Question: My wife’s Medicare Advantage Plan covers accupuncture and massage; does Medicare cover those services also?

Answer: Medicare Advantage Plans include coverage for everything that Original Medicare Part A & B include and often add additional benefits for their enrollees that are above and beyond what Original Medicare includes.

Original Medicare Part B does cover Acupuncture, but the coverage is limited and very specific. Medicare Part B covers up to 12 acupuncture visits within 90 days for chronic low back pain. It can cover an additional 8 visits if you are showing improvement, giving you a maximum of 20 acupuncture visits within a 12 month period (not necessarily a calendar year).

Medicare does have additional restrictions for this Acupuncture coverage. The definition of chronic low back pain is defined as “lasting 12 weeks or longer, not having a known cause (cancer, infectious disease or inflammatory disease), and pain that isn’t associated with surgery or pregnancy”.

You also must receive the acupuncture from a doctor or health care provider (like nurse practitioner, or physician assistant) that has a masters or doctoral level degree in acupuncture or oriental medicine from an accredited school, as well as an active, current, and unrestricted license to practice acupuncture in the state you are receiving care.

If you were interested in acupuncture, you may have a hard time finding an individual locally, who meets the listed criteria set up by Medicare. I know individuals who practice acupuncture and are Licensed Acupuncturists, trained at reputable institutions to do acupuncture, but they do not meet this Medicare standard. In bigger urban areas those with the required credentials may be more common.

Medicare Advantage Plans are required to include all the services that Original Medicare covers, but they often include additional benefits. I have talked many times in my articles about gym memberships, hearing aid coverage and others. With regard to Acupuncture their coverage is also different. All of the Medicare Advantage Plans have included the coverage illustrated above and are regulated by Center for Medicare and Medicaid Services (CMS), but many of them have expanded with additional coverage. Many of the Medicare Advantage Plans have allocated monies to reimburse enrollees for Massage and Acupuncture. This may require you to pay up front for the service and file a claim to get the potential reimbursement back. In this coverage, the practitioners may not have to meet the standard required by Original Medicare, they could be licensed Acupuncturist in the state, but not a physician.

The Medicare Advantage Plan coverage would be in addition to what Original Medicare covers. So you could use the Original Medicare coverage of up to 20 visits for lower back pain, and also use the plan benefit of reimbursement for Acupuncture or Massage. This benefit is usually a dollar limit of possibly $250 per calendar year of reimbursed Acupuncture or Massage services, but not $250 for both.

When evaluating and choosing your insurance product, it is important to look at all the coverage and benefits of the plan you are choosing. Getting $250 for massages can be an exciting benefit, but if your physicians are not participating physicians in the plan, or your medication is not covered well, you may end up paying more than $250 for medical care and medications.

To reach Janell Sluga, GCMC, email editorial@post-journal.com.