Acupuncture is, as the years go by, becoming a covered benefit more and more with health insurance companies. While this is great news, many patients do not know that there may be certain restrictions unique to acupuncture coverage, let alone the basic ins and outs of their insurance plan. Here we will discuss the basics of most insurance plans, and what to ask your insurance company in reference to being covered for acupuncture sessions.

Health Insurance Basics

            Before we get into what to look for as far as acupuncture coverage, it is important to first know basic definitions and terminology when it comes to understanding your health insurance. Understanding these terms will help in obtaining cost-effective coverage that meets your individual or family medical needs. Most importantly, knowing this information will help you make educated decisions when looking for an acupuncturist.

• Premium – this is the amount that you pay your insurance company annually or each month for medical coverage. This could be through an employer, your state, or out of your pocket.
• Copay – this is an amount of money, determined by your insurance company, that you will pay at the time of service. The amount you pay will depend on the service itself based on your insurance plan coverage. For a standard office visit, this is normally in the range of $10-$30, and for a specialist can be upwards of $50 or more.
• Deductible – this is the amount of money that you must pay out of your pocket before any type of medical coverage kicks in to pay. Deductibles are usually set amounts such as $500 or $1000. Most often, the lower the premium, the higher the deductible will be. It is important when choosing an insurance plan to take the deductible into careful consideration. If you are relatively healthy, then it may be okay to go with a higher deductible plan, whereas if you have some medical issues, it may be wiser to go with a lower deductible plan so that you will have coverage for your services quicker.
• Coinsurance – this is the amount of money that will need to be paid to the healthcare provider after the deductible has been met. Coinsurance is usually indicated on your insurance plan as a percentage. For instance, if the policy has a coinsurance of 15%, and the total for the service was $100, the patient would owe $15 coinsurance to the provider. It is important to note that the coinsurance is also dependent on the service, and may be different percentages for different services. For example, something like a regular office visit may have a 15% coinsurance, and an acupuncture visit may not have any patient coinsurance responsibility once the deductible is met.
• Out-of-Pocket Maximum – this is the amount of money you pay annually encompassing deductibles, coinsurances, and sometimes even copays, and if met within the plan year, insurance will then pay 100% for all covered expenses.
• In-network – this refers to a healthcare provider or facility that have contracted with a certain insurance company to accept their in-network negotiated (discounted) rate for the service provided.
• Out-of-network – this refers to a provider or facility that is providing care is not contracted with your insurance company to accept their negotiated rate. Some insurance plans have out of network coverage, but this also means that a provider can potentially bill you for the full billed amount as they are not contracted with the insurance company.
• Referral – this refers to a notice from another provider, usually your primary doctor, referring you to a specialist. In the case of acupuncture, some insurance companies may require a referral for the service, and this will depend on your particular plan if this is necessary or not. Many times, now-a-days, these can be sent electronically to your acupuncturist, and you may not need a physical referral slip. Ask your acupuncturist and primary doctor if this is an option.
• Plan year vs. Calendar year – this refers to when your benefits (deductible, out-of-pocket, visits) will reset back to zero. If your plan runs on a plan year, this means that it will reset whenever you first signed up for benefits (for example, 7/1/20 – 6/30/21). If your plan runs on a calendar year, this means that no matter when you signed up, your benefits will reset January 1^st and go until December 31^st.

Any one of these is solely dependent on the plan you have with your insurance company. It is important to understand the basics of your insurance plan when going to book an appointment with an acupuncturist, or any healthcare provider.

Acupuncture Coverage Questions

The good news is that more and more insurance companies are offering acupuncture coverage to combat the opioid crisis in the United States, and offer members proven drug-free, holistic treatment options for their health concerns. When contacting your insurance company about acupuncture coverage, since it is a service that many are still unaware of, it is important to ask these key questions so that you have all of the right information to move forward with your acupuncture visit.

Do I have acupuncture benefits under my plan?

This is the number one question to ask. If there are no benefits under your plan, check with your acupuncture practitioner to see how much it would cost to pay them out of pocket for treatment. Many times, some healthcare providers will charge a little less if you are paying out of pocket, but every acupuncture practice is different.  Follow up with your acupuncturist to see what they offer.

Is my acupuncturist considered in or out-of-network?

This is a very important question as benefits, and more importantly, what you are possibly responsible for paying, differs between in and out of network. You can contact your acupuncturist for their National Provider Identifier (NPI) to give to the insurance company when you call, and the acupuncture provider should also be able to tell you whether or not they participate with your insurance. Additionally, you may be able to search for your acupuncture providers NPI by using this tool. However, if you are unable to get or find an NPI number, your insurance company should be able to look them up by the name of the acupuncturist or the practice name.

How many times am I able to come in for treatment?

If there are acupuncture benefits under your plan, some insurances only permit a certain number of acupuncture treatments each benefit year. For example, your benefits may state that you are covered for acupuncture for 12 sessions. This means that you can only have 12 visits with your acupuncturist during the benefit or calendar year, (depending how your plan runs), and once those 12 visits are met you will no longer be covered for the service until it resets at the beginning of the year or plan year.

Do I have acupuncture coverage for (insert your condition here)?

While many insurance companies are now providing acupuncture benefits to its members, they are still particular about what health conditions are actually going to be covered. To get a definitive answer, it’s important to ask your insurance company if you would be covered for the condition you need treatment for.  Many insurance companies only cover acupuncture for replacement of anesthesia or what they call “in lieu of anesthesia.” If this is the case with your insurance plan, you will not be covered for acupuncture treatments, unless you are receiving acupuncture instead of anesthesia.

It is wise to note that even if your insurance company states that you have acupuncture coverage, this does not always mean that you have coverage for every diagnosis, and your insurance representative may not know those specific diagnoses either. However, the representative should be able to direct you to a medical policy which will lay out specific conditions that your insurance company dictates as suitable for acupuncture treatment.

Acupuncture Coverage and You

Above all, if you are calling yourself to check if you have acupuncture coverage, it is always vitally important to ask for your insurance representatives’ name, and get a reference number for the call. This way, your acupuncturist, and/or insurance company, can track what you were told when you called in for information. It is also important that you know that while more and more acupuncturists are becoming in network providers with certain insurance companies, if they are out-of-network, it is common for some acupuncture providers to ask for payment up front, and then offer you the paperwork needed to get reimbursement through your insurance company for the service. Either way, it is important to have a good understanding of what your insurance company offers so that you are prepared when speaking with your acupuncturist to come in for treatment, and with these basics, you’ll be ready to go!

Reposted from AcupunctureNearMe blog, July 2022

Erika joined us in August after we suddenly and sadly lost Mercedes to an unexpected illness. Our thoughts and prayers are with her children and family.

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