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Medicare Physical Therapy & Rehab Coverage in Sioux Falls 2026: What Part B Pays for PT, OT, and Speech Therapy

No annual cap, a 20% gap with no ceiling, and two health systems competing for your rehab dollar — here's how the numbers actually work.

Big Sioux Benefits Data Desk

Published July 18, 2026 · 9 min read · Sourced from CMS.gov & CDC

Medicare Part B covers outpatient physical therapy, occupational therapy (OT), and speech-language pathology — but not without a cost-sharing gap that surprises many Sioux Falls beneficiaries. After the $257 annual Part B deductible, Medicare pays 80% of the approved amount and leaves 20% on you with no annual ceiling under Original Medicare alone.

Every figure below comes from public federal data — the CMS PY2026 plan landscape, CMS Hospital Compare star ratings, CDC PLACES 2023 county health data, and the CMS standardized Medigap coverage matrix. No invented numbers.

What Medicare Part B Covers — and What It Doesn't

Outpatient rehabilitation therapy breaks into three distinct services, each carrying the same cost-sharing structure but different eligibility triggers:

• Physical therapy (PT) — restoring movement, strength, and function after injury, surgery, or a chronic condition like arthritis or a joint replacement. Sanford and Avera both run extensive outpatient PT departments widely used by Sioux Falls Medicare beneficiaries.
• Occupational therapy (OT) — relearning activities of daily living (ADLs) after a stroke, injury, or joint replacement. Covers adaptive equipment, fine motor retraining, and home-safety assessment for patients returning home after surgery or hospitalization.
• Speech-language pathology (SLP) — recovering speech, language, or swallowing function. Common after stroke, traumatic brain injury, oral or throat cancer, Parkinson's disease, or other neurological conditions.

For all three, Medicare Part B requires: (1) a physician or other qualified provider orders and periodically certifies a written plan of care; (2) the therapy is medically necessary, meaning it requires the skill of a licensed therapist to perform or safely supervise; and (3) the provider accepts Medicare assignment. Your therapist must also document measurable progress or — since the 2013 Jimmo v. Sebelius settlement — document that a therapist's clinical judgment is needed to maintain function or prevent decline.

What Medicare does not cover in an outpatient rehabilitation context: purely recreational fitness programs, gym memberships, non-prescribed exercise classes, or care that can be safely carried out by the patient alone without a therapist's skill. Maintenance programs run by non-credentialed staff are not covered. If therapy has reached a plateau and no longer requires a therapist's clinical judgment, Medicare coverage ends — though you have appeal rights if you disagree.

The 20% Gap — Your Real Cost Under Original Medicare

The cost structure is straightforward but often underestimated. Once you've met the $257 annual Part B deductible, Medicare pays 80% of the approved amount for every covered therapy session. You owe the other 20% — with no dollar ceiling on your annual exposure under Original Medicare alone.

Under Original Medicare without a supplement, there is no yearly ceiling on that 20%. A beneficiary recovering from a total knee replacement who needs 30–40 outpatient PT sessions over several months is accumulating uncapped 20% coinsurance on each visit. That's precisely the gap that Medigap supplements and Medicare Advantage annual MOOP protections are designed to close.

Note that the Part B deductible resets every January 1. A therapy episode that bridges two calendar years — say, a fall surgery with rehab running through the new year — means paying two deductibles, one per year.

No Annual Therapy Cap — But a Medical Review Threshold Exists

A widespread misconception among Medicare beneficiaries: "Medicare only covers a certain number of PT visits per year." That was partially true under the old Medicare therapy spending cap, which Congress permanently eliminated effective January 1, 2018 (Bipartisan Budget Act of 2018, §50202). There is no longer a hard annual dollar limit on covered PT, OT, or SLP services.

What does exist is a CMS-set annual spending threshold above which therapy claims are flagged for targeted medical review. When a beneficiary's therapy expenditures cross that threshold in a calendar year, Medicare administrative contractors (MACs) review claims more carefully to confirm continuing medical necessity. Exceeding the threshold does NOT end your coverage — therapy continues as long as your clinician documents ongoing medical necessity using the KX modifier on each claim. CMS adjusts this threshold each year; your therapist or provider billing department will know the current figure.

If Medicare or a Medicare Advantage plan denies a therapy claim, you have structured appeal rights: a Redetermination by the MAC, a Reconsideration by a Qualified Independent Contractor (QIC), an Administrative Law Judge hearing, and further federal review levels. Pursue an appeal if you believe care was medically necessary and properly documented.

Why Minnehaha County's Health Profile Drives High PT Demand

Sioux Falls is not an average Medicare market. CDC PLACES 2023 data for Minnehaha County shows a chronic-condition burden that directly generates physical therapy, occupational therapy, and speech therapy demand:

Source: CDC PLACES: Local Data for Better Health, County 2023 (2023), Minnehaha County adults.

Arthritis alone — at 22.9% of Minnehaha County adults — translates to roughly 9,053 of the county's 39,532 Medicare beneficiaries managing a condition that commonly leads to outpatient PT before and after joint-replacement surgery, or for ongoing pain management. Coronary heart disease (5.5% of adults) generates cardiac rehabilitation demand — a structured, Medicare-covered Part B program for qualifying cardiac events. COPD (5.6%) drives pulmonary rehabilitation, also a covered Part B benefit. Depression (22.3%) appears frequently as a comorbidity alongside conditions requiring rehab, often extending treatment timelines.

Sanford vs. Avera: Choosing Your Outpatient Rehab Network

Sioux Falls' two health systems each operate extensive outpatient rehabilitation networks, and both carry strong CMS hospital quality ratings that reflect the quality of their care overall:

Source: CMS Hospital Compare — Overall Star Ratings.

Under Original Medicare, you can use any Medicare-participating provider — Sanford or Avera — at the same 80/20 cost-sharing without a referral to a specific system. Under a Medicare Advantage PPO, you retain the right to go out of network, but your cost-sharing is typically lower when you stay in-network. Importantly, Sanford's Align plans favor in-network Sanford rehab facilities — if your orthopedic surgeon, cardiologist, or neurologist is at Avera, confirm that your specific Avera therapy location is in-network before you schedule the first session. Getting that wrong partway through a rehabilitation course can affect your cost-sharing mid-episode.

How Medigap Plan G and Plan N Handle Your Therapy Bills

A Medigap supplement that covers Part B coinsurance converts an open-ended 20% exposure into a fixed, predictable annual deductible. The standardized Medigap plan matrix shows exactly which plans protect you from the therapy cost-sharing gap:

Source: CMS — Choosing a Medigap Policy (Publication 02110), standardized per 42 CFR §403.205.

Plan G is the most comprehensive option for beneficiaries who enrolled in Medicare Part B on or after January 1, 2020. After the $257 annual deductible, Plan G picks up 100% of the 20% coinsurance on every covered service — including every PT, OT, or speech therapy session. A beneficiary going through a 12-week post-hip-replacement PT course averaging two visits per week faces 24 sessions of coinsurance exposure; Plan G makes that entire course $0 after the deductible, regardless of the approved amount per session.

Plan N covers the 20% coinsurance but charges a $20 copay per office visit. For a 24-session PT episode, that's $480 in copays above the deductible — often significantly less than the uncapped 20% at higher per-session approved amounts, but a real ongoing cost to plan for. Plan N also does not cover excess charges (the 15% some non-participating providers can bill above Medicare's approved amount). Confirm that your Sanford or Avera therapist participates with Medicare before you start.

One critical timing note: your guaranteed-issue Medigap window is when you first enroll in Medicare Part B (usually at 65). After that window, South Dakota carriers can medically underwrite — and conditions like arthritis, past joint replacements, or coronary heart disease can make Medigap more expensive or unavailable. If you're approaching 65 and expect to need therapy services, the turning-65 window is the lowest-cost time to secure Medigap.

How Sioux Falls' 5 Medicare Advantage PPOs Cover Outpatient Therapy

Medicare Advantage PPOs must cover all services that Original Medicare covers — including PT, OT, and SLP — and replace the uncapped 20% coinsurance with their own cost-sharing structure plus an annual maximum out-of-pocket (MOOP) that places a hard yearly ceiling on what you owe. Here is the full 2026 standard PPO roster in Minnehaha County:

Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County, 2026.

For therapy-intensive users — a beneficiary managing arthritis who anticipates regular PT, or someone recovering from a major surgery — the MOOP protection of an Advantage PPO can be more valuable than open-ended 20% exposure under Original Medicare alone. The trade-off is prior-authorization requirements: most PPOs require authorization before extended therapy episodes, and approval must be renewed as treatment progresses. Under Original Medicare, any licensed Medicare-participating therapist can continue billing for medically necessary care without plan pre-authorization (though CMS's own contractors conduct targeted reviews at higher utilization).

Two plans — Aetna Medicare Signature and Sanford's Align ChoicePlus — carry a $0 monthly premium. Align ChoicePlus is Sanford-backed; in-network PT at Sanford rehab locations is the preferred cost-sharing tier. If your orthopedic surgeon, cardiologist, or neurologist is in the Avera system and refers you to Avera rehab, confirm that Avera therapy sites are covered in-network for your specific Align plan before your first appointment. The other three plans — Aetna Enhanced Extra, Align ChoiceElite, and Wellmark Blue Medicare Advantage Enhanced — include higher premiums that often come with lower per-visit cost-sharing and different prior-auth thresholds; compare your expected therapy utilization against each plan's Evidence of Coverage.

All five plans carry a 3.5★ CMS overall rating for 2026 — the Average tier in CMS's stability classification. No plan in the Sioux Falls area holds a 4★ or higher standard PPO rating this year, which means the year-round 5-star Special Enrollment Period is not available locally.

Cardiac Rehab, Pulmonary Rehab, and Specialty Programs

Beyond the standard PT/OT/SLP trio, Medicare Part B covers two specialty rehabilitation programs relevant to Minnehaha County's health profile:

• Cardiac rehabilitation — a structured, medically supervised program covered after a qualifying cardiac event (heart attack, coronary artery bypass surgery, stable angina, percutaneous transluminal coronary angioplasty or stenting, heart valve repair/replacement, or heart/heart-lung transplant). Medicare covers up to 36 sessions in Phase II; 72 sessions in intensive cardiac rehab programs. With 5.5% coronary heart disease prevalence in Minnehaha County, this benefit reaches thousands of local beneficiaries. The same 80/20 cost-sharing applies.
• Pulmonary rehabilitation — a Medicare-covered Part B benefit for moderate-to-severe COPD. With 5.6% COPD prevalence locally, eligible beneficiaries can access supervised exercise and education programs through Sanford and Avera pulmonary services. Same cost-sharing as outpatient PT.

Both programs require physician certification of medical necessity and a formal plan of care. Both face the same Medigap and Advantage PPO cost-sharing dynamics described above.

What to Watch in 2026

1. Confirm Medicare assignment status before your first session — a non-participating therapist can bill up to 15% above Medicare's approved amount, an exposure only Medigap Plan G covers.
2. Track your Part B deductible across services — the $257 deductible resets every January 1 and applies to all Part B services collectively, not per-therapy-type. If you had imaging or outpatient procedures earlier in the year, you may have already met it.
3. Understand your Advantage plan's prior-auth renewal cycle — many PPOs issue therapy authorizations in blocks (e.g., 10 sessions); when that block runs out, your therapist must request a renewal before the next visit or the claim may be denied.
4. Review your plan's AEP changes (Oct 15–Dec 7) — PPOs can change their therapy copays, MOOP, and prior-auth requirements every year. If you're in active rehab, read your Annual Notice of Change before Dec 7.
5. Know the Jimmo settlement — if your therapy claim is denied because you're "not improving," that denial may be wrongly applying the old improvement-standard rule. The correct standard since 2013 is whether a therapist's clinical skill is needed to maintain function or prevent decline, not whether measurable improvement must occur.

How we know this: Big Sioux Benefits runs every article through a data desk that cross-references the CMS plan landscape, county enrollment, 2026 star ratings, hospital quality data, and CDC health data — built by Strategic AI Architects. Every figure here is from a public federal dataset. The Medigap coverage matrix follows CMS Publication 02110 (standardized plan rules per 42 CFR §403.205). This is education, not advice; confirm your plan, costs, and coverage with a licensed agent or Medicare.gov. We take no payment from any carrier to feature a plan.