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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

$20 copayment or 50% of total cost of service, whichever is less

Non-Network

40% coinsurance after deductible

Copayment covers office visit only. Lab, X-ray or other services associated with the visit apply to deductible and out-of-pocket maximum.

Chiropractic manipulation and adjunct therapeutic procedures/modalities (e.g., mobilization, therapeutic exercise, traction) are considered medically necessary when all of the following conditions are met:

  • A neuromusculoskeletal condition is diagnosed that may be relieved by standard chiropractic treatment in order to restore optimal function; and
  • Chiropractic care is being performed by a licensed doctor of chiropractic who is practicing within the scope of his/her license as defined by state law; and
  • The individual is involved in a treatment program that clearly documents all of the following:
    • A prescribed treatment program that is expected to result in significant therapeutic improvement over a clearly defined period of time;
    • The symptoms being treated;
    • Diagnostic procedures and results;
    • Frequency, duration and results of planned treatment modalities;
    • Anticipated length of treatment plan with identification of quantifiable, attainable short-term and long-term goals;
    • Demonstrated progress toward significant functional gains and/or improved activity tolerances.

Following previous successful treatment with chiropractic care, MCHCP covers chiropractic manipulation and adjunct therapeutic procedures/modalities (e.g., mobilization, therapeutic exercise, traction) as medically necessary for an acute exacerbation or re-injury when ALL of the following criteria are met:

  • The individual reached maximal therapeutic benefit with prior chiropractic treatment;
  • The individual was compliant with a self-directed home care program;
  • Significant therapeutic improvement is expected with continued treatment;
  • The anticipated length of treatment is expected to be short-term (i.e., no more than six visits within a three-week period).

Preauthorization by medical plan required for any services after twenty-six (26) visits annually.


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