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READ: The Answers to Ten FAQ’s about Medicare

Updated: Jan 25


AHM Coalition logo featuring a yin-yang symbol with an acupuncture needle and a green leaf, surrounded by the text 'AHM Coalition' and affiliated organizations: NCCAOM, ACAHM, ASA, and CCAHM.

The ASA Webinar about Medicare Inclusion Strategy 2025 was held on Wednesday, Jan 22, 2025.


The American Society of Acupuncturists (ASA) has created a Medicare Top Ten FAQ. It addresses key topics such as what Medicare covers, how acupuncture fits into the system, and what these changes mean for your practice and your patients. You can re-watch the Town Hall by clicking the link below or HERE.



Acupuncturists and Medicare

Frequently Asked Questions Provided by ASA

Background

Medicare is a federal health insurance program for people who are 65 and older, as well as

those with disabilities and certain significant medical conditions. It is administered federally,

and recognition of provider groups requires an act of Congress to amend the Social Security

Act (SSA).


The Centers for Medicare and Medicaid Services (CMS) began covering acupuncture services for chronic lower back pain in January 2020. CMS Decision Memo For Acupuncture For Chronic Lower Back Pain. Prior to this decision, Medicare did not cover any form of

acupuncture.

1. Are LAc’s currently Medicare providers?

No. Licensed Acupuncturists (LAc’s) are not currently listed as a Medicare provider type in the SSA.

2. Can LAc’s become Medicare providers?

Yes. An act of Congress to amend the SSA would add LAc’s as providers under Medicare.


This is the purpose of the Acupuncture for Our Seniors Act (formerly H.R. 4803, H.R.

3133) and the soon-to-be reintroduced 2025 version with a distinct new bill number.

3. If the Acupuncture for our Seniors Act becomes law, do I have to enroll in Medicare?

No. All LAc’s will have a choice once the profession receives Medicare recognition.


If you DO ENROLL as a Medicare provider, you:

● Have the option to become either a Participating or Non-Participating provider.

○ Participating Providers “agree to accept claims assignment for all Medicare-covered services to your patients. By accepting assignment, Participating Providers agree to accept Medicare-allowed amounts as payment in full and may not collect more from the patient than the Medicare deductible and coinsurance or copayment.

○ Non-Participating Providers accept Medicare assignments on a case-by-case basis and can charge 15-percent more than Medicare’s reimbursement rate, but are reimbursed at 95 percent of Medicare’s determined rate.

  • Learn more about Participating and Non-Participating options from CMS.

  • Would only bill Medicare for covered conditions and services and would be allowed to collect cash for any diagnosis or services that Medicare does not cover. At this time, Medicare only covers acupuncture services for chronic lower back pain.

  • Both Participating and Non-Participating providers can treat Medicare Advantage Members.


If you DO NOT ENROLL (aka “Opt-out”) as a Medicare provider, you:

  • Choose NOT to be involved in any Medicare program, including original fee-for-service Medicare and Medicare Advantage Plans.

  • Can only see Medicare patients under a private contract where the patient is fully responsible for the cost of treatment and no Medicare claims can be submitted for those services.

  • Providers can opt-out of Medicare for two-year periods, but can continuously opt-out every two years.

4. Would an “Opt-out” Option be Guaranteed for LAc’s once recognized by Medicare?

Yes. All providers defined as Medicare “Practitioners” have the right to opt-out of Medicare.


The Acupuncture for our Seniors Act defines LAc’s as Medicare “Practitioners,” which would automatically grant all LAc’s opt-out privileges.


Here is the CMS “opt-out” explanation.


The most recent group to obtain “Practitioner” status is the LMFC group - Licensed Marriage and Family Therapists who became Medicare Providers in 2022. NOTE: No group requesting Medicare provider status has ever been assigned a different one, hence our bill request will not be changed. Once LAc’s become providers, we will be able to opt in or out, just like LMFCs and all other Medicare providers.

5. If added to the Social Security Act as Medicare Practitioners, could LAc's bill Medicare?

Yes. If added as providers under Medicare, LAc’s would be able to bill Medicare directly.


Q 5.1 What services will Medicare pay for?

As of January 2025, Medicare reimburses for the following CPT codes: 97810, 97811,

97813, 97814, 20560, and 20561. Medicare patients would pay for all other services out

of pocket.


Q 5.2. What are the current reimbursement rates for 97810, 97811, 97813, 97814, 20560, 20561?


Fee schedules vary by state and state regions, and are based on RVUs calculation of

several factors. The CMS Fee Schedule Search can be found here.


The current national average fee schedule for acupuncture services (effective 1/1/2025)

97810: $44.64

97811: $25.55

97813: $51.43

97814: $28.79

20560: $24.58

20561: $35.90

6. Can LAc’s currently use Medicare’s 1490 S reimbursement form to enable Medicare beneficiaries to pay them directly?

The 1490 S reimbursement form is available ONLY to Medicare-recognized providers . When LAc’s become providers under Medicare, LAc’s can choose to opt out and have patients private pay and be reimbursed directly through the 1490S form.


HERE is a copy of the 1490S Form

7. Will Electronic Health Records (EHR) be required if I am a Medicare provider?

No. Mandatory use of EHR is not a requirement for Medicare enrolled providers unless they meet ALL of the following criteria:


Low Volume Threshold Criteria (SOURCE)

  • Bill more than $90,000 in Medicare Part B covered professional services; AND

  • See more than 200 Medicare Part B patients; AND

  • Provide more than 200 covered professional services to Medicare Part B patients

8. If Chiropractors can’t opt-out, why would LAc’s be able to?

Chiropractors and LAc’s took two very different and distinct paths toward Medicare recognition. Chiropractors have pursued "Physician" status under the Medicare program, and do not have the ability to opt-out of the Medicare program. LAc’s are seeking "Practitioner" status, which guarantees the ability to opt out of the Medicare program.

9. How will Acupuncture for Our Seniors Act impact LAc’s after becoming providers?”

The acupuncture profession currently has a seat at the AMA CPT HCPAC Committee, which creates and manages CPT codes. Once recognized as Medicare providers, acupuncturists, will have a voice on the AMA RUC (Relative Value Scale Update Committee), which assigns reimbursement value to CPT codes and services.

10. Have LAc’s benefited from acupuncture being covered under Medicare?


Explore More: Past Town Halls and FAQs on Medicare, Medicaid, and Acupuncture


If you're looking for even more insights on Medicare, Medicaid, and acupuncture, check out the previous town halls and their accompanying FAQs. These sessions cover important topics and answer common questions, providing valuable information.


  • What Medicare and Medicaid Can Do for the Acupuncture Profession October 30, 2024 Q&A pdf HERE

  • AHM Coalition Town Hall October 24, 2024 Q&A pdf HERE

You can re-watch all Town Halls by clicking HERE.


Joining your state association supports local, state, and national efforts to present the profession as subject matter experts of acupuncture while improving standards of education, practice, doctorate programs, continuing education, credentialing, and privileging.







 
 
 

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