Purpose

Prepare health plan coverage for augmentative and alternative communication (AAC) systems and related habilitation services, and set up how the state will reimburse plans for these added costs. The goal is to ensure people with severe expressiveness challenges have access to necessary communication tools and training.

Key definitions

• Augmentative and alternative communication system (AAC): any electronic or nonelectronic device and related software/components (including mounting systems) that help a person with severe expressive communication limitations supplement or replace speech that isn’t functional.
• Habilitation services: speech therapy and related activities to assess, select, develop, and train use of AAC systems when normal speech initiation is significantly limited due to congenital, developmental, or medical conditions.

Main provisions

• Coverage requirements

  • Health plans must cover AAC systems and repair/replacement as prescribed by the patient’s physician, when medically necessary and the system is the most appropriate for the enrollee’s needs.
  • Health plans must cover habilitation services as prescribed by the physician and deemed medically necessary.
  • AAC systems and habilitation services must not be subject to separate financial requirements or quantitative limits when ordered by the prescribing physician.

• Prior authorization and utilization review

  • Plans may require prior authorization for AAC and habilitation services, like other covered benefits.
  • Review decisions must use the most recent evidence-based guidelines recognized by relevant clinical specialists.
  • Reviews must be conducted in a nondiscriminatory manner and must not deny coverage solely due to an enrollee’s actual or perceived disability.

• Reimbursement and funding

  • The commissioner of commerce must reimburse health plan companies for the added coverage costs, but only for coverage that would not have been provided without these requirements.
  • AAC and habilitation services already covered by a health plan as of January 1, 2025 are not eligible for state reimbursement under this provision.
  • Plans must report quantified costs attributable to the added benefit to the commissioner, using a format developed by the commissioner.
  • The plan’s January 1, 2025 coverage level serves as the baseline to determine what costs are attributable to the new requirements.
  • Payments to health plans follow the rules in 45 C.F.R. title 45, section 155.170.

• Appropriation

  • Each fiscal year an amount is appropriated to the commissioner of commerce to pay health plans for the added coverage cost.

Significant changes to existing law

• Establishes a new mandatory coverage requirement for AAC systems and associated habilitation services within health plans, including criteria for medical necessity, prior authorization, and nondiscrimination.
• Adds a reimbursement mechanism where the state finances part of the incremental cost through the commissioner of commerce, with a defined baseline (as of January 1, 2025) and a prohibition on reimbursing pre-existing coverage.
• Integrates use of evidence-based guidelines for utilization reviews and ties payments to federal regulatory guidelines (45 C.F.R. 155.170).

Relevant terms - augmentative and alternative communication (AAC) systems - habilitation services - health plan - coverage - prior authorization - utilization review - evidence-based guidelines - nondiscriminatory - enrollee - prescribing physician - repair and replacement - most appropriate system - disability (actual or perceived) - commissioner of commerce - reimbursement - appropriation - January 1, 2025 - Code of Federal Regulations title 45 section 155.170