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How to determine if your insurance covers acupuncture.

Insurance is a wonderful thing, especially when your insurance provides acupuncture benefits. However determining what you need to ask your insurance company can be a little difficult as many insurance companies don't understand acupuncture and even fewer patients know what to expect.

The following represents some of the questions that you can ask your insurance company when determining your benefits. The information provided is unofficial. This is just stuff that I've found while in practice, working with insurance companies. Insurance is regulated on a state level in the USA and if you are not in California, you may find some of these items to be a bit different for you.

Step One: Call your insurance company's consumer or benefits line. This number will likely be found on your membership card. Inquire about your acupuncture benefits.

If you don't have benefits, you may have what's called an "affinity program". This is basically saying that if you pick an acupuncturist off of one of their lists, you can get your treatments at a discounted price. The discount will vary from plan to plan.

Step Two: If you have benefits, you'll also want to know the following:

How many treatments do I get?

  1. best answer: unlimited. This is going to mean that you can get three treatments per week for as long as necessary. By the time you start thinking about acupuncture, you've probably been through a great many different treatments and this is your last resort (or at least your most recent resort). The reason that this matters is that for every year that you've had a problem, expect one month to fix it.

    Insurance companies that provide unlimited benefits will periodically stop paying for them to force the acupuncturist to write up a letter of medical necessity which pretty much lays out what's wrong, how we're fixing it, and how much longer we think it'll take. This is fair and reasonable on the part of the insurance company to do this. Whether or not they do it well (as in responding when you've faxed in what they requested, etc.) is a whole different story.

  2. good answer: 35 per year. This too is going to get the job done in many cases. Generally acute conditions (meaning that they're really intense, but don't last that long or came on quickly) are going to respond better than the low-grade long-term chronic issues. Still, even for the chronic issues, 35 treatments inside of a year should be a pretty good start.

  3. another good answer: 12 to 18 per quarter. Still okay, see above.

  4. Not such a good answer: 12 per year. Now, we're pretty much limited to a few key issues that just so happen to respond quickly to acupuncture. These would be stress or hormonally induced issues among sensitive individuals such as PMS where you only need one treatment per month, or else some other musculo-skeletal problem where its simply a sprain or strain, perhaps a pinched nerve. All these things can respond rather quickly, so 12 treatments may do what is necessary.

  5. The worst answer: 2 per month. Welcome to the state of California's MediCal program. Two treatments are meaningless for most, especially the elderly where most of their problems have been brewing for years and years. This is likely why you'll be hard-pressed to find an acupuncturist who has jumped through all the hoops necessary to become a MediCal provider. Then again, many of my patients are Russian Babushkas who have little money and no insurance but MediCal, so I have become a MediCal provider.

Does this number also include any other therapies?

  1. best answer: nope, this is only about acupuncture.

  2. not the best answer: The use of chiropractic, physical therapy, or other therapy is also be counted on your benefits. Sometimes that acupuncture benefit for 35 per year is shared by all these different modalities. You'll want to find that out too, especially if you're getting chiropractic care, etc.

What's my deductible?

    If your acupuncturist turns in a claim, but you haven't met your deductible, your insurance company will not pay your acupuncturist and you will be liable for that unpaid portion. The amount that your insurance company would have paid your acupuncturist will however be applied to your deductible paid, so you'll at least get credit for that amount. Still, there may be some discrepancy between what you pay and what they'll apply to your deductible. You might want to ask about that too. For instance, I charge $70 for a treatment, but perhaps the insurance company only pays $25. That means that I will bill you for the remaining $45. If you haven't yet met your deductible, I'll bill you for that unpaid $25 as well. The insurance company will apply only $25 (their normal pay-out rate) to your deductible. To my knowledge (and I could easily be wrong on this one) they'll only apply the $25 to your deductible, not what I actually charged you.

    1. best answer: Your deductible for this time period in question (usually the calendar year) has been met, and the coverage for your acupuncture treatments has begun.

    2. not the best answer: You still owe $$$ on your annual deductible, so the acupuncture will be completely out of your pocket.

    3. a really bad answer: You still owe $$$ on your annual deductible, AND your car is parked in the street cleaning area and so you just got a ticket.

Next question you'll want to ask is who must provide the acupuncture.

  1. best answer: anyone who is licensed to perform acupuncture in your state.

  2. so-so answer: only employees in an HMO facility can provide your acupuncture. This is often times an MD with or without any decent training who works in the HMO facility. I give this a so-so rating mostly because it locks me out personally, however therapeutically, it may be just fine for you.

  3. really lousy answer: Only an MD may bill your acupuncture benefits. Now, in some states, only MD's can perform acupuncture so this is a moot point. However, in California, MD's can perform acupuncture services with a few weekend courses. I'm going to avoid getting on my soap box here, but when we who study for four years get locked out of the insurance billing game, well, it just isn't right. Still, there are few insurance plans out there that follow this archaic policy.

How much does the insurance company actually pay?

  1. This is a real tough one as some insurance companies won't tell you. However as the consumer you really should be able to find out. What they'll often say is some percentage of reasonable and customary charges. You still don't have your answer until you ask them what is reasonable and customary since this is so far useless information. If you can nail them down to a dollar amount, congratulations. You will still be responsible for anything owed to the acupuncturist that the insurance company doesn't pay.

Which pathologies are covered?

  1. best answer: there is no restriction in this regard.

  2. an okay answer: pain syndromes only. Even if I'm treating you for diarrhea, as long as there are cramps involved, we can call it abdominal pain and get the insurance claim paid.

  3. not such a great answer: musculo-skeletal pain not including headaches or menstrual cramps or pain that is otherwise being treated by whatever...

There, now you know what to ask. Given this information you'll have a much better sense of what is going to work for you.

Here's a great resource for both acupuncturists and patients to determine which conditions are covered and which are not.

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