#Chiropractic coverage in Medicare

• VIDEO explanation Chiropractic by Steve
• 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.

• 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} * .

•  
•  MAPD plans are required to offer at least as much coverage as Medicare does.
  •  See the summary of benefits for the Blue Shield plan you are interested.
  • call ASH American Specialty Health Network customer service at (800) 678-9133

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