Q. Are visits to the chiropractor or physical therapist covered under the Affordable Care Act?
A. All ACA-compliant individual and small group plans include coverage for physical therapy. Some individual market plans, sold via the health insurance marketplaces and off-exchange, include coverage for chiropractic services – but many do not. It depends in large part on where you live, as different states have different rules.
The ACA establishes a set of essential health benefits (EHBs) that defines the benefits required to be offered to consumers in broad categories but do not specify specific services to be included in many cases. Chiropractic care is not spelled out specifically in the EHB, but the ACA granted states a significant degree of flexibility to further define specific services to be included in the set of EHBs to be offered in each state.
The law allows states to choose a “benchmark” plan that serves as a model for all ACA-compliant plans sold in the small group and individual markets within that state.
CMS has a page that provides details for each state’s benchmark plan. That page also includes links to each state’s list of state-mandated benefits. If a state mandates coverage for chiropractic care, it will be included in the state’s benchmark plan. But a state’s benchmark plan might include chiropractic care even if the state doesn’t mandate it.
In many cases, state mandates and/or benchmark plan coverage for chiropractic care are limited to a set number of visits per year, and coverage is typically based on medical necessity, i.e., as long as the patient makes medical improvement claims are covered within the policy visit or other maximums. But “maintenance” chiropractic care would generally not be covered, nor would chiropractic care used for general wellbeing rather than to treat a specific injury.
For physical therapy-related services, inclusion in the essential health benefits is a bit more direct as both rehabilitation and habilitation services are specifically listed in the essential health benefits. However, the benchmark plan still plays an important role in terms of how physical therapy is covered from one state to another.
Rehabilitative health care services are designed to help a person regain or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Habilitative health care services are designed to help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Although rehabilitative and habilitative services are required to be covered on all ACA-compliant individual and small group plans, there are typically limits on the total number of visit that the plan will cover in a given year, depending on the specifics of the benchmark plan in that state and/or the state’s mandated benefits.
Covered doesn’t mean covered in all cases
The ACA prohibits insurers from imposing dollar limits on coverage for essential health benefits (so an insurer cannot, for example, limit rehabilitative care benefits to $1,000 per year), but insurers can – and most do – impose limits on the number of visits. So your plan might cover a maximum of 20 physical therapy visits in a given year, as long as the therapy is determined to be medically necessary.
Insurers can also impose other limits on physical therapy, if the benchmark plan includes those limits. For example, In New York, the state has designated an Oxford EPO small group plan as the benchmark. It includes up to 60 annual visits per condition for speech, occupational, or physical therapy. But it notes that all three types of therapy are “only covered following a hospital stay or surgery.” So in New York, insurers offering individual and small group health insurance are not required to cover physical, occupational, or speech therapy if the patient has not had a hospital stay or a surgery.
But this varies from state to state. In Colorado, the benchmark plan limits physical therapy to just 20 visits per year, but it notes that PT is “covered if, in the judgment of a Plan Physician, significant improvement is achievable within a two-month period.” So insurers in Colorado cannot stipulate that physical therapy is covered only if the patient had a prior hospital stay or surgery. (Note that Colorado’s benchmark plan will undergo some changes as of 2023, including new coverage for acupuncture, but nothing has changed about the physical therapy benefits.)
As always, ask a lot of questions of your health plan about what’s covered and to what extent.