When Does Medicare Cover Acupuncture for Arthritis?

Medicare Benefits Solutions
Aug 22, 2022

If you’re living with arthritis, you may be exploring all your options for pain management and relief. Aside from medication, there may be alternative treatments that will reduce inflammation and lower the discomfort or pain you feel.

Acupuncture has been used to treat pain, relieve stress, and improve overall wellness. If you qualify for Medicare, you’ll want to understand how acupuncture may be covered to treat your arthritis.

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Acupuncture Medicare Benefits

For many people with chronic pain, acupuncture brings impressive results. “The total annual cost of patients seeking acupuncture services in the U.S. was about $3.5 billion in 2018,” according to the Journal of Integrative Medicine. Medicare describes acupuncture as “a technique where providers stimulate specific points on the body, most often by inserting thin needles through the skin.” But does Medicare pay for acupuncture?

The Centers for Medicare & Medicaid Services (CMS) defines chronic low back pain as pain that is:

  • Long-lasting: at least 12 weeks
  • Of unknown origin and not attributed to a disease like metastatic cancer, or an infectious or inflammatory disease
  • Not associated with surgery or pregnancy

Medicare covers acupuncture only for chronic lower back pain if administered by a physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), or auxiliary staff under supervision. The practitioner must:

  • Meet state requirements
  • Have a master’s degree or doctorate in acupuncture or Oriental medicine from an institution that earned accreditation from the Accreditation Commission on Acupuncture and Oriental Medicine
  • Possess an active and unrestricted license to perform acupuncture within the United States

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What Will Medicare Pay for Acupuncture?

If you qualify for coverage, Medicare offers coverage of up to 12 acupuncture sessions within 90 days. If you demonstrate improvement, you are eligible for an additional eight visits. Twenty treatments are the maximum for the year. If your physician determines that the condition has worsened or is no longer improving, Medicare will stop covering the acupuncture treatments.

Out-of-pocket costs will vary depending on where you live and what provider you visit. First-time visits may cost between $15 to $400, and follow-up visits may cost $15 to $300. If Medicare approves your acupuncture treatments, you are responsible for the Part B deductible and 20% of Medicare-approved charges.

Do Medicare Advantage Plans Cover Acupuncture?

Medicare Advantage (MA) is Part C of the Medicare program, and includes Part A, Part B and often Part D. Medicare Advantage appeals to beneficiaries who want all their Medicare benefits under one umbrella. Many MA plans offer additional coverage for services and products unavailable under Original Medicare.

Medicare-approved private insurance companies that sell MA policies must follow Medicare rules. Coverage can exceed but cannot reduce Original Medicare benefits. MA members have access to the same acupuncture coverage as beneficiaries who get their benefits from Original Medicare. Research your Evidence of Coverage (EOC) to determine if your MA plan offers additional benefits.

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When Did Medicare Start Covering Acupuncture?

CMS finalized the national coverage determination (NCD) for acupuncture on January 21, 2020. CMS points to acupuncture research revealing that “patients with chronic low back pain in these studies showed improvements in function and pain,” even though the research included few participants ages 65 and above. Major private insurers offer acupuncture coverage on some level.

The opioid addiction crisis influenced the decision to add acupuncture to Medicare coverage. CMS explained that “over-reliance on opioids for people with chronic pain is one of the factors that led to the crisis, so it is vital that we offer a range of treatment options for our beneficiaries.”

Does Medicare Cover Other Alternative Therapies for Arthritis?

Arthritis is not simply one disease, explains the Arthritis Foundation. Instead, arthritis refers to pain and disease of the joints. Contrary to popular belief, it is not a disease of aging, but it is more common for older adults to be diagnosed with specific types of arthritis.

People with arthritis experience mild-to-severe swelling, stiffness and limited range of motion. A severe case can cause chronic pain and irreversible changes in your joints. Certain kinds of arthritis impact major organs as well as joints.

The Arthritis Foundation suggests the following natural therapies to help manage arthritis symptoms:

  • Guided imagery
  • Hypnosis
  • Touch therapy
  • Physical therapy
  • Supplements
  • Massage
  • Meditation
  • Anti-inflammatory diet

Original Medicare does not cover most alternative therapies, but you may be eligible for medically necessary treatments like physical and occupational therapy.

Chronic Care Management Part B Benefits

Medicare Part B (medical insurance) is optional coverage, but most people sign up for it when they are first eligible for Medicare to avoid late enrollment penalties unless they have other creditable coverage. Part B includes benefits for doctor visits, lab work, durable medical equipment, some preventive services, and other medically necessary outpatient services. Part B will cover many expenses for arthritis care if you have chosen to enroll and pay the monthly premium.

Beneficiaries with two or more chronic health conditions, such as arthritis and diabetes, with a projected duration of at least one year, are eligible for support in managing the conditions. The services include developing and coordinating a comprehensive plan that includes medication management and round-the-clock access to urgent care.

If your injury or disease alters your capacity to function, your doctor may prescribe physical therapy (PT). Occupational therapy (OT) helps people who have difficulty bathing or dressing. Medicare may approve PT and OT if your doctor certifies that these therapies may improve or maintain your functionality or slow the decline. Your cost-sharing for PT and OT is the Part B deductible ($233 in 2022) and 20% of the Medicare-approved amount.

How Part D Can Help if You Have Arthritis

It should be noted that Part B does not include prescription drug coverage, so if you need medications to treat your arthritis, you’ll need to be enrolled in Part D. If you have Original Medicare, you can enroll in a stand-alone Medicare Prescription Drug Plan (PDP).

As an alternative, you can enroll in a Medicare Advantage (MA) plan that includes prescription drug coverage. MA plans are required to include all the same Part A and Part B benefits as Original Medicare, but many plans include additional benefits.

TIP: Find out if your existing Medicare plan covers arthritis care and services.

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