Advocating for CI Coverage under Affordable Care Act Marketplace Plans
Peter Thomas, JD and Sara Rosta, MA
Government Affairs Counsel to the ACI Alliance
Powers, Pyles, Sutter & Verville PC
The ACI Alliance national leadership, State Champions, clinicians, educators, consumers, and parents have monitored cochlear implant coverage under the Affordable Care Act (ACA) Marketplace plans for several years now. Despite our close attention to this issue, denials of CI coverage have occasionally occurred in such plans.
To be effective at the state level on ACA private plan coverage issues, CI advocates must first identify any coverage limitations and then develop relationships with the key state individuals making decisions on health coverage issues. Many of our State Champions have already developed such relationships. If your patients encounter an ACA Marketplace coverage challenge, we encourage you to first contact the State Champion(s) in your state and solicit his or her assistance. A list of Champs is located on the ACIA website: HERE
Our State Champions have been trained on these topics and may have already been in touch with the appropriate person(s). In any case, they can help you with the contact to your state’s Department of Insurance to discuss concerns regarding specific CI coverage denials. For example, in Florida our State Champion determined that the Florida Essential Health Benefits Benchmark Plan makes specific mention of cochlear implant coverage in ACA Marketplace Plans. Hence it was surprising to find that several patients at her center were declined coverage under their Marketplace Plan issued by Humana. She and her colleagues are in the process of appealing this denial.
In an effort to aid individual advocates in appealing coverage denials, we have constructed a general template letter that you can adapt when advocating to your state insurance commissioner on a specific coverage issue. Click HERE for the template letter.
Please make use of this template as appropriate and report coverage denials to the ACI Alliance. Together with our State Champions, we will track these issues closely and stand ready to provide guidance on best practices for appealing denials or other issues related to ACA Marketplace plan coverage.
To locate your State Benchmark Plan to determine what it says about cochlear implants, visit: https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html
To locate contact information for contact of your State’s Insurance Commissioner, visit: http://www.naic.org/state_web_map.htm