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 2020, the federal government issued regulations that will allow states greater flexibility in crafting the coverage requirements for EHBs, including coverage of services provided by audiologists and speech-language pathologists (SLPs).
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To improve consumer education and choice in health plan benefits, the ACA mandated the development of a standard summary of benefits and coverage (SBC) [PDF] 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, habilitation, and medically necessary in the uniform glossary. For example, 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 (visit limits, for example).
The level of coverage for speech, language, and hearing services and devices by ACA health plans will depend on the state.
As of April 2020, 11.41 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—will increase the number of people who can be served. By understanding the specific services covered, audiologists and SLPs can be better prepared to negotiate with ACA health plans and provide services to these individuals.
Consumers can enroll in ACA health plan coverage through the federally-facilitated marketplace or their state’s marketplace, if available.
Since 2019, consumers no longer have to pay a federal penalty (individual mandate) for being uninsured. However, some states, like Massachusetts and New Jersey, have their own mandates and penalties that will require individuals to purchase health insurance. Despite the reduction of the individual mandate penalty to $0, the individual insurance market has remained stable.
ASHA continues to work with the ASHA co-founded Habilitation Benefits (HAB) Coalition, ASHA-recognized state speech-language and hearing associations, and state-based 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.
The following resources provide additional information and tools to help you understand EHBs.