The Patient Protection and Affordable Care Act (ACA)
Essential Health Benefits
Patient Protection and Affordable Care Act
What They Are
Under the Patient Protection and Affordable Care Act (ACA), rehabilitative and habilitative services and devices constitute one of
10 essential health benefits (EHBs), or mandated benefit categories, that ACA health plans must offer to consumers who purchase health insurance coverage in the individual or small group markets.
In 2018, the federal government issued regulatory changes to no longer require health plans in the
small group markets to automatically cover all 10 EHBs. The federal government also issued regulations that will allow states greater flexibility in crafting the coverage requirements for EHBs in 2020.
Summary of Benefits and Coverage: Consumer Education and Choice in
Health Plan Benefits
The ACA mandated the development of a standard
summary of benefits and coverage (SBC) that accompanies private health plan documents provided to 180 million Americans (including for ACA plans). This section of the ACA also mandated the development of a
uniform glossary of medical and insurance terms (uniform glossary) [PDF], written in plain language, to help consumers understand commonly used terms in health insurance. Of particular importance to audiologists and SLPs are the definitions of rehabilitation,
medically necessary in the uniform glossary. The SBC helps increase consumers’ awareness of coverage for rehabilitative and habilitative services because health plans must list whether speech-language pathology is covered and disclose any quantitative limits (e.g. visit limits).
What This Means for Audiologists, SLPs,
The level of coverage for ACA health plans will depend on the state.
As of March 2018, 10.6 million Americans received coverage through the ACA. The addition of these individuals—who may be able to access covered services, including audiology and speech-language pathology services—will increase the number of people who
can be served. By understanding the specific services covered, audiologists and SLPs can be better prepared to offer services for these individuals and to negotiate with ACA health plans for provision of services.
Consumers can enroll in ACA health plan coverage through the
federally-facilitated marketplace or their state’s marketplace, if available.
Beginning in 2019, consumers will no longer have to pay a federal penalty (
individual mandate) for being uninsured. However, some states, like
New Jersey, will have their own mandates and penalties that will require individuals to purchase health insurance. It is unclear how the removal of the federal individual mandate penalty will impact ongoing enrollment in ACA health plans. In addition, with the added flexibility afforded by the federal
government to states in designing their EHB coverage, it is possible that states could adjust the list of health care services required by ACA health plans, including habilitation and rehabilitation services.
Additional information on how to protect habilitation and rehabilitation services in your state is available on ASHA’s website.
ASHA will continue to work with the Habilitation Benefits Coalition—co-founded by ASHA—ASHA-recognized state speech-language and hearing associations, and
Habilitation Advocates to protect access to habilitation and rehabilitation services. ASHA will use grassroots efforts to help formulate how the states address benefits, particularly coverage of rehabilitative and habilitative services and devices
provided by audiologists and SLPs.