|Tally of Insurance Coverage of NDs |
Laura Culberson Farr l Executive Director, OANP
Updated April 2014 - The Affordable Care Act prohibits insurance plans from discriminating against providers in either participation or coverage in a plan. This provision applies to all non-grandfathered commercial plans issued or renewed after 1/1/14.
Oregon law that governs Coordinated Care Organizations (Oregon's medicaid) also contains provider non-discrimination language identical to that of the federal ACA. Consequently Oregon CCO's are also prohibited from discriminating against providers in both participation and coverage in CCOs. This provision applies to all Oregon Health Plan medicaid patients. This page will track changes to insurance coverage of NDs, as CCOs and private insurers come into compliance with the provider non-discrimination provisions in the private marketplace and medicaid populations. We will ONLY be reporting here on positive changes in insurance coverage. This list is not intended to be a comprehensive list of problems with insurers.
The ACA launched many new initiatives, and many insurers are
struggling either to come into compliance with the details of the law, or have come into compliance
but are struggling to update their materials or adequately train their
customer service staff on their new policies.
If an insurer and/or their policy is listed here, it is because an ND has successfully been credentialed, or because OANP has directly received confirmation from the insurer of their policy on insurance coverage for NDs. Please be aware that individual customer service representatives MAY NOT be aware of these policies. If you get information that is contradictory to what is listed here, please ask for a supervisor and reference this information. We will list the source of information where we can so you can speak directly with someone knowledgeable in the companies. Please also inform OANP immediately if you find anything wrong or missing, or if you have new information to add.
Coordinated Care OrganizationsNDs are credentialed as either a Primary Care Provider or Specialist in the following CCOs:
|HealthShare Oregon (through CareOregon)||PDX Metro||NDs can be PCP||Call 503-416-4100|
|FamilyCare ||PDX Metro||NDs can be credentialed only if share office with MD/DO|| |
|Yamhill CCO (through CareOregon)||Yamhill County||NDs can be PCP||Call 503-416-4100|
|Columbia Pacific CCO (through CareOregon)||N. Coast||NDs can be PCP||Call 503-416-4100|
|Western Oregon Advanced Health ||Coos Bay/Bandon||NDs can be Specialist. May be open to PCP dependent on certain criteria being met. ||Karen Gannon, firstname.lastname@example.org|
|Willamette Valley Community Health||Salem Area||NDs can be PCP|| |
|Jackson Care Connect (through CareOregon)||Medford Area||NDs can be PCP|| Call 503-416-4100|
|Trillium CCO||Lane County||NDs in Primary Care Homes can be PCPs. Other NDs can be Specialists|
|Oregon Health Co-Op|
|Statewide major metro areas||NDs can be PCP and covered IN ALL PLANS as out-of-network provider if not credentialed with the Co-Op as a PCP. ||Call 503-416-4100|
|ODS||Statewide||NDs covered IN ALL PLANS if CPT code is same as a code the insurer covers for traditional providers. Labs, prescriptions, office visits in these scenarios covered under normal copays & deductibles. Any code that insurer doesn't normally cover for traditional providers may be covered as part of "alternative care benefit" subject to different annual cap (usually $1000 for LAcs, DCs, and NDs) || |
| PacificSource||Statewide||NDs covered IN ALL PLANS. Claims processed based on billed service under patients normal plan benefits and under same copays & deductibles. See bulletin explaining compliance with Section 2706.|| |
| Regence|| Statewide|| Any provider providing a service covered by an insurance plan is eligible for reimbursement based on the member's benefits. Simply put, if you do a service that is covered by the plan, Regence will cover it when done by an ND too. Read their bulletin here.|| |
| United||Statewide||If using the same CPT codes as a medical doctor, United will cover NDs if they are in network and as a specialist. The specialist co-pay will apply. || |