Ontario Insurance FAQ’s

For years, there has been great confusion in Ontario regarding acupuncture and reimbursement for acupuncture treatments. The origin of the confusion is easy to identify: [inappropriately] acupuncture has been treated simultaneously as a modality and as a profession by insurers, by practitioners with acupuncture within their scope of practice, and by the general public.

Still many continue to make the same mistake, but for clarification: Acupuncture in Ontario is not a profession, it is a therapeutic modality shared by 11 professions (one of which happens to have a professional denomination derived from this word).

None of these 11 professions has exclusive rights to the practice of acupuncture as a modality, although, since April 1, 2013, a new regulated profession in Ontario, Licensed Acupuncturist, has the exclusive right to use a derivative of this word (the word “Acupuncturist”) as part of their professional denomination.

License Acupuncturist is a new, self-regulated profession with acupuncture within its scope of practice, like the new profession of TCM Practitioner. Nothing has changed for the previously existing nine professions with acupuncture within their scope of practice.

All these professions have equal rights to provide professional services that include acupuncture to the general public and to invoice and get paid for doing so.

All professional services provided by these 11 professions are equally eligible to be reimbursed to an insured person with coverage for the specific services claimed.

Incidentally, it is illegal for anyone in Ontario to provide health care related professional services unless the provider belongs to the regulatory college that governs the practice of that profession in Ontario.

To further understand this relatively straightforward topic:

In Ontario, Extended Health Care Insurers provide reimbursement to their insured customers for specific health interventions included in their policies, such as physiotherapy, chiropractic, or massage therapy, when these services are provided by the regulated health care professional whose profession matches the professional services covered by the policy: , for instance, the benefit of physiotherapy to be eligible for reimbursement must be provided by a physiotherapist, as chiropractic services must be provided by a chiropractor and massage therapy by a registered massage therapist.

In addition, to reimburse professional services provided by a specific professional, some policies also provide reimbursement for miscellaneous benefits (goods or services) such as orthotics. These miscellaneous benefits are eligible for reimbursement when provided by any regulated professional part of an accepted list of providers by that company (of course, eligibility criteria vary from company to company).

As explained above, in Ontario most Extended Health Care Insurers do not reimburse modalities (such as acupuncture or soft tissue treatment), instead, they reimburse professional services.

Unfortunately, before April 1, 2013, acupuncture was treated by many Extended Health Care Insurers as a modality and considered a special benefit where reimbursement was provided to their insured if the services had been provided by any of a list of eligible providers.

Of course, as it happens in this industry, the list of eligible practitioners varied from company to company. Due to the lobbying efforts of some private acupuncture associations (like the Canadian Contemporary Acupuncture Association, the AFCI or the ACO), one of the common eligibility requirement was that practitioners provided a number that demonstrated membership on an association (official or not) on the list of acceptable associations by each particular insurance company.

Unfortunately, this rather unusual insurance practice regarding reimbursement of “acupuncture” has created a great degree of confusion among practitioners and insured patients alike in Ontario.

Some regulated health professionals with acupuncture within their scope of practice has [inappropriately] become accustomed to having their professional services involving acupuncture treated by the Extended Health Care Insurers as a separate benefit (from their professional services).

Incidentally, this practice is against the official recommendations of most colleges governing the health professions with acupuncture within their scope of practice. From now on, every service in which the modality of acupuncture is used, will just be eligible for reimbursement under the professional services of the professional providing the treatment, whether Licensed Acupuncturists, Physiotherapist, Chiropractors, Registered Massage Therapists, Naturopathic Doctors, or any of the other nine professions with the ability to provide acupuncture within their scope of practice.

What most people are now still [wrongly] calling “acupuncture coverage” simply represents “licensed acupuncturists professional services coverage”, in the same way, physiotherapy coverage refers to the specific professional services provided by physiotherapists, or chiropractic coverage to those provided by chiropractors.

This does not mean that a given professional cannot provide the same techniques (such as acupuncture or a specific soft tissue technique) as part of a given treatment. Indeed, many professionals provide the exact same techniques to their patients. However, professionals cannot invoice for techniques or modalities but for professional services.

The Extended Health Care Insurers’ general rules mean that each professional should always invoice for their professional services and not for the specific modalities used during the provision of these services.

Having said that, a degree of confusion regarding this topic is doomed to remain in Ontario as colloquially many are going to continue to use “acupuncture” and “professional services provided by a licensed acupuncturist” as synonyms, a common mistake that even insurers are still making in their official communications, but that should be detected and automatically corrected by any knowledgeable healthcare practitioner.