Advocates fear limited coverage for habilitative services

Essential health services requirement for long-term support open to interpretation

While advocates for the disabled applaud the inclusion of habilitative services as an essential health benefit under the Affordable Care Act, they worry payers can "pick and choose" which therapies they will cover come Jan. 1, Kaiser Health News reported this week.

The essential health benefit category covering rehabilitation and habilitative services--one of 10 categories covered under the ACA--leave room for interpretation about what payers must cover, KHN reported. While physical therapy following an injury might be covered, for example, long-term support for patients needing help improving daily living skills or something like speech therapy might not, according to the article.

While buoyed that policies next year will be much more likely to cover habilitative services, the Urban Institute's Lisa Clemans-Cope told KHN she fears insurers might structure benefits "in a way that discourages people with expensive chronic conditions" from seeking policies with them. Consumers also will have to carefully read the fine print to understand what habilitative services will be covered, she said.

 "This is a big improvement, but we should emphasize that it's not totally fixed," she told KHN. "And people are really going to have to get help to decide which plans cover the benefits they need."

Earlier this year Carl Schmid, deputy executive director of the AIDS Institute, expressed similar disappointment that the essential health benefits didn't spell out explicit, uniform national standards for AIDS treatment to include a broad range of drugs. "We thought the federal government would spell out essential health benefits in more detail," he said. "Under this rule, patients might have access to a total of 500 drugs in one state and more than 1,000 in another state."

The KHN article also noted that the benefits will vary by state, each of which has its own model policy.

"I certainly hope the way the Affordable Care Act is implemented is a game changer for people in the disabilities community. It can be," activist Jill Tappert of Colorado told KHN. "The opportunity is there for policy makers to vastly improve lives."

Only 2 percent of insurers currently offer all the benefits that will be required under the ACA, according to an analysis last spring of 11,100 private health insurance plans from technology company HealthPocket.

The greatest deficiencies were in coverage for maternity and newborn care, pediatric dental and vision care, mental health services and substance abuse services, the analysis found.

For more information:
- read the KHN article

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