Health Care Reform Update

One of the key provisions in the bill is Sec. 2706, the provider non-discrimination section, which attempts to outlaw health insurance plan discrimination against providers based on their license or certification.

The provision is a federal protection applicable to ERISA and other private health insurance plans established or regulated under the bill including both insured and self-insured plans. The provision does not take effect until January 1, 2014, and the ACA will be working vigorously to ensure that the regulations that are ultimately adopted are genuinely effective and accurately reflect congressional intent. Draft regulations to implement the Sec. 2706 have not yet been released and are not expected to be finalized until much later in the regulatory process.

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A major regulatory battle over the provisions is expected, as it is anticipated that insurance company and some employer interests may attempt to significantly weaken the reach of the provision via the regulatory process. Also, the American Medical Association has declared its intent to “condemn and repeal” the non-discrimination provision. The ACA is already working with a large coalition of non-MD provider groups, known as the PARCA Coalition, to ensure the provision is effectively implemented – and to also ensure that any legislative attempts to “repeal” the provision will be defeated.

Essential Benefits

Another important issue concerns how “essential benefits” are defined under the new law. Under PPACA an “essential benefits” package for plans to be sold through new marketplaces called “exchanges” will be established. The statutory language defining the broad outlines of the essential benefits package is written in such as manner as to allow for the inclusion of chiropractic benefits, but the language does not specifically include them or any other provider-specific service. Under PPACA a strong argument can be made that chiropractic services fit under the general categories of ambulatory patient services, rehabilitative services or preventive and wellness services.

The precise services included in the essential benefits package will be made clear during the regulatory process. The opportunity to provide public comment has not begun, but the ACA and Summit partners will work to ensure they are written in a manner favorable to chiropractic patients and providers.

While the non-discrimination and essential benefits provisions are a long way from resolution, one important provision is well on its way towards final implementation. This is the provision that will allow some plans to obtain “grandfathered status” – and thus maintain their current structure and thus escape the application of some of the PPACA’s provisions, including Section 2706.

ACA President Dr. Rick McMichael submitted comments to HHS regarding the grandfather status of plans, as it is in the interests of the profession to limit the number of plans that do not have to comply with Section 2706.

The interim final rule provides seven triggers that would revoke the grandfathered status of a group health plan:

• Mergers or acquisitions with the sole intention of maintaining grandfather status
• Elimination of substantially all benefits to treat a particular condition
• Elimination of benefits for any element necessary to eliminate or diagnose a condition
• Any change to coinsurance level
• Fixed-amount cost-sharing (Deductibles/OOP) Inflation +15%
• Co-payments (Medical Inflation +15% or $5 adjusted for medical inflation)
• Employer contribution (> 5% reduction in Employer Contribution)

Seemingly straightforward, these guidelines may still result in marketplace confusion in their application and so ACA continues to monitor the progress of the rule. The rule is not final – grandfathering regulations were issued in an interim final rule effective June 12, 2010, and will be considered as having the support of the law until HHS issues a confirmation of the IFR or issues a revised final rule. ACA expects the final rule to be promulgated early next year.

Finally, as most DCs practice in individual or small group practices, you should be aware of activity on the small business front. In 2010, businesses with fewer than 50 employees will get tax credits covering 35 percent of their health care premiums, increasing to 50 percent by 2014. Next year, a plan to provide a vehicle for small businesses to offer tax-free benefits will be created. This would ease the small employer’s administrative burden of sponsoring a cafeteria plan.

The ACA is closely monitoring any and all developments that are occurring through the regulatory process and the ACA is working to ensure that our contacts on the Hill and at HHS are aware of the concerns of the chiropractic profession.

Updates on ACA’s regulatory actions can be reviewed at www.acatoday.org/hcr and in all ACA publications.