October 9, 2012 News

Judge Tells Washington Insurer to Cover Habilitation

by Carol Polovoy

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A federal judge has ruled that a health plan in the state of Washington must remove age restrictions on habilitation services for children with developmental disabilities.

The case, Z.D. v. Group Health Cooperative, was brought by the parents of a 12-year-old girl diagnosed with "moderate-severe receptive language disorder" and "other specific developmental learning disabilities." The child received speech-language treatment from the Group Health Cooperative until she was 7, when the plan refused to provide further treatment because of its policy limiting neurodevelopmental treatments to beneficiaries age 6 and younger.

A U.S. District Court judge found that treatments for developmental disabilities are covered under the state's Mental Health Parity Act, which forbids treatment limitations for mental health services if those limitations are not generally imposed on medical and surgical services.

The class action against Group Health is one of six brought against insurers in the state over the exclusion of neurodevelopmental and behavioral therapies. These types of treatments are "habilitative"—they help a person learn, keep, or improve skills and functional abilities that they may not be developing normally—rather than "rehabilitative," which focus on regaining skills and abilities lost to injury or illness.

The use of exclusionary clauses to eliminate coverage for specialty services to treat developmental disabilities is a common practice among Washington insurers, according to the plaintiff's attorneys. Lawsuits are pending against Premera Blue Cross, Regence Blue Shield, and the public employees' coverage, the Uniform Medical Plan.

A notice on the Group Health website indicates that "Given a recent federal district court ruling regarding the reach of Washington's Mental Health Parity Act, Group Health has expanded coverage of certain therapies for children over the age of 7 with neurodevelopmental disabilities."

Carol Polovoy, assistant managing editor of The ASHA Leader, can be reached at cpolovoy@asha.org.

cite as: Polovoy, C. (2012, October 09). Judge Tells Washington Insurer to Cover Habilitation. The ASHA Leader.

What Happens to Habilitation Services Under Health Care Reform?

Habilitation services are receiving more attention as federal agencies develop regulations for the Patient Protection and Affordable Care Act. Under this health care reform legislation, certain plans—starting in 2014—must cover a set of health care service categories called "essential benefits." Insurance policies must cover these benefits to be certified and offered in health care marketplaces.

The U.S. Department of Health and Human Services has indicated that habilitation services (designed to help individuals learn, keep, or improve skills) and rehabilitation services (designed to help individuals regain skills followed injury or illness) will be included in the essential health benefits, but it has not clearly defined the scope of those services (The ASHA Leader, March 13). In addition, the federal information was issued as guidance, not as regulation, meaning that states may interpret how to include habilitation in health insurance coverage.

The guidance defined the 10 service categories that must be included in essential health benefits, and included habilitation and rehabilitation services and devices in one category that previously was listed only as rehabilitation services. ASHA views this guidance as a welcome start in helping states develop health insurance benefit packages, and has suggested further clarification:

  • Define habilitation, using the definition from the National Association of Insurance Commissioners workgroup, and contrast it with rehabilitation.
  • Recognize that habilitation services are similar in type and scope to rehabilitation services, though the cause of the difficulty, condition, and exact course of treatment may differ.
  • Mandate that habilitation services be offered at least on parity with rehabilitation services.
  • Define "medical necessity," citing the ASHA medical review guidelines as a resource, when used to justify the need for requested services.
  • Describe maintenance programs, stressing that they are time-limited based on the needs of the patient.
  • Clarify that habilitation 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 habilitation services may be provided in a variety of settings, and ensure that services that may be provided in schools are not excluded.


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