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The Affordable Care Act

The Affordable Care Act and Access to Cochlear Implants

The Affordable Care Act (abbreviated as ACA) was passed by Congress in early 2010. Some provisions went into effect immediately, such as extending coverage to young adults under their parents’ health insurance plans until they reach age 26 and prohibiting non-coverage of children because of pre-existing conditions. The Marketplaces opened for applications in October 2013. Over 8 million individuals were covered as of June 2014.

The new law has provided an opportunity for individuals and their families who do not otherwise have health insurance to secure coverage from the new marketplaces. Regardless of whether or not a state has opted to operate its own exchange, each state has its own Essential Health Benefits (EHB) plan, which determines what benefits must be covered by the state’s small group and individual health plans under the new health care exchanges (or marketplaces, as they are now called).

American Cochlear Implant Alliance in a non-partisan organization and has taken no position—for or against—the Affordable Care Act. Rather we recognize that the Patient Protection and Affordable Care Act of 2010 is the law and may provide opportunities or conversely, challenges for individuals or families seeking cochlear implant coverage. We want to work towards utilizing the law to improve access to care and also address any access problems that may arise. In order to proactively address access on a state-by-state and at the national level, ACI Alliance created its State Champion Program.

To proactively address coverage of cochlear implantation at the state and national levels, ACI Alliance has established a State Champion Program.  At present, we have 33 states with one or more State Champions. The State Champions contact details are listed. Initially our State Champions will lead activities related to the Affordable Care Act. We expect that they will lead other access initiatives such as state coverage provisions under Medicaid.

Webinar on Cochlear Implantation Under the Affordable Care Act

In collaboration with Audiology Online, ACI Alliance conducted an online seminar on the ACA. The seminar was recorded and is available for free playback. CEUs are also available for those who are registered with the Audiology Online Open Access Program. (There is a charge to be registered but anyone can take the course without CEUs for free.)

Expanding Access to Cochlear Implantation Under the Affordable Care Act

The webinar was first given on January 15, 2014.

Course Description:

The Patient Protection and Affordable Care Act (ACA for short), often referred to as "Obamacare,” offers coverage opportunities for individuals who previously may not have had access to health insurance. This course provides a primer on the ACA and the state Benchmark Plan process and discusses what we have discovered so far regarding cochlear implant coverage under the new State Health Insurance Marketplaces.

For more details, please visit the Audiology Online website:

Click Here to open the Course.

ACA Marketplace Plans and Coverage of Cochlear Implantation

The ACA Marketplace plans typically cover cochlear implantation.  One teen in Chicago purchased her own Marketplace plan when her parents' employer insurance refused to cover her cochlear implant surgery.

Click Here

Ongoing Public Policy Monitoring of the Affordable Care Act

ACI Alliance has engaged the firm of Powers Pyles Sutter & Verville, PC to monitor and advice us on the ACA rollout and how we may positively involve our members in monitoring and addressing access issues. Theresa Morgan writes a regular column in our e-magazine, ACI Alliance Calling. The first two issues are available here:

The Affordable Care Act Medicaid Expansion and Coverage of Cochlear Implantation (First published: ACI Alliance Calling, February 2014, Vol 2, No 1) Theresa Morgan, Public Affairs Consultant to ACI Alliance Legislative Director, Powers Pyles Sutter & Verville, PC

Over the last months of 2013, most health policy stakeholders focused on the private market reforms which started this month under health care reform. States and the Federal government opened, with varying success, a number of "exchanges” across the country to operate as online shopping destinations for individuals and small employers looking to purchase health insurance plans. States and the US Department of Health and Human Services (HHS) certified new insurance products for the marketplaces, reviewing these plans to ensure they meet the new requirements under the Affordable Care Act (ACA). President Obama’s administration was also busy addressing the significant technical problems, which have caused widespread enrollment problems for the 2014 plan year.

What has gotten less national attention as we enter the New Year is the work states continue to undertake to dramatically reform their Medicaid programs. Because of recent budgetary pressures at the local and state levels, many state legislatures and administrations have embarked on changes to expand the use of managed care and have implemented other measures to bring down the cost of health care. For its part, the Federal government has launched a number of state-level demonstrations to coordinate care for "dual eligibles” (individuals who are eligible for both Medicaid and Medicare) and funded programs to provide incentives to states to provide Medicaid services in the community and in the home, rather than in an institution.

In addition, about half of the states will expand Medicaid eligibility in 2014. The ACA encourages states to add a new mandatory eligibility category to their Medicaid program: low income adults who would otherwise not be eligible for Medicaid. For the expansion population, the Federal government will pay 100% of the Medicaid expenses in the first year, and phase down to paying 90% of expenses in future years.
 
The ACA stipulates that states offer the new eligibly population a benefits package separate from the state benefits plan. States can use existing "benchmark” plan authority to shape a package to the new group. Some states are also using this opportunity to reshape the benefits plan for multiple Medicaid eligibility categories.

By law, when states utilize the existing Medicaid authority to create benchmark or benchmark equivalent plans (now called "Alternative Benefit Plans” or ABPs), these plans must cover Essential Health Benefits (EHBs). EHBs encompass ten broad categories of benefits, including rehabilitative and habilitative services and devices, and are intended to reflect the scope of coverage found in a typical employer plan.

Cochlear implantation is considered an optional service for adults under the Medicaid program. However, as states create ABPs for the new adult population and for other Medicaid eligible groups in the future, it is plausible that CI could become a required benefit when medically necessary because it is covered by most healthcare plans. Indeed, it is a stated goal of the administration that coverage under ABPs reflect similar EHB coverage to that covered under new private plans meeting ACA requirements so as to create greater consistency between the health care delivery mechanisms.

Many states are undertaking the ABP process as of January 2014. As 2014 state legislative sessions consider how to approach health care, states that have not yet decided to expand Medicaid will likely have the debate anew. Even in states that have opted to forgo expansion in 2015, there is an opportunity to use the Alternative Benefit Plan process to alter Medicaid coverage for other eligible groups in states.

To expand understanding of the Affordable Care Act and how it may impact access to cochlear implantation, ACI Alliance conducted a one-hour webinar on January 15, 2014 in partnership with Audiology Online. A follow-up course will be offered in August; watch the website and Twitter @acialliance for details.

Healthcare Reform Overview: Big Changes in 2014

(First published: ACI Alliance Calling, August 2013, Vol 1, No 1)
Theresa Morgan
Public Affairs Consultant to ACI Alliance Legislative Director,
Powers Pyles Sutter & Verville, PC

In early 2010, Congress passed and President Obama signed the healthcare reform law entitled the Patient Protection and Affordable Care Act (known as "ACA” for short, and called "Obamacare” by many in the media). A number of the law’s provisions took effect almost immediately, such as extending coverage to young adults until the age of twenty-six and prohibitions on insurance plans denying coverage to children with pre-existing conditions. But many of the most significant changes are going into effect in the next six months.

The ACA created a new health insurance marketplace organized into state-based "Exchanges.” Health insurance consumers will use Exchanges to compare and purchase insurance plans for plan year 2014 and beyond. Consumers should be able to purchase health insurance coverage for next year on the Exchanges starting on October 1, 2013. Individuals will have the option to purchase plans for themselves or their families. Small businesses will be able to purchase plans for their employees. Some individuals will qualify for federal premium subsidies to help them afford health insurance cover- age, and small employers will be eligible for tax credits to encourage them to provide health insurance coverage for their employees.

Individuals who now participate in group plan coverage through a large employer will have the choice to maintain that coverage, unless their employer ceases to offer health insurance benefits in the future. The ACA established fines for certain large employers who fail to offer affordable coverage and whose employees receive tax credits to purchase insurance on an Exchange, though the Administration just recently chose to delay application of those fines until 2015.

Most new insurance plans offered to individuals and small groups for plan year 2014 must cover, at a minimum, some benefits which fall within each of 10 statutorily named categories. These categories include rehabilitative and habilitative services and devices. Which benefits are specifically covered under that category will depend on existing coverage in each state. For example, if cochlear implants are covered by the plan which your state has selected as a base plan from which to determine a minimum benefits floor, then it is likely that all new individual and small group plans in that state will cover cochlear implants in 2014—unless an issuer substitutes another actuarially equivalent benefit for cochlear implantation.

At the same time, many states are expanding their Medicaid program under ACA authority to a new category of eligible, low-income adults. If your state chooses to expand Medicaid, then newly qualified beneficiaries will have a choice to access a Medicaid alternative plan, which covers Essential Health Benefits (EHB), as defined by that state. If cochlear implantation is part of that EHB plan, then the new Medicaid beneficiaries may be able to access what otherwise may be uncovered cochlear implant services under the traditional Medicaid plan in your state.

The upcoming changes are significant and complicated, and ACI Alliance is working with our State Champions to monitor health care reform. There are still many unanswered questions. We know the program will continue to evolve. We will provide updates and welcome information from our members that will help us advocate at the state and federal levels to ensure that health care reform is implemented in a manner that protects and enhances access to cochlear implantation.

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