This is a guest post by my classmate and colleague Teresa Lau from http://tlc-medicine.com
In a previous post, I covered the basics of how health insurance coverage works. But there were a lot of details which I left out for simplicity’s sake. As some of you may already have discovered, just because your insurance says acupuncture or other services are covered in your plan, it doesn’t necessarily mean they will actually pay for it. Why? Because there are exceptions, and plenty of them. I’ve highlighted a few of the common ones:
YOUR PLAN COVERS ACUPUNCTURE ONLY FOR CERTAIN CONDITIONS.
Plans may limit coverage of acupuncture to specific health conditions. Typically, low back pain and nausea from pregnancy or chemotherapy are covered by even the most restricted plans. Other plans may be vague and state they they will cover acupuncture when it is considered “medically necessary.” I once came across a plan that would only pay for acupuncture “in lieu of anesthesia,” which, in practical purposes, is pretty useless — unless you are having surgery!
YOUR PLAN LIMITS THE NUMBER OF VISITS PER YEAR.
A plan can place a cap on the number of times you can get acupuncture in a year (typically 20–30). Once you hit that ceiling, you are on your own for the rest of the year. It doesn’t matter if you’ve met your deductible or your out-of-pocket maximum. Also, sometimes they will classify acupuncturists, chiropractors, and other therapy providers in the same category; each time you see any of these providers, it will count toward the running total of visits allowed.
YOUR PLAN HAS A “MAXIMUM BENEFITS” LIMIT.
Instead of limiting the number of visits, as described above, a plan may limit the total dollar amount they will pay for acupuncture services per year. Once the total is reached, you will be paying out-of-pocket for any future care for the remainder of the year.
YOUR PLAN HAS SET AN “ALLOWABLE AMOUNT” FOR EACH SERVICE.
Let’s say your plan covers services from an out-of-network provider. They tell you that you have a coinsurance of 20%, and they will cover 80% of the bill. What they don’t tell you is that they pay 80% of their allowable amount for the particular service. For example, if your provider’s bill is $100, but the plan says their allowable amount is $50, they’ll only pay out 80% of that amount, which is $40. Because the provider is not in your network, he or she can bill you for the balance of $60.
As you can see, navigating the world of health insurance can be quite complex. Fortunately, your practitioner should be well versed on these details to ensure you get the most out of your insurance plan. Be sure to discuss with your practitioner your goals and needs. In the ideal case, your practitioner will establish a plan with you and structure your visits to fit within the constraints of your insurance plan.
Teresa Lau is a licensed acupuncturist in the State of California. She completed her Master of Science degree in Traditional Chinese Medicine at the American College of Traditional Chinese Medicine (ACTCM) in San Francisco, CA, as well as a master’s degree in Public Health from Harvard School of Public Health.