Does Medi-Cal Cover Chiropractic Care in California?

Navigating healthcare coverage in California often raises questions about Medi-Cal’s coverage of chiropractic care. This article provides clear information on whether and how Medi-Cal includes these services for eligible individuals.

Understanding Medi-Cal

Medi-Cal is California’s Medicaid program, providing healthcare to low-income individuals and families. Eligibility depends on income, household size, and specific aid categories. Its purpose is to ensure access to necessary medical care.

Income limits are tied to the Federal Poverty Level (FPL); most adults qualify if their income is at or below 138% of the FPL. Specific groups, including pregnant individuals, children, persons with disabilities, and seniors, may have different eligibility pathways. The program operates through managed care plans, influencing how beneficiaries access services and select providers.

Understanding Chiropractic Care

Chiropractic care is a healthcare profession focused on the diagnosis, treatment, and prevention of musculoskeletal disorders, particularly those affecting the spinal column. Practitioners use a hands-on approach, primarily employing manual adjustments and manipulations to address issues within the body’s structure. This treatment method aims to improve function, reduce pain, and support the body’s natural healing processes.

The scope of practice for chiropractors in California allows them to manipulate and adjust the spinal column and other joints. They may also incorporate mechanical, hygienic, and sanitary measures such as massage, exercise, and certain physical therapy techniques as part of a treatment course. While chiropractors can diagnose and treat conditions, their practice does not include performing surgery, prescribing drugs, or delivering babies.

Medi-Cal Coverage of Chiropractic Services

Medi-Cal covers chiropractic services in California, subject to specific conditions and limitations. Currently, these services are a Medi-Cal benefit when medically necessary. Medical necessity means treatment must address a significant neuromusculoskeletal condition.

Medical necessity requires symptoms to be directly related to the treated anatomical region, with manual manipulative services having a direct therapeutic relationship to the patient’s condition. Generalized pain alone is insufficient, and maintenance therapy is not covered. Coverage is primarily limited to manual manipulation of the spine.

For adults, Medi-Cal generally limits chiropractic services to a maximum of two visits per calendar month. Additional visits may be authorized with documented medical justification and prior authorization. Certain beneficiaries are exempt from this limit, including pregnant individuals and those under 21 years old, covered through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.

Chiropractic services provided at Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are also covered. Diagnostic tests or X-rays performed by a chiropractor solely to demonstrate medical necessity for chiropractic treatment are typically not covered, though X-rays ordered by a physician may be.

Accessing Chiropractic Care Through Medi-Cal

Beneficiaries seeking chiropractic care through Medi-Cal should contact their managed care plan. This helps understand benefits, referral requirements, and in-network providers. Plans can provide directories of approved chiropractors.

For members aged 21 and over, some Medi-Cal managed care plans require a referral from their primary care provider (PCP). Confirm this requirement with your plan or PCP to ensure coverage. Once a referral is secured, choose a Medi-Cal approved chiropractor from your plan’s network.

When scheduling, confirm the chiropractic provider accepts Medi-Cal and is aware of any referral status. During the initial visit, the chiropractor will assess the patient’s condition and develop a treatment plan aligning with Medi-Cal’s medical necessity guidelines. Providers maintain documentation of the patient’s condition and medical necessity to support covered services.