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Most Medicare plans do not cover acupuncture treatment unless it is for treating chronic lower back pain. As defined by Medicare, this chronic lower back pain:
- Is not associated with any surgery or pregnancy.
- Does not have a known cause, like inflammation originating from an infectious disease or a recent accident or surgery.
- Lasts 12 weeks or longer.
Many Medicare beneficiaries rely on acupuncture to manage chronic pain and reduce stress. Understanding Medicare’s acupuncture coverage is vital for them to manage their acupuncture therapy costs.
Medicare Coverage for Acupuncture
Medicare covers acupuncture services only for treating chronic lower back pain under Medicare Part B (Medical Insurance). Further, the extent of the coverage can vary based on the type of plan chosen.
There are some limited cases where other Medicare plans can help cover the costs of acupuncture. Let’s review each plan and its coverage.
Medicare A and B (Original Medicare)
Original Medicare has limited coverage for acupuncture. In this case, Medicare Part B covers acupuncture only when:
- It is part of a clinical research study, or,
- A doctor administers it as a part of their services.
In such cases, Medicare Part B can cover up to 12 acupuncture sessions over 90 days. There is a possibility of the coverage extending to an additional 8 sessions if a person shows improvement in his or her symptoms. In other words, Medicare can cover a maximum of 20 acupuncture sessions in 12 months.
However, Medicare Part B does not cover routine acupuncture for chronic low back pain.
Medicare Part C (Medicare Advantage)
Medicare Advantage (Part C) plans may provide additional coverage for acupuncture. As opposed to Original Medicare, these plans often include supplementary benefits, such as,acupuncture services.
Individuals considering acupuncture should carefully review the details of their Medicare Advantage plan to determine the extent of coverage and associated costs.
Medigap
Medigap, or Medicare Supplement, may cover 50% of the acupuncture charges not covered under Medicare Part B. Consider this scenario for further clarity:
If Original Medicare is your sole coverage, Medicare Part B may covers 80% of the approved amount for acupuncture services.
Let’s say your acupuncture therapist charges you $300 for a session. However, the Medicare-approved coverage for that particular therapy is only $100.
In that case, Medicare Part B will cover 80% of $100, which is $80.
Your Medigap plan may take care of 50% of the remaining $20, or $10.
You’ll have to pay the remaining $10 out of pocket.
Here’s a table explaining this example:
| Acupuncture Session Cost | $300 |
| Medicare-Approved Cost | $100 |
| Amount Covered By Medicare (80%) | $80 |
| Amount Covered By Medigap (50% of the pending costs) | $10 |
| Out-of-Pocket Costs | $100-$80-$10 = $10 |
Please note that if Medicare rejects a claim, you will not be eligible for Medigap payments and will need to pay the entire cost out of pocket.
Tips for Maximizing Acupuncture Coverage
Here are some tips to help you make the most of your Medicare coverage for acupuncture therapy.
Maintain Open Communication with Healthcare Providers
Explain your condition and the role acupuncture plays in recovery clearly to your healthcare provider.
This will enable them to accurately document if and why you need acupuncture therapy. It is vital for maximizing your acupuncture coverage under Medicare.
Understand Coverage Limits and Cost-Sharing
Familiarize yourself with the specific acupuncture-related details of your Medicare plan. They include:
- The number of visits allowed
- Duration or frequency restrictions, if any
- Any necessary documentation
Be aware of your cost-sharing responsibilities, such as deductibles, copayments, or coinsurance. This will help you plan and budget for acupuncture expenses effectively.
You can also change Medicare Advantage plans if they don’t cover your preferred doctors.
Explore Additional Supplemental Coverage Options
Medicare Advantage plans may offer broader coverage for complementary therapies, including acupuncture. These plans often provide comprehensive coverage beyond what Original Medicare offers. Explore additional supplemental coverage options to enhance your acupuncture coverage.
Alternatively, Medigap plans can help partially cover out-of-pocket costs associated with acupuncture services. Research and compare different plans to find one that provides the acupuncture coverage you need.
Reach out to CoverRight if you have queries or need guided assistance with any aspect of Medicare coverage.
Frequently Asked Questions (FAQs)
What is the cost of acupuncture under Medicare?
The cost of acupuncture under Medicare can vary depending on your specific Medicare plan. For Original Medicare (Part A and Part B), acupuncture coverage is limited to certain conditions, primarily chronic low back pain. Medicare covers 80% of the approved amount in this case, while you are responsible for the remaining 20% after meeting your deductible.
How many acupuncture sessions are covered per year?
Medicare covers up to 12 acupuncture visits for chronic low back pain within 90 days. If there is improvement in your condition, Medicare may cover eight extra sessions. This allows for a total of up to 20 acupuncture treatments in a calendar year.
Can Medicare Advantage plans offer additional acupuncture benefits?
Yes, Medicare Advantage (Part C) plans may offer additional acupuncture benefits.
These plans often provide supplemental coverage for various services, including acupuncture. Review the details of each Medicare Advantage plan to determine the extent of acupuncture coverage applicable.
Are referrals or prescriptions required for acupuncture?
Under Original Medicare, you don’t need referrals or prescriptions for acupuncture services. However, it is essential to check with your healthcare provider and confirm if they have any specific documentation or medical necessity requirements for acupuncture.
The referral or prescription requirements for Medicare Advantage plans can vary. You must review the plan details or consult with the insurance company to understand their requirements for acupuncture services.
Can I choose any licensed acupuncturist under Medicare?
Yes, you can choose any licensed acupuncturist who accepts Medicare assignments for acupuncture. Ensure that the acupuncturist is enrolled in Medicare and accepts Medicare-approved payment rates. You can use the Medicare Physician Compare tool or contact acupuncturists directly to ask if they participate in Medicare.
Are there any limitations on the conditions that Medicare covers for acupuncture?
Yes, Medicare covers acupuncture primarily for chronic low back pain. For eligibility, the pain must:
- Last 12 weeks or longer
- Not be associated with surgery or pregnancy
- Not be related to conditions like cancer, inflammation, or infectious disease.
Medicare does not currently cover acupuncture for general pain management or other conditions. Your healthcare provider should be able to determine if you meet the requirements for Medicare coverage.
