Two issues of concern to audiologists and speech-language pathologists regarding habilitation benefits—parity and substitution of services—are addressed in frequently asked questions about essential health benefits issued by the U.S. Department of Health and Human Services (HHS).
Habilitation services are part of the essential health benefits that health insurance companies must include in coverage under new health care reform legislation. ASHA and other organizations successfully advocated to ensure that habilitation services, in addition to rehabilitation services, are part of essential health benefits in the new legislation (The ASHA Leader, November 22, 2011; March 13, 2012). These benefits will be offered to millions of uninsured Americans beginning in 2014. The FAQs [PDF], released in February, address parity of services for rehabilitation and habilitation, and substitution within categories.
Under parity of services, health plans must offer similar services to individuals who need rehabilitation and individuals who need habilitation. Because many plans do not currently offer habilitation services, HHS is considering how to include habilitation, and has indicated two options:
- Plans would be required to offer the same services for habilitative needs as it offers for rehabilitative needs and to offer them at parity.
- A plan would decide which habilitative services to cover and report the coverage to HHS. HHS would evaluate and further define habilitative services in the future.
ASHA has endorsed the first alternative, but more clarification is needed in defining parity, because treatment needs are different for an individual who has never developed a skill and needs habilitative services (e.g., a child born with Down syndrome) than for someone who has had a skill and lost it (e.g., as a result of a stroke).
"Substitution within categories" also needs more clarification. "Within" is central to the issue—it means that within the category of rehabilitation and habilitation, an individual may substitute speech-language visits, for example, for physical therapy visits. An individual could not, however, substitute speech-language visits for services in other essential health benefit categories (i.e., diabetes care).
ASHA continues to advocate individually and with the Habilitation Benefits Coalition, a group of professional and consumer organizations, for refinements. Many of the initiatives of the Affordable Care Act have already been implemented, despite legal challenges. ASHA as an association will continue to advocate for inclusion of habilitation and rehabilitation services for all payers, and urges members to do the same. For a sample letter, visit ASHA's website [PDF].