Medicare is a federal health insurance program for:
- people age 65 or older,
- people under age 65 with certain disabilities, and
- people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Limited chiropractic care is covered by Medicare Part B Medical Insurance when it is medically necessary. The only services provided by a chiropractor which are covered by Medicare are spinal adjustments. This means that new patient exams, X-Rays, extra-spinous adjustments (knee or elbow for example), re-exams and therapies are not covered by Medicare at all and therefore must be paid by the patient (or their secondary coverage insurance if they have it).
In the state of Alabama, Medicare will only pay for 25 chiropractic adjustments per patient per 12 month period. This 12 month period is not a calendar year, but for 12 months preceding the current date of service.
There is a $198 deductible which must be paid each year before Medicare pays for any claims. This deductible is for ALL Part B coverage, including medical doctors, physical therapy, chiropractors, etc. Some supplemental or secondary insurance policies pay the deductible for the patient. If you don’t have this coverage, you will be responsible for paying.
There is also a small coinsurance amount due for each chiropractic adjustment visit. Most supplemental or secondary insurance policies pay the coinsurance for the patient. If you don’t have this coverage, you will be responsible for paying the coinsurance amount.
Once a year, Medicare patients are asked to sign a Notice of Exclusions from Medicare Benefits (NEMB) which explains what chiropractic services do not meet the definition of a Medicare benefit for chiropractic care.
In the event that your care requires more than 25 visits in a 12 month period or your condition improves to the point that your care is classified as “maintenance care” (see definition below), you will be notified and asked to complete and sign an Advanced Beneficiary Notice of Noncoverage (ABN). This form lists the estimated cost of the services that Medicare isn’t expected to cover and gives you the option to refuse care, to pay for it out of pocket yourself while we file a claim with Medicare or to pay for it out of pocket yourself without filing a claim with Medicare. Filing a claim even when Medicare is not expected to pay reserves your Medicare appeal rights.
What is maintenance care?
Medicare defines it as: “Maintenance care includes services that seek to prevent disease, promote health, and prolong and enhance quality of life, or maintain or prevent deterioration of a chronic condition.” As a practical matter, maintenance care begins when you have reached Maximum Medical Improvement (MMI). That is, when care is not expected to improve your diagnosed condition, but only expected to maintain your current level of improvement.