October 1, 2013 Departments

Policy Analysis: Expanded Medicaid Plans Must Include Habilitation Services

Federal rules allow individual states to define the services to be included.

States that choose to offer expanded Medicaid plans under the Affordable Care Act must include habilitation and rehabilitation services and devices in their essential health benefits, according to regulations issued in July. The rule, however, does not clearly define those services.

The inclusion of habilitation services underscores the importance of these services for individuals who may not have lost a skill but who may require assistance in learning new skills.

The regulation applies only to expanded Medicaid programs—those that cover beneficiaries who will be newly eligible for Medicaid benefits when ACA provisions are fully implemented. Existing Medicaid programs are not required to cover essential health benefits.

The rule references the National Association of Insurance Commissioners definitions of rehabilitation and habilitation services. It indicates that states may want to consider those definitions in designing their expanded Medicaid plans, but does not require them to do so. The NAIC defines habilitation as health care services that help a person keep, learn or improve skills and functions for daily living; it defines rehabilitation as health care services that help a person keep, get back or improve skills and function.

According to officials at the Centers for Medicare and Medicaid Services, which issued the regulations, habilitation is an area that continues to be refined. States have the option to determine the habilitation services and devices that will be covered but, at the very least, must include habilitation services in the same amount, duration and scope as rehabilitation services.

The rule addresses several other important areas:

  • Setting. The settings in which services are furnished are largely determined by the providers authorized by the state. School-based practitioners can become Medicaid providers if they meet the state's provider qualifications.
  • Medically frail. The category now includes certain children with special needs and adults with disabling mental disorders or chronic substance abuse disorders; serious or complex medical conditions; physical, intellectual or developmental disabilities that significantly impair their ability to perform activities of daily living; or a disability determination. Beneficiaries in this category may enroll in the expanded Medicaid program or in a plan that best meets their special medical needs.
  • Early and Periodic Screening, Diagnosis and Treatment (most children covered by Medicaid). Expanded Medicaid plans must include the full range of EPSDT services up to age 21.
  • Non-discrimination policy. Medicaid agencies cannot arbitrarily deny or reduce the amount, duration or scope of a required service based solely on diagnosis, type of illness or condition. In addition, all providers of Medicaid services must operate within the scope of their licensure or certification.

Speech-language pathologists who want more information on the plans offered by an individual state and definitions of habilitation services should contact the state's Medicaid office.

Laurie Alban Havens, MA, CCC-SLP, is ASHA director of private health plans and Medicaid advocacy. lalbanhavens@asha.org

cite as: Havens, L. A. (2013, October 01). Policy Analysis: Expanded Medicaid Plans Must Include Habilitation Services : Federal rules allow individual states to define the services to be included.. The ASHA Leader.

Medicare Postpones SGD Rule

The effective date for a new Medicare rule [PDF, 12.5MB] that requires a patient to have a face-to-face visit with a physician before the physician can prescribe a speech-generating device has been postponed indefinitely.

The Centers for Medicare and Medicaid Services delayed enforcement until a date to be announced in 2014, citing "concerns that some providers and suppliers may need additional time to establish operational protocols" for compliance. Under current rules, a physician need only sign an SGD evaluation performed by a speech-language pathologist.

Register to receive updates on this and other Medicare rules through ASHA Headlines. Send an e-mail to emailsupport@asha.org with "subscribe to Headlines" in the subject line.


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