July 31, 2012 News

The Health Care Ruling and You

Now that the U.S. Supreme Court has upheld the Affordable Care Act (ACA)—which expands access to health care for almost 30 million Americans and strengthens existing protections for consumers in the health insurance market—speech-language pathologists and audiologists need to be ready to participate in the act's provisions.

The Supreme Court decision illustrates changes in the U.S. health care environment that are rapidly gaining momentum with increased calls for value, coordination of care, transparency, and outcome-based health care (see articles on pp. 10 and 36), all of which are part of the ACA.

Health Insurance Exchanges

One of the most sweeping provisions of the ACA is the development of health insurance exchanges, organized marketplaces that will make health insurance available to previously uninsured or underinsured people (The ASHA Leader, Apr. 26, 2011). ASHA is working to ensure that habilitative and rehabilitative services—including those provided by audiologists and SLPs—are included in the plans' mandated essential health benefits (The ASHA Leader, Mar. 13, 2012; Nov. 22, 2011) and to define the scope of these services.

What do the exchanges mean for audiologists and SLPs? Clinicians who want to take part should:

  • Determine how participating exchanges include habilitative and rehabilitative services. The Centers for Medicare and Medicaid Services has not specified treatment guidelines, allowing each state to individualize plans for its residents. The prevalence of certain health conditions will influence a state's needs; for example, a state that has a high incidence of throat cancer may determine a higher need for treatment associated with laryngectomy patients.
  • Determine coverage within specific insurance plans. Coverage documents—with names such as Coverage Determination Guidelines (UnitedHealthcare) or Clinical Utilization Management Guidelines (BlueCross)—specify what a plan will and will not cover. The generic UnitedHealthcare Coverage Determination Guideline for Speech-Language Pathology Services includes habilitative service, but notes that some plans exclude the condition of idiopathic developmental delay (a delay without a known cause) from coverage.

Medicaid Expansion

The decision also calls for the expansion of the Medicaid program by 16 million recipients. By 2014, states must cover all individuals under age 65 with incomes of less than 133% of the federal poverty line. Because Medicaid is state and federally funded, the Supreme Court ruled that states can't be forced to participate in the new program, nor can the federal government take away existing Medicaid funding. States must decide whether to participate; as an incentive, federal funding for the expansion is 100% in the initial phase (beginning in January 2014) and decreases to 90% in later years.

As many SLPs and audiologists have experienced, many states have already decreased Medicaid funding for services, especially for the adult population, for whom speech-language services are optional. The combination of states not choosing the expansion and limitations in current Medicaid plans jeopardize provider funding. Many providers choose not to participate in the Medicaid program; however, providers in states with many Medicaid recipients rely on income generated from providing services to these clients.

Efficiency, Effectiveness, and Value

The ACA provisions emphasize efficiency and effectiveness—to take part in the provisions, SLPs and audiologists will need to demonstrate that their services meet these requirements and collaborate with other providers to manage care. For SLPs and audiologists, this means collecting data to document initial status and functional outcomes.

Clinicians have a number of ways to participate in data collection. SLPs can report data through ASHA's National Outcomes Measurement System. Audiologists can participate in the Medicare Physician Quality Reporting System. Data can be used to evalauate treatment outcomes, inform quality improvement efforts, and conduct cost-benefit analyses.

The bottom line? The provisions of the ACA all are based on value—the efficiency and effectiveness of health care services. Providers will need tools to evaluate the value of their services to participate in health care exchanges, accountable care organizations, and other ACA provisions. ASHA will continue to keep members informed on the implementation of the ACA and on options for documenting patient outcomes.

Laurie Alban Havens, MA, CCC-SLP, director of private health plans and Medicaid advocacy, can be reached at lalbanhavens@asha.org.

cite as: Havens, L. A. (2012, July 31). The Health Care Ruling and You. The ASHA Leader.


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