A working group charged with developing standard definitions for several insurance and medical terms—including habilitation services—has submitted its recommendations to the Department of Health and Human Services (HHS) for inclusion in national health care reform regulations.
ASHA is a member of this working group, formed under the Patient Protection and Affordable Care Act of 2010 (PPACA), which calls for the development of uniform explanation of coverage documents and standardized definitions. The group, sponsored by the National Association of Insurance Commissioners, comprises health insurance industry representatives, health care professionals, government officials, and consumer and patient advocate groups, including the American Medical Association, the American Diabetes Association, URAC, the Federal Trade Commission, and UnitedHealthcare.
The working group developed standard definitions for terms outlined in the PPACA. Insurance-related terms included premium, deductible, co-payment, preferred provider, and excluded services. Medical terms included hospitalization, physician services, durable medical equipment, skilled nursing care, and rehabilitation services. ASHA lobbied successfully for the inclusion of a definition of habilitation services as well, because both rehabilitation and habilitation products and services are listed as essential health benefits under the law.
The working group defines rehabilitation services as "Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings."
This definition includes important concepts, such as the need for services due to illness, injury, or disability and the fact that such services may be needed to help someone preserve levels of functioning, not just regain lost skills.
The working group defines habilitation services as follows: "Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings."
The inclusion of a habilitation services definition underscores the importance of these services for children and adults who may not have lost a skill but may require assistance in learning new skills. In addition, the definition recognizes that not only daily living skills are needed, but also functional abilities that allow a person to engage in daily activities as fully as possible.
Plan Summary Form
The working group also was charged with developing a standardized form to be used by group and individual health plans to summarize the plans' insurance benefits and coverage. The law mandates that this summary meet certain specifications—no longer than four pages in 12-point or larger font; written in culturally and linguistically appropriate language that is understandable to the average consumer; and inclusion of specific information, such as a description of coverage for essential health benefits, a list of exclusions and exceptions, and cost-sharing provisions.
When insurance companies use the standardized form, consumers shopping for or enrolling in health insurance will understand more easily what is or is not covered by a particular plan. Although the final product submitted to HHS exceeds four pages, the working group was able to include all required information as clearly as possible.
The summary form and standardized definitions are not final; they will be considered by HHS and the Department of Labor as regulations are developed. However, this work represents the consensus of the working group and is an important step in making health insurance more understandable for all consumers.
The complete list of definitions and the final summary of benefits and coverage form, as well as the cover letter explaining the work and some concerns of the group are available at the National Association of Insurance Commissioner's website [PDF].