Network Access for Physical and Occupational Therapists

Physical and occupational therapy practices are often told a plan has enough therapy providers, yet Medicare Advantage networks are measured on physical therapy and occupational therapy access county by county. Here is how those standards work, what federal nondiscrimination rules cover, and how a therapy practice builds a case when a panel says no.

Outpatient physical therapy and occupational therapy practices hear the same answer as everyone else when a panel closes: the plan has enough providers in your area. For therapy, though, that claim is often easier to test than it is for physicians, because Medicare Advantage measures therapy access directly and because therapy demand is local. A patient recovering from a joint replacement will not drive an hour three times a week.

Are physical and occupational therapy measured in Medicare Advantage networks?

Yes. CMS's network adequacy rule lists "Physical Therapy," "Occupational Therapy" and "Speech Therapy" among the facility-specialty types every Medicare Advantage network is evaluated on (42 CFR 422.116(b)(2)(ix) to (xi)). For those types, the minimum number requirement is 1 (422.116(e)(2)(iii)), but the time and distance standard applies county by county: at least 90 percent of beneficiaries in large metro and metro counties, and 85 percent in micro, rural and counties with extreme access considerations, must have access within the published limits (422.116(d)(4)).

The minimum count of one is why plans close therapy panels early. The time and distance test is why a practice in an under-served part of a county can still matter. If the plan's contracted therapy sites cluster in one city, beneficiaries elsewhere in the county may be outside the standard. Our post on time and distance standards shows how plans meet them on paper.

Can a plan refuse therapists as a category?

Not solely by license. Group health plans and issuers "shall not discriminate with respect to participation" against a provider acting within the scope of a state license (42 U.S.C. 300gg-5(a)), and Medicare Advantage (42 CFR 422.205(a)) and Medicaid managed care (438.12(a)(1)) plans have parallel rules. None of those provisions requires a plan to contract with a particular therapist, and plans may decline providers beyond the number they need (422.205(b)(1); 438.12(b)(1)).

In practice, therapists rarely face a categorical exclusion. More common is a closed panel for a specialty and area, or a plan that routes therapy through a contracted management company. In the second case, ask who actually controls admission; the dispute may belong with the vendor's network team rather than the plan's.

What evidence works for a therapy practice?

Distance and drive time from the ZIP codes you serve to the nearest in-network therapy site the plan lists, compared to CMS's published county standards for the year.
Real availability. Call listed sites and record which accept new patients for the plan and the first available evaluation date. Medicare Advantage directories must be kept current through the plan's provider directory API, "updated no later than 30 calendar days" after the plan receives new information (42 CFR 422.120(b)(1)); see provider directory accuracy rules.
Services others do not offer. Pelvic floor therapy, vestibular rehabilitation, lymphedema care, hand therapy, pediatric feeding, driver rehabilitation, aquatic therapy, or home-based visits.
Referral demand. Letters from referring surgeons, physiatrists or pediatricians about where their patients in that plan are going and how long they wait.

Is the problem enrollment rather than the panel?

Sometimes. Medicare Advantage plans check "eligibility for payment under Medicare" when they credential (42 CFR 422.204(b)(2)(i)), so a therapist who is not enrolled in Medicare, or whose enrollment is stuck, may be denied for that reason. Therapists in private practice are suppliers for Medicare enrollment appeals (42 CFR 405.800(d)), and physical and occupational therapists can bill retroactively up to 30 days before their effective date when circumstances prevented earlier enrollment (424.521). White Glove DPT explains why a license is not payer enrollment, and White Glove OT covers Medicare for occupational therapists.

What if you are joining or opening a clinic?

A therapist joining a clinic that already participates usually has a far easier path than a new solo practice; see joining a participating group and group or individual contracts. A new location of an existing practice raises a different question: whether the plan will extend your contract to the new address. Ask before you sign a lease.

Where does state law help?

Kentucky's any willing provider statute applies to health insurers for any provider in the plan's geographic area willing to meet its terms, and Virginia's applies to PPO policies. Texas requires PPOs to give a fair opportunity to apply and an advisory review of denials. Several states also set credentialing deadlines. Check your state on the network access laws index; none of these laws reach self-funded employer plans.

How do we help?

We map the plan's listed therapy sites against your service area, run the availability calls, and prepare the dispute letter and evidence for your signature. You send it; we track the response and any reconsideration window. We do not represent practices or give legal advice. Pricing is on our pricing page: a $249 review credited toward a $799 per-payer dispute, or $1,999 for three payers, and a flat win fee only when a plan offers participation. Legal questions, such as what a contract term means or whether to pursue a hearing, belong with a healthcare attorney.

Common questions

Do Medicare Advantage plans have to include physical therapists?

Physical therapy and occupational therapy are facility-specialty types CMS evaluates in every MA network (42 CFR 422.116(b)(2)). The minimum number for those types is one, but time and distance standards also apply in each county.

Can a commercial insurer refuse all physical therapists?

Federal law bars group plans and issuers from discriminating in participation solely by license (42 U.S.C. 300gg-5). It does not require them to contract with any particular therapist willing to accept their terms.

My therapy clinic was denied because the network is full. What evidence helps?

Drive time and distance from the areas you serve to the nearest listed in-network sites, calls showing which listed sites accept new patients, services others do not offer, and referral letters describing waits or travel.