Insurance Coverage for Naturopathic Medicine?

Insurance for NDs in Maine: Fact or Fiction? 

Insurance coverage for office visits with Naturopathic doctors (ND) is relatively new to Maine. Although coverage went from non-existent to partial over the last few years, it remains incomplete.  Currently, the following insurance plans cover ND services in-network: Maine Community Health Options (MCHO) and Anthem/Blue Cross Blue Shield.  This is big news for many individuals in Maine who value and utilize the services of NDs!Unfortunately, Harvard Pilgrim and Aetna remain lacking in their coverage of ND services. Harvard Pilgrim and Aetna refuse to allow NDs to become in-network providers, though some Harvard Pilgrim plans accept NDs as out-of-network. However, usually an out-of-network deductible is significantly higher than the in-network deductible, making this almost the same as non-coverage. Aetna goes a step further and refuses to acknowledge NDs as medical providers, effectively squashing any submitted claim at the outset.

What’s the big deal?

Firstly, lack of coverage interferes with an individual’s ability to fully utilize their dearly purchased health insurance by receiving reimbursement for valid healthcare services.  Secondly, it’s in direct violation of the Affordable Care Act (ACA) AKA Obamacare. The ACA section 2706, titled “Nondiscrimination in Health Care,” requires insurance companies to cover services by any licensed provider acting within their scope of practice.

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.*ACA effective 1/1/2014.

Refusing to cover services provided by NDs that would normally be covered by MDs/DOs/NPs violates this section of the ACA.

Will all my visits to an ND be covered?

Ideally, insurance companies would cover all ND health services, but this isn’t the case.  In fact, many patients experience denial even for services provided by MDs.   However, preventative services (ex. annual exams) fall under the category of medical necessity and insurance companies must cover them according to the ACA.Therefore, at the very least, annual exams, paps, clinical breast exams, etc. performed by NDs should be covered by Aetna and all insurance companies in the state of Maine. This isn’t happening. Aetna is refusing to acknowledge NDs as providers despite the fact that NDs are licensed in the state of Maine.

What can I do to change this? 

The Maine Bureau of Insurance (BOI) is responsible for enforcing the ACA and making sure insurance companies follow the law. Unfortunately, as of yet, they’ve been ineffective in altering Aetna’s stance.This is where you come in. The BOI needs to know how many people are being affected by Aetna’s denials. If each person who experiences discrimination of coverage by Aetna (or any insurance company) submitted a complaint to the BOI, things would likely change.If you have Aetna and/or Harvard Pilgrim and are denied coverage for ND services then please submit a complaint to the BOI.To submit a complaint, go to the following website and follow the directions:http://www.maine.gov/pfr/insurance/complaint.htmThings can change but it requires the voices of many!