The essential benefits requirement of individual and small business health insurance plans has been one of the most well publicized components of the Affordable Care Act (ACA). Within the ten categories is the inclusion of rehabilitative and habilitative services and devices. Is it likely that previously non covered habilitative services–for the developmentally challenged with autism, cerebral palsy and others–would be included in new coverage?

Historically, rehabilitative services have been covered by most health insurance. These services, physical and occupational therapy for example, are considered for individuals who are recovering from accidents or illnesses. Habilitative services, however, assist people in learning and maintaining daily functional skills, not getting them back. These types of services were often excluded from coverage.  In addition, conditions that required habilitative benefits were frequently considered pre existing conditions and individuals were excluded altogether.

Will the habiliative services component of essential health benefits be mandatory in all states? That depends. The ten essential health benefits categories are broad in scope and not every item in every category is required to be included. Each state has its own “benchmark” plan which delineates which essential benefits will be offered in that state. If the benchmark plan doesn’t specify levels of habilitative services, the state can do themselves. Should there be no specific guidelines, the states can suggest that the habilitative services be covered at a similar level that coverage is provided for rehabilitative services. Ultimately, though, without clearly identified rules, insurers can determine their own benefits and submit their proposed coverage to Health and Human Services (HHS).

Habilitative services are ongoing for most individuals; rehabilitative services are most often finite in their duration, and therefore, a more attractive benefit for insurers to provide. Enhanced rehabilitative services may also be more attractive to the general population.  As long as the essential benefits category is satisfied, insurers may decide to offer more rehabilitative services than habilitative services.

How habilitative benefits are offered remains to be seen. Many organizations who advocate for people with developmental difficulties would like to see definite increases in habilitative services, some benefits will mostly increase. Once this essential benefits category becomes clearer, there will certainly be more media coverage.

For additional information, contact EAB HealthWorks.