Frequently Asked Questions: insurance and billing

Our clinic’s services fall under three benefit categories: 

• Specialist office visit: This category applies to new patient visits or re-examination visits.
• Chiropractic/spinal manipulations: This category exclusively covers chiropractic adjustments or spinal manipulations and adjustments. Occasionally, this benefit may also be shared with other alternative care benefits, such as acupuncture or massage therapy. For more information, see the “What does chiropractic benefit cover” section.
• Outpatient rehabilitation (physical therapy): This includes physical therapy activities and exercises, soft tissue manipulations, and manual or massage therapy provided at our clinic. It also covers services not rendered at our clinic, such as occupational and speech therapy. Visits with providers offering services under this category (e.g., physical therapists) will count toward any visit or payment limitations associated with it.

Coverage for chiropractic benefits depends on your insurance plan. Many plans specify that chiropractic benefits only apply to spinal manipulations or adjustments. Other plans may cover all services provided by a chiropractor under the chiropractic benefit, regardless of the type of service. If the plan covers benefits by service type, any cost shares will apply to the specific services performed.

Most commonly, we find that chiropractic benefits cover only chiropractic adjustments or spinal manipulations, and services such as massage therapy or soft tissue manipulations are covered under the physical therapy benefit. Our insurance specialist will review your plan before your first appointment to determine how your insurance will cover treatment provided at our clinic. 

When determining if we accept your insurance, there are three key tiers to consider: in-network, out-of-network, and plans we do not accept.

In-network vs. out-of-network:

• In-network. We have negotiated rates with these insurance companies which means lower costs for you. It is generally best to use an in-network provider for the best rates. 
• Out-of-network. Our providers are not contracted with your insurance company, leading to higher rates for services. Benefits are less comprehensive or may not be available.

Contact us directly for current information on our network status with your insurance company. We can provide up-to-date details on our status with specific plans and how different treatment codes apply.

Insurance companies we are in network with accept: 

• BlueCross Blue Shield (Regence) 
• Moda Health
• PacificSource 
• Providence Health Plans 

If your plan is not listed above, we are out-of-network with those insurers.

Insurance plans we do not accept: 

• Health Net
• TriCare 
• Kaiser 
• Medicaid
• Oregon Health Plan (OHP) 
• Cigna 
• International Longshore and Warehouse Union (ILWU) plan through First Choice Health Network

Medicare has specific conditions for chiropractic services. According to their guidelines:

• Medicare Part B covers spinal manipulation by a chiropractor to correct vertebral subluxations (when spinal joints don’t move properly but remain in contact).
• Medicare does not cover other services or tests ordered by a chiropractor, including X-rays, massage therapy, and acupuncture.

We are not contracted with Medicare and do not accept their payment conditions, meaning we are out-of-network. Generally, we do not bill directly to Medicare. However, if you prefer, we can attempt to submit bills to Medicare. Any payments from Medicare would be made directly to you, and you would need to pay Hosmer Chiropractic Health out-of-pocket initially. You can choose the best financial option for you on our Advanced Beneficiary Notice.

Medicare Advantage Plan:
These plans are offered by private companies and include Part A, Part B, and usually Part D. They must cover all medically necessary services that Original Medicare covers and may include additional benefits like vision, hearing, and dental services.

Coverage for chiropractic services under Medicare Advantage plans can vary. For 2024, we will check if your specific plan offers coverage for our services. Note that claims processing might differ from what we expect.

Medicare Supplemental Plan (Medigap):
Medigap policies help cover out-of-pocket costs like copays and deductibles not covered by Original Medicare. These plans are standardized and typically only accepted by providers who are contracted with Medicare.

Since we are not contracted with Medicare, we do not offer coverage for Medicare Supplemental plans.

For any questions about coverage or to check if your Medicare Advantage plan offers chiropractic services, please contact our insurance specialist.

A deductible is the amount of money you must pay out-of-pocket before your insurance begins to cover your expenses. The deductible amount can vary depending on the type of insurance, coverage level, and other factors.

Each person on a plan has their own individual deductible to meet. If the plan includes family-level benefits, there may also be a family deductible. Contributions made toward an individual deductible also count toward the family deductible. Once the family deductible is met, individual deductibles no longer need to be met.

Contracted, or in-network, providers have negotiated lower rates with your insurance plan, while non-contracted, or out-of-network, providers have not. Generally, seeing an in-network provider will give you the best rates for care.

Out-of-network providers typically have higher rates, and their services may not be covered by your plan. In-network providers usually have lower deductibles, while out-of-network providers often come with higher deductibles.

An out-of-pocket maximum is the amount your insurance caps your financial responsibility at. Once this amount is reached, your medical care will be covered at 100% for the rest of the year.

Like deductibles, there are both individual and family out-of-pocket maximums. If a plan includes family-level benefits, any individual contributions will also count toward the total family maximum. Once a family out-of-pocket maximum is met, individual out-of-pocket costs no longer need to be met.

If you have two insurance plans, you might think, “Great, I’ll never have a bill for my medical care! The two plans will cancel each other out, right?” The reality is, it’s not that straightforward. Unique billing situations, especially involving deductibles, can make this more complex.

With primary and secondary billing, your medical costs are billed to your primary insurance first. Any amount not covered by your primary plan is then sent to your secondary insurance. If your primary plan has a deductible but your secondary plan does not, the secondary plan may cover those costs. However, you will still be responsible for any copays or coinsurance.

What if both your primary and secondary insurance plans have deductibles? In this scenario, you’ll need to meet your primary deductible first. Once that’s covered, you may then need to meet your secondary deductible before you pay any copays or coinsurance. If either your primary or secondary plans don’t have deductibles, or if the deductibles are already met, you generally won’t have any additional out-of-pocket costs for your medical care.

As outlined in the “Benefit categories we bill to” section, our clinic bills for service under three main categories: Specialist Office Visit, Chiropractic, and Physical Therapy. If your insurance plan separates the services we provide, they will be categorized accordingly.

Treatments involving the spinal column are considered chiropractic care, while soft tissue work or adjustments not directly on the spinal column are classified as physical therapy by your insurance. 

The Specialist Office Visit category applies only to new patient appointments or re-examination appointments.

For both chiropractic and physical therapy benefits, there are typically limits on the number of visits covered per year. Insurance policies often feature "hard visit limits" and "soft visit limits." A soft visit limit allows for a set number of visits before additional visits can be requested, with the possibility of extending this number depending on the plan.

A hard visit limit is a fixed number of visits. Once this limit is reached, no additional visits are covered until the next year. Most insurance policies have hard visit limits, though there may be a separate process for requesting additional visits if certain criteria are met, such as post-accident care or recovery from surgery. This special process generally does not apply to services rendered at our clinic.

One of the most common questions about health insurance benefits is, “How much do I owe?” This depends on your plan details, but typically, you may need to pay either a copay, coinsurance, or a combination of both, after any deductible has been met.

A copay is a fixed dollar amount you pay for each applicable service. Insurance plans usually require one copay per appointment, often based on the highest amount for the services provided. For example, if you have a $45 copay for a new patient exam, a $25 copay for spinal manipulations, and a $35 copay for physical therapy, the copay for a new patient appointment would be $45.

Coinsurance, on the other hand, is a percentage of the treatment cost. Estimating costs can be challenging because it depends on the final insurance claim processing. Unlike copays, which are a flat amount, coinsurance percentages apply to each service performed, and this can vary from appointment to appointment. As well, each benefit may have a different coinsurance rate.

As an alternative to billing your insurance plan, we offer a flat-rate discount program through ChiroHealthUSA (CHUSA). To enroll, there is a one-time fee of $49, and the enrollment is valid for one year. Under this program, a new patient chiropractic appointment is $250, follow-up visits are $125, and massage appointments are $115. For more information, visit ChiroHealthUSA.

If you are working to meet your deductible, we will collect a portion of your total bill at the time of service, and will invoice you for the remaining balance after your insurance claims have been processed. We follow CHUSA rates when collecting deductible amounts at the time of service: For a new patient appointment, we collect $250; for a re-examination appointment, $175; for follow-up visits, $125; and for massage visits, $115. The estimated remaining balance will vary based on your insurance plan.

Prior authorization is a process required by insurance companies to approve medical necessity before certain types of care can be performed. This process is usually handled by a third-party company hired by the insurance plan to assist with the review. 

The conditions for approval, documentation, and the number of visits granted can vary depending on the insurance plan and third-party company involved. 

The good news is that if we don’t tell you about a prior authorization requirement, your insurance doesn't require one!

A medical necessity review is a process required by  insurance companies to ensure that services provided are medically necessary. Like prior authorizations, the conditions for approval can vary widely depending on the plan. If you don’t hear from us about a medical necessity review, it usually means everything is proceeding smoothly!

All services billed to health insurance at our clinic are processed under our chiropractors’ licenses, including massage therapy. If you wish to have massage therapy services provided at our clinic to be billed to your insurance, you must first establish care with one of our chiropractors to determine medical necessity, and to establish a treatment plan.

Insurance plans typically operate on a calendar-year basis, meaning coverage starts on January 1st and ends on December 31st each year. If you exhaust your benefits before December 31st, they will not reset until January 1st of the following year.

Contract year plans, on the other hand, follow a schedule predetermined by your plan. For example, a plan might start on October 1st and end on September 30th of the following year. Similar to calendar year plans, if you exhaust your benefits before the end of the contract year, they will not reset until the beginning of the next contract year.