EHB Discrimination

As I wrote about last week, insurance companies have been doing a great deal of “creative interpretation” in order to make the ACA guarantee only what insurers intend to cover. We see this very clearly with Section 2706: the broad, umbrella coverage of “any health care provider” has been reinterpreted to mean… well, nothing.

In the state of Oregon where I work, I’ve been in contact with the Insurance Division through filing complaints regarding discrimination. It hasn’t been fun.

The process has gone something like this:

  1. I send a list of complaints/denials to the analyst.
  2. The analyst forwards each complaint to the insurance company in question and asks them to explain their actions.
  3. The insurance company replies to the analyst with some reason as to why they denied coverage for this claim.
  4. The analyst forwards the reply to me and tells me that my denial is not, in fact, discrimination under Section 2706.

What’s missing from this chain of events? Something pretty important, actually: Any critical analysis at all of what the insurance companies say. Of course insurance companies are going to defend their actions! It’s the state’s job to tell them when they’re breaking the law. Instead, the excuses are being taken at face value.

After some back-and-forth exchanges, I’ve landed on the overarching reason as to why my massage services keep getting denied: Massage is not considered an Essential Health Benefit.

Way back when Oregon came up with their benchmark plan – that is, a plan that covers all of the Essential Health Benefits outlined in the Affordable Care Act – they did not choose a plan that covered CAM services. Acupuncture, chiropractic, and naturopathic could be added to the plan for an extra fee, but massage was nowhere to be found.

However, just because you say something doesn’t make it true. Massage has been proven to fulfill several of the EHBs in multiple ways. Mental health services. Rehabilitative services. Preventative and wellness services, including chronic disease management. There are documented medical benefits to massage therapy.

But because Oregon decided, however erroneously, that massage therapy did not meet any EHB requirements, LMTs were removed from the (not actually existent) list of “any health care provider” covered by Section 2706.

Most insurance companies aren’t fully denying the service of massage, though. That would effect other provider types who do meet the EHB requirements. Some insurers have placed massage in a category with physical therapy, which means that massage clients need to meet a large deductible before the service is covered, even though other CAM services are available without this hurdle.

Other companies have decided that massage is covered, but only in conjunction with another treatment, such as an chiropractic adjustment or a naturopathic visit. Since LMTs are, by their license, only allowed to perform massage, the only massage therapists who can take advantage of this are those who work under a DC or ND and don’t do their own billing.

…And just like that, we’re back to where we started: CAM coverage for everyone except LMTs. Massage coverage when performed by anyone except an LMT. In what world is a massage necessarily more effective when given by someone who doesn’t have 600+ hours of exclusive training? How can insurance companies claim not to discriminate when they refuse to accept a massage CPT code on its own, but cover the same exact code when it’s coupled with an adjustment or office visit code?

I pointed this out to the analyst, and he just shrugged.

I don’t know if Oregon has drafted a state-specific bill intended to reiterate the aims of Section 2706 (as a few other states have done), but I haven’t heard anything about one. The only reassurance I can find is that the Insurance Division just created a committee to talk about EHB coverage for a new benchmark plan for 2017 and beyond. I wasn’t chosen to be on the committee, but you can bet that I’ll be sharing my opinion.

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One thought on “EHB Discrimination

  1. Pingback: Massage Therapy Portland Oregon - Natalie Weintraub, LMT » Essential Health Benefits

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