A little remarked upon requirement in the health law expands
treatments for people with cerebral palsy, autism and other
developmental disabilities. But some advocates and policy experts are
concerned that insurers may find ways to sidestep the new requirement.
The health law requires that individual and small group plans sold on
or off the health insurance marketplaces cover 10 essential health
benefits,
including “rehabilitative and habilitative services and devices.”
Health plans of all kinds typically cover rehabilitative services,
such as physical, occupational and speech therapy to help people who had
an accident or illness, such as a stroke, recover their ability to
walk, talk and function in their daily lives. But before the health law
passed, coverage of similar services for habilitative purposes — that
is, to help people learn or maintain functional skills, rather than
regain them — was often excluded.
Insurers would “say they’re not medically necessary,” says Sara
Rosenbaum, a professor of health law and policy at George Washington
University who authored
a recent paper
about the law’s habilitative coverage requirements. “They’d say
patients are not recovering function, but rather developing function,
and that was an education issue.”
For years, Elizabeth Hecht and Scott Simmons have struggled to get
their son, Will, the habilitative care he needs. Will has cerebral
palsy, and as a child needed speech therapy to learn to speak
intelligibly and physical therapy to learn to stand and walk with
assistance, among other things. Now 25 years old, Will needs periodic
therapy to help his body remain as functional as possible and avoid
pressure sores, as well as to help him learn to use a speech-generating
device so he can communicate better, says Hecht.
The couple’s insurance, through her job at an academic research
center for people with developmental disabilities in Madison, Wis.,
generally doesn’t cover habilitative services. But it has covered some
of Will’s therapy as if it were rehab, says Hecht. Services were
frequently approved only after the couple filed an appeal following a
denial, however.
“It becomes exhausting,” she says. “He could have two to three denials at one time, so we had to set priorities.”
The law’s new coverage requirement doesn’t apply to large employer
group plans like the one covering Will. But Hecht says she hopes that
the new rules may eventually encourage broader coverage overall.
“It’s a wonderful recognition of the needs these people have and a great first step in addressing them,” she says.
But advocates fear that insurers may avoid providing benefits to the
extent needed by people, many of them children born with serious
developmental problems that require life-long care. That’s because
instead of clearly defining habilitative services and spelling out what
must be covered in individual and small group plans under the law, the
U.S. Department of Health and Human Services permitted states and
insurers to decide.
Under the health law, each state
had to identify
a “benchmark plan” that would serve as a basis for defining the
essential health benefits offered there. In the final essential health
benefits rule, HHS said that if a state’s benchmark plan doesn’t define
habilitative benefits, states can choose to do so themselves. If they
don’t set specific rules, they can either require insurance plans to
cover those benefits at “parity” with rehabilitation services so that
they’re similar in scope, amount and duration, or leave it to the
insurers to determine how to cover the benefit and report that to HHS.
Regulators will review the rules in 2016.
“We were pretty disappointed” with the language in the final rule,
says Kim Musheno, director of public policy at the Association of
University Centers on Disabilities, a membership organization of
academic programs that advocates for disability issues.
Based on an initial tally, fewer than half of states have explicitly
defined the services that are covered under habilitative services or
required parity with rehabilitative services, says Katie Keith, director
of research at the Trimpa Group, which consults with the advocacy group
Autism Speaks on health law issues.
Strong advocacy by groups representing patients with autism has
resulted in coverage by private insurers of at least some habilitative
services. Thirty-four states now mandate coverage of intensive therapy
called applied
behavioral analysis for children with autism, says Lorri Unumb, vice president for state government affairs at Autism Speaks.
Full Article & Source:
Health Law Adds Coverage For Developmental Disability Services
