Medicare, the federal health insurance program primarily for people aged 65 and older, provides crucial coverage for various medical services and treatments. However, many beneficiaries often wonder if Medicare covers alternative therapies like acupuncture.
Understanding acupuncture
Acupuncture — an alternative treatment based on traditional Chinese medicine — involves inserting tiny needles into specific points on the body to alleviate pain, stimulate the central nervous system, and promote overall well-being. It is an increasingly popular treatment for various conditions such as chronic pain, migraines, and even stress management.
Does Medicare cover acupuncture?
Let’s examine the coverage options within Medicare and their stance on acupuncture. Medicare has different parts, namely Part A (hospital insurance) and Part B (medical insurance), which offer varying levels of coverage.
Medicare Part A primarily covers inpatient hospital care, care provided at skilled nursing facilities, and some home health services. It mainly focuses on acute medical conditions requiring hospitalization or medically necessary treatments. Unfortunately, acupuncture does not fall under the covered services provided by Part A.
On the other hand, Medicare Part B covers outpatient medical services, including doctor’s visits, preventive care, and durable medical equipment. While Part B generally covers a wide range of medically necessary services, acupuncture has traditionally been considered an alternative therapy rather than a recognized medical treatment.
The exception: chronic lower back pain
In January 2020, the Centers for Medicare & Medicaid Services (CMS) updated their coverage definitions to allow for acupuncture coverage as a treatment for chronic low back pain — under specific conditions.
To qualify for coverage, the following criteria must be met:
1 – Chronic low back pain must be persistent and last at least 12 weeks (3 months).
2 – The pain must have an unknown cause (that is, pain unrelated to cancer or other diseases) and not be related to surgery or pregnancy.
3 – Conventional medical treatments must have already been tried and failed.
4 – Acupuncture services must be provided by a qualified healthcare professional who meets Medicare’s standards.
This last point is critical because CMS doesn’t recognize licensed acupuncturists as Medicare providers. Instead, Medicare requires you to be treated by a doctor or healthcare provider (like a nurse practitioner or physician assistant) with the following qualifications:
- The provider must have a master’s or doctoral-level degree from a school recognized by the Accreditation Commission on Acupuncture and Oriental Medicine.
- The provider must have an active, unrestricted license to practice acupuncture in the state you’re getting care in.
- The provider must be a Medicare provider or be supervised by one.
How will Medicare Part B’s acupuncture coverage work?
Medicare allows up to 12 acupuncture sessions over 90 days. If your condition improves and your pain decreases as a result of acupuncture, Medicare may approve eight more visits for a maximum of 20 treatments per year. However, if your state does not improve after the initial 12 sessions, Medicare won’t approve the additional eight.
Medicare’s coverage kicks in once you’ve paid your Part B deductible. It pays 80% of the Medicare-approved amount for each acupuncture session. You then pay the remaining 20% directly out of pocket.
Why doesn’t Medicare cover acupuncture for other conditions?
While this coverage expansion is undoubtedly beneficial for eligible beneficiaries suffering from chronic low back pain, it’s important to note that other conditions do not currently qualify for Medicare coverage of acupuncture.
This is because, despite studies finding that acupuncture helps many other conditions, evidence about its effectiveness is patchy and sometimes unclear. For instance, the CMS had considered acupuncture coverage for osteoarthritis but ruled the technique was “not reasonable and necessary.”
Other uncovered conditions include migraines, neck pain, knee pain, seasonal allergies, arthritis, cancer-related fatigue and nausea. So, you’ll likely have to pay out of pocket to try acupuncture for anything other than chronic lower back pain.
What about Medicare Advantage?
If you want acupuncture coverage outside Original Medicare, consider exploring Medicare Advantage (Part C). Offered by private insurance firms, Medicare Advantage provides all the benefits of original Medicare but will often include coverage for treatments such as acupuncture.
However, the availability of acupuncture coverage can vary depending on the specific Medicare Advantage plan and its network of providers. For example, some providers may extend acupuncture coverage for pain relief but not nausea. Unfortunately, every Medicare Advantage plan is different.
Making smart decisions about acupuncture
Caring for your health involves exploring all available resources and making informed decisions. Acupuncture is known for helping relieve pain and encouraging the body to heal itself. Some private health insurance plans outside of Medicare may offer coverage for acupuncture.
If you’re considering acupuncture treatments, it’s essential to carefully review the benefits and coverage details of any health insurance plan you’re considering, including Medicare Advantage and private plans.
Need help to understand your coverage and your options? Contact a Medicare expert at Guided Solutions today. We’re happy to help!
