How is Chiropractic Covered by Medicare A & B?

Medicare Advantage?

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Chiropractic coverage in Medicare

Here’s how Medicare A & B and the a Typical MAPD Plan. and Medi Gap would pay the 20% that Medicare allows, but leaves as a co payment.

Medicare Part B pays 80% for spinal manipulation if medically necessary. Thus, Medi Gap and Medicare Advantage only pay, if Medicare does.

Medicare doesn’t cover other services or tests ordered by a chiropractor, including X-rays, massage therapy, and acupuncture. If you think your chiropractor is billing Medicare for chiropractic services that aren’t covered, you can report suspected Medicare fraud ^Medicare.gov *

Medical Necessity get’s quite complicated.
Here’s more detailed definitions:

Here’s a Medicare Fact Sheet, something a little easier to read for the lay person.

For chiropractic services, medically necessary means the patient must have “a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct, therapeutic relationship to the patient’s condition and provide a reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine, as demonstrated by x-ray or physical exam.”

Treatment by means of manual manipulation of the spine to correct a subluxation (incomplete or partial dislocation of a joint or organ.^[1] ^Wikipedia ) (that is, by use of the hands).

Patient must require treatment by means of manual manipulation.
Manipulation services rendered must have direct therapeutic relationship to the patient’s condition.
There must be a reasonable expectation of recovery or improvement of function resulting from the planned treatment. ^CMS.gov *

Medicare Exclusions from Coverage

Note that the specimen Medicare Advantage policy we used to analyze coverage has exclusions on page 115 for chiropractic, they only cover what Medicare covers, nothing extra!

For those of you who think that “Medicare for All” will be the solution to every health problem and that Medicare pays everything, take a look at this NINE page bulletin on the the Medicare records required from your chiropractor.

Excerpts of Sample Medicare Advantage Plan

See above for Medicare definitions & requirements

Here’s an example where a Medicare Advantage plan is covering more than required

Sample Medi Gap EOC Plan G

Medi Gap will provide coverage for the coinsurance amount or, in the case of hospital outpatient Services, the copayment amount of Medicare Eligible Expenses under Part B …, subject to the Medicare Part B Deductible provided the Subscriber is receiving concurrent benefits from Medicare for the same Services. ^{Blue Shield EOC} *

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Do #Health Care Reform compliant plans cover chiropractic?

No, Chiropractic is Excluded on page 106 of the Specimen policy, Page 14 brochure It’s not an essential benefit, in CA

Here’s the CA Kaiser Benchmark Plan which is the “model” for ACA compliant plans

Other States may cover chiropractic, but CA doesn’t. Here’s a report from dynamic chiropractic.com

However,

Blue Shield INDIVIDUAL

Chiropractor benefits available for Silver 1950 PPO and Silver 2600 HDHP PPO plans as of Jan 1, 2021

We are the first off-exchange health plan to offer embedded chiropractic services to members through the American Specialty Health (ASH) network with Silver 1950 PPO and Silver 2600 HDHP PPO plans.

Benefits include:

$15 copayments for Silver 1950 PPO
35% coinsurance for Silver 2600 HDHP PPO
Both plans have an annual limit of 15 visits

There is coverage under Medicare A & B, Medi Gap and Medicare Advantage!

At one time you could Buy your OWN Chiropractic Plan!

But Landmark Health Plan has discontinued selling for individuals. Employer Groups can still enroll.

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by Steve