Acupuncturists and Obamacare

I wanted to write an article explaining what is going to be happening with the changes in the health insurance arena starting January 1, 2014 with the next phase of the Affordable Care Act (ACA) aka “Obamacare”. I say I wanted to do this but I can’t. Nobody can because nobody knows exactly what is going to happen. And I mean nobody. There are too many changes in the law that will ultimately end-up being decided in the courts or by new legislation and different insurance companies will be interpreting the law very differently until the legal challenges get worked-out. What is needed is for Acupuncturists in each state to be communicating with each other to gather information about what is happening in the states so we can better understand how to respond to these changes.  Otherwise we will fumble the opportunity this juncture provides us to advance our profession and help practitioners build their practices. 

My experience in the insurance industry has helped me to gain some insights regarding what is now taking place. I currently sit on the Board of Directors of the insurance company American Specialty Health Group, Inc. I have been working with (not for) ASH for nearly 15 years including as an advisor to the development of their first Acupuncture HMO plan in 1999. There are now about 5,000 Acupuncturists contracted with ASH and some 25,000 Chiropractors. ASH also contracts with Naturopaths, Massage Therapists, Physical Therapists, and Dietitians. ASH contracts with all the major insurance companies offering them a full range of different services to aid those companies to deliver the health care services provided by the practitioners listed above. My point in mentioning this is not to promote ASH but to underscore that I am probably as involved in matters relating to the changes taking place as anyone in our profession and there is a lot I don’t yet understand so be careful of misinformation and mindful of your sources. The fluidity and scope of changes in the insurance industry that is happening right now is unprecedented and we need to do our best to stay on top of it.

There are two main ways these changes will impact Acupuncturists – one relating to what Acupuncturists can expect to see happen with their patient’s insurance plans and the other what we and our families can expect purchasing our own health insurance policies. Most Acupuncturists work as private practitioners rather than employees and so they fall into the category of the “Individual” or “Small Group” insurance plans. Many of us have been going without health insurance due to the costs but now, under the ACA, such self-employed or otherwise uninsured individuals are required to purchase insurance. Depending on your income level, under the ACA, you might qualify for federal subsidies to help pay for these plans through State or Federal exchanges. You probably know all this already but what you may not know is the big picture of what a major focus of the ACA is attempting to do.

The ACA should greatly simplify purchasing health insurance while also (eventually) stabilizing what you get from insurance by setting minimum standards for what those plans will cover. Your health history (pre-existing conditions) and gender will no longer matter. All any health plan will need to know to give you a quote on rates is your age and zip code. There will be 4 plans to choose from – Bronze, Silver, Gold, and Platinum – that will have set benefits regarding co-pays and deductibles. Bronze plans will be the least expensive but have greater cost sharing and Platinum plans will cost the most but have the least cost sharing. The specific price for those plans will vary state by state and be based on your age and zip code. Health insurance companies are still free to offer other plans that tweak those benefits and costs but they will have to meet or exceed the benefits of the Bronze ACA plans. 

Before the ACA, there was no federal standard for the minimum of what a health plan was required to cover. This created a lot of confusion in the marketplace where people thought they had coverage only to learn when they had a health issue that their plan did not cover the needed service or the health problem. This was also true for how the stipulations over pre-existing conditions were sometimes applied. Some people would be paying their premiums year after year and then when they had an expensive health issue the health plan would deny those bills because they reviewed the original application and found some discrepancy in what was attested to. Some of these were for minor things like failing to mention that you were once prescribed an anti-depressant 10 years ago even if you never filled that prescription! These types of problems will (as I understand it) eventually be gone when the ACA is fully implemented by 2018 and all health plans will be ACA compliant.

The ACA allowed each state to set the specifics of their own minimum standards (Essential Health Benefits) as long as they meet the new federal standards. Some 16 states set-up their own Exchanges. The other states defaulted to or will partner with the Federal Exchange. Most states that set-up their own exchanges and standards did so by using a health plan that was already being sold in their own state – usually a Small Group plan as those tend to have less robust benefits than Large Group plans. In other words, no state was forced to establish a new type plan that they did not already have approved for sale in their state. 

A handful of state exchanges (I believe the number is 6) have acupuncture as an essential health benefit (EHB). Most of those likely ended-up including acupuncture because the plan that was chosen as the template for the state happened to have acupuncture in it already. However this took place, it will take some time to better understand how these changes will impact Acupuncturists who accept insurance. My state of California is one that has acupuncture as an EHB and it seems most ACA compliant plans here that have to cover acupuncture are doing so by considering a visit to an acupuncture provider the same way they cover a visit to a Primary Care Physician (PCP). There is a set “office visit” fee to be paid when seeing a PCP and another slightly higher fee for seeing a specialist. In California, the fee for seeing an acupuncture provider (or a PCP) will be $60 for a Bronze Plan, $45 for a Sliver Plan, $30 for a Gold Plan and $20 for a Platinum Plan. Although not called a “co-payment”, I guess you can consider those office visit fees a type of co-pay.

What is unknown is what kind of fees beyond those office visit fees will be allowed by any given insurance plan as the ACA or state Exchanges say nothing about fees for service rates. Some of the insurance companies now covering acupuncture as an EHB only paid $30-$40 for acupuncture before so it will be interesting to see how they will manage payment for acupuncture as an EHB. I don’t see how an insurance company could expect someone with a Bronze plan to pay $60 for an acupuncture Office Visit and not at least then pay another $40 when being billed for acupuncture for someone who has a Platinum plan where the office visit fee is $20 but we will see. 

Besides the issue of if acupuncture is covered as an EHB in any given state the other major issue with these changes is the stipulation in the ACA regarding non-discrimination between state licensed/certified practitioners. In a nutshell, this provision states that health plans cannot discriminate between licensed/certified practitioners delivering the same services allowed under their scope of practice (SOP). My friend, Bill Reddy, wrote an excellent article for Acupuncture Today that details the non-discrimination aspects of the ACA so you can read more about that at this link:http://www.acupuncturetoday.com/mpacms/at/article.php?id=32794

What will be most interesting to see is how different health plans will react to the non-discrimination provision. One way of interpreting that provision would be considering that everything a state licensed/certified practitioner is allowed to do under their SOP that a health plan would pay another licensed/certified practitioner to do – such as an exam by a medical doctor – must be allowed and paid for. Health plans may not see it this way, their legal departments may come to a different conclusion and that is why I think it will take some time to work these legal ramifications out. There have already been calls from physicians’ groups to repeal the non-discrimination provision (they apparently are FOR discrimination) and I think it is likely that if Acupuncturists, Chiropractors, and Massage Therapists start submitting bills for everything they are allowed to do under their SOP, there will be much more push-back.

This, especially, is where the acupuncture profession needs to be communicating together. Acupuncture groups in each state should build a database of what their SOP of practice allows them to do so that we can begin to wrap our heads around what we may now be legally able to bill insurance for. I am not saying we SHOULD start billing for every procedure under our SOP because this would encourage policy makers to rethink the non-discrimination provision, but we need to know what every state’s scope of practice COULD allow. 

I got involved with the insurance industry 15 years ago because I believed that the use of third party reimbursement (health insurance) was, for better or worse, how the U.S. health care system came to pay for care and that if Acupuncturists wanted to see acupuncture reach its potential here we needed to learn how to work with the insurance system. The opportunity the ACA is creating gives us the best chance to influence our future in that system we have ever had. I hope we can start to build a network to gather and share information so that we can take advantage of this opportunity rather than being taken advantage of. We need our schools, state and national members groups, as well as individual practitioners, to begin pooling their resources to take-up this challenge. I look forward to working with others to make that happen.  

Matthew Bauer

As Always, Thanks Matt,

Just trying to digest the materials here!

Peter C Doyle