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Insurance coverage for alternative medicine

Alternative medicine, such as acupuncture, herbal therapy, naturopathy and acupuncture, has been embraced by many cultures but, in general, has been sidelined by physicians and health insurers in the United States. Complementary and alternative medicine (known together as CAM) cover a wide range of medical approaches, therapies and philosophies. Complementary medicine is used together with conventional medicine, while alternative medicine is used in place of conventional medicine.

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Questions to ask your insurer before you get alternative medicine treatment

Is this treatment covered for my health condition?

Does this care need to be preauthorized or preapproved?

Do I need to order this by prescription and is it covered?

Do I need a referral from my primary care provider?

Do I have to see a practitioner in your network in order to be covered?

Do I have any coverage if I go out of network?

Are there any limits and requirements on the number of visits or amount you will pay?

What do I have to pay out-of-pocket?

Source: National Center for Complementary and Alternative Medicine

According to a report released in May 2004 by the National Center for Complementary and Alternative Medicine (NCCAM) and the National Center for Health Statistics, 36 percent of adults in the U.S. are using some form of CAM.

Treatments include herbal therapy, chiropractic care, massage therapy, vitamin therapy, homeopathy, yoga, acupressure, acupuncture, biofeedback, hypnotherapy and naturopathy.

Access to — or insurance coverage for — alternative health care benefits is provided in these ways:

  • It can be provided as a core benefit with limits equal to traditional health care services.
  • It can be provided a separate benefit from traditional health care, with a higher deductible.
  • It can be an optional rider, such as a complementary and alternative medicine (CAM) rider.
  • It can be offered as a discounted service. For example, HMOs may refer members to a network of alternative treatment providers who offer discounts of up to 30 percent for their services, such as tai chi, hypnotherapy or vitamin therapy.

Despite the growing popularity of CAM, insurance coverage is sparse and often limited to more established treatments like chiropractic care, according to AARP. It is also important to note that Medicare does not cover alternative care that it deems experimental or not medically necessary.

The best approach if you have group health insurance through an employer is to ask your employer to investigate the cost of alternative treatment coverage and add it as a covered benefit for the next year. Or, if you are buying individual coverage, ask your insurance agent to find a policy with CAM coverage and then weigh the premium costs and benefit limits.

Mandated coverage for alternative treatments

Some states mandate coverage for certain treatments that are considered alternative. These mandates apply to certain group health plans offered by employers but not individual policies. According to the Council for Affordable Health Insurance, for example:

  • Acupuncturist coverage is mandated in California, Florida, Maine, Montana, New Mexico, Nevada, Oregon, Rhode Island, Texas, Virginia and Washington.
  • Massage therapist coverage is mandated in Maryland, New Hampshire, Utah and Washington.
  • Naturopath coverage is mandated in Alaska, Montana, Vermont and Washington.

Making a claim

If your claim for CAM treatment is denied, first make sure that the treatment you received is a covered benefit under your plan. If it is, then NCCAM recommends you check with your practitioner's office to see if there was a billing coding error made when the claim was sent in. If you think your insurer made a mistake in denying your claim, request a review directly from the insurer. And if that still doesn't settle matters, you can file a formal appeal of the denial with the insurer.

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