Medicare Benefits Explained for 2023
Every January I cover the topic of Medicare benefits. Insurance plans restart and we get a new influx of patients who are confused or misinformed about their benefits. There are also frequently patients who are using Medicare for the first time and are unaware about how their new benefits work. Here I present to you, an explanation of your chiropractic Medicare benefits for 2023.
First of all, you must understand that chiropractic Medicare coverage is entirely unique. It works completely different than coverage for your other types of doctors and services. Also, be advised that whenever I refer to Medicare for the rest of this article, I am also including Medicare replacement plans. These are third-party plans that mirror Medicare benefits.
Before we dive deep, there is one sentence that answers most of the questions people ask regarding Medicare, and it's a bit surprising. Ready?
Medicare pays for one thing, and one thing only: the spinal adjustment.
People don't believe me when I tell them this. Any other service that you receive aside from getting your back or neck adjusted is not covered. This includes required services, such as the examination. Furthermore, Medicare actually only covers 80% of the cost of a spinal adjustment. The patient is responsible for the remaining 20%. Often, Medicare patients will also have a supplemental or secondary policy (two separate things!). If you do have one, then this policy may cover that remaining 20%, as long as your deductible has already been met.
Just like many other private insurance plans, Medicare has a deductible. A deductible is the yearly amount of money you must pay out-of-pocket for covered health services before Medicare begins reimbursement. In 2023, the Medicare deductible is $226 and the reimbursement rate for a spinal adjustment to 1-2 areas is $27.37, and for 3-4 areas is $39.27. That means that each chiropractic visit in which you receive a spinal adjustment you are responsible for paying $27.37 or $39.27 respectively, plus the cost of any additional services you receive. Once your deductible has been met, Medicare will now reimburse 80% of the spinal adjustment fee.
There are circumstances where Medicare doesn't cover the spinal adjustment at all. Medicare requires that the adjustment is medically necessary. Essentially, a condition being treated must demonstrate continual, objective improvement that can be measured in symptom intensity or frequency, improvement in range of motion, or activities of daily living. What would not be considered "medically necessary?" Chronic conditions that do not continuously improve, as well as maintenance care for general wellness. There must be a specific, acute complaint. Medicare does not cover maintenance or wellness care!
What is Supplemental Insurance?
Some patients opt into a supplemental insurance plan. According to Medicare, 53% of Americans opt to buy a supplemental plan. A supplemental plan is very simple, and has one purpose only as far as chiropractic care is concerned. After your Medicare deductible has been met, it supplements the remaining 20% of the spinal manipulation fee that Medicare does not cover. Here are a few example scenarios of what you would pay for a 1-2 area spinal adjustment:
- You have not met your deductible: $27.37
- You have met your deductible but you only have Medicare: $5.47
- You have met your deductible and you have Medicare and a supplemental: $0
Your supplemental will pay the remaining 20% of your $27.37 fee, which is $5.47 for each visit that you receive spinal manipulation. You are also responsible for the full cost of any other additional services you receive along with the spinal adjustment. This may include working on any area besides the spine, as well as muscle work, rehabilitative exercise, electrical muscle stimulation, ultrasound therapy, kenesio-taping, etc. Literally anything except a spinal adjustment.
What is Secondary Insurance?
Secondary insurance is far less common than a supplemental insurance and its benefits vary greatly depending on your individual plan. The reason it is far less common is usually because of cost; it can be nearly as expensive as your regular insurance. The reason for this is because a secondary insurance may cover more types of services than just the spinal adjustment, in contrast to Medicare and supplemental plans.
Secondary plans may cover examinations, manual therapy, rehabilitative exercise, electrical muscle stimulation, ultrasound, etc. Secondary insurance plans may also have a separate deductible or co-pay that is entirely independent from your Medicare plan deductible. A co-pay is a fixed amount of money you pay each visit regardless of what types of services you received that day. I cannot predict the costs for your individual plan, it's different for everyone. While secondary insurance typically covers more services than Medicare alone, that doesn't mean that every service is eligible for coverage and you will need to verify coverage for your specific plan.
I know that this is a lot of information, so if you have Medicare, please take the time to fully read and understand the details of this article. For reference, I've included a very simple chart to help you understand the different coverage between Medicare, supplemental, and secondary insurances.