Medicare Advantage (MA) HMO members have coverage for Original Medicare-covered chiropractic benefits of manual manipulation of the spine to correct subluxation of an acute condition. Prior authorization may be required, except in an emergency. Maintenance care is not considered by Medicare to be medically reasonable and necessary, and is not covered. For MA PPO members, authorization is not required for out-of-network services; however, the services must meet the requirements indicated in the Coverage Criteria section. Enrollees may also self-refer for out-of-network coverage.

Health Net and its delegated participating physician groups (PPGs) apply Medicare's coverage criteria when determining whether a referral to a chiropractor (or equivalent manipulative practitioner) is warranted.

A chiropractor may use an X-ray or other diagnostic test, performed for diagnostic purposes, to demonstrate medical necessity before commencing treatment; however, these diagnostic tests or X-rays are not covered when ordered, taken or interpreted by a chiropractor. Therefore, if the existence of subluxation is not known, an evaluation to determine subluxation should be considered prior to issuing a denial of chiropractic treatment.

Coverage for chiropractic services is limited to those services performed by a doctor of chiropractic, osteopathy or medicine licensed by the state of California.

The primary diagnosis for chiropractic coverage must be subluxation. Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact. A subluxation may be demonstrated by an X-ray or physical examination.

Chiropractors must use the acute treatment (AT) modifier when billing chiropractic claims (CPT codes 98940, 98941, 98942) to identify services that are active/corrective treatment of acute or chronic subluxation, which are covered Original Medicare benefits.

Physical therapy is not equivalent therapy. Physical therapists cannot perform manual manipulation of the spine, which is the extent of Original Medicare-covered chiropractic services covered under the member's medical benefits.

Coverage for routine chiropractic services (non-Medicare covered services) is available to some Health Net HMO Medicare Advantage (MA) members as part of the Optional Supplemental Benefits Package or in some plans as a core supplemental benefit. Employer groups may purchase additional chiropractic care benefits through American Specialty Health Plans, Inc. (ASH Plans). All members with supplemental coverage must obtain routine services through ASH Plans' network of contracting chiropractors in accordance with the requirements of the Optional Supplemental Benefits Package.

Routine chiropractic services are covered as part of the Optional Supplemental Benefits Package (s) administered by American Specialty Health Plans, Inc. (ASH Plans). Some members under an individual MA plan or the employer group have the option to purchase the benefits package for a monthly premium in addition to the member's monthly plan premium. Benefits and premiums vary by plan. Providers should refer to the member's Evidence of Coverage (EOC) to confirm specific coverage information exclusions, limitations and cost-sharing.

The Optional Supplemental Benefits Package may also include coverage for supplemental acupuncture and FitOn Health. Acupuncture benefits are administered by ASH.

Members may self-refer to an ASH Plans participating provider for an initial examination. Subsequent visits and treatment require approval by ASH Plans.

The following is a list of exclusions and limitations applicable to the ASH Plans program for MA members. These benefits and services are not covered: