AG Bell ACA for Publication.pptx

Affordable Care Act and Hearing Healthcare
www.acialliance.org Twi;er: @acialliance Donna L. Sorkin MA / Execu4ve Director, ACI Alliance Ive;e Cejas PhD, Dir, Kids Hear Now CI Resource Ctr, U Miami & FL State Champion Hannah Ruark MS, LSLS AVT, Director, CASTLE, UNC & NC State Champion Our Presenters
Hannah Eskridge Ive0e Cejas Donna Sorkin SLP, LSLS Cert. AVT Clinical Psychologist PhD Execu4ve Director ACIA Director, CASTLE, UNC Facility devoted to care of children with cochlear implants and other hearing technology Director, Barton G. Kids Hear Now CI Family Resource Center, University of Miami Ear Ins4tute Advocate for access to care including appropriate (re)habilita4on for children and adults and school support to meet unique needs of the child Carolyn J. Brown Center for Acquisi4on of Spoken language Through Listening Enrichment funded by private/public partnership. Provides services and financial support Non-­‐profit assists in the health and con4nuing educa4on of children who are deaf/hard of hearing and their families, with an emphasis on the viability of cochlear implants Worked for nonprofits and cochlear implant device company prior to joining ACIA NC State Champion FL State Champion Agenda
•  Introduction
•  Overview of the Affordable Care Act and
Coverage of Hearing Healthcare
•  FL State Champion Efforts
•  Understanding Insurance Documents—yes you
can! (NC State Champion shares tips)
•  Discussion / Questions and Answers
American Cochlear Implant Alliance
Unique Organization in Field
•  Membership organization concerned with cochlear
implantation and access to care
•  Comprised of physicians, audiologists, speech
pathologists, educators and other professionals +
consumer/parents/other advocates
www.acialliance.org
American Cochlear Implant Alliance
•  Mission: To advance access to the gift of hearing
provided by cochlear implantation through
research, advocacy and awareness
•  Address factors contributing to underutilization of
cochlear implants
–  6% of Americans who could benefit have CIs
–  Pediatric utilization is higher than adult use at 50% of
eligible children but still lower (almost half) of use
rates in Western Europe and one state (NC)
www.acialliance.org
For further details regarding Symposium, please visit:
•  Symposium website www.ci2014usa.com
•  ACI Alliance website www.ACIAlliance.org
•  Follow us on Twitter @acialliance
Why focus on the Affordable Care Act?
•  Law is an opportunity for expanding access
•  Most public and private insurance plans cover CI
•  Still, there are candidates without insurance and
a few remaining outlier plans that don’t cover
•  ACI Alliance hopes to:
1.  Ensure plans offered under the new insurance
marketplaces cover cochlear implantation and other
typically covered hearing care appropriately
2.  Advise patients who want to purchase insurance
3.  Impact state coverage policies
Objectives
•  State Level:
–  Seek Gold Standard Language in each each state’s EHB
Plan
–  Make contact with appropriate state officials
–  Serve as point of contact for ACI Alliance and others
–  Monitor ACA roll-out in each state to proactively protect CI
•  National Level:
–  Report back to allow impact on Federal policies and
Federal Exchange
Overview of the
Affordable Care Act
Health Care Reform Overview
•  Overhaul of U.S. health insurance market
•  Reforms implemented using existing state systems
•  Numerous stakeholders:
–  American citizens, health care providers, hospitals,
private insurance companies, Medicare and
Medicaid
–  State and federal regulators and legislators, small
and large employers
11 Reforms that may help
•  Ban on pre-existing condition denials for children
•  Young adults can stay on parents’ insurance plans
until age 26
•  No lifetime monetary caps on essential health
benefits (EHBs)
•  Significant premium increases subject to state and
federal review
•  Coverage of preventive services without costsharing
12 Cochlear Implantation as an
Essential Health Benefit
and Benchmark Plan Process
What Benefits Are Covered?
• Ten categories of EHBs
– Emergency services
– Hospitalization
– Maternity and newborn care
– Mental health and substance abuse disorders, including behavioral
health treatment
– Prescription drugs
– Rehabilitative and habilitative services and devices
– Laboratory services
– Preventive care and wellness services and chronic disease
management (Medicare, Medicaid and private will cover preventive
care without co-pays)
– Pediatric services, including oral and vision care
14 Benchmark Plan Coverage
•  Plans operating in an exchange must provide benefits
substantially equal to those provided in their state’s
benchmark plan but don’t mandate specific services
•  Although monetary annual and lifetime caps are
prohibited, plans can place limits on visits, and use
other “utilization management techniques”
•  Since most benchmark plans cover CI, we expect that
most 2014 plans will cover CI (although substitution is
allowed). Our concerns lie with above limits
15 ACA Marketplace Plans
•  Underlying premise of ACA è plans offered
must mimic what is typical of commercial
insurance plan coverage
•  Benchmark plan è “typical” small plan
•  At present, cochlear implantation covered by
over 90% of commercial plans, Medicaid
(primarily for children), Medicare, Tricare
•  Would expect Benchmark plans to cover based
on the law’s intent for typical coverage
Cochlear Implant Coverage:
What we have found so far
•  Have found no stated exclusions
•  Some states mention cochlear implants by name in
their EHB plans as a covered service—most make no
mention
•  All Benchmark Plans examined cover CI (confusion
remains in one state—GA and we are confirming
coverage)
•  ACI Alliance Goals vis a vis ACA:
–  Ensure the entire continuum of care is appropriately covered
–  Coverage language is clear
–  As other carriers come on, ensure that they also cover
Continuum of Cochlear Implant Care (1)
Preopera8ve CI Hearing (Audiology) Assessment Comprehensive hearing and rehabilita4on history Comprehensive diagnos4c audiological evalua4on Op4miza4on of hearing aids (Hearing aid trial as indicated) Aided speech percep4on evalua4on Counseling -­‐  CI candidacy or con4nua4on with amplifica4on -­‐  Expecta4ons Considera8on of Bilateral Cochlear Implanta8on As appropriate for Children and Adults Preopera8ve Medical Assessment Comprehensive hearing and medical history Physical ENT examina4on & addi4onal examina4ons as indicated Radiological assessment Meningi4s immuniza4on & others as indicated Counseling & team discussion -­‐  Review of surgical procedures and poten4al risks -­‐  Expecta4ons Including implant device Surgery Continuum of Cochlear Implant Care (2)
Postopera8ve Medical Appointments Postopera4ve check prior to ini4al ac4va4on Annual follow-­‐up appointments Addi4onal medical follow-­‐up as needed Postopera8ve Audiological Appointments Ini4al ac4va4on (2-­‐4 weeks post-­‐surgery or earlier if indicated) One-­‐month, three-­‐month, six-­‐month and twelve-­‐month follow-­‐up Annual follow-­‐up appointments (Re)Habilita8on As determined by Implant team for children and Adults Device Maintenance Replacement and upgrades of processor and peripherals Ba;eries (covered by Medicaid, Medicare. May not be covered by Private Insurance)` Con$nuum of Care Chart available at www.ACIAlliance.org in FAQ sec4on Some Typical Coverage Challenges
(pre ACA and continuing)
•  Replacement parts including processor upgrades
–  Large co-pays
–  Upgrades limited to every 4 or 5 years unless lost,
broken or stolen
•  Number of covered (re)habilitation sessions
•  Adult and pediatric rehab typically covered though
# of sessions may be limited (can be appealed but
is challenging)
•  Such issues not necessarily “fixed” by ACA
What else we will watch for
•  Insurers can offer plans that are not identical to
the Benchmark Plan
•  Could substitute another actuarially equivalent
service for cochlear implantation
•  ACI Alliance State Leaders are monitoring their
states’ Marketplace plan offerings
Health Care Marketplaces and
State Oversight
Health Insurance Marketplaces Overview
Exchanges operate as online markets to
purchase and sell regulated insurance products
called qualified health plans
•  17 states established own Exchanges through
which issuers offer approved plans for purchase by
individuals and small groups
•  7 States partnering with the Feds
•  27 State Exchanges run entirely by the Feds
23 State Oversight Role
•  State insurance commissioners and department
of health play significant enforcement and
oversight role of qualified health plans
–  Even in states using federal marketplace, state
retains oversight authority
•  Many states still learning the ins and outs of the
law and welcome input from sincere
stakeholders
•  Authority can lie in different offices in different
states
•  Hence our focus on STATES
Washington Montana North Dakota Oregon Idaho Maine Minnesota Wisconsin South Dakota Nevada Nebraska Utah Colorado California Arizona New Mexico Pennsylvania Iowa Illinois Indiana Kansas Oklahoma New York Michigan Wyoming Missouri Arkansas Ohio West Virginia Virginia Kentucky New Hampshire Vermont Massachuse;s Rhode Island Connec4cut New Jersey Delaware Maryland North Carolina Tennessee South Carolina Alabama Georgia Mississippi Texas Louisiana Florida State Exchange Federally Facilitated Exchange Partnership Exchange Alaska
Hawaii
25 State Champion Program
State Champion Program
•  Allied Orgs indicated ACA coverage of CI a key
priority
•  Initiated State Champion program to support
individuals in each state to address CI coverage
•  Contact state insurance offices
•  Monitor Marketplace roll-out / report back
•  Serve as point of contact in the state
•  As of June 1, 2014, 30 states with
active ACIA State Champions
What State Champions Do
•  Contact state insurance offices to confirm
coverage and establish point of contact
•  Request Gold Standard Language to ensure
clarity of coverage for CI Continuum of Care
•  Resource for clinicians and professionals in state
•  Aid consumers/parents to negotiate sign-up
•  Feedback to ACIA on roll-out
•  State Champion contact information under
Advocacy tab on the website
ACA Marketplace Plan Covered Alexa’s CIs
•  http://hearinghealthmatters.org/hearingnewswatch/2014/studentgets-cochlear-implant-thanks-coverage-affordable-care-act/
Florida Case Study
Ivette Cejas PhD
KHN Goals
•  Pre and post-cochlear implant surgery
•  Patient and family-centered treatment
–  Audiology
–  Auditory Verbal Therapy
–  Psychology
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Counseling
Mentoring program
School consultations
Outreach
Professional trainings
Florida: Cochlear Implant Coverage Issues
•  Bilateral coverage
–  Medicaid was denying all submission for bilateral
implantation
–  Since January 2013 Medicaid has been approving
bilateral implantation
•  CI coverage prior to 12 months
–  This year we have had a few cases that were
approved & implanted prior to 12 months
•  Only one processor for Medicaid families
My First Step
•  To identify the Essential Healthcare Benefits (EHB)
Benchmark Plan for Florida & identify whether they
are running their own exchange program
Who did I contact?
Theresa Morgan ACIA Public Affairs Consultant Jack McDermo; Director of Life & Health Product Review at OIR Jim Bracher Robin Wesco; Michael Kliner Execu4ve Vice President FAHP Insurance Consumer Advocate Senior A;orney Insurance Consumer Office What was their response?
•  Jim Bracher (FAHP)
–  Introduced myself and described the American
Cochlear Implant Alliance
–  Emailed the “gold standard” language for coverage
•  Our communication
–  Received an email response within a month
–  “Our members had a lengthy discussion of your
request. Their conclusion was that the current
language is satisfactory and they do not support any
changes.”
Communication with the Insurance Consumer
Advocate Office
•  Michael Kliner (Senior attorney) facilitated
communication with Robin Wescott
–  Informed me that Robin Westcott wants to add this to
her legislative package for the 2014 session
ACIA Gold Standard Language for EHB
Plans when mentioning cochlear
implants:
Outpatient and inpatient (as deemed appropriate)
surgery and device inclusive of bilateral cochlear
implants; early intervention; needed follow-up
clinical services including audiology,
(re)habilitation, and DME.
What was the Result?
•  Communication with Michael Kliner & ICA
–  “Due to the fact that the bill focused on the
homeowner insurance claims process, anything
outside that scope was left out of the sponsored bill”
–  “Although nothing was accomplished this session with
cochlear implants for children, you have ten months
until the start of the next Legislative Session to
acquire compatriots to your cause.”
–  Recommendations:
•  Reach out to your own House and Senate Members
•  Reach out to new ICA, Steve Burgess
Quick Glance at Some Plans
•  Aetna
•  BlueSelect
•  Cigna
Next Steps for Florida
•  Communicate with new ICA, Dr. Steve Burgess
•  Contact the Department of Insurance Regulation
–  Have any regulations occurred?
•  Visit healthcare.gov
–  Continue searching/monitoring Florida plans
–  Do any Florida plans specify CI coverage?
•  Communicate with individual insurance
companies– urge that they list CI coverage in
plans listed in healthcare.gov
North Carolina Case Study
Hannah Eskridge MSP, LSLS Cert. AVT
ACA and North Carolina
•  North Carolina has 2 insurance plans
participating in the NC Marketplace with federal
subsidies
–  Blue Cross Blue Shield NC
•  26 plans
•  Subsidized coverage in all 100 NC counties
–  Coventry Healthcare of the Carolinas
•  25 plans
•  Subsidized coverage in only 39 counties
•  UNC CI team has not yet had a pediatric patient with a
plan from this carrier
UNC Insurance History
•  The impact of ACA on families with children
with hearing loss varies in North Carolina in
comparison to some states due to already
existing programs
•  Due to efforts by Dr. Paul Biggers and Dr. Rick
Pillsbury, the NC general assembly approved
the CCCDP grant in 1991
UNC CCCDP Grant
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North Carolina residents less than 21years of age are eligible for application to
the program. Acceptance is based upon financial need, as determined by:
Gross income
Number of dependents
Number of children with communication disorders
Extenuating circumstances, such as additional medical expenses
The financial criteria are designed to be flexible so that we may include as many
children as funding allows.
The CCCDP, after insurance has paid, will pay for:
UNC-CH Hospitals' bills for Hearing Related Charges
Hearing Aids - Up to Mid End Digitals, replaced every 5 to 7 years.
Repairs to Hearing Aids not covered by insurance.
Implant devices, accessories, service, and hospital charges for Implant
Candidates.
Auditory Habilitation/ Speech-language Therapy
The CCCDP is the payer of last resort
Back to ACA in NC…
EHB QHP EOC Affordable Care Act What does it all Mean??? Where to Start
•  Identify your resources
•  Contact to determine current status
•  Determine if steps need to be made to create
change in the language being used
Where to Start: My Process
•  UNC Policy Analysts
•  Identified the plans and the medical policies
•  Each plan or ‘product’ has it’s own Evidence of
Coverage
•  Found the language used for BCBS in relation to
cochlear implants
BCBS: Medical Policy: Cochlear Implants
•  “BCBSNC will provide coverage for Cochlear
Implants when it is determined to be medically
necessary because the medical criteria and
guidelines shown below are met.”
–  Age 12 months and older; and
–  Bilateral severe-to-profound pre- or post-lingual
(sensorineural) hearing loss, defined as a
–  Hearing threshold of pure-tone average of 70dB
(decibels) hearing loss or greater at 500 Hz (hertz),
1000 Hz and 2000 Hz; and
–  Limited or no benefit from hearing aids.
BCBS / Medical Policy: Cochlear Implants
•  http://www.bcbsnc.com/assets/services/public/
pdfs/medicalpolicy/cochlear_implant.pdf
•  Applicable codes: 69930, 92601, 92602, 92603, 92604,
92605, 92606, 92607, 92608, 92609, 92626, 92627,
92630, 92633, L8614, L8615, L8616, L8617, L8618,
L8619, L8621, L8622, L8623, L8624, L8627, L8628,
L8629, V5273
ACA and Impact in NC
•  Already referenced CCCDP grant for pediatrics
•  Adults: adult CI team at UNC has not seen any
decrease (or increase) in the number of CI
surgeries or patients deterred from pursing
surgery as a result of insurance changes. There
may be an increased deductible for some
patients, but this has not been documented
ACA and Impact in NC
•  Medicaid does not cover patients ages 21 and over
for CI in NC
•  NC is a state that did not expand Medicaid
Coverage
•  Cochlear implants have not been denied for
pediatrics or adults in the past due to the preexisting condition clause, so this has not increased
access to CIs
•  We continue to see No coverage (Exclusion to
Insurance) for some private insurance plans in
adults
ACA and NC: Anecdotal Evidence
•  Self-employed Adult
•  Family of Five and child with bilateral CIs
•  Is this helping families in the cracks in NC?
•  Is the language there for families that choose the
exchange?
Contact us for more information
•  Donna Sorkin / [email protected]
•  Ivette Cejas / [email protected]
•  Hannah Eskridge /
[email protected]
Resources
•  www.healthcare.gov
•  •The Daily Briefing:
http://www.advisory.com/Daily-Briefing/Resources/Primers/
MedicaidMap
•  •The Center for Consumer Information and Insurance Oversight,
CMS: http://www.cms.gov/cciio/resources/data-resources/ehb.html
•  •Cochlear Implant Continuum of Care is in the FAQ section of the
ACI Alliance website: http://acialliance.org/member/faq
•  •ACI Alliance will be updating ACA materials periodically on our
website and also posting on Twitter:
–  ACI Alliance: www.acialliance.org
–  Twitter @acialliance