Does Texas Medicaid Cover Chiropractic Care?

Texas Medicaid is a joint federal and state healthcare program providing medical assistance to eligible low-income individuals and families. This program aims to ensure access to a range of healthcare services for those who might otherwise face financial barriers. Chiropractic care, which focuses on diagnosing and treating musculoskeletal disorders, particularly those affecting the spine, is one such service that can address various physical needs.

Texas Medicaid Chiropractic Coverage

Texas Medicaid covers chiropractic manipulative treatment (CMT) when medically necessary. This coverage is available under specific conditions and for certain populations. Its purpose is to address acute conditions or acute exacerbations of chronic conditions, helping beneficiaries manage pain and improve function. Coverage is typically not extended for maintenance therapy, which aims to prevent recurrence or prolong benefits from previous treatment.

Medical necessity for chiropractic services must be clearly documented by a licensed chiropractor. This documentation involves detailing the patient’s symptoms, diagnosis, and how the treatment is expected to improve their condition. Medicaid focuses on providing care that is restorative or ameliorative, requiring treatment to be directly linked to a diagnosed medical issue.

Medicaid Programs with Chiropractic Benefits

Chiropractic benefits in Texas Medicaid are generally available through managed care programs such as STAR, STAR Kids, and for eligible children and adolescents under Texas Health Steps. The STAR program serves various low-income individuals, including children, pregnant women, and families. Within STAR, chiropractic services are a covered benefit, alongside other medical services like primary care visits and prescription drugs.

The STAR Kids program is designed for individuals aged 20 or younger with disabilities or complex medical needs, ensuring chiropractic care is available. Texas Health Steps, which encompasses the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, provides comprehensive health services for Medicaid-eligible individuals from birth through age 20. Under Texas Health Steps, chiropractic services address health conditions identified through screenings.

Covered Chiropractic Services and Limitations

Chiropractic manipulative treatment (CMT) is covered when performed by a chiropractor. Coverage for CMT is typically limited to a maximum of 12 visits within a consecutive 12-month period. This 12-month period begins from the date the individual receives their first chiropractic treatment.

Chiropractic care is not covered for maintenance therapy. If a condition persists beyond 180 days from the start of therapy, it is considered chronic, and further treatment might not be covered if solely for maintenance. Additionally, some services, such as massage therapy, acupuncture, or specialized equipment, are generally not covered under Texas Medicaid’s chiropractic benefits.

Accessing Chiropractic Care Through Medicaid

To access chiropractic care through Texas Medicaid, individuals must be enrolled in a Medicaid managed care plan that includes this benefit. While a direct referral from a primary care provider (PCP) may not be required, consulting with a PCP is advisable to coordinate care. A PCP can help guide beneficiaries to appropriate in-network providers and ensure care aligns with their overall health plan.

Chiropractic services often require prior authorization from the Medicaid health plan before treatment begins. The chiropractor submits a request to the health plan. Beneficiaries can find Medicaid-enrolled chiropractors through their health plan’s provider directory, available online or by contacting member services. Confirm with the provider that they accept Texas Medicaid and are in-network with your specific health plan before scheduling an appointment.