Does Medicare Cover a Chiropractic Visit?
Understand how Medicare covers chiropractic care, including eligible services, necessary conditions, patient costs, and exclusions.
Medicare is a federal health insurance program designed to provide health coverage for individuals aged 65 or older, younger people with certain disabilities, and people with End-Stage Renal Disease. Chiropractic care focuses on the diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system, especially the spine, through manual adjustment and manipulation.
Covered Chiropractic Services
Medicare Part B covers manual manipulation of the spine. This manipulation must be performed to correct a vertebral subluxation, which refers to a condition where spinal joints fail to move properly, though the contact between the joints remains intact. This service must also be considered medically necessary, meaning it is required for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body part. It is not for general back or neck pain unless directly related to a subluxation.
Requirements for Coverage
For Medicare to cover manual spinal manipulation, several conditions must be met. The service must be performed by a chiropractor or other qualified provider who is legally authorized to provide chiropractic services in the state where they practice. The treatment must address a subluxation of the spine, which needs to be demonstrated by an X-ray or physical examination. Furthermore, the care must be part of an active treatment plan, indicating that the patient’s condition is expected to improve or stabilize.
This requirement means that Medicare does not cover maintenance therapy, which aims to prevent disease or prolong quality of life rather than treat an active illness or injury. Clinical documentation is essential, including patient history, physical exam findings, a precise diagnosis of subluxation, a treatment plan, and progress notes. Providers must also include a specific modifier, “AT,” on claims for active or corrective treatment to signify that the service is not maintenance therapy.
Understanding Your Costs
Beneficiaries should understand the financial aspects of chiropractic care under Medicare Part B. After meeting the annual Part B deductible, Medicare pays 80% of the Medicare-approved amount for eligible chiropractic services. The patient is then responsible for the remaining 20% coinsurance. This payment structure applies to services received from chiropractors who accept Medicare assignment.
Accepting assignment means the chiropractor agrees to accept the Medicare-approved amount as full payment for the service. If a chiropractor does not accept assignment, they may charge up to 15% more than the Medicare-approved amount, which is known as a limiting charge, and the patient would be responsible for this additional amount in addition to the coinsurance. While Original Medicare follows these cost-sharing rules, Medicare Advantage plans (Part C) may have different cost structures, so beneficiaries with these plans should consult their specific plan details.
Services Not Covered by Medicare
Many services a chiropractor may order or perform are not covered by Medicare. These include X-rays, unless medically necessary for a covered condition and ordered by a medical doctor; routine X-rays for chiropractic assessment are not covered. Additionally, services such as massage therapy, acupuncture (unless for chronic lower back pain, which has specific coverage criteria), nutritional counseling, and supportive devices like orthotics or pillows are not covered. Patients are fully responsible for the cost of these non-covered services.