Can I Use Health Insurance for Functional Medicine in Denver? A Firsthand Guide to Your Coverage Options
Navigating health insurance can feel like a maze, especially when considering something like functional medicine. Most people don't fully understand how their health insurance works- and honestly, who could blame them? It's confusing, full of jargon, and not exactly designed for clarity. Sadly, it is set up to manage chronic conditions that are largely preventable; but the education and resources for non-pharmaceutical intervention are not prioritized.
If you’re in Denver and seek a more personalized approach to healthcare, you are not alone. Understanding the basics of health insurance can help you make informed choices about your care (and maybe even save some money)! We’ll answer the big question: Can you use your insurance benefits for Functional Medicine?!
Health Insurance Terms You Actually Need to Know
Before we dive in, let’s start by explaining some key terms that tend to make insurance feel like a foreign language:
Premium – The amount you pay for insurance each month, whether you use it or not. Think of it like a subscription fee for coverage.
Deductible – The amount you have to pay out of pocket before your insurance starts covering costs. (Example: If your deductible is $2,000, you pay for all medical expenses until you hit that amount.)
Co-pay – A fixed amount you pay for a service (e.g., $30 for a doctor’s visit). Typically applies only to in-network providers.
Co-insurance – The percentage of costs you share with your insurance after hitting your deductible. (Example: If your co-insurance is 20%, you pay 20% of the bill, and insurance covers 80%.)
Out-of-pocket maximum – The most you’ll pay in a year before insurance covers 100% of covered expenses. (Yes, there’s a cap to the madness.)
In-network vs. out-of-network – In-network providers have negotiated rates with your insurance; out-of-network providers don’t, but you may still have benefits (more on that below!).
Superbill – An itemized receipt for out-of-network services that you can submit for possible reimbursement.
Explanation of Benefits (EOB) – Not a bill! This is a statement from your insurance explaining what was covered, what wasn’t, and what you might owe.
Got it? Great. Now let’s get into how to actually use this knowledge to your advantage.
In-Network vs. Out-of-Network: What's the Deal?
When looking into functional medicine insurance in Denver, understanding your insurance network is key. In-network means your provider has a contract with your insurance, leading to set (often lower) rates.
Out-of-network means no contract—BUT that doesn’t always mean no coverage. Many plans offer out-of-network benefits, and that’s where things get interesting...
Out of Network Benefits: The Silver Lining
If you see a provider who’s out of network, your insurance might still reimburse part of the cost. This varies by plan, but you’ll often need to meet a higher deductible first.
The key to using this to your advantage: Knowing what your out-of-network reimbursement rate is! [This is something you can call and ask and/or find in the policy fine print]
“Out-Of-Network” Functional Medicine = “Cash-Based Practice”
Most functional medicine clinics, including ours, operate as out-of-network or “cash-based practices”. That means patients pay out-of-pocket for consultations, testing, and treatments up-front; directly to the clinic. We do not handle any insurance billing or paperwork!
However, some services, like lab tests, may be covered depending on your insurance plan.
What Parts of Functional Medicine Might Be Covered by Health Insurance? […and which definitely are not…]
While coverage varies widely, here are some components that might be eligible for insurance reimbursement:
Lab Testing: Some routine and advanced lab tests may be partially covered. In our experience, specialized functional tests (e.g., stool testing, micronutrient panels, hormone tests) are usually not reimbursed as they will be deemed “not medically necessary”.
Comprehensive Preventative Medicine: Occasionally, insurance companies will offer reimbursement for preventative visits ("wellness"). There are various codes used depending on age range and status (initial assessment vs evaluation and management).
Medical Nutrition Therapy: Some insurance plans recognize the importance of nutrition counseling and may cover visits with a Certified Nutrition Specialist (CNS), coded as Medical Nutrition Therapy depending on your policy.
Supplements: Most insurance companies do not cover supplements. There is no “code” for submitting a reimbursement. On a positive note, HSAs/FSAs may provide some flexibility.
So much possibility, how do you go about securing this reimbursement?? … That’s where superbills come in when considering insurance coverage for Functional Medicine in Denver.
What the Heck is a Superbill?
A superbill is basically a receipt with all the details your insurance company needs. You pay your provider upfront, get a superbill, and submit it to insurance for potential reimbursement.
How to check your insurance policy for potential coverage: Call your insurance company and ask if they reimburse for out-of-network functional medicine services.
Pro Tip: Use the Right Terminology. When speaking with your insurance provider, ask about coverage for “medical nutrition therapy” or “preventative health services” rather than just “functional medicine.”
Here’s an example script: “Hi, I’m interested in seeing a Functional Medicine Doctor for preventative health services. My provider is out-of-network. Can you confirm if my plan offers any reimbursement for these services?”
Key Limitations: Many functional medicine clinics cannot provide a superbill for telehealth patients out-of-state (we don’t! which is why this article is focused on 'Functional Medicine in Denver!). There are still plenty of reasons to see a functional medicine doctor or nutritionist without the potential of insurance reimbursement - keep reading!
How to Submit an Out-of-Network Claim (Without Losing Your Mind)
The paperwork is your responsibility! Most clinics do not submit out-of-network claims on your behalf (we certainly do not). Luckily, it is fairly straightforward …
Get a superbill from your provider. Confirm your details are correct; at a minimum it needs to show your full name, date of birth and appointment details (date of service, diagnosis code, CPT code, amount paid).
Submit it through your insurance portal or mail it in.
Wait for reimbursement (and maybe follow up, because… insurance).
Essential Questions for Your Insurance Provider
To maximize your experience with functional medicine, consider asking your insurance provider the following:
Which specific functional medicine services are covered?
Is a referral required to see a functional medicine practitioner?
What documentation will I need for out-of-network reimbursements?
These questions can clarify your coverage and prevent unexpected expenses later on.
Alternative Payment Options: Health Savings Accounts (HSAs), Flexible Spending Accounts (FSAs) and Paying with Pre-Tax Dollars
If your health insurance plan won’t directly cover functional medicine services, you may be able to use Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs) to pay for qualified expenses. These accounts let you pay for medical expenses pre-tax, meaning you save money in the long run.
Our clinic accepts HSA/FSA as direct payment, and it can be used towards lab testing and treatments. You can likely use these funds towards supplements and other health devices as well!
How to Check? Contact your HSA/FSA provider to confirm coverage for specific services before using funds.
Comparing Out-of-Pocket Costs with Insurance Coverage
OK, Now we can finally debunk this big myth—Using Your Health Insurance Benefits doesn’t mean “FREE HEALTH CARE”
The average American pays $400/month toward a health insurance premium. You may see your primary care provider once, with a $0 co-pay. The 8-minute visit probably doesn’t offer much actionable help or education.
Any sick care, diagnostics, and intervention? You pay out-of-pocket (deductible or co-insurance) until you hit your maximum. The average maximum is $9,400.
Without even thinking about it, we’re spending $14,000 per year toward “healthcare” while remaining sick, tired, and confused.
While health insurance is necessary for the unavoidable (accidents, injuries, serious illness), we have to go outside of the system for PREVENTABLE problems.
Bottom line: The out-of-pocket expenses associated with addressing general wellness are significantly lower than those incurred in treating a chronic (preventable) disease.
Research shows that about 98% of patients view their investment in functional medicine at The Facility as worthwhile, citing the quality and personalized attention they receive*.
*"research" is a loose term here to mean reading through our google reviews 😜
Final Thoughts on Functional Medicine in Denver and Insurance Coverage vs. Alternative Payment Options
Health insurance might be a headache, but understanding your benefits can help you make better choices about your care. Whether your plan explicitly covers preventative services or not, it is crucial to feel confident in your healthcare decisions.
Ultimately, we have chosen to structure our practice outside of the insurance model because it allows us to treat the way we believe in. We can spend the time getting to know you, educate you on the "why" behind any interventions, and support you over the long-term (even when things are going "WELL").
Price transparency is important to us, and that is one thing we can promise. You’ll know exactly what it costs before committing so you can best plan your finances for your wellness goals. [Click here to find out what it’s like to become a patient at The Facility Denver]
With more individuals turning to functional medicine for comprehensive health solutions, the landscape of coverage is likely to shift. Stay informed and proactive about your health choices. Remember, your wellness journey is just as important as the outcomes you seek. (heh, heh, I love a good corny finish). Here's to health, happiness, and holistic healing!
Learn more about Functional Medicine at The Facility Denver:
→ Meet The Team [Dr. Mitchell Rasmussen, DC, CFMP + Kate Daugherty, MS, CNS]
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