ASHA would like to thank to the 456 speech-language pathologists (SLPs) who contacted the Centers
for Medicare & Medicaid Services (CMS). The agency has since finalized
their proposal regarding copay equity for speech, physical, and occupational
therapy services. Effective for 2018, Affordable Care Act (ACA) health plans,
which elect to offer Simple Choice plans, must make the copayment amount for
speech, physical, and occupational therapy services equal to the copayment
amount for primary care services in states with cost-sharing requirements. These
states are Arkansas, Delaware, Iowa, Kentucky, Louisiana, Missouri, Montana,
and New Hampshire.
Of the 662 comments that were submitted to CMS on the 2018
Notice of Benefit and Payment Parameters (NBPP) Final Rule [PDF], 70% were from ASHA members.
This cost-sharing parity requirement is consistent with ASHA’s position on fair copays. To date, Iowa has passed copay
equity legislation for SLPs. ASHA will continue tracking this issue in 2017 and beyond.
In previous years, the NBPP final rule ushered in other important coverage
protections related to the rehabilitative and habilitative services and devices
benefit. For example, the NBPP requires ACA health plans to have
separate visit limits for habilitation and rehabilitation—visit limits for these services
cannot be combined. Moreover, the regulation adopted a uniform federal definition
that ACA health plans must follow for habilitation services and devices, which states
Health care services and devices that help a person keep, learn, or improve sills and
function for daily living, e.g., therapy for a child who is not walking or
talking at the expected age. 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.
The Center for Consumer Information and Insurance Oversight is the division of CMS
that is responsible for enacting many of the reforms related to the ACA insurance
Marketplace via the NBPP final rule. Rehabilitative and habilitative
services and devices is a
required benefit category that ACA health plans must offer to individuals.
Coverage of speech-language pathology services falls under this category.
Simple Choice plans (known as standardized
benefit options) were intended to simplify a consumer’s health insurance
shopping experience in the ACA Marketplace. These plans include elements such
as one cost-sharing structure for all services (i.e., copayment or coinsurance)
and one provider tier to help consumers decide which ACA health plan to select.
For more information, please contact Daneen Grooms, MHSA, ASHA's director of health
reform analysis and advocacy, at firstname.lastname@example.org or by phone 301-296-5651.