Illinois Medicaid does cover chiropractic care, but the benefit is narrow: it pays for manual spinal manipulation to correct a subluxation that is causing a neuromusculoskeletal condition, and nothing else performed in a chiropractor’s office. Adults and children are both covered, the copayment is $3.90 per visit for most enrollees, and the chiropractor has to be enrolled with Illinois Medicaid for the visit to be paid.
What Illinois Medicaid Pays For
The Illinois Department of Healthcare and Family Services (HFS) reimburses chiropractors for three procedure codes, all variations of spinal chiropractic manipulative treatment (CMT):
- 98940 – CMT, spinal, one to two regions
- 98941 – CMT, spinal, three to four regions
- 98942 – CMT, spinal, five regions
Only one of these codes can be billed per date of service, so a single visit produces a single charge no matter how many regions of the spine the chiropractor adjusts.1Illinois Department of Healthcare and Family Services. Handbook for Providers of Chiropractic Services
Children under 21 have had continuous chiropractic coverage. Adult coverage was restored effective December 2021 after being eliminated in 2012.2Illinois Department of Healthcare and Family Services. Public Notice – Chiropractic Services Revised
What It Will Not Pay For
The exclusion list is longer than the covered list, and most denials trace back to it. When billed by a chiropractor, Illinois Medicaid will not reimburse:
- Office visits, consultations, or diagnostic screenings billed as separate evaluation and management codes
- X-rays and lab tests (another Medicaid-enrolled provider can order and bill those separately if medically necessary)
- Maintenance therapy, meaning continued treatment after the condition has stabilized or reached maximum improvement
- Manipulation when there is no diagnosable pathology
- Fracture care, home visits, and injections
The maintenance rule is the big one. Medicaid pays for treatment aimed at measurable improvement. Once the chart stops showing progress toward a treatment goal, the plan has grounds to deny further visits, and the chiropractor cannot turn around and bill you for the difference on a covered service.1Illinois Department of Healthcare and Family Services. Handbook for Providers of Chiropractic Services
What You Pay at the Visit
The copayment is $3.90 per chiropractic visit, the same amount Illinois Medicaid charges for a physician or clinic visit.3Illinois Department of Human Services. PM 20-03-04-a: Customer Copays A Medicaid provider cannot refuse to treat you because you cannot pay the copay at the time of service, and some enrollees, including pregnant women and children, are exempt from copayments altogether. Beyond the copay, a covered visit with an enrolled provider should cost you nothing.
Referrals and Prior Authorization
Most people on Illinois Medicaid get their benefits through a HealthChoice Illinois managed care organization (MCO). The participating MCOs are Aetna Better Health of Illinois, Blue Cross Community Health Plan, CountyCare Health Plan (Cook County only), Meridian Health Plan, and Molina Healthcare.4Illinois Department of Healthcare and Family Services. Illinois’ Managed Care Programs
Each MCO writes its own rules on chiropractic. Some require a referral from your primary care provider before you see a chiropractor. Some require the chiropractor to get prior authorization before starting treatment, or after a set number of visits. Call the member services number on your Medicaid card before you book the appointment and ask what your plan requires. If you skip that step and the plan needed a referral or authorization, the claim gets denied and the visit is on you.
If you are in fee-for-service Medicaid rather than an MCO, the chiropractor bills HFS directly, and authorization rules can differ from the managed care plans.
Finding a Chiropractor Who Takes Illinois Medicaid
The chiropractor has to be licensed in Illinois and enrolled as a Medicaid provider through the state’s IMPACT system. Plenty of licensed chiropractors do not participate, so confirm enrollment before you go.
HFS runs a provider directory at ext2.hfs.illinois.gov where you can search by provider type.5Illinois Department of Healthcare and Family Services. Provider Directory If you are in an MCO, start with your MCO’s own directory instead, because the MCO network is usually smaller than the full state list, and going outside the network typically means no coverage at all.
Then call the office. Directories go out of date, and a quick call confirms the practice still takes your specific plan, is accepting new patients, and knows who handles any prior authorization paperwork.
If You Have Medicare and Medicaid
If you are enrolled in both programs, Medicare pays first. Medicare also covers manual spinal manipulation for subluxation, under its own medical necessity standards and visit limits. After Medicare processes the claim, any patient responsibility that remains can cross over to Medicaid through the Coordination of Benefits Agreement, which in most cases moves the claim automatically.6Centers for Medicare & Medicaid Services. Claims Crossover – Medicare Billing CMS-1450 and 837I
Some dual eligibles are enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) that handles both benefits through one managed care plan. In that case, call the plan to confirm chiropractic coverage and which chiropractors are in network.
Appealing a Denied Claim
If your MCO denies a chiropractic visit, start with an internal appeal to the MCO. You generally have 180 days from the denial notice. Send your name, claim number, Medicaid ID, and any supporting notes from your chiropractor explaining why the treatment is medically necessary. The MCO must decide within 30 days for services you have not yet received, or 60 days for services already provided. If waiting would seriously jeopardize your health, ask for an expedited review, which has to be decided within four business days.7HealthCare.gov. Internal Appeals
If the MCO still denies the claim, you can request a State Fair Hearing through HFS. You have 120 calendar days from the date on the MCO’s appeal resolution notice to file. To keep services going while the hearing is pending, you have to file within 10 calendar days of that notice, and if you lose the hearing you may have to pay for the services you received in the meantime. Requests go to the HFS Bureau of Administrative Hearings at 69 W. Washington Street, 4th Floor, Chicago, IL 60602, by fax at (312) 793-2005, by email at HFS.FairHearing@illinois.gov, or by phone at 1-855-418-4421.8Illinois Department of Healthcare and Family Services. How Illinois Medicaid MCO Enrollees Can File Grievance or Appeals