Saturday, November 17, 2012

Obamacare: The Effect of the Affordable Care Act on Music Therapy, Part I

This is a huge and scary beast to tackle!  Now that the election is over, however, the ACA (Affordable Care Act) looks like it will begin its inexorable creep into the healthcare system.  I present it like this only because the law is scheduled to be implemented in stages.  The first of these new policies began in 2010. The rest of the new regulations will begin over the next few years.  

I will not necessarily be presenting my point of view, although my bias leans against the government being able to do much of anything with efficiency and receive an A grade (I can think of the U. S. Post Office and Amtrak as good examples of government inefficiency which are in constant need of bailout money!).  My goal is to try and give you a sense of the key points of the law and then break it down into some possible influences on how the changes will affect patients with disabilities as well as their access to services like music therapy.  

I also see the bigger picture as something important to examine.  It seems like most people discuss or highlight the benefits or negatives of the new law, but fail to note that actual implementation will not look like the ideal presented on paper.  This is something we can no longer ignore, or put on the mental backburner for another day.  Unfortunately, the ACA is incredibly complicated and many members of congress who voted it into place haven't even read the full document or claim to not understand it!  

At the 2010 Legislative Conference for the National Association for Counties, then House Speaker, Nancy Pelosi said, "But we have to pass the bill so that you can find out what is in it...".   

I have nominated myself to bring you as much detail as a primer for your own investigation!  I will attempt to cite a variety of sources from both sides of the ideological aisle.  I hope that you will join me in the discussion and provide a sounding board as we try to figure this out together.

The music therapy profession is really in its infancy in terms of reimbursement and payment from third-party sources.  Some local and regional success stories exist regarding payment for music therapy services through private insurance companies.  There has also been some progress in getting music therapy included in group billing to Medicare for music therapy occurring as part of daily services in certain types of rehabilitation and care for older adults.  
How will this recent success in third-party billing be affected by the ACA?  Good question!  I am not sure anyone knows exactly, but shouldn't we get at the front end of this?  

I envision at least three parts to this mini-series:  (1) the proposed changes to healthcare listed in the ACA, (2) the effect these changes might have on access to care for people with disabilities, and (3) obstacles and hurdles to full implementation that may cancel or significantly alter the promises as outlined in part 1.  

Let's get started...

Major proposals contained in the ACA:

1.  Insurance companies are not allowed to deny coverage for preexisting conditions under age 19.  (Those over age 19 will receive the same guarantee in 2014.)
2. Insurance companies will not be able to impose annual benefit caps (the total dollar amount) starting in 2014.  (...but, companies will still be able to cap the number of visits for some individual benefits such as physical or mental health treatment.)
3. Rescission will be prohibited except in the case of provable fraud. (This was the practice of dropping a high user of insurance services by looking for an inadvertent mistake or omission in an application.) 
4. Insurance companies will also have to guarantee issue or renewal of coverage regardless of health status or high-utilization.
5. New Health plans after 2010 will have to cover certain preventative care without co-payments, co-insurance or deductibles.  
6. Medicaid eligibility will be expanded to all whose income is less than 133% of the Federal Poverty Level.  
7. Beginning in 2014, if your employer does not offer a health care plan, you will be able to sign up for one of the health care plans offered through federal and state exchanges.  The exchanges will be offered state by state and will involve a "marketplace" of sorts that has choices of public and private health insurance programs.  Insurance programs in the new exchange markets will be subject to a variety of coverage and pricing guidelines.  *Note: Insurance plans that existed before March 2010 will be exempt from many of the provisions in the ACA.  

(Note: A full list of new taxes can be found here. Here are a few:)
8. An increase in the payroll tax from 2.9% to 3.8% for couples earning more than $250,000 a year.  This new Hospital Insurance part of the payroll tax will also now be applied to investment income for the first time.  (Note: I am not sure what kinds of investment, but I will find out!)
9. Penalty paid by employers who do not offer health care coverage for employees.
10. Tax on individuals who do not purchase health insurance. (If you recall, this was what all the hubbub was about this past summer with the Supreme Court ruling.  The ACA was declared constitutional, but only implemented as a tax and not an individual mandate.  Some of the uproar occurred because President Obama promoted the ACA as a mandate and not a tax.)
11. 2.3% excise tax on manufacturers and importers of certain medical devices. (Begins 2013) (Get your pacemakers before Christmas!)
12. Limit to the amount taxpayers can put into their flexible spending accounts.  (Begins 2013) (Bias alert! This is irritating to me since I have never had the opportunity to use a flexible spending account until my new job this year, and now it is being reduced!)
13.  I hadn't heard about this next one.  Have you?  The 7.5% adjusted gross income floor on medical expenses deduction is raised to 10%! (Begins 2013) 
14. I do remember hearing about this one!  A 10% excise tax on indoor tanning services.  (Began in 2011)

15. $716 Billion in cuts to Medicare Advantage, hospice services, nursing homes, etc. 
16.  The ACA aims to increase the number of people with insurance by increasing the coverage to people through Medicaid and the health insurance exchanges.  A sliding-scale subsidy based on a new standard related to income and the federal poverty level will be provided to low and middle income families to purchase insurance.  (This will be a key point to remember when we talk about obstacles to implementing the new law later in the series.)

Whew!  This really only touches on the tip of the ice berg!  But this should give you an idea of the breadth and scope of what the new law seeks to accomplish.  I can only mention some of the things that seem to be major points in the law since it is full of seemingly hundreds of large and small provisions.

If you would like to read the law, here it is in all its glory! 
H. R. 3962

Please let me know if I have not discussed one of the provisions that you think is also very important.  My next task will then be to try to make some sense of how the new law may impact people with disabilities, their access to insurance coverage, and ultimately, the effect of all this on music therapy services.  Will our fledgling attempts at third party reimbursement be interrupted?  Will music therapy that currently exists in hospitals, hospice, nursing home and rehab facilities continue to be offered?  

Don't let this keep you awake at night!  But I appreciate your help and patience as we figure this out together!  



  1. Please explain #15 further, since this applies to myself and many Music Therapists like me

  2. Certainly. Here is a very good explanation from the Washington Post, although I don't think it will specifically answer your question about how specific therapies might be impacted:

    A little more detail is here:

    You will notice that Mr. Frakt is also worried about the large cut to annual increases in Medicare to hospitals and other facilities. I would suspect that this might be the most important one for us to consider since music therapy services are sometimes lumped into the billing of services "per day" for a patient in order to receive a slightly higher reimbursement "per day" for a patient. So, even though music therapy is not often directly billed for to Medicare, it can increase the reimbursement amount by a little bit per day if it is included correctly in the billing. Since most facilities don't rely on this reimbursement to fund music therapy, it is unlikely that music therapy would be cut as a result of the decrease in money from the ACA. However, it has been nice to be able to show that music therapy does sometimes contribute to a higher pay out in reimbursement.

    And just in case it is not confusing enough, some people say that the cuts are not really "cuts" and that they will save Medicare rather than hurt it:

    Thanks for asking the question! Let's keep investigating! The scary thing is that nobody seems to know what is really in the law or what is going to happen! Maybe next time they can get this all figured out before passing it into law.


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