INSURANCE

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Insurance must cover nutrition services.

Read this carefully.  Some limitations apply.

OBAMACARE:  “Nondiscrimination in Health Care” Clause:

Section 2706(a) of the Affordable Care Act states that insurers offering group or individual health

plans "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 statutory language of Section 2706(a) is self-implementing and HHS

does not expect to issue regulations in the near future.  Section 2706(a) is applicable to non-

grandfathered insurers offering group or individual health coverage beginning January 1, 2014. 

The US Department of Health and Human Services issued an informal guidance, which is a

recommendation, not law or regulations.  This affects "in network" providers only.  It states: "This

provision does not require plans or issuers to accept all types of providers into a network.”  [April

2013]

WHAT YOUR TYPE OF INSURANCE COVERS

HMO: In-network coverage only, requires primary care doctor, requires referral for specialist.

EPO:  In-network coverage only, NO referral required for a specialist.

PPO: In-network & Out-of-Network coverage, NO referrals required for specialists.

POS:  In-network & Out-of-Network coverage, requires primary care doctor referral for specialist.

CATASTROPHIC: In-network only, under age 30.

HDHP: High deductible: coverage depends on which plan you have: HMO, EPO, PPO, POS.

HSA:  Health Savings Accounts cover all eligible medical expenses in-network & out-of-network.

HSA are currently only offered with HDHP, but will likely change with new legislation.

INSURANCE COVERAGE -- OUR OFFICE VISITS

Out of Network: Dr. Power receives insurance coverage at out-of-network rates by PPO and POS

insurance plans, also HSA plans.  HMO and EPO plans will not cover us.  They MAY cover us if they

have NO in-network nutritionists with Dr. Power's specialties.  Grandfathered plans will not cover us

unless they previously offered nutrition coverage.

Conditions covered:  BCBS of Virginia is covering Nutritionists for the following conditions under

their PPO Plans: obesity, eating disorders, malnutrition, digestive problems, metabolic disorders,

endocrine hormone imbalances, diabetes, heart disease, hypertension, kidney disease, cancer, and

possibly others.  They have also been covering food allergies and intolerances, and developmental

delays such as autism & ADHD.

Payment required upfront.  We provide a Superbill packet, including: (1) a Claim form for your

insurer; (2) a Superbill with codes signed by Dr. Power; (3) code sheet for Medical Nutrition

Therapy; (4) a copy of the Affordable Care Act's Nondiscrimination clause; (5) and the Virginia

insurance law covering autism and ADHD (if needed).

VIRGINIA -- COVERAGE FOR AUTISM & ADHD

Section 38.2-3412.1:01 of the Virginia insurance law mandates coverage of "biologically based

mental illness," which specifically includes autism and ADHD.  It applies to children and adults, and

both PPO and HMO plans.  Therefore, these conditions are also being covered now.  HMO will

cover us only if they have no in-network nutritionists with Dr. Power's specialty.  To see the law, click

here.

SUPPLEMENTS

Nutritional supplements are not covered by insurance or Health Savings Account plans.

INSURANCE COVERAGE – LAB TESTING

Most lab tests are billed directly by the lab to your insurance company.  HMO and EPO cover Lab

Corp and/or Quest Diagnostics Labs.  Only PPO, POS and HSA plans, Medicare and Tricare cover

specialty nutrition labs; and there may be a modest co-pay.  A small fee is charged by the Clinic for

specialty lab kits and Hair tests.

INSURANCE COVERAGE - TRI CARE  (Military)

TriCare does NOT have a category for "Nutritionists", and does not cover nutrition services.  The

military is not regulated by Obamacare.

INSURANCE COVERAGE - MEDICARE

Under Medicare law:  "Medicare may cover medical nutrition therapy and certain related services if

you have diabetes or kidney disease, or you have had a kidney transplant within 36 months, and

your doctor or other health care provider refers you for the service."   Our office participates in out-

of-network only.  Medicare is not regulated by Obamacare.

INSURANCE COVERAGE – MEDICAID

Virginia Medicaid does not have a category for “Nutritionists”, and does not cover nutrition services.

We do not participate with Maryland Medicaid.  Medicaid is not part of Obamacare.

AUTISM LAWS IN YOUR STATE

National Conference of State Legislatures:

See Autism legislation for your state.

VIRGINIA INSURANCE LAWS -- AUTISM

Va. Code § 38.2-3412.1:01

Mandates insurance coverage of biologically-based mental illness, specifically including Autism and

ADHD.  This law covers children and adults.  It applies to all insurance policies including PPO's and

HMO's.    Insurance companies have been paying nutritionists for counseling for patients with

autism and ADHD.  To see the law, click here.   (1999 Va. Acts, Chap. 941; SB 430)  State

employees must also receive this coverage.

Under the Virginia 2011 law: insurance must also cover:  Diagnosis, assessments, evaluations,

neuropsychological evaluations, and genetic testing.  Coverage also includes rehabilitative care:

professional counseling, guidance, services, ABA, pharmacy care, psychiatric care, psychological

care, speech therapy, occupational therapy, physical therapy, and social workers services.  Limit of

$35,000 for Ages 2-6.

MARYLAND INSURANCE LAWS -- AUTISM

Md. Insurance Code Ann. § 15-835

Requires insurers (PPO's), nonprofit health service plans and health maintenance organizations

(HMO's)  to provide coverage of habilitative services for children less than 19 years of

age. Habilitative services include occupational, physical and speech therapy for the treatment of a

child with a congenital or genetic birth defect to enhance the child's ability to function. This definition

includes  autism spectrum disorder.

DISTRICT OF COLUMBIA INSURANCE LAWS -- AUTISM

D.C. Code Ann. § 31-3271 and § 31-3272

Defines habilitative services as occupational, physical and speech therapy for the treatment of a

child with a congenital or genetic birth defect to enhance the child's ability to function.  This definition

includes autism or an autism spectrum disorder.  Requires health insurers to provide habilitative

services for children less than 21 years of age. The coverage shall not be more restrictive than

coverage provided for any other illness, condition or disorder. A health insurer shall not be required

to provide reimbursement for habilitative services delivered through early intervention or school

services.

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