Q. Are visits to the chiropractor or physical therapist covered under the Affordable Care Act?
A. A significant number of plans offered through the health insurance marketplaces will include coverage for chiropractic services – but some will not. 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.
Chiropractic care is not spelled out specifically in the EHB, but the ACA grants states a significant degree of “flexibility” to further define specific services to be included in the set of EHBs to be offered in the state exchanges. The law allows states to choose a “benchmark” plan that will serve as a model for all qualified health plans available in the exchanges and in the small group and individual markets.
In many cases, that state benchmark plan limits chiropractor visits to a set number annually and also base coverage on medical necessity, i.e., as long as the patient makes medical improvement claims are covered within the policy visit or other maximums.
For physical therapy-related services inclusion in the essential health benefits is a bit more direct as both rehabilitation and habilitation services are listed in the EHB.
Rehabilitation Services: Health care services that help a person keep, get back 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.
Habilitation Services: Health care services that 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 services will be mandatory services in most Qualified Health Plans (QHPs), states will most likely impose annual visit limits, caps, or other restrictions for therapy services as current employer sponsored plans do. As always, ask a lot of questions of your health plan about what’s covered and to what extent.