Does Insurance Cover Functional Medicine?

Does Insurance Cover Functional Medicine Services?

In recent years, functional medicine has gained popularity as a holistic and alternative approach to healthcare. With its focus on identifying and treating the root causes of chronic health issues, rather than merely masking symptoms, many folks are turning to functional medicine (and functional nutrition) for more personalized and comprehensive care. However, a common question arises: Does insurance cover functional medicine? 

(The short answer is “sometimes”, but it depends on a LOT of different factors!)

The good news is even when functional medicine isn’t covered by insurance, there are some great alternatives and work-arounds that may potentially allow you to still receive the right functional medicine treatment for your individual needs.

With over a decade of experience accepting eight different health insurances in two states as an in-network functional medicine registered dietitian in private practice, let’s just say I’ve learned a thing or two about insurance coverage for functional medicine! (For the record, I’m now only accepting two health insurances in ONE state, but that’s a conversation for another time.) 😉

In this blog article, we’ll delve into the intricacies of health insurance coverage for functional medicine, shedding light on what YOU need to know – and how you can advocate for yourself as the patient.

Disclaimer: The information provided in this blog post is for general informational purposes only and should not be construed as professional advice. Please consult with your insurance provider and licensed healthcare professionals for specific guidance regarding your individual coverage and treatment options.

Understanding functional medicine

Before we dive into health insurance coverage, let’s first touch on exactly what functional medicine is, and what it entails.

Functional medicine is a holistic, evidence-based, and patient-centered branch of healthcare which aims to identify and address the underlying factors contributing to your health issues and imbalances on the cellular level.

A functional medicine treatment plan will usually begin with assessment, consultation, and cutting-edge lab testing (which detects subclinical imbalances before they spiral into full-blown medical conditions) with a licensed healthcare provider who is trained in functional medicine/functional nutrition.

Once you have clarity on your root causes, a typical functional medicine protocol will usually include customized diet/lifestyle interventions and herbal/nutraceutical supplements, as needed.  If you’re working with a doctor, you may also receive pharmaceutical consultation and clinical diagnostic testing as needed.

How is it different from conventional medicine?

Conventional or “allopathic” western medicine is all about clinical diagnostics and treatment from a medical, surgical, and pharmaceutical standpoint. These types of services can only be offered by licensed medical doctors (MD’s), nurse practitioners (NP’s), physician’s assistants (PA’s), and/or doctors of osteopathy (DO’s).

While we need this type of medicine (it saves millions of lives everyday), it doesn’t serve those of us who are looking to live optimally (versus just being clinically stable).

Despite the plethora of research confirming that what we eat and how we live does in fact have a profound impact on the state of our health and wellbeing, aka how we think, feel, and function, conventional medicine providers aren’t required to receive nutrition education beyond ONE semester of “Nutrition 101” in their undergrad curriculum.

(In the United States, most medical school research and funding is provided by pharmaceutical companies.  Whether or not this is a conflict of interest is still up for debate.)

So the limitation of conventional medicine is that it’s all about keeping you comfortable and clinically stable on the surface level, versus getting you to a state of optimal health.

The goal of functional medicine, on the other hand, is not just to mask symptoms or get patients clinically stable.  In this branch of healthcare, you can address and resolve long-standing health issues at the root-cause level, via a “food as medicine” approach.

In functional medicine, you’ll also receive more comprehensive, personalized treatment plans (versus a general pharmaceutical protocol) with an emphasis on holistic nutrition, herbal medicine, lifestyle changes, and a range of complementary therapies.

Lastly, unlike conventional medicine which must be provided by a doctor or nurse practitioner, functional medicine treatment is a little different.

  • This is relevant to note, because knowing how this works can potentially increase your chances of getting functional medicine treatment covered by insurance. Keep reading!

How is functional medicine different from functional nutrition?

You’ll likely notice the term “functional medicine” is actually used interchangeably with “functional nutrition” a lot.  This is because about 90% of integrative and functional medicine overlaps with functional nutrition! (This shouldn’t be too surprising, considering it’s all based on a “food as medicine” foundation.)

So as a functional dietitian nutritionist, the major foundational pillars of functional medicine (functional nutrition lab testing, dietary modification, herbal medicine, and holistic lifestyle change) are all within my scope of practice.

This means that even if you can’t find a functional MD, DO, NP, or ND in network with your insurance coverage plan, you may still be able to receive functional nutrition services from a functional registered dietitian who is in network with your health insurance plan!

  • You can call the Member Services phone number on the back of your health insurance card to consult with an insurance representative about this, or you may also customize your search online through a website such as HealthProfs.com.

The remaining 10% of functional medicine (i.e. prescribing pharmaceuticals and giving a formal diagnosis) is outside the scope of practice of registered dietitians, so it’s important to also consult with doctors and nurse practitioners as needed for this type of support.

When does insurance cover functional medicine? (Stuff to consider)

The following factors come into play when determining whether or not health insurance will cover functional medicine…

Let’s unpack each of these.

Your state/province and country

There are different licensing requirements which vary by state and country.

  • For example, I can’t provide 1:1 services for you unless you live in the United States.

Some states are more strict than others when it comes to whether or not a state license is required in order for out-of-state providers to provide remote patient care.

  • For example, I can’t provide 1:1 services for Florida residents because I don’t currently have a Florida dietitian license.  However, I can still work with nutrition clients 1:1 in California and Michigan without having a license in either of those states.

Lastly, in order for a provider to be in-network with your health insurance plan, we’re still usually required to obtain a state license in order to bill the insurance in your particular state.

  • For example, dietitians can’t be in-network with Blue Cross Blue Shield of Massachusetts without a Massachusetts dietitian license.

Insurance company and plan

Different health insurance companies and plans have varying policies and scopes of practice regarding coverage for functional medicine.

Insurance policy coverage and benefits

The type of health insurance policy you have can significantly impact coverage.

Employer-sponsored group plans, government programs like Medicare or Medicaid, and individual/family plans all have different rules regarding functional medicine coverage.

Call the Member Services phone number on the back of your card to speak with a live insurance representative to get custom consultation and guidance on your insurance plan’s coverage and benefits.

Medical necessity

For most types of insurance plans, coverage for functional medicine services with an in-network provider is often contingent upon the “medical necessity” of the treatment.

If a conventional medical treatment option is deemed more appropriate or effective, insurance providers may be hesitant to cover functional medicine.

However, in my experience, if patients meet criteria for “medical necessity” and I’m in network with their insurance plan, we can usually at least get 1:1 nutrition consultations covered (since I’m a licensed dietitian) when I’m in-network, or sometimes even out-of-network.

Some examples of “medical necessity” that commonly meet criteria for insurance coverage with an in-network functional dietitian include but aren’t limited to:

  • Irritable Bowel Syndrome (IBS)with or without diarrhea
  • Crohn’s disease
  • Celiac disease
  • Ulcerative colitis
  • Diabetes
  • Kidney disease
  • High cholesterol / hyperlipidemia
  • Metabolic syndrome
  • Eating disorders

Unfortunately what constitutes “medical necessity” is something that will vary greatly from one insurance plan to another.

  • For example, certain types of Blue Cross Blue Shield plans and United Healthcare plans won’t cover nutrition unless you have an eating disorder or diabetes.
  • If you have Blue Cross Blue Shield of Alabama or Georgia, you likely won’t be eligible for coverage to consult with a registered and licensed dietitian – even if a representative tells you otherwise, and even if you do have a nutrition-related medical condition.
    • I speak from a lot of experience. Don’t choose Blue Cross Blue Shield of Alabama or Georgia as your insurance provider if you’re hoping to access functional nutrition services with a registered dietitian through your insurance! They don’t cover it.

Preventive / routine coverage

In my experience, certain plans within Aetna, Cigna, AllWays, and some Harvard Pilgrim Healthcare networks would only cover nutrition services with a licensed dietitian when deemed “preventive” or “routine”.

Make sure to verify your nutition coverage and benefits with your insurance in advance, so you can inform your in-network functional medicine provider of any billing codes needed for claim submission and reimbursement.

In-network providers

Health insurance plans typically have a network of healthcare providers. You’re most likely to find coverage for functional medicine / functional nutrition services f you consult with an in-network functional medicine practitioner or clinic.

Out-of-network providers may result in reduced or no coverage at all, unless you have out-of-network benefits.

  • If that’s the case, you can ask your provider to submit claims to your health insurance as an out-of-network provider.
    • If insurance doesn’t reimburse, you’ll still need to pay your provider for the services, but in some cases, the out-of-pocket payments may get applied towards an annual insurance deductible.

Type of healthcare provider

If you’d like to work with a functional medicine or functional nutrition provider through your insurance, your best shot is to first search for local licensed holistic, functional healthcare practitioners in private practice. (Health insurance companies will only accept licensed healthcare providers in their networks.)

The following are examples of functional medicine providers who are authorized to contract with health insurance companies as in-network providers (if they want to):

It’s important to note that no two providers are going to have the same approach in functional medicine – we all have different levels of training, experience, and niche expertise, even within the niche of functional medicine/functional nutrition.

Just because a holistic provider takes your insurance doesn’t mean you’ll automatically get all the care that you need.  Make sure to do your research and ask various providers about their level of training and experience before making a decision.  Or if you’re working with someone and it doesn’t feel like a great mutual fit, you can always find another provider!

Pre-authorization and documentation

In my experience, certain insurance plans (specifically Health Maintenance Organization or “HMO”plans) sometimes require prior authorization and/or a PCP referral before you can receive specialty services in the scope of functional medicine / functional nutrition.

Make sure to consult with your insurance provider, primary care doctor (PCP), and your functional medicine practitioner of choice in advance, before your initial functional medicine/functional nutrition consultation, to understand the required documentation and procedures for potential reimbursement.

How to appeal an insurance denial

So, here’s the deal: if your insurance company denies a claim for a medical service or treatment, don’t fret! You’ve got options to fight back and appeal their decision. While it doesn’t always work, here’s what you can do just to leave no stone unturned:

First, check out the denial letter they sent you. Take a good look at the reasons they gave for denying your claim. Next, dig into your insurance policy and get to know it inside out. Look for any coverage limitations, exclusions, or guidelines that could be relevant to your situation.

Now, gather all your ammo! Collect all your medical records, test results, and any other paperwork that supports your case. Talk to your healthcare provider too, and see if they can provide any extra documents or backup.

Once you’ve armed yourself with all the necessary documents, get in touch with your insurance company and find out their appeals process. It might involve filling out a form, writing a letter, or submitting additional info. Make sure you meet all their deadlines!

Next, it’s time to write a killer appeal letter. Be clear and concise, laying out the reasons why their denial is wrong. Use your supporting evidence and policy references to make a solid case.

Keep copies of everything and stay organized. Track all your communications with the insurance company, noting any dates (and always ask for a call reference number), names of the people you speak with, and any other important info.

If your appeal is denied again, don’t throw in the towel just yet. Reach out to a patient advocacy organization or your state insurance commissioner’s office for extra guidance. And if things get really tough, consider consulting with a legal pro who knows their stuff when it comes to healthcare disputes.

Remember, you’ve got the right to fight for what you deserve. Stay persistent, be confident, and let your voice be heard throughout the whole appeals process.

Does insurance cover functional nutrition?

In many cases, insurance will cover 1:1 consultation with an in-network functional registered dietitian who accepts your insurance, or sometimes an out-of-network functional dietitian who is wiling to submit out-of-network claims (if you have out-of-network benefits).

Otherwise, if you choose to work with another type of functional nutritionist, these services won’t be covered by any insurance.

Does insurance cover functionl nutrition testing?

In most cases, functional nutrition testing (such as the GI MAP test, micronutrient testing, and food sensitivity testing) won’t be covered by insurance- however, it may still be worth the investment.

This specialty testing can also potentially get covered (or partially covered) via some of the following alternative options for more affordable coverage.

Alternative options for affordable coverage

Okay, so what if at the end of the day, you either don’t have insurance, or you’ve got crappy plan coverage, and you can’t find in-network functional medicine / functional nutrition providers who are accepting new clients?

If your health insurance does not cover functional medicine or if you don’t have insurance, there are alternative options to consider:

  1. Health Saving Account (HSA) / Flexible Spending Account (FSA)
  2. Superbills
  3. Memberships / concierge practices
  4. Supplementary insurance or group programs
  5. Group programs
  6. Care Credit

Health Savings Account (HSA) or Flexible Spending Account (FSA)

These accounts provide you with a special debit card which contains funding, so you can set aside pre-tax money specifically for healthcare expenses.

In my experience, functional medicine services (functional nutrition testing, consultation, 1:1 and group coaching, etc.) and herbal/nutraceutical supplements are usually eligible for reimbursement using funds from these accounts.

You’ll just need to request an itemized receipt from your provider, within an allotted time frame following the date of a service/purchase.

Itemized receipts for HSA/FSA card expenses will need to include the following information:

  • Provider/facility’s official letterhead
  • Your name and date of birth
  • Your insurance member ID
  • The provider’s name and credentials
  • The facility or company name & contact info
  • The services rendered (or product sold)
  • The date of service (or date of purchase)
  • An ICD-10 diagnosis code (the primary reason for the services/product – usually determined by your provider)
  • The amount you paid for the services/product
  • The date of your payment

Superbills

A superbill is a type of document that summarizes any medical or nutritional services you received during a visit with a licensed healthcare provider. It includes your personal information, the date of the visit, and the contact details of your healthcare provider.

This is a nice way to potentially receive reimbursement for medical/nutritional services even if the functional medicine provider is out of network with your health insurance plan.

If you have this benefit included on your insurance plan, your insurance company will review the superbill (to be provided by your licensed healthcare provider) and determine the covered benefits according to your policy.

Membership-based “concierge” functional medicine practices

Some practitioners operate on a membership or cash-pay basis, eliminating the need for insurance. These practices often offer comprehensive functional medicine services and may provide more affordable options for ongoing care.

You may also want to consider asking providers if they offer a sliding scale discounted option.

Supplementary insurance programs

Certain supplementary insurance plans or discount programs specifically cater to alternative and integrative medicine. These options can help mitigate the out-of-pocket costs associated with functional medicine.

Group programs

Nowadays, more and more functional medicine providers are offering group programs or hybrid 1:1 + group coaching programs, which can be more affordable and cost-effective compared to 1:1 programs.

Care Credit

Care Credit is an awesome option that lets you take care of health expenses without worrying about immediate payment for functional medicine services. It works like a healthcare financing program, designed to assist patients in covering the costs of their medical needs, including functional medicine/functional nutrition.

To get started, all you need to do is apply for a Care Credit credit card either online or through a participating healthcare provider. It’s super easy! Once approved, you can use your credit card to pay for your functional medicine treatments or consultations.

One of the great things about Care Credit is its flexibility. You can choose from different payment plans, including interest-free and extended options. This way, you can manage your expenses over a period that works best for you.

What’s even better is that Care Credit has a vast network of healthcare providers who accept a Care Credit card. So, you’ll have plenty of options when it comes to finding the right functional medicine practitioner for your needs.

With Care Credit, you can prioritize your well-being and receive personalized treatments without the burden of paying the full cost upfront.

Why is functional medicine NOT covered by insurance in so many cases?

If you’ve noticed there seems to be a shortage of holistic healthcare providers in-network with your insurance, it’s not in your head – and it’s not a coincidence!

Needless to say, there are some major challenges many functional medicine providers are facing when it comes to accepting health insurance and1:1 private practice.

While these things usually stay within the inner circles of healthcare provider conversations, I think it’s worth sharing openly and transparently, so you’ll have more awareness and understanding of what’s going on behind the scenes in healthcare right now. (Awareness precedes change.)

Unethical insurance company practices

Unfortunately I’ve noticed that health insurance companies will often do anything and everything to NOT reimburse healthcare providers for our services – or at the very least. they make it really difficult and inconvenient for us to get reimbursed.

For example, every few months, Aetna, Cigna and United Healthcare would “accidentally” deny some of my claims that were supposed to get reimbursed, based on their criteria for coverage and based on my clients’ nutrition benefits.   Their computer systems would “mistakenly” categorize me as an out of network provider which, at the time, was untrue. (This has happened to lots of my colleagues, as well.) While I always made sure to call and follow up on this, lots of providers don’t tke the time to do it – so they write it off as a loss. It’s a ripoff.

Ugh. That’s just ONE of dozens of examples! I’ll spare you the rest. (For the record, I’m no longer in any of those insurance provider networks, for obvious reasons!)

Unfair compensation

Running a functional medicine/functional nutrition practice isn’t just a hobby – it’s also a career and a livelihood.  Functional medicine providers need to be able to support ourselves and our families while also serving our clients!

And sadly, some insurance companies don’t reimburse fairly and sustainably based on the amount of time it takes for functional medicine providers to deliver high-quality patient care in a private practice. (I accepted all of the very low-paying insurances for many years – because I did, and still do, want everyone to have access to functional medicine!)

However, providing consistent high-quality care takes a great deal of time and energy, even in between the 1:1 meetings – especially for functional medicine and functional nutrition providers. Low reimbursement makes it more difficult for us to run and sustain a private practice long-term, without burning out. (This is why I eventually had to leave a bunch of insurance provider networks – I was turning into a shell of a person by 2021.)

Most functional medicine providers (who are usually also very empathic and pour into our clients) eventually find that we can no longer keep up energetically with the number of clients we would need to see each week in order to sustain our practice and make ends meet.

No compensation

On another note, I think it’s safe to say most (if not all) healthcare providers in insurace-based private practice have worked with,  or will work with (at one point or another) entitled people.  I’m talking about the people who feel they don’t need to reimburse their providers, even when their insurance decides not to cover our services (after the services have already been rendered). Or when they book sessions, don’t show up, and decide not to pay the no-show fee.

  • Can you imagine if you worked at your job fulltime each month, and then your employer decided to only pay you for a fraction of the hours because the customers felt entitled to free labor? This is exactly how healthcare providers feel when masses of people want our help and choose to work with us, but their insurances don’t pay – and they don’t think they need to pay us either.

(As a seasoned practitioner in private practice, this no longer happens to me very often if at all anymore, thank goodness!  I’m very selective about who I let into my world these days. But it still happens to some of my colleagues a LOT.)

This stuff can happen only so many times before functional medicine providers will decide that it’s just not worth the trouble to deal with those people! (Please don’t be one of those people.) 😉

Lower-commitment, higher-turnover client model

In my experience, the health insurance-based practice model generally tends to bring in very high volumes of people with higher no-show rates and less commitment to the journey. (Not always the case, but often enough!)

The insurance-based higher turnover + lower commitment client model makes it challenging for functional medicine providers to support the more committed clients who are on a healing journey with us.

Red tape (restrictions and limitations)

While taking health insurance can help to make functional medicine and functional nutrition services more affordable and accessible for more people, it also comes with a lot of red tape – especially for medical doctors (MD’s).

  • Doctors are very restricted around the types of tests they can order without getting accused of insurance fraud, especially if the testing is more preventive or root-cause oriented versus “medically necessary”.
    • For example, running an annual celiac disease test should be a routine test in every primary care practice and gastrointestinal (GI) clinic, but it isn’t (in the U.S.) because of health insurance coverage restrictions limitations. As a result, I’ve observed that lots of people are walking around with undiagnosed celiac disease masquerading as IBS, in many cases. (Go get a celiac test before going gluten free, please!)

Functional medicine providers enjoy having clinical freedom.  We don’t enjoy being bossed around or manipulated by health insurance companies. We prefer to practice in ways that we feel are in the best interest of our patients.  Do you really want your healthcare insurance company dictating your treatment plan of care? I know I don’t. Be your own advocate, always. 😉

How YOU can help keep functional medicine more accessible via insurance, as a client

I truly believe functional medicine and functional nutrition can improve the entire trajectroy of healthcare, but clearly some stuff needs to change first!

Here are a few ways you can do your part as a patient, to help keep 1:1 functional medicine services accessible through health insurance (and in general) in the coming years:

  1. Show up for scheduled appointments on time, and give us enough notice when you need to reschedule. (With enough notice, somebody else who needs to be seen can book your canceled appointment.)
  2. Pay the no-show/late cancellation fees when you cancel last-minute – outside of true emergency situations. (We get it… life happens!  But running a 1:1 private practice requires a great deal of our time and energy, which is very finite! Providers can’t sustain a functional medicine practice if we let everyone cancel or no-show, unless we’re getting reimbursed for the lost time.  Paying the late cancellation/no-show fee when it’s warranted will also hold you more accountable to show up for yourself and make health more of a priority.)
  3. When you have lots of questions and/or complex questions, please book a consultation.  Insurance-based providers (especially empaths and introverts) unfortunately don’t have the time or infrastructure to provide a concierge level of support or comprehensive/ongoing consultation in between client meetings. Quick, simple, occsional questions are totally fine – but it’s stressful and overwhelming when we get bombarded with paragraphs of complex updates/questions or long lists of questions from hundreds of people each month in between the 1:1 meetings, clinical notes, after-meeting protocols, and insurance billing!
  4. Pay your healthcare providers appropriately and on time if your insurance isn’t covering the services!  Functional medicine providers are people with monthly expenses and families to support, just like you. When one too many clients decide not to pay us for our services when insurance doesn’t cover, it breeds resentment. More and more providers will eventually decide to stop taking insurance or even close our functional medicine/functional nutrition practices if this doesn’t change.

More on functional and integrative medicine

Conclusion

The question of whether insurance covers functional medicine services can be answered with a “sometimes” – because it depends on lots of different factors.

Factors that determine insurance coverage for functional medicine include the state or country you reside in, your insurance company and plan, the type of healthcare provider you consult with, and the medical necessity (or in some cases, “preventive” / “routine” status) of the treatment.  Consult with your insurance provider and licensed healthcare professionals in advance, before scheduling your initial consultation, for specific guidance on coverage and treatment options.

While functional nutrition can’t totally replace functional medicine, ~90% of functional medicine is within the scope of practice of a functional registered dietitian, since there’s a huge emphasis on “food as medicine”.  Functional nutrition services with a registered dietitian may still be covered by insurance even if functional medicine is not!  It’s worth considering, since lots of functional dietitians accept health insurance.

While functional medicine and functional nutrition services may not always be covered by insurance, there are alternative options and workarounds to receive personalized and comprehensive care without incurring high costs.  Health Savings Accounts, Flexible Spending Accounts, superbill reimbursements, membership-based practices, supplementary insurance, Care Credit, or discount programs can potentially make functional medicine services more affordable and accessible.

Next steps

Remember, investing in your health and exploring personalized approaches like functional medicine (with or without health insurance) can have long-term benefits if you’re ready and committed on this journey.

If you live in the U.S. and you’re ready to start addressing your health issues impacted by food, I invite you to consider booking a 1-1 holistic health consultation with yours truly!

(Insurance accepted:  Blue Cross Blue Shield of Massachusetts) 

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