By Mark A. Knoll, DC Chief Medical Officer
Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. The Medicaid and Medicare programs became law in 1965. Medicaid is administered by the states, according to federal requirements, and is funded jointly by the states and federal government. As of July 2020, Medicaid enrollment is estimated at 68.8 million people. Chiropractic coverage under Medicaid traditionally has been very limited. Expansion is a worthy endeavor as many children and adults can benefit from all the services that doctors of chiropractic have to offer.
In 2016, SecureCare and the Nebraska Chiropractic Physicians Association made the decision to actively pursue Medicaid expansion for chiropractic benefits in Nebraska. The process began by researching current benefits across the country. Information was difficult to come by, but based on my findings, only 30 states had some level of coverage. Twenty states had no coverage for chiropractic at all. At that time, Nebraska’s coverage was 12 annual CMT (Chiropractic Manipulative Therapy) visits for adults and 18 CMT visits per diagnosis for children. There was also coverage for x-rays and a small payment for the initial evaluation. Eleven states had coverage that exceeded Nebraska.
Nebraska Medicaid is currently administered by three managed care organizations (MCO’s): Healthy Blue (formerly WellCare), Centene (Nebraska Total Care), and UnitedHealthcare. Bids for these contracts occur every three years and the MCO’s administer benefits which have been developed by the state of Nebraska and the Department of Health and Human Services. MCO’s can choose to exceed the coverage by the state plan, but in Nebraska, we did not have any success in this area. Therefore, our only recourse was to make changes at the state level.
Initially, we scheduled a meeting with the director of Medicaid and Long-Term Care (MLTC), someone with decision-making authority for this project. In addition to myself, our meeting participants included the executive director of the Nebraska Chiropractic Physicians Association and legal counsel. Our initial meetings were minimally productive. They provided us with data for analysis which aided us in discussions regarding the cost-effectiveness of chiropractic. During this project, we met with two department directors and an interim director. A keyword to keep in mind is persistence, persistence, persistence. These types of changes take time.
After several meetings, we made the decision to develop an evidence-based presentation that included important topics related to the use of chiropractic services:
- Cost-effectiveness
- Reduction of opioid use
- Lack of parity between chiropractic and physical therapy coverage
Many times, with these projects, important events occur which are out of our control. One such event was the hiring of a new Nebraska director of MLTC, Matthew Van Patton, DHA. He really understood and supported our goals. Lou Andersen, our CEO, as well as Dr. Brad Stauffer and others, did a terrific job of presenting to Dr. Matthew Van Patton, helping him to understand the benefits of expanding conservative care in managing overall health care costs. After our meeting with Dr. Van Patton, he asked for copies of all the studies which supported our presentation. This really got the ball rolling to move this project along and a verbal agreement was made to enact Medicaid benefits for chiropractic administratively.
Simultaneously, with our approach of implementing these administrative changes, Dr. Brad Stauffer and our legal counsel, began conversations with Nebraska State Senator, Sue Crawford to introduce legislation regarding the expansion of chiropractic benefits. As a result, Senator Crawford became very knowledgeable about the goals and benefits behind this project and was a champion in moving it forward. Once a legislative bill was introduced, the process moved forward. However, having legislative support was a major factor in getting this over the finish line.
Expanded chiropractic benefits for Nebraska now include the following:
- Treatment for patients of all ages is limited to those treatments deemed medically necessary
- Visit limits are no longer in place
- The following CPT codes are now covered:
- E/M: 99201, 99202, 99203, 99211, 99212, 99213
- Radiology: 72040, 72070, 72081, 72082, 72100
- CMT: 98940, 98941, 98942 and
- Therapy: 97012, 97014, 97032, 97035, 97110, 97112, 97140, 97530
In all, it took four years to complete this process, but it was well worth the time and resources involved. In our opinion, Nebraska now has the best chiropractic Medicaid benefits of any state in the country. Many people were responsible for the success of this project and we are very thankful for your contributions. We are hopeful that the re-telling of our success will spur other states to take similar steps for expansion in their states. We are happy to share our presentation and studies with you and give you guidance. Further expansion in this area will only serve to benefit the entire chiropractic profession.