Acupuncture Added As Essential Health Benefit in California
Section 3502 of the PPACA, aka “Obamacare”, states that primary health care practitioners must “provide coordination of the appropriate use of complementary and alternative (CAM) services to those who request such services.”
On Sept. 30, 2012 Gov. Jerry Brown signed measures SB 951 and AB 1453, which included acupuncture to be covered under the federal health reform also known as the Patient Protection and Affordable Care Act (PPACA) that was signed into law on March 23, 2010.
The two measures included acupuncture as an essential health benefit that the state can begin to offer through federally subsidized plans for individuals and families as well as unsubsidized plans. According to the plan, patients would pay a $30 co-pay for acupuncture services to treat “nausea and chronic pain.”
Essential health benefits were defined in the federal Patient Protection and Affordable Care Act (PPACA). It is up to individual states to determine the precise details of the essential health benefits that are broadly outlined in the federal law. This new California law defines and enacts provisions for California essential health benefits and includes acupuncture for the treatment of pain and nausea. Other services defined as essential health benefits include ambulatory patient services, hospitalization, maternity care, newborn care, vision screening and tobacco cessation.
This new law and its acupuncture provisions apply to all individual health insurance policies and small group policies including all HMOs and PPOs. Small group policies are all policies written for companies with 50 or less employees. In 2016, the definition of small group policies changes and the new California law will apply to all companies with 100 or less employees.
The new California law does not apply to self-insured plans, grandfathered plans and large employers. Grandfathered plans are those plans officially designated as a grandfathered plan as of March 2010. Any grandfathered plan that has either a change in benefits or cost structure will no longer be considered a grandfathered plan and will no longer be exempt from the new law’s provisions. As a result, the impact of grandfathered plans is expected to be minimal.
The definition of essential health benefits as stated in this new California law was formulated using the Kaiser Permanente Small Group Agreement Plan 1637 Plan 3-N as a basis for determining standard medical provisions for health insurance policies originating in California. Medical treatment limitations can be no greater than those imposed in the Kaiser plan. As a result, no cap on the maximum number of acupuncture office visits per year may be imposed although a physician’s referral may be required by some health insurance plans.
Commencing January 1, 2014, existing law, the federal Patient Protection and Affordable Care Act (PPACA), requires a health insurance issuer that offers coverage in the small group or individual market to ensure that such coverage includes the essential health benefits package, as defined. PPACA requires each state to, by January 1, 2014, establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans by qualified individuals and qualified small employers. PPACA defines a qualified health plan as a plan that, among other requirements, provides an essential health benefits package. Existing state law creates the California Health Benefit Exchange (the Exchange) to facilitate the purchase of qualified health plans by qualified individuals and qualified small employers by January 1, 2014.
Debra Gorman Acupuncture is happy to check your benefits and work with billing insurance. Please call 707-284-1402.