In-Network Acupuncture Benefits Via Health Insurance
Health insurance is an intentionally complicated system here in the United States. As we’ve navigated and worked with insurance plans for the past 7+ years, below is a couple of topics in regards to Insurance Terminology, Medical Policies regarding Acupuncture, Coverage, and examples of Coverage. At the end of the day, your insurance benefits are your responsibility as a patient. Your employer, human resources department, benefit department, or your insurance broker are the ones that you should contact if you have questions about your coverage.
All costs for services rendered at Box Acupuncture will go to the patient, in the event that coverage lapses, changes, or if the health insurance benefit for whatever reason is not covered.
At the end of the day, we are in-network with many health insurance companies and plans, not because of the money, but because we want our services to be accessible for patients so that they can experience the benefits of Acupuncture and Traditional Chinese Medicine.
Health Insurance Terminology 101
General Health Insurance terms:
Deductible: The amount a patient must pay out-of-pocket before the health insurance company begins to cover any expenses. Patients may have individual or family deductibles that need to be met. Sometimes, acupuncture is a specific service that does not require the deductible to be met. Verify your Benefits Here
Co-pay: A fixed amount a patient pays for a covered health care service, usually when receiving the service. The amount can vary by the type of service. In-Network Co-pays range from $5-$50, depending on the plan.
Co-insurance: The percentage of costs of a covered health care service that a patient pays after they have paid their deductible. In-Network Co-Insurance costs can be anywhere from 5%-30% of the allowed amount.
An example of how this goes into play - let’s say your deductible is $1000, this is how much you must pay out of pocket before insurance begins sharing the cost of your treatment. Let’s say the allowed amount for a treatment is $100, that means when billing your insurance, $100 will be deducted from the $1000, so essentially after 10 treatments or (10 x $100 = $1000), insurance will begin sharing the cost of your treatment. If your co-insurance is 10%, then you will be required to pay $10 after the first 10 visits because you’ve met your deductible.
Out-of-Pocket Maximum: The most a patient has to pay for covered services in a plan year. After reaching this amount, the health insurance company pays 100% for covered services. Usually your deductible will also go towards your out of pocket maximum.
In the example listed above, if your out of pocket max is $2000, then you will have already met $1000 since your deductible was $1000. Then every $10 that is paid, will go towards the out of pocket max. Once your out of pocket is met, then you’ll pay 0% as your insurance will cover 100%. In California, because Acupuncture treatments go towards medical insurance, anytime you go to the doctor for daily check-ups, lab work, etc, will all go towards a deductible and out of pocket amount.
Premium: The amount a patient pays for their health insurance every month.
In-Network Provider: A health care provider who has a contract with the health insurer to provide services to plan members at pre-negotiated rates. We are in-network with many insurance networks.
Out-of-Network Provider: A health care provider who does not have a contract with the health insurer. Services from out-of-network providers may cost more or not be covered at all.
Prior Authorization: Approval from a health plan that may be required before a patient receives a certain service or fills a prescription for it to be covered by the plan. Authorizations have expirations, so it is of utmost importance that if we receive an authorization that as a patient you try your best to use your benefits during the time period allowed, otherwise there will be a lapse in authorization and we will need to submit for more treatment, which will create a delay and pause in your treatment.
Claim: A request for payment that a patient or health care provider submits to the health insurer for items or services the patient believes are covered.
Explanation of Benefits (EOB): A statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.
Exclusions: Specific conditions or circumstances for which the policy does not provide benefits. Patients need to be aware of any exclusions related to acupuncture services in their insurance plan. Most plans will cover musculoskeletal pain, they do not cover internal conditions, psychoemotional conditions, or wellness or cosmetic visits. Any conditions that are covered, usually need to interfere with a patient’s activity of daily living. If after receiving an evaluation, it is determined that what you are seeking treatment for is not covered, you will be required to pay our time of service or out of pocket pricing.
How this all looks as an example:
A member has a health plan, say Kaiser, we call and verify their MEDICAL BENEFITS since acupuncture falls within the same category as Medical i.e. regular MD check ups, physicals, labs, etc. We verify their benefits, they have an individual deductible of $1000 and an individual out of pocket max of $2000. They have throughout the year, gone to different checks ups and therapies and they have paid accumulated $500 of services towards their deductible and out of pocket. So that means that they would technically have $500 left of their deductible and $1500 left of their individual out of pocket max, because $500 is applied or subtracted from the $1000/$2000 respectively.
Since we are In Network with this insurance plan, let’s say their plan will apply $100 for every acupuncture treatment but their deductible needs to be met first. Once their deductible is met, they have a 10% co-insurance responsibility of the $100 that is applied, and that means that the insurance plan will cover 90% of $100, or $90 will be paid to us directly from the insurance plan once their individual deductible is met. That means the patient until the leftover $500 of their individual deductible has been applied through seeing us for treatment, or receiving medical care from doctors and other specialists, they would technically need to pay us $100 for every visit because this is the allowed amount and agreed upon rate with the health plan. This equates to about 5 visits before insurance starts because 5x$100 is $500 which is the leftover amount of their individual deductible.
Once 5 visits have been met and we’ve billed their insurance, to let their insurance plan know we saw them, their deductible amount has been met or acummulated. Now the patient will pay us $10 or 10% of $100 allowed amount, and insurance will pay us the $90 or 90% of allowed amount, until the leftover $1000 of the individual out of pocket is met. All future visits or $10 will be applied towards their individual out of pocket, which equates to 100 treatments if they came in for acupuncture only, but again, all Medical Services will go towards the deductible and out of pocket max amount. Once the out of pocket max has been accumulated or met, insurance will then pay 100% of all medical services until this amount resets at the beginning of the calendar or plan year. In addition every health plan has a limitation of how many visits of acupuncture they allow for. Some plans have unlimited visits as long it’s deemed medically necessary, and some visits have 10-12 or even 20-40 visits per calendar year. Once these visits have been used up, the patient will need to wait until the visits reset and will then need to pay our out of pocket rates until then.
This is all an example, but our clinic and specifically Dr. Aaron is well versed in health insurance lingo, and it can get quite complicated as you can see above, but there are caveats where some plans don’t deem all acupuncture treatments medically necessary because they have to follow their specific guidelines, meaning that health plans limit coverage based on what diagnosis is actually being treated. For instance, we cannot bill for anxiety, depression, digestive disorders, pelvic floor treatments, heart conditions like high blood pressure, or even generall wellness/stress or maintenance treatments. Insurance companes have what are called “Medical Policy Bulletins” that all providers must follow in order to bill and use their benefits. In addition, insurance company contracts limit what we can actually do. Some health plans don’t recognize Cupping Therapy or Manual Therapy as a billable service or treatment modality for acupuncturists, as well as dry needling therapy and cosmetic services. They also do not cover the initial evaluation fee, so that cost is passed to the patient, because effectively, we cannot come up with a treatment plan or diagnosis or prognosis for your condition without evaluating a new patient, doing a history and physical exam, that’s just not how medicine works at all, it would be like going to a heart surgeon without them reading your past medical files or doing a thorough intake with you.
Health Insurance Terms Specific to California:
Covered California: California’s health insurance marketplace where individuals, families, and small businesses can find affordable health insurance.
Medi-Cal: California's Medicaid program offering free or low-cost health coverage for children and adults with limited income and resources. In our clinic we do accept certain Medi-Cal Plans. These plans follow very specific guidelines and limitations. Verify your Benefits Here
Essential Health Benefits (EHB): A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. In California, these include services like emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive and wellness services, chronic disease management, and pediatric services, including oral and vision care. Acupuncture is considered an Essential Health Benefits in California.
Qualified Health Plan (QHP): An insurance plan that is certified by Covered California, provides essential health benefits, follows established limits on cost-sharing, and meets other requirements.
Cal-COBRA: A state program that allows employees of companies with 2-19 employees to keep their group health insurance plan for up to 36 months if they leave their job or lose their coverage.
Plan-Based Enroller (PBE): An individual or entity that is certified by Covered California to assist consumers in enrolling in a health insurance plan through the marketplace.
Third Party Payor: In California and across the United States, some health plans work with Third Party Payors to help administer benefits on behalf of the health plan for their health plan members. How this ends up working is that we, the provider, submits bills to the third party payor, the third party payor analyzes the bill, if approved, submits it to the health plan, the health plan approves and pays the third party payor, then the third party payor takes a portion of the pay out, and pays the provider upon the agreed upon rate. An example would be we submit the bill to a third party payor like American Specialty Health Networks (ASH), which is not an actualy health insurance company, but processes on behalf of Blue Shield of California, Kaiser, Anthem Blue Cross, and more. Then, they submit the bill directly to the health plan and then the process begins. How this looks :say we submit a $200 bill to ASH, ASH approves the treatment and submits the bill to Blue Shield, Blue Shield pays say $175 of the $200 to ASH, ASH then pockets $120 of the $175 payout, and then pays us providers the remaining $55 of the $175 bill.