A December 2011 bulletin includes habilitative services in essential health benefits that health insurance companies must, under new federal health care reform legislation, include in their coverage—but falls short of clearly defining the scope of those services.
And although the inclusion of habilitative services in the essential benefits is good news for those who need speech-language treatment or physical or occupational therapy, the format of the information—guidance, rather than regulation—means that states may interpret how to include habilitation in health insurance coverage.
Essential health benefits are a set of health care service categories that must be covered by certain insurance plans, starting in 2014, under the Patient Protection and Affordable Care Act (The ASHA Leader, Jan. 18, 2011; Nov. 22, 2011).
The U.S. Department of Health and Human Services (HHS), through its Center for Consumer Information and Insurance Oversight, issued the December Essential Health Benefits (EHB) Bulletin, and released additional information in January. The guidance was issued with input from the Institute of Medicine, comments from ASHA and other professional and consumer organizations, and other meetings with HHS staff.
The December bulletin offered guidance on defining the 10 service categories that must be included in essential health benefits, and included habilitative and rehabilitative services and devices in one category that previously was listed only as rehabilitative services. ASHA views this guidance as a welcome start in helping states develop health insurance benefit packages; however, as HHS pointed out in the bulletin, further clarification is needed.
In comments submitted to HHS at the end of January, ASHA indicated that the concept of habilitative services is still unclear to many providers and insurers. To provide more clarity, ASHA recommended that HHS:
- Define habilitation, using the definition from the National Association of Insurance Commissioners workgroup, and contrast it with rehabilitation.
- Recognize that habilitative services are similar in type and scope to rehabilitative services, though the etiology of the difficulty, condition, and exact course of treatment may differ.
- Mandate that habilitative services be offered at least on parity with rehabilitative services, so that a child who had never acquired language, for example, would receive the same benefits as someone who had a stroke and lost the ability to speak.
- Define "medical necessity" when used as a requirement to justify the need for requested services, citing the ASHA medical review guidelines as a resource.
- Describe maintenance programs, stressing that they are time-limited based on the needs of the individual receiving treatment.
- Clarify that habilitative services may be provided to children and adults (such as adults with developmental disabilities who may need assistance acquiring skills never demonstrated at a younger age).
- Clarify that habilitative services may be provided in a variety of settings, and ensure that services that may be provided in schools are not excluded.
In its comments, ASHA also addressed its significant concern about the form of the EHB information. Because HHS issued the EHB bulletin as guidance—rather than as a regulation—there will be no strict oversight to ensure that health plans are including all of the benefits.
The health reform law calls for states to provide, beginning in 2014, health insurance coverage for those who are uninsured or underinsured, many because they are self-employed or work for small companies. HHS has suggested that states choose designated "benchmark plans" that include the desired benefits to serve as coverage models for other plans that want to participate in the program.
Many insurers, however, including some that are named as benchmark plans, have begun to change coverage policies and are narrowing the diagnoses and conditions for which rehabilitative and habilitative services are covered (e.g., only stroke, head injury, and head/neck cancer). In the absence of regulations, ASHA and other professional organizations are concerned that plans may deny treatment for services previously covered, and have asked HHS to address the specific monitoring that will be established to prevent this narrowing of coverage.
ASHA will continue to advocate with HHS and the insurers for coverage of speech-language and audiology treatment and, as further guidance becomes available, will develop recommendations on how to advocate for continued service coverage.