It’s not a given that Medicare automatically approves helpful, alternative medical care. The better news is that alternative care is not automatically denied, either.
The challenge for many Medicare beneficiaries is understanding the rules of their state and insurance carrier, who must prescribe the care, and whether it is medically necessary.
Different States = Different Policies
Over the past several years, Medicare has gone through changes that have led to new partnerships between federal oversight agencies and their state counterparts. As a result, holistic and alternative care may be viewed quite differently between states, resulting in different approval policies for services like yoga or acupuncture.
Because of the Pandemic, Congress approved telehealth for Medicare services. This changed the way delivery of services (and alternative treatments) were approved. It has special implications for anyone who lives a long way from more abundant and easy access to traditional doctors’ offices. This Congressional rule allowed for services to be prescribed without an in-person consult with an M.D., who has in the past may have functioned as gatekeeper for nontraditional treatments.
A Key Threshold of Care: Who Decides What’s Medically Necessary?
When is alternative care medically necessary and covered by Medicare? Alternative therapies are less commonly seen as a necessity in and of themselves. Usually, it takes a traditional doctor who accepts Medicare to say that an alternative treatment is medically necessary for a primary treatment to succeed.
For example, chiropractic care, which could help a person feel better after cancer treatment, is nevertheless not essential or necessary to the cancer treatment itself. Feeling better, oddly enough, is not by itself usually medically necessary.
Depending on the carrier and plan, massage therapy may be covered in Texas when necessary and authorized by the contracting Primary Care Physician. Therapeutic massage therapy could be covered in some circumstances if done by a physical therapist.
Yoga and Acupuncture … Can You Get a YES?
Both yoga and acupuncture have undeniable evidence of improving specific cases of health. Yet, usually, yoga isn’t covered by original, Part A Medicare in most States. On the other hand, Acupuncture is always in limited circumstances covered by some part of Medicare. Acupuncture approval is usually limited to chronic lower back pain, not associated with another problem and up to 12 visits. Then, if the results show improvement in pain management, you can get an additional eight visits. The person delivering the services has to have at least a master’s level degree and be licensed by a state authority. This contrasts with yoga, which virtually begins with NOT being covered by original Medicare or Part B.
But this does NOT mean that yoga—and other less accepted techniques—is never paid for, at least in part, by Medicare. As we mentioned, it depends on the specific state and the facts of your case.
Part C Medicare (Medicare Advantage) can sometimes allow for alternative health treatments. Gym memberships and stretching classes have been approved for short periods. It can be confusing because some TV commercials for Part C include imagery of seniors engaging in yoga or Tai Chi, which may seem to imply that alternative treatments are covered. The bottom line: Get promises for alternative care and its costs in writing. Never assume something is covered based on imagery you’ve seen in a television commercial.
There should be a sense of optimism in looking at the direction alternative care is moving. Just because you may have gotten a NO before, doesn’t mean you won’t get a YES in the future.
Stay in touch with your licensed Medicare agent and ask them to check plans for coverage of alternative providers and treatments every year. Policies and plans are always evolving.
For additional guidance, visit https://healthcare-educators.com/.