Selling PT Packages: What State Boards Said in 2026
Two physical therapy boards said no to prepaid visit packages in 2026. The North Carolina Board of Physical Therapy Examiners published an article stating that selling a pre-determined number of visits in advance, or discounting services for prepaying, violates the state’s practice act. In August 2026 the Texas Board of Physical Therapy Examiners answered a licensee who asked whether Texas would see it the same way: yes, and the board pointed to a criminal patient-solicitation statute, not a billing rule.
In the same two states, plus Wyoming, chiropractic boards regulate prepaid treatment plans instead of banning them. Each requires a written plan and a refund of unused funds if the patient cancels, North Carolina and Texas require a defined visit count with a pro-rata refund, and Wyoming adds an escrow requirement for the funds. That contrast, one board treating prepayment as an inducement to solicit patients, another treating it as a regulated consumer contract, means the answer to “can I sell packages” depends entirely on which board licenses you.
There is also a widely cited correction to make. The Texas rule most often quoted online as “the” prepaid-package rule for physical therapy, 22 TAC §75.5, “Prepaid Treatment Plans,” is not a physical therapy rule at all: it belongs to the Texas Board of Chiropractic Examiners. A Texas-licensed physical therapist cannot rely on it, and the Texas PT board’s own rules contain no prepaid-plan provision to substitute for it. This post lays out what each board said and cited in 2026, what the chiropractic rules require where prepaid plans are allowed, and which pricing structures hold up under either regulatory theory. Current as of September 2026.
Can a physical therapist sell prepaid packages right now?
By state, as of this writing:
- North Carolina: No, as described in the state PT board’s own 2026 article (see below).
- Texas: No, per the Texas Board of Physical Therapy Examiners’ August 2026 answer to a licensee question.
- Everywhere else: Check your own board’s practice act and published guidance before assuming the answer is the same. This post covers North Carolina and Texas for physical therapy, and North Carolina, Texas, and Wyoming for chiropractic; other boards vary.
What the Texas PT board said in August 2026
The Texas Board of Physical Therapy Examiners’ Communiqué for August 2026 ran an article titled “A Cash-Based Practice Trap (that many would not expect!!!),” describing a licensee’s question: she had read the North Carolina Board of Physical Therapy Examiners’ article (discussed below) and asked how Texas would view the same practices. The newsletter frames the practices at issue as “[b]illing for pre-purchased PT services or offering discounts for PT services when bundled in packages that are paid for by the patient or responsible party in advance,” a patient purchasing “a pre-determined number of visits ‘package’ prior to the physical therapy service being delivered,” and a patient receiving “a discount for pre-paying for PT services.”
The board’s answer does not cite a billing regulation. It cites Texas Occupations Code §102.001, Soliciting Patients; Offense, a criminal anti-kickback statute enacted in 1999: “A person commits an offense if the person knowingly offers to pay or agrees to accept, directly or indirectly, overtly or covertly any remuneration in cash or in kind to or from another for securing or soliciting a patient or patronage for or from a person licensed, certified, or registered by a state health care regulatory agency.” A first offense is a Class A misdemeanor, rising to a third-degree felony with a prior conviction or if the person was a government employee at the time. A violation is also grounds for board discipline under §102.008 and a civil penalty of up to $10,000 per day of violation under §102.010.
The newsletter’s “Key Aspects of the Law” section stresses that this statute is broader than federal anti-kickback law: it covers “any form of remuneration, including cash, free rent, gifts, inflated marketing fees, or disguised kickbacks tied to patient volume,” and applies to “all patients and payors, including private commercial insurance,” unlike the federal Anti-Kickback Statute, which reaches only Medicare and Medicaid. The board’s stated conclusion: “The Texas Board of Physical Therapy would find the above activities to be violations of state law which at the least would constitute detrimental practice resulting in sanctions against a licensee, and likely a referral to The Attorney General’s Office for criminal prosecution.”
The statute’s text does not mention packages, prepayment, or discounts: §102.001 targets remuneration paid “for securing or soliciting a patient.” Whether a discount a clinic offers directly to the patient it treats counts as such remuneration is the board’s stated interpretation, not settled statutory text. That distinction does not change the practical answer: a Texas-licensed PT should treat the board’s published position as the operative standard. The board’s rules separately treat this kind of remuneration as detrimental practice under 22 TAC §322.4(b)(12), unless “said business arrangement or payments practice is acceptable under 42 United States Code §1320a-7b(b),” the federal anti-kickback statute, “or its regulations.”
The “prepaid treatment plan” rule everyone cites is not a PT rule
Search for “Texas physical therapy prepaid treatment plan” and the rule that surfaces is 22 TAC §75.5, titled exactly “Prepaid Treatment Plans.” It permits a “licensee” to “accept prepayment for services planned but not yet delivered” if the arrangement is cancellable without penalty, refunds unused fees on a pro-rata basis, covers a limited and defined number of visits, and is documented in the patient’s file with a treatment plan and dates.
That rule is real, current, and detailed. It is also not a physical therapy rule. It sits in Title 22, Part 3 of the Texas Administrative Code, Chapter 75, “Business Practices,” of the Texas Board of Chiropractic Examiners, not Part 16 (the PT board); its “licensee” and “the doctor” mean a Texas-licensed chiropractor. A Texas physical therapist who cites §75.5 as authorization to sell prepaid PT packages is citing the wrong board’s rule. The Texas PT board’s rules, current as of the November 2025 rulebook (corrected February 26, 2026), contain no prepaid-treatment-plan provision: a full-text search for “prepay,” “advance payment,” “refund,” and “discount” turns up only an unrelated application-fee rule, and the anti-remuneration rule discussed above is the closest provision the rulebook has. There is no PT-specific prepaid-plan rule in Texas; the board’s newsletter answer is the only published board guidance we found.
What North Carolina’s PT board said, and the rules behind it
The North Carolina Board of Physical Therapy Examiners’ own article is the source both boards’ 2026 positions trace back to, but we were unable to retrieve the board’s original text directly. As described in the Texas board’s August 2026 newsletter, the North Carolina board’s article stated that it is a violation of that state’s practice act for a physical therapist to bill for pre-purchased PT services, to offer a discount for services bundled into a package paid in advance, or to let a patient purchase a pre-determined number of visits before the services are delivered. Because we have not read the North Carolina board’s article directly, this post does not quote it and does not attach a publication month beyond “2026.”
North Carolina’s underlying rules give a sense of why a package draws scrutiny even without the article in hand. 21 NCAC 48G .0601, “Prohibited Actions”, lists board-disciplinable conduct including “billing or charging for services or treatment not performed,” “charging fees not supported by documentation in the patient record,” and “promoting an unnecessary device, treatment intervention, nutritional supplement, product, or service for the financial gain of the practitioner.” A visit package sold before an evaluation establishes clinical need touches several of these at once: it prices a fixed number of visits before the record can support that number. Any rule violation is independently grounds for discipline under N.C.G.S. §90-270.103, which lists “[e]ngaging in any act or practice violative of any of the provisions of this Article or of any of the rules and regulations adopted by the Board” among the grounds for action (this language is scheduled for a revised version effective October 1, 2026). The board’s own article remains the authority for the specific prohibition; these rules are the most plausible basis for it, not a substitute for reading it.
How chiropractic boards regulate prepaid plans instead of banning them
The same two states, plus Wyoming, show the other regulatory model at work: instead of prohibiting prepayment, the chiropractic board defines the mandatory terms a prepaid plan must carry to be lawful.
| Requirement | North Carolina chiropractic (21 NCAC 10 .0305) | Texas chiropractic (22 TAC 75.5) | Wyoming chiropractic (030-11 Wyo. Code R. §11-6) |
|---|---|---|---|
| Written plan document required | Yes: plan document with duration, objectives, cost, included services | Yes: patient file must contain the proposed treatment plan | Yes: “a written plan, signed by both the licensee and the patient,” listing covered services and fees, the reimbursement formula, and the cancellation right |
| Defined, limited visit count or duration | Yes: duration by visit count or calendar days | Yes: “a limited, defined number of visits” | Applies once advance collections reach $500 in a 12-month period; not stated as a fixed visit cap |
| Refund if patient cancels | Yes: strictly pro-rata by visits or days; “[n]o other method of refund calculation shall be permitted” | Yes: “complete refund of all fees paid on a pro rata basis” | Yes: the patient may “terminate the prepaid care plan at any time without financial penalty,” and “the patient’s remaining funds shall be reimbursed to the patient in full” |
| Refund deadline | Yes: within 10 business days of notice of termination | Not specified in the rule text | Within 7 working days for a cancellation made in the first 3 business days; the plan must state the reimbursement formula for later termination |
| Administrative fees on the plan | Prohibited, other than pass-through costs like credit card processing | Not addressed in the rule text | Not addressed in the rule text |
| Escrow for prepaid funds | Not required | Not required | Required: FDIC-insured account, not commingled with the licensee’s own funds |
| Discount tied to prepayment | Not addressed as such | Not addressed as such | Permitted, but the discount “must bear a reasonable relationship to the expense avoided by the provider” |
North Carolina’s chiropractic rule, 21 NCAC 10 .0305, was readopted effective April 1, 2026, and treats a non-conforming plan as fraud, deception, or misrepresentation under N.C.G.S. §90-154(b)(9). Its plan provisions include therapeutic objectives “based on a physical examination and assessment of the patient performed by the physician prior to the plan’s start date.” Wyoming’s rule, 030-11 Wyo. Code R. §11-6, takes a third approach: it explicitly allows a lower price for a prepaid plan, but only where the discount reflects the provider’s avoided cost (less accounting and debt-collection work), requires the money to sit in a segregated, FDIC-insured escrow account, and gives the patient a non-waivable right to cancel within three business days with a refund of unused funds within seven working days, plus the right to terminate at any time with remaining funds “reimbursed to the patient in full.” All three rules govern chiropractors licensed by the respective chiropractic board; none extend to a physical therapist in the same state.
Does a package change anything for Medicare patients?
No, and this is a separate rule from anything above. Federal law does not allow physical therapists to opt out of Medicare: if a PT furnishes a Medicare-covered service to a Medicare beneficiary, the PT must be an enrolled Medicare provider and must submit a claim to Medicare, per APTA’s cash-practice compliance guidance. Selling a Medicare beneficiary a prepaid bundle of otherwise Medicare-covered PT visits does not change that obligation; see our cash-pay Medicare guide for how ABNs and mandatory billing interact for those beneficiaries. A package is, at most, a pricing question layered on top of that federal requirement, not a substitute for it.
Pricing structures that survive both regulatory theories
Some pricing structures map cleanly onto settled rules, either because a board above has already blessed them or because they don’t trigger either regulatory theory (prepayment-plus-discount as an unlawful inducement, or prepayment as a regulated consumer contract) in the first place.
| Structure | Why it holds up |
|---|---|
| Pay per visit, at time of service, published rates | No prepayment and no discount tied to bundling; not the fact pattern either board’s article addresses |
| A reasonable deposit against one scheduled visit | A deposit tied to a single booked appointment is a different arrangement from prepaying for a “pre-determined number of visits.” A board that objects to packages may still accept a booking deposit; confirm this with your own board before relying on it |
| Episode-of-care programs priced by duration, defined after an evaluation | Mirrors the North Carolina chiropractic rule’s own structure: duration set in visits or days, objectives based on an exam performed before the plan starts |
| A compliant prepaid plan, where your board is a chiropractic board that permits one | Put every mandatory term in writing: defined duration, pro-rata refund, no administrative fee beyond pass-through costs, escrow where required (Wyoming) |
| Memberships priced for non-covered wellness services | APTA’s own framing describes “a monthly membership fee or set price for enrollment in a series of sessions or classes” for services like fitness, wellness, prevention programs, and educational seminars, services that are not billed to insurance in the first place |
| A discount conditioned on prepaying a fixed count of covered PT visits | Do not use this in North Carolina or Texas: it is the exact fact pattern both PT boards addressed in 2026 |
What does not survive, in the two states with published 2026 positions, is a discount conditioned on buying visits in bulk before they are delivered.
A checklist before you sell anything in advance
- Confirm your own board’s current position: both 2026 positions here appeared in a newsletter and a board article, not the printed practice act, so check recent newsletters and guidance, not just the statute.
- If you are a physical therapist, do not assume a chiropractic board’s prepaid-plan rule, including 22 TAC §75.5 in Texas, applies to you. It doesn’t.
- Where a prepaid plan is permitted for your license type, put every mandatory term in writing: duration, objectives from a prior evaluation, cost, included services, cancellation terms, and a pro-rata refund method, with escrow if your board requires it.
- Never condition a discount on prepaying a fixed visit count in North Carolina or Texas physical therapy.
- Remember Medicare’s mandatory claim-submission rule applies to a beneficiary regardless of how you price the visit.
- This is not legal advice; confirm any pricing structure with your own board and your practice’s counsel before you launch it.
Whichever pricing structure a practice settles on, per-visit, episode-of-care, or a compliant prepaid plan, the plan of care in the chart is the document that has to match the contract: the same visit count, duration, and objectives the patient agreed to pay for. A multi-specialty system like PrismEHR that serves both physical therapy and chiropractic practices has to accommodate both boards’ rules rather than assuming one set fits every license type. Read our companion post on Medicare and cash-pay physical therapy for the federal layer that applies regardless of how you price a visit.