Thursday, January 31, 2013

The Effect of the Affordable Care Act on Music Therapy: A Call for Advocacy

A call for Advocacy

Advocacy --> Recognition --> Access

Since 2005, the American Music Therapy Association and the Certification Board for Music Therapists have collaborated on a State Recognition Operational Plan. The primary purpose of this plan is to get music therapy and our MT-BC credential recognized by individual states so that citizens can more easily access our services. The AMTA Government Relations staff and CBMT Regulatory Affairs staff provide guidance and technical support to state task forces throughout the country as they work towards state recognition. To date, their work has resulted in over 35 active state task forces, 2 licensure bills passed in 2011, 1 licensure bill passed in 2012, and an estimated 7 bills being filed in 2013 that seek to create either title protection or a licensure for music therapy. This month, our focus is on YOU and on getting you excited about advocacy.

For the last three months, I have been focused on the Affordable Care Act and how it might affect music therapy. In order to humanize our discussion I want to relate an experience about music therapy advocacy in our area.  

There is an agency in our town in Virginia which has a weekly program that invites families with children on the autism spectrum to come together for networking, sharing and learning.  This program employs a respite care model where the children who have ASD are involved in recreational therapy, physical therapy and music therapy while the parents gather to learn and network with one another.  In the fall, two music therapy students doing their practicum assignments were part of the music therapy services offered to the children.

The music therapy was so effective and popular that the music therapy students were asked to be the highlight of a presentation for a media event sponsored by a future US Senator and his wife.  This event put a spotlight on the music therapy groups offered by the program and was widely hailed as a superb success!  In fact, the two music therapy students who demonstrated music therapy services at the event were so well received that they were offered future jobs at the agency after they graduated! Currently, these same students volunteer their time at the same program so that this agency can continue to offer some level of music therapy type activities.  

This was a great success story, but how can we make it easier for agencies to employ music therapists?  Everyone at this agency was pleased with music therapy and wants to continue offering the service, but how can we make funding programs like this easier and more accessible.  Will the Affordable Care Act impact opportunities for music therapy?  How can music therapy receive more reimbursement through health care dollars?     

Let's dig in...

Please catch up on the background stories if you have missed Part I and Part Ia of this series.

Part II is a look at what the effects of Obamacare (Full text version of law is here.) might be on access to music therapy services.  I hope that you will contribute to this post and the discussion as we explore this together.  Before I go any further, I should warn you that many of the opinions linked to in this post, as well as my own conclusions, are educated guesses about what might occur.  As we discussed in Part I, many parts of Obamacare have yet to be implemented, and to further muddy the waters, the Department of Health and Human Services has only recently begun releasing detailed regulations regarding the plan.  I also remind you that the ACA as conceived by President Obama and the congress at the time is not the same plan being implemented as result of the Supreme Court ruling in 2012.  (I will discuss the ramifications of all this in Part III.)  

Music therapy is not specifically mentioned in the ACA, but access to music therapy through insurance and medical facilities may be affected as a result to changes in funding and coverage.  While there have been some isolated success stories in obtaining third party coverage through private insurance companies for music therapy services, music therapy is generally paid for through private pay or as an included service during in-patient care, rehabilitation or hospice services.  Reimbursement through private insurance companies varies by state, company, and even by case manager.  Some people don't see an improvement in this situation and the ACA may even make things worse.  Perhaps you have a different perspective? 

At least in the beginning, Obamacare will establish state or federal run insurance exchanges or companies that will provide insurance for those who cannot obtain insurance through their employment.  (Note:  As of today, only 18 states have said they will set up insurance exchanges.  The other states have left it up to the federal government or have asked only to be a partner in the process.  These exchanges are supposed to be up and running by October 2013.)  More people will gain coverage, but for the person trying to file for third party reimbursement, it means learning about one more of 50 new state sponsored programs and new kinds of bureaucracy!  So the lack of standardization may be a real hindrance to improving reimbursement rates for music therapy.  

Sometimes music therapy has been included in billing to Medicare as part of an array of services offered in skilled nursing and rehabilitation facilities.  This money is usually a fringe benefit for facilities that include music therapy and is not used to pay outright for the music therapy personnel.  There will not be a boost to this funding, and in fact, Medicare payments to facilities and physicians may face cuts since the ACA cuts $716 billion from Medicare.  There is an Independant Advisory Payment Board (IPAB) tasked with finding ways to make these cuts.  We will just have to wait and see what happens with this.        

Obamacare also attempts to significantly increase funding for low-income  individuals and families through Medicaid.  (Again, the Supreme court ruling has left this provision in flux because it allows states to opt out of the Medicaid expansion.)  Since Medicaid coverage is a "bare-bones" type program, it has not traditionally paid for services like music therapy except through state agencies that receive block grants of Medicaid money to use as they see fit.  So the increase in people getting healthcare through Medicaid will probably not directly increase access to music therapy services except possibly via mental health treatment that involves a music therapist in a facility.

Given this  basic outline of how music therapy has been funded in the past and the scope of the ACA, there are a few things that are fairly certain to occur:

1. Starting on January 1, 2014 (except for "grandfathered" plans where people purchased individual policies before March 23, 2010 directly from an insurance company.) most insurance companies will be prohibited from using pre-existing conditions to deny health insurance coverage for adults.  This prohibition is already in effect since 2010 for children under age 19. 
  • This is important as it relates to children and adults with developmental disabilities who have lost insurance coverage in the past.  Unfortunately, it still does not address the issue that some coverage within the plans is still restricted for a diagnosis of developmental disabilities.  For example, many companies (...although this can even vary from state to state) will not cover certain therapies for a diagnosis of developmental delay.  You have to dig deep to find this exclusion, but sometimes insurance companies will not cover physical, speech, occupational, music therapy, etc., if there is not a baseline physical functioning level.  In other words, you can get therapy for a disability from sickness or accident, but not something congenital or considered developmental delay where there is no evidence of a previous functioning level to work toward. 
 2. Beginning in 2014, insurance companies will not be able to impose any annual benefit cap.  This may have a large impact on people with disabilities since there will not be a lifetime limit on dollar amount.  
  • This should help people with ASD or DD especially, who often require high frequency therapy and treatment.  A limit to this potential benefit is that the law does not say how many therapy sessions or mental health treatment sessions will be covered per year. 
3.  The Bright Futures Initiative that recommends regular surveillance and screening for ASD and DD at ages 18 and 24 months could be included in the regulations for preventative screening and treatment.  These regulations are yet to be defined by the DHHS. 
  • If this does indeed become included in the free screenings, then many more children with ASD and DD will be identified and covered under insurance at earlier ages.
4. Some low-income families will become eligible for additional insurance coverage through the Medicaid expansion.  (...although, here again, this is still a very messy situation to figure out since so many states have declined to participate in the Medicaid expansion.)  In states where the CHIP program is separate from Medicaid, families may become part of the Medicaid Early Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit for children.  This program is supposed to be more generous and comprehensive in benefits than many private insurance plans.  

5. Once the health insurance exchanges become active in October 2013, all of the plans in the exchanges as well as any non-grandfathered private plan, will have to include coverage for rehabilitative and habilitative services and devices as well as prescription drugs and mental and behavioral health services. 
  • Some people with ASD/DD related conditions may still receive benefits even if they are part of a plan exempt from the new laws if they are in a state which already has state laws mandating some level of coverage for services to individuals with ASD/DD.  (There are currently 29 states that have some kind of mandated coverage.) 
6. There is a movement to change Medicaid reimbursement for certain types of hospital care from a per diem rate to a DRG rate (Diagnosis Related Group).  States that begin using this new method will be much more concerned with reducing the length of stay and increasing quality of care.  This may be a positive development for music therapy where we can show that music therapy services helps patients go home sooner while improving patient satisfaction.  One example we can point to is the benefits of music therapy treatment for cancer that reduce pain medication and improve patient perception of quality of life.  Other important statistics can be highlighted in the NICU where babies receiving music therapy services, and specifically, the Pacifier Activated Lullaby protocol go home sooner.  This saves the hospital thousands of dollars per baby since many of these babies are paid for through Medicaid.  

I want to point out that none of these six points specifically mentions music therapy.  Music therapy may peripherally benefit from the influx of people with insurance coverage and inclusion in services as a cost saving measure for facilities.  This may especially be true for mental health facilities and some hospital departments, where there are already established music therapy programs. 

My overall impression is that the law is very complicated for several reasons: 

Number one, the law was put into place as a framework passed by the Congress without specifics.  These specifics are only now being meted out piecemeal by the Department of Health and Human Services years after some parts of the law have already gone into effect.  

Number two, the decisions by the Supreme Court in 2012 upheld the overall law while at the same time weakening some of its key provisions.  This has resulted in a struggle between the states and the federal government so that the new law will be nothing like a "national healthcare" plan.  Every state will be different, requiring much individual research.  

Number three, there is much speculation (including my own!) about what may happen when insurance coverages increase, taxes go up, payments to certain doctors and facilities decrease, etc.  Nobody actually knows what will happen to the health care system and the integrity of the new law when society begins changing its behavior to adjust to the new reality.  Lawmakers essentially wrote a law based on a static universe.   

As a therapist, the one thing that I know, is that intervention often (hopefully!) changes behavior.  We do not live in a static universe. 

My point is that most of the families dealing with disabilities and receiving music therapy are already confused by the current system of insurance coverage and medical treatment.  Some have figured out how to navigate through this better than others, but many are just trying to keep up with the day-to-day tasks of living.  What are we going to do as therapists and as a music therapy profession to prepare for this?

It has taken me months of investigative study to even begin to understand this new law.  I have my doubts that many people will have the time or inclination to figure this all out.  

The Affordable Care Act essentially adds a whole new layer of bureaucracy to the mix.  It is vital that we, as music therapists, become aware of the impact ACA will have on our own states.  Then, we must individually, and I believe, as a profession, begin advocating for music therapy in the new laws and regulations. 

Many people maintain that government run programs are less responsive to the consumer.  That is not to say that a majority are supportive of the current state of insurance companies and their practices, but just in general, private businesses are usually concerned about the consumer and trying to please them and obtain more business.  That is just a basic fact of the free market.  

For example, you will often hear that a phone call to customer service in the private sector is being monitored for quality assurance.  This is because the company cares about how its customer service representatives are treating the customer.  Many of us have also been in the situation where we were able to obtain some resolution to a matter by speaking to managers or someone up the chain of command.  In my experience, this has never happened with a government agency.  Have you had success getting a call through to a manager or getting any kind of headway to fixing a problem? 

The bottom line is that in the private sector, the "customer is always right."  This does not apply to individual circumstances, but to the group of consumers as a whole.  Customers vote with their dollars.  The problem with "government run anything" is that they live by the motto, "the regulations are always right."  Sometimes a government agency can put on a good show about treating constituents like "customers", but inevitably, there is no flexibility to situations or special arrangements because everything is prescribed by regulation rather than motivated by what will be most efficient.  

--I realize this is getting a little philosophical, but I think it is an argument for more involvement by music therapists in the process of legislation and regulation.  

Currently, some music therapy services may obtain third-party reimbursement on a case by case basis depending on the insurance company or even case manager discretion.  After reviewing the new laws coming into force, I fear that the national insurance exchanges will not allow this flexibility.  If music therapy is not specifically mentioned, we may just be left out of the equation.  What do you think?  Do you share my concern?  

Advocacy at the state level may be the best avenue.  Each state is tasked with setting up its own insurance exchange system and deciding on what to include in the coverage.  

I hope that it is not too late to influence this process... 

Note:  In Part III I will explore the dynamics of the implementation process more closely.  We will examine the many problems faced by states trying to get Obamacare functioning and what might happen if things don't go the way it was planned.



  1. Excellent, excellent, excellent. I am so glad that you posted this!! I can't wait to send you the results of my thesis! It is so important for Music Therapists to know about this law so that we can prepare for the possible changes in our field. Thank you so much for all of your research into this.

  2. Hi Elisa,

    I am glad it is helpful. I can't wait to read your thesis! Please continue to spread the word about this important topic. I hope you will also chime in when you can about things that you are finding out about the law as you do your own research. Perhaps even write a guest post!?

    Take care and good luck,

  3. Hi, you explained the topic very well. The contents has provided meaningful information thanks for sharing info

    Music Therapy


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