ASHA collaborated with the American Occupational Therapy Association (AOTA) and the American Physical Therapy Association (APTA) to develop a new resource for public and private insurers, employers, consumers, state regulators, and other stakeholders to evaluate the appropriateness of rehabilitation and habilitation benefit design. The document, Joint Habilitation/Rehabilitation Benefit Coverage Statement: Guide to Assessing Adequacy of Benefits [PDF], outlines the principles that should be evaluated when determining whether an insurance product provides adequate coverage of habilitation and rehabilitation services and devices. Investing in habilitation and rehabilitation benefits is not only a smart investment, but is cost effective, representing only 2% of the premium for a silver plan in the Affordable Care Act (ACA) market.
ASHA, AOTA, and APTA recently met with staff of the U.S. Department of Health and Human Services’ Administration for Community Living and with state insurance commissioners at the National Association of Insurance Commissioners’ summer meeting to discuss potential barriers and how to improve access to these services. Topics included utilization management, cost-sharing mechanisms like affordable copays, and the importance of clear understandable benefit implementation guidelines for both providers and patients.
To further support coverage for habilitation and rehabilitation, ASHA’s Speech, Language, and Hearing Services: Essential Coverage of Habilitation and Rehabilitation [PDF] resource lists steps that states can take to protect individuals needing medically necessary habilitative and rehabilitative services and devices. The guide is part of a toolkit to assist ASHA-affiliated state associations in habilitation and rehabilitation advocacy since states now have greater flexibility to design ACA insurance products.
The level of coverage for ACA health plans increasingly depends on the state in which you reside. The ACA requires that individual and small group plans cover 10 categories of services called essential health benefits (EHBs), including habilitative and rehabilitative services and devices. Starting with the 2020 plan year, the federal government will still require coverage of the 10 EHBs, but states will have more flexibility in deciding what benefits are covered or excluded in each category.
The habilitation benefit is particularly vulnerable because, prior to the ACA, health plans did not typically cover these services. The Congressional Budget Office, which conducts nonpartisan analyses of legislation, projected [PDF] that habilitation and rehabilitation would be one of the EHB categories that states would most likely cut if they are given the opportunity to narrow the scope of EHBs in an effort to reduce premiums.
Several federal protections that support coverage for habilitation and rehabilitation still remain. In January 2016, a nationwide uniform definition for habilitative services and devices for ACA health plans went into effect that listed speech-language pathology as an example of a covered service. And, as of January 1, 2017, habilitation and rehabilitation services had to be provided as distinct—not combined—benefits, and the habilitation benefit must be provided at least in the same amount as rehabilitative coverage for ACA health plans.
Additional details on the ACA and EHBs are available on ASHA’s Essential Health Benefits webpage. For more information, contact firstname.lastname@example.org.