ASHA Advocacy Report Issue. An update on the Association s legislative and regulatory advocacy efforts. Federal Lobbying.

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1 ASHA Advocacy Report Issue An update on the Association s legislative and regulatory advocacy efforts. Federal Lobbying State Outreach Member Advocacy Political Action

2 Dear ASHA Member: I want to begin by thanking you for your continued engagement in advocacy. This year we experienced an overall increase in ASHA member engagement, as noted by the number of action alerts that members responded to, the increase in donors and donations to ASHA- PAC, the number of members flocking to Washington, DC, to participate in Capitol Hill visits, and the ever-growing number of followers on ASHA Advocacy s social media sites. So, thank you for being an active grassroots advocate! This spring, ASHA s Government Relations and Public Policy Board (GRPPB) will be soliciting ASHA members input for the development of the 2016 Public Policy Agenda. By completing an online survey, you can help determine our public policy priorities and let us know what you really care about in the upcoming year. Based on past survey results and with the help of members grassroots efforts ASHA has been able to target and achieve advancements in federal, state, and regulatory issues that are most important to members. One of ASHA s strategic objectives is to show the value of the professions to public and private stakeholders through advocacy. Your continued engagement in advocacy is critical to achieving that goal. On the following pages, you will find a summary of the outcomes related to the issues that you considered important for We realize that many of these issues repeat from year to year; however, each year progress is made toward advancing our professions in the legislative and regulatory arena. On behalf of the 2015 GRPPB, I thank you for your efforts and encourage your continued engagement in grassroots advocacy. We hope you enjoy this issue of Agenda in Action and remember to always advocate and be an advocate! Sincerely, Kellie Ellis 2015 Chair, Government Relations and Public Policy Board 2015 Government Relations and Public Policy Board Members: [Back L-R] Nancy Mellon, Christine Freiberg, Martin Audiffred, Gregg Altobella, Mary Jo Schill, George Lyons, D Jaris Coles-White [Front L-R] Donna Edwards, Kellie Ellis, Kathryn Dowd, Joan Mele- McCarthy [Not pictured] Ryan McCreery

3 Table of Contents Considerable Federal Regulatory and State Legislative Activity Public Policy Agenda Overview... 3 Federal Level Issues Medicare Reimbursement and Coverage Policies Appropriate Alternative Payment Policies to Replace the Therapy Caps... 4 Medicare Coverage of Audiology Services... 5 Reimbursement Codes... 5 Physician Quality Reporting System Speech-Generating Devices Osseointegrated Implant Devices... 6 Additional Medicare Advocacy Reauthorization of Federal Education Legislation... 7 Additional Federal Issues... 8 Protecting Student Athletes Act... 8 Classroom Acoustics... 8 Federal- and State-Level Issues... 9 Funding and Practice Issues for School-Based Members and Early Intervention Services... 9 Federal Hearing Health Care Issues State Hearing Health Care Issues Loan Forgiveness as a Recruitment and Retention Tool Medicaid Reimbursement and Coverage Policies Services for Individuals With Autism Patient Protection and Affordable Care Act Essential Health Benefits Private Health Plans Reimbursement and Coverage Policies Telepractice Demonstrated Value and Quality of Service 13 Scope of Practice State-Level Issues Comprehensive (Universal) Licensure Service Continuum State Consultants Additional State-Level Issues Licensure Scope of Practice Military Exemptions Truth and Transparency Legislation Music Therapy Licensure State Requirements for SLPs Providing Early Intervention Services Professional Privilege Taxes Telehealth Requirements for Delivery of Services to Student With Dyslexia Performance Assessment of Contributions and Effectiveness of Speech-Language Pathologists State Association Grants Member Advocacy Member Engagement ASHA Advocacy Social Media Political Action National Office Contacts For more information, please contact: American Speech-Language-Hearing Association Government Relations and Public Policy 2200 Research Boulevard Rockville, MD

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5 Although 2014 was marked by the inaction of Congress and political posturing by Democrats and Republicans during the 2014 midterm election cycle, there was considerable rulemaking at federal agencies including the U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) and Food and Drug Administration (FDA) and the U.S. Department of Education (ED) as well as legislation in the states. The 113th Congress closed as one of the least productive Congresses in U.S. history; however, Republicans were able to make large gains by increasing their House majority to its largest level since World War II, adding to gubernatorial and state house majorities, and taking control of the U.S. Senate. During 2014, there were repeated unsuccessful attempts in the House of Representatives to either repeal or roll back provisions of the Patient Protection and Affordable Care Act (ACA) and to sue the President over his attempts to delay implementing the individual mandate of the ACA through executive order. Congress spent a considerable amount of time campaigning in the 2014 midterm elections and either taking or avoiding taking action to bolster their campaigns back home. Despite the stalemate at the federal level, Congress did (1) extend the Medicare therapy caps exceptions process and adjust the sustainable growth rate (SGR) formula to prevent a Medicare cut of 23.7% to health care providers, including audiologists and speech-language pathologists (SLPs), until March 31, 2015; (2) pass a post-acute care transformation bill; and (3) agree to a $1.1 trillion federal discretionary cromnibus spending bill that avoided a government shutdown on December 11, There is additional spending beyond that for nondiscretionary entitlement programs (e.g., Medicare, Medicaid, and Social Security). The cromnibus budget plus a subsequent Department of Homeland Security bill fund all government agencies through September The budget bill held the line on most education spending, including $300 million in Pell grants. After the 2014 mid-term elections, the new 114 th Congress began to address major issues in 2015, such as permanently repealing SGR and reauthorization of the Elementary Secondary Education Act (ESEA) or No Child Left Behind (NCLB) law. To date, Congress has repealed the flawed SGR formula and extended a modified therapy caps exceptions process till The Senate is considering a bill to reform ESEA. Looming budget battles will occur in the fall of 2015, as the Republican House has approved a budget blueprint that would cut $5.5 trillion in spending from the federal budget over the next 10 years. Considerable Federal Regulatory and State Legislative Activity There was also an uptick in regulatory activity at the federal level. ASHA was actively engaged in addressing various proposals at CMS. These included whether Medicare would continue to cover implanted osseointegrated devices, whether application of the Value-Based Payment Modifier to audiologists and SLPs in private and clinical settings would be postponed, and whether CMS would rescind its policy on speechgenerating devices (SGDs) and open up National Coverage Determination to proposed updated language to reflect current technology. ASHA was successful in obtaining favorable outcomes to these CMS proposals. ASHA and members of its Health Care Economics Committee (HCEC) also met with CMS officials to address lower code values assigned by CMS than those recommended and approved by the American Medical Association coding committees for some of the audiologic vestibular codes. The states continued introducing numerous bills addressing appropriations, budgets, health care, and other measures. In 2014, ASHA s Government Relations and Public Policy (GRPP) staff reviewed 1,551 bills and 545 regulations related to audiologists and speechlanguage pathologists. Of those, 83 pieces of legislation passed and 195 regulations were adopted. At the state level, bills related to the professions addressed these topics: licensure and scope of practice, insurance coverage and licensure of autism service providers, hearing aid coverage, Medicaid services and expansion, essential health benefits, education, truth and transparency, hearing aid dispensing, loan forgiveness, music therapy licensure, telehealth, privilege taxes, Common Core State Standards (CCSS). States continued to face economic challenges. With tight budgets, state legislatures were reluctant to pass laws that added expenses to their budgets, and they struggled again with Medicaid and education costs. Teacher accountability continues to be an issue for state education departments and local education agencies. ASHA continues to work with state agencies and local school districts to advocate for the adoption of the Performance Assessment of the Contributions and Effectiveness of SLPs (PACE) to evaluate SLPs in school 1

6 Considerable Federal Regulatory and State Legislative Activity settings. The PACE is based on the explicit roles and responsibilities of SLPs in school settings. A number of states and local districts have utilized the PACE, and ASHA continues to advocate for greater acceptance and use of the PACE system. With regard to CCSS, Indiana, Oklahoma, and South Carolina dropped out of the program. Additional states may follow this year, as Common Core has become a 2016 campaign issue. There was also considerable activity at the state level with implementation of ACA mandates. With regard to federal expansion of Medicaid under the ACA, Republican governors of Wyoming, Utah, Idaho, North Carolina, and Tennessee have tried to persuade their legislators to accept federal funding, while Democratic governors in Montana and Pennsylvania are working with Republican-controlled legislatures in a similar manner. The Wyoming measure passed, while Arkansas voted to extend funding of the state s alternative Medicaid expansion plan. ASHA has continued to argue before the states and exchanges that participating health care plans in those exchanges should include habilitative and rehabilitative coverage for services and devices provided by audiologists and SLPs Capitol Hill Day: ASHA s Board of Directors, Audiology Advisory Council, Speech-Language Pathology Advisory Council, and Political Action Committee 2

7 The 2015 Public Policy Agenda (PPA) was prepared by the 2014 Government Relations and Public Policy Board (GRPPB) and approved by ASHA s Board of Directors. The GRPPB named the PPA the Blueprint for Action 2015 Public Policy Agenda. The Blueprint guides the advocacy efforts taken on by the Association and its members. The Blueprint is based primarily on ASHA member input. It includes the most pressing issues facing our members at the federal and/or state levels. The Blueprint provides the framework that guides the Association s level of engagement in advocacy efforts. The GRPPB developed the issue objectives with input from a survey of the entire ASHA membership on significant policy issues in order to focus and strategically plan the Association s advocacy and policy initiatives for Of the more than 173,000 ASHA members surveyed, ASHA received responses from 2,391 respondents on 11 issue objectives. Audiologists and speech-language pathologists (SLPs) showed strong agreement in ranking the importance of the issues involving reimbursement. Survey participation by school-based members increased as they focused on school funding and practice issues Public Policy Agenda Overview The GRPPB added two issues in the Blueprint for These include policies on scope of practice and demonstration of the value and quality of services provided by the professions. Following is the list of issues ASHA has been addressing from April 2014 through April The issues follow the layout of the 2015 Blueprint and are divided based on the level at which ASHA advocated issue-related goals. There are two federal-level issues, nine federaland state-level issues, and three state-level issues. Federal-level issues require advocacy and lobbying with members of Congress and federal agencies. Federal- and state-level issues exist at both the federal and state levels. Those issues require advocacy and lobbying with members of Congress as well as federal and state government agencies. State-level issues require advocacy and lobbying with state legislatures and state and local government agencies. See Blueprint for Action: 2015 ASHA Public Policy Agenda (www.asha.org/advocacy/ 2015-ASHA-Public-Policy-Agenda/). Blueprint for Action 2015 Public Policy Agenda 3 American

8 Federal-Level Issues Medicare Reimbursement and Coverage Policies ASHA members who treat Medicare beneficiaries constantly face the challenges of working with the Medicare system. Speech-language pathologists (SLPs) continue to deal with the results of Congress s inability to find a solution regarding the Medicare therapy cap on reimbursement for speech and physical therapy services. Audiologists contend with the lack of comprehensive Medicare coverage of services, specifically including treatment services. Both audiologists and SLPs seek fair compensation for their services and the ability to opt out of the Medicare program. Following are the Medicare reimbursement and coverage policies that ASHA focused on over the past year. ASHA advocated appropriate alternative payment policies to replace the therapy caps, Medicare coverage of audiology services, appropriate reimbursement codes, appropriate Physician Quality Reporting System (PQRS) measures, improved coverage of speech-generating devices, continued coverage of osseintegrated implants, postponement of the value-based modifier, modifications in home health reimbursement policy. Appropriate Alternative Payment Policies to Replace the Therapy Caps In December 2013, Congress addressed the sustainable growth rate (SGR) and Medicare therapy cap by adjusting the SGR formula to prevent a cut in Medicare reimbursement for physicians and other health care providers, including audiologists and speech-language pathologists (SLPs), and extending the exceptions process for the physical therapy and speech therapy cap through March 31, On February 5, 2015, Congressman Charles Boustany (R-LA) introduced H.R. 775, the Medicare Access to Rehabilitation Services Act of This legislation would create an outright repeal of the Medicare cap on outpatient rehabilitation therapy services and would ensure that patients are not denied vital coverage for much needed therapy services. This bipartisan legislation had 225 cosponsors in the 113th Congress, over half of the House of Representatives. On April 16, 2015, President Obama signed into law the $210 billion Medicare Access and CHIP Reauthorization Act of 2015 which repeals the old Medicare payment formula, called the sustainable growth rate, and replaces it with a new one based on quality, outcomes and a merit-based payment system. The law averts a 21% cut in Medicare reimbursement to physicians and other health care providers. The law extends a modified therapy cap exceptions process through The SGR will remain in place for five years as providers transition to the new system. Moving forward, physicians and other health care providers will be paid more if they meet quality criteria. The specifics of those criteria will now be developed. The law also funds the Children s Health Insurance Program (CHIP) and community health centers for two more years. Before the new law passed, efforts were made by Senator Ben Cardin, (D-MD), and Senator David Vitter, (R-LA), to amend the law to repeal the therapy caps. It failed from passing by only two votes (58-42) where 60 votes were needed for passage. There was a heavy push in the Senate to pass a clean SGR package free of any amendments. Although the therapy cap amendment failed, the strong showing of bipartisan support on the Senate floor will help in future efforts to repeal the caps. Additionally, this was the first time that therapy cap repeal was addressed on the Senate floor, and a bipartisan vote with almost two thirds support, clearly indicates Senate opposition to hard caps on outpatient therapy services. The House had sent strong messages that they would not consider any amendments to the House-passed H.R. 2. Any amendment could have served to effectively kill the bill. See ASHA s Issue Brief, Medicare Outpatient Therapy Cap (www.asha.org/uploadedfiles/ IB-Medicare-Outpatient-Therapy-Cap.pdf). See Shelly Victor: Advocating Against Medicare Therapy Caps (https://youtu.be/qs_ B2e84reM?list=PL8XYIFygdg6U8uXhkmy_ tvo45xvwh6dgc. 4

9 Federal Level Issues Medicare Coverage of Audiology Services In the 114 th Congress, Representative Gus Bilirakis (R-FL) reintroduced the Medicare Coverage of Audiology Services Act (H.R. 1116) that would allow audiologists to bill for both diagnostic and rehabilitation services. Congressman Bilirakis is a member of the House Energy and Commerce Committee, which has jurisdiction over Medicare coverage policies, and he also sits on its Health Subcommittee. ASHA believes the Medicare bill is the best approach for audiology in that the bill (1) has the support of the medical community and Congressional Hearing Health Caucus; (2) is consistent with the trends for coordinated care embodied in alternate payment models and systems, including the home health model, episodic payments, and accountable care organizations; (3) has the highest chance of passage of any current Medicare audiology legislation in Congress; (4) will allow audiologists to bill Medicare directly for services for which other professions can bill; and (5) ensures that the best plan of care is available to improve patient outcomes. ASHA is working to educate other potential cosponsors and the audiology community about the benefits of a comprehensive approach as well as to get the Congressional Budget Office (CBO) to score the bill. See ASHA s Issue Brief, Medicare Coverage of Audiology Services (www.asha.org/uploadedfiles/ IB-Medicare-Coverage-of-Audiology-Services.pdf). See Wayne Foster: Advocating for Comprehensive Audiology Legislation (https://youtu.be/hn1a5gm37jm?list=pl8xyi Fygdg6U8uXhkmy_tVo45xVwH6Dgc). Reimbursement Codes ASHA s Health Care Economics Committee (HCEC) continues to play an active role in the development, revision, and revaluation of Current Procedural Terminology (CPT) codes through ASHA s membership on the American Medical Association (AMA) Relative Value Update Committee (RUC) and CPT Editorial Panel Health Care Professionals Advisory Committee. ASHA presented two new audiologic vestibular testing codes (caloric irrigations bi thermal and monothermal) with the American Academy of Audiology, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Neurology before the AMA RUC. The results of our presentation will be presented in the 2016 fee schedule rule. ASHA and others also advocated that CMS allow more time for code presenters to comment on the agency s final determination of relative code values as recommended by the AMA RUC. Previously, commenters had between the issuance of the final fee schedule rule in November till the end of the year to address unfavorable values with CMS. Now, commenters will have from July through the end of the year to provide comments. Physician Quality Reporting System The Medicare Part B Physician Quality Reporting System (PQRS) is a mandated program for health care providers, including audiologists and SLPs in private practice, to report measures to CMS that represent the quality of services they provide. PQRS was primarily an incentive-based program through 2014, but then transitioned to a payment reduction program. Due to advocacy efforts by ASHA, the Audiology Quality Consortium, and other audiology organization stakeholders, CMS determined to change their position to retire audiology measure #261, Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness. ASHA requested the reconsideration to (1) ensure audiologists have a clinically relevant measure to report in 2015, (2) have a measure by which to train and educate, and (3) have an interim measure while audiology stakeholders develop and finalize six measures, currently in the testing phase of measure development. In 2015, and to avoid a 2% penalty in 2017, audiologists will report: Measure #261 for a minimum of 50% of all Medicare beneficiaries; Measure #130, the documentation of medication, for a minimum of 50% of the Medicare patient visits; Measure #134, screening for depression, for a minimum of 50% of the Medicare beneficiaries receiving tinnitus evaluations. In 2015, and to avoid the 2017 penalty, SLPs continue to participate in the documentation of medication measure and have pain assessment as an optional measure for participation. Other measures include documentation and verification of medication in the medical record and screening for high blood pressure. See Medicare Clarifies PQRS Requirements for Audiologists and SLPs (www.asha.org/ news/2014/medicare-clarifies-pqrs-requirementsfor-audiologists-and-slps/). 5

10 Federal Level Issues Speech-Generating Devices Augmentative and alternative communication (AAC) systems, including speech-generating devices (SGDs), provide a way for individuals with complex communication needs to communicate effectively and independently. SGDs are necessary when an individual cannot rely on natural speech to meet daily communication needs. In February 2014, Medicare contractors that administer Durable Medical Equipment (DME) claims issued a coverage reminder that prohibits SGDs from having any non-speech capabilities (e.g., , Internet, environmental control) or the ability to upgrade in the future at the patient s own expense. Related to the coverage reminder prohibitions, Medicare s contractors are routinely denying coverage for eye-gaze, a technology that is needed by patients with limited or absent mobility in the arms and hands. Also, in April 2014, CMS changed the manner for which it pays for SGDs, requiring patients to rent them over a 13-month period before owning the device. Capped Rental adversely affects patients in an extended hospital stay or in a skilled nursing facility, because while the patient is in the rental period, Medicare will not cover the rental fees. As a result of advocacy by ASHA and other interested parties, CMS rescinded the policies from the February 2014 DME contractors Coverage Reminder that required SGDs to undergo product approval and reclassification and opened up the National Coverage Determination for additional comment. We believe CMS will not reinstitute the policy change. ASHA is working with Representative Cathy McMorris Rodgers (R-WA), who introduced the Steve Gleason Act of 2015, H.R This legislation would allow immediate purchase and transfer of ownership of SGDs to the Medicare beneficiary/patient, thereby removing SGDs from the capped rental requirement. In addition, access to eye-tracking devices is included in the bill. 6 See Medicare Rescinds Speech-Generating Device Policies (www.asha.org/news/2014/ Medicare-Rescinds-Speech-Generating-Device- Policies/). See ASHA s Issue Brief, Ensure Medicare Beneficiary Access to Speech-Generating Devices (SGDs) (www.asha.org/uploadedfiles/ib-ensure- Access-to-Speech-Generating-Devices.pdf). Osseointegrated Implant Devices Regarding durable medical equipment, prosthetics, orthotics, and supplies for 2015, CMS proposed that osseointegrated implants (OIs) be reclassified from prosthetic devices to hearing aids. ASHA and other audiology advocates were successful in getting CMS to reverse its proposal in the final rule. The proposal would have eliminated Medicare coverage of OIs, which ASHA objected to in comments. Medicare Keeps the Audiology Osseointegrated Implant as Benefit (www.asha.org/news/2014/ Medicare-Keeps-the-Audiology-Osseointegrated- Implant-as-Benefit/). Additional Medicare Advocacy ASHA provided comments and/or met with CMS officials on numerous CMS proposals. 1. Value-Based Modifier (VBM): Medicare finalized the expansion of the VBM and associated rules to specialty-care providers not previously subject to the additional requirements. However, due to advocacy efforts from ASHA and other audiology and therapy organizations, CMS agreed to postpone the implementation as applied to audiologists, SLPs, and other nonphysician professionals. This is a significant decision for ASHA members providing services to Medicare beneficiaries, as noncompliance in 2015 would result in an additional 4% deduction from all Medicare claims in Home Health Agencies (HHA) Final Rule: Home health services have been paid by a prospective payment system under which the computation must include amounts based on the most recent audited cost report and adjusted to account for the effects of case mix and wage levels. CMS accepted ASHA s request to change the therapy reassessment timeframe to on or before every 30th calendar day. The HHA provider qualification regulations were updated to be consistent with the CMS statute and regulations, revising the SLP qualifications to an individual who has a master s or doctoral degree in speech-language pathology and is state licensed. 3. Physician Payment Sunshine Act: CMS proposed deleting the specific exemption for payments made to speakers at accredited continuing medical education (CME) events. ASHA supported the proposal to equalize things; ASHA s accredited providers were not exempt from the rule, because we were not written into

11 Federal Level Issues the existing rule as a recognized accreditor. In the final rule, CMS deleted the CE Exclusion in its entirety. CMS effectively expanded the CME exemption by stating that it would not consider any CME-related payments to be reportable so long as the commercial supporter does not require, instruct, direct, or otherwise cause the CE event provider to provide the payment to a covered recipient. Outlook in 114 th Congress While Congress repealed the SGR formula used to determine Medicare pay for physicians and other health care providers, they only modified the therapy caps exceptions process for two years. Senate Finance Committee Chair Orrin Hatch (R-UT) vowed to work to find a permanent solution to the therapy caps in the coming years. ASHA will work in Congress to find a permanent solution to the therapy caps. Additional cosponsors and support will be garnered for the McMorris bill to modify CMS s SGD capped rental policy. Reauthorization of Federal Education Legislation The Senate Committee on Health, Education, Labor and Pensions (HELP) approved the Every Child Achieves Act (ECAA) of 2015, a bill that would reauthorize the Elementary and Secondary Education Act (ESEA), aka No Child Left Behind (NCLB). The bill now moves to the Senate floor for consideration. The House of Representatives began debating H.R. 5, the Student Success Act (the House s ESEA reauthorization bill) in February, but have not voted on it yet. Senate Health, Education, Labor and Pensions Committee Chair Lamar Alexander (R-TN) worked with Senator Pat Murray (D-WA) to build support over the testing and accountability standards (e.g., teacher, low-income students achievement scores). Last reauthorized in 2001, ESEA remains the law of the land until changed by Congress. There is near universal agreement that the law, its testing regimen, and its accountability system need to be changed; however, Congress has been unable to produce legislation to do so. Below are key points of interest to ASHA s school-based members. Changes will be made related to the category of school-based professionals that audiologists and speech-language pathologists belong to: Pupil services under current law will become specialized instructional support personnel (SISP) in both the ECAA and H.R. 5. This change, requested by the community, better reflects the roles that these professionals, including audiologists and speech-language pathologists, play in schools. SISPs will receive greater recognition in this regular education law, including many new references included in Title I and Title II professional development. Title I funds may be used for early intervening services to be coordinated with the similar program authorized under IDEA. This change could allow schools to use general education funds for SLPs to work with struggling learners, rather than use limited IDEA funds. Below are key features of the Every Child Achieves Act. Title I dollars for low-income students cannot follow them to the school of their choice a policy known as Title I portability. The annual federal testing schedule will be maintained. States will continue to be required to report disaggregated testing data for subgroups of students, including minorities, low-income students, English-learners, and those with disabilities. States will be required to establish generic challenging academic standards for all students a move that separates the issue from the Common Core State Standards. The legislation clarifies that the federal government can play no role in the process of states choosing standards. Over the last several years, the Administration has been granting states waivers to the testing and accountability standards as long as they adopted comparable measures. The effect of the waivers has been to give more life to Common Core standards. Outlook in 114 th Congress Although the House and Senate continue to work on these bills, there are concerns from the education community related to funding. Should the House and Senate be able to compromise and pass legislation, that legislation would still need to satisfy White House concerns over states having the flexibility to move funds away from poorer school districts to more affluent ones in order to be signed into law. Although there may be congressional hearings, it is unclear if any real legislative action will be taken on the Higher Education Act before the next election. 7

12 Federal Level Issues See ASHA s Issue Brief, IDEA Funding for Special Education (www.asha.org/uploadedfiles/ IB-Protect-IDEA-Funding-for-Special- Education.pdf). See ASHA s Issue Brief, Protect Reauthorization of the Elementary and Secondary Education Act (www.asha.org/uploadedfiles/ib- Reauthorization-Elementary-Secondary- Education-Act.pdf). Additional Federal Issues In addition to the above issues identified in the 2015 Public Policy Agenda, two other opportunities arose over the past year that ASHA was involved in: student concussion act, classroom acoustics. Protecting Student Athletes Act Senator Dick Durbin (D-IL) reached out to ASHA for support on legislation the Protecting Student Athletes from Concussions Act, S that he introduced in S would direct local education agencies (LEAs) to develop and implement a standard plan for concussion safety and management. The plan must include educating school personnel including schoolbased audiologists and SLPs about concussions. Outlook in 114 th Congress Senator Durbin may reintroduce his bill. It s a legislative piece where bipartisanship could be achieved. Classroom Acoustics In an effort to address classroom acoustics, ASHA submitted a code amendment to the International Code Council s (ICC) American National Standards Institute (ANSI) A117.1 that would add a national classroom acoustics standard to the code. ICC ANSI A117.1 pertains to ensuring that buildings and facilities are accessible to and usable by persons with disabilities. The ASHA amendment was considered and passed by a voice vote of the ICC s A117.1 code committee at its January 2013 meeting. Pursuant to ICC procedures, ASHA s proposed classroom acoustics standard under the International Building Code (IBC) was posted for comment. We received a few comments, and those comments are now subject to further review and comment. See the Classroom Acoustics Facebook page at Outlook in 114 th Congress If no further comments are forthcoming after the latest round of comment review, the ICC subcommittee will submit the amendment for final consideration. 8

13 Critical issues related to the professions of audiology and speech-language pathology exist at both the federal and state levels. Many issues begin with a bill passed at the federal level to be implemented by states enacting laws and regulations. State legislatures also address issues that Congress has not acted on or provided any guidance for. In other areas, both the federal and state governments have acted. The following issues were ranked as having the highest importance for ASHA s membership. Funding and Practice Issues for School-Based and Early Intervention Services Hearing health care Loan Forgiveness as a Recruitment and Retention Tool Medicaid Reimbursement and Coverage Policies Patient Protection and Affordable Care Act (ACA) Private Health Plans Reimbursement and Coverage Policies Telepractice Demonstrating Value and Quality of Services Funding and Practice Issues for School- Based Members and Early Intervention Services During the past year, ASHA continued to advocate with educational consortiums and alliances, such as the Committee for Educational Funding (CEF) and the Consortium for Citizens with Disabilities (CCD), to promote reauthorization of ESEA and IDEA and to preserve funding for the related educational programs. ASHA advocated for achieving adequate federal financial support for our nation s educational system and continued to reach out to Congress regarding funding for special education as part of IDEA. Due to the collective efforts of these educational advocacy groups, Congress approved a $1.1 trillion dollar federal spending bill for discretionary programs that funded all government agencies (omnibus) through September 2015, except for the Department of Homeland Security, whose funding was extended by a subsequent funding bill. Although funding held the line on most education spending, the good news is that there was not a decrease in education funding. For example, Title I was essentially flat-funded. Although there was no money for Race to the Top, retired Senator Tom Harkin (D-IA), who chaired the Labor-HHS-Education appropriations subcommittee, got one priority through $300 million worth of Pell Grants would again be available to students who do not complete high school, but enroll in Federal- and State-Level Issues a career-training program under the omnibus bill. The Investing in Innovation grant program was cut by about $21.6 million. Federal Work Study got a $15 million boost. The National Science Foundation got a small bump, from $7.17 billion to $7.34 billion. Federal Hearing Health Issues At the federal level, hearing health care advocacy efforts focused on legislation for a hearing aid tax credit and legislation concerning the marketing and promotion of hearing aids as personal sound amplification products (PSAPs). ASHA is actively working with other stakeholder groups in the hearing health community to garner support for the hearing aid tax credit legislation. Representatives Devin Nunes (R-CA) and Mike Thompson (D-CA) have introduced hearing aid tax credit legislation, H.R. 1882, which would provide for a $500 tax credit towards the purchase of a hearing aid. The tax credit would apply to all individuals and could be used every three years. The legislation is identical to S. 315, which was introduced by Senator Dean Heller (R-NV) and Amy Klobuchar (D-MN) in January of See ASHA s Issue Brief, Hearing Aid Assistance Tax Credit (www.asha.org/uploadedfiles/ IB-Hearing-Aid-Assistance-Tax-Credit.pdf). Learn more about the Hearing Aid Assistance Tax Credit in this video (https://youtu.be/z3 bfx9xe34i?list=pl8xyifygdg6u8uxhkmy_ tvo45xvwh6dgc). ASHA submitted comments in May 2014 to the FDA opposing the Citizen s Petition (a.k.a. Mead C. Killion, PhD, ScD) that said FDA hearing regulations are outmoded, ineffective, and excessively burdensome to consumers. The petition also maintained that the regulations unduly restrict the availability, and competitiveness, of wearable sound amplifiers to the consuming public. Citizen argued further that the FDA should not regulate hearing aids or PSAPs, as current FDA regulations are not based on valid scientific evidence. In effect, such regulation contributes to financial and mental health problems for individuals with hearing impairment. ASHA refuted each argument in its comments and is waiting for the FDA to rule on the petition. 9

14 Federal and State Level Issues ASHA is also waiting for the FDA to finalize its draft Guidance Document, which is designed to further clarify the regulatory distinctions between hearing aids and PSAPs. ASHA s comments supported stronger guidance in distinguishing PSAPs from hearing aids, the context and environments when PSAPs are used, and additional product labelling safeguards for consumer safety. ASHA recommended that the FDA include a label on all PSAPs that would advise consumers that such products do not address medical conditions that may exist and require an appropriate hearing evaluation by a hearing professional. These Guidelines are in response to a joint effort by ASHA and several hearing organizations to get the FDA to take action against vendors who avoid the FDA regulation by selling hearing aids as PSAPs. Outlook in 114 th Congress ASHA will be working with other stakeholders to garner support for the hearing aid tax credit legislation. The challenge will be for Congress to find funds to pay for the benefit. State Hearing Health Care Issues Several key issues related to audiology practice continued to be prevalent during the legislative sessions. These issues include expansion and increased coverage of hearing aids, exempting the purchase of aids from state sales tax, prohibiting or requiring additional provisions in order to sell aids over the Internet, and expansion of the scope of practice for hearing aid dispensers. A number of states made changes to hearing health care provisions. Connecticut, Illinois, Hawaii, Ohio, Rhode Island, South Dakota, and Utah expanded or increased coverage for hearing aids. A few states (Alabama, Arizona, and Illinois) added a national exam requirement, while Utah removed the experience requirement for hearing aid dispensers. In the 2015 legislative session, ASHA has opposed a bill in Illinois that would require SLPs to notify parents of children with suspected hearing loss of services provided by the school for the deaf. ASHA is supporting bills in Mississippi and Oklahoma that would exempt the sale of hearing aids from sales tax and a bill in New York that would provide a tax credit for the purchase of an approved device. ASHA is also opposing bills in Alaska and Georgia that would expand the dispensers scope of practice. Loan Forgiveness as a Recruitment and Retention Tool At the federal level, ASHA lobbied on Capitol Hill to gain support for the Access to Frontline Health Care Act, which amends the Public Health Service Act to establish a student loan repayment program in exchange for health professionals providing 2 years of services in scarcity areas. Outlook in 114 th Congress The federal bill will need a new sponsor in the 114th Congress, as Representative Bruce Braley (D-IA) lost his Senatorial bid. We may see more state legislation on loan forgiveness. Loan forgiveness legislation passed in Mississippi and Texas in Mississippi passed an appropriations bill to fund loan forgiveness for SLPs willing to work in hard-to-staff schools. The Texas speech-language-hearing association provided funding for the loan forgiveness program in 2014 and has legislation pending to fund the program through the legislature in Additional states that are interested in loan forgiveness legislation are considering bills to authorize and fund in Medicaid Reimbursement and Coverage Policies Medicaid reimbursement and coverage policies continued to present challenges. ASHA continued to advocate that all state Medicaid programs (e.g., early and periodic diagnostic, screening, and treatment programs), including expansion programs, provide coverage for services to children in schools and in health care settings, as well as preserve coverage of audiology and speech-language pathology services; appropriately define essential health benefits; include coverage for autism and for adult services; eliminate limits on visits and reduction in reimbursement rates; monitor increased co-pays for services. Nonetheless, several states enacted laws and regulations that restrict services provided to audiology and speechlanguage pathology consumers in order to reduce overall cost. 10

15 Federal and State Level Issues Outlook in 114 th Congress Under a House budget blueprint, federal spending on Medicaid may fall $913 billion over a decade once the health program is turned to block grants to the states. This is part of efforts by congressional Republicans to trim $5.5 trillion from the federal budget over the next decade. At the state level, implementation of the four new speech-language pathology CPT codes continues to be problematic for many providers who participate in state Medicaid programs. Some states limit the number of codes available for use. This has caused particular problems, not only for cognitive therapy but also for swallowing. This may stem from the introduction of the new evaluation codes, as previously was used for all evaluations (including swallowing and cognitive impairment). Reimbursement rates for codes are still problematic in some states. Some have severely cut rates; other states have divided the old code into three or four, assuming that all people will receive three or four of the new evaluation codes. Some states (e.g., Alaska) still have not figured out how to reimburse for those clients who are in Medicaid managed care organizations. ASHA has worked with Georgia and other states to make appropriate determinations. Prior authorization is a growing problem, as many states are contracting for utilization review/prior authorization. Many states passed laws and approved regulations related to Medicaid rates, benefits, and provider issues. Below is a chart summarizing some of the recent laws and regulations that impact audiologists and SLPs State Laws and Regulations Related to Medicaid State Colorado District of Columbia Illinois Kentucky Maine Missouri New Mexico Ohio Outcome Adopted rules to define the amount and scope of speech-language and hearing benefits Adopted rules to establish the reimbursement of speech-language pathology services provided under a Home and Community based waiver for individuals with developmental disabilities Promulgated rules to eliminate the maximum visit number for speech-language and hearing services Adopted several rules regarding specific limitations for speech-language pathology, occupational therapy, and physical therapy services and required Kentucky Medicaid to expand the base of therapy service providers to ensure that beneficiary needs are met Promulgated rules to utilize federal Medicare rates as a basis for Medicaid reimbursement Clarified rules to detail medical benefit and covered charges under Medicaid Adopted guidelines to reimburse practitioners and facilities that serve eligible Medicaid recipients Developed rules to specify that audiologists and SLPs are eligible providers who can submit claims on their own behalf 11

16 Federal and State Level Issues Services for Individuals With Autism In 2014, over half of the states enacted laws and regulations related to the coverage of services for individuals with autism and standards for autism service providers. Although ASHA supports increased coverage of services for these individuals, we continue to closely monitor proposed legislation/rules to ensure that speech-language pathology services are included. A few state highlights are listed below State Laws and Regulations Related to Autism Services State Arizona Maryland Tennessee Virginia Kansas Maine New York Utah Outcome Enacted a law to establish standards for behavioral analysts Enacted measures to establish a behavioral analyst committee and adopt a code of ethics, among other provisions Created a behavior analyst board Established that a behavioral analyst student may perform behavioral analysis as part of his/her program of study Provided for insurance coverage for autism services Enacted a law to expand health care coverage for autism services to persons 21 years of age and under Adopted regulations for the profession and practice of applied behavior analysis providers Enacted legislation that outlines the terms of shared costs of applied behavior analysis benefits See ASHA s Issue Brief, Alternatives to Applied Behavior Analysis (ABA) Therapy (www.asha.org/ uploadedfiles/ib-applied-behavioral-analysis- Alternative-Therapy.pdf). See ASHA s Issue Brief, Preserve Medicaid Coverage of Audiology and Speech- Language Pathology Services (www.asha.org/uploadedfiles/ IB-Preserve-Medicaid-Coverage-of-Aud-and-SLP- Services.pdf). Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act (ACA) was signed into law in March The intent behind the ACA is to ensure that all Americans have access to quality health care that is affordable. ASHA closely monitors the ACA program and advocates on issues affecting the professions of audiology and speechlanguage pathology. As of March 1, 2015, over 11 million people had enrolled in plans under the ACA. The enrollment data included signups from federally run health insurance exchanges on HealthCare.gov in 37 states, as well as from those operated by 13 states and the District of Columbia. Outlook in 114 th Congress If the IRS rule is invalidated by the US Supreme Court and absent effective contingency planning a state that has declined to create its own exchange probably will not be able to stave off the immediate destabilization of its insurance market. Some believe the states without state-run exchanges will be under pressure to act quickly with the help of HHS, and/or Congress will enact short-term measures. Essential Health Benefits HHS has included habilitation as one of the essential health benefits required for health plans participating in state health insurance exchanges. ASHA commented on CMS s proposal to adopt a uniform definition of habilitative services that would ensure adequate coverage and clarify the distinction between habilitative and rehabilitative services that may be used by the states. As a finalized rule, qualified health plans are no longer permitted to determine the scope of or define habilitative services. The definition for habilitation is health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical therapy, occupational therapy, 12

17 Federal and State Level Issues speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. ASHA was successful in urging the agency to adopt the National Association of Insurance Commissioners (NAIC) definition of habilitation as the uniform definition to be used by states and health plans. HHS also finalized their proposal to require separate limits on habilitative and rehabilitative services beginning with the 2017 plan year. ASHA also commented on proposed CMS regulations regarding health care reform/aca: (1) Summary and Benefits of Coverage (SBC), (2) CMS Letter to Issuers wishing to participate in the Marketplace; and (3) Wraparound coverage for existing individual coverage in the Marketplace. CMS delayed implementation of the revised SBC template until 2017 to allow feedback from the NAIC. Private Health Plans Reimbursement and Coverage Policies ASHA receives phone calls and letters from audiologists, speech-language pathologists, patients, and parents regarding denials by private health insurance companies of previously covered services. ASHA continues to document these cases and write letters to insurance companies appealing the denials in order to seek coverage for consumers and reimbursement for ASHA members. Additionally, ASHA proactively seeks to change existing policies that restrict coverage of audiology and speech-language pathology services. For example, ASHA submitted appeal letters to insurance companies for coverage of the following issues: spastic dysphonia, vocal hoarseness, and cognitive rehabilitation. Finally, ASHA responds to insurance companies requests for information on whether certain services should be covered. For example, UnitedHealthcare asked ASHA to comment on coverage for the intraoral bone conduction hearing aid, such as SoundBite. Telepractice ASHA s Board of Directors voted to allow staff greater flexibility in advocating our telepractice policy to address legislative efforts at the federal and state levels. The Board endorsed the concept of a limited license/ registration to provide telehealth services across state lines. In the event of proposed federal legislation providing for reimbursement of telehealth services by audiologists and speech-language pathologists (SLPs), the Board approved of the negotiation of licensure requirements as specified within the legislation. ASHA is now better positioned to advocate for legislation with registration and credentialing components. The Telemedicine for Medicare Act of 2013 (H.R. 3077) was introduced in the House of Representatives in The bill allows Medicare to reimburse physicians and other practitioners for providing services remotely. The bill goes one step further in allowing Medicare providers to treat patients in other states under one state license. The Medicare Telehealth Parity Act of 2014 (H.R. 5380), introduced last year by Representatives Mike Thompson (D-CA) and Gregg Harper (R-MS), specifically identified audiologists, SLPs, and other non-physician practitioners to receive reimbursement by Medicare for providing telehealth services. See ASHA s Issue Brief, Medicare Telehealth Coverage for Audiology and Speech-Language Pathology Services (www.asha.org/uploadedfiles/ IB-Medicare-Telepractice-Coverage-AUD-SLP- Services.pdf). Outlook in 114 th Congress There could be bipartisan support in the House for this legislation. It is unclear how this situation will play out in the Senate. ASHA has been actively involved in promoting the use and appropriate regulation of telepractice. Currently, 19 states regulate, define, or have policy statements regarding telepractice services; six states reimburse for speech-language pathology services delivered via telepractice in education settings; and six states reimburse for such services in health care settings. In 2014, states passed a variety of laws and regulations related to telepractice. For information on requirements for practice in the states, go to state/state-telepractice-requirements/. Demonstrated Value and Quality of Service The 2015 Public Policy Agenda requires ASHA and its members to: 1. coordinate advocacy strategies with health care and school-based payers, 2. utilize data to support advocacy efforts related to adequate reimbursement across payers, 3. empower members and state association leaders to effectively demonstrate the value of audiology and speech-language pathology services in achieving desired client outcomes that reflect payer demands, 13

18 Federal and State Level Issues 4. take a leading role in establishing policies that (a) define the quality and desired outcomes of audiology and speech-language pathology services and (b) reflect the needs of the clients and professions. Pursuant to Strategic Pathway 5, to increase influence and demonstrated value of audiology and speechlanguage pathology services through advocacy and this Public Policy Agenda Initiative, ASHA is collecting data on pediatric populations that can be used to show the value of the professions to third-party and public payers. ASHA commented on and supported legislation that would standardize data used across post-acute care (PAC) settings. This legislation, the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, became law in It standardized patient assessment data, quality, and resource use measures for PAC providers, including home health agencies (HHAs), skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs). services to veterans) prior to making any changes to the provision of hearing health services via legislation. We also requested a meeting with Congressional staffers to get their take on the Office of Inspector General s report on productivity. IHS has reintroduced the bill in the 114th Congress, and ASHA, once again, is opposing it. At the state level, there has been a plethora of bills introduced to expand the scope of practice of other professions or restrict the ability of audiologists to practice at the top of their license. For example, bills in numerous states to expand music therapy to speech evaluation have been successfully defeated as well as efforts by hearing aid dispensers to expand their practices to audiology services. ASHA has been addressing efforts of applied behavioral analysts to restrict the services of SLPs. Outlook in 114 th Congress ASHA will submit comments to CMS on proposed regulations, and CMS will adopt final regulations. Scope of Practice The 2015 PPA requires that ASHA empower its members to advocate with payers and educate consumers on the value and expertise of audiologists and SLPs, support recognition of the ASHA CCCs, and advocate for policies that require use of the highest qualified provider. In addition, ASHA will oppose practice acts and licensure efforts that would expand the scope of practice of other professionals and practitioners into the scope of practice of audiologists and SLPs. Finally, ASHA shall engage and inform other professional organizations about the unique training, value, and expertise of audiologists and SLPs. At the federal level, ASHA was instrumental in helping to defeat legislation H.R. 3508, the Veterans Hearing Access Improvement Act that would allow the Veterans Administration (VA) to utilize hearing aid specialists alongside audiologists to help fill the need for services. The American Academy of Otolaryngology- Head and Neck (AAO-HNS), Academy of Doctors of Audiology (ADA), and ASHA had notified the International Hearing Society (his; proponents of the legislation) and bill cosponsors Representatives Sean Duffy (R-WI) and Tim Walz (D-MN) that we would request that they allow the Veterans Administration (VA) to conduct its productivity and staffing reports (currently being done in an effort to improve the VA s 14

19 The public policy agenda called for a focus of resources on comprehensive (universal) licensure, service continuum, state consultants. Comprehensive (Universal) Licensure In 2014, Virginia approved rules to eliminate the Board of Education as a licensing entity for school-based SLPs; thus, all SLPs in the state will be regulated by the Board of Audiology and Speech-Language Pathology. As a result, there are now 17 states (Connecticut, Delaware, Hawaii, Indiana, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Montana, New Mexico, North Carolina, Ohio, South Dakota, Texas, Vermont, and Virginia) that require a single license to practice in the state. Service Continuum In 2011, the Professional Service Continuum Summit was held to collect information on supporting a service continuum. Of the six recommendations from the Summit, one required developing model licensing language to promote uniform credentials for audiology, speech-language pathology, and assistant practice in states. In 2013, ASHA completed model licensing language that was approved by ASHA s Board of Directors. The language includes education, training, and supervision requirements for speech-language pathology assistants (SLPAs). ASHA s state advocacy team is promoting adoption of the new language to promote uniform requirements across states, including universal licensing provisions for SLPs and SLPAs. In 2014, several states adopted rules governing the practice of SLPAs, and still others are considering adding licensing requirements based on ASHA s model language to their licensing rules. Virginia and West Virginia passed legislation to regulate SLPAs. New Hampshire adopted several rules related to certification of SLPAs. Oklahoma updated rules regarding the responsibilities of SLPAs and audiology assistants. In 2015, ASHA is developing model rules for audiologists, speech-language pathologists, and speechlanguage pathology assistants. See ASHA s Model Bill for State Licensure of Audiologists, Speech-Language Pathologists, and Audiology and Speech-Language Pathology Assistants (www.asha.org/uploadedfiles/state- Licensure-Model-Bill.pdf ). State-Level Issues See ASHA s Speech-Language Pathology Assistant Scope of Practice (www.asha.org/policy/ SP /). See ASHA s Professional Issues Document on Audiology Assistants (www.asha.org/practice- Portal/Professional-Issues/Audiology-Assistants/). State Consultants ASHA works closely with members who serve as state education consultants. In 2014, several phone and face-to-face meetings were held with the state education consultants organization (SEACDC), including a meeting with ASHA leaders at our Annual Convention. ASHA and the consultants discussed issues of mutual interest and concern, including the promotion of state education consultant positions in state education agencies and updating of ASHA resources, including ASHA s list of assessments on the ASHA website. Additional State-Level Issues Daily, states are introducing new legislation, reintroducing existing bills in sessions, and proposing changes to regulations that affect the professions. Over the past year, ASHA s state advocacy team reviewed 1,551 bills and 545 regulations related to audiologists and speech-language pathologists. Of those, 83 pieces of legislation passed and 195 regulations were adopted. Since April 2014, ASHA has worked with state associations on the following issues. Licensure Scope of practice Military exemptions Truth and transparency legislation Music therapy licensure State requirements for SLPs providing early intervention services Privilege Taxes Telepractice expansion Requirements for professionals delivering services to students with dyslexia Performance Assessment of Contributions and Effectiveness of Speech-Language Pathologists State association grants 15

20 State-Level Issues Licensure In North Carolina (NC) Board of Dental Examiners v. Federal Trade Commission, 134 S. Ct (2015), the U.S. Supreme Court held that a licensing board can claim protection from the federal antitrust laws under the state action doctrine only if its conduct is actively supervised by disinterested state officials rather than by interested parties (Board members) acting alone. The Court found that the NC Board of Dental Examiners had failed to show that in acting as a state agency under NC law, it was actively supervised by the state to claim the state action exemption and that it s prohibiting non-dentist from teeth whitening was an unlawful restraint of trade. As a result of this case, ASHA s State Team is collecting data on the appointment process, structure and composition, and current oversight of state boards. Many, if not most of the state boards, have public members and representatives from other professions (most notably medicine). Some, but not all, have members appointed by the Governor s office. Several are under the umbrella of a professional or occupational licensing board. ASHA is collecting data to provide resources and support to our boards. Scope of Practice A few states made some changes to scope of practice language. Hawaii and Indiana added swallowing to the occupational therapists scope of practice. Pennsylvania added interoperative monitoring (IOM) and Virginia added cerumen management to the audiology scope of practice. Oregon made revisions to the audiology scope of practice related to qualifications for supervisors. Military Exemptions Five states enacted laws in 2014 related to military spouses and active duty service personnel. 1. California passed legislation to expedite licensure for military and associated personnel. 2. Montana adopted regulations that require the Board of Speech-Language Pathologists and Audiologists to develop rules that provide mechanisms for military experience to be counted toward certification and/or licensing requirements. 3. New Hampshire added provisions that remove barriers for individuals who must relocate during post-graduate experience. 4. New Jersey amended provisions for licensure of military personnel and military spouses. 5. Ohio s Board of Speech Language Pathology and Audiology developed guidelines to give consideration to military personnel regarding initial licensure and renewal. Truth and Transparency Legislation In 2014, Utah passed legislation resulting in 11 states with Truth in Advertising provisions. Supported by the American Medical Association, this type of legislation requires professionals particularly those with doctoral degrees to identify themselves to the public as doctors of their stated professions, such as a doctor of audiology. Non-physician health care professionals believe that truth and transparency legislation is unnecessary, redundant, and designed to allow physician organizations to assess the professional competence of other health care providers. Music Therapy Licensure Montana passed amendments to licensure requirements for music therapists, while Rhode Island passed guidelines to register music therapists. In 2015, several states have proposed music therapy licensure; however, none have adopted such proposals. State Requirements for Speech-Language Pathologists Providing Early Intervention Services Arkansas clarified the referral process. Connecticut approved regulations regarding the right of recovery of funds and schedules of co-payments for enrolled families. Minnesota adopted changes to comply with IDEA Part C regulations passed in Nebraska adopted revisions to guidelines, including special educator qualifications.. Professional Privilege Taxes In 2015, Tennessee proposed legislation to repeal the professional privilege tax of $400 per year. ASHA supported this effort as well as an initiative to adopt a professional tax in Mississippi. The legislation in Tennessee remains active, while the bill to institute a tax in Mississippi died in committee. In a related measure, Washington approved a surcharge to credentialing fees for professionals, including SLPs. This bill provides funding for a resource library at the University of Washington and was supported by the state association. 16

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