Health reform presents coverage uncertainty for habilitative services

A new analysis found that, as a result of the initial implementation of the Affordable Care Act, uncertainty may arise regarding the scope and extent of health insurance coverage for habilitative services for children with disabilities.

The Department of Health and Human Services approach to implementation will allow health insurance plans to define the parameters of health insurance coverage for habilitative services, as well as potentially scale back coverage for habilitative services in favor of broader coverage for rehabilitation services, according to the analysis by Sara Rosenbaum, JD, the Harold and Jane Hirsh professor of Health Law and Policy at the George Washington University School of Public Health and Health Services. Although the National Association of Insurance Commissioners define habilitative services as “health care services that help a person keep, learn or improve skills and functioning for daily living”, rehabilitative services are aimed at restoring a person’s skills or functioning and may not help them acquire new skills or achieve optimal development.

According to the analysis, in health policies for children with disabilities, state standards should be established for health insurance plans sold in the individual and small group markets; currently, only 37 states ensure coverage for habilitative services for children. Key regulatory issues that should be addressed include the definition of coverage, permissible limitations and exclusions, medical necessity evaluation, the permissibility of substitution and the interaction between habilitative services and mental health parity.

“Currently, 37 states have laws that require insurers to cover at least some level of habilitative treatment for specific classes of patients such as children with autism spectrum disorders,” Rosenbaum said in the analysis. “But most states do not yet appear to have adopted the National Association of Insurance Commissioners model definition, and most have not yet addressed the question of whether insurers will be required to achieve coverage parity between habilitative and rehabilitative services.”

For more information:

Habilitation Services Coverage for Children Under the Essential Health Benefit Provisions of the Affordable Care Act. Available at: Accessed June 28, 2013.

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