Closing Conservative Care Coverage Gaps in Medicare and Medicaid

Arbitrary Restrictions Impact Beneficiaries

Given the arbitrary limits placed on chiropractic and acupuncture within Medicare and most Medicaid programs, these services remain an illusory benefit for beneficiaries. When Medicare and Medicaid beneficiaries seek care from either chiropractic physicians or acupuncturists, one would expect they are able to receive all covered clinical services that are within their provider’s scope of practice. Simply stated, if a clinical procedure is a covered benefit when provided by a medical physician, physician assistant, nurse practitioner or physical therapist, it should remain a covered benefit when provided by a chiropractic physician or acupuncturist if it is within their scope of practice. Unfortunately, this is not the case and is an example of blatant discrimination against categories of qualified healthcare providers.

Medicare and Medicaid policy should align with Congressional intent of section 2706 of the Affordable Care Act, “Nondiscrimination in Healthcare”, which stipulates that group health plans and health insurance issuers may not discriminate against a healthcare provider acting within the scope of their license under state law. Arbitrary restrictions on the ability of chiropractic physicians and acupuncturists to deliver Medicare and Medicaid covered benefits should be removed.

When chiropractic services were first included in Medicare in 1972, manual manipulation of the spine was the only covered service. While considered physician-level providers by the Social Security Act, coverage of the services doctors of chiropractic provide has not kept pace with the expansion of their scope of practice, nor does it reflect contemporary chiropractic education. The lone chiropractic benefit covered by Medicare has not been modernized or expanded over the last 50 years, prohibiting chiropractic physicians from delivering Medicare-covered benefits within their scope of practice. The result is a Medicare benefit out of step with the chiropractic benefits received from most other private insurers in the US, as well as federal employees and the Department of Veterans Affairs (VA).

The unfortunate result of this is that many seniors lose meaningful coverage for chiropractic services once they age into Medicare. For example, consider an individual with episodic back pain who has had successful treatment with chiropractic which was covered by their employer sponsored insurance in the past. Upon retirement and as a Medicare beneficiary, they could still seek care from their chiropractic physician, but may need to pay out-of-pocket for the examination needed prior to treatment, obtain a referral from a medical physician before traveling to an imaging center for x-rays, and get a referral for rehabilitative exercises delivered by a PT, in order to fully use their Medicare benefits. The layers of unnecessary care, additional costs and delayed treatment (7) becomes unreasonable, considering all of this could have been provided at that person’s first visit to their chiropractic physician.

Acupuncture has just recently been added as a covered Medicare service by the Centers for Medicare and Medicaid Services (CMS) and only to treat chronic low back pain lasting 12 weeks or longer. Coupled with a Decision Summary published by CMS that limits authorized providers to physicians or “auxiliary personnel” who must be supervised by a physician, physician assistant or nurse practitioner, access is limited both in terms of services and available providers. Few licensed acupuncturists are classified as “auxiliary personnel” which, in practical terms, dramatically limits beneficiaries’ ability to receive acupuncture from practitioners who are most highly trained to deliver this modality safely and effectively.

Further, this restriction severely limits Medicare beneficiary access to acupuncture as a covered service, given that the overwhelming majority of acupuncture is delivered by licensed acupuncturists in private care settings. Again, this constitutes a shadow benefit for the majority of Medicare beneficiaries, and arbitrarily discriminates against an entire class of licensed and qualified healthcare providers. Medicare beneficiaries should have access to acupuncture services, provided by any properly credentialed provider, for an expanded group of conditions for which there is evidence of effectiveness. (19)

Outside of Minnesota, some state Medicaid programs are increasing access to chiropractic and acupuncture services as one strategy to stem the use of opioids while concurrently improving care for back pain through innovative and guideline-informed policy initiatives. For example, the Oregon Health Plan expanded coverage for nonpharmacologic therapies beginning in 2016, coupled with restrictions on opioid prescribing.

Since then, utilization of chiropractic and acupuncture services has increased without increasing overall utilization of services. (23) This suggests a replacement of low-value services with higher-value, more effective treatment, similar to what has been seen elsewhere. (24) In 2019, the MO HealthNet Division of the Missouri Department of Social Services implemented a new program for the management of chronic pain through an expansion of “complementary and health and alternative therapy services” to include chiropractic, acupuncture, cognitive behavioral therapy and physical therapy, following a referral from and coordinated by the patient’s primary care provider. (25) This decision was made in part by an actuarial analysis estimating that expanding chiropractic services alone would save the state of Missouri between $14 and $49 million annually. (26)

Another example of a statewide attempt to address the disproportionate use of opioids in Medicaid population: Ohio. Earlier this year, the Ohio State Legislature passed – and the Governor signed into law – legislation that aligns Medicaid payer policy with guidelines recommending chiropractic care for the treatment of acute and chronic pain. In addition to the inclusion of evaluation and management services and a prohibition on prior authorization requirements, there is also a provision in House Bill 136 requiring the Ohio Medicaid program to reimburse chiropractors at the same rate for the same service provided by other healthcare professionals.

These examples illustrate efforts in other states to modernize Medicaid benefits and align them with best practices to include greater access to chiropractic and acupuncture services. Minnesota policymakers should take note and collaborate on ways Minnesota can improve its Medicaid coverage.

To advance these changes, we support the following:

• The Chiropractic Medicare Coverage Modernization Act (H.R. 2654/ S. 4042) amends existing federal law to allow beneficiaries to access chiropractic physicians for any Medicare-covered service that is within their scope of practice. This bill will improve spine care among older adults, increase access to non-opioid pain management, and overall lead to cost savings in the Medicare system.
• The Acupuncture for Our Seniors Act of 2021 (H.R. 4803) authorizes CMS to recognize licensed acupuncturists as Medicare providers. This would increase beneficiary access to acupuncture services for the treatment of chronic back pain, a currently covered service, and expand access to non-opioid treatment options.
• Legislation is needed in Minnesota to meaningfully expand coverage in MinnesotaCare and other Minnesota health plans to include chiropractic and acupuncture services. Doing so will increase Minnesotans’ access to non-opioid pain management, improve healthcare outcomes, and alleviate the strain on a burdened healthcare system.