Understanding Chiropractic Insurance Coverage
If you have health insurance, the first thing you want to know as a patient is, does my insurance cover this? For most major insurance companies, the answer is yes!
Now, coverage looks different for each insurance carrier. This intention of this article is to explain key insurance terms, break down each major insurance company, determine if they generally have benefits for chiropractic care, and what does that coverage look like.
First, let’s talk about the basic structure of an insurance plan. The first thing that is done in any office is to check the insurance benefits. These questions, asked in a specific order, help determine payment for health benefits. The deductible is the starting place for any patient, do they have one, and does it apply to chiropractic? The deductible is an initial pre-determined amount of money that the patient must spend on healthcare before their insurance benefits kick in. Some plans offer high-deductible plans that may never hit the threshold limit of benefits, and some do not have a deductible at all. A deductible also does not have apply to certain types of care, such as primary care physician, or chiropractic, or preventative screenings.
After the deductible is addressed, it is important to look at whether a plan has a copay or coinsurance. A copay is a specified dollar amount that is paid by the patient on each visit (after or excluding deductible). The copay can be listed under chiropractic specifically, or in Maryland, it can also be listed under Specialist copay. This number varies from plan to plan and between insurance companies. Similarly, instead of a copay, a patient may have a coinsurance instead. Coinsurance is a percentage of the overall reimbursement for services that the patient will owe. This is not a set dollar amount, as it depends on what services are performed by the provider on each visit. The patient should understand that on any examination days, or if a new treatment or modality or added, their payments will be different on those visits.
Last of the insurance money terms is the out-of-pocket maximum. This is a number that is set by the insurance company that once the patient has hit, their copay or coinsurance no longer apply, and all payments are covered by the insurance company.
All insurances will list a visit limit for each benefit. This is the number of visits that the insurance will pay before they deny payment, and everything is expected to be patient responsibility. Each provider must be contracted with the patients’ specific companies for these rules to apply
There are several major health insurance companies traditionally seen in Maryland. CareFirst is a very large insurance carrier that can be found through employers, or on healthcare exchange. CareFirst is an umbrella in which many other policies are listed under. These other policies include Anthem, BlueCross/Blue Sheild, Medicare Advantage, Blue Choice, Independence, and individual state plans (such as CareFirst of Florida or Michigan). This is a very large insurance carrier with many different deductibles, reimbursement rates, co-pays, coinsurances, and out of pocket maximums. If the provider has their physical therapy privileges, which means the clinician can practice physical therapy, they can also bill for the physical therapy codes, in which a patient’s benefits may look different.
Cigna is another large and growing insurance company in Maryland. Large companies, and school systems alike use this insurance. It also has a few variations that are run by Cigna, most commonly seen at National Chiropractic & Sports Rehabilitation as Allegiance (also known as APL). Cigna traditionally has three variations of coverage based on visits, not on payment. The plan will only ever pay a maximum per day of $47 dollars (at this practice). On initial exams days it is $79, and on re-exam days the maximum is $69 dollars. All deductibles, copays, and coinsurance get applied to those maximum reimbursement rates. For example, if the patient has a 10% coinsurance, they would owe $4.70 per regular treatment day, $7.90 for day one exam, and $6.90 per re-exam. What makes this insurance company unique when it comes to chiropractic benefits in Maryland is how they determine visits. There are two types of plans based on visits. Type one is where the patient can use their visits at their leisure as long as it is documented and it does not run over the visit limit. Type two is when, depending on the tier of the doctor, there is a set number of visits they can use, and then the doctor and patient fill out a form called an MNR and request additional visits. The insurance company then reviews the request and the clinical information submitted and tells the doctor that the company will pay for a specific number of visits in a set period of time. An example would be they approved 6 visits in 30 days.
United Healthcare (UHC) is another example of an insurance company that has a maximum daily reimbursement rate and requires a request for visits. For UHC, the maximum reimbursement for chiropractic daily is $60. Unlike with Cigna, this number does not change based on exams or procedures. The visit request form is called a PSF (patient Summary Form). It is filled out by the patient and the provider to give an accurate picture of the patient’s conditions, treatments, and future plans. It is very dependent upon showing improvements in the patient’s condition otherwise further visits may be denied.
Kaiser Permanente is a very unique insurance. For things that are covered, patients have rarely complained in this office. A referral from the patient’s primary care is required, and Kaiser will only refer for the condition of low back pain. Other body parts may not be approved for treatment. After a referral is acquired, the patient can typically be seen for 12 visits without having to requ
est additional visits from their PCP. Kaiser also has a very low reimbursement maximum of $45 daily.
Aetna is far less complicated than the last 3 insurances. This insurance rarely needs pre-authorization, referral, or request of visits. This large insurance company is very similar to CareFirst and its subsidiaries. There is no maximum daily reimbursement rate, but their reimbursement rates are able to be determined based on codes. For more information about specific codes, please visit your code look-up in the member portal and check 98941,97710, 97032 97530, and 99203. These are the most common codes used in chiropractic treatment.
Last but not least Medicare has chiropractic benefits! This is the only insurance company that is illegal for chiropractors to opt-out. Medicare will only cover what is called active treatment. This means they will only cover a spinal condition that is showing improvement. They do not cover maintenance care, which is preventive treatment for future musculoskeletal spinal conditions and must be treated at a frequency that reflects their injury or condition. This coverage does not need a referral but there are special rules for patients on Medicare that they should understand. First and most importantly, Medicare will only pay or the adjustment code 98941. Anything outside of the adjustment, including manual massage, stretching, electrical muscle stimulation, and extremity treatment are considered patient responsibility out of pocket expenses. This means they do not pay for the first day exam, which is required to be done by law. Due to this confusion, patients are presented with a document called an ABN (Advanced Beneficiary Notice). This should be done before the patient gives consent to exam and treat. The ABN explains what is covered, what is not, and gives the patient the option whether to bill it to Medicare anyway or not, and that they understand they are responsible for the exam fees. Being that those exam fees are not included in Medicare, these fees do not go towards the Medicare deductible.
The Medicare deductible for the past 2 years has been $250. This is the amount paid by the patient before any of their benefits will kick in. For Chiropractic, once those benefits start, Medicare covers the majority of payment for the chiropractic adjustment. The rest of the payment, a very small portion, is either patient responsibility, or is picked up by a Medicare supplemental or secondary plan. What is the difference between a supplemental and a secondary plan? A supplemental plan will cover the portion of the adjustment code that Medicare did not pay, typically around $8. A secondary insurance will cover other treatment codes that Medicare does not include, and cover the rest of the adjustment code. This means if there is a true secondary insurance plan, the exam codes will be included in benefits. Here is an example of the difference between a supplemental and a secondary insurance plan for Medicare:
| Without Supplemental after Deductible:
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With Supplemental after Deductible:
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With Secondary after Deductible
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| 1. Medicare pays partial adjustment code, patient pays the rest (around $8)
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1. Medicare pays partial adjustment code, supplemental pays the rest
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1. Medicare pays partial adjustment code, secondary pays the rest
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| 2. Medicare will not pay any other codes including exam fee ($90)
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2. Medicare will not pay any other codes including exam fee ($90) or other treatments
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2. Medicare will pay any other codes including exam fee ($90) or other treatments
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Overall, most providers know, insurance is a beast to understand. This basic breakdown of how your insurance may cover your chiropractic care may help! For more information, patients can look up their benefits on their member portal or have it checked by the individual clinic to understand that specific plan. If you have insurance you probably have chiropractic coverage, why would you waste it?