Essential Health Benefits (EHBs)

An important aspect under the Affordable Care Act (ACA) is the establishment of the essential health benefits (EHBs). EHBs are a package of benefits that assure certain health plans offered in the state Health Insurance Exchanges (Exchanges)provide a baseline of coverage, benefits, and services to their enrollees. Most health plans that will be offered in exchanges, with some exceptions, must cover the following benefits in order to be certified and offered in the Exchanges. Additionally, designated groups of newly eligible Medicaid beneficiaries must also receive these benefits by 2014.

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

Of interest to the physical therapy profession, is the "Rehabilitative and habilitative services and devices." Insight into how these terms may be interpreted may be gleaned from the National Association of Insurance Commissioners (NAIC) Glossary of Health Insurance and Medical Terms which has defined the terms as:

Rehabilitation Services: Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Habilitation Services: Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Why this Matters to the Physical Therapy Profession and the Patients We Serve

Although rehabilitative services will be mandatory services in most Qualified Health Plans, states will most likely impose annual visit limits, caps, or other restrictions for therapy services as current employer sponsored plans do. Therefore, it is imperative that physical therapists continue to educate state legislators, state policy makers, and consumers of the value, benefits and cost savings of physical therapy services.

Regulations and APTA Summaries

Articles

Additional Resources

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