Chiropractic Medicare Benefits Explained

This is a topic I've been meaning to write about for a long time. Every January I kick myself for not writing it sooner because I end up sounding like a broken record. Insurance plans restart and we get a new influx of patients who are confused or misinformed about what kind of coverage Medicare provides for chiropractic. Here I present to you, chiropractic Medicare explained.

Chiropractic Medicare coverage is completely different than coverage for other types of doctors and services. Rules may change year-to-year, so this article may be updated in the future. Be advised that whenever I refer to Medicare for the rest of this article, I am also including Medicare replacement plans, which are third-party plans that offer identical coverage to Medicare.

The Basics

Before we dive deep, there is one sentence that answers 80% of the questions people ask regarding Medicare, and it's a bit surprising. Ready?

The one and only chiropractic service that Medicare covers is the spinal adjustment.

Are you shocked? Because a lot of people seem to disbelieve me when I tell them this. Furthermore, Medicare actually only reimburses 80% of the cost of a spinal adjustment. You are responsible for the remaining 20%, plus all other services you may receive during your treatment. This includes required services, such as the examination. Even more surprisingly, is that there are circumstances where they don't reimburse the spinal adjustment either. Confused? We'll start from the beginning.

First of all, just like many other private insurance plans, Medicare has a deductible. A deductible is the yearly amount of money you are required to personally pay for any covered health services before Medicare begins reimbursement. In 2022, the Medicare deductible is $223 and the reimbursement rate for a spinal adjustment to 1-2 areas is $28.58, and for 3-4 areas is $40.79. That means that each chiropractic visit in which you receive a spinal adjustment you are responsible for paying $28.58 or $40.79 respectively, plus the cost of any additional services you receive. Once your deductible has been met, Medicare will now reimburse 80% of the spinal adjustment fee, or $22.86 and $32.63, respectively.

I also mentioned that there are circumstances where Medicare doesn't cover the spinal adjustment at all. Medicare requires that the adjustment is medically necessary. Medicare defines medically necessary as: "Health care services needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine." What the heck does that mean?

Essentially, a condition being treated must demonstrate continual, objective improvement that can be measured in symptom intensity or frequency, improvement in range of motion, or activities of daily living. What would not be considered "medically necessary?" Chronic conditions that do not continuously improve, as well as maintenance care for general wellness. There must be a specific, acute complaint.

What is Supplemental Insurance?

Some patients opt into a supplemental insurance plan. A supplemental plan is very simple, and has one purpose only as far as chiropractic care is concerned. After your Medicare deductible has been met, it supplements the remaining 20% of the spinal manipulation fee that Medicare does not cover. Here are a few example scenarios of what you would pay if the only service you receive is a 1-2 area spinal adjustment:

• You have not met your deductible: $28.58
• You have met your deductible but you only have Medicare: $5.72
• You have met your deductible and you have Medicare and a supplemental: $0

Your supplemental will pay the remaining 20% of your $28.58 fee, which is $5.72 for each visit that you receive spinal manipulation. You are also responsible for the full cost of any other additional services you receive along with the spinal adjustment. This may include working on any other body part but the spine, muscle work, rehabilitative exercise, electrical muscle stimulation, ultrasound therapy, kenesio-taping, etc. Literally anything except a spinal adjustment.

What is Secondary Insurance?

Secondary insurance is far less common than a supplemental insurance and its benefits vary greatly depending on your individual plan. The reason it is far less common is usually because of cost; it can be nearly as expensive as your regular insurance. The reason for this is because a secondary insurance may cover more types of services than just the spinal adjustment, in contrast to Medicare and supplemental plans.

Secondary plans may cover examinations, manual therapy, rehabilitative exercise, electrical muscle stimulation, ultrasound, etc. Secondary insurance plans may also have a separate deductible or co-pay that is entirely independent from your Medicare plan deductible. A co-pay is a fixed amount of money you pay each visit regardless of what types of services you received that day. I cannot predict the costs for your individual plan, it's different for everyone. While secondary insurance typically covers more services than Medicare alone, that doesn't mean that every service is eligible for coverage and you will need to verify coverage for your specific plan.

I know that this is a lot of information, so if you have Medicare, please take the time to fully read and understand the details of this article. For reference, I've included a very simple chart to help you understand the different coverages between Medicare, supplemental, and secondary insurances.