An Update on the Affordable Care Act

The Patient Protection and Affordable Care Act (ACA), was signed into law by President Obama in March, 2010.  The ACA focuses primarily on new consumer protections, improving quality and lowering the costs of healthcare, and increasing access to affordable care. In addition, there are sections in the law that have the potential to support the integration of massage professionals and other complementary and alternative health care providers into state-regulated insurance plans.

The ACA ensures that health insurance is comprehensive by requiring insurance plans to cover essential health benefits. All insurance plans must include these benefits beginning in 2014.

 Section 1302. (b) Essential Health Benefits.—(1) IN GENERAL.—Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories: (A) Ambulatory patient services. (B) Emergency services. (C) Hospitalization. (D) Maternity and newborn care. (E) Mental health and substance use disorder services, including behavioral health treatment. (F) Prescription drugs. (G) Rehabilitative and habilitative services and devices. (H) Laboratory services. (I) Preventive and wellness services and chronic disease management. (J) Pediatric services, including oral and vision care.

Massage therapy is not listed as an essential health benefit; however, it can certainly fit into the covered categories. Research shows that massage therapy has been effective for many health conditions. Patients choose to pay out of pocket for massage therapy because they are seeking non-intrusive ways to improve their health or relieve pain and muscular soreness. Even clients seeking massage for relaxation or stress reduction purposes recognize the health benefits of massage. There is a reason why massage therapy is a multi-billion dollar industry; it is a much desired therapy that is not prevalently offered as a stand-alone health insurance benefit. If it’s covered, it’s usually in conjunction with other rehabilitative services.

Most insurance plans must cover these essential health benefits beginning January 1, 2014. However, states have had a lot of discretion as to how the ACA is implemented, including the authority to further define the essential health benefit categories. In reality though, there was little to no discussion, or desire, among state officials to expand insurance benefits to include massage therapy or any other treatment historically not covered by most health insurance plans. States simply chose an existing health plan in their state to serve as the “benchmark” plan. For this reason, ABMP does not expect to see massage therapy covered more often now than it was prior to the ACA passing.

Section 2706 of the ACA was designed to provide patients with greater access to a variety of providers, which results in better access to healthcare in general and lowers the cost of healthcare.

Section 2706, Non Discrimination in Health Care.  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. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

Some groups interpret this section to mean that when a CAM provider treats any health condition covered in an insurance plan, the CAM provider is eligible for reimbursement so long as the provider is licensed by his or her state and can treat the condition under that provider’s scope of practice. This is where some confusion arises.

ABMP does not believe inclusion of services by massage therapists will prove to be this straightforward. Providers contract with insurance companies and by doing so, accept certain terms and conditions for participating in the plan, including reimbursement rates. Section 2706 specifically does not require that health insurance companies contract with any and all types of providers and there is nothing in the ACA that sets provider reimbursement fees; insurers set fees that are subject to state law and are agreed upon by the network providers that contract with the insurance company.

If a provider is not contracting with an insurance company they are an “Out of Network” provider. Out of Network providers receive an even lower reimbursement rate providing a treatment that is a covered health insurance benefit than an in-network contract provider receives. They would also be held to higher standards for treatment documentation. Payment by the insurance company would take longer at best and reimbursement would not be automatic.

The U.S. Department of Health and Human Services, the federal agency most responsible for implementing the ACA, has already stated they do not intend to issue clarifying regulations on Section 2706, so it will be up to the states to implement this section. Section 2706 goes into effect on January 1, 2014 and, while not perfect, this section of the ACA is an important one to non-MD health care providers and it’s worth protecting.

And it needs protection. In July 2013, Representative Andy Harris M.D. introduced H.R. 2817, which would remove the non-discrimination requirements in Section 2706. The American Medical Association immediately issued a letter of support for H.R. 2817, arguing that this section of the ACA is too vague, conflicts with state scope of practice policies, and could harm patients. ABMP submitted a letter of opposition that can be read here, we will alert members if H.R. 2817 is scheduled for a hearing.

ABMP believes Section 2706 will provide additional justification for insurance companies to reimburse massage therapists. For example, when massage therapy is a covered benefit of a health plan, it is not uncommon for an insurance company to reimburse massage provided by a physical therapist, chiropractor, or osteopathic doctor – but not massage therapy provided by a massage therapist. Evidence shows that massage therapy, especially when performed by a massage therapist, is a cost-effective delivery method of health care.

It defies logic that patients are denied access to a massage therapist, whose primary service is the manipulation of the soft tissue, and are required to see another provider, who provides massage therapy as an ancillary service at a more costly rate. Patients and massage therapists providers will have a more substantial argument to make if they are denied insurance reimbursement just because they aren’t a physical therapist, for example.

HIPAA changes
The Administrative Simplification provisions of the Affordable Care Act of 2010 (ACA) build on the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with several new, expanded, or revised provisions, including requirements for:

  • Operating rules for each of the HIPAA transactions
  • Enumeration of a unique, standard Health Plan Identifier (HPID)
  • New standards for electronic funds transfer and electronic health care claims attachments
  • Health plans to certify compliance with the standards and operating rules
  • Penalties for health plans that fail to comply or to certify their compliance with applicable standards and operating rules.

The US Department of Health and Human Services issued new HIPAA rules in 2013 that change some aspects of the current law. ABMP has provided a summary on as well as a link to the entire rule. If you bill health insurance, you must comply with HIPAA requirements.

Do you need health insurance?
There are more than 45 million people uninsured and many more under-insured in this country. Decreasing this number is the first priority of the ACA. If you are uninsured, please be aware that starting in 2014, most people must have health coverage or pay a fee (the “individual shared responsibility payment”). If you have job-based insurance, you are already covered.

ABMP members generally mirror these national patterns. When we last checked, approximately 3/4 of members possessed health insurance. A good portion of the remaining 25% will qualify for insurance through ACA state exchanges, with a number of them qualifying for partial subsidies. It’s worth checking out.

For people who don’t have health insurance from an employer and must buy it on their own, states have either set up their own health insurance marketplace, will work with the federal government to co-run the state marketplace, or have opted to have the federal government run its marketplace. This is the new way to find quality health insurance coverage. Open enrollment begins October 1, 2013 and coverage starts as soon as January 1, 2014. If you are currently uninsured or want to look at other insurance options, now is the time for that assessment.

Insurance plans in the Marketplace are offered by private companies and cover the essential health benefits previously mentioned in this article. These are the services that all insurance plans must cover beginning January 1, 2014. No plan can turn you away or charge you more because you have an illness or medical condition. They must cover treatments for these conditions and plans cannot charge women more than men for the same plan. Many preventive services are covered at no additional co-pay or cost to you other than the premium.

If you are interested in shopping for an insurance plan through your state exchange or the Marketplace go here ( , enter your state, and you will be directed to next steps. It is important to note that by completing one application, you’ll be able see all the plans and programs you’re eligible for and compare them side-by-side. You’ll also find out if you qualify for discounted rates on monthly premiums and out-of-pocket costs, which is dependent on your income and the size of your family.

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