Friday, June 24, 2016

The Affordable Care Act and Acupuncture coverage or ObamaCare and Acupuncture

Keywords:  Affordable health care act, “Obamacare”, insurance coverage for acupuncture, non-discrimination in health care, essential health benefits
The patient protection and affordable care act

The Affordable Care Act, (ACA), also nicknamed "Obamacare", while long and complex had some important nods to integrative medicine.
The Act noted that integrative medicine, which includes acupuncture, chiropractic, and massage (not all therapies listed) decreases the overall cost of healthcare.  Integrative medicine decreases complications from surgery, improves recovery rates, and improves quality of life.  It is based on a wellness model and that the maintenence of wellness is paramount to life and prevention of chronic disease.  The Act noted that chronic disease has been on the rise in the U.S. in the past few decades and that a wellness model for medicine is much needed.  [For more about this discussion, I recommend the Escape Fire documentary (rated by Roger Ebert) and the Bravewell Collaborative.]

The conclusion of this recognition of integrative medicine as national way to reduce health care costs was to require integrative medicine therapies be available as an option to all Americans.  This aspect of the federal act broke down when the states were allowed to pick and choose what they wanted to name as essential health benefits as their state version of the federal ACA.  Most states picked only a few of the therapies.  I do not think any state picked all possible integrative medicine therapies.

So, how the ACA/Obamacare works in your state and your access to integrative medicine as covered care varies greatly by state.  The Act directly affects those Americans who are on "the Exchange", the new federal-state insurance coverage (now in its toddler years) versus a private insurer.

Acupuncture is an Essential Health Benefit in 6 states
Essential Health Benefits, Section 2707.
Acupuncture is an Essential Health Benefit (EHB) in 6 states:
New Mexico
New Jersey—but limited to services in lieu of anesthesia

The paraphrased reference from ACA:
Section 2707.  Comprehensive insurance coverage.  (a) Coverage for essential health benefits package.  –a health insurance issuer that offers health insurance coverage in the individual or small group market shall ensure that such coverage includes the essential health benefits package required

In Washington state, the EHB is as follows:
Acupuncture 12 visits/year and unlimited for ddx of substance abuse
Chiropractic manipulation 10 visits/year
Rehabilitation 25 visits
Diagnostics—no limits (E&M)
Preventative care—no limits

This is mandatory on individual “exchange” policies.  Non-exchange policies may not have same benefits

In Washington state, the "every category of provider" law also applies:  RCW 48.43.045

The Non-Discrimination in Health Care 2706
Basically, if your health care plan covers acupuncture performed by a physician but not by a L.Ac./EAMP, then that health care plan is discriminating and not compliant with federal law.

Non-Discrimintation 2706—scope of practice (physical medicine and rehabilitation services, E&M, nutrition, etc)
Section 2706 Non-discrimination in health care.
(a)    Providers.  –a group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.
2706 applies when:
Payment is equal for services and not based on provider
Services done by an L.Ac. within scope cannot be limited differently from other providers
An insurer or group health plan cannot deny specific forms of care provided by an L.Ac. when those services are within scope and covered with other providers
LAc.s as a profession cannot be excluded as a group from participation in a network’s plan.

Technical jargon
Plenty of technical stuff above.
Generally, the world of insurance can be a maze to navigate.  Paying out of pocket for services is an option and used to be the only option 50-100 years ago in our country.

coverage by insurance--Remember:  insurance companies cover procedures and private insurers do this arbitrarily in the U.S.  CMS (Medicare—a federal insurance) goes through a data collection process to determine code value and then goes through [some process] to determine whether or not it will cover a procedure, etc.

More about EHB and WA state, a link to the Lund Report

Related posts:
Acupuncture covered by Worker's Comp in many states
the VetChoice program

The Patient Protection and Affordable Care Act, 111th Congress of the United States, H.R.3590. 


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  5. Dear Megan,
    Can you please provide source used to create the table in the post "" which indicates Worker's Compensation is covered by state of West Virginia. I will appreciate your help as I have to represent myself to fight for treatment of pain which has not resolved itself due to constant denials by the insurance company administrating my claim for last 5 years. I will appreciate your help and support if I can present my argument in front of the Office of Judges on Nov 9th by when I must submit my response to a hearing. I can be reached at 304 690 1687 or

    1. That post was from 2016.

      For most recent information on acupuncture coverage by workers' comp, contact the AAC Info Network, which does training for Acupuncturists and their admin and billing staff on coding and billing in the field.

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