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Health Insurance and Alternative/Complementary Medical Treatment

Jacques Chambers, CLU, Benefits Consultant

Many people dealing with HCV have found they benefit from using “non-Western” complementary treatments in conjunction with their other medical care. One small survey of about 1,000 people with chronic liver disease, including HCV, found that approximately 40% of them use or have used some form of complementary medicine.

Paying for such treatments can be a hardship since most health insurance plans, including Medicare and Medicaid do not provide much coverage, if any, for these types of treatment.

Alternative/Complementary treatments may include:
o Chiropractic treatment
o Acupuncture
o Herbal medicines (such as milk thistle)
o Massage Therapy
o Mind/Body medicine
o Naturopathy
o Hypnotherapy
o Meditation
o Yoga
o T’ai Chi
o Nutrition Therapy
o Art Therapy/Music Therapy
o Medical protocols from other cultures, such as Native American or Chinese medicine
o And almost any other therapy that is not administered by or under the supervision of a licensed medical doctor.

Health insurance plans have historically resisted providing coverage for these treatments for a variety of reasons. Insurance companies maintain that in the absence of strict oversight and regulation, they are unable to distinguish legitimate treatments from “quackery,” as well as determine which providers should be covered and which should not. Of course, there is also the fact that health insurance was created, and is still overseen, by practitioners of Western style medicine who have resisted the inclusion of many of these treatments in their medical protocols.

In recent years, some progress has been made. Many health insurance plans provide varying degrees of coverage for chiropractic treatment and acupuncture.

Chiropractic. Some states mandate limited coverage for chiropractic treatment in all health insurance plans. However, most health plans that do provide chiropractic coverage will put limitations on the number of treatments they will cover and the amount of coverage they will provide.

For example, they may limit coverage to only ten or twenty visits per year, and limit the payment to $25, or other limited amount per treatment. Also, many health insurance plans will limit covered treatment by a chiropractor to spinal manipulation only in an effort to avoid paying for ancillary treatments such as massage or ultrasound treatments.

Some larger employers and some health insurance companies provide broader chiropractic coverage but require that all treatment be provided through a network of contracting chiropractors. While such plans limit the choice of provider, they will often provide broader coverage, such as twenty to fifty visits per year, and require only a minimal copay such as $5 or $10 per visit.

To determine your policy’s coverage, it is important to read the Summary Plan Description to see what chiropractic benefits, if any, are provided.

Medicare will cover only manual manipulation for subluxation of the spine. A chiropractor is defined in the Social Security Act as a physician for only one service, manual manipulation or treatment of subluxation of the spine. This coverage comes under Part B of Medicare, which provides 80% of the Medicare Allowable Amount after a $100 annual deductible.

Chiropractic coverage is an optional coverage under the federal Medicaid mandate, so each state determines whether or not to provide coverage under its program. In those states that provide coverage, it is usually limited in a manner similar to Medicare’s restrictions.

Acupuncture. There also has been some movement to provide coverage for acupuncture treatments under health insurance. Again, plans will limit their coverage in several ways. Some plans require that the treatments be provided by a licensed physician, MD or DO. In those states that license acupuncturists, some insurance companies will cover them, but require that the treatment be recommended or referred by a licensed medical physician.

More and more physicians and hospitals are incorporating acupuncture into their regimen of treatments. Acupuncture treatments in such medical settings are more likely to be covered by health insurance unless there is a specific exclusion listed in the plan document. The coverage, when provided, is similar to the coverage provided for other treatments by the same provider, under the hospital or doctor benefit of the plan.

Medicare specifically excludes treatment by acupuncture. Those states that provide coverage under their Medicaid program limit the benefits or require that coverage be provided only for treatments in a hospital or doctor’s office.

Unfortunately, acupressure and other related treatments have not enjoyed the expansion of acceptance that acupuncture has. Most are treated as a form of massage and rarely covered.

Other Treatments. Insurance rarely covers the other types of alternative or complementary therapies.

There will be some exceptions when the treatments are provided by a licensed medical professional. Health insurance plans typically state that they will cover services provided by a “legally licensed physician performing within the scope of their license.” This phrase allows the insurance company to refuse to cover treatments that they believe are too far removed from “Western” style medicine.

Herbal medications, homeopathic treatments, nutritional supplements, and other treatments that require ingestion of substances are rarely, if ever, covered by health insurance. This is because insurance plans limit coverage for “medications” to those that are only available by prescription. This excludes coverage for virtually anything that can be sold over-the-counter. Also, insurance plans rely exclusively on medications that are approved by the Federal Drug Administration.

The primary exception to medications are when the prescriber is a licensed medical provider and he/she directly provides the medication as part of an office visit, and the cost is included in the office visit fee. In those cases, it may be possible that the insurance company will pay the charge; as an office visit, however, not as a medication.

Massage therapy and similar therapies are normally only covered if they are part of a physical therapy regimen, supervised by a physician and administered by a physical therapist.

Some employers offer Medical Savings Accounts that allow tax sheltered-dollars to pay for medical treatment and supplies that are not covered by insurance. A new type of tax-sheltered account, the Health Savings Account, was just created by the recent Medicare Reform Act. It, too, will allow individuals to set aside money in a tax shelter and pay medical bills from it with untaxed dollars.

However, both of the tax-sheltered savings accounts allow payment only for those medical charges that the Internal Revenue Service considers tax deductible for income tax purposes. This includes many complementary treatments such as chiropractic, acupuncture, Christian Science readers, and medical care provided by physicians, surgeons, specialists, and “other medical practitioners.”

However, the IRS specifically limits medications to those that require a prescription and insulin. No over-the-counter herbs or medicines would qualify. Through the IRS website at http://www.irs.gov/, you can find more information on what are deductible medical expenses.

While some progress has been made in the coverage of complementary / alternative treatments, there are still expensive treatments that are not covered by insurance and will not be for the foreseeable future. Only as they are proved efficacious through formal studies will they move into the mainstream of Western medical treatment and be covered by health insurance. Of course, the insurance companies will move a little faster if the treatments are also cost effective and can save them money as well.

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[Jacques Chambers, CLU, and his company, Chambers Benefits Consulting, have over 35 years of experience in health, life and disability insurance and Social Security disability benefits. For the past twelve years, he has been assisting people with their rights, problems, and other issues concerning benefits and disability. He can be reached at jacques@helpwithbenefits.com or through his website at: http://www.helpwithbenefits.com.]

Copyright December 2003 – Hepatitis C Support Project - All Rights Reserved. Permission to reprint is granted and encouraged with credit to the Hepatitis C Support Project.

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