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).
The passage 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).
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.
The definitions for both habilitation and rehabilitation create the opportunity for coverage of additional services, including rehabilitative and habilitative audiology and related devices.
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 services.
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:
Health 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 exist previously.
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.
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, Speech, Language, and Hearing Services: Essential Coverage of Habilitation and Rehabilitation [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.
Audiologists are 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" benefit category.
Olivia 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.
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.
The advocacy guide 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.
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.
ASHA 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 at email@example.com.
ASHA is 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 services.
Daneen 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.). Speech, Language, and Hearing Services: Essential Coverage of Habilitation and Rehabilitation. Retrieved from www.asha.org//siteassets/uploadedfiles/ASHA/Practice/Health-Care-Reform/essential-coverage-of-habilitation-and-rehabilitation-advocacy-guide.pdf [PDF].
Avery, 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].
Cox, C., & 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].
Nondiscrimination 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 2017.