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Posted on 03-28-2018

~~WHY HEALTH INSURANCE DOESN’T COVER WELLNESS CHIROPRACTIC CARE

To successfully describe why health insurance will not cover chiropractic wellness care, we first need to understand the difference between medically necessary care (also known as active care) and wellness care (sometimes known as maintenance care).

MEDICALLY NECESSARY CHIROPRACTIC CARE

Care is considered medically necessary when there is a reasonable expectation it will encourage improvement and/or recovery of the patient’s issues. It is based on a combination of subjective and objective improvements. If after evaluation it is determined that chiropractic care is a viable treatment option, a custom treatment pan will be developed for that patient. It is common for an initial plan to start with frequent visits which are then tapered off to less frequent visits over time. As long as the patient is showing improvement over a reasonable amount of time, then the treatment is considered medically necessary.

At this point the patient is considered to be on active care.

Health insurance company’s base members chiropractic coverage on medically necessary care only. Unfortunately, medical care in the United States for the most part is ‘sick care’, not healthcare. Once symptoms are gone, active care is complete. The insurance won’t cover anything else after that unless or until the symptoms return.

So, one may ask, if the symptoms are gone, then why would future care be needed and recommended? Well, that’s where we get into wellness care and corrective care.

WELLNESS CHIROPRACTIC CARE

Wellness care is designed to help maintain the progress that a patient has made. For permanent/chronic issues, the goal is to reduce the intensity, frequency and duration of any flare-ups they may experience. The goal is to keep a person functioning at the highest level possible.

That’s the difference between medically necessary and wellness care. When people ask me why their insurance doesn’t cover wellness care, well, because it’s not considered medically necessary according to the guidelines through the insurance companies. And unfortunately, when healthcare providers sign contracts to be in-network with insurance companies, we then must follow their rules. 

Medicare has published its own definition of maintenance care as follows:

“Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvements cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.” Medicare Benefit Policy Manual

A lot of people choose chiropractic maintenance care because they want to function at the highest level possible and help prevent issues in the future.

CORRECTIVE CHIROPRACTIC CARE

Corrective care is designed to help fix the underlying issues that have given you the symptoms you have.  Corrective care starts after the initial phase of medically necessary care, also known as “active care”. It is impossible to try and change the spine and the subluxation pattern when the patient is in pain.  Therefore, as part of the care plan, we add additional phases to help correct the underlying cause. 

More specifically with corrective care, as many of our patients know, we look at pre and post x-rays to determine our progress.  This is an amazing technology to have at our finger tips and increases the positive outcomes in our office. 

Once again, insurance companies do not and will not cover corrective care due to the fact that we are not in “active care” as determined by your health insurance plan.

BUT MY INSURANCE POLICY SAYS I GET 20 VISITS PER YEAR

Lastly, even with a clear understanding of what was discussed above, there can still be some confusion when a health insurance policy states that a specific number of chiropractic visits are allowed per year. The number of visits allowed vary plan to plan but a common number is 20 per year. So shouldn’t I get all 20 visits no matter what? Not necessarily, and that is because it actually means UP TO 20 visits per year of medically necessary care is allowed.

For example, let’s say patient John Doe comes in with a plan and their policy allows up to 20 chiropractic visits per year. Let’s say they get better in 10 visits and are now symptom free, recovered and stable. They can’t continue on with care for another 10 visits because the insurance won’t cover it since they’ve reached maximum medical improvement. If it is determined that no further improvement is expected with continued care, then any additional care will be considered maintenance/supportive care and as we now know health insurances don’t cover that. This can lead to a lot confusion because sometimes patients ask, if I have 20 visits, why can’t I use them all? Well, you could use them all if the care is considered medically necessary according to those insurance parameters discussed above.


Overall, I think it is unfortunate that health insurance plans don’t cover wellness and corrective chiropractic care. If they did then maybe people would stay healthier, prevent issues down the road and in the long run spend less money on healthcare.

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