The Patient Protection and Affordable Care Act (ACA)
Essential Health Benefits
Patient Protection and Affordable Care Act
What They Are
Essential health benefits (EHB), mandated by the ACA, comprise health care service categories that, beginning in 2014, must be covered by certain qualified health insurance plans. These plans initially will be offered to small employers and must cover EHB to be certified. There are 10 benefit categories:
- ambulatory patient services
- emergency services
- maternity and newborn care
- mental health and substance use disorder services, including behavioral health treatment
- prescription drugs
- rehabilitative and habilitative services and devices
- laboratory services
- preventive and wellness services and chronic disease management
- pediatric services, including oral and vision care
Section 2715 of the ACA mandated the development of a standard summary of benefits and coverage to be used by individual and group health plans in health insurance exchanges. This section of the ACA also mandated the development of a glossary of medical and insurance terms, written in plain language, to help consumers understand the benefits and coverage documents. A working group of the National Association of Insurance Commissioners (NAIC), made up of representatives from the health insurance industry, health care providers, government officials, and consumer and patient advocacy groups, including ASHA, developed these forms and the glossary (see The ASHA Leader, Nov. 22, 2011). Of particular importance to speech-language pathologists (SLPs) and audiologists are the definitions of rehabilitation and habilitation, which will help shape the benefits provided in this category.
In recommendations to the U.S. Department of Health and Human Services, the Institute of Medicine (IOM) endorsed the definitions proposed by the working group that defined rehabilitation services as
Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
The working group defines habilitation services as
Health care services that help a person keep, learn, or improve skills and functional for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
What This Means for SLPs and Audiologists
The plans covering EHB will be provided for the 24 million Americans who are currently uninsured. The addition of these individuals—who may be able to access covered services, including speech-language pathology and audiology services—will greatly increase the number of people who can be served. By understanding the specific services covered and regulations regarding conditions, SLPs and audiologists can be better prepared to offer services for these individuals and to negotiate with health plans for provision of services.
For more information on habilitation and rehabilitation services and advocacy for coverage of those services as EHB, see "Habilitation—What It Is and Why It Matters to You" and "FAQs Address Habilitation, But Questions Remain."
Implementation Time Line
Initially, the benefits will be offered through the private pay insurance plans participating in the health insurance exchanges. Those exchanges will be implemented in 2014. Qualified health plans, providing high-quality coverage, like that of a typical employer plan, may be expanded to other payers, such as Medicaid.
ASHA will continue to work with the Habilitative Benefits Coalition—co-founded by ASHA—and state advocacy organizations and networks, such as the Council for State Association Presidents (CSAP)—to focus on how state health insurance exchanges implement inclusion of EHB. ASHA will use grassroots efforts to help formulate how the states address benefits, particularly coverage of rehabilitative and habilitative services and devices provided by SLPs and audiologists.