Chiropractic as a Covered Benefit

Although one of the fundamental principles guiding the Patient Protection and Affordable Care Act (PPACA) is to provide affordable insurance for all, the legislation undoubtedly targets the estimated 40-50 million Americans who currently do not have health insurance; and even more specifically, the millions who cannot afford to purchase insurance for themselves and/or their families. And while patients in all economic brackets often choose to pay for chiropractic care out of pocket, whether by choice or lack of coverage for chiropractic services, it is a relatively safe assumption that patients who cannot afford health insurance also cannot afford chiropractic care.

A fairly dramatic change in those circumstances appears to be taking shape now that states are choosing their respective benchmark health plans to meet the requirements of the act. According to a February 2013 review of proposed state benchmark plans, 45 of 50 states cover chiropractic care as an essential benefit. What's more, as of press time, many of the plan summaries specify annual visits / dollar caps for chiropractic services.

In reviewing the proposed benchmark plans, one finds that the only five states not currently providing chiropractic as a covered benefit are California (which does cover acupuncture), Colorado, Hawaii, Oregon and Utah. The District of Columbia's proposed benchmark plan also does not cover chiropractic as an essential health benefit. Among the states covering chiropractic, many offer specific coverage details / limitations as follows.

(Keep in mind that these coverage specifics represent coverage limits for chiropractic care in dollars or visits per year, but are undoubtedly not available without restriction to plan insureds. As with all insurance benefits, they remain subject to insurer approval and referral requirements as determined by the insurer.)

• Alabama: $600 per year
• Alaska: 12 visits per year
• Arizona: 20 visits per year
• Arkansas: 30 visits per year
• Connecticut: 20 visits per year
• Delaware: 30 visits per year
• Florida: 26 visits per year
• Georgia: 20 visits per year
• Idaho: $800 per year
• Illinois: $1,000 per year
• Indiana: 12 visits per year
• Kentucky: 12 visits per year
• Maine: 40 visits per year
• Massachusetts: 12 visits per year
• Michigan: 30 visits per year
• Mississippi: 20 visits per year
• Missouri: 26 visits per year
• Montana: $600 per year
• Nebraska: 20 visits per year
• Nevada: 12 visits per year
• North Carolina: 30 visits per year
• North Dakota: 20 visits per year
• Ohio: 12 visits per year
• Oklahoma: 25 visits per year
• Pennsylvania: 20 visits per year
• Rhode Island: 12 visits per year
• Tennessee: 20 visits per year
• Texas: 35 visits per year
• Vermont: 12 visits per year
• Virginia: 30 visits per year
• Washington: 10 visits per year
• Wyoming: 15 visits per year

While 90 percent of states' proposed benchmark essential benefit plans cover chiropractic care, it is interesting to note that only six (Alaska, California, Maryland, Nevada, New Mexico and Washington) cover acupuncture, and only one (Arkansas) covers massage therapy.

The benchmark approach to determining essential health benefits, as stipulated by the U.S. Department of Health and Human Services in accordance with the Patient Protection and Affordable Care Act, gives states “the flexibility to select a benchmark plan that reflects the scope of services offered by a 'typical employer plan.' To that end, states were allowed to select one of the three largest small-group plans in the state by enrollment; one of the three largest state employee health plans by enrollment; one of the three largest federal employee health plans by enrollment; or the largest HMO plan in the state's commercial market by enrollment. If a state chose not to select one of the above options (nearly half of the states did not), then the state's default benchmark health plan went into effect: the largest small-group plan by enrollment in the state.

For additional information regarding essential health benefits and how state benchmark health plans help achieve the goals of the Patient Protection and Affordable Care Act, visit www.healthcare.gov.