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Do you know what your health insurance covers?

John-David Kato, DC, MSc, ACSM-RCEP, CSEP-CEP. Sept 5th, 2008

I am frequently asked by patients what is commonly covered by extended health insurance. This is difficult to answer because of the great variability between different plans. The following questions will help you to learn about chiropractic (or any health care service) benefits covered by your insurance. They are intended to help you make better-informed decisions about your health. Jot down some or all of the questions and give your insurance company a call. Their phone number or website address (to look up the number) will be on the health insurance card or mailings they issued you. You will need one of those because they will ask for your membership number on it. When speaking to them, do not be afraid to ask anything. Some people are intimidated by the large insurance companies, but remember you are their customer and are already paying for the benefits.

How much chiropractic coverage do I have with my insurance plan?
Some insurance companies will only cover a certain amount (eg. $500 per year). It is good to know what is the limit of how much they cover. Most people do not require and extensive number of visits, but it depends on the nature of your injury. If you require more treatment, you should know how much your insurance will pay before you will have to pay out of your own pocket.

Is there a limit to the amount covered per visit?
Some plans set a limit on how much they will cover per visit. So you may have to pay a small portion of the bill each time you go. Give the chiropractor's office a call to ask how much they charge. A few things to note, the initial visit to the chiropractor (when they will interview and examine you) is usually more than a regular office visit. X-rays are not included in the cost of an office visit, but are only necessary in certain cases.

Is the coverage based on the calendar year or fiscal year? If it is the fiscal year, when does the year end?

If you plan to continue care from year to year as some people chose to, it is good to know when the insurance company resets the coverage.

How long does it take to get a claim covered once I have submitted a receipt?
If you are on a budget, you will want to know the turn around time for the insurance company to mail a check back to you.

Is a referral from a primary care provider necessary for coverage of chiropractic services?
Chiropractors are doctors, and you do not need any referral to see one. However some insurance companies require a referral for chiropractic treatment from a medical doctor before they will pay your bill. It can be an annoying delay for you to get the treatment you need, but if you want them to pay the bill you may have to schedule an appointment to your family doctor first.

Orthotics:

  • Are orthotics covered under my plan? How much is covered for orthotics?
  • Does my insurance plan allow for my chiropractor to prescribe and dispense orthotics?
  • How often can I get orthotics covered? Do I need a new prescription for orthotics each time?

Most plans cover the cost of foot orthotics. Just to make sure there are no surprises, I suggest patients to ask their insurance company the above questions.

Other services:
I find that many people do not know a service they have wanted was already covered by their insurance. Like I said before you are already paying for it so you should find out what is offered. There are many health care professionals out there who can help you with a whole list of problems and concerns. When you call the insurance company ask about other services you may be interested in like:

  • Dentistry
  • Naturopathic medicine
  • Massage therapy
  • Psychology
  • Physiotherapy
  • Osteopathy
  • Chiropody
  • Registered dietician
  • Acupuncture
  • Speech language pathology

 

If you would like to see other services or a different level of service covered, let your human resources at work know. They are the ones who negotiate with the insurance companies for the benefits that are covered.

I hope you find these questions helpful. If you are unsure about your coverage, simply call the insurance company. As a consumer myself, I have found the customer service agents helpful in answering my questions.

 

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