifying part-time or intermittent skilled services, have care ordered by an eligible provider, and receive it from a Medicare-certified home health agency.

The MLTC plan’s authorization for personal care does not by itself establish Medicare home health eligibility. Likewise, Medicare home health PT does not automatically increase or replace the MLTC personal-care hours. The two organizations should coordinate around the patient’s needs, but they administer distinct benefits. https://www.medicare.gov/coverage/home-health-services and https://www.health.ny.gov/health_care/managed_care/mltc/coverservices.htm

What to say to the MLTC care manager: “Medicare home health PT is being evaluated. Please review whether the therapy findings change the member’s long-term-care needs or care plan.”

If Medicare denies the proposed therapy

Get the reason in writing. A denial might concern medical necessity, the homebound requirement, the provider, the setting, or a Medicare Advantage authorization. The next step depends on that reason.

Ask the MLTC plan whether the proposed service is within its benefit package or whether a Medicaid benefit outside the MLTC package may apply. Have the provider identify the correct payer before starting visits. A Medicare denial does not automatically transfer the bill to MLTC or Medicaid. New York notes that MLTC covered services vary by plan type. https://www.health.ny.gov/health_care/managed_care/mltc/coverservices.htm

What if someone says they have MLTC but do not have Medicare?

Check the exact plan name and enrollment first. New York identifies people with both Medicare and Medicaid among those subject to mandatory MLTC Partial Capitation enrollment when other criteria are met. Someone who says “I have MLTC” may mean a different Medicaid plan, may have recently gained or lost Medicare, or may be in a different long-term-care arrangement. Do not assume that every Medicaid-only member has a standard partial-capitation MLTC plan. https://www.health.ny.gov/health_care/managed_care/mltc/partial_cap.htm

If there is no active Medicare coverage, Medicare cannot be billed for the therapy. The member or provider should call the Medicaid plan listed on the card and ask:

“Is outpatient physical therapy included in this plan’s benefit package, or is it paid by Medicaid fee-for-service? Who authorizes clinic visits, and who authorizes therapy delivered at home?”

For Medicaid-only patients in standard MMC or HARP, the Medicaid managed care plan is generally the place to start for covered outpatient PT. For any person actually enrolled in an MLTC product without active Medicare, obtain that plan’s written explanation of benefits and payer responsibility rather than relying on a general rule about dual-eligible MLTC members.

New York’s MLTC covered-services page is here: https://www.health.ny.gov/health_care/managed_care/mltc/coverservices.htm. Its Medicaid Managed Care member handbook is here: https://www.health.ny.gov/health_care/managed_care/medicaid/mmc_model_member_handbook.htm.

If you are enrolled in Medicaid Advantage Plus, or MAP

Call the MAP plan first. New York’s MAP arrangement brings together a Medicare plan and Medicaid managed long-term-care coverage. The plan should identify a participating physical therapist, explain which part of the benefit applies, and tell the member whether clinic or home treatment requires approval. https://www.health.ny.gov/health_care/managed_care/mltc/map.htm and https://www.health.ny.gov/health_care/managed_care/mltc/map_member_hndbk.htm

A MAP member can say:

“My clinician ordered physical therapy. Please coordinate my Medicare and Medicaid benefits, identify a therapist who can treat me, and explain whether this should be clinic PT, outpatient PT at home, or certified home health PT.”

Ask for one contact person or care manager to follow the request through both sides of the coverage. If the plan says a service belongs to a different benefit or provider network, request the name of the responsible department and a clear next step.

An approval for personal care through MAP is not itself a PT authorization. The plan should evaluate each requested service under its applicable benefit.

If you have a D-SNP plus a separate MLTC plan

A D-SNP is a Medicare Advantage plan for people who also have Medicaid. It is not always the same arrangement as MAP. If the person has a D-SNP card and a separate partial-capitation MLTC card:

Call the D-SNP about Medicare-covered outpatient clinic PT, its therapist network, and its authorization rules.

Ask about Medicare home health through the Medicare plan when a certified home health agency is being considered.

Call the MLTC care manager about the member’s long-term-care services and whether therapy findings require a reassessment of the long-term-care plan.

Ask the two plans to identify the payer for a proposed service before the first visit. https://www.medicare.gov/health-drug-plans/health-plans/your-health-plan-options/SNP and https://www.health.ny.gov/health_care/managed_care/mltc/partial_cap.htm

If you have standard Medicaid Managed Care or HARP

For MMC, call the Medicaid health plan on the member card and request an in-network PT provider. Ask whether the evaluation, subsequent visits, or a home setting requires authorization.

For HARP, also start with the HARP’s member-services team or care manager. HARP’s behavioral health focus does not mean a patient must seek physical therapy through a mental health provider; ask the plan to process PT under the appropriate medical benefit. https://www.health.ny.gov/health_care/managed_care/medicaid/mmc_model_member_handbook.htm and https://omh.ny.gov/omhweb/bho/enrollment-process.html

If someone with MMC or HARP also has newly active Medicare, tell the Medicaid plan and the therapist immediately. Medicare generally becomes the first payer for Medicare-covered therapy, and the person’s Medicaid plan arrangement may need to change or be clarified. https://www.medicare.gov/basics/costs/help/medicaid and https://www.health.ny.gov/health_care/medicaid/redesign/mltc_policy_15-02.htm

Who approves clinic PT, outpatient PT at home, and certified home health PT?

The word “home” does not identify the benefit. Ask the payer which of these three services the clinician is requesting:

Requested care Main question to resolve Who should the member contact?

Outpatient PT at a clinic Which medical plan covers the visits, and is the clinic in network? The Medicare plan when Medicare is active and covers the service; otherwise the responsible Medicaid plan or fee-for-service program. Outpatient PT delivered in the home Does the payer allow the eligible outpatient provider to treat and bill for visits at home, and is a separate authorization required for that location? The plan responsible for the outpatient PT benefit. Do not rely on a clinic authorization without confirming the home setting. CMS discusses outpatient therapy furnished in a patient’s home at https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56566. PT through a Medicare-certified home health agency Does the person meet Medicare’s homebound, skilled-care, ordering, and agency requirements? Original Medicare and the referring clinician, or the member’s Medicare Advantage, D-SNP, or MAP plan and its home health network. https://www.medicare.gov/coverage/home-health-services A Medicaid home health or long-term-care therapy service Is this specific service part of the member’s Medicaid plan package, and who must authorize the agency and visits? The responsible Medicaid managed care plan, MLTC care manager, MAP plan, or Medicaid fee-for-service program, as applicable. https://www.health.ny.gov/health_care/managed_care/mltc/coverservices.htm

Homebound status is required for Medicare’s home health benefit. It is not a blanket rule for every outpatient therapy visit furnished in a home. A patient does not have to be homebound to receive outpatient PT at a clinic. https://www.medicare.gov/coverage/home-health-services and https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56566

How many visits can you receive?

There is no universal number of weeks under Medicare, MMC, HARP, MLTC, MAP, or PACE. A managed plan may authorize a defined number of visits and then evaluate a request for continued treatment.

Original Medicare has no annual dollar cap on medically necessary outpatient PT. Medicare also does not impose a universal six-week limit on qualifying certified home health PT, although home health eligibility and the need for each service must continue. https://www.medicare.gov/coverage/physical-therapy-services and https://www.medicare.gov/coverage/home-health-services

New York Medicaid states that medically necessary PT can continue beyond the former 40-visit annual figure. Effective July 1, 2024, the state also removed prior authorization for medically necessary PT visits under Medicaid fee-for-service. That fee-for-service change should not be assumed to eliminate an MMC, HARP, MLTC, or MAP plan’s applicable review process. https://www.health.ny.gov/health_care/medicaid/program/update/2021/no05_2021-04.htm and https://health.ny.gov/health_care/medicaid/program/update/2024/no05_2024-05.htm

Ask the plan for the approved number of visits, approval dates, treatment setting, and process for requesting more care. Those four details are more useful than an outdated general visit limit.

Why can Medicare home health therapy end while an MLTC member still gets daily home care?

Medicare home health PT is skilled treatment. MLTC personal care addresses long-term help with daily activities under a separate Medicaid benefit. A person’s need for one does not automatically prove continued eligibility for the other.

Medicare home health generally requires that the patient remain homebound and need qualifying part-time or intermittent skilled services. The care plan must be reviewed at least every 60 days if services continue. Sixty days is a review cycle, not a maximum length of coverage. Medicare says qualifying beneficiaries may receive an unlimited number of home health visits, subject to continued eligibility and medical necessity. https://www.medicare.gov/coverage/home-health-services and https://www.cms.gov/training-education/medicare-learning-networkr-mln/compliance/medicare-provider-compliance-tips/home-health-services

If skilled home health PT ends, the patient might still qualify for outpatient PT at a clinic. If the patient continues to need assistance with bathing, dressing, or other daily activities, the MLTC care manager should review those needs separately. Medicare does not ordinarily pay for long-term personal care when that is the only care needed. https://www.medicare.gov/coverage/physical-therapy-services and https://www.medicare.gov/coverage/long-term-care

Will Medicaid pay what Medicare leaves unpaid?

For someone with both programs, Medicare generally pays first for a Medicare-covered PT service, and Medicaid pays last. Do not assume Medicaid pays every dollar of the Medicare deductible or coinsurance. The patient’s eligibility category and payment rules matter. Give the therapist all coverage cards and ask the office to verify secondary billing before issuing a patient bill. https://www.medicare.gov/basics/costs/help/medicaid

People in the Qualified Medicare Beneficiary (QMB) program have a specific protection: providers cannot bill them for Medicare Part A or Part B deductibles, coinsurance, or copayments on Medicare-covered services. A small Medicaid copayment may apply in some circumstances. and

A Medicare denial does not automatically make Medicaid the payer. Ask for the denial reason, then have the responsible Medicaid plan determine whether the proposed treatment independently qualifies under its benefit rules.

A practical call script for families

Give the plan the patient’s insurance identification, the clinician’s PT order, and the proposed treatment setting. Then ask:

“My clinician ordered physical therapy. I need to know whether Medicare or Medicaid is responsible for this exact service. Is treatment covered at a clinic, through a certified home health agency, or as outpatient PT in the home? Which providers can take the case? Is authorization required, how many visits are approved, and who handles an extension?”

If the person has separate Medicare and MLTC plans, call both and record each answer. If the person has MAP, begin with the MAP care team and ask it to coordinate the request. If the person has MMC or HARP without Medicare, begin with that Medicaid plan.

Before an approval ends, ask the therapist to document the continuing skilled need and submit any required request for more visits. If coverage is denied or reduced, request the written decision and its appeal instructions.

The takeaway

To get physical therapy without unnecessary delays, identify the exact insurance product, the treatment setting, and the payer responsible for that benefit. For a person with separate Medicare and MLTC coverage, Medicare is generally the first payer for Medicare-covered PT, while MLTC manages its defined long-term-care benefits. With MAP, the integrated plan should coordinate both sides. With standard MMC or HARP and no Medicare, begin with the Medicaid managed care plan.

Marton Care Health Center is preparing multidisciplinary services, including physical therapy, in East Flatbush, Brooklyn. Visit for updates. Confirm service availability and participation with your specific health plan before scheduling.