While the Affordable Care Act (ACA) contains provisions that aim to increase patient access to habilitative services, rules around how states approach "essential health benefits" requirements could weaken the intended outcome, according to a recent article in Kaiser Health News (KHN).
KHN reporter Michelle Andrews explored the ways in which individual states are responding to the ACA requirements to identify "benchmark" insurance plans that define the essential health benefits that will be covered in the health insurance exchanges. These essential benefits must include rehabilitative and habilitative services, but states are allowed some leeway in how habilitative services are defined. Andrews wrote that some policy experts are concerned that this leeway will allow insurers to "find ways to sidestep the new requirement."
According to the article, states can choose to handle the definition of habilitative services in 1 of 3 ways—by directly establishing the definitions, by requiring that insurance companies establish habilitative benefits at parity with rehabilitative benefits, or by allowing the insurance companies to decide how to cover habilitative services. The KHN story reports that "fewer than half of states have explicitly defined the services that are covered under habilitative services or required parity with rehabilitative services," leaving private insurers to create their own definitions.
The problem, according to Andrews' sources, is that private insurance companies may craft policies in ways that do little to actually increase habilitative coverage. A possible approach described in the article involves the substitution of more extensive rehabilitation coverage while reducing habilitative coverage—an allowable tradeoff when items are within the same health benefit category.
Essential health benefits are more clearly defined in Medicaid and the Children's Health Insurance Program (CHIP), where enrollees have access to habilitative services as defined by rules released in summer of 2013. APTA contributed comments during the creation of the rule and offers an explanation of essential health benefits as well as summaries of the ruling.
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