• Overview
  • Forms of Treatment
  • Prevalence and Use in the U.S.
  • Costs and Coverage
  • Licensure and Credentials
  • Transmission of Chinese Medical Thought
  • East Asian Medical Theory and Diagnosis
• Interventions
  • Acupuncture
  • Chinese Herbal Medicine
  • Meditative Exercises
• Conditions
  • Acupuncture and Smoking Cessation
  • Acupuncture in the Treatment of Hypertension
  • Tai Chi and Cardiovascular Health

Insurance Costs and Coverage

With East Asian Medicine (EAM), as with conventional medicine, there are two primary ways consumers pay for care.

1. Out-of-pocket payment. Most consumers must pay for East Asian medical services and therapeutic products themselves.

2. Health Insurance. Some health insurance plans offer some coverage for acupuncture, and a few cover services and products for Chinese Herbal Medicine. While generally limited, coverage does vary considerably from state to state.  In addition to health plans, some state workers’ compensation programs and personal injury protection insurance, e.g., automobile insurance, cover acupuncture services. 

While current coverage for acupuncture and EAM is limited, reimbursement for these services is becoming more available and is appearing on a disease-based occurrence.  As of March 2004, the Massachusetts Department of Industrial Accidents (Workers’ Compensation) produced guidelines for treatment and coverage of up to 16 acupuncture treatments.

There is no one central resource that collects information about insurance coverage across the US.  To determine coverage, patients should consult their health insurance plan.  For more information see Paying for CAM Treatment (National Center for Complementary and Alternative Medicine, CAM Basics). [1] As with any service covered by a health insurance plan, patients may need a referral from their primary care physician, co-payments may be required, only specific diagnoses may be covered, and practitioners may be required to have specific credentials.

A survey conducted in 1999-2000 identified that the five most influential factors for managed care organizations and insurance companies that determined whether they would offer coverage for complementary and alternative (CAM) services included: market research, retention of existing enrollees, demand from consumers, attraction of new enrollees, and demand from purchasers (employers). [2]  This report also noted that eight US states have state-mandated reimbursements for CAM providers including acupuncture.

Assessment of Reported Coverage

In recent years, managed care organizations have begun advertising expanded coverage for CAM services.  While the expectation of coverage is building, there is conflicting information regarding actual services covered.  A 1999 survey of Medicaid reimbursement specialists throughout the United States identified 7 of 47 states surveyed offer coverage for acupuncture; 2 of these 7 also offer some coverage for herbal products. [3]  An earlier study conducted in 1997 by Cooper, et. al. [4] reported that no state Medicaid programs cover acupuncture services.  There are a number of sources for this apparent confusion regarding coverage: information reported is frequently at summary level and does not specify disease entities, actual services, or type of treatments covered.  Summary data describing general insurance coverage for CAM services is affected by the inclusion of chiropractic as a CAM therapy and  chiropractic is covered by most managed care and insurance organizations surveyed. [3], [4], [5]

Further, the report of the 1999 study notes that their findings “bring in to question how one can follow coverage trends for CAM practitioners by stated Medicaid programs without accessing primary data sources… [as] many CAM providers do not use ICD-9 or E&M codes and many therapies do not have codes associated with them.” [3]  Massachusetts is one of the seven states noted in the 1999 survey that provides public funds for acupuncture services; these funds support acupuncture used in substance abuse programs at a select number of venues.  Covered treatments consist of a standardized 5 needle auricular acupuncture protocol.  Patients are not diagnosed using East Asian Medicine diagnoses nor are treatment plans developed for each patient (for more information see www.acudetox.com and the smoking cessation case study on this website). Thus, confounding factors include the use of summary data and lack of specificity regarding actual coverage. Looking more closely at the individual insurance plans and types of coverage lends a better understanding.

Fees and Costs

In urban areas of the US, an average fee for a one-hour acupuncture session for a returning patient falls in the range of $60-85; fees for initial visits including an intake and acupuncture treatment are $90-120 (personal correspondence June 2004 with David Molony of the American Association of Oriental Medicine - AAOM).

As with pharmaceuticals, Chinese Herbal Medicine costs and fees vary based on the price of the substance as well as on the form (e.g., pills, concentrated powders, or bulk herbs) and dosage administered.  Patients may be charged dispensing/ compounding fees, herb product costs, and consultation fees. Consultation fees are charged particularly if the patient is not receiving acupuncture at the same visit.  Average fees for Chinese Herbal Medicine in metropolitan areas of the US range from $15-30 per week (personal correspondence, AAOM).

Numerous studies have called for further evaluation of acupuncture’s cost effectiveness. [6], [7] A 2004 article concluded that acupuncture for chronic headache improves health-related quality of life at a small additional cost; it is relatively cost effective compared with a number of other interventions provided by the National Health Service (NHS). [8]  In a separate study, the cost effectiveness of acupuncture for persistent back pain remained unclear. Although appearing to be relatively safe, preliminary evidence suggested that massage, but not acupuncture or spinal manipulation, may reduce the cost of care after an initial course of therapy. [9]  As with the 2004 Massachusetts extension of Workers’ Compensation coverage for the treatment of carpal tunnel syndrome with acupuncture, cost effectiveness will likely continue to be assessed by disease-entity.

Reduced Fee Services

Throughout the United States there are public health initiatives offering CAM services.  In the New England area, one such organization is Pathways to Wellness, the sponsoring organization of the AIDS Care Project, see http://www.pathwaysboston.org/.

Beyond privately funded public health initiatives, free or low-cost acupuncture clinics are frequently hosted by local acupuncture colleges.  In the Boston area, patients can be treated by third-year students from the New England School of Acupuncture, which hosts acupuncture and Chinese Herbal Medicine clinics throughout the area, see  www.nesa.edu/nesa_clinic.html.

Detox clinics are available to patients participating in drug addiction programs.  For Boston area acupuncture clinics participating in substance abuse treatment see http://www.nesa.edu/library/kelly_AOMorgs.htm#Detox.

University student services may include acupuncture services. For example, see Oregon State University Student Health Services.

If a patient receives care at a hospital or clinic, that facility may have a social worker or patient advocate who can advise the patient regarding area resources relating to East Asian Medicine services.