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
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
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.