Why doesn’t my health insurance cover maintenance care?

Chiropractor examining patient with insurance

This is one question I get asked often.

To effectively describe why health insurance will not cover chiropractic maintenance care, I first need to explain the difference between medically necessary care (also known as active care) and maintenance care (also known as wellness care).

Medically Necessary Chiropractic Care

Care is considered medically necessary when there is a reasonable expectation it will encourage improvement and/or recovery of the patient’s issues. It is based on a combination of subjective and objective improvements. If after evaluation it is determined that chiropractic care is a viable treatment option, a custom treatment plan will be developed for the patient. It is common for an initial plan to start with frequent visits which are then tapered off to less frequent visits over time. As long as the patient is showing improvement over a reasonable amount of time, then the treatment is considered medically necessary care.

At this point the patient is considered to be on active care.

The amount of improvement attained differs from patient to patient. Hopefully 100% recovery is end result but sometimes only partial improvement is possible before reaching a plateau. If they do hit a plateau, that’s called maximum medical improvement, which means continued care would not be expected to promote any additional significant improvement.

Health insurance companies base members’ chiropractic coverage on medically necessary care only. Medical care in the United States for the most part is sick care, not healthcare. Once symptoms are gone, active care is complete. The insurance won’t cover anything else after that unless or until the symptoms return.

So one may ask, if the symptoms are gone, then why would future care be needed and recommended? Well, that’s where we get into maintenance/wellness care.

Maintenance Chiropractic Care

Maintenance care is designed to help maintain the progress that a patient has made. For permanent/chronic issues, the goal is to reduce the intensity, frequency, and duration of any flare-ups they may experience. The goal is to keep a person functioning at the highest level possible.

That’s the difference between medically necessary care and maintenance care. When people ask me why their insurance doesn’t cover maintenance care, well, because it’s not considered medically necessary according to the guidelines through the insurance companies.

Medicare has published its own definition of maintenance care as follows:

“Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvements cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.” Medicare Benefit Policy Manual

I like to use automobile insurance to help explain the difference between medically necessary care and maintenance care.

Medically Necessary: If you get in a car accident or there’s damage to your car of some sort, maybe a rock hit your car, your insurance should cover the cost of repair. Of course you may have to meet the deductible first, just like with health insurance, but then they’ll fix your car.

Maintenance: Your car is due for an oil and oil filter change. These services are considered a part of typical vehicle maintenance.  Other examples would be replacing the tires, changing the spark plugs, etc. Auto insurance will not cover the costs associated with these services. You even want to maintain proper car alignment. It is important to make sure it’s well aligned to encourage the extended life and optimal function of numerous automobile components.

The same thing goes with the human body. A lot of people choose chiropractic maintenance care because they want to function at the highest level possible and help prevent issues in the future.

So Why Won’t Health Insurance Cover Maintenance Care?

I am not 100% sure, but I can take a guess. Probably because there is more money to be made with the treatment of symptoms than the prevention of disease.  Of course, just because insurance doesn’t cover something doesn’t mean that it is not beneficial.

But My Insurance Policy Says I get 20 Visits Per Year.

Lastly, even with a clear understanding of what was discussed above, there can still be some confusion when a health insurance policy states that a specific number of chiropractic visits are allowed per year. The number of visits allowed vary plan to plan but a common number is 20 per year. So shouldn’t I get all 20 visits no matter what? Not necessarily, and that is because it actually means UP TO 20 visits per year of medically necessary care is allowed.

For example, let’s say patient John Doe comes in with pain and their policy allows up to 20 chiropractic visits per year. Let’s say they get better in 10 visits and are now symptom free, recovered and stable. They can’t continue on with care for another 10 visits because the insurance won’t cover it since they’re reached maximum medical improvement. If it is determined that no further improvement is expected with continued care, then any additional care will be considered maintenance/supportive care and as we now know health insurances don’t cover that. This can lead to a lot of confusion because sometimes patients ask, if I have 20 visits, why can’t I use them all? Well, you could use them all if the care is considered medically necessary according to those insurance parameters discussed above.

I think it’s unfortunate that health insurances don’t cover maintenance care. If they did then maybe people would stay healthier, prevent issues down the road and in the long run spend less money on healthcare. This is the same reason why most people have their teeth checked on a regular basis. Of course some people are going to wait for whatever reasons until their teeth fall out and then go to the dentist – we call that crisis care. Other people may say, You know what? I’m going to go in for my routine cleanings to try to keep my teeth functioning the best possible to prevent issues and then that way maybe I will have healthier teeth and less dental expenses down the road.

Disclaimer: On writing this post, I have yet to come into contact with an insurance policy that expressly states they cover chiropractic maintenance care. Maybe one day it will, but until that day it is our responsibility to make the best decisions we can to ensure our best health now and in the future.

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