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 ensure that 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 are certified and offered in the Exchanges, with some exceptions, must cover the following benefits.
- Ambulatory patient services
- Emergency services
- 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
As advocates of societal health, the physical therapy profession believes all these benefits should remain essential, reinforced with the adoption in 2018 of the House of Delegates position APTA Statement in Support of Essential Health Benefits (.pdf). However, of particular interest to the profession is the rehabilitative and habilitative services and devices benefit. The National Association of Insurance Commissioners (NAIC) Glossary of Health Insurance and Medical Terms 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 are mandatory services in most Qualified Health Plans, states can impose annual visit limits, caps, or other restrictions for therapy services as current employer sponsored plans do. In addition, updates to the ACA that will take effect in 2020 will loosen requirements around how states configure their "benchmark" plans offered through the Exchanges. 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. Here are some resources and tools for use in our education efforts.
Joint Habilitation/Rehabilition Benefit Coverage Statement: Guide to Assessing Adequacy of Benefits (.pdf)
APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association developed this statement to encourage public and private insurers to advance the best value for their health care dollar while improving the quality of patient-centered health care services. Insurers, employers, individual insurance plan subscribers, and public policymakers can use this tool when considering any modifications to insurance benefit plan design. Rather than call for a specific number of rehabilitation/habilitation visits, this statement of guidance sets forth a set of principles that enable payers to deliver access to and coverage of appropriate habilitative and rehabilitative services for their patients.
EHB-Benchmark Changes: What You Need to Know
Another collaboration between APTA, AOTA, and ASHA, this free recorded webinar and presentation slides (.pdf) discuss possible changes to state EHB-benchmark plans and how you can take action to preserve therapy benefits. (Slides require APTA member login for access.)