For many people, health insurance is essential for accessing medical care. But what about non-conventional treatments like acupuncture? Let’s explore whether health insurance typically covers acupuncture and the key points you need to know about accessing this service.
Understanding Acupuncture
Acupuncture is a traditional Chinese medicine practice that involves inserting fine needles into specific points on the body to promote healing, alleviate pain, and restore balance. It has gained widespread recognition in Western medicine for treating various conditions, including chronic pain, migraines, stress, and more.
The practice is based on the concept of “Qi” (pronounced “chi”), the body’s vital energy flow. By targeting specific acupuncture points, practitioners aim to unblock stagnated energy and stimulate the body’s natural healing processes.
Does Health Insurance Cover Acupuncture?
The extent of acupuncture coverage depends on your health insurance plan. Let’s break it down:
Types of Insurance Plans Covering Accupuncture
- HMO (Health Maintenance Organization): Typically requires you to use in-network acupuncturists. You may need a referral from your primary care physician (PCP).
- PPO (Preferred Provider Organization): Allows more flexibility to choose out-of-network acupuncturists but may involve higher out-of-pocket costs.
Many PPO plans also require that the acupuncture treatment be deemed medically necessary. This classification often limits coverage to specific conditions, such as chronic pain or nausea caused by chemotherapy.
In-Network vs. Out-of-Network Acupuncturists
Many health insurance plans have a network of preferred providers. If you choose an in-network acupuncturist, you are more likely to receive coverage for their services. Out-of-network acupuncturists may still be covered to some extent, but you might incur higher out-of-pocket costs.
In recent years, some insurance companies have implemented tiered systems that further categorize acupuncturists based on treatment metrics. Providers who typically recommend fewer visits or align closely with the insurer’s medical necessity guidelines may result in lower co-pays for patients. Conversely, acupuncturists who frequently recommend longer or more intensive treatment plans may fall into higher co-pay tiers, leading to increased out-of-pocket expenses.
Medical Necessity of Acupuncture Visits
Insurers typically cover acupuncture when it is considered medically necessary. This means that your acupuncturist’s diagnosis and treatment plan must align with your health insurance company’s guidelines. If the care is deemed not medically necessary, it may not be covered.
Wellness-focused treatments, maintenance care, and general relaxation therapies are not considered medically necessary and are typically denied by insurance. Retrospective reviews often reveal that treatments were not medically necessary after visits have been completed, and in some cases, years later.
The discovery of such visits can prompt an audit of the provider’s office and may result in repayment demands from the insurer, creating potential financial and administrative burdens for the provider.
Acupuncture Visit Limits
Health insurance plans often have visit limitations or a cap on the number of acupuncture sessions covered within a specific time frame. It is important to understand your plan’s specific limits and how they may apply to your treatment.
In many cases, insurance companies use medical necessity guidelines to enforce stricter visit limits. For example, while your plan might offer coverage for 20 acupuncture visits per year, this does not guarantee that all 20 visits will be deemed reasonable and necessary by the insurer. Claims are often reviewed individually, and coverage may be denied if the insurer determines that additional sessions are not medically justified.
Pre-Authorization of Acupuncture Treatment
Today, MOST insurance plans require pre-authorization before you can begin acupuncture treatment. It is essential to check with your insurer to fully understand their specific requirements.
In many cases, pre-authorization requests are handled by third-party companies that manage acupuncture benefits on behalf of the insurance provider.
These programs can impose additional limitations and requirements that may not be immediately apparent to consumers and are often not well understood by acupuncturists themselves. This can result in delays or denials of coverage if the proper procedures are not followed.
Pre-authorization requirements can vary widely between insurance companies, so it’s crucial to confirm the process with both your insurer and provider.
Deductibles and Co-pays
Even if your acupuncture care is covered, you may still be responsible for deductibles and co-pays, which are out-of-pocket expenses you must pay before your insurance coverage begins. Co-pays are typically due at the time of service, and collection by the providing office is required by law.
Routinely waiving co-pays or deductibles is considered fraud and is a serious, federally-recognized offense. It’s important to understand your plan’s specific deductible and co-pay amounts to avoid any unexpected financial responsibilities.
How to Verify Your Acupuncture Coverage
To determine whether your health insurance covers acupuncture, follow these steps:
- Contact Your Insurance Provider: Call the customer service number on the back of your insurance card or visit their website to review your policy details.
- Inquire About Network Acupuncturists: Ask for a list of in-network acupuncturists if your plan is an HMO, as this can reduce your out-of-pocket costs.
- Understand Coverage and Costs: Clarify what conditions are covered, any visit limits, pre-authorization requirements, and the associated costs such as co-pays or deductibles.
- Get a Referral: If required by your plan, obtain a referral from your primary care physician before scheduling an appointment.
Paying for Acupuncture Out of Pocket May Save You Money
If you have insurance AND your acupuncturist has a contract with your insurance carrier, they are required to submit claims to your carrier, and the rules are often very strict. However, if your care involves services that are not covered OR if your acupuncturist operates as a self-pay practice, you might be able to save a significant amount of money on your care.
The surprising reality is that insurance company guidelines sometimes require more acupuncture sessions than may actually be necessary. Even if your symptoms are resolved, failing to complete the required treatment plan could result in your care being labeled “not medically necessary.” In recent years, some acupuncturists have chosen to address this issue by opting out of insurance networks.
By canceling participation with insurance carriers, these acupuncturists can offer lower fees and recommend treatment on a per-visit basis. This means there are no external regulations dictating the frequency or type of care you receive. Decisions about your care are now strictly between you and your acupuncturist. This approach can lead to significant savings for you as a consumer.
Each acupuncturist will have their own fees and financial policies, so it’s essential to contact the offices you are considering to discuss their specific payment options and procedures.
Insurances That Cover Accupuncture
Click the insurance company below to learn more about their specific policies.
Aetna
Aetna (now CVS Health) has a mixed history with acupuncture care, offering coverage for treatments that align with evidence-based practices such as chronic pain management and chemotherapy-related nausea. However, the company maintains strict guidelines and imposes limits on the number of visits or services covered. While many policyholders value the inclusion of acupuncture in their plans, others find these restrictions to be a source of frustration. This page explores Aetna’s acupuncture coverage, highlighting both its benefits and limitations to help you make informed decisions. Learn more…
AmeriHealth Caritas
AmeriHealth Caritas includes acupuncture services in its coverage, particularly for members under 21, as part of their physical therapy and wellness benefits. However, for members over 21, acupuncture may only be covered for specific conditions such as chronic pain or post-surgical recovery, and it must meet strict medical necessity criteria. This selective approach has been helpful for certain members but has also created limitations in access for others.
Learn more…
Anthem (now Elevance Health)
Formerly known as Anthem, Inc., Elevance Health operates various health plans, including those under the Blue Cross Blue Shield brand. Coverage for acupuncture services under Elevance Health’s plans varies by state and specific policy. While some plans offer comprehensive benefits for acupuncture, others provide limited or no coverage. This variability can sometimes create confusion among members seeking acupuncture care.
Learn more…
Blue Cross Blue Shield (BCBS)
Blue Cross Blue Shield (BCBS) has increasingly recognized the value of acupuncture in managing various health conditions, leading to its inclusion in many of their health plans. However, coverage specifics—such as the number of allowed sessions, referral requirements, and eligible conditions—vary by state and individual policy.
For instance, Blue Cross Blue Shield of Massachusetts introduced an acupuncture benefit starting January 1, 2020, covering up to 12 sessions annually for members, excluding those on Medicare Advantage plans. Members can receive these treatments from licensed acupuncturists without needing a referral, with cost-sharing similar to that of a specialist visit.
Blue Cross Blue Shield MA MediaRoom
Similarly, Blue Cross Blue Shield of Michigan provides additional coverage for acupuncture to members under the State Health Plan Medicare Advantage PPO group, enhancing options beyond Original Medicare.
Blue Cross Blue Shield of Michigan
In Minnesota, Blue Cross health plans cover acupuncture when it is deemed medically necessary and prescribed by a doctor, particularly for chronic pain unresponsive to conservative treatments or for nausea related to surgery or chemotherapy.
Given the variability in coverage, it’s essential for members to review their specific plan details or contact their local BCBS provider to understand the extent of acupuncture benefits available to them.
Centene Corporation
Centene Corporation, through its subsidiaries like Health Net, offers acupuncture coverage in certain plans. These plans often collaborate with entities like American Specialty Health to administer benefits. Coverage specifics, including visit limits, eligible conditions, and pre-authorization requirements, vary by state and plan. This variability can create inconsistencies in patient access, so it’s important to review your specific policy details.
Learn more about Centene’s acupuncture coverage here.
California Physicians’ Service (Blue Shield of California)
Blue Shield of California includes acupuncture coverage in many of its plans, making this service accessible for patients seeking non-invasive treatment options. However, limitations such as visit caps, pre-authorization requirements, and exclusions for maintenance or wellness care can restrict access. Coverage is typically available for conditions like chronic pain and chemotherapy-related nausea.
Learn more about Blue Shield of California’s acupuncture coverage here.
CareSource
CareSource offers acupuncture coverage primarily through its Medicaid and Medicare Advantage plans. Although beneficial for many patients, this coverage often includes strict eligibility criteria, visit limitations, and narrow provider networks. Accessing care may require pre-authorization and additional documentation, which can complicate the process for patients.
Learn more about CareSource’s acupuncture coverage here.
Cigna
Cigna provides acupuncture coverage for medically necessary treatments, such as chronic pain management or chemotherapy-induced nausea. However, the company imposes strict guidelines, including visit caps, pre-authorization requirements, and documentation to demonstrate medical necessity. These policies may present challenges for patients seeking ongoing or preventative care.
Learn more about Cigna’s acupuncture coverage here.
EmblemHealth
EmblemHealth offers acupuncture coverage under many of its plans, recognizing its role in managing pain and promoting overall health. However, limitations such as medical necessity requirements, visit caps, and pre-authorization can make accessing care challenging. Members should review their plan’s details to understand their specific coverage.
Learn more about EmblemHealth’s acupuncture coverage here.
GuideWell Mutual Holding (Florida Blue)
Florida Blue, under GuideWell Mutual Holding, includes acupuncture in many of its health plans. Coverage supports evidence-based treatments for conditions like pain management and nausea. However, restrictions such as visit caps, referral requirements, and pre-authorization can limit access for some members.
Learn more about Florida Blue’s acupuncture coverage here.
Health Care Service Corporation (HCSC)
HCSC, the parent company of several Blue Cross Blue Shield plans, offers acupuncture coverage as part of its health benefits portfolio. However, coverage specifics vary significantly by state and plan. Pre-authorization is often required, and visit limitations may apply, impacting the ability to access ongoing care.
Learn more about HCSC’s acupuncture coverage here.
Highmark Group
Highmark Health supports acupuncture services in many of its health plans, emphasizing its value in managing pain and promoting wellness. Policies often include visit limits, pre-authorization requirements, and strict documentation of medical necessity, which may restrict access for some patients.
Learn more about Highmark’s acupuncture coverage here.
Humana
Humana covers acupuncture services, particularly through its Medicare Advantage plans. These plans generally support treatments for medically necessary conditions such as chronic pain. Coverage specifics vary, with pre-authorization and strict visit caps often required.
Learn more about Humana’s acupuncture coverage here.
Independence Health Group
Independence Health Group offers acupuncture coverage through its Blue Cross Blue Shield affiliates. While many plans include benefits for acupuncture, restrictions such as visit caps, pre-authorization, and medical necessity requirements can limit access for ongoing care.
Learn more about Independence Health Group’s acupuncture coverage here.
Kaiser Permanente
Kaiser Permanente’s approach to acupuncture coverage varies by region and plan. While some plans include coverage for medically necessary treatments, others may offer limited or no benefits. Pre-authorization is often required, and coverage may be restricted to affiliated providers.
Learn more about Kaiser Permanente’s acupuncture coverage here.
Medical Mutual of Ohio
Medical Mutual of Ohio provides acupuncture coverage under many of its health insurance plans. Coverage supports treatments for conditions like chronic pain but often includes restrictions such as visit caps, referrals, and strict documentation requirements.
Learn more about Medical Mutual’s acupuncture coverage here.
Metropolitan Group
The Metropolitan Group includes acupuncture coverage in its employer-sponsored health plans. Benefits typically focus on medically necessary treatments, but visit limits and pre-authorization requirements can create barriers for some patients.
Learn more about Metropolitan Group’s acupuncture coverage here.
Molina Healthcare
Molina Healthcare provides acupuncture coverage under many of its Medicaid and Medicare Advantage plans. Access to care is often limited by narrow networks, strict pre-authorization requirements, and visit caps, which can make it difficult for patients to receive consistent treatment.
Learn more about Molina Healthcare’s acupuncture coverage here.
UnitedHealthcare (UHC)
UnitedHealthcare covers acupuncture services for medically necessary treatments such as chronic pain or chemotherapy-related nausea. However, coverage often includes visit caps, pre-authorization requirements, and strict medical necessity guidelines, which can make accessing care challenging.
Learn more about UnitedHealthcare’s acupuncture coverage here.
WellCare Health Plans
WellCare offers acupuncture coverage primarily through its Medicare Advantage plans. While this inclusion supports treatments for medically necessary conditions, coverage is often constrained by strict criteria, visit caps, and limited provider networks.
Learn more about WellCare’s acupuncture coverage here.