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Wellness Coverage and Obamacare

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Everyone is talking and worrying about the Affordable Care Act (ACA), which became law in 2010. Much of the focus on Obamacare these days is on the "individual mandate" provision, which will require almost everyone to have health insurance coverage starting Jan. 1, 2014. What has received less attention are the provisions for preventive care and potentially increasing access to health care providers who practice from a whole person, naturalistic perspective.

Preventive Coverage

For decades, insurance coverage for routine disease prevention exams was spotty. Gradually, more insurers have included some coverage for preventive exams. But that care was often prohibitively costly until a deductible was met, and both deductibles and premiums have been increasing by leaps and bounds. Especially during these economically challenging times, people have been trading lower premiums for higher deductibles. For the millions of uninsured, preventive exams are simply unaffordable luxuries.

That changed for all new health plans and policies issued on or after Sept. 23, 2010. Under the ACA mandate, insurers were then required to cover certain preventive services without requiring any cost-sharing. That means no out-of-pocket payments and no waiting to meet deductibles.

Among the 15 covered services for adults are immunizations, screenings for blood pressure, cholesterol, colorectal cancer and depression, as well as diet and alcohol abuse counseling. Coverage for children includes 26 preventive services ranging from immunizations to a host of developmental and other screenings. Specific provisions for women were expanded in 2012 to include well-woman visits, contraception and domestic violence screening and counseling. In 2012, the Department of Health and Human Services (HHS) estimated that 54 million Americans had received preventive benefits without cost-sharing. For details about the coverage, see here.

Medicare beneficiaries also began to benefit from ACA preventive care mandates in 2011, when cost-sharing for certain preventive services was eliminated and coverage for personalized prevention plans and annual wellness visits was initiated.

Preventive care is one of the 10 required services to be offered by all insurers that will participate in their state's health insurance exchanges. These online marketplaces, which are being built right now, open for business Oct. 1. They will be the source for purchasing mandated health insurance for individuals and small businesses, which will become effective Jan. 1, 2014.

Employer Incentives

Prior to the passage of the ACA, workplace wellness programs had been required to comply with a number of state and federal requirements, including one that allowed employers to offer a financial incentive to employees for participating in a wellness program of up to 20 percent of the total annual cost (employer and employee) of the health plan. Gym membership discounts, smoking cessation and weight loss programs have been the most common offerings.

In 2014, that incentive will be increased to 30 percent for workplace programs. In addition, there will be further clarification of what type of intervention qualifies as a wellness program and the initiation of 10 pilot programs in the individual marketplace.

Improved Coverage for Holistic Practitioner Care

As described above, there has been some definitive progress made in insurance coverage for disease prevention under Obamacare. But how disease gets treated and by what type of heath care practitioners are still issues that limit most Americans from access because of insurance coverage exclusions and limits.

The ACA will be providing a potential new opening for some types of holistic practitioners who have been struggling for decades to be included on equal footing with medical doctors (M.D.s) and doctors of osteopathy (D.O.s) for the delivery of primary care services. Section 2706 of the ACA, the "anti-discrimination" provision, becomes effective Jan. 1, 2014.

The provision states that insurance companies and group health plans cannot discriminate against any health care provider who is acting within the scope of that provider's license or certification under applicable state law. One professional group that stands to benefit is doctors of naturopathic medicine (N.D.s). N.D.s are trained as primary care providers. They learn to treat all aspects of family health and wellness, from pediatrics to geriatrics. Their scope of practice may include everything from nutrition and botanical medicine to clinical diagnosis. In some states they are even licensed to prescribe the same drugs as M.D.s and D.O.s.

Naturopaths are currently licensed to practice in 16 states. Some states, such as Washington, Oregon and Vermont, already require that state-regulated health plans cover naturopaths in their networks for the treatment of conditions within the scope of the profession. This new provision has the potential to expand insurance coverage for naturopathic care in other states as well. Chiropractic doctors (D.C.s) and licensed acupuncturists (LAcs) have been included in some insurer network panels for years, but coverage, when offered, is usually for a limited number of visits or for minimal payments. The 2014 provision may enable more widespread coverage of these practitioners as well.

It's too soon to tell exactly what these changes will look like, as there is often a gap between regulation and implementation -- and each state will define its own specific rules. But complementary and alternative medicine (CAM) and integrative healthcare are included in seven separate sections of the ACA. Those of us who have been promoting such changes are hopeful that the nearly 40 million Americans, according to the National Center for Complementary and Alternative Medicine, who visit naturopaths, chiropractors, acupuncturists and other licensed CAM providers will soon experience some financial relief. The best places to check for updates are the professional associations: http://www.naturopathic.org, http://www.amerchiro.org, http://www.aaomonline.org.

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