How Does Medicare Cover Functional Medicine?

This article explores Medicare’s position on functional medicine. We’ll show how Medicare works with functional medicine, delineating what is covered and what is not. From acupuncture to chiropractic care and medical nutrition therapy, we’ll help you understand Medicare’s approach to these treatments and eligibility criteria.

[keytakeaways]

Medicare covers up to 20 acupuncture sessions in 90 days to treat chronic low back pain.
Medicare covers chiropractic care for manual spinal manipulation.
Medicare covers medical nutrition therapy for patients with diabetes and/or kidney disease.
Medicare Advantage plans cover the same functional medicine treatments that Original Medicare covers, although the out-of-pocket costs may vary.
Some Medicare Advantage plans cover expanded services not covered by Original Medicare, such as gym memberships, massage therapy, and additional holistic treatments.
Medigap can help with the out-of-pocket costs for functional medicine treatments covered by Original Medicare.

[/keytakeaways]

What Is Functional Medicine?

Functional medicine, sometimes called complementary or alternative medicine, is an umbrella term for non-mainstream approaches that focuses on identifying and addressing the root cause of disease. Symptoms may be one of many contributing to an illness. Functional medicine looks at symptoms from a holistic medicine approach.[mfn referencenumber=1]Medlineplus.gov, “Complementary and Integrative Medicine“, Accessed December 10, 2023[/mfn]

When Does Medicare Cover Functional Medicine?

As a rule, Medicare does not cover functional medicine. It covers specific procedures for obtaining other regular treatments under Medicare’s approved services.

Acupuncture

Medicare Part B covers up to 12 acupuncture sessions in 90 days to treat chronic lower back pain. Medicare will also cover an additional 8 sessions if the acupuncture treatment has proved effective in relieving back pain. Medicare will not cover acupuncture for any other conditions, such as opioid addictions.[mfn referencenumber=2]Medicare.gov, “Acupuncture“, Accessed December 10, 2023[/mfn]

To qualify for acupuncture treatment coverage, you must meet the following conditions: [mfn referencenumber=2]Medicare.gov, “Acupuncture“, Accessed December 10, 2023[/mfn]

Your doctor has diagnosed you with chronic lower back pain that has lasted over 12 weeks.
Your back pain is not a symptom of another underlying medical condition.
Your back pain is not the result of pregnancy or post-surgical discomfort.

Chiropractic Care

Medicare Part B will cover chiropractic care needed for spinal manipulation-related procedures. For example, if you are experiencing pain due to one of your vertebrae being misaligned (spinal subluxation), Medicare will cover the cost of a chiropractor to realign it manually. Any other services ordered by your chiropractor will not be covered, such as x-rays or massage therapy.[mfn referencenumber=3]Medicare.gov, “Chiropractic services“, Accessed December 10, 2023[/mfn]

Medical Nutritional Therapy

Another example is medical nutrition therapy (MNT) for patients diagnosed with kidney disease or diabetes, as well as beneficiaries who had a kidney transplant within the last 36 months. Medicare will consider covering medical nutrition therapy under Part B if patients have a referral from their doctor.[mfn referencenumber=4]Medicare.gov, “Nutrition therapy services“, Accessed December 10, 2023[/mfn]

MNT services that Medicare covers include:[mfn referencenumber=4]Medicare.gov, “Nutrition therapy services“, Accessed December 10, 2023[/mfn]

An initial nutrition and lifestyle assessment
Individual and/or group nutritional therapy services
Help with managing the lifestyle factors that affect your condition
Follow-up visits to check on your progress in managing your diet

Medicare Advantage Plans

Medicare Advantage plans are an alternative for accessing holistic medicine and expanded coverage beyond Original Medicare. While Original Medicare (Part A and Part B) may have limitations in covering certain holistic treatments, Medicare Advantage plans, also known as Medicare Part C, often provide a broader spectrum of services, including holistic medicine.

Medicare Advantage plans operate through private insurance companies approved by Medicare. Unlike traditional Medicare, many plans offer coverage options not included in Parts A and B. Benefits may include acupuncture, chiropractic care, and medical nutrition therapy, among others.[mfn referencenumber=5]Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed December 10, 2023[/mfn]

Gym Memberships

While Original Medicare typically does not cover gym memberships or fitness programs, certain Medicare Advantage plans, like those affiliated with programs such as SilverSneakers, may include gym membership benefits.[mfn referencenumber=6]Medicare.gov, “Gym memberships & fitness programs“, Accessed December 10, 2023[/mfn][mfn referencenumber=7]tools.silversneakers.com, “SilverSneakers“, Accessed December 10, 2023[/mfn]

Gym memberships can provide beneficiaries access to fitness facilities, classes, and programs to promote physical activity. These memberships may offer cardiovascular exercise, strength training, flexibility exercises, and social engagement opportunities.

Beneficiaries should carefully review the specifics of their Medicare Advantage plan’s coverage for gym memberships, including eligible fitness centers, fees, and any restrictions. Additionally, it’s important to confirm that your preferred gym or fitness facility participates in your plan’s network to avoid unexpected costs.

Massage Therapy

Massage therapy, which promotes relaxation, reduces muscle tension, and alleviates pain, is a popular holistic treatment option. While Original Medicare typically does not cover massage therapy, some Medicare Advantage plans may offer coverage for this service as an additional benefit. However, it’s important to note that coverage for massage therapy varies widely.[mfn referencenumber=8]Medicare.gov, “Massage therapy“, Accessed December 10, 2023[/mfn]

For beneficiaries interested in accessing massage therapy through their Medicare Advantage plan, reviewing the plan’s coverage details carefully is essential. This includes understanding any limitations or restrictions on the frequency and duration of massage therapy sessions. Most plans covering this service require patients to use a licensed massage therapists within the plan’s network to receive coverage.

Be aware that even if your Medicare Advantage plan offers coverage for massage therapy, you may still be responsible for certain out-of-pocket costs, such as copayments or coinsurance. Additionally, coverage for massage therapy may be subject to medical necessity requirements. This means it may only be covered for specific conditions or with a referral from your doctor.

Other Considerations

Patients considering Medicare Advantage plans for holistic medicine coverage should carefully review plan documents, including the Summary of Benefits and Evidence of Coverage. It is important to understand the scope of coverage, network providers, and any associated costs.

Additionally, consulting with plan representatives or a health insurance agent can provide clarity on specific coverage details and help you select a plan that aligns with your holistic healthcare needs and preferences.

For millions of Medicare beneficiaries, Medicare Advantage plans expand access to holistic medicine within the Medicare system, offering flexibility and choice.

Medicare Supplement Insurance

Medicare Supplement Insurance, commonly known as Medigap, is a complementary option to Original Medicare, offering coverage for certain out-of-pocket, including holistic medicine. While Medigap plans themselves do not directly cover functional treatments, they play a crucial role in mitigating the financial burden of deductibles, coinsurance, and copayments that Medicare may not fully cover.[mfn referencenumber=9]Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?“, Accessed December 10, 2023[/mfn]

For individuals seeking holistic medicine treatments, having a Medigap policy can provide financial relief by reducing or eliminating the costs associated with Medicare-approved services. However, Medigap plans do not extend coverage to alternative treatments like acupuncture, chiropractic care, or medical nutrition therapy.

NOTE: Beneficiaries interested in holistic medicine should also explore Medicare Advantage plans, which may offer broader coverage options.

While Medigap plans may not directly cover holistic medicine, they serve as a valuable resource for managing the overall cost of healthcare. By providing predictability and financial stability, Medigap plans help beneficiaries to pursue holistic healthcare while by avoiding excessing out-of-pocket costs in the Medicare system.

Advocacy for the Expansion of Functional Medicine Coverage

Spurred by growing recognition of their benefits, advocacy efforts aimed at expanding Medicare coverage for functional medicine is gaining traction. Organizations such as the Integrative Healthcare Policy Consortium (IHPC) and the American Association of Naturopathic Physicians (AANP) advocate for broadening Medicare’s coverage of alternative treatments like acupuncture, chiropractic care, and medical nutrition therapy.

These advocacy groups engage in legislative lobbying, public awareness campaigns, and coalition-building initiatives to promote reforms that prioritize patient-centered, comprehensive care. Patients seeking access to alternative treatments can leverage resources such as the National Center for Complementary and Integrative Health (NCCIH), which provides evidence-based information on complementary health approaches.[mfn referencenumber=9]Integrative Healthcare Policy Consortium (IHPC), “https://www.ihpc.org/“, Accessed February 14, 2024[/mfn][mfn referencenumber=10]American Association of Naturopathic Physicians (AANP), “https://www.naturopathic.org/“, Accessed February 14, 2024[/mfn][mfn referencenumber=10]National Center for Complementary and Integrative Health (NCCIH), “https://www.nccih.nih.gov/“, Accessed February 11, 2024[/mfn]

Summary

In conclusion, while Medicare’s coverage of functional medicine may be limited, our research revealed several exceptions and opportunities. From acupuncture to chiropractic care and medical nutrition therapy, Medicare does provide avenues for accessing certain holistic treatments. Additionally, Medicare Advantage plans offer expanded coverage options, albeit with variations in out-of-pocket costs.

For those seeking alternative treatments beyond Medicare’s coverage, advocacy groups like the IHPC and resources such as the NCCIH serve as invaluable allies, advocating for policy changes and providing evidence-based information. By exploring these resources and understanding Medicare’s coverage nuances, patients can make informed decisions to enhance their well-being and access the holistic care they deserve.