2017 ASHA Public Policy Agenda: Summaries

Health Care Issues

Medicare Reimbursement and Coverage Policies

Changes in Medicare reimbursement and coverage policies will be affected by value-based purchasing and evidence‑based practice.

ASHA will 

  • advocate for equitable inclusion/reimbursement for audiologists and SLPs as well as coverage of services and devices for beneficiaries of Medicare health plans; represent both audiologists and SLPs
    • before the Centers for Medicare & Medicaid Services (CMS) to ensure the maintenance and/ or expansion of appropriate values, coverage, and reimbursement rates and
    • on the American Medical Association (AMA) coding committees;
  • promote an appropriate alternative payment policy for Medicare outpatient therapy services to eliminate the reimbursement cap placed on rehabilitation services and reflect the value of member services;
  • support Medicare coverage of audiologic diagnostic and treatment services; and
  • support implementation of alternative Medicare payment reforms.

Background: ASHA members who treat Medicare beneficiaries face challenges within a complex Medicare system. Reimbursement is affected by changes to the Medicare payment system—changes that call for value-based purchasing and evidence-based practice, heightened economic restrictions, and issues related to bundling. Changes to the valuation of procedural codes and the development of outcome measures will continue to challenge the reimbursement of service delivery. Managed care emphasizes physician-directed care models—such emphasis could result in challenges to clinical judgment and could affect the dynamics of coordinated care.

Medicaid Reimbursement and Coverage Policies

Changes in Medicaid reimbursement and coverage policies will be affected by value-based purchasing, evidence-based practice, and the expansion of managed care.

ASHA will 

  • advocate for coverage and adequate reimbursement of services provided by audiologists and SLPs who work in schools and health care settings;
  • promote reimbursement for devices and subsequent habilitation/rehabilitation, including but not limited to hearing aids, cochlear implants, other implantable devices and related equipment, and augmentative and alternative communication (AAC) devices;
  • advocate for access to audiology and speech-language pathology services through the federally mandated Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit and state requirements for health care and school settings;
  • advocate for appropriate policies, guidance, and regulations related to Medicaid-covered services in schools and other settings;
  • advocate with managed care organizations for appropriate coverage and reimbursement policies that reflect the value of member services; and
  • advocate for consistency of streamlined procedures and requirements for school-based Medicaid services.

Background: The Medicaid program—a federal/ state partnership implemented on the basis of state priorities—affects both health care and school-based providers. ASHA members will continue to see changes in the Medicaid requirements for value-based purchasing and evidence-based practice, coverage determinations, economic restrictions, expansions of managed care, issues related to bundling of provider services, and implementation of the Patient Protection and Affordable Care Act. These factors will play a significant role in the reimbursement of audiology and speech‑language pathology services. The Medicaid requirements for reimbursement have created unique challenges for providers in health care and school-based settings.

Patient Protection and Affordable Care Act (ACA)

The implementation of the ACA requirements— implementation that includes habilitation and rehabilitation services—encompasses the work of audiologists and SLPs. ASHA continues to collaborate with state associations to advocate for implementation of ACA requirements to reflect the value of member services related to habilitation and rehabilitation services.

ASHA will

  • advocate for reimbursement policies that include habilitative and rehabilitative services in private health care plans and programs of other stakeholders;
  • advocate for the repeal and/or delayed implementation of the Cadillac Tax, which would impose a tax on premium employer benefit plans;
  • advocate for appropriate coverage and co-pays of audiology and speech-language pathology services;
  • advocate for appropriate state implementation of ACA requirements for essential health benefits; and
  • advocate with the Center for Consumer Information and Insurance Oversight for federal monitoring and enforcement of essential health benefits.

Background: States are continuing to face challenges in implementing ACA requirements. ASHA will continue to advocate and offer support to state associations for adoption of the ACA requirements, including insurance coverage of essential health benefits as implemented through regulations, that reflect the value of member services. ACA plans (i.e., those regulated through the exchanges) differ from employer-sponsored plans due to ACA’s requirements for essential health benefits, such as the inclusion of the habilitation benefit.

Private Health Plans Reimbursement and Coverage Policies

Private health plans are increasing restrictions that demand demonstration of the value of member services to ensure appropriate coverage and reimbursement.

ASHA will

  • advocate for coverage and adequate reimbursement for services and devices provided by audiologists and SLPs, and provide input to coverage policies in private health plans and
  • advocate for consumers and providers through the appeals process with private health plan providers and insurance commissioners; such advocacy may result in coverage changes for all participants.

Background: Private health plans (i.e., employer-based and self-insured plans) vary significantly in their coverage policies, reimbursement rates, and interpretation of federal and state regulations. Private health plans are regulated through various federal and state laws and agencies.

Hearing Health Care

The changing landscape of the hearing health care environment will affect the practice of audiology.

ASHA will

  • advocate for audiologic intervention services in the management of hearing loss that includes therapeutic hearing rehabilitation services, counseling, and the dispensing of hearing aids, including retail and Internet sales, so that patient safety is not compromised and appropriate hearing health options are provided;
  • support the U.S. Food and Drug Administration’s regulations and guidance documents that distinguish between hearing aids and personal sound amplification products (PSAPs);
  • monitor and evaluate the effect of any proposed legislation/regulations intended to change the current delivery model of hearing aids;
  • continue to monitor and report to the Federal Trade Commission any deceptive advertising by sellers of PSAPs;
  • support warning labels on PSAPs, devices, and hearing aids regarding “red flags” for conditions that require medical treatment;
  • advocate for consumer access to safe and effective audiological hearing health care services, devices, hearing aids, and environments;
  • promote a comprehensive system of children’s hearing health care services, including state hearing screening standards; insurance coverage of hearing aids, cochlear implants, implantable hearing devices, and other related devices and equipment; and diagnostic and treatment services for children;
  • support hearing aid tax credit legislation to increase affordability of hearing aids;
  • support legislative and regulatory efforts related to classroom acoustics;
  • support reasonable, cost-effective regulations and standards set by the American National Standards Institute and the Occupational Safety and Health Administration to prevent noise-induced hearing loss in the environment; and
  • oppose efforts by hearing aid dispensers to increase their scope of practice as health care providers within state and federal programs, such as the Veterans Health Administration programs.

Background: Due to exponential growth in hearing loss, there is an urgent need to increase the affordability and accessibility of hearing health care, particularly because only 15%–30% of those with hearing loss actually receive treatment. Federal and state legislative and regulatory agencies are exploring opportunities to address these issues. Both the National Academy of Science and President’s Council of Advisors on Science and Technology have issued reports calling for increased accessibility and affordability of hearing health care, including over-the-counter hearing aids. ASHA understands the problems of access, diagnosis, treatment, and reimbursement of individuals with hearing loss. Increased attention on accessibility of hearing aids and amplification devices is positive. However, the absence of audiological involvement will be detrimental to patient outcomes and the profession. In addition, an increase in the use of hearing aid dispensers may compromise the effectiveness of patient care.

Telepractice/Telehealth

Telepractice/telehealth is an appropriate model of service delivery and can be used to overcome barriers and increase access to services.

ASHA will

  • advocate for the recognition and coverage of appropriate services delivered through telepractice;
  • advocate for laws that support appropriate licensing standards and interstate licensure;
  • advocate for coverage and reimbursement of telepractice/telehealth services through federal and state legislation and regulation for coverage under Medicaid, Medicare, and other health plans and federal programs; and
  • advocate with CMS and AMA for appropriate coding policy for telepractice/telehealth.

Background: Telepractice/telehealth is an appropriate model of service delivery for the professions of audiology and speech-language pathology when equivalent to those provided face to face. Congress recognizes the overall efficacy of telepractice and urges the use of this model to increase access to services; however, current law does not recognize audiologists and speech-language pathologists under Medicare for reimbursement. Medicaid coverage, which is determined by the state, and private insurance coverage, are rapidly expanding. Provision of telepractice/telehealth models requires federal and state action and licensure models that cross state boundaries. Telepractice/telehealth can be used to overcome barriers to individuals’ accessing and receiving services.

Education Issues

Legislation and Regulations

ASHA supports the inclusion of audiologists and SLPs in educational programs with the reauthorization of the Individuals with Disabilities Education Act (IDEA) as a priority.

ASHA will

  • support the appropriate use of audiologists and SLPs in literacy programs and professional development initiatives;
  • support provisions that allow for greater flexibility for use of general education funds for at-risk children in general education (e.g., Response to Intervention);
  • create and advocate for a framework of revisions to IDEA reauthorization that supports ASHA members in school settings;
  • support (a) consistent language and common terminology for specialized instructional support personnel (SISP; including audiologists and SLPs) in IDEA and ESSA and (b) use of the term highest qualified provider in IDEA;
  • promote the reallocation of IDEA Part D funds so that they align with the needs of ASHA’s school-based members and graduate-level academic programs;
  • support legislation that includes audiologists and SLPs as a part of concussion management teams; and
  • seek opportunities to include audiologists and SLPs in Higher Education Act (HEA) provisions.

Background: School-based audiologists and SLPs play an integral role in both general and special education settings (e.g., concussion management team, literacy, struggling learners). Federal and state law provide guidance related to the roles, responsibilities, and funding of school-based services. The three major federal education laws are IDEA, ESSA, and HEA. In 2016, Congress passed ESSA, and the U.S. Department of Education is currently developing rules and regulations for ESSA implementation. States will be required to implement ESSA starting in the 2017–2018 school year. 

Funding and Practice Issues for School-Based and Early Intervention Services

Threats to the provision of early intervention services include reduced funding, difficultly obtaining reimbursement, scope of practice issues, and constraints for providing services.

ASHA will

  • educate and support state associations and member advocacy efforts with administrators and decision makers regarding workload/caseload management;
  • seek alternatives to help reduce the paperwork and administrative burden on school-based audiologists and SLPs through advocacy efforts related to the reauthorization of IDEA;
  • oppose cuts in education funding;
  • promote state and local adoption of appropriate accountability/evaluation measures (e.g., Performance Assessment of the Contributions and Effectiveness of SLPs) for audiologists and SLPs;
  • advocate and provide educational resources to members on the implementation of ESSA;
  • advocate for states and local agencies to implement IDEA Part C Infants and Families Program requirements and ensure appropriate use of audiologists and SLPs in the identification and treatment of children in early intervention programs;
  • advocate for appropriate and timely reimbursement for early intervention services;
  • advocate for increased funding for Part C services;
  • advocate with states and local agencies to implement federal standards related to IDEA Part B and ESSA; and
  • advocate for audiologists and SLPs to be included as part of the diagnostic, intervention, and management of concussions.

Background: Early intervention and school-based audiology and speech-language pathology programs are affected by staff shortages, increased paperwork, funding cuts, greater workload/caseload demands, and changing delivery models and standards (e.g., State Standards, Response to Intervention). Threats to the provision of early intervention services include reduced funding, difficulty obtaining reimbursement, scope of practice issues, and constraints providing services. These issues result in uncertainties for members and threaten to undermine their ability to provide effective services to children.

Professional Issues

Social Security Benefit for Public Employees

Government restrictions reduce Social Security benefits for public sector employees, including audiologists and SLPs who are in non–Social Security retirement systems in the schools.

Social Security benefits could be reduced for public sector employees who are in non–Social Security retirement systems.

ASHA will

  • support legislation to repeal or replace the Government Pension Offset (GPO) and/or Windfall Elimination Provisions (WEP), both of which reduce Social Security benefits for public sector employees who are in non–Social Security retirement systems and
  • continue to work with other groups to support modification of these laws.

Background: The GPO and WEP reduce Social Security benefits for public sector employees who are in non– Social Security retirement systems, including many teacher retirement systems throughout the country. Audiologists and SLPs who work in the schools are frequently part of these non–Social Security retirement systems. Any Social Security benefits to which they are entitled will be reduced if/when they draw benefits from the non–Social Security teacher retirement system. This creates a disincentive for individuals to work in different settings, schools, and other environments because doing so will have a negative impact on their retirement benefits.

Loan Forgiveness/Tuition Assistance as a Recruitment and Retention Tool

College loan forgiveness and tuition assistance programs have proven to be an effective recruitment tool.

ASHA will

  • continue to support state legislative efforts to adopt loan forgiveness and tuition assistance provisions for audiologists and SLPs and
  • advocate for the inclusion of federal incentives, loans, and refinancing as well as advise members when opportunities arise at the state and/or federal level.

Background: ASHA supports strategies to increase recruitment and retention of audiologists and SLPs through financial aid and loan forgiveness. Some states, including Mississippi and Texas, have passed loan forgiveness legislation specifically for SLPs.

Demonstrating Value and Quality of Services

Consumers and decision makers across health care and school settings are increasing their demands for evidence-based interventions and quality outcomes.

ASHA will

  • establish policies that define quality and desired outcomes of audiology and speech-language pathology services and that reflect the needs of the clients and the professions;
  • empower members and state association leaders to advocate with payers, school administrators, and/ or consumers regarding the value and expertise of audiology and speech-language pathology services;
  • develop clinical data registries to support advocacy efforts related to adequate reimbursement for audiology and speech-language pathology services across payers;
  • support recognition of ASHA’s Certificate of Clinical Competence and advocate for policies that require use of the highest qualified provider; and
  • engage, inform, and collaborate with other professionals to promote comprehensive, interprofessional practices.

Background: The use of outcomes data and quality indicators demonstrates the value of audiology and speech-language pathology services in all settings. Furthermore, coordinated care and bundled payment models will continue to emerge, which will require advocacy to ensure that audiologists and SLPs are recognized as valued and integral members of the health care team.

Scope of Practice

Providers without proper credentials are being employed to provide audiology and speech-language pathology services, which infringes on the scope of qualified professionals and compromises consumer outcomes.

ASHA will

  • monitor industry trends and advocate to ensure that less qualified providers are not being employed as cost-saving measures to provide audiology and speech-language pathology services;
  • oppose legislation, practice acts, and licensure efforts that would expand the scope of practice of other professionals and practitioners (e.g., hearing aid dispensers, technicians, apprentices) into the scope of practice of audiologists; and
  • oppose legislation, practice acts, and licensure efforts that would expand the scope of practice of other professionals and practitioners (e.g., music therapists, applied behavior analysis therapists, developmental therapists, dyslexia therapists) into the scope of practice of SLPs.

Background: Audiologists and SLPs are independent professionals with a defined scope of practice based on their education, training, and skills. The clinical practice of other providers without audiology or speech-language pathology credentials infringes on the scope of practice and clinical expertise of audiologists and SLPs, and it may compromise consumer outcomes. For example, hearing aid dispensers are attempting to expand their scope of practice at the state level through an apprenticeship program recognized by the U.S. Department of Labor as well as through professional recognition in the Veterans Health Administration. Similarly, speech-language pathology services are being infringed upon by a variety of unqualified providers who claim to assess and treat communication disorders without the proper credentials.

Licensure

Comprehensive licensure reduces barriers by allowing audiologists and SLPs to practice with a single license in any setting within the state.

ASHA will

  • support legislation and regulations that allow audiologists to dispense hearing aids under a single license;
  • support comprehensive licensure for SLPs that ensures maintenance of existing employment benefits;
  • oppose state legislation that would incorporate, eliminate, and/or consolidate state audiology and speech-language pathology licensure boards under the state medical board;
  • explore opportunities to ensure that expedited licensing provisions for military spouses/active military are implemented appropriately;
  • assist state licensure boards that are sunsetting (e.g., expiration of a board’s authority) with advocacy materials to demonstrate the need for continued licensure for audiologists and SLPs;
  • support legislation, regulation, and policies that allow Clinical Fellows to obtain a provisional license and be reimbursed for services; and
  • support the development of interstate licensure.

Background: State regulatory agencies create unnecessary barriers by requiring members to obtain and maintain multiple licenses and/or certifications. Many states require audiologists to hold a separate license to dispense hearing aids; however, a majority of states allow audiologists to dispense hearing aids with a single license, with some exceptions (e.g., passing an exam, completing a training program, registering with the hearing aid dispensing board). AMA’s efforts, in conjunction with shrinking state budgets, have resulted in some states seeking to consolidate audiology and speech-language pathology licensure boards under the medical umbrella. Other issues, such as expedited military licensure and sunsetting boards, also create challenges.

Audiology and Speech-Language Pathology Assistants Within the Service Continuum

ASHA supports the appropriate education, training, use, and supervision of audiology assistants and speech-language pathology assistants (SLPAs).

ASHA will

  • advocate for state licensure and regulations— including education, training, and supervision requirements—for audiology assistants and SLPAs and
  • support and promote the continuum of service providers from audiology assistants and SLPAs to certified audiologists and SLPs.

Background: Given the shortage of audiologists and SLPs, more states seek options for identifying standards for service providers. ASHA supports the adoption of model licensing language and the implementation of a service continuum that defines the credentials and competency requirements for audiologists, SLPs, audiology assistants, and SLPAs.

State Consultants

State consultants provide valuable technical support to school-based members and educate state policymakers on the value of services to consumers provided by the professions of audiology and speech-language pathology.

ASHA, in collaboration with state associations and organizations, will

  • support member efforts and states seeking qualified audiologists and SLPs as consultants to state departments of education (DOEs);
  • provide DOEs with information about the importance of audiology and speech-language pathology services; and
  • promote the retention of qualified audiologists and SLPs who are currently serving as employees/ consultants to state agencies.

Background: State DOEs and/or state education agencies hire individuals to implement DOE policies, assist with educator questions, and provide training and support. In some states, audiologists and SLPs are hired as consultants to help members in the state meet DOE requirements. With increased demands on state budgets, fewer audiology and speech-language pathology consultants are being hired and/or retained, which has had an adverse effect on policies developed at the state level and services provided. 

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