There are few things more frustrating than finding a health care treatment that works for you — a chiropractic adjustment that relieves nagging lower back pain or a yoga class that helps reduce anxiety — only to find that your insurance won't pay for it.
But this is often the case when using products and services deemed "alternative" or "complementary medicine."
Most individuals with private insurance have little, if any, coverage for alternative medicine. Those with employer-based insurance often have some coverage, but it typically applies only to a few select treatments and comes with more stipulations — like higher deductibles and preauthorization — than traditional care.
This is in spite of the fact that alternative medicine is rapidly moving into the mainstream. Americans spend more than $33 billion annually on complementary treatments, amounting to just over 11% of the total out-of-pocket health care spending in the United States, according to the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health.
Much of this spending likely comes from people who are insured.
"Folks who have had really good insurance expect that all kinds of treatments will be covered," said Janet Shaffer, a licensed acupuncturist at Duke Integrative Medicine in Durham, N.C., which is affiliated with Duke University. "People often end up disappointed."
What is covered varies according to a number of different factors, including the employer, the insurance provider and even geography.
At Blue Shield of California, most of the PPO plans include some chiropractic and acupuncture coverage, said Julie Lintz, the company's senior network management specialist in San Francisco. The company began offering chiropractic benefits about 25 years ago and has added coverage for other non-traditional services as demand has grown.
"Customers have increasingly asked for alternative benefits," she said. "Being proactive about staying healthy is important in keeping costs down."
Across the board, the alternative treatments insurers are most likely to cover are chiropractic, acupuncture and massage therapy, all of which have been validated by medical studies.
"The common factor for chiropractic, massage and acupuncture is that there is evidence that these have therapeutic value for certain conditions," says Mark Slitt, a spokesman for Cigna Corp. in Bloomfield, Conn.
The Cigna plans that cover chiropractic care do so for most conditions. Those with acupuncture coverage only provide it in some cases, such as to treat chronic pain and nausea related to chemotherapy or pregnancy. Cigna also covers massage therapy when used in conjunction with another approved treatment for chronic pain or physical therapy.
Other, lesser-known therapies are not covered because there is no "proven evidence of therapeutic value," Slitt says.
Aetna Inc. covers the same three services on some of its plans, with similar stipulations, says spokeswoman Anjie Coplin.
For members of Kaiser Permanente's health maintenance organization, complementary and alternative treatments typically aren't covered under employer-sponsored and individual plans. If an employer chooses, they can add a supplemental plan to their coverage for services like chiropractic or acupuncture. Otherwise, a treatment is only covered if it is ordered by a primary care physician, which does not happen frequently, according to Jim Anderson, a Kaiser spokesperson in Oakland.
Like other insurers, Blue Shield requires its providers to go through a credentialing process. Credentialing for PPO network providers is handled in-house; for HMO providers, it is taken care of by a company called American Specialty Health Inc., a specialty benefit plan provider that works with many insurers.
American Specialty ensures that all providers have proper education, a valid license, and haven't been hit with state sanctions or malpractice claims, according to Douglas Metz, the company's chief health services officer.
Insurance companies sometimes offer their members discounts for alternative medicine, even when the treatments aren't covered as part of their plans.
For instance, Blue Shield offers a 25% discount for services such as massage therapy, chiropractic adjustments and acupuncture as long as they are offered through the American Specialty network. They also offer discounts of up to 40% on vitamins and natural supplements, fitness and yoga equipment, health books and DVDs.
Aetna customers can get discounts of at least 25% for chiropractic visits and other treatments. Through an Aetna website, they can buy more than 2,400 health-related products — including aromatherapy, homeopathic remedies and herbal supplements — at reduced cost.
Cigna Healthy Rewards program gives members discounts on natural supplements, subscriptions to Yoga Journal, and other products and services, Slitt says.