One of the common questions about functional medicine is whether it is covered under insurance benefits. While the Accountable Care Act (ACA) did expand benefits for wellness and CAMs (complementary and alternative medicine), the ACA has not had much impact on expanding coverage for functional medicine. In general, functional medicine services are not covered by insurance for a variety of reasons.

One issue affecting the coverage of functional medicine services is the approach of functional medicine in comparison to the approach of traditional medicine that is the basis of the current billing system. The current billing system is predicated on diagnosis and procedure codes supporting traditional medicine and not functional medicine. 

Insurance companies often do not recognize or cover the diagnosis codes used by functional medicine due to its emphasis on preventive and root cause issues. The typical annual wellness insurance visit does not cover the services included in the functional medicine approach, including a detailed personal history timeline, specialty labs and interpretation and educating patients on functional medicine lifestyle changes. Even when insurance “covers” services such as dietary counseling, the coverage does not provide for the level of service delivered by most functional medicine providers.

Because insurance-based coverage does not adequately recognize or reimburse functional medicine services, many functional medicine providers do not participate with insurance. Patients of cash-pay physicians may be able to submit their encounters to their insurance, but each insurance plan is unique and some may not offer reimbursement for out-of-network services provided by a functional medicine provider. Some plans may not provide coverage for specialists or ancillary services referrals by out-of-network providers, which would leave the patient with the entire bill.

Functional medicine providers who participate with insurance companies have to be very specific about the services provided under their insurance contracts and services that are in addition to those services. These providers may provide patients with a summary of services covered typically covered by insurance and services not covered by insurance. Patients will be responsible for the services not covered by insurance and may be asked to sign a advanced beneficiary notice, or ABN, acknowledging that they are responsible for services that their insurance company does not cover. The elements of a standard ABN form can be viewed here.

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