Does Virginia Medicaid Cover Chiropractic Care?

Virginia Medicaid provides healthcare coverage to qualifying residents. Many individuals inquire about coverage for specialized services like chiropractic care. Understanding these benefits is important for beneficiaries seeking alternative treatment options for musculoskeletal conditions. This article clarifies Virginia Medicaid’s approach to chiropractic services, outlining specific criteria, covered treatments, and how to access care.

Virginia Medicaid Chiropractic Coverage Criteria

Virginia Medicaid generally covers chiropractic services for beneficiaries under the age of 21 through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. These services must be medically necessary to correct or ameliorate a physical or developmental disability identified during an EPSDT screening. For individuals enrolled in the Family Access to Medical Insurance Security (FAMIS) program, which serves children under 19, medically necessary spinal manipulation and outpatient chiropractic services for an illness or injury are also covered.

Coverage hinges on medical necessity, meaning the treatment must be appropriate for a specific condition. This involves acute or chronic neuromusculoskeletal conditions where there is a reasonable expectation of recovery or functional improvement. Chiropractic care is not covered for long-term maintenance or wellness purposes once a member’s functional status has stabilized.

A referral from an EPSDT screener or a primary care provider (PCP) may be necessary for chiropractic services under the EPSDT program. For beneficiaries enrolled in a Managed Care Organization (MCO), prior authorization from the MCO is often needed when services are sought from non-participating providers to ensure medical necessity and coverage.

Covered Chiropractic Services and Visit Limits

Virginia Medicaid’s coverage for chiropractic services primarily focuses on manual spinal manipulation. Common codes for chiropractic manipulative treatment (CMT) include 98940, 98941, and 98942, which correspond to the number of spinal regions treated. Diagnostic radiological examinations related to covered chiropractic services, such as X-rays, may also be reimbursed if performed by the chiropractor.

For FAMIS members, there is an annual monetary limit of $500 for medically necessary spinal manipulation and outpatient chiropractic services. Beyond this financial cap, beneficiaries become responsible for the costs. Services beyond a certain number of treatments may require prior authorization to ensure continued medical necessity.

Services not covered by Virginia Medicaid include those deemed not medically necessary or for maintenance therapy. This includes treatments like nutritional counseling, massage therapy not performed as part of a covered chiropractic service, or the use of mechanical or electrical equipment separate from manual manipulation. The intent of covered chiropractic care is to address an active condition, not to provide ongoing supportive care.

Finding a Virginia Medicaid Chiropractic Provider

Locating a chiropractic provider who accepts Virginia Medicaid involves utilizing the state’s official resources. Beneficiaries can use the Virginia Medicaid provider search tool available through the Department of Medical Assistance Services (DMAS) website. If enrolled in a Managed Care Organization (MCO), each MCO also provides its own specific provider search tool on its website.

When contacting a chiropractic office, verify their current participation with Virginia Medicaid and your specific MCO, if applicable. This step helps ensure that the services will be covered under your plan. When scheduling an appointment, beneficiaries should have their Virginia Medicaid identification card readily available, as this information will be required by the provider’s office.

For certain services or if seeking care from an out-of-network provider, obtaining prior authorization may be necessary. The process for requesting prior authorization often involves the provider submitting a request to the MCO or DMAS through online portals, by phone, or via fax. This pre-approval confirms that the requested service meets the medical necessity criteria for coverage.

Patient Financial Responsibilities

Co-payments for Medicaid and FAMIS enrollees have been removed. This means beneficiaries do not incur out-of-pocket costs for covered chiropractic visits. Deductibles or co-insurance are not applied to services covered by Virginia Medicaid.

Beneficiaries are responsible for the cost of any chiropractic services that are not deemed medically necessary or that exceed established coverage limits. For instance, if a FAMIS member exceeds the $500 annual limit for chiropractic care, the patient would be responsible for any additional charges. It is advisable to discuss potential costs with the chiropractic provider’s office before receiving services, especially if there is uncertainty about coverage for a particular treatment or if care extends beyond initial authorizations.