Beginning Jan. 1, 2010, insurance carriers that provide health coverage under the Federal Employee Health Benefits Program (FEHBP) will be required to cover habilitative speech-language pathology services, effectively ensuring that carriers must include speech-language treatment for children with communication disorders.
FEHBP provides health insurance coverage to approximately 8 million federal employees and retirees and their families through hundreds of commercial carriers. These carriers are required to meet coverage requirements established by the U.S. Office of Personnel Management (OPM).
In its annual "call letter" to health insurance carriers that want to participate in the next year's FEHBP, OPM states that beginning in 2010, plans must provide "speech therapy" when medically necessary. Carriers that limit speech-language treatment to rehabilitation only must remove that limit for FEHB plans.
The requirement is stated in OPM guidance related to health maintenance organizations (HMOs); however, the directive is official OPM policy that should be implemented across all FEHBP plans. FEHBP participants, therefore, cannot deny treatment coverage for children with communication disorders.
The OPM call letter also requires the plans to examine and provide additional information on the treatment modalities—including speech-language treatment—that insurance companies will cover for children with autism. In addition, plans will be required to provide information to their consumers on benefit changes for 2010; the information must be in plain language and from the enrollee's perspective. (To read the letter, visit the OPM Web site [PDF].)
ASHA has worked with OPM over the past several years to ensure the appropriate coverage of speech-language pathology services for children. In the past, pediatric coverage has been limited, even for communication disorders caused by neurological injury or dysfunction that insurance companies erroneously label as developmental delays or educational in nature.
The new OPM policy also may affect the current health care reform debate. The bills being debated in the House and Senate include language that any health care reform legislation should contain benefits that mirror those provided to federal employees under FEHBP. Additionally, the House proposal (H.R. 3200) and the legislation passed by the Senate Health, Education, Pension, and Labor Committee have language that would require insurance coverage of habilitative services.
Open enrollment for federal employees begins Nov. 9. Speech-language pathologists who accept FEHBP insurance should check with their carriers for specific coverage information and alert ASHA if there are concerns that medically necessary habilitative services continue to be denied.
Information on how to document medical necessity can be found on the ASHA Web site (search "medical necessity"). ASHA will continue to work with OPM to make sure that insurance companies adhere to this new policy.
If you have any questions related to this FEHBP policy, contact Angela Foehl, director of private health plans, at firstname.lastname@example.org.