JOEL MEKLER: Medicare coverage for acupuncture -- What you need to know

Medicare now will cover acupuncture for chronic low back pain.

Does Medicare cover acupuncture?

If you had asked me this question four months ago, I would have said no unless you were being treated for chronic low back pain as part of a clinical trial or Medicare-approved study. The Centers for Medicare & Medicaid Services (CMS) changed their stance on acupuncture on Jan. 21, when they announced that Medicare will cover acupuncture for chronic low back pain.

This is a significant breakthrough due to the administration’s concerns about the raging opioid crisis and the need to expand alternative nonpharmacologic treatment options that could help reduce reliance on prescription opioids.

•When will Medicare coverage of acupuncture take effect? The effective date of the decision has not been announced. Many details remain to be worked out, including the fee schedule, how services will be billed and the exact nature of supervision required.

•What types of low back pain are covered? Medicare covers acupuncture for pain that affects your lower back and is chronic. “Chronic,” lower back pain must meet these criteria: The pain has lasted at least 12 weeks; pain doesn’t have an identifiable cause such as cancer or a disease; isn’t related to surgery or pregnancy.

•How many acupuncture sessions will be covered, and for how long? You may be able to receive up to 12 acupuncture treatments during a 90-day period if the above criteria are met. You may be eligible for eight more sessions if your symptoms improve, but Medicare won’t cover more than 20 sessions each year. Treatment will be discontinued if a patient does not show improvement.

•Will Medicare cover acupuncture for conditions other than chronic low back pain? At this time, Medicare does NOT cover acupuncture to treat pain in other parts of the body. Also, Medicare doesn’t pay for acupuncture to treat temporary acute pain such as pain from a recent injury.

•Does Medicare have any specific requirements for acupuncturists administering the chronic low back pain treatment to be covered? Under the new Medicare coverage, physicians can administer acupuncture “in accordance with applicable state requirements.” If a non-physician (i.e. physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel administer acupuncture, he or she must: Meet all applicable state requirements; hold a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and have a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth of the United States, or District of Columbia.

Acupuncturists are not recognized as Medicare providers, so they won’t be able to bill Medicare directly for the service. Instead, CMS states, acupuncturists may provide the service “incident to the service” of a physician as auxiliary personnel. This means they will need to provide the therapy under a plan of care established by and under direct supervision of a physician.

•Which part of Medicare covers acupuncture? Acupuncture is covered under Medicare Part B. A beneficiary is responsible for paying 20 percent coinsurance after the Part B deductible of $198 is met. A Medicare supplemental policy may pick up some or all of these costs. Average acupuncture costs are between $50 to $90 dollars, depending on location. Remember, acupuncture will only be covered for chronic low back pain. If you receive acupuncture treatment for any other physical or mental condition, you must pay the full cost.

•Will Medicare Advantage plans pay for acupuncture? Medicare Advantage is a way to get your Medicare Part A and Part B benefits from a private insurance company. When you enroll in a Medicare Advantage plan, you’re still in the Medicare program and are required to pay your Part B premium along with any premium the plan charges.

Medicare Advantage plans must cover everything that Original Medicare covers and often offers additional benefits. Some extra benefits covered by Medicare Advantage plans could include routine vision, dental, and hearing. Not all Medicare Advantage plans cover the same services or benefit package.

If your Medicare Advantage plan does cover acupuncture, you may need to see in-network providers. You may also need a referral from your primary care doctor and preauthorization. It’s quite possible that your plan may offer acupuncture treatment for other conditions than chronic low back pain.

•Will Medicare be expanding coverage of other alternatives? No other new decisions have been announced for the expansion of coverage of alternative pain treatments. However, this decision does indicate an openness by CMS to consider broader coverage of alternative pain treatment options.

 Joel Mekler is a certified senior adviser. Send him your Medicare questions at mekbab2000@verizon.net.

Recommended for you

(0) comments

Welcome to the discussion.

Keep it Clean. Please avoid obscene, vulgar, lewd, racist or sexually-oriented language.
PLEASE TURN OFF YOUR CAPS LOCK.
Don't Threaten. Threats of harming another person will not be tolerated.
Be Truthful. Don't knowingly lie about anyone or anything.
Be Nice. No racism, sexism or any sort of -ism that is degrading to another person.
Be Proactive. Use the 'Report' link on each comment to let us know of abusive posts.
Share with Us. We'd love to hear eyewitness accounts, the history behind an article.