Understanding How Insurance Works: Active Care vs. Maintenance/Wellness Care

Trying to understand how your health insurance works can be like learning a foreign language! This post aims to help you understand how your insurance treats services like Chiropractic and Acupuncture.

If you have health insurance, and your benefits include Chiropractic and Acupuncture (which almost all insurers now do!), you may hear terms like "medically necessary", "active care" or "maintenance care". So let's start by defining these terms:

Medically Necessary - According to Medicare.gov, “medically necessary” is defined as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine.” For any of those circumstances, if your condition produces debilitating symptoms or side effects, then it is also considered medically necessary to treat those.

Active Care - This is care/treatment for a health condition or symptoms aimed at providing significant, lasting, or progressive improvement to your condition. Your provider is providing care to either eliminate and resolve your condition, or to stabilize it.

Maintenance/Wellness Care - Once you have reached the point where your condition is resolved or stable (you may still have some pain or symptoms, but the condition has stabilized and not expected to further improve/change), your health insurance plan will no longer cover additional treatments. They consider the "active/medically necessary" phase of care completed. However, if you suffer a new injury or complaint, or have a flare-up of your existing condition, you move back into "active care," which IS covered under your insurance again.

So the good news is that active care is covered under insurance plans! The amount or length of treatment that is covered by insurance is not necessarily determined by the number of visits or types of treatment, unless your plan has specific limitations (such as only covering 12 chiropractic visits per year, or only covering spinal adjusting). Be aware, some plans only cover certain conditions as well, so it's important to call your insurer and be educated. Found out that your specific condition is not covered? Improving your health and well-being is important, and we offer affordable cash rates so you can get the care you need.

Maintenance/Wellness Care is an important part of keeping your condition improved and you healthy, and your provider will determine with you how often your wellness visits should take place. You can continue to receive this important care on a cash/out-of-pocket basis. Our clinic makes this affordable by offering cash rates that are in line with what most co-pays are.

Knowing the terminology surrounding care, and what your specific benefits are, is important in helping to determine what your financial responsibilities may be with care. It is also important to get the care you need in order to be healthy, happy, and live a fully functional life! Please visit the Insurance page on our website or call us at 651-232-6830 if you have questions.