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 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.
In addition, Medicaid provides comprehensive coverage for habilitative services for children who are enrolled in the program and others who meet state-specific standards based on their degree of disability or eligibility category. Under the health law, states that expand Medicaid to adults with incomes up to 138 percent of the federal poverty level (currently $15,856 for an individual) must cover the essential health benefits for those new enrollees, ensuring that they’ll have access to habilitative services, says Joe Touschner, a senior health policy analyst at Georgetown University Health Policy Institute’s Center For Children And Families.