Insurance Changes for In Network Coverage in 2021

Please read if you use or intend to use Acupuncture Insurance benefits.

If you have been using In Network insurance coverage in our office OR are planning to change your insurance in 2021, please read.  We hate fine print, and right now we’re pretty averse to more change, but more than anything, we hate insurance surprises!

The change: We’re about to start the process to get out of our contracts with all insurance providers and switch to only billing for Out of Network benefits in our office

  • What insurance companies ARE affected?  If you use In Network benefits in our office this will affect you.  The most common plans affected are Blue Shield, Cigna, Sutter, United, and a few other plans that are managed by the same administrators.
  • What insurance companies are NOT affected?  If you use Out of Network benefits in our office or pay without using insurance, this change will not affect you.  The most common Out of Network plans are Aetna and Anthem Blue Cross, but there are lots of other plans with Out of Network benefits.

Why are we going Out of Network?  There was a change to insurance fee schedules this year that has reduced the reimbursement for acupuncture by 25-55% across the US.  We can’t survive as a small business in northern CA with this reduction in pay, especially now while we have reduced treatments and increased costs associated with Covid-19 distancing and cleaning.  The change began mid-year without warning from some of the companies that we have contracts with and will continue to take effect for the rest of the companies.

When?  Sometime in 2021 between mid-January and end of March we won’t be In Network with any insurance anymore.  Each insurance plan has a different process and timeframe for getting Out of Network.  As we get confirmations and effective dates for the different insurances, we will share them with you.

Can you still use your insurance in our office in 2021 after the change is effective?  That depends on your plan.  If your plan has Out of Network acupuncture benefits, we can still bill directly for you.  In the new year we can run a verification to see what your Out of Network benefits are in 2021 and explain how they would work in our office.  Some Out of Network benefits are really good and the patients pay very little.  Some Out of Network plans aren’t worth using because it’s less money to pay our Time of Service discounted rate.  Some plans don’t have Out of Network acupuncture benefits. 

What can you do now?  If you want to find out before the new year if your current plan will have Out of Network acupuncture benefits in 2021, you can call your insurance or your broker and ask them.  They will not tell us what your 2021 benefits are at this time, but they will tell you.  Now is the time for many people to choose their insurance for 2021.  If you have the option, choose a plan that has good Out of Network acupuncture benefits.

What are my other options? For those that don’t have Out of Network coverage or opt not to use it, the Time of Service discounted rate will apply with the following options:

  1. Per Treatment Payment:  $100.00 each visit.
  2. Prepayment Plans Terms and Conditions:  This office offers two prepayment plans for patients paying at the time of service. In return for the patient’s agreement to prepay for a specific number of visits in advance, the patient is offered free treatment(s):
    —$500: With the purchase of 5 treatments at $100/treatment, the patient receives one treatment for free, for a total of 6 treatments. ($83.00 per treatment)
    —$900: With the purchase of 9 treatments at $100/treatment, the patient receives two treatments for free, for a total of 11 treatments. ($81.00 per treatment)

Sad times for Chinese Medicine

I don’t like this change and I don’t like having to tell you about it.  Most acupuncturists I know are making the same hard decision.  It’s not if, but when they will go Out of Network.  Which means there will be less options for patients.  Many patients will be forced to change the frequency of treatments or give up treatments entirely, which makes me really sad.  I first got enough acupuncture to make a difference when my treatments were partially covered by insurance so I know what a difference it can make.  We’ve been exploring how to make it work in our office because we don’t want anymore changes, but we just can’t find a way.  We have to change in order to survive.

What happened that changed the fee schedule?  The simple explanation is that Medicare created an Acupuncture Fee Schedule and the other insurance companies are aligning to it and reducing their reimbursement for acupuncture. 

For those that like details…In January 2020 it was announced that Medicare would cover acupuncture for chronic low back pain.  The problem is that Acupuncturists are not in the Medicare system so we can’t actually treat the patients and it will literally take an act of Congress to change that.  There are some clauses in the coverage that look like they intended for acupuncturists to be able to perform the treatments under MD supervision.  But how that should work and how to bill for it have not been defined, so no one is providing the treatments.

On top of all that, the coverage is only for 12 visits a year for a certain type of back pain and only if the patient has failed to respond to several other specific treatments.  If your back pain has failed other treatments and it’s been going on long enough to rule them out, you most likely need more than 12 acupuncture treatments a year.  As you can see, it’s not a benefit that can be used the way it’s set up, but it’s reducing acupuncture reimbursements anyway.

Questions:  Please contact us with any of your questions or concerns.  We will do our best to help you understand what we know about how this will affect you.

And don’t forget to use your acupuncture benefits for the rest of 2020 and into 2021 while they are effective in our office, no matter what kind of insurance you have!

Here’s to adaptability and resiliency for us all!

Christina Ness-Hawks, LAc

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