Laura Culberson Farr
Implementation of the Affordable Care Act (ACA) across the country has been confusing at best, and in some states truly reminiscent of the wild Wild West. With every lawyer, insurance company, and government agency seeming to have different ideas on how to interpret various parts of the ACA, implementation of the law is proving to be bumpy for everyone, and naturopathic physicians are no exception.
Not surprisingly, implementation of the ACA is big news, and people ask me all the time, “So how will ObamaCare change life for NDs?”
The best way to respond is this: “We know what should happen. But making sure it does happen is a little more tricky.”
What Should Happen
The ACA says insurers “…shall not discriminate with respect to participation under the plan or coverage against any health care provider acting within the scope of that provider’s license or certification under applicable state law.”
(Section 2706(a) of Public Health Service Act, created by the Patient Protection and Affordable Care Act, Section 1201)
It’s important to note first that Section 2706, also known as the Harkin Amendment, after Senator Harkin who drafted it, applies only to naturopathic doctors in licensed states and only to commercial insurance plans issued or renewed after January 1, 2014. This includes large employer plans (called ERISA plans), group plans, individual health insurance plans, and plans sold through the healthcare exchanges. It does not apply to Medicare or Medicaid (except in Oregon, where state law includes identical non-discrimination language for Medicaid insurers.)
The provider non-discrimination provision should change insurance coverage of naturopathic medicine in the following ways:
- Coverage – if an ND in a licensed state performs, orders, or treats something that an insurer would normally cover when done by another provider (eg, an MD/DO), then the insurer should also cover it when done by an ND. Any additional barriers, caps, limitations on scope, or different co-pays or deductibles would constitute discrimination.
- Participation – What should also happen is that insurers would need to contract with at least some NDs in their networks, as the law clearly states that insurers may not discriminate “with respect to participation” in the plan. The law is not an “every willing provider” law, meaning insurers are not required to contract with anyone willing to sign a contract; they still can put limits and controls on their networks. But the intent of the law is that insurers shall not discriminate against entire categories of providers (ie, “Plan X doesn’t contract with NDs, period” would constitute discrimination).
- Reimbursement – The law goes on to say that reimbursement rates may only vary based on “quality or performance” measures. So, assuming that naturopathic physicians provide similar or better quality of care and help insurers meet their performance benchmarks, NDs theoretically should be paid commensurately with other providers.
But all told, the potential of this one paragraph of the Affordable Care Act is, obviously, unprecedented in its potential to clear the way for patients of naturopathic doctors to finally get insurance coverage for their provider of choice.
What is Happening
AANP and state leaders have been meeting with insurance commissioners, insurance companies, and elected officials in almost every licensed state since the summer of 2013. Since Section 2706 is but 1 tiny paragraph buried in a 1000-page document, most conversations started from a place of very little – if any – awareness of the provision.
Are we starting to see some movement? Yes – absolutely!
Some insurers are taking steps to come into compliance with Section 2706. Indications we’ve seen include:
- Blue Cross Blue Shield’s benefits plan for federal employees states that they will now cover any licensed provider for covered services as required by Section 2706
- The White House response to the naturopathic community’s petition to include NDs in the Affordable Care Act reaffirmed that Section 2706 means insurers may not discriminate against providers in their networks
- Some insurers are doing away with caps, limitations, scope restrictions, and more
- Carriers like the Oregon Health Co-Op are credentialing NDs as Primary Care Providers – with close to 100 NDs contracted in network already!
The Bumps Along the Way
Yet, despite efforts to be proactive with administrators and insurers in implementing the law before its effective date of January 1, 2014, we are now seeing that non-compliance with Section 2706 is fairly widespread.
Many commissioners have different interpretations of the provision and/or are not interested in enforcing the law. No state insurance commissioner has made efforts to proactively offer clarification or guidance to insurers to establish expectations on how the law should be implemented.
Inexplicably, many insurance carriers and commissioners are also asserting that “participation in the plan” still means that they can exclude entire categories of providers from their networks. What seems like clear language in the law to most people is, I suppose, not so clear to those who don’t wish it to be so.
Insurers have also not defined what “quality and performance” metrics will be, or how they will peg reimbursement rates to them – leaving this a very gray area.
Without clear guidance to insurers from either federal agencies or state insurance commissioners, we are seeing very uneven implementation of the non-discrimination provision – with some insurers coming into quick compliance, others rolling out implementation in phases, and others who are yet completely unaware or completely dismissive of the law.
Why Does It Matter?
This single provision of the ACA holds the possibility of opening insurance panels, coverage, and patient access to naturopathic physicians in all states where they are licensed.
This does not mean that every ND in licensed states will be forced to take insurance. It just means that if you are so inclined, you will legally have the opportunity.
Securing insurance coverage for naturopathic medicine will lead to many downstream effects, including:
- Naturopathic doctors will be on more equal footing with other providers with commensurate training
- More patients will have access to naturopathic medicine
- More consistent reimbursement and access to patients will help financially support many NDs currently struggling under the weight of over $200 000 in medical school debt
- More students will come to naturopathic medical schools knowing their chosen profession is accepted by mainstream health systems and that their clinics will be financially viable
- Insurance coverage and broader utilization of naturopathic medicine will eventually pave the way for recognition of naturopathic doctors by Medicare and Medicaid, loan repayment programs, the ability to serve in the Public Health Service Corp, and so much more
Ultimately, what we all strive for is to improve healthcare of the masses through the principles and practice of naturopathic medicine, and that can only be achieved by making sure that the masses have access to naturopathic doctors. Section 2706 is a tremendous opportunity to achieve just that.
AANP’s Priority
For all these reasons, enforcement of the non-discrimination provision is a top priority for the AANP and many state associations in licensed states. Here’s what we’ll be doing, and how you and your patients can help:
- Naturopathic doctors and their patients in licensed states can take action by signing through AANP’s website www.CoverMyND.org to encourage your elected officials to enforce the law.
- State associations and state leaders in licensed states are invited to join AANP’s monthly strategy meetings on implementing Section 2706. Email Mike Jawer, AANP’s Director of Government and Public Affairs, for details at [email protected].
- Contact your state association in licensed states to see how you can help. For example, Oregon and Montana NDs are currently being asked to file complaints with the state insurance commissioner anytime they encounter what seems like discrimination under Section 2706.
Ironing Out the Bumps
We all have to be realistic that any time of great change is never a smooth journey.
But on a positive note, the process of ironing out these bumps in the road is giving us all the opportunity to educate insurers, commissioners, state leaders, medical directors, and administrators alike about naturopathic medicine and the important role we play as we move into a new healthcare paradigm.
A difficult and bumpy road it is, yes…but the only thing that we can achieve through the journey is better awareness, better communication, better understanding, and ultimately better coverage and healthcare for patients who turn to naturopathic doctors as their provider of choice.
So put on your safety belt…or maybe grab the 5-point safety harness. Blue skies await for those willing to forge ahead through the storm of implementation!
Laura Culberson Farr has served as Executive Director of the Oregon Association of Naturopathic Physicians since 2005. She also co-chairs the State & Federal Affairs Committee of the AANP. A political organizer by training, her advocacy work as a grassroots organizer and consultant spans almost 20 years. She has a deep knowledge of the complexities of healthcare reform, and has become an expert on how naturopathic doctors, conventional clinics, and insurers can work together to improve patient care and reduce healthcare costs. She is married to a naturopathic physician and is passionately committed to integrating naturopathic medicine into primary care systems across the country.
