A prominent new national report may have brought habilitation services—including speech-language and hearing services for individuals with developmental delays—a step closer to reimbursable status as part of national health care reform legislation. At the same time, ASHA has formed an advocacy coalition to help push for inclusion of these services as "essential benefits" in the legislation.
Essential benefits are a set of health care service categories that must be covered by certain plans, starting in 2014, under the Patient Protection and Affordable Care Act (ACA). Insurance policies must cover these benefits to be certified and offered in health care exchanges.
The October report from the Institute of Medicine (IOM)—the health arm of the National Academy of Sciences—responds to a request from the U.S. Department of Health and Human Services (HHS) to develop recommendations for essential benefits under ACA. The report proposes a set of guidelines for HHS to follow in deciding what benefits should gain coverage.
The IOM report endorses a definition of essential benefits as "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."
This definition was developed by a working group of representatives from the health insurance industry, health care providers, government officials, and consumer and patient advocate groups, including ASHA (The ASHA Leader, Jan. 18, 2011).
The inclusion of a habilitation services definition with the essential health benefits underscores the importance of these services for children and adults who may not have lost a skill but who may require assistance in learning new skills. The definition also recognizes the importance of daily living skills and functional abilities that allow a person to engage in daily activities as fully as possible.
The report recommends a process for establishing the initial essential health benefits package; it does not dictate specific requirements. It suggests that HHS:
- Start with the scope of benefits provided by a typical small employer plan, then modify those benefits to reflect the ACA's 10 general categories of benefits and an IOM framework that factors in economics, ethics, evidence-based practice, and population health.
- Adjust this preliminary package by a cost target based on what small employers and their employees can afford.
- Weigh possible trade-offs through public discussion of benefit costs.
- Define the essential health benefits package as specifically as possible. A service that qualifies for a general category and that is not expressly excluded should be considered eligible for coverage if medically necessary for a particular patient.
As HHS develops the regulations, ASHA and other professional and consumer organizations have joined to advocate for the inclusion of habilitation services in the essential health benefits. ASHA is the lead organization in the newly formed Habilitation Benefits Coalition, a group that includes representatives from 20 consumer and habilitation service provider groups, including the American Physical Therapy Association, the American Occupational Therapy Association, the American Heart/American Stroke Association, and Easter Seals. More organizations are expected to join the effort.
The coalition is designing and implementing a consensus strategy, establishing links with key stakeholders, and developing educational materials. Following the release of the IOM report, for example, the coalition issued a press release urging HHS to include in the benefits package rehabilitation and habilitation services and devices to address functional deficits regardless of condition or diagnosis. A narrower focus risks excluding services for individuals who need habilitation services.
In preparation for a formal notice of proposed rulemaking, HHS invited providers, consumers, insurers, and health plans to offer comments on the creation and update of benefits at a series of listening sessions. At the provider session, ASHA and the coalition provided written and verbal testimony regarding evidence of the benefits of and need for habilitation services, the cost-benefit ratio of adding habilitation services to health care coverage, models for inclusion of habilitation services in essential benefits packages, and concerns about the IOM report and the proposed rule. ASHA emphasized the need for inclusion of habilitation services by using examples of critical speech-language pathology and audiology services.
HHS staff subsequently invited ASHA and coalition representatives to a formal meeting to discuss further the distinction between rehabilitation and habilitation services.