ACA Plans May Reduce Therapy Coverage A new federal rule allows states to adjust coverage of essential health benefits, including rehabilitative and habilitative services. Policy Analysis
Free
Policy Analysis  |   August 01, 2018
ACA Plans May Reduce Therapy Coverage
Author Notes
  • Daneen G. Sekoni, MHSA, is ASHA’s director of health care reform policy. dsekoni@asha.org
    Daneen G. Sekoni, MHSA, is ASHA’s director of health care reform policy. dsekoni@asha.org×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   August 01, 2018
ACA Plans May Reduce Therapy Coverage
The ASHA Leader, August 2018, Vol. 23, 26-27. doi:10.1044/leader.PA.23082018.26
The ASHA Leader, August 2018, Vol. 23, 26-27. doi:10.1044/leader.PA.23082018.26
States could soon adjust the list of health care services covered by Affordable Care Act (ACA) health plans, possibly setting lower coverage levels for rehabilitation and habilitation and, therefore, limiting access to audiology and speech-language pathology services.
The changes are allowed by the 2019 Notice of Benefits and Payment Parameters final rule issued in April by the Centers for Medicare and Medicaid Services (CMS). The regulations, which differ greatly from those in previous years, give states more leeway to craft benefit packages in 2020.
The ACA requires that individual and small group plans cover 10 categories of services—called essential health benefits (EHBs)—including rehabilitative and habilitative services and devices. To determine what items and services are actually covered in those categories, states chose from a set of 10 plans already sold in the state. This standard-setting plan is called the benchmark. States have twice been allowed to choose benchmark plans (or been assigned them by default), in 2012 and 2015.
Starting with the 2020 plan year, the benchmark selection process will be different. States will still have to offer the 10 EHBs, but they will be able to update their benchmark every year and have more flexibility in deciding what benefits are covered or excluded. Under the new framework, states will be able to:
  • Keep their current benchmark plan.

  • Copy another state’s benchmark plan in its entirety.

  • Replace one or more EHB categories with the same category from another state’s benchmark. For example, state A could replace its rehabilitative and habilitative services and devices category with state B’s rehabilitation and habilitation benefit.

  • Select a new set of benefits to designate as the state’s EHB-benchmark plan.

States were required to select their benchmark by July 2, 2018, for the 2020 plan year.

ASHA is concerned that states looking to save money or lower premiums may offer less-generous benefits and are likely to target rehabilitative and habilitative services.

Services at risk
In 2020, states can also allow benefit substitution both within and between EHB categories as long as the substituted benefit is actuarially equivalent to the benefit being replaced.
For example, a state could allow ACA health plans to reduce the rehabilitative and habilitative services and devices benefit by increasing the mental health and substance use disorder benefit. Although technically the plans must offer the 10 EHBs, industry-watchers predict that the current administration may not enforce the EHB standards as strictly as in the past.
Connecticut, for example, is holding true to the 10 categories. But Illinois has embraced the added flexibility by expanding access to mental health and substance use disorder treatment and services to address the state’s opioid crisis.
ASHA public policy analysts are concerned that states looking to save money or lower premiums may offer less-generous benefits and are likely to target rehabilitative and habilitative services as well as maternity care, pediatric dental care, and mental health/substance abuse services. The habilitation benefit is particularly vulnerable, because most private health plans did not typically cover these services prior to the ACA.
Rehabilitation and habilitation would be an EHB category that states would most likely exclude if allowed to narrow the scope of EHBs to reduce premiums—because they were not typically provided by individual health plans before the ACA and they affect a small share of enrollees—according to projections by the Congressional Budget Office, which conducts nonpartisan analyses of legislation.
Despite the changes to the EHB-benchmark process, federal protections support coverage for rehabilitation and habilitation. Effective January 2016, the federal government created a nationwide uniform definition for habilitative services and devices for ACA health plans that lists speech-language pathology as an example of a covered service.
Specifically, the definition reads: “Health care services and devices 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 and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”
ASHA supports the federal definition, but also advocates for the inclusion of audiology as another example of covered services.

In 2020, states can allow benefit substitution both within and between EHB categories as long as the substituted benefit is actuarially equivalent to the benefit being replaced.

Guidance available
In addition to defining habilitation, federal law requires that effective Jan. 1, 2017, habilitation and rehabilitation services be provided as distinct—not combined—benefits, and that the habilitation benefit must be provided in at least the same amount as rehabilitative coverage. For example, if an ACA health plan provides no visit limits for rehabilitation, it must also provide no visit limits for habilitation.
The level of coverage for ACA health plans will largely depend on the state.
ASHA hosted a joint webinar with the American Occupational Therapy Association and the American Physical Therapy Association to guide state associations and leaders in the EHB-benchmark selection process.
ASHA is also available to offer guidance or support to audiologists and speech-language pathologists who are practicing in states considering changes to rehabilitation and habilitation coverage (email dsekoni@asha.org).
0 Comments
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
August 2018
Volume 23, Issue 8