Provider Nondiscrimination Provision and the ACA
The ACA’s provider nondiscrimination provision can be tricky to understand. As your clients may have questions, we wanted to give you a little more information about the provision and how it works.
The provider nondiscrimination provision of the Affordable Care Act (ACA) applies to all nongrandfathered commercial business (self-funded and fully insured), including individual, small group and large group policies upon renewal on or after January 1, 2014. This ACA provision prohibits health insurers and plans from certain types of discrimination against healthcare providers. If a provider is acting within their scope of practice and is in compliance with the state’s licensure requirements, insurers must reimburse them for covered services under the member’s policy. For example, if physical therapy is covered, a member can obtain treatment from any provider that has physical therapy within their scope of license.
In addition, all covered benefits must be reimbursed based on the “service.” A particular provider type cannot be carved out for a different level of payment, other than any differences between primary care physicians and specialists. Prior to this ACA provision, insurers may have covered some services based on the “provider.” As policies renew in 2014, such coverage is considered discriminatory, and insurers can no longer reimburse one type of provider for a service that is not reimbursable for other providers within their scope of license.
Please note that insurers are not required to contract with every provider willing to accept plan terms. Insurers are also not required to cover every service provided (except as otherwise defined by state or federal provisions).
- For our large employer policies, unless the employer and PacificSource have agreed to otherwise amend the policy, PacificSource will continue to exclude services for chiropractic manipulations, acupuncture, and massage therapy.
- For our small employer and individual polices, massage therapy will continue to be an exclusion, and coverage of chiropractic manipulations and acupuncture will be determined by the plan design selected.
Upon medical plan renewals in 2014, PacificSource began processing claims in compliance with the provider nondiscrimination provision of the ACA. In mid-March, we made additional adjustments to our system to process outpatient rehabilitation services by an alternative care provider within their scope of license towards the member’s outpatient rehabilitation therapy benefit and limitations.
Claims will be subject to the participating and nonparticipating provider benefit levels based on the type of service billed, regardless of the type of provider. Following are examples of how claims will be processed based on the service billed by an eligible provider.
- If for physical therapy, the outpatient rehabilitation therapy benefit and accumulator will apply.
- If for an office visit, the office visit benefit will apply.
- If for lab or x-ray, the diagnostic lab and radiology benefit will apply.
- If for chiropractic manipulations, the chiropractic benefit and accumulator maximum will apply (if the member has chiropractic coverage).
- If for acupuncture, the acupuncture benefit and accumulator maximum will apply (if the member has acupuncture coverage).
- If for massage therapy, the massage therapy benefit and accumulator maximum will apply (if the member has massage therapy coverage).
For example, if physical therapy is covered, a member can obtain treatment from any eligible provider that has physical therapy within their scope of license.
Alternative Care and Chiropractic Benefit Summaries
If the employer’s policy includes any of the following or similar language, it is changed as indicated below effective upon their renewal date on or after January 1, 2014. This removes language that limits services to certain providers, and replaces it with the additional covered services not already otherwise outlined in the Member Benefit Handbook. Line-through text indicates a deletion; text in square brackets indicates an addition.
services of a licensed acupuncturist or physician [from a licensed provider] when necessary for diagnosis and treatment of illness or injury.
Services of a licensed chiropractorChiropractic manipulations for medically necessary diagnosis and treatment of illness or injury , including chiropractic manipulations and chiropractic massage therapy.
Services of a licensed naturopath for medically necessary diagnosis and treatment of illness or injury.
- Any service or supply [noted as being] excluded or not otherwise covered by the medical plan.
Drugs, Homeopathic medicines or homeopathic supplies. furnished by an alternative or chiropractic care provider.
Services of a licensed massage therapist. [Massage therapy].
Although naturopaths are no longer listed on the benefit summary, they continue to be covered. However, they are no longer subject to alternative care member cost-share or benefit limitations. Instead, claims will be processed based on the billed service.
In addition, if a policy covered chiropractors, they were previously reimbursed for “massage therapy” even if massage therapy was excluded under the contract. This is considered discriminatory under the ACA, and we can no longer reimburse any provider for massage therapy unless an employer has an amendment to cover massage therapy for any provider within scope of license.
We will notify our large employer groups of this change by mail within the next week. The notice will explain how we will apply the provision to claims and will show the revisions that will be made to the alternative care and chiropractic benefit summaries.
As always, if you have any questions, you’re welcome to contact your PacificSource Sales or Service Representative.