From Dr. Rich Healy, ANJC Medicare Consultant

Q: What are the different types of Medicare Advantage Plans?

A: There are 5 main types of MA plans.

• Coordinated Care Plans, which are sub-divided into HMO plans (In-Network), PSO (Provider Sponsored Organizations) plans and PPO plans (In or Out-of-Network)
• Special needs Plans which may include institutionalized individuals, those on Medicaid, or those who have a severe chronic or disabling condition that may benefit from a MA plan.
• Medicare Savings Account (MSA) which can be a high deductible plan. With this plan the enrollee does not pay a premium except if they have supplemental benefits. They have to pay out of pocket until the deductible is met. The MSA will then pay for all covered services once the deductible is attained. The second MSA plan is a true Medical Savings plan but with one exception. The plan, not the individual, puts money into the account at the beginning of the calendar year. Any remaining money will be added to the next year’s deposit if the individual wishes to stay enrolled in a MSA plan.
• Private Fee for Services plans: All PFFS plans must cover all Part A and Part B original Medicare services whether or not the PFFS plan has a full network of contracted providers.
• Religious Fraternal Brotherhood Society: An RFB society is an organization that is described in the Internal Revenue Code of 1986, is exempt from taxation under that code and is affiliated with, carries out the tenets of, and shares a religious bond with, a church or convention or association of churches or an affiliated group of churches.

Q: Does a MA plan have to cover services provided by a DC?

A: Yes. According to the “Basic Rule” a MA organization offering a MA plan must provide enrollees in that plan with all Part A and Part B original Medicare services, if the enrollee is entitled to benefits under both parts, and Part B services if the enrollee is a grandfathered “Part B only” enrollee.

This would include the spinal adjustment. MA plans may offer supplemental coverage which could extend beyond the CMT services.

Q: What types of services may be included by a MA plan as a supplemental benefit?

A: MA may choose to offer routine chiropractic services (services beyond the CMT) as a supplemental benefit as long as the services are provided by a state-licensed chiropractor practicing in the state in which he/she is licensed and is furnishing services within the scope of practice defined by that state’s licensure and practice guidelines.

The routine services may include conservative management of neuromusculoskeletal disorders and related functional clinical conditions including, but not limited to, back pain, neck pain and headaches, and the provision of spinal and other therapeutic manipulation/adjustments. X-rays or other diagnostic or therapeutic services furnished or ordered by a chiropractor may be covered by the MA plan as a supplemental benefit as long as the chiropractor is state-licensed and is practicing within the state’s licensure and practice guidelines.

Q: Can a Medicare Advantage plan enroll a PT to perform chiropractic services instead of a DC?

A: No. Section 1861(r) of the Social Security Act provides the definition of a physician for Medicare coverage purposes, which includes a chiropractor for treatment of manual manipulation of the spine to correct a subluxation. (As a standard Medicare Part B benefit, manual manipulation of the spine to correct a subluxation must be made available to enrollees of cost plans.) The statute specifically references manual manipulation of the spine to correct a subluxation as a physician service.

Thus, Medicare cost plan organizations offering cost plans must use physicians, which include chiropractors, to perform this service. They may not use non-physician physical therapists for manual manipulation of the spine to correct a subluxation.

Medicare cost plans may continue to use physical therapists to treat enrollees for conditions not requiring physician services as defined in §1861 (r) of the Social Security Act.

Q: Can a Medicare Advantage Plan establish caps on chiropractic care?

A: Medicare Advantage plans may impose:

• Deductibles;
• Coinsurance; or
• Copays; for any of the services which it provides
• May also impose annual, semi-annual, quarterly, monthly or any other periodic limits on the Optional Supplemental Benefits it offers its enrollees provided these limits are not prohibited by State law.

However, MA plans may not impose caps on any Medicare covered benefit unless original Medicare also imposes a cap (example: capping # of visits).

For covered chiropractic services under Traditional Medicare, there are no caps on visits. It is based on Medical Necessity. There may be parameters in place by Medicare Contractors to ascertain if Medical Necessity Guidelines are met thereby leading to a record request.

Since Traditional Medicare does not impose a cap, MA plans may not impose them either.

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ABOUT THE AUTHOR:

Richard C. Healy, DC, CCSP, is the ANJC Medicare Consultant. A New Jersey Medicare Carrier Advisor Committee delegate and a Certified Chiropractic Insurance Consultant, Dr. Healy is in private practice in Dumont, NJ.