Health First Colorado is the name for Colorado’s Medicaid program, a joint federal and state partnership providing comprehensive health coverage to eligible low-income adults, children, and families. Chiropractic care focuses on diagnosing and treating mechanical disorders of the musculoskeletal system, particularly the spine, often involving manual adjustments. Medicaid coverage for services like chiropractic adjustments varies widely by state. This article outlines the parameters and limitations for accessing chiropractic services through Health First Colorado.
Coverage Status in Colorado
Health First Colorado covers chiropractic services for its members, but coverage is tied directly to medical necessity. For adults, coverage is restricted to treating neuromusculoskeletal disorders. This means the service must actively treat a diagnosed condition causing pain or functional impairment. This benefit includes care for specific conditions, such as spinal subluxation, where the spinal bones are slightly out of position.
A separate, more comprehensive benefit exists for children and young adults under age 21 through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Under EPSDT, the state must cover any medically necessary service required to correct or treat a physical or mental diagnosis, even if it is not a standard benefit for adults. Therefore, chiropractic treatment for a child is covered when it is part of an approved, medically necessary care plan.
Chiropractic services are also included under the Complementary and Integrative Health (CIH) waiver for members who qualify for Home and Community-Based Services. This waiver is available for adults over 18 living with specific conditions, such as a spinal cord injury, multiple sclerosis, or cerebral palsy, that result in the inability to ambulate independently. This specialized program expands access to chiropractic care, acupuncture, and massage therapy beyond the standard Health First Colorado offerings.
Scope of Covered Services
The core service covered is the manual manipulation of the spine and musculoskeletal system, commonly referred to as a chiropractic adjustment or CMT. Coverage includes the evaluation and treatment necessary to address spinal-related neuromusculoskeletal issues causing active symptoms. The focus of the covered treatment must be therapeutic, aiming to provide active symptom relief or correct a diagnosed condition.
The program explicitly excludes several services often provided in a chiropractor’s office that do not meet the definition of medically necessary manipulation. Maintenance care, which involves routine adjustments provided after a patient has reached maximum therapeutic benefit, is not covered. Services intended for long-term wellness or prevention without an active treatment plan are considered the patient’s financial responsibility.
Other ancillary services are typically excluded from coverage under the standard benefit, including massage therapy and nutritional counseling. Diagnostic imaging, such as X-rays, ordered by the chiropractor may not be covered unless specifically authorized by an in-network provider and deemed medically necessary for the diagnosis. Patients should always confirm that the specific procedure code for a service is covered before receiving treatment.
Patient Eligibility and Access Requirements
To access the covered chiropractic benefit, the member must be fully enrolled in Health First Colorado. Accessing the care generally requires a referral or prior authorization, as the Primary Care Provider (PCP) functions as the patient’s medical home. The PCP is responsible for managing the member’s overall healthcare needs, including coordinating specialty services and making referrals to appropriate providers.
The process begins when a member presents with a neuromusculoskeletal issue that the PCP determines may benefit from chiropractic intervention. The PCP initiates a referral for the initial evaluation by an enrolled chiropractor who must be an approved Health First Colorado provider. The chiropractor must then document a clear diagnosis and a specific treatment plan to establish medical necessity for continued care.
Prior authorization may be required for treatment, particularly if the care is expected to extend beyond the standard visit limits. This process ensures that the proposed treatment remains medically necessary and is the most appropriate course of action for the member’s condition. Obtaining prior authorization is necessary, as services rendered without it may not be reimbursed by Health First Colorado.
Frequency Limitations and Patient Costs
Chiropractic care for adult Health First Colorado members is subject to specific frequency limitations imposed by the state’s benefit structure. Adults typically have an annual limit on the number of chiropractic visits they can receive per calendar year. This cap is generally set at 20 visits. Extended care beyond this limit may be authorized if the patient’s condition still demonstrates a need for active treatment.
In contrast, the EPSDT benefit for children and young adults under 21 does not impose a set annual visit limit. For this population, the determining factor is medical necessity, meaning a child can receive as many visits as are required to treat their condition, provided it is documented as part of an approved care plan. This ensures children have access to all necessary treatment.
Copayments may apply for some covered services for adult members of Health First Colorado. The amount of the copay varies by the service received, but there is a household monthly maximum limit based on the member’s income. Certain member groups are exempt from all copayments, including all children aged 18 and under and pregnant women.