Most states now offer Medicaid enrollees access to chiropractic services

Photo Cred: Yan Krukov/Pexels

By Judy Packer-Tursman

Shaken by the human toll of the United States opioid crisis, most states now cover chiropractic services in their Medicaid benefit packages as a non-drug alternative for pain management.

It’s happening under the radar since much attention is focused on lobbying Congress for broader chiropractic benefits under Medicare, but the pattern seems consistent: Missouri began Medicaid chiropractic coverage in 2020 and Illinois at the end of 2021, joining a couple dozen states taking action earlier. More recently, a Senate bill for Medicaid chiropractic benefits reintroduced in Arizona passed its first legislative hurdle in late January 2022.

“With nearly 25 percent of Illinoisians on Medicaid, we believe this change will help improve the ongoing opioid epidemic by providing a non-pharmacological approach to assist patients by evaluating, diagnosing, and managing many neurologic, muscular, skeletal, and other conditions,” said Marc Abla, CAE, executive director of the Illinois Chiropractic Society (ICS).

“We also look forward to being able to deliver care that has proven to reduce overall Medicaid costs in other states,” Abla said, noting the association continues working with Illinois Medicaid on some administrative functions related to chiropractic coverage.

Under the federal government’s framework for Medicaid and its 76.3 million low-income enrollees nationwide, inpatient and outpatient hospital services and physician services are among a dozen-plus mandatory benefits that states are required to cover. Chiropractic services are among two dozen-plus optional Medicaid benefits that states may choose to cover either by submitting a state plan amendment, or a section 1115 demonstration waiver for populations served through demonstration programs, for approval by the Centers for Medicare and Medicaid Services (CMS).

CMS officially gave the go-ahead to Illinois’ state plan amendment in January 2022. Abla said the approval is only for spinal manipulation for adult Medicaid enrollees in managed care and fee-for-service (children already are covered), “but statutorily, HFS [i.e., the Illinois Department of Healthcare and Family Services] can expand that” to cover a licensed chiropractor’s full scope of practice in the state.

“Although Medicaid payments continue to undercompensate the spinal adjustment at rates that are only 33 percent of Medicare allowable rates, we look forward to working closely with HFS to soon allow chiropractic physician patients to receive Medicaid covered examinations, diagnostic services, modalities, and other physical therapies,” Abla said.

In Missouri, Quinn James, DC, FICC, who has a private practice in St. Peters, Mo., helped advance Medicaid chiropractic coverage through the state legislature. Now a Medicaid provider himself ─ for MO HealthNet’s managed care plans and fee-for-service (FFS) program component, plus a statewide chronic pain management program offering chiropractic and other complementary therapies for Medicaid patients with opioid use disorder ─ he sees positives in broadening underserved patients’ access to care and offering another option to costly emergency room visits.

“For me, it’s about access…and if it turns out that it saves the state money as well, then it’s a win-win situation,” James said.

He anticipates chiropractors’ inclusion in Medicaid will help to facilitate their expected shift from mostly private practices into more work in integrated care settings, such as federally qualified health centers (FQHCs), as they become able to bill Medicaid for chiropractic services.

But James, legislative chair of the Missouri Chiropractic Physicians Association (MCPA) and American Chiropractic Association (ACA) delegate for Missouri, who’s been in chiropractic practice for 22 years, said Missouri chiropractors’ views ─ and level of interest in taking on Medicaid patients at roughly 60 to 65 percent of Medicare’s payment rate ─ are highly variable.

“Some chiropractors are really happy with it and others are not taking Medicaid patients,” James said. “It’s really provider by provider. If their rent is high or they have high overhead costs, they may not be able to see a Medicaid patient.”

Currently, 351 chiropractors are actively enrolled as MO HealthNet providers, said spokesperson Heather Dolce of the Missouri Department of Social Services. That’s out of approximately 1,600 licensed chiropractic physicians actively practicing in the state, according to the MCPA.

In November 2021, the most recent month for complete claims data, 137 participants received services through Missouri Medicaid’s Alternative and Complementary Therapies for Chronic Pain Program, Dolce said. Of 217 claims submitted, 86 were for chiropractic services totaling $2,455, she said, adding, “We do not have a full historical look-back with totals at this time.”

Information on states’ varying Medicaid chiropractic coverage is hard to come by and not tracked closely by the ACA since autonomous state chiropractic associations handle the issue. The Kaiser Family Foundation’s latest data (from 2018 shows 24 states offered Medicaid chiropractic benefits with varying limits and 21 states didn’t offer it; six states didn’t respond to the benefits survey. Missouri, a “no” at the time, and Illinois, a nonrespondent, have since introduced Medicaid chiropractic benefits ─ meaning most states now offer them.

John Falardeau, the ACA’s senior vice president of public policy and advocacy, said the national chiropractic trade organization is “always advocating for increased access in Medicaid, Medicare, Tricare [the U.S. military’s health care program], and private insurance.”

At times, chiropractic services may be seen as “low-hanging fruit for [state] legislators as they’re trying to get their budgets under control,” said Falardeau. “They might pay $5 million a year for chiropractic and cut that…They see what they spend, but they don’t see the cost savings.”

Falardeau, as the ACA’s chief lobbyist, said its top legislative priority is passage of the Chiropractic Medicare Coverage Modernization Act (H.R. 2654) that sits in committee but has gained strong bipartisan support: 58 Democrats and 58 Republicans sponsored the bill as of Feb. 7. The bill would broaden Medicare’s current coverage for manual manipulation of the spine by a chiropractor or other qualified provider if it’s medically necessary to correct subluxation (spinal bones out of position). Currently, Medicare has no limits on number of visits, but doesn’t cover other services or tests a chiropractor may order, including X-rays, or post-therapy services such as exercise, which Falardeau terms as being “handcuffed by the statute.”

James said Missouri Medicaid’s chiropractic coverage goes further in some respects than Medicare. “In Missouri, it’s up to 20 visits for the rolling calendar year [beginning with the patient’s first visit],” he said. “It covers more than subluxation, allows you to do evaluations, order X-rays, do some physiotherapy, up to the scope of practice in Missouri.”