Health Care Reform Update
By Barbara Griswold, LMFT
(November 12, 2012)
With the election behind us, the country can now turn its attention to the healthcare overhaul. The Patient Protection and Affordable Care Act (also known as the ACA) was enacted in 2010, but the bulk of the provisions will go into effect in 2014. Many of you are wondering what this will mean for you and your practices. Let’s review what we’ve gained so far.
Some benefits already in effect include:
- Coverage for adult children was extended until their 26th birthday, even if the child is married, not living at home, is in school, employed, or financially independent
- Plans can’t deny coverage for children under age 19 with pre-existing conditions
- A temporary plan (PHIP) for adults with health conditions, uninsured at least six months
- Plans can’t cancel coverage when a client gets sick
- Forbids annual or lifetime limits on coverage
- Plans must provide certain preventive services at no cost to the client (see the list of free covered services)
- States received funding for consumer assistance programs to help clients with insurance problems
- Prescription drug costs were cut in half for some Medicare clients
While the current employer-based insurance system will still survive, the reform calls for:
- New state health insurance exchanges to enable individuals and small businesses to shop for private insurance
- The expansion of eligibility for Medicaid, the federal/state program for the poor and disabled
- Tax credits to help people (and small businesses) to afford coverage
- A requirement that all U.S. citizens and legal residents have basic health coverage, if they can afford it, or pay a fee to offset the costs of caring for uninsured Americans
- Penalties for some employers that do not offer health insurance
In the coming years, we will see more reforms and benefits:
- As of 2014, plans may no longer deny coverage (or charge more) for adults due to their health condition or gender
- New plans must now include mental health as a basic service, and mental health/substance abuse coverage must be at parity with (equivalent to) medical coverage
- Plan acceptance/renewal is guaranteed, and coverage may not be rescinded (except for fraud)
- The law encourages integrated, preventive care and coordination of care
What will this mean for therapists? Hard to tell at this stage. But here are my predictions:
- Almost every client who calls you may now have some coverage for mental health services. It may get a bit harder to convince clients to pay out of pocket, if you are not on their network.
- Insurance plans may be recruiting new providers. 20-30 million previously uninsured clients will either be purchasing private insurance, getting insurance through the new state Exchanges, or joining the expanded version of Medicaid. With all these new members, plans will likely need more providers.
- New opportunities for previously excluded providers. The law forbids plans from discriminating against health providers with respect to plan participation. While it does not require a plan to contract with every available provider, it does prevent them from excluding an entire type of provider from its network.
- Providers will be encouraged to embrace electronic health records and billing to decrease fragmentation of care, and improve quality of (and coordination of) care.
- There will be new opportunities in community or group health settings, including those supporting primary care practices, where interdisciplinary and integrative care is possible. This could mean a loss of autonomy for those who otherwise would be private practitioners. On the plus side, it could mean more holistic care, more physician referrals, lower costs, and the shared resources of a clinic (i.e. the agency might handle billing).
- “What about private practice?” No immediate changes are foreseen in terms of the way we do business. The current employer-based insurance system will not go away. However, if more therapists move into interdisciplinary settings, practitioners working alone in private offices could become less prevalent.
- “What about reimbursement?” This remains to be seen. I believe private insurance carriers will be asking current providers whether they want to participate in the new plans they are developing. And they may be asking providers to accept lower-than traditional reimbursement rates as they enter this highly uncertain and lower-premium market.
- “I don’t really understand the Exchanges.” Join the club. Each state is currently figuring out how they will structure their exchange, or whether they will let the federal government come in and set it up. Therapists will likely provide services in the same way they do now, and will negotiate fees directly with the Exchange.
- Best of all, more clients can afford your services. This influx of people into the private and Medicaid market, and the requirement that mental health services be offered – and at parity – has great potential to increase America’s use of mental health services.
For more detailed information about the Affordable Care Act, visit the government’s amazingly user-friendly website at http://www.healthcare.gov.
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Barbara Griswold, LMFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should. To purchase the book or other resources for therapists, click here. Contact Barbara at firstname.lastname@example.org to get answers to your insurance questions.
Copyright 2008-, Barbara Griswold, LMFT. No part may be reproduced without written permission of the author.