A Guide to Insurance and Acupuncture

One of the most common conversations I have with new patients over the phone goes something like this:

Inquiring mind over the phone, “Does insurance cover Acupuncture?” 

Rebecca, “Yes! In fact over 60% of my patients have insurance that covers treatment.”

Inquiring Mind, “REALLY??!! Does MY insurance cover Acupuncture?”

Rebecca, “I don’t know, but let’s find out!” 

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And quite commonly, patients DO have coverage!  Here in Portland we are extremely lucky.  Indeed, as the conversation above illuminates, over 60% of my patients actually have insurance that covers Acupuncture.  These patients are typically responsible for a $10-$20 copayment at time of service and nothing else, the rest of their treatment is covered 100%.

With the advent of the Affordable Care Act, more people have Acupuncture coverage than EVER before but many people don’t realize it or don’t know how to utilize their benefits.  In Washington in particular, 12 Acupuncture visits per year are included in the state essential benefits plan, meaning that all insurance plans originating in Washington State include Acupuncture benefits.

Understanding insurance benefits can be very confusing, however, so today, in an effort to help you understand your insurance, I’m going to walk you through how to determine if you have Acupuncture coverage, how to get Acupuncture coverage, and some insurance terminology basics to help you navigate the tangled web of coverage insurance companies weave.

How to Determine if You Have Acupuncture Coverage

Finding out if you have Acupuncture coverage is quite simple, but finding out what is covered can be hard if you don’t know the right questions to ask.  Acupuncture isn’t always covered for everything - despite the 3,000 years of history behind it.  

Here is a simple step by step guide to finding out all the pertinent information about Acupuncture benefits under your insurance plan.  Have a piece of paper and a pen ready to record your answers:

1. Call the Member Services phone number on the back of your card.  Be prepared to give them your Insurance ID#, your name and your birth date to verify coverage.
2. Tell the Member Services Representative on the other end of the line you want to verify Acupuncture benefits.
3. Ask the following questions and record the answers:
1. Is Acupuncture a Covered Benefit? (if the answer is no, you don’t have coverage and can stop here)
2. Is Acupuncture Subject to Deductible?
1. if the answer is YES ask - What is my Deductible?
2. How much of my Deductible has been met for the plan year?
3. What is my Copayment or Coinsurance for Acupuncture treatment?
4. How much treatment is covered? This could be a dollar value or a number of treatments per plan year.
5. Does Acupuncture require prior authorization or referral? 
1. Who does the authorization/referral come from?
6. Does Acupuncture have to be performed In Network or is it covered Out of Network as well?  Are the rates different?
7. Are there any exclusions for Acupuncture Treatment?
1. Sometimes this question will get you a clear answer like, “acupuncture for weight loss is not covered” while other times the Member Services Rep will not answer or will not know how to answer.  If they don’t answer, be more specific like, “Is Acupuncture covered for Pain treatment? for Headache?” etc.  This is especially useful if you know what you want to be treated for ahead of time.

If all of this sounds too confusing - call your local Acupuncturist, give them a copy of your insurance card along with your birth date, and they will be able to call and verify your benefits for you!

Acupuncture is NOT Covered Under My Plan!  How Do I Get Benefits?

Not every insurance plan will cover Acupuncture, but if yours doesn’t and you want to get Acupuncture treatment don’t fret - there are options.  First, of course, you need to determine if Acupuncture coverage would be more cost effective than paying out of pocket.  

The average 60 minute Acupuncture treatment costs somewhere between $65-$90 in the Portland area (might be different in your town, a quick web search will yield results).  An average course of treatment is probably 6 treatments for any individual illness, 12 on the high end.  12 treatments at a $75 average = $900 per illness or injury, so if you’re paying more than that per year for extra insurance coverage you’re probably wasting your money and would be better served by paying out of pocket.  

If you utilize other services, like Chiropractic and Naturopathic treatment as well, or if you intend for Acupuncture to be part of your regular wellness and stress management care (it should be!), then paying more in premiums would be worth it since CAM services are often combined.

If you want coverage and you don’t have it, therefore, you have two basic options:

1. Purchase additional or secondary insurance coverage

2. Lobby your HR department to add Acupuncture as a covered benefit for an employer-provided health insurance plan.

If you want to purchase additional or secondary coverage, the first thing to do is to call Member Services for your current insurer and ask about options.  They may have an additional rider you can purchase which will add more benefits to your current plan for a monthly premium.  If they don’t, you can go to the Healthcare Exchange and purchase a secondary plan.  I compiled a list of plans from the Cover Oregon site which cover Acupuncture back in October which you can review on my blog HERE.

Purchasing a secondary insurance plan can be costly, however, so you have to think about your healthcare needs and choose wisely.  Secondary coverage that compliments your current plan benefits can often result in almost never paying for any treatment for anything - whatever isn’t covered by your primary insurance can be billed through to your secondary insurance plan and will likely be covered - but premiums can be high on individual plans, so do your math carefully.

If you are insured through your employer, lobbying for Acupuncture benefits to be added to the company plan is your best option to get care.  If you can get other people in your office to toot the Alternative Medicine Coverage horn, all the better.  Your employer wants to keep you happy (or they should anyway!) and Acupuncture is great way to do so!  People that utilize CAM services such as Acupuncture, Massage, Chiropractic and Naturopathic care are generally more aware of and engaged in their health, and healthier people have lower premiums for group health insurance.  This is a big benefit to your employer because it means they are going to pay less to insure you over time because you will be healthier (are you taking notes to bring to HR yet?…) 

Acupuncture in particular has been proven to reduce blood pressure, assist in weight loss and reduce stress hormones in the blood stream - all common concerns in an office environment.  Acupuncture coverage, if utilized therefore, is a big benefit for employees and employers alike.

If you need help making the case for Acupuncture coverage in your office, contact me! Or your local Acupuncturist for some specific key words and phrases to bring to your HR department.

Understanding the Basics of Insurance Terminology

Insurance is about the using the money of the many to cover the needs of the few.  Everyone pays premiums, but only those in need seek care requiring the insurance companies to pay up, and in this way the insurance company can make sure there are funds available as needed for everyone.  Or at least that is the theory.  Its a balancing system, a balancing act, and a darn confusing bunch of jargon and terminology.

The most confusing part of accessing benefits for most people is understanding their deductible.  Some benefits are subject to deductible, meaning the deducible must be met before the benefit will kick in, while other benefits are not subject to deductible, which means you can access the benefits immediately and are only responsible for a copay or coinsurance amount whether you have met your deductible or not. This is where most people get confused about Acupuncture and alternative care benefits in particular, because this is very individual plan by plan.

For example: if Acupuncture is a covered benefit but is subject to deductible, you must meet your deductible - meaning you must pay for that dollar value worth of medical services (any covered medical services) before your benefits will kick in.  If Acupuncture is not subject to deductible, it doesn’t matter what your deductible is or whether you have one or not, Acupuncture treatment will be covered immediately at your copayment or coinsurance rate.

Here is a list of the insurance terminology that people find most confusing and what it means for your benefits:

Deductible - this is a dollar amount you must meet out of pocket before certain benefits “kick in.” There is typically a separate deductible for “in network” and for “out of network” providers. For example, if you have a $500 in network deductible and then a coinsurance of 20%, you would be required to pay $500 worth of medical expenses (doctor visit fees, lab fees, etc) for in network services out of pocket at the start of the plan year.  Once that value had been met, you would only be responsible for 20% of the fee charged for any visit or service.

In Network vs. Out Of Network - In Network providers (doctors, hospitals, medical professionals) have contracted with the insurance company and provide reduced rates to plan members.  Out of Network providers have not contracted with the insurance company and can charge whatever they want.

Coinsurance - Coinsurance is the percentage of total (contract rate for in network) fees you, as the patient, are responsible for paying.  It is often different in network vs. out of network.  Benefits which have a coinsurance amount due are usually subject to deductible, meaning you must meet the deductible first before you can pay only the coinsurance amount. 

Copayment - this is a flat dollar value that you are responsible for paying for treatment.  It is often different in network vs. out of network, or you will have a copayment in network and a coinsurance out of network.  Benefits which have a copayment are usually not subject to deductible, meaning you can access that benefit immediately without meeting any deductible amount for the plan year.

Plan Year - the date on which your insurance benefits reset, meaning the date you are responsible for meeting your deductible again.  Insurance plans run on 12 month cycles and the plan year is usually the same as the calendar year, but can vary with some insurers.

Complementary and Alternative Medicine or “CAM” Services - This generally refers to Acupuncture, Chiropractic, Massage and Naturopathic care.  Sometimes these services are bundled into a single category meaning you have one benefit pool to share among them.  Physical Therapy is always separate from CAM services, and Chiropractic is often singled out as a separate benefit as well.

Authorization - Some benefits require authorization before they can be utilized.  Services that require authorization typically require the provider him or herself to seek authorization on or before your first visit for treatment.  If not authorized, the insurance company will not pay for treatment.

Referral - Some benefits require a referral, typically from your PCP or Primary Care Provider, before the insurance company will pay for them.  In Oregon an MD, DO (Doctor of Osteopathy), ND (Naturopathic Doctor) or DC (Doctor of Chiropractic) can be a Primary Care Physician, but an ND or DC must be covered under your specific insurance plan despite state law to be recognized as a referral party.

Contact Rebecca with Questions

Insurance can be confusing, but with a little know how and a provider who knows the ropes on your side, everything can be understood and clarified with ease.  If you have questions about your insurance plan, contact me via email anytime or book a free consultation online.  I am happy to help navigate your benefits!

Until next time,

~Rebecca