In this season of open enrollment in the United States, I want to share a bit about how to choose an insurance plan if you want to use your coverage to get acupuncture care. Since January 1st, 2022, acupuncture has been considered an essential health benefit in the state of Oregon. This was already the case in other states like California and Washington, but each state has its own guidelines, so check yours for details. In Oregon, this means that every private insurance plan in the state is required to include at least 12 visits per year. However, having benefits and using them are often two different things. In this article I will attempt to clear up some confusion about how insurance works so that we can all be more empowered to get the care we need.
Most of us do not actually know how to use our insurance benefits, which makes surprise bills common. This is especially true with acupuncture because of the way medical billing works. Many practitioners of Chinese and East Asian medicine not only perform acupuncture during their treatments, but a whole host of other modalities, including Chinese bodywork (Tuina), cupping, and other kinds of massage. This is because traditional East Asian medicine is so much more than acupuncture, and includes many tools we can use in our holistic approach working with the particular needs of the patient. This is a major asset for healing, but can be confusing when it comes to insurance billing. That is because insurance billing is based on what a practitioner does in the time spent with you. This means that generally practitioners are not paid simply for the time we spend with a patient, but for the procedures that we perform with that patient during a particular visit.
Another piece of the equation is authorizations. When your insurance plan requires an authorization for care it means your providers have to send in proof to the insurance company that the care you are receiving is medically necessary. Insurers do not generally pay for wellness care, you have to have something wrong. Proving medical necessity is the way insurers determine if the care you are receiving is medically warranted or not. For acupuncture care, the provider has to show that your daily functioning is compromised significantly enough by whatever it is you are getting treatment for, usually pain. This involves an assessment, which may include questionnaires you fill out asking how your pain is affecting your daily activities. Additionally, the amount of care you are approved for is usually determined by the severity of the pain. You could technically have 12 visits of acupuncture on your plan, but your insurer only approves 4 visits for your low back pain because it is not bad enough to warrant approving all 12. Your provider will have to ask for more visits after the initial 4, and your insurer may or may not approve it. This makes it much harder to use all your visits.
Now, for some technical jargon. The way medical providers tell an insurance company what treatment a patient receives in a particular visit is through CPT codes. CPT stands for Current Procedural Terminology, and according to the AAPC, “refers to a set of medical codes used by physicians, allied health professionals, non-physician practitioners, hospitals, outpatient facilities, and laboratories to describe the procedures and services they perform.” CPT codes translate your treatment into payment. Because Chinese and East Asian medicine lives outside of the paradigm of Western medicine, but is still covered by insurance, it can be tricky to encapsulate everything we do in CPT codes. Acupuncture has it’s own specific codes, but other things like Chinese bodywork and cupping generally borrow codes from physical therapy (PT). This is important because it affects how your insurer covers a visit. For example, if an acupuncturist is billing PT codes (instead of, say, a physical therapist), some insurers might count those codes against your PT benefits, and some may not. In addition, when your acupuncturist does an intake or reassessment (when we talk about your symptoms and health goals as well as take your pulse and look at your tongue) we often bill an office visit code. That means a typical visit to an acupuncturist could include three types of codes: acupuncture, PT, and office visits. And if your insurer applies different rules to these three benefits, things can get complicated very fast.
Let’s see how this works in real life.
Say you buy an insurance plan. Your insurer tells you that you get 12 visits for acupuncture per year with a $10 copay. There is no deductible applied, so you can use your benefits right away. Great! Most people stop here and think they are covered. However, this particular company applies the rules for their physical therapy coverage when the acupuncturist bills PT codes for cupping. The $5,000 deductible applies to those codes, as well as an additional 10% coinsurance. In addition, office visits have an additional $80 copay.
This means that in addition to the $10 copay for acupuncture you will be paying $80 every time you have an assessment (this almost always includes the first visit, and generally monthly after that if you are getting care weekly). Also, because the deductible is high and applied to the PT codes you will be paying out of pocket for that code, about $60, every visit you get any kind of bodywork. All total, that runs you $70-$150 PER VISIT. That is higher than the time-of-service, discounted, non-billing rates many practitioners offer. As you can see, the coverage on this plan is not what it seemed to be. Unfortunately, this is not uncommon. This example is from a real plan a patient had last year. Once they realized the reality of what the plan actually covered they switched to another plan as soon as they could.
By this time your head may be spinning and you may be wondering why it has to be this complex. The truth is, it doesn’t have to be, but until we have single payer, this is the reality of our for-profit, privatized healthcare system. For reference, public healthcare plans (OHP) in Oregon also cover acupuncture, but they are much simpler to understand and designed for there to be no out-of-pocket surprises for their members.
Let’s take a pause and a breath, or two.
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So, how do you know what your coverage really is?
Here are some questions you can ask when choosing a plan (and the reasoning behind them) to get a better sense of how it will work in the real world.
Acupuncture Benefits
- What are the acupuncture benefits? (This could be a set number of visits or a dollar amount covered.)
- Is there a copay or coinsurance? (A copay is a set amount you pay per visit, coinsurance is a percentage, which makes it a bit harder to estimate out of pocket costs.)
- Does the deductible apply to the acupuncture benefits? (If the deductible applies, that means you have to pay the deductible down before your benefits will kick in. If your deductible is low, under $1000 or so, and you use your insurance regularly, this is usually doable in a calendar year. If it is higher than $1000, or you don’t use your insurance much, you may end up paying more using your insurance than you would if you just paid out of pocket.)
- Do I need an authorization to use these benefits?
Physical Therapy Benefits
- What are the physical therapy benefits?
- Is there a copay or coinsurance for these benefits?
- Does the deductible apply?
- When billed by an acupuncturist, do these codes apply to my PT benefit or not? (If your insurer needs specific CPT codes, use these: 97140, 97124)
- Do I need an authorization to use these benefits?
Office Visit Benefits
- What is the coverage for office visits?
- Is there an additional copay or coinsurance for an office visit?
- Does the deductible apply?
When figuring out what you will pay with coinsurance you can use $100 as a rule of thumb. A 10% coinsurance will be about $10 out of pocket, etc.
Add up all the copays and coinsurances for these three categories and that will generally be the max you will pay for a given session. Unfortunately, all of this is a guesstimate until you actually use your plan to get care. Insurance companies do not guarantee coverage or estimates for out-of-pocket costs.
May this information help you make more informed choices when choosing your plans, this year and into the future. You are the customer and have the most power to make change, both for your personal healthcare, but also in general. If your insurer is making it too hard to get care, you have a right to complain and also shop for a new plan. Also, if you purchase your own insurance plan from the marketplace, a good insurance broker is invaluable. They are paid by insurance companies to help you find the right plan at no out-of-pocket cost to you. If you get your insurance through an employer be sure to ask your HR representative these questions and understand what you are signing up for. If your company does not offer benefits you can use, make that problem known.
And if you have questions about your acupuncture coverage, we at Zócalo Wellness are always happy to go over your benefits with you. Don’t hesitate to contact us by phone or email. Let’s get you some care!