Direct Access PT by State: Limits, Medicare, and Payers

Patients in all 50 states can now see a physical therapist without a physician’s referral in some form. APTA’s July 2025 count puts 21 states at unrestricted direct access and 29 states (plus the District of Columbia and the U.S. Virgin Islands) at provisional access, meaning a time or visit limit, or a referral requirement for a specific procedure. But “the practice act allows it” answers only the first of three questions a front desk has to settle before the first visit.

Direct access is three stacked questions. First, what does the state practice act allow, for how long, and with what notices? Second, will this patient’s plan pay without a referral or order? Third, if the patient is on Medicare, who will certify the plan of care? Medicare does not require a referral, but it does require a physician or nonphysician practitioner (NPP) signature on the plan, due within 30 days of the first treatment, with recertification at least every 90 days. The 2025 certification shortcut does not help a patient who arrives without an order.

Current as of October 2026.

Can you see a physical therapist without a referral in every state?

Yes, for licensure purposes. APTA reports that “as of July 1, 2025, patients in all 50 states, the District of Columbia, and the U.S. Virgin Islands have either provisional or unrestricted direct access.” Unrestricted means evaluation and treatment are allowed without restrictions or limitations. Provisional means a time or visit limit, or a referral for a specific intervention such as needle electromyography or spinal manipulation.

Those tiers describe the practice act only. APTA is direct about payers: “for commercial payers, most plans do not explicitly require a referral in their payment policy,” but providers “should review their contracts with each payer to ensure that payment for services provided via direct access is allowed.”

Direct access limits by state

The table covers 13 states, each cited to its own statute or board rule. Where both limits appear, the first one reached controls. Current as of October 2026.

Two states practice owners often ask about, Illinois and Georgia, are left out of the table because we could not retrieve their current practice act text from a primary source for this post; check the state board before relying on any summary of their limits.

A few notes the table cannot carry:

• Texas counts consecutive business days. A PT also needs one year of licensure, liability insurance, and a doctorate or 30 hours of continuing competence in differential diagnosis.
• Florida’s 30 days triggers a signature, not a new referral. When treatment is needed beyond 30 days for a condition not previously assessed by a practitioner of record, one must review and sign the plan. The sign-off is not required when a physician licensed in another state has examined the patient and diagnosed the condition being treated.
• Virginia gates direct access on a credential. A PT without a DPT or certificate of authorization may conduct only a one-time evaluation without treatment. Virginia’s statute has no day or visit limit.
• Washington’s carve-outs are narrow. Wound care requires a referral or consultation, and an endorsed PT must consult a non-PT practitioner authorized to manipulate beyond six spinal manipulation treatments.
• In New Jersey and Ohio the 30 days is a clinical checkpoint, not a hard cap. Both require bringing in another provider when the patient is not progressing. Ohio also requires, with consent, informing the relevant practitioner within five business days of the evaluation.

Pennsylvania direct access: the 30-day cap and what changed in 2026

Under 49 Pa. Code §40.61, a certificateholder may treat without a referral for up to 30 calendar days from the date of the first treatment. The clock starts on the date the patient is treated by any physical therapist treating without a referral, so a patient seen at another clinic has already used part of the window. The certificate of authorization is a separate credential on top of the license and requires two years of qualifying practice.

What changed in 2026:

• Act 12 of 2026 (HB 1251) was signed May 6, 2026 and took effect July 5, 2026. It lets a PT accept the referral of a licensed dentist, podiatrist, or midwife. It does not change the 30-day limit or the certificate.
• HB 1583 would extend the window to 60 days and eliminate the certificate. It was referred to the House Professional Licensure Committee on June 10, 2025 and had an informational meeting on July 28, 2026, where the packet noted that only Pennsylvania and Virginia still require the certificate.

As of October 22, 2026, HB 1583 has not moved out of committee, so the 30-day cap and the certificate of authorization remain the law.

California has a similar pending bill. AB 2497 would replace the 45-day, 12-visit limits with no referral or prior authorization requirement, but the Medical Board of California’s analysis for its August 20, 2026 meeting states that “AB 2497 is not expected to move forward this year.”

Does Medicare require a referral for physical therapy?

No. But the patient must be under the care of a physician or NPP, and the plan of care certification is how that is shown. In APTA’s words, the physician certifies the PT’s plan of care for direct access patients, or the PT submits the plan to the physician for referred patients.

Under 42 CFR 424.24(c), the initial certification must be obtained “as soon as possible after the plan is established.” The Medicare Benefit Policy Manual, Ch. 15, §220.1.3 defines that as within 30 days of the initial therapy treatment. A verbal order counts if followed by a signature within 14 days. Recertification is required at least every 90 days.

Here is where the 2025 change gets misread. If the patient’s record contains a written order or referral and the therapist documents delivering the plan to the physician or NPP within 30 days of completion of the initial evaluation, the certification does not need a separate signature. CMS finalized that in the CY 2025 Physician Fee Schedule rule (89 Fed. Reg. 97710, effective January 1, 2025), and kept the signature requirement for patients without an order and for all recertifications. Under 424.24(c)(5), with no written order or referral the therapist “must obtain the signature.”

For a direct access Medicare patient:

1. Identify a physician or NPP willing to certify. The patient’s primary care provider is the usual choice.
2. Send the plan and obtain a dated signature, or a verbal order followed by a signature within 14 days, within 30 days of the first treatment.
3. Recertify at least every 90 days.

For an evaluation-only patient, the manual (§220.3) still requires a referral, order, or certification of the evaluation for payment. For delayed certification and the rest of the mechanics, see Medicare plan of care certification, and see documentation requirements for what the record must show.

Medicare Advantage adds another layer. UnitedHealthcare requires prior authorization for PT, OT, SLP, and chiropractic in office and outpatient hospital settings for Medicare Advantage members, a requirement that began September 1, 2024 (document updated November 1, 2025). It applies to in-network providers, exempts the initial evaluation and home settings, and excludes UnitedHealthcare Dual Complete plans among others. See Medicare Advantage outpatient therapy rules.

Which commercial payers still require a referral or prior authorization?

There is no national answer, and payer policy changes. These are the primary documents we could verify, each with its date.

Aetna. APTA reported on June 17, 2025 that Aetna “will no longer require a referral or signed plan of care for physical therapy,” effective June 17. We could not locate an Aetna-authored document stating the change, so treat it as APTA’s report. APTA’s statement does not say precertification was removed, so where an Aetna plan applies it to therapy, it still runs. State law still governs what a PT may do regardless of payer: a Texas PT treating an Aetna member is still bound by §453.301.

UnitedHealthcare. The 2026 Care Provider Administrative Guide says that for open access plans “no referral or PCP approval is required for members to see other network providers,” though prior authorization is required for certain services. For gated plans, the PCP must submit electronic referrals first. Gated products include Navigate, Charter, Compass, NexusACO R, and the UHC Complete versions of Navigate, Charter, and Compass, and gated members have “Referrals Required” on the front of the ID card. PT submissions for providers contracted with Optum Physical Health route to a separate portal (see the July 2026 advance notification list and our UnitedHealthcare prior authorization guide).

Cigna. Coverage policy CPG 135, effective December 15, 2025, requires a written plan of care established by a licensed PT and contains no referral or physician-order requirement. But Cigna’s NQTL summary (last revised October 23, 2025) states that American Specialty Health reviews physical therapy on Cigna’s behalf, so whether review or precertification applies depends on the plan. Check before the first visit.

Blue plans. Blue plans are independent licensees, so there is no national Blue rule. As one documented example, Blue Cross Blue Shield of Massachusetts’ authorization grid (current as of July 2026) requires no authorization for the first 16 commercial PT/OT visits, but “a prescription from the ordering provider is required.” Massachusetts is an unrestricted state in APTA’s July 2025 state chart (reproduced in the Pennsylvania House packet), which shows the gap between practice act and payer. See commercial payer therapy visit limits.

Workers’ compensation and self-funded plans. Contracts and plan documents control. Verify before the first visit.

California’s §2620.1(d) and Ohio’s §4755.481(B) both say the practice act does not require insurers to cover direct access services.

What to collect at intake for a direct access patient

Every item traces to a rule above. A patient intake form that captures them turns the three questions into data before the first treatment.

1. Referral status and date of first treatment. The clocks in California, Texas, Pennsylvania, New York, Michigan, New Jersey, and Ohio run from the first treatment or the initial visit, and Florida’s 30 days of treatment cannot be counted without that date either. Ask about prior PT episodes in Pennsylvania.
2. The patient’s physician or practitioner of record, and written consent to notify them. California requires written authorization to notify. Virginia requires written consent to release records and notice within 14 days after treatment commences. Ohio requires notice within five business days of the evaluation, and New Jersey within 30 days.
3. The state-mandated signed notice. California requires an oral and written notice in at least 14-point type, signed by the patient. Texas requires a signed disclosure on a board-prescribed form. New York requires a form attesting to the coverage notice, signed and dated by both therapist and patient.
4. Insurance and plan type. Is the plan gated? Does precertification or a prescription apply? For Medicare, which physician or NPP will certify?
5. A date-driven tracker for the state clock (day 30 in Pennsylvania and Florida, visit 10 or day 30 in New York, 45 days or 12 visits in California, 10 or 15 business days in Texas, 21 days or 10 treatments in Michigan) and the Medicare clock (certification within 30 days, recertification every 90).

The two clocks are independent. A Pennsylvania Medicare patient can be inside the 30-day state window and still out of compliance with Medicare if no one has asked a physician or NPP to sign.

Wellness and fitness carve-outs in practice acts

California, Virginia, Ohio, and Michigan exempt wellness and fitness services from some or all of their limits. In California, only the 45-day and 12-visit sign-off condition in §2620.1(a)(4) is lifted for wellness physical therapy as described in §2620; the duty to refer and the other conditions still apply. Virginia lets a PT treat without a referral in listed settings, including services to the public for “wellness, fitness, and health screenings,” health promotion and education, and prevention. Ohio’s 30-day consult-or-refer duty does not apply to fitness, wellness, or prevention services. Michigan allows treatment without a prescription when the patient seeks to prevent injury or promote fitness.

Texas, New York, New Jersey, Pennsylvania, and Florida have no such carve-out in the provisions cited here, so a wellness label does not by itself extend the window in those states.

The Medicare clock is the one most clinics miss with direct access patients, because nothing in the visit prompts it. PrismEHR tracks each certification period against the initial certification date and alerts before the 90-day recertification deadline, and CuratoForm, the healthcare form builder from Rehabilitation Health that runs standalone or as part of PrismEHR, builds HIPAA-compliant intake forms with conditional logic, timestamped e-signature capture, and automated delivery when an appointment is scheduled. See how it fits physical therapy practices, and read Medicare plan of care certification for the certification rules in depth.