Are visits to the chiropractor or physical therapist covered under the Affordable Care Act?
All ACA-compliant individual and small group plans include coverage for physical therapy, although the specifics vary from one state to another. Some individual and small-group plans, sold via the health insurance marketplaces and off-exchange, include coverage for chiropractic services – but many do not. It depends in large part on where you live, as different states have different rules.
The ACA established a set of essential health benefits (EHBs) that define broad categories of care that must be covered on all new individual and small-group health plans. For the most part, the EHB rules do not specify specific services that must be covered. Instead, the ACA granted states a significant degree of flexibility to further define specific services to be included in the set of EHBs to be offered in each state. To accomplish this, the ACA directed each state to choose a “benchmark” plan that serves as a model for all ACA-compliant plans sold in the small group and individual markets within that state.
CMS has a page that provides details for each state’s benchmark plan. That page also includes links to each state’s list of state-mandated benefits.
(Note that large group plans are not subject to EHB requirements, and do not have to mirror the coverage offered by a state’s benchmark plan. But if a state has specific coverage mandates that apply to all state-regulated plans, that would apply to fully-insured large-group plans as well as individual and small-group plans. Self-insured plans — which are commonly used by large employers — are often quite generous but are not subject to state mandates or EHB rules, regardless of their size.)
Chiropractic care
Chiropractic care is not spelled out specifically in the essential health benefits requirements, so chiropractic coverage on individual and small group plans will depend on the state’s benchmark plan and/or benefit mandates.
If a state mandates coverage for chiropractic care, it will be included in the state’s benchmark plan. But a state’s benchmark plan might include chiropractic care even if the state doesn’t mandate it.
In many cases, state mandates and/or benchmark plan coverage for chiropractic care are limited to a set number of visits per year, and coverage is typically based on medical necessity, meaning as long as the patient’s condition continues to improve, claims will be covered until if and when the maximum number of visits is reached. But “maintenance” chiropractic care would generally not be covered, nor would chiropractic care that’s used for general well-being rather than to treat a specific injury.
Physical therapy
For physical therapy-related services, inclusion in the essential health benefits is a bit more direct, as both rehabilitation and habilitation services are specifically listed in the essential health benefits. However, the benchmark plan still plays an important role in terms of how physical therapy is covered from one state to another.
Rehabilitation Services:
Rehabilitative health care services are designed to help a person regain 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:
Habilitative health care services are designed to 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 and habilitative services are required to be covered on all ACA-compliant individual and small group plans, there are typically limits on the total number of visit that the plan will cover in a given year, depending on the specifics of the benchmark plan in that state and/or the state’s mandated benefits.
Covered doesn’t mean covered in all cases
The ACA prohibits insurers from imposing dollar limits on coverage for essential health benefits (so an insurer cannot, for example, limit rehabilitative care benefits to $1,000 per year), but insurers can – and most do – impose limits on the number of visits. So your plan might cover a maximum of 20 physical therapy visits in a given year, as long as the therapy is determined to be medically necessary. In some states, the visit limit applies to a combination of different therapies, including physical therapy, speech therapy, and occupational therapy, while other states have separate limits for each type of therapy.
Insurers can also impose other limits on physical therapy, if the benchmark plan includes those limits. For example, In New York, the state has designated an Oxford EPO small group plan as the benchmark. It includes up to 60 annual visits per condition for speech, occupational, or physical therapy. But it notes that all three types of therapy are “only covered following a hospital stay or surgery.” So in New York, insurers offering individual and small group health insurance are not required to cover physical, occupational, or speech therapy if the patient has not had a hospital stay or a surgery.
But this varies from state to state. In Colorado, the benchmark plan limits physical therapy to just 20 visits per year, but it notes that PT is “covered if, in the judgment of a Plan Physician, significant improvement is achievable within a two-month period.” So individual and small group plans in Colorado cannot stipulate that physical therapy is covered only if the patient had a prior hospital stay or surgery. (Note that Colorado’s benchmark plan has undergone some changes as of 2023, including new coverage for acupuncture, but nothing has changed about the physical therapy benefits.)
As always, ask a lot of questions of your health plan about what’s covered and to what extent.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
