Home > Uncategorized > Making Sense of the System

Making Sense of the System

The Patient Protection & Affordable Care Act is at the forefront of many health care providers minds these days, but with all the new terms being used it is easy to become overwhelmed.

Patient Protection & Affordable Care Act (PPACA) – The official name for the entire health care reform package. Also referred to as Affordable Care Act (ACA), National Health Care Reform, and Obamacare.

State Based Exchanges – Think of the Exchange as an online marketplace where the public can get information, compare, and then choose their own health insurance plan. Much like a Travelocity, Priceline, or Expedia for health insurance.  The main difference is that this exchange will be established, run, and monitored by either state or the federal governments.

Essential Health Benefits (EHB) – The broad package of services that must be covered by any plans within the Exchanges as well as Medicaid (by 2014).

Benchmark Plan – A plan identified as a ‘typical’ health care plan within a particular state. This provides a baseline of coverage for the EHB, and Illinois has chosen Blue Cross/Blue Shield’s BlueAdvantage plan. If a plan within the exchange modifies or removes a service that was covered in the benchmark, they must replace that service with another of equal actuarial value within the same category.  Note: chiropractic care is listed within the same category as other primary care providers (ambulatory services), separate from other physical medicine providers such as the physical and occupational therapists (rehabilitation).

Non-Discrimination Clause – Also known as the Harkin Amendment, this was language pursued by organizations such as the American Chiropractic Association to ensure provider equality under the PPACA.  Specifically it states that health insurance coverage cannot discriminate against any health care provider acting within their state scope.  Staunchly opposed by the American Medical Association.

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Categories: Uncategorized
  1. October 12, 2012 at 2:07 pm

    Could it not be argued that these third party parasite company arrangements violate the non discrimination clause because they set different standards for a profession or group of professions based on their license?

    • October 12, 2012 at 3:05 pm

      “Could it be argued…?” Yes. Without a doubt.

      The ICS has pursued this on a state level in years past but we were denied. In light of this new language however, we believe there is a much stronger case that can be made (and at the federal level). The ICS supports the American Chiropractic Association in its efforts with that very argument and seeing that it is a federal matter, we defer to them on much of this topic.

    • Steven Santolin
      October 13, 2012 at 7:01 am

      Thanks Rob. Yes, I can see that federal law should carry much more weight than state law in this regard. Probably even more so now that ERISA will apply to all insurance plans.

  2. October 12, 2012 at 2:11 pm

    One more question. As we are licensed as primary care in the Medical Practice Act so our services are considered ambulatory care, does that fairly guarantee that our services will be an essential benefit in the exchange plans?

    • October 12, 2012 at 3:48 pm

      Alright, this one is a bit tricky but I’ll do my best. Primary care is frequently used in a very casual sense but if you are talking about legal terms, with regard to chiropractic, it is mentioned a few times in some of the rules and regs – not specifically the laws or acts.

      Ambulatory care is one of the 10 Essential Health Benefit Categories under the Affordable Care Act: http://www.healthcare.gov/news/factsheets/2011/12/essential-health-benefits12162011a.html

      Chiropractic Care IS listed under the Ambulatory category, instead of under the rehabilitation category. Individual insurance companies are able to modify the specifics under each of the 10 broad categories, but can only change one service for another of equal actuarial value within the SAME category. This means that chiropractic care can not be bargained or traded away for additional PT or OT services, but instead may only be traded for other ambulatory services.

      So does it guarantee anything? No. However, when an insurance company begins to tailor a new insurance plan for the market, the benchmark that it must start from does include chiropractic care. There is no guarantee against any one provider type being cut out of a plan altogether (the “any willing provider” didn’t make it into the final version.) Basically we are in about the best position we could hope for at this point in time, but there are no guarantees.

    • October 12, 2012 at 3:57 pm

      Also, as a final note. The Illinois Chiropractic Society has taken a strong position that even if “chiropractic care” is removed by any particular insurance plan, the anti-discrimination language protects our doctors from being denied from performing other covered services that are within our scope. This means that you couldn’t be discriminated against for performing physiotherapy, issuing orthotics, nutritional counseling or smoking cessation (to name a few) if the insurer is paying for those services to be done by another provider type.

  3. Steven Santolin
    October 13, 2012 at 7:13 am

    Yes, that was a poor choice of words on my part. I know that there is very little guaranteed with the ambiguity of many laws 🙂
    I know that insurance companies and others commonly misuse the profession titles chiropractic and physical in place of manipulation and physical medicine, but when you talk about “chiropractic care” being removed from an insurance plan are you referring to manipulation?

    • October 15, 2012 at 10:47 am

      The word choice is where all of this starts getting tricky, and is going to be something I will be focusing on at the Statehouse. I should also take a moment to emphasize that the importance of the manipulation and ensuring that it is a covered service is something we argue very strongly for. This is evidenced by our Medicaid packets touting the cost effectiveness of the chiropractic adjustment during last session. However, with regard to the Essential Health Benefits, locking in any one specific service (chiropractic manipulations, physical therapy, or any other) is not an option. We are instead using this time as an opportunity to take a better look at what is meant when an insurance company talks about “chiropractic coverage.”

      This isn’t a philosophy argument or any other such debate about what chiropractic should or should not be, this is a legal discussion of terms. If insurance companies have a list of 50 individual types of service, and when it says “chiropractic” that should refer to the chiropractic specific service of the manipulation. There have been select instances however when an insurer has taken “chiropractic” to mean the provider type. We believe this is a double standard that needs to be addressed.

      If an insurer chooses to limit “chiropractic” then we believe that should be referring to the chiropractic manipulation only as a specific service. It should not be interpreted to mean any and all services that may be performed by a DC.

  4. October 15, 2012 at 2:04 pm

    I agree Rob with the arguement that ‘chiropractic’ should be considered to refer to CMT only. There is so much more that we do that is not a specific spinal adjustment. Keep on fighting to make that door stay open to us.

  5. October 17, 2012 at 11:58 am

    Thanks very much Rob for the info!

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