Does Medicare Cover Osteopathic Manipulation?
Gain clarity on Medicare's coverage for osteopathic manipulative treatment, detailing requirements and financial implications.
Osteopathic manipulative treatment (OMT) is a hands-on approach used to diagnose, treat, and prevent illness or injury by focusing on the body’s interconnected systems. It involves manual techniques to address musculoskeletal imbalances and promote natural healing. For Medicare beneficiaries, OMT can be a covered service, but specific conditions and requirements must be met. Understanding these criteria is important for those seeking this care.
OMT Under Medicare Part B
Osteopathic manipulative treatment falls under Medicare Part B, covering medically necessary outpatient services. OMT is a distinct manual procedure that improves health and function through manually guided forces. It addresses somatic dysfunction, which involves impaired function of the body’s framework, including skeletal, joint, and myofascial structures, along with related vascular, lymphatic, and neural elements.
Doctors of Osteopathic Medicine (DOs) primarily employ OMT to diagnose and treat various conditions. Medical Doctors (MDs) trained in OMT may also provide these services. Techniques vary, encompassing methods like muscle energy, counterstrain, myofascial release, and high velocity-low amplitude adjustments. This therapy is frequently used for muscle pain and may help individuals with conditions such as asthma, sinus disorders, or migraines.
Meeting Medicare’s Coverage Requirements
Medicare coverage for osteopathic manipulative treatment requires medical necessity. OMT must be “medically reasonable and necessary” for diagnosing and treating a specific illness or injury. This means the treatment should improve the patient’s condition or functional status, such as reduced pain. Documentation is crucial, requiring a clear diagnosis, a treatment plan, and evidence that OMT will benefit the patient.
The medical record needs to support the medical necessity of OMT, identifying the body regions affected by somatic dysfunction. Somatic dysfunction is diagnosed by identifying one or more elements of TART: tenderness, asymmetry, restriction of motion, and tissue texture abnormality. Routine or maintenance OMT, performed without a specific medical condition or an expectation of improvement, is generally not covered.
Understanding Your Out-of-Pocket Costs
When Medicare covers osteopathic manipulative treatment, beneficiaries are responsible for certain out-of-pocket costs. After meeting the annual Medicare Part B deductible, which is $257 for 2025, individuals typically pay 20% of the Medicare-approved amount for OMT services. Medicare then covers the remaining 80% of the approved amount.
The concept of “assignment” impacts your financial responsibility. If a provider accepts Medicare assignment, they agree to accept Medicare’s approved amount as full payment for the service. You are only responsible for your deductible and the 20% coinsurance. If a provider does not accept assignment, they may charge up to 15% more than the Medicare-approved amount, known as balance billing, in addition to your coinsurance and deductible.