This article is general information, not medical, insurance, legal or financial advice. Coverage varies by country, state, insurer, employer and plan, so your own plan documents are the authority on what is included.
What “alternative” usually means to a plan
“Alternative,” “complementary” and “integrative” are loose labels for treatments outside conventional medicine, such as chiropractic care, acupuncture, massage therapy, naturopathy, herbal products or mind-body practices. Insurers do not use these labels consistently. A plan may cover one of these services under a specific benefit name, treat another as an exclusion, and say nothing at all about a third.
For that reason, the question to ask is not “does my plan cover alternative therapies?” but “does my plan cover this specific service, from this type of provider, for this reason?” This article explains how to find the answer. It does not evaluate whether any therapy works, which is a question for you and your clinician.
Services plans more commonly address
Some services are more often found in plans than others, though this varies widely:
- Chiropractic care. Many plans cover some chiropractic visits, often with an annual visit limit and sometimes a requirement that the care be for a specific condition.
- Acupuncture. Some plans cover it for particular conditions such as certain kinds of pain, and others do not cover it at all.
- Massage therapy. Coverage is often limited to cases where it is part of a treatment plan, and may be handled like physical therapy coverage if ordered by a doctor.
- Naturopathic and herbal care. These are frequently excluded, though some plans cover certain visits while excluding supplements.
If a service is provided as part of a conventional treatment plan, for instance a physical therapist using a technique that is also called complementary, the plan may process it under the standard benefit for that provider rather than as alternative care.
Reading the plan language
The details are usually in the summary of benefits and in the longer policy documents. Look for these terms:
- Covered services and exclusions. Search for the therapy by name and also for words like “alternative,” “complementary,” “experimental” and “investigational.” An exclusion list may name specific services. Understanding coverage exclusions helps you tell the difference between “not covered” and “not mentioned.”
- Visit limits. A plan may cover a set number of visits per year across a group of services, such as a combined limit for chiropractic and acupuncture, so using one can reduce what is left for the other.
- Provider requirements. Coverage may depend on the practitioner holding a particular license or being in the plan’s provider networks. The same service from an unlicensed or out-of-network provider might be paid differently or not at all.
- Referral or authorization. Some plans require specialist referrals or prior authorization before these services.
- Medical necessity. Plans often cover a service only if it is considered medically necessary for a diagnosed condition, using the plan’s definition, which may differ from your or your practitioner’s view.
Cost sharing
If a service is covered, the usual cost-sharing rules apply. You might pay a copay for each visit, or the deductible and coinsurance may apply, with charges based on the allowed amount rather than the practitioner’s usual fee. Many practitioners in this area charge flat fees and may be out of network, in which case the plan might pay little or nothing and you pay the difference. Ask the practitioner’s office whether they bill insurance and whether they are in your plan’s network.
Stand-alone or add-on benefits
Some employers or insurers offer a separate wellness or discount arrangement for alternative care. A discount arrangement is different from insurance: it typically lowers the price you pay but does not pay any part of the bill, and it does not count toward your deductible. Rider or add-on coverage, where offered, usually has its own premium and limits. Read what is promised, and what is not.
Other ways people pay
If your plan does not cover a therapy, there may be other routes. A health savings account or flexible spending account can sometimes be used for eligible medical expenses, but what counts as eligible depends on the account rules, and a practitioner’s documentation may be required. Paying for alternative therapies this way depends on the account rules, so check the list of eligible expenses before spending.
If a claim is denied
If a claim is denied, the denial letter should say why. Common reasons include a service being excluded, a visit limit being reached, or the provider not qualifying under the plan. Check the explanation of benefits first, since the fix is sometimes a coding issue the provider can correct. If the denial stands and you think it is wrong, a claim appeal may be possible, and an external review may follow depending on where you live. Keep dispute documentation such as the plan wording you relied on, dates and names of calls.
A short list of questions
- Is this specific therapy a covered service under my plan?
- Does it require a referral, a diagnosis or prior approval?
- What are the visit limits and do they combine with other services?
- Which kinds of practitioners qualify, and are they in my plan’s network?
- What will I pay per visit?
Answers given by phone are not always binding, so ask for a reference number and, where possible, written confirmation.