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 Carolyn J. Brown Center for Acquisi4on of Spoken language Through Listening Enrichment funded by private/public partnership. Provides services and financial support Director, Barton G. Kids Hear Now CI Family Resource Center, University of Miami Ear Ins4tute 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 Advocate for access to care including appropriate (re)habilita4on for children and adults and school support to meet unique needs of the child 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 Oregon Nevada California Idaho Utah Arizona Montana Wyoming Colorado New Mexico North Dakota Minnesota South Dakota Wisconsin Michigan New York Iowa Pennsylvania Nebraska Ohio Illinois Indiana Kansas Missouri West Virginia Virginia Kentucky Oklahoma Arkansas Tennessee North Carolina South Carolina Alabama Mississippi Georgia Maine New Hampshire Vermont Massachuse;s Rhode Island Connec4cut New Jersey Delaware Maryland 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 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 Execu4ve Vice President FAHP Robin Wesco; Insurance Consumer Advocate Michael Kliner 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 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 / dsorkin@acialliance.org Ivette Cejas / icejas@med.miami.edu Hannah Eskridge / Hannah.Eskridge@unchealth.unc.edu
www.healthcare.gov Resources 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