Does Health Insurance Cover Acupuncture Treatments?
When I tell someone I’m an Acupuncturist, often I’m asked “Is Acupuncture covered by health insurance?” This a complicated question to answer. The short answer is yes. The more accurate answer is it depends. Navigating insurance coverage requires a bit of a road map and unfortunately there isn’t a GPS short cut. Read on to learn more.
Does Your Health Insurance Plan Cover Acupuncture?
First you must determine if your plan has coverage. Not all plans cover Acupuncture. Even some of the more expensive plans don’t provide Acupuncture coverage. I’ve had patients multiple times say to me, “I have a top tier plan, Acupuncture must be covered,” only to find out it’s not.
The good news is we are seeing more coverage added each year. In 2017, The National Association of Attorneys General sent a letter signed by 33 State Attorney Generals to America’s Health Insurance Plans (AHIP). In the document they urged:
“America’s Health Insurance Plans to take proactive steps to encourage your members to review their payment and coverage policies and revise them, as necessary and appropriate, to encourage healthcare providers to prioritize non-opioid pain management options over opioid prescriptions for the treatment of chronic, non-cancer pain.”
They specifically called out Acupuncture as one of the modalities for consideration for health insurance coverage. As a result more plans are offering Acupuncture benefits, including Medicare.
The only way to know if your plan has an Acupuncture benefit is to contact the plan directly. At Ronald Pratt Acupuncture, we offer benefits checks as a service for all current and prospective patients. If you’d like to check on your own there are two places you can check. Most plans have a portal and you can log in and see your coverage. That said if you don’t specifically see Acupuncture listed as covered or not covered, you’ll want to call your health insurance company and ask if you have an Acupuncture benefit included with your health plan.
One mistake people will make is they will check their plan website for providers and assume that if a provider is listed for their plan, they have coverage. Unfortunately provider lists are not a confirmation of coverage.
Does Your Health Insurance Cover Acupuncture for Your Condition?
This is usually where people get tripped up. It’s not enough to just determine if Acupuncture is covered. Once it’s been determined there is an Acupuncture benefit, the next step is to determine will your plan cover Acupuncture for the issue you are seeking help with. Health insurance companies are very specific about what conditions they will cover Acupuncture for and each company is different and sometimes there are variations even within the same company. For instance, Aetna has some plans that only cover Acupuncture in lieu of Anesthesia. They also have other plans that cover back pain, neck pain, knee pain due to osteoarthritis and chemo-induced side affects. Some companies publish a list of conditions they provide Acupuncture coverage for, while others do not.
You may ask, how will my health insurance company know what I’m getting treatment for? When an Acupuncture claim is submitted we have to provide procedures codes for Acupuncture along with a diagnosis codes for the condition treated. If a diagnosis code isn’t included or if the diagnosis code isn’t one a given company provides coverage for, the claim is denied. Since covered diagnosis codes aren’t always published, medical providers often will tell you, benefits checks are not a guarantee of coverage.
In-Network versus Out-of-Netowork?
The next step is determining if your chosen provider accepts your insurance and are they in-network or out-of-network. Some plans have the same benefit for both in and out-of-network providers but many have different copays and coinsurances for each. Further you may have separate deductibles for in and out-of-network services.
If you receive Acupuncture from an in-network provider your insurance company sets the rate and the provider must accept that as the full fee. The Explanation of Benefits (EOB) form you will receive from your insurance company once the claim has been processed will state the full fee, the portion you must pay (co-pay, co-insurance or deductible) and the portion the insurance company must pay. An in-network Acupuncturist must adhere to the EOB and can’t charge you more or less for the covered benefit. They may charge you for services not covered but for anything that’s covered, your fee should correspond with your EOB.
For out of network providers, you’ll want to know what the billed amount is as you will be responsible for the portion not covered by your insurance company. Some providers will discount this, technically this isn’t allowed as providers are required to discount the insurance company’s portion and the patient’s portion equally. In recent years Insurance companies have been using the legal system to require this of providers.
What About HSA, FSAs, HRAs?
In New York State Healthcare Spending Accounts, HSAs, and Flexible Spending Accounts, FSAs, can be used to cover your Acupuncture appointment fees, copays and coinsurance. Health Reimbursement Accounts, HRAs are employee sponsored and the terms are set by your employer. These type of accounts can vary significantly and it’s best check with you benefits administrator if you don’t have documentation confirming Acupuncture coverage.
Regardless of your health insurance coverage and condition treated you may use your HSAs and FSAs for Acupuncture treatments. This may or may not be the case with your HRA and it’s best to confirm with your benefits administrator.
What About Automobile Crashes and Work Related Injuries?
If you’ve been in an automobile accident or suffered a work related injury, your health insurance plan will not cover your Acupuncture.
In New York State most automobile insurance plans provide coverage for Acupuncture. Injuries that occur from a motor vehicle accident are pretty clear. If you’ve been in an crash and suffered an injury and are seeking Acupuncture treatment, you will need to use the personal injury protection insurance provided with your auto insurance or the vehicle you were in. These claims are straight forward. To determine coverage and limits, contact the adjuster for your claim and they can get paperwork started for you to see a provider. Likely limits will be set for a time period or a set number of treatments and you may be required to do an independent medical exam and re-evaluation during the course of treatment.
Workers compensation claims aren’t always so clear. Certain chronic conditions like neck or back pain from poor desk ergonomics are very hard to classify as a work related injuries. However, an injury while using a piece of machinery, a fall while at work or an acute injury while conducting a work task are clear and typically covered. To determine coverage contact the adjuster or case worker and ask about Acupuncture benefits.
What if My Provider Doesn’t Accept my Plan?
If you’ve found an Acupuncturist you prefer to work with and they don’t accept your health insurance, motor vehicle insurance or worker’s compensation, there is a way for you to still see them and get reimbursed. It’s a little more work on your behalf. You will need to request a superbill from your provider and then submit it directly to your insurance provider. Usually an additional form from you is required to do this. Once the claim is processed any reimbursement will be mailed directly to you.
Copays, Coinsurance, Deductibles and Out of Pocket Maximums Oh My!
Some definitions:
Copay - a set fee defined by your health insurance plan that you pay with every Acupuncture treatment regardless of what is billed.
Coinsurance - a portion or percentage of the amount billed for Acupuncture treatment that you must pay, varies based on billed amount. Note -occasionally plans require a person to pay both a copay and a coinsurance.
Deductibles - a set amount you must pay before your health plan provides reimbursement. Note - if you’re seeing an in-network provider they still must adhere to the fee schedule set by the insurance company regardless of deductible status.
Out of Pocket Maximum - This is a set maximum of out of pocket payments you pay in a given year. You may have a separate out of pocket max for in-netowrk and out-of-network or no out-of-pocket max at all for out-of-network. This count resets every year. Once you reach your out of pocket maximum, your plan will pay the full fee.
All of us spend a hefty chunk of change on insurance premiums each month. The insurance maze can definitely be challenging. There are a lot of moving pieces to navigate. That said having a clear understanding of how it all works can help you leverage benefits to offset the cost of your Acupuncture treatments.
If you’re local to one of our practices and interested in starting Acupuncture treatments, let us check your health insurance benefits so you can better understand your financial responsibility?