GREAT STRIDES IN THE CASE FOR ALTERNATIVE PROVIDERS IN NEW JERSEY!

14Dec 2018 by Ralph Fucetola 12522 Comments

The Affordable Care Act’s “Provider Nondiscrimination” Clause
Requires Insurance Carriers to Cover Holistic and Integrative Therapies
https://fundly.com/support-natural-therapies/

I have been working closely with an integrative practice in New Jersey for years helping them stand up to the state medical board and Horizon BCBS as their practice has been harassed since 2012. By the way, since this practice first opened in 2002, not one patient has ever filed a complaint. 

When the state medical board and the largest insurer in the state set their sights on an alternative medicine practices, they usually shut the practice down. This is because most alternative providers can’t afford a multi-year a legal defense.

However, with a little support from folks like you, a judge just ruled against Horizon BCBS as it asked the judge to rule in its favor without going to trial. The law firm handling this case says it doesn’t know of another example where a small provider survived this type of Summary Judgment attack!

The Affordable Care Act (ObamaCare), Section 2706(a), prohibits insurers from discriminating against healthcare providers who are acting within their legal scope of practice. [1] Horizon is saying it doesn’t have to cover alternative medicine, even though it is being delivered by an MD, advanced practice nurses and a naturopath, working under them. What this means is that this case may be a proper vehicle to test the extent of the PHS’s “provider nondiscrimination” clause — this case may set a precedent forcing insurers to cover holistic and integrative care!

You can help set an important legal precedent with a small donation to put insurers on notice that the courts are going to require them to obey the law and cover holistic and integrative care!

Small donations from large groups of consumers and providers will help assure more people have access to alternative medicine and harassing providers legally is less attractive to insurers. As little as $5 can help assure that insurers like BCBS are forced to comply with Section 2706 of ObamaCare which states:“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.” (emphasis added) We strongly believe that getting this case before a jury will prove, not only that BCBS and the State Medical Board are discriminating against this practice, but that this law cannot be ignored without consequences.

By supporting this case, consumer access to holistic MDs, DOs, advanced practice nurses, chiropractors, acupuncturists, naturopaths, midwives, behavioral health providers and more can grow as more insurance reimbursement for holistic and integrative alternatives gain the reimbursement their patients deserve and want.

Please donate by clicking on:  https://fundly.com/support-natural-therapies/

Ralph Fucetola JD
Retired Attorney at Law
President – Institute for Health Research

Please share this message with this link: https://tinyurl.com/ProviderNondiscrimination

[1]  The Affordable Care Act (ACA, or Obamacare) amended the Public Health Services Act (PHS) by adding section 2706(a).

PHS Act section 2706(a), as added by the ACA, provides that 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.”

The Federal government’s CCIIO office states:

“The statutory language of PHS Act section 2706(a) is self-implementing and the Departments do not expect to issue regulations in the near future. PHS Act section 2706(a) is applicable to non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage for plan years (in the individual market, policy years) beginning on or after January 1, 2014.

Until any further guidance is issued, group health plans and health insurance issuers offering group or individual coverage are expected to implement the requirements of PHS Act section 2706(a) using a good faith, reasonable interpretation of the law. For this purpose, to the extent an item or service is a covered benefit under the plan or coverage, and consistent with reasonable medical management techniques specified under the plan with respect to the frequency, method, treatment or setting for an item or service, a plan or issuer shall not discriminate based on a provider’s license or certification, to the extent the provider is acting within the scope of the provider’s license or certification under applicable state law. This provision does not require plans or issuers to accept all types of providers into a network. This provision also does not govern provider reimbursement rates, which may be subject to quality, performance, or market standards and considerations.

The Departments will work together with employers, plans, issuers, states, providers, and other stakeholders to help them come into compliance with the provider nondiscrimination provision and will work with families and individuals to help them understand the law and benefit from it as intended.”

https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs15.html

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