Medicare Covers Chiropractic Adjustments!
In this section, we’ll cover the basics of how Medicare works with chiropractors and how it applies specifically to our office, where we are a “participating” provider for Medicare Part B.
Who Qualifies for Medicare?
To be eligible for Medicare in the United States, individuals must meet one of the following criteria:
• Be 65 years or older
• Be disabled and have received Social Security benefits for at least two years
• Have End Stage Renal Disease or Amyotrophic Lateral Sclerosis (ALS)
Chiropractic Care and Medicare
Medicare Part B is typically the one that covers chiropractic care, but Medicare Advantage (Part C) plans can also provide coverage. Medicare Part A is primarily for hospital visits, and Part D covers prescription drugs.
If you’re a new patient at our office, we’ll scan your Medicare card to handle billing. Before scheduling, please check your card to ensure you have either Part B or a Medicare Advantage (Part C) plan that covers chiropractic services.
adjust.clinic: Your Participating Provider for Medicare
At our Petaluma chiropractic office, Dr. Lloyd is a “participating provider” (PAR) for Medicare. This means that after completing a thorough screening and validation process (which is renewed every five years), Dr. Lloyd has signed an agreement with Medicare to accept assignment on all claims. Medicare sends payments directly to us, and if you have Medigap insurance, it will also be billed automatically.
Because we are a Participating Provider, we can bill 5% higher than non-participating providers for chiropractic adjustments. Medicare covers 80% of the approved amount, which is sent directly to us, while the remaining 20% is your co-pay. For example, if we bill code 98941, your co-pay will be $8.76, due at the time of your visit. Unfortunately, as these figures show, Medicare reimbursement hasn’t kept pace with inflation.
Medicare Covers Adjustments, But Not Other Services
Here’s what Medicare doesn’t cover: While adjustments are covered, you will be responsible for additional costs, such as new patient examinations or other therapies that may be necessary to address your pain.
For example, if you’re a new patient with Medicare Part B, your first visit fee will be $162.22. If interferential treatment is required, which may help in acute situations, there will be an additional charge of $23.89 (with a prompt-pay discount). So, while your regular co-pay for an adjustment might be $8.76, additional services could bring the total for a visit to $32.65.
Important: Beware of any office that waives exam fees or co-pays—it’s considered fraud unless for very rare exceptions.
Medicare Deductible: What You Need to Know
For Medicare Part B, there is a $233 annual deductible. As a Participating Provider, we are required to collect this deductible if it has not been met for the year.
Billing Supplemental (Medigap) or Secondary Insurance
As a courtesy, we will bill your secondary insurance along with Medicare. However, because we are out of network with most major insurance companies, coverage through your secondary insurance may be limited. Primary insurance is billed first, and then the remainder is relayed to Medicare.
Active Care vs. Maintenance Care Under Medicare
Medicare covers chiropractic care that helps improve your condition, which is classified as “active care.” To qualify as active care, our treatment notes must show progress toward relief or functional improvement. If you experience a consistent level of pain that does not improve with care, this is considered “maintenance care,” which Medicare does not cover.
For example, if you discontinue treatment and your pain worsens, and upon restarting care you see improvements, Medicare will consider this active care. However, adjustments to maintain your health and prevent future issues fall under maintenance care and are not covered by Medicare.
Billing Medicare for Active Care
When we bill Medicare for active care, we use the AT modifier to indicate that the treatment is meant to improve your condition and is therefore eligible for coverage.
