Audiology and the Affordable Care Act
Daneen Grooms, MHSA
On November 1, 2016, the Health
Insurance Marketplace—created by the Patient Protection and Affordable Care Act
(ACA) of 2010—begins its fourth year of open enrollment for the roughly 11
million Americans receiving health care coverage through the Marketplace.
The ACA Health Insurance Marketplace (hereafter,
"the Marketplace") serves to help individuals and employees of small businesses
shop for and enroll in health insurance. The federal government operates the
Marketplace for most states. However, some states run their own Marketplaces.
In addition, the ACA can be credited with adopting consumer protections for
individuals who purchase health insurance coverage inside or outside the
Marketplace. For example, guaranteed
availability is one such consumer protection requirement. Effective January
1, 2014, guaranteed availability laws require individual and group health plans
to issue a health plan to any applicant regardless of the applicant’s health
status. Prior to the ACA, health plans could deny coverage to people based on
their health status or their medical expenses. Guaranteed renewal is another consumer protection requirement stipulating
that individual and group health plans must offer all enrolled members the
opportunity to renew an insurance policy as long as the individual continues to
pay premiums (Centers for Medicare & Medicaid Services, 2013).
of ACA has led to historic gains in health insurance coverage (Avery, Finegold, & Whitman, 2016).
Individuals and families of all income levels, age groups, races, and
ethnicities have seen substantial reductions in uninsured rates. Coverage
expansion provisions of the ACA (i.e., the Marketplace) and reforms have worked
in concert to reduce the national uninsured rate to 8.6%. Although the ACA has
allowed more Americans to access health insurance coverage, there are reports
calling into question the stability of the program after several health plans
announced that they are pulling out of the Marketplace in 2017 (Cox & Semanskee, 2016).
Coverage for Rehabilitative and Habilitative Services and Devices
The ACA also ushered in important
insurance coverage requirements for nongrandfathered health plans in the
individual and small-group markets to cover essential health benefits (EHB),
which include items and services in 10 categories. "Rehabilitative and Habilitative
Services and Devices" is one of the EHB-required categories. This means that
ACA health plans must offer coverage for rehabilitative and habilitative
services and devices.
in How Habilitation and Rehabilitation Are Defined
The definitions for both habilitation and rehabilitation create the opportunity for coverage of additional
services, including rehabilitative and habilitative audiology and related
As of January 2016, the Centers for
Medicare and Medicaid Services (CMS)—the federal agency responsible for
overseeing implementation of the Marketplace—created a nationwide uniform
definition for habilitative services and devices that lists speech-language
pathology, occupational therapy, and physical therapy as examples of covered
CMS formally adopted the National
Association of Insurance Commissioners' definition for habilitation services and devices:
Health care services that help a person keep, learn,
or improve skills and functioning 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 (SLP),
and other services for people with disabilities in a variety of inpatient
and/or outpatient settings. (Patient
Protection and Affordable Care Act, 2015)
Like habilitation, the definition for rehabilitation specifically lists
speech-language pathology, occupational therapy, and physical therapy as
examples of covered services:
care services that help a person keep, get back, or improve sills and
functioning for daily living that have been lost or impaired because a person
was sick, hurt, or disabled. (Patient Protection and Affordable Care Act, 2015)
Prior to the uniform federal definition
for habilitation, states or health plans were allowed to define the habilitative benefit, which led to variation
in how habilitation was defined and what services were included in ACA health
plans. The federal definition now establishes baseline coverage that did not
In addition to defining habilitation,
beginning January 1, 2017, CMS also requires that habilitation and
rehabilitation services be provided as distinct—not combined—benefits, and that
the habilitation benefit be provided at least in the same amount as
rehabilitative coverage. For example, if an ACA health plan provides 60 visits
for rehabilitation, then it must also provide 60 visits for habilitation. It is
anticipated that the most common method for distinguishing the two types of
services is through a habilitative services modifier—SZ—added to the
corresponding Current Procedural Terminology (CPT®) code on the claim form.
Coverage: Rehabilitative and Habilitative Services and Devices
In response to the significant gains
that CMS's provisions afforded the therapy provider community to improve access
to coverage of audiology and speech-language pathology services, the American
Speech-Language-Hearing Association (ASHA) developed a comprehensive advocacy guide,
Essential Coverage: Rehabilitative and Habilitative Services
and Devices [PDF] (ASHA, n.d.). This guide is meant to be used by
ASHA-recognized speech, language, and hearing state associations and interested
members, and it explains the integral role that audiologists and
speech-language pathologists play in providing services to individuals who
require rehabilitation and habilitation services.
described as the experts in providing services related to the prevention,
diagnosis, and evidence-based treatment of hearing, balance, and other auditory
disorders. These professionals are uniquely qualified to provide an
individualized plan of care to support enhanced functional communication
outcomes for their patients. The comprehensive advocacy guide also provides
clinical examples for when audiology and speech-language pathology services are
medically necessary under the "Rehabilitative and Habilitative Services and Devices"
Habilitation Services: Cochlear Implants
was identified with a permanent, sensorineural, severe-to-profound hearing loss
at 6 months of age and currently wears hearing aids in both ears. Her family
chose an auditory/oral communication approach. Olivia is receiving a cochlear
implant evaluation from an interdisciplinary team—including a surgeon, an
audiologist, a speech-language pathologist (SLP), and a social worker—at a
hospital three hours away. An early intervention (EI) SLP has been providing
habilitation services in the home since Olivia's hearing loss was diagnosed.
The audiologist and SLP have been collaborating with the cochlear implant team
on habilitative treatment and will continue to provide services locally to the
family following the cochlear implantation. This professional collaboration
will help the audiologist in programming the cochlear implant to maximize Olivia's
hearing benefit. A collaborative plan of treatment is critical for developing
speech and language skills following cochlear implantation.
Rehabilitation Services: Benign Paroxysmal Positional Vertigo
Mary is a
57-year-old woman who recently began suffering from dizziness every time she
rolls over in bed. Her primary care physician referred her to an audiologist
for a full audiologic evaluation and vestibular assessment. The hearing
thresholds were within normal limits, and the vestibular evaluation revealed
that she has benign paroxysmal positional vertigo (BPPV) in the left ear. The
audiologist performed a Canalith Repositioning Procedure (a.k.a. Epley Maneuver),
which provided some relief from the dizziness. However, after 2 weeks, Mary
experienced a short episode of disequilibrium when turning over in bed. She
returned to the audiologist, who repeated the procedure and instructed her on
habituation exercises. He counseled Mary about the nature of BPPV and taught
her how to perform this maneuver at home if the dizziness returned. A follow-up
appointment with the audiologist was made for 1 month later to monitor her
dizziness and self-treatment using the prescribed maneuver.
also provides model statutory language that states can adopt for the
definitions of habilitation and rehabilitation. Both definitions specifically
list audiology as an example of a habilitation and/or rehabilitation therapy
service. The definition explicitly states that audiology and speech-language
pathology services shall be provided by an audiologist or SLP.
Opportunities, Challenges Remain
One major advocacy opportunity is that
these federal provisions to cover habilitative and rehabilitative services and
devices in ACA health plans can potentially affect coverage of hearing aids for
individuals of all ages. CMS clarified that state benefit mandates—enacted to
define and supplement habilitative services and devices to meet the uniform
federal definition—are part of the essential health benefit and that states do
not need to defray the cost. In other words, if a state wants to improve coverage
for habilitative services and devices through a state mandate, the ACA health
plans would have to include these enhanced services as part of the essential
health benefit. This clarification allows states to address coverage gaps in
their state. For example, a state could cover hearing aids through a
habilitation state mandate. Moreover, these provisions could increase the scope
and range of audiology services available to individuals with a variety of
medical conditions and functional impairments.
However, there is still work to do.
Audiologists are usually not recognized by health plans or states as
rehabilitation or habilitation therapy providers. With the exception of
Washington state, audiology services are typically covered for hearing screening
or hearing aids but not for outpatient rehabilitation (aural rehabilitation).
Another advocacy opportunity is through the ACA Nondiscrimination in Health Programs and Activities
Final Rule [PDF] that prohibits discrimination on the basis of race,
color, national origin, sex, age, or disability. It is ASHA's position that failing to cover hearing aids
discriminates against people with hearing loss. In addition, coverage of
hearing aids for children only, and not for adults, violates the ACA
prohibition against discrimination in plan design based on age because hearing
aids are medically appropriate for individuals regardless of age.
What You Can Do
would like to partner with members to educate and advocate for the inclusion of
audiology services under the EHB "Rehabilitative and Habilitative Services and
Devices" benefit category for ACA health plans. To keep the momentum going, we
request that state associations appoint a habilitation advocacy point person
within the state. That person could be a State Advocate for Reimbursement
(STAR) representative or another individual willing to work on such an
initiative. To date, volunteers have been identified for Alaska, California,
Connecticut, Illinois, Louisiana, Ohio, Massachusetts, Minnesota, Mississippi,
Nevada, New Jersey, New Mexico, Pennsylvania, South Carolina, Texas, Vermont, and
West Virginia. If you are interested in learning more about becoming the
habilitation advocacy point person in your state, please contact Daneen Grooms
Ensuring Access to Audiology Services
committed to ensuring that individuals have access to medically necessary
audiology services. With the ACA including rehabilitation and habilitation
services and devices as one of the 10 essential health benefits that ACA health
plans must cover, it creates an opportunity to expand coverage for and access
to audiology services for the roughly 11 million individuals who participate in
the Marketplace. Furthermore, a national definition for habilitation provides
leverage for continued advocacy. With a federal definition in place, ASHA,
state associations, and other interested stakeholders can reference this
definition when determining whether individuals who purchase their health
insurance in the Marketplace are receiving adequate coverage for habilitative audiology
About the Author
Grooms, MHSA, is the director
of health reform analysis and advocacy at ASHA. She is ASHA's liaison to two
CMS centers—the Center for Consumer Information & Insurance Oversight and
the Center for Medicare & Medicaid Innovation. Her focus is on advocating
for the inclusion of audiologists and SLPs in health reform initiatives,
including alternative payment models. Prior to joining ASHA, Daneen worked at
the American Academy of Neurology as the regulatory affairs manager.
U.S. Department of Health & Human Services. Affordable
Care Act. Retrieved from http://www.hhs.gov/healthcare/about-the-law/index.html#.
American Speech-Language-Hearing Association. (n.d.). ASHA's essential coverage: Rehabilitative
and habilitative services and devices. Retrieved from http://www.asha.org/uploadedFiles/Rehabilitative-Habilitative-Services-Devices.pdf [PDF].
K., Finegold, K., & Whitman, A. (2016, September 29). Affordable Care Act
has led to historic, widespread increase in health insurance coverage. ASPE Issue Brief [Newsletter from Office
of the Assistant Secretary for Planning and Evaluation]. Retrieved from https://aspe.hhs.gov/sites/default/files/pdf/207946/ACAHistoricIncreaseCoverage.pdf [PDF].
Centers for Medicare and Medicaid Services. (2013). Overview: Final rule for health insurance market
reforms. Retrieved from https://www.cms.gov/CCIIO/Resources/Files/Downloads/market-rules-technical-summary-2-27-2013.pdf [PDF].
& Semanskee, A. (2016). Preliminary data
on insurer exits and entrants in 2017 Affordable Care Act marketplaces.
Retrieved from http://kff.org/health-reform/issue-brief/preliminary-data-on-insurer-exits-and-entrants-in-2017-affordable-care-act-marketplaces/.
Patient Protection and Affordable Care Act; HHS Notice of Benefit and
Payment Parameters for 2016; Final Rule, 80 Fed. Reg. 10750 (February 27, 2015)
(to be codified at 45 C.F.R. pts. 144, 147, 153, 154, 155, 156, & 158). Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2015-02-27/pdf/2015-03751.pdf [PDF].
in Health Programs and Activities, 81 Fed. Reg. 31375 (September 8, 2015) (to
be codified at 45 C.F.R. pt. 92). Retrieved from https://www.federalregister.gov/documents/2016/05/18/2016-11458/nondiscrimination-in-health-programs-and-activities.
Please Note: ASHA's policy analysis is based upon current law and regulations
at the time the article was submitted. Recent events with the election and
Republican control of the White House and both chambers of Congress likely will
have significant consequences for health care policy—particularly related to
the Affordable Care Act. ASHA is actively engaged in health care advocacy and
will keep members up to date as information becomes available in early