This fall, a new era in health

Transcription

1 The Wisconsin Chiropractor s Guide to the Affordable Care Act This fall, a new era in health coverage began. Starting on October 1, individuals and small businesses began purchasing health insurance through the so-called Insurance Exchange for coverage beginning January 1, The initial open enrollment period runs until March 31, After that, open enrollment periods for the Exchange will occur annually between October 15 and December 7. The first day of 2014 also marks the date on which the Affordable Care Act requires most individuals in the United States to have health insurance or face a penalty on their tax return. In 2014 that penalty could be the greater of $95 or 1 percent of taxable income. Penalties increase gradually to the greater of $695 per adult or 2.5 percent of taxable income in For chiropractors, the Exchanges bring opportunity for acquiring By Barabara Zabawa, WCA Legal Resource new patients and helping shape the delivery of health care to bring more value to the system. The Benchmark Plan Wisconsin s Benchmark Plan is the largest plan by enrollment in the largest product by enrollment in the small group market in Wisconsin. That plan is offered by UnitedHealthcare and is dubbed the Choice Plus Definity HAS Plan A92NS. Importantly for chiropractors, the Benchmark Plan covers chiropractic care for manipulative treatment. It does not place any limitations or restrictions on manipulative treatment provided by chiropractors. Therefore, any of the Qualified Health Plans offered on Wisconsin s Exchange must, at a minimum, offer the same coverage for chiropractic care as the Benchmark Plan. Qualified Health Plans are free to offer additional benefits, but, at the very least, all the plans offered on the Exchange must cover unlimited manipulative treatment by chiropractors. Wisconsin s Benchmark Plan also covers outpatient rehabilitation services, such as physical therapy. Such services are limited to 20 visits and must be performed by a Physician or by a licensed therapy provider. The Benchmark Plan defines a physician as any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law. (See Obamacare on page 16) Inside This Guide Which Plans are Where? p. 15 What s a Qualified Health Plan? p. 15 Exchange Enrollment Outlook p. 16 Maximizing the Exchanges p. 17 The Benchmark Plan defines Manipulative Treatment as: The therapeutic application of chiropractic and/or osteopathic manipulative treatment with or without ancillary physiologic treatment and/or rehabilitative methods rendered to restore/improve motion, reduce pain and improve function in the management of an identifiable neuromusculoskeletal condition. 14 The Wisconsin Chiropractor Fall 2013

2 Which plans are where? Eau Claire County Health Tradition Security Health Plan The variety of plans available on the Exchanges differs on a county-by-county basis. Here are some of the offerings Wisconsinites will find in a selection of six counties. For the comprehensive list of every health plan provider in all 72 Wisconsin counties, please visit Marathon County Compcare Health Services Security Health Plan WPS Health Plan (Arise) Winnebago County La Crosse County Gundersen Health Plan Health Tradition Health Plan Dane County Dean Health Plan Group Health Coop. Physicians Plus Unity Health Plans Common Ground Healthcare Compcare Health Services Molina Healthcare WPS Health Plan (Arise) Waukesha County Common Ground Healthcare Compcare Health Services Dean Health Plan Molina Healthcare WPS Health Plan (Arise) Source: Office of the Commissioner of Insurance What s a Qualified Health Plan? A Qualified Health Plan is an insurance plan that is certified by the Exchange, provides Essential Health Benefits and follows established limits on cost-sharing. The Essential Health Benefits are ten categories of benefits that constitute the minimum level of coverage that insurers in the individual and small group markets must offer beginning January 1, The following service categories comprise the Essential Health Benefits: 1) Ambulatory patient services 2) Emergency services 3) Hospitalization 4) Maternity and newborn care 5) Mental health & substance use disorder 6) Prescription drugs 7) Rehabilitative & habilitative services/devices 8) Laboratory services 9) Preventive/wellness services & chronic disease management 10) Pediatric services Insurers must not impose annual or lifetime dollar limits on Essential Health Benefits. The Affordable Care Act requires plans offering individual and small group coverage must provide coverage of Essential Health Benefits, but exempts large group plans (i.e., more than 50 employees) from offering such coverage. However, if a large group plan covers any Essential Health Benefits, the plan is prohibited from imposing annual or lifetime dollar limits on those benefits. To provide direction as to whether a package of benefits meets the Essential Health Benefits standard, the Affordable Care Act requires each state to have a Benchmark Plan. All plans in the individual and small group markets in a state must offer, at a minimum, benefits that are substantially equal to the benefits offered in the Benchmark Plan, including covered benefits, limitations on coverage, and prescription drug benefits. Fall

3 Exchange Enrollment Outlook 800,000 insurance seekers Who are they? 500,000 Uninsured Wisconsinites 180,000 Insured, but likely to switch 92,000 Transitioned from Badgercare 25,000 On soon-to-be defunct HIRSP (Obamacare continued from p. 14) However, the Benchmark Plan notes that any podiatrist, dentist, psychologist, chiropractor, optometrist, clinical social worker, marriage and family therapist, nurse practitioner, professional counselor or other provider who acts within the scope of his or her license will be considered on the same basis as a Physician. Thus, as long as a Chiropractor acts within his or her scope of practice, he or she could provide and be reimbursed for outpatient rehabilitation services offered through plans on the Exchange. Indeed, state statutes prohibit insurers from excluding coverage for diagnosis and treatment of a condition by a chiropractor acting within the scope of his or her license if the plan covers diagnosis and treatment of the condition by a licensed physician or osteopath. In addition, the Affordable Care Act added language to the Public Health Service Act, which, similar to Wisconsin law, prohibits discrimination by an insurer of practitioners acting within the scope of their state licenses such as chiropractors if the insurer covers those services source: The Wisconsin State Journal when provided by a different class of practitioners. It is possible practitioners could use this provision to argue for equal reimbursement for covered services that are provided at the same level of quality, but such use remains to be seen. It should also be noted that a bill was introduced by Representative Andy Harris on July 24, 2013, H.R. 2817, to repeal Section The ultimate fate of that bill is unclear at the moment. In any event, any plans offered in the Exchange that cover services provided by an MD or DO should also cover those services if provided by a Wisconsin-licensed chiropractor acting within the scope of his or her license. Enrollment Outlook Just how many Wisconsinites will enroll through the Exchange? In September the Wisconsin State Journal reported there may be about 800,000 Wisconsinites seeking coverage from the Exchange. Of that group, about 500,000 are currently uninsured. Another 180,000 buy (See Obamacare on page 17) Exchanges Explained Federal rules define the Exchange as a governmental agency or non-profit entity that meets the applicable standards and makes Qualified Health Plans available to qualified individuals and qualified employers. Individuals and Small Businesses will be able to access the Exchange through the website Exchanges may be operated in one of the following three ways: 1) by the State (State-Based) 2) by the Federal government (Federally-Facilitated Exchanges, or FFEs ) 3) by a State-Federal partnership (State-Partnership Exchanges). The three methods of operation offer different levels of control to states, with the most control going to States that choose the State-Based model and the least control going to States that select the FFE model. On November 16, 2012, Wisconsin selected the FFE model, meaning that the federal government will establish and operate the Exchange. Wisconsin is far from alone: more than half of the states have opted for FFEs. (See Exchanges on page 18) 16 The Wisconsin Chiropractor Fall 2013

4 Two Ways Chiros can maximize Wisconsin s Exchange The Exchanges present two unique opportunities for chiropractors to enhance their practice. 1First, chiropractors should take advantage of the Affordable Care Act requirement that Qualified Health Plans must ensure network adequacy. This standard is set forth in 45 CFR Specifically, this section requires Qualified Health Plans to maintain a network that is sufficient in the number and types of providers to assure that all services will be accessible without unreasonable delay. The Centers for Medicare and Medicaid Services (CMS) will monitor network adequacy through complaints filed with the agency; thus, consumers who complain to CMS that a Qualified Health Plan does not have sufficient types of providers in the plan may subject that plan to CMS review. Hence, if a consumer believes that a Qualified Health Plan has an insufficient number of chiropractors in its network, the consumer can complain to CMS which may prompt the plan to increase the number of chiropractors in its network. 2Second, the Wisconsin Benchmark Plan covers not only manipulative services provided by chiropractors, but also any covered service that would otherwise be covered if performed by a medical doctor or osteopathic physician, so long as that covered service falls within a chiropractor s scope of practice. Under Wisconsin law, the scope of practice for chiropractors is more limited than for medical doctors or osteopathic physicians. For example, Wis. Admin. Code Chir 4.05 prohibits chiropractors from prescribing drugs or administering substances subcutaneously. Chiropractors are also limited in the types of imaging services they may provide. Even though prescription drugs and many imaging services would be covered under the Benchmark Plan, because chiropractors are unable to provide those services, patients will not benefit from receiving those services from chiropractors until the scope of practice for Wisconsin chiropractors is broadened. At a time when hundreds of thousands of patients are likely to gain insurance coverage through the Exchange, chiropractors can seize the moment by expanding their scope of practice to meet an increased demand for quality health care service. (Obamacare continued from p. 16) insurance on the individual market and may begin switching over to the Exchange after October 1, 2013 to take advantage of premium tax credits and cost-sharing subsidies (discussed below). Approximately 25,000 of those residents will be switching from Wisconsin s current high-risk insurance plan, HIRSP, which ceases to exist on December 31, Finally, approximately 92,000 people will be shifted from Medicaid to the Exchange because of Wisconsin s new Medicaid eligibility standards created in the last state budget. The new eligibility standards lower income eligibility for adults in the BadgerCare program to 100 percent of poverty level, or about $11,490 annually, down from 200 percent, or about $22,980 a year; however, about 82,700 childless adults who make less than the poverty level would be added to the program. These 800,000 individuals are possible insured patients for chiropractors, depending upon how popular the Exchange becomes. How many of these 800,000 actually participate in the Exchange will depend upon a number of factors, such as the availability of health plans on the Exchange, the cost of those plans, and promotional efforts/assistance offered to help people buy coverage on the Exchange. The Wisconsin Office of Commissioner of Insurance (OCI) recently released information about the number of Wisconsin plans expressing interest in participating (See Obamacare on page 19) Fall

5 (Exchanges Continued from p. 16) There are also two types of Exchanges relating to who the Exchange serves: 1) Individuals 2) Small Businesses (otherwise known as the Small Business Health Options Program, or SHOP Exchange). Starting in 2014, individuals can select from a number of health plan options coverage. Within those plan options an individual must choose a desired amount of cost-sharing. This amount depends upon whether an individual chooses a Bronze Plan (which pays 60% of healthcare expenses), a Silver Plan (the plan pays 70% of healthcare expenses), a Gold Plan (meaning it pays 80% of healthcare expenses), or a Platinum Plan (which pays 90% of healthcare expenses). Individuals will be responsible for covering the remaining percent of health care expenses, up to a maximum out-of-pocket amount for all plans for in-network coverage. That maximum out-of-pocket limit functions as a cap on the amount individuals must pay towards deductibles, coinsurance and copayments. It does not apply to premiums, non-covered services, or cost sharing for out-of-network providers. The out-of-pocket-limit is tied to the limits in high-deductible plans that are eligible to be paired with a Health Savings Account. Those limits are currently about $6,000 for self-only coverage and about $12,000 for family coverage. In 2014, small businesses (employers with fewer than 50 employees, as defined in Wisconsin) may offer a single health plan option from the choices available in the Federally Facilitated SHOP Exchange, rather than a choice of plan options. Starting in 2015, small employers will be able to offer qualified employees a choice of plans at a single level of coverage selected by the employer. 18 The Wisconsin Chiropractor Fall 2013

6 ( Obamacare continued from p. 17) in the Exchange and the percent increase in premium payment in the individual market. In all, 13 insurers in Wisconsin applied to be Qualified Health Plans in the Individual Exchange and 9 insurers applied to be part of the SHOP Exchange. According to the 2013 Wisconsin Health Coverage Option Report by Citizen Action of Wisconsin, based on this participation level, 100% of all Wisconsin citizens will have at least two insurance company options available to them on the Individual Exchange. Dane and Fond du Lac counties will have the highest number of plans from which to choose at six each. It should be noted that although United Healthcare and Humana did not express interest in participating in the Exchange in 2014, both companies have expressed interest to participate in Although the expressed interest in participation by Wisconsin insurers is robust, the recent premium data released by OCI appears much grimmer. According to the OCI, insurance rates will vary based on a consumer s age and where they live. The highest percent increase will be experienced by younger insured individuals in Madison. For example, a 21-yearold person in Madison will see a percent increase in their premium from 2013 to 2014, whereas a 63-year old person in Kenosha will only see a 9.72 percent increase in premium. Critics of the OCI s calculations are quick to point out that the percent increases do not account for the premium tax credits or cost sharing subsidies that will be available to consumers whose income ranges from 100 to 400 percent of the Federal Poverty Level, or roughly $11,490 to $45,960 for individuals and $23,550 to $94,200 for a family of four. The premium tax credit can be paid directly to the individual s insurance company to help reduce the cost of health insurance for that person or family. (See Obamacare on page 20) BARGE NUTRITION & SUPPLY Our products & prices will make you & your patients smile! For the past 33 years and counting, chiropractors have built trust, seen results, and have enhanced their practices with the help of Barge Nutrition & Supply. This family-owned chiropractic distributor has 14 Doctors of Chiropractic in their own family, so be assured that your expectations are their expectations as well. NEW PRODUCTS! Biospec introduces the NEW state of the art ADAPT - ADREN, for adrenal exhaustion stress related issues. Made with no raw glandulars. Ashwagandha Root Extract (Standardized to a minimum 2.5% total withanolilides) mg Eleutherococcus Senticosus Root Extract (Standardized to 0.8% eleutherosides B, E and F) mg Rhodiola Rosea Extract (Standardized to 3 % rosavin) mg Panax Ginseng Root (Standardized to 14% ginsenosides) mg Other Ingredients: Gelatin and Magnesium Stearate. Gluten Free We d love to hear from you! Call or visit For Professional Pricing: Password: tyler Press green Log in button

7 ( Obamacare continued from p. 20) For example, according to a premium tax credit calculator available on the Kaiser Family Foundation website, a family of four 2 adults and 2 children making $80,000 per year are at 340 percent of the Federal Poverty Level and could receive a tax credit of approximately $3,900, which would cover about 34 percent of the projected $11,547 unsubsidized annual premium for In addition, consumers with incomes up to 250 percent of the Federal Poverty Level $58,875 for a family of four in 2013 may be eligible for cost-sharing subsidies that can reduce the amount consumers pay in deductibles, coinsurance and copayments. Thus, after one factors in premium tax credits and cost sharing subsidies, the overall increase in premium may not be as high for some consumers as the OCI data initially suggests. To help promote the Exchange and assist consumers in determining their eligibility for public assistance, the Affordable Care Act also set aside funding for Navigators and Application Counselors and Assistors. These persons may not sell health insurance or provide advice to consumers about which health insurance plan best meets their needs, but they may guide consumers through the Exchange website and familiarize them with how the Exchange works. The interest level and participation by consumers in the Exchange depends upon the success of the Navigator and Application Counselor program, as well as efforts by health care providers, insurers, the State of Wisconsin and other interested groups. The more consumers that know about the Exchange and their obligations to purchase insurance coverage under the Affordable Care Act, the more likely they are to buy insurance coverage. For chiropractors, that may translate to more insured patients and reimbursement for services Wisconsin s Premier Chiropractic X-Ray Company Specializing in Digital Imaging New & pre-owned X-Ray Systems DR-Digital & CR-Digital Radiography Authorized Dealer For / dhohandley@aol.com PO Box 115, Hartland, Wisconsin Helping Chiropractors Succeed Since 1982