Insurance coverage for complementary or alternative medicine
Insurance coverage for complementary and alternative medicine (CAM) refers to the approval by health insurance providers for payments related to various CAM therapies. While a variety of CAM therapies exist, only a select few, such as chiropractic services, acupuncture, and certain nutritional therapies, are widely accepted by traditional medicine and included in health insurance plans. Coverage is typically contingent upon several factors, including whether a medical or osteopathic doctor orders the treatment, the licensing of the CAM provider, and the availability of research supporting the therapy's effectiveness.
Certain CAM services, like midwifery, may also be covered, provided practitioners meet specific educational and licensing requirements. Despite the limited insurance coverage, CAM remains a significant sector in the healthcare market, valued at approximately $30 billion in the U.S. Individuals utilizing CAM often report lower overall healthcare costs and a sense of improved health, although they may bear higher out-of-pocket expenses due to insurance limitations. The disparity in earnings between CAM providers and traditional healthcare providers highlights the complex dynamics of insurance, patient choice, and healthcare economics in the realm of CAM.
Insurance coverage for complementary or alternative medicine
DEFINITION: The approval by a health insurance carrier for payment of services by a complementary or alternative medicine provider.
Criteria for Coverage
There are many complementary and alternative medicine (CAM) therapies, but only a few have been accepted by traditional medicine and are covered by health insurance plans, even when ordered by a medical or osteopathic doctor. A covered CAM therapy is reimbursed directly to the provider or the patient by the patient’s health insurance company. If the payment goes directly to the CAM provider, the patient is responsible for a copayment (the patient’s up-front share of the cost of treatment). Other health insurance companies have negotiated a discount with selected CAM providers. The patient pays this discounted amount out-of-pocket. This discounted payment, however, is not considered insurance coverage.
Health insurance companies consider several factors when deciding whether to cover a CAM service. These factors include whether the treatment is experimental, whether a medical or osteopathic doctor orders the treatment, whether the CAM provider is licensed by their respective state, whether the treatment is generally known, and whether the treatment has been adequately researched and scientifically proven effective. Treatments or therapies considered experimental are rarely covered by health insurance, and services ordered by a medical doctor or an osteopath are more likely to be covered.
CAM providers who are licensed by their states have had their education and training validated and meet the standards of their states of practice. Licensing standards vary from state to state. Therapies that have been adequately researched are those that have been proven effective by a body of research. The therapy does not have to be 100 percent effective, but it should demonstrate a reasonable amount of effectiveness in treating patient conditions across the general population or in a specific group, like those with diabetes or high blood pressure. Medical doctors and osteopaths are more likely to accept therapies that have been adequately researched. Often, medical doctors reject CAM therapies because they are not knowledgeable about them.
Coverage for Specific Types of CAM
Some CAM services are accepted by traditional medicine and covered by health insurance. Biofeedback and nutritional therapy are covered if they are ordered by a medical doctor. Midwives and osteopathic physicians are covered in most states. The midwife, for example, must be a registered nurse midwife with a master’s degree in midwifery and must be working in a hospital or office with a medical doctor. Midwives who are not registered nurses are not covered. Osteopaths receive education in ways similar to medical doctors, are considered physicians, and function like medical doctors within their medical specialty. Another CAM service, pet therapy, is usually provided at no charge. The pets, usually dogs, visit patients in hospitals or extended care facilities.
The CAM therapies that are most often covered by health insurance are chiropractic, acupuncture, and massage. Chiropractic is almost universally covered by insurance, although there are often limits on the number of office visits that will be covered.
Acupuncture and massage therapy are covered less often and may be covered only for specific conditions. Acupuncture is often covered only for pain management for persons with cancer, and massage therapy may be covered only for persons with fibromyalgia. The Agency for Healthcare Research and Quality recommends acupuncture for back, neck, and fibromyalgia pain, but most health insurance coverage does not cover this treatment. A review of forty-five commercial health plans as well as government-sponsored plans revealed only around one-third of plans covered acupuncture. Of those plans that did include acupuncture, most covered a very low percentage of the total treatment cost.
Implications of Limited Coverage
Despite the limited insurance coverage for CAM services, the services remain popular with consumers. In America, CAM is a $30 billion industry. People who use CAM tend to be wealthier and better educated. They also seem to feel that CAM treatment is helpful to them. Some research indicates that individuals with access to CAM and who attend these therapies have lower healthcare costs overall regarding the number of office visits, prescription costs, and emergency room visits.
One effect of limited insurance coverage for CAM services is the relatively low cost. This is good for consumers but not necessarily good for providers. CAM providers often earn much less than their counterparts in traditional medicine and are more likely to keep their business expenses low with, for example, a small staff and a small leased office.
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