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  • HHS Issues Proposal to Define Essential Health Benefits

    The Department of Health and Human Services (HHS) today issued its long-awaited proposal to define essential health benefits (EHB) under the Affordable Care Act. Of particular importance to physical therapists is the agency's proposal to cover the 10 categories of services identified in the statute, which include rehabilitative and habilitative services and devices.

    Under the intended approach, states have flexibility to develop their plans around 4 benchmark plan types:

    • 1 of the 3 largest small group plans in the state
    • 1 of the 3 largest state employee health plans 
    • 1 of the 3 largest federal employee health plan options
    • the largest HMO plan offered in the state's commercial market  

    HHS believes this will allow states to tailor their plans based on its population's unique needs. The agency states, "To meet the EHB coverage standard, HHS intends to require that a health plan offer benefits that are "substantially equal" to the benefits of the benchmark plan selected by the state and modified as necessary to reflect the 10 coverage categories. This is the same equivalency standard that applies to plans under CHIP. Similar to CHIP, HHS intends to propose that a health insurance issuer have some flexibility to adjust benefits, including both the specific services covered and any quantitative limits provided they continue to offer coverage for all 10 statutory EHB categories."

    Specific to habilitative services, HHS is considering 2 options if a benchmark plan does not include coverage for habilitative services: (1) Habilitative services would be offered at parity with rehabilitative services -- a plan covering services such as physical therapy, occupational therapy, and speech therapy for rehabilitation must also cover those services in similar scope, amount, and duration for habilitation; or (2) As a transitional approach, plans would decide which habilitative services to cover, and would report on that coverage to HHS. HHS would evaluate those decisions, and further define habilitative services in the future.

    Based on the states' ability to tailor the plans and consider adding optional services or increased numbers of visits, it is important that APTA's state chapters continue to educate and foster relationships with their state agencies to ensure that rehabilitative services are optimized in the plans. 

    APTA will respond to the HHS bulletin before the January 31, 2012, deadline. The association also will provide resources to members to use at the state level.

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