Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

SEPTEMBER 1998 

OEI-06-97-00480 

CHIROPRACTIC CARE 

Medicaid Coverage 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 

protect the integrity of the Department of Health and Human Services programs as well as the 

health and welfare of beneficiaries served by them. This statutory mission is carried out through a 

nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The 

Inspector General informs the Secretary of program and management problems and recommends 

legislative, regulatory, and operational approaches to correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 

Inspector General. It conducts short-term management and program evaluations (called 

inspections) that focus on issues of concern to the Department, the Congress, and the public. The 

inspection reports provide findings and recommendations on the efficiency, vulnerability, and 

effectiveness of departmental programs. 

OEI's Dallas Regional Office prepared this report under the direction of Chester B. Slaughter, 

Regional Inspector General. Principal OEI staff included: 

REGION HEADQUARTERS 

Clark Thomas Alan Levine 

Nancy Watts Barbara Tedesco 

Lisa White 

To obtain copies of this report, please call the Dallas Regional Office at (214) 767-3310. 

Reports are also available on the World Wide Web at our home page address: 

http://www.dhhs.gov/progorg/oei 
EXECUTIVE SUMMARY

PURPOSE 

To determine and describe the current and anticipated chiropractic care benefits provided under 

each State Medicaid program. 

BACKGROUND 

Recent changes to Medicare chiropractic coverage policy under the Balanced Budget Act of 1997 

require that the Health Care Financing Administration (HCFA) establish, by January 1, 2000, new 

utilization guidelines for Medicare chiropractic care in cases where spinal subluxation has not 

been demonstrated by x-ray. The Balanced Budget Act also eliminates the Medicare requirement 

for supporting x-rays by the year 2000. Additionally, recent changes in New York State law 

require private insurers to include chiropractic coverage in their benefit packages. 

To better understand the impact of these changes on the Medicare and Medicaid programs and to 

learn more about other forms of utilization control, we undertook this inspection resulting in two 

reports. This report, "Chiropractic Care; Medicaid Coverage, (OEI-06-97-00480)" describes 

current and expected chiropractic care benefits under State Medicaid programs. A companion 

report, "Chiropractic Care; Controls Used by Medicare, Medicaid, and Other Payers, (OEI-04-97-

00490)" examines Medicare, Medicaid, and private insurers' mechanisms for controlling 

expenditures and protecting the chiropractic benefit from potential waste and abuse. 

A particular concern in the Medicaid program was whether there were any indications of potential 

explosive growth in the program overall. 

FINDINGS 

Thirty States Report Offering Some Form of Medicaid Chiropractic Benefit Under a Fee-ForService Arrangement. 

Twenty six States cover all categorically needy Medicaid eligible beneficiaries and twenty of these 

extend coverage to those considered to be medically needy but who do not qualify for financial 

assistance. All 30 States provide coverage for children under Early Periodic Screening, Diagnosis 

and Treatment (EPSDT) plans. 

Conditions and Chiropractic Services Which Qualify for Reimbursement Vary by State. 

Twenty States reported they only reimburse manual manipulation of the spine for treatment of 

spinal subluxation. Five States offer additional coverage for the treatment of back pain associated 

with nerve root damage. Eight States report they cover any treatment considered medically 

necessary. 

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States Impose a Variety of Limits on the Number and Duration of Chiropractic Treatments a 

Beneficiary May Receive. 

The number of chiropractic treatments a beneficiary may receive is limited in twenty six States. 

These limits range from one treatment per day to one treatment per year. Some States also limit 

the length of the period within which beneficiaries can receive treatment. 

Twelve States Have Changed the Level of Their Chiropractic Benefit Since 1990. No 

Tendency of General Expansion of Benefits is Evident, However. 

Only two States adopted program changes that only limited their programs over the period. The 

remainder made changes that resulted in both expansions and limits. In some cases, such as 

Louisiana, later changes directly offset earlier ones, while other States expanded to include 

additional beneficiaries while limiting their numbers or duration of treatments. No State reported 

pending plans to expand their fee for service chiropractic benefit. Of the States reporting no 

current coverage, none indicated immediate plans to add a chiropractic benefit, although South 

Carolina reported the issue is under study. 

Chiropractic Care Comprises a Small Proportion of Total State Medicaid Expenditures. No 

Consistent Trends in Expenditures Appear. Some States Experienced Decreasing Costs over 

Time, While Others Saw Only Minor Fluctuations in Expenditure Levels. 

California, Iowa, Maine, Montana, and North Dakota appear to have experienced a slight 

downward trend in chiropractic payments relative to total expenditures between 1994 and 1996, 

while Vermont's expenditures decreased sharply. Louisiana and Indiana saw relatively large 

increases in 1995 which diminished in 1996. With the exception of Louisiana, where limiting 

eligibility to EPSDT beneficiaries likely drove expenditures down sharply between 1995 and 

1996, we are unable to correlate States' expenditure patterns with their reported benefit coverages 

and limits. 

CONCLUSION 

While thirty States offer some form of coverage for chiropractic care under their Medicaid feefor-service plans, State reported utilization data show no discernable trends suggesting explosive 

growth in Medicaid expenditures. Also, no State reported legislative or regulatory plans to 

expand their Medicaid chiropractic benefit beyond current coverage. 

COMMENTS 

The Assistant Secretary for Management and Budget (ASMB) provided comments on this report. 

ASMB asked us to further explain the growth in Medicaid chiropractic expenditures in the State 

of Utah. We provided this information on page eight of this report. The full text of these 

comments appears in Appendix A. 

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TABLE OF CONTENTS

INTRODUCTION .......................................................... 1

FINDINGS ................................................................ 3

! State chiropractic coverage and eligibility .................................... 3

! Limits to coverage ..................................................... 4

! Changes in coverage ................................................... 6

! State expenditures ..................................................... 7

CONCLUSION ............................................................ 9

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INTRODUCTION

PURPOSE 

To determine and describe the current and anticipated chiropractic care benefits provided under 

each State Medicaid program. 

BACKGROUND 

Chiropractic Care 

Traditional chiropractic philosophy holds that the principal cause of disease is a bone out of place 

along the spine. Because nerves branch off the spine between the vertebrae to every part of the 

body, chiropractors theorized that a slight misalignment of the vertebrae could pinch a nerve 

extending to another part of the body causing pain and disease. Relieving that pressure through 

spinal manipulation should, therefore, eliminate or ameliorate the disease. Currently, 

chiropractors are prohibited from prescribing drugs or performing surgery. While some are 

willing to treat problems beyond back pain, many rely on x-rays to locate a kink in the spine that 

may cause the back pain and limit their treatment to that ailment. 

Chiropractors commonly treat patients by manual manipulation of the spine, using either their 

hands or hand held devices to adjust spinal alignment. The Agency for Health Care Policy and 

Research (AHCPR) has found that this method of treatment is effective for patients suffering from 

acute low back problems, especially when used within the first month of symptoms. 

Section 273 of the 1972 Social Security Act Amendments expanded the Medicare definition of 

"physician" to include chiropractors. Expansion of this definition allowed chiropractors to 

participate in the Medicare and Medicaid programs. 

Current Medicaid Coverage 

Coverage of chiropractic care is an optional benefit available to Medicaid beneficiaries 

in some States. Medicaid coverage of chiropractic care is limited to services that are provided by 

a chiropractor licensed by the State and consist of treatment by means of manual manipulation of 

the spine. States may also allow chiropractors to provide and bill for x-ray services, although 

there is no Federal Medicaid requirement that x-rays must be provided before services may be 

reimbursed. The mechanisms used to control expenditures on chiropractic treatments vary among 

the States providing benefits. Several have no restrictions and some simply require that the 

treatment be deemed medically necessary. Others restrict the number of visits or length of 

treatment period. Among these States, the limits range widely as well. 

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Medicare Coverage 

Medicare chiropractic coverage is limited to manual manipulation of the spine to correct a 

subluxation, defined as a functional or structural abnormality involving one or more of the 

vertebrae. Medicare does not pay for spinal manipulations that provide preventative or 

maintenance care. Medicare currently requires an x-ray to determine or demonstrate that a 

subluxation exists. An x-ray for this purpose is covered by Medicare if ordered, taken, and 

interpreted by a physician who is a doctor of medicine or of osteopathy, but not when ordered by 

a chiropractor. In 1996 Medicare allowed charges for chiropractic care totaled more than $294 

million and averaged about $24 per claim. 

Recent changes to Medicare chiropractic coverage policy under the Balanced Budget Act of 1997 

eliminate the requirement for supporting x-rays effective January 1, 2000. The Balanced Budget 

Act also requires that, by the year 2000, the Health Care Financing Administration (HCFA) 

establish new utilization guidelines for Medicare chiropractic care in cases where spinal 

subluxation has not been demonstrated by x-ray. Additionally, recent changes in New York State 

law require private insurers to include chiropractic coverage in their benefit packages. 

To better understand the impact of these changes on the Medicare and Medicaid programs and 

learn more about other forms of utilization control, we undertook this inspection resulting in two 

reports. This report, "Chiropractic Care; Medicaid Coverage, (OEI-06-97-00480)" describes 

current and expected chiropractic care benefits under State Medicaid programs. The companion 

report, "Chiropractic Care; Controls Used by Medicare, Medicaid, and Other Payers, (OEI-04-97-

00490)" examines Medicare, Medicaid, and private insurers' mechanisms for controlling 

expenditures and protecting the chiropractic benefit from potential waste and abuse. 

A particular concern in the Medicaid program was whether there were any indications of potential 

explosive growth in the program overall. 

SCOPE AND METHODOLOGY 

We distributed a mailed questionnaire to the Medicaid Administrators in the 50 States and the 

District of Columbia. We asked each State Administrator to forward this instrument to the 

individual most qualified to provide information about the chiropractic benefit. All 51 

questionnaires were returned. We followed with telephone interviews where we required 

clarification or additional information. Published State Medicaid plans supplemented this 

information. 

Although some States offer chiropractic coverage under managed care plans, because variation 

between plans both within and across States is great and because encounter data about 

chiropractic visits is limited, the discussion below focuses on the extent of benefits under fee for 

service plans. 

We conducted this inspection in accordance with the Quality Standards for Inspections issued by 

the President's Council on Integrity and Efficiency. 

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FINDINGS

Thirty States Report Offering Some Form of Medicaid Chiropractic Benefit Under a Fee For 

Service Arrangement. 

Twenty six States cover all categorically needy Medicaid eligible beneficiaries and twenty of these 

extend coverage to those considered to be medically needy but who do not qualify for financial 

assistance. All thirty States provide coverage for children under Early Periodic Screening, 

Diagnosis and Treatment (EPSDT) plans. Seventeen of these States also offer coverage to some 

beneficiaries under a managed care arrangement, including Oregon, which covers 85 percent of 

Medicaid beneficiaries under managed care. The remaining States and the District of Columbia 

reported that they offer no fee for service Medicaid coverage of chiropractic care. 

TABLE 1. CHIROPRACTIC COVERAGE by STATE 

STATE 

MEDICALLY 

NEEDY 

CATEGORICALLY 

NEEDY EPSDT STATE 

MEDICALLY 

NEEDY 

CATEGORICALLY 

NEEDY EPSDT 

ARKANSAS T T T NEBRASKA T T T

CALIFORNIA T T

NEW 

HAMPSHIRE T T T

CONNECTICUT T T T NEW JERSEY T T

FLORIDA T T T NEW YORK T

IDAHO T T N. CAROLINA T T T

ILLINOIS T NORTH DAKOTA T T T

INDIANA T T OHIO T T T

IOWA T T T OREGON T T

KANSAS T PENNSYLVANIA T T T

LOUISIANA T T T SOUTH DAKOTA T T T

MAINE T T T TEXAS T T

MASSACHUSETTS T T T UTAH T T T

MICHIGAN T T T VERMONT T T T

MINNESOTA T T T WEST VIRGINIA T T T

MONTANA T WISCONSIN T T T

Conditions and Chiropractic Services Which Qualify for Reimbursement Vary by State. 

Twenty States reported that they limit reimbursement to coverage of manual manipulation of the 

spine for treatment of spinal subluxation. Five States also allow coverage for treatment of back 

pain associated with nerve root damage. Eight States reported that they allow coverage of 

additional treatments considered medically necessary or acceptable under State chiropractic 

regulations. One State, Kansas, covers only an annual chiropractic history and physical. 

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TABLE 2. CONDITIONS COVERED, by STATE 

SPINAL NERVE 

STATE SUBLUXATION DAMAGE OTHER or ADDITIONAL COVERAGE 

ARKANSAS T

CALIFORNIA T Strain, Sprain or dislocation of spine or neck 

CONNECTICUT T

FLORIDA T Other Medically Necessary Treatment 

IDAHO T

ILLINOIS T

INDIANA T Medically Necessary Treatment 

IOWA T

KANSAS Chiropractic Screening Only 

LOUISIANA T T Medically Necessary Treatment 

MAINE T

MASSACHUSETTS T T Medically Necessary Treatment 

MICHIGAN T

MINNESOTA T

MONTANA T No Restriction By Medical Condition 

NEBRASKA T

NEW HAMPSHIRE T

NEW JERSEY T T

Cover Any Conditions Within Scope of Chiropractic Care 

Under State Law 

NEW YORK T

NORTH CAROLINA T T

NORTH DAKOTA T T Strains/sprains 

OHIO T

OREGON T

PENNSYLVANIA T

SOUTH DAKOTA T

TEXAS T

UTAH T

VERMONT T

WEST VIRGINIA T

WISCONSIN T

States Impose a Variety of Limits on the Number and Duration of Chiropractic Treatments a 

Beneficiary May Receive. 

The number of chiropractic treatments a beneficiary may receive is limited in 26 States. These 

limits range from one treatment per day to one treatment per year, with Kansas reporting 

coverage of a single examination with an allowed reimbursement of one dollar. Some States also 

limit the length of the period within which beneficiaries can receive treatment. Four States impose 

no limits, as their coverage only includes EPSDT eligible beneficiaries. Tables 3 and 4 describe 

these limits and allowed exceptions, by State, as they affect Medicaid coverage of chiropractic 

care. The companion report, "Chiropractic Care; Controls Used by Medicare, 

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Medicaid, and Other Payers, (OEI-04-97-00490)", considers these limits in greater detail as they 

are used to control utilization. 

TABLE 3. LIMITS TO COVERAGE, by STATE 

STATE LIMITS to COVERAGE 

ARKANSAS 12 Treatments per State Fiscal Year for Adults. 

CALIFORNIA 2 Treatments per Month. (24 per year) 

CONNECTICUT 

No More Than 1 Visit in 24 hours. Maximum of 4 Exams or Treatments in Single Visit to 

Home or Nursing Facility. (60 visits per year) 

FLORIDA 24 visits per calendar year. 

IDAHO 2 Office Visits per Month. (24 per year) 

INDIANA 5 Office Visits per Year, 50 Therapeutic Treatments per Year 

IOWA 

Acute Condition 40 Treatments in 6 months (80 per year) 

Chronic Condition 2 Treatments per month 

KANSAS 

1 Chiropractic History per Year 

1 Physical 

LOUISIANA 

8 Treatments per Year Without Pre-authorization for EPSDT 

12 Treatments per Year Without Pre-authorization for Adults, Maximum of 18 

MAINE 

Acute Condition 2 Treatments per Week for 1 month 

Chronic Condition 1 Treatment per Week 

MASSACHUSETTS 

20 Treatments per Year. State Does Not Cover Treatment and Initial Examination on the 

Same Day 

MICHIGAN 18 Visits per 12 Month Period 

MINNESOTA 

6 Manipulations per Month 

24 Manipulations per Year 

NEBRASKA 

18 Visits in First 5 Months of Treatment 

1 Visit per Month Thereafter if Needed (25 per year) 

NEW HAMPSHIRE 6 Treatments per State Fiscal Year 

NEW JERSEY 1 Treatment per Calendar Day (365 per year) 

NORTH CAROLINA 24 Visits per State Fiscal Year for Combination of All Physician Services 

OHIO 4 Treatments per Month (48 per year) 

OREGON 1 Treatment per Day (365 per year) 

PENNSYLVANIA 1 Treatment per Day (365 per year) 

SOUTH DAKOTA 

1 Treatment per Day 

30 Treatments per 12 Month Period 

TEXAS 

12 Treatments per Benefit Period 

Benefit Period is 12 months Beginning With First Treatment 

UTAH 

Limited to Number Appropriate for Diagnosis 

1 Evaluation, All Additional Services are Preauthorized 

VERMONT 10 Treatments per Year 

WEST VIRGINIA 12 Treatments per 12 Month Period 

WISCONSIN 20 Treatments per Spell of Illness (New spell of illness required to exceed 20 per year) 

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Twelve States Allow Exceptions to Their Chiropractic Coverage Limits. 

When medically necessary, treatment may continue beyond the standard limits in several States. 

Most require documentation or prior authorization before allowing exceptions, however. 

TABLE 4. EXCEPTIONS TO COVERAGE LIMITS, by STATE 

STATE EXCEPTIONS TO COVERAGE LIMITS 

CONNECTICUT Authorized Treatment Must be Initiated Within 6 Months of Date of Authorization 

IOWA Medically Necessary Treatment May be Authorized Upon Review by Chiropractic Consultant 

MICHIGAN Documented Medically Necessary Treatments Can Exceed Limits 

MINNESOTA Prior Authorization and Documented Medical Necessity . Can Exceed Limit 

NEW HAMPSHIRE Overridden by Medical Director with Substantial Evidence of Medical Necessity 

NORTH CAROLINA Medically Necessary Treatment May be Authorized by Medical Director 

OHIO Medically Necessary Treatment Can be Authorized by the Department on a Case by Case Basis 

SOUTH DAKOTA Medically Necessary Treatment May be Authorized Upon Review by Chiropractic Consultant 

UTAH Additional Services May be Approved Through Preauthorization 

VERMONT Prior Authorization Based on Documentation of Medical Necessity 

WEST VIRGINIA 

Medical Necessity Documented and Reviewed by State Chiropractic Consultant. 

No More Than 40 Total Treatments 

WISCONSIN Medical Necessity Reviewed by Chiropractic Consultant 

Twelve States Have Changed the Level of Their Chiropractic Benefit Since 1990. No 

Tendency of General Expansion of Benefits is Evident, However. 

Only two States adopted program changes that only limited their programs over the period. The 

remainder made changes that resulted in both expansions and limits. In some cases, such as 

Louisiana, later changes directly offset earlier ones. Other States expanded to include additional 

beneficiaries while also limiting the numbers or duration of treatments. No State reported 

pending plans to expand their fee for service chiropractic benefit. Of the States reporting no 

current coverage, none indicated immediate plans to add a chiropractic benefit, although South 

Carolina reported the issue is under study. 

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TABLE 5. CHANGES IN COVERAGE SINCE 1990, by STATE 

STATE YEAR EXPAND LIMIT CHANGE 

ARKANSAS 

1991 

1991 

1994 

1996 

T

T

T

T

Expanded to include adults(7/91) 

Limited coverage to under 21 only(12/1/91) 

One x-ray per State fiscal year covered (7/94) 

Expand to all ages (7/96) 

FLORIDA 1992 T Treatment limit expanded from 12 to 24 per year 

ILLINOIS 1995 T

Limited to EPSDT and 

Qualified Medicare Beneficiaries 

INDIANA 1992 T Treatment and diagnosis limits added 

KANSAS 

1983 

1991 

T

T

Limited or eliminated many services 

Limited to history and physical for EPSDT 

LOUISIANA 

1995 

1997 T

T Limit to EPSDT only 

Expanded to include all Medicaid beneficiaries 

MICHIGAN 

1991 

1993 

1996 

T

T

T Eliminated adults 

Reinstated adults with 12 visits per year 

Increased 12 visits to 18 

NEBRASKA 1993 T Limited number of treatments 

NEW HAMPSHIRE 1995 T Allow coverage of x-rays 

NEW JERSEY 1997 T Added initial diagnostic visit to coverage 

NORTH CAROLINA 1991 

Budget neutral. Allows chiropractor to perform x-ray, no 

longer requires physicians. 

WEST VIRGINIA 1992 T

Began x-ray reimbursement and raised limits from 6 

treatments to 40 per year (more than 12 require prior 

approval) 

Chiropractic Care Comprises a Small Proportion of Total State Medicaid Expenditures. No 

Consistent Trends in Expenditures Appear. Some States Experienced Decreasing Costs over 

Time, While Others Saw Only Minor Fluctuations in Expenditure Levels. 

We asked States to report data for the years 1994 through 1996, distinguishing between adult and 

EPSDT beneficiaries and between managed care and fee-for-service expenditures. Few reported 

data in that form, either because the data was unavailable or could not be extracted in the form 

requested. Several States indicated they did not maintain separate data for adult and EPSDT 

beneficiaries or did not disaggregate EPSDT expenditures. Also, most States did not have 

managed care data within which chiropractic expenditures were identifiable. However, 15 States 

did provide financial data reflecting total Medicaid expenditures and allowed payments for 

chiropractic care under their fee-for-service plans. Table 6. summarizes this information. 

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TABLE 6. STATE-REPORTED CHIROPRACTIC EXPENDITURES 

AND PERCENT OF TOTAL MEDICAID EXPENDITURES, 

by STATE 

1994 1995 1996 

STATE 

Chiropractic 

Payment 

% 

Total 

Chiropractic 

Payment 

% 

Total 

Chiropractic 

Payment 

% 

Total 

ARKANSAS 36,912 0.0034 44,095 0.0035 36,407 N/A 

CALIFORNIA 638,226 0.0064 607,915 0.0056 632,545 0.0553 

IDAHO 42,117 0.0127 41,962 0.0117 52,622 0.0130 

INDIANA 7,068,000 0.3020 2,822,000 0.1388 6,736,000 0.2766 

IOWA 1,664,533 0.1665 1,676,029 0.1523 1,648,935 0.0384 

LOUISIANA 9,177,891 0.3412 15,995,086 0.5777 4,282,654 0.1746 

MAINE 408,795 0.0455 376,786 0.0384 359,034 0.0363 

MINNESOTA 1,758,851 0.0811 2,246,935 0.0843 1,814,085 0.0617 

MONTANA Not Available N/A 15,693 0.0049 10,488 0.0031 

NEW JERSEY 439,919 0.0111 568,693 0.0135 503,829 0.0115 

NORTH CAROLINA 459,733 0.0161 700,158 0.0208 770,540 0.0207 

NORTH DAKOTA 255,085 0.0898 231,086 0.0779 224,490 0.0753 

TEXAS 783,882 0.0101 777,752 0.0101 1,028,304 0.0134 

UTAH 64,451 0.0125 235,237 0.0423 349,088 N/A 

VERMONT 166,557 0.0409 116,211 0.0345 114,374 N/A 

Beyond noting that chiropractic care is a very small percentage of total Medicaid expenditures, 

few overall trends are apparent. Within States, California, Iowa, Maine, Montana, and North 

Dakota appear to have experienced a slight downward trend in chiropractic payments relative to 

total expenditures, while Vermont's expenditures decreased sharply. In all but three of the 

remaining States, chiropractic expenditures and their relative proportion of State totals 

fluctuated only slightly over the three year period. Utah's expenditures increased, while 

Louisiana, and Indiana saw relatively large increases in 1995 which diminished in 1996. With the 

exception of Louisiana, where limiting eligibility to EPSDT beneficiaries likely drove expenditures 

down between 1995 and 1996, and Utah, where chiropractic coverage began in July of 1994 and 

expenditures rose over the next two years, we are unable to correlate States' expenditure patterns 

with their reported benefit coverages and limits. 

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CONCLUSION 

While thirty States offer some form of coverage for chiropractic care under their Medicaid feefor-service plans, State reported utilization data show no discernable trends suggesting explosive 

growth in Medicaid expenditures. Also, no State reported legislative or regulatory plans to 

expand their Medicaid chiropractic benefit beyond current coverage. 

COMMENTS 

The Assistant Secretary for Management and Budget (ASMB) provided comments on this report. 

ASMB asked us to further explain the growth in Medicaid chiropractic expenditures in the State 

of Utah. We provided this information on page eight of this report. The full text of these 

comments appears in Appendix A. 

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APPENDIX A

TEXT OF AGENCY COMMENTS 

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A - 1
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A - 2
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A - 3