Medicare Advantage plans are required to provide, at a minimum, the same coverage for services that beneficiaries receive under Original Medicare Parts A and B. As such, acupuncture is covered under some circumstances by all Medicare Advantage plans.
Original Medicare is split into parts, which each cover specific services. Medicare Part A pays much of the cost of hospitalization and inpatient care, while Part D is the Medicare prescription drug benefit. Part B picks up much of the rest, including outpatient treatments such as acupuncture and other alternative treatments.
Part B, like the rest of Original Medicare, only provides coverage for treatments it deems medically necessary. Unfortunately, Original Medicare only authorizes acupuncture for lower back pain. Beneficiaries diagnosed with chronic back pain can get up to 12 acupuncture treatments in a 90-day period. Treatment can be extended by up to eight additional sessions if some improvement is shown. Original Medicare benefits are limited to a maximum of 20 sessions per year, or less if the condition worsens.
Medicare Advantage plans are meant to supplant Original Medicare Parts A and B, and so they’re required to provide all the same benefits as Part A and Part B as a baseline, with some room to expand services. That means that every Medicare Advantage plan provides the same 12 to 20 acupuncture sessions per year as Original Medicare.
Since Medicare Advantage policies are provided by private insurers, Medicare Advantage plans vary from state to state, so the details of plans offered in Massachusetts are likely to differ from those available in California, Texas and Florida. In spite of this, Medicare Advantage plans do have some details in common. Most are organized as health maintenance organizations, preferred provider organizations, private fee-for-service or special needs plans. Some of these plans are more likely to cover alternative therapies than others, although it may take some research to find a state-specific plan that has the necessary coverage.
HMO plans are by far the most popular form of Medicare Advantage coverage because all services offered by the network are generally covered by the insurance. An HMO network that offers acupuncture should also have a corresponding insurance plan that pays for it, though only a member services representative can definitively say which plan does.
PPOs operate with a network of preferred providers, but the plans usually include coverage for beneficiaries who go outside the network for specialist care. If a given Medicare Advantage plan has a preferred network that includes an acupuncture provider, the plan likely includes coverage for that service. PPO participants who wish to go outside their network for acupuncture treatment are likely to have more flexibility than HMO plan participants.
Some PFFS plans have loose networks of preferred providers, just like PPO plans, while others cover care with any qualified practitioner. These plans are typically very flexible in the services they cover, and so they might be a good choice for beneficiaries who need expanded coverage for acupuncture.
SNPs provide focused benefits to treat seniors with certain chronic health conditions, including some neurological conditions that cause back pain. SNP enrollees are usually required to have a primary care doctors who can write up the diagnosis of lower back pain and recommend acupuncture for the number of sessions the SNP allows.