Keep an Eye on the Affordable Care Act

The Politics of Autism includes an extensive discussion of insurance issues, including the impact of the Affordable Care Act.

At NPR, Michelle Andrews reports:

Since the 10 required benefits are spelled out in the Affordable Care Act, the law would have to be changed to eliminate entire categories or to make them less generous than typical employer coverage. And since Republicans likely cannot garner 60 votes in the Senate to do that, they will be limited in changes that they can make to the ACA. Still, there's room to "skinny up" the requirements in some areas by changing the regulations that federal officials wrote to implement the law.

Habilitative services

The law requires that plans cover "rehabilitative and habilitative services and devices." Many employer plans don't include habilitative services, which help people with developmental disabilities such as cerebral palsy or autism maintain, learn or improve their functional skills, via speech or occupational therapy or other support services. Federal officials issued a regulation that defined habilitative services and directed plans to set separate limits for the number of covered visits for rehabilitative and habilitative services. Those rules could be changed.

"There is real room for weakening the requirements" for habilitative services, says Dania Palanker, an attorney and assistant research professor at Georgetown University's Center on Health Insurance Reforms, who has reviewed the essential health benefits coverage requirements.
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Mental health and substance use disorder services

The health law requires all individual and small group plans to cover mental health services and treatments for substance use disorders. In the regulations, the Obama administration said that means those services have to be provided at "parity" with medical and surgical services, meaning plans can't be more restrictive with one type of coverage than the other regarding cost sharing, treatment and care management.
"They could back off of parity," Palanker says.

Obamacare and Habilitative Services

ACA requries individual and small-group plans to cover habilitative services. Kaiser Health News notes a catch:

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.

Habilitation and Obamacare

Michael Ollove writes at Stateline:

Thanks to the Affordable Care Act (ACA), habilitation services will now be widely covered for the first time in private insurance plans. Rehabilitative and habilitative services are among the 10 “essential benefits” that must be provided by all plans sold on all the state and federally run health insurance exchanges. Starting in 2014, all individual and small group health policies sold outside the exchanges also will have to cover habilitative services.

But as is the case with some of the other “essential benefits,” the federal health law mandates coverage of habilitation services without spelling out exactly what that means. The states, together with insurers and advocacy groups, will have a big say in what, and how much, is covered.
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The cost of habilitative therapy varies widely, but can be quite expensive. One form of therapy used to treat those with autism, “applied behavioral analysis,” can cost $50,000 or more a year.

Before the ACA, habilitative services were inconsistently covered in health insurance plans. Most insurers took the view that teaching skills to the developmentally disabled was an educational matter rather than a health care concern. But as the disabled movement has gained influence over the last 50 years, that view has become far less than universal, even among insurers.

For one thing, it has become clear that financially strapped school systems do not have the resources or expertise to meet the habilitation needs of their students. In response, Medicaid in 1989 added habilitative services to its benefits menu, and dozens of states began to require insurers operating in their states to offer habiliative benefits. However, the coverage requirement varies widely from state to state, and many states have limited it to children with autism.

Habilitative Services

Kaiser Health News reports:

Habilitative services are for people who can benefit from one-on-one time with a therapist to improve daily living skills. But such services can be expensive, and not all insurance plans have covered them.

The Affordable Care Act is changing that, says health economist Lisa Clemans-Cope with the Urban Institute.

"You're much more likely to find these benefits in a plan in the individual market [starting in 2014] than you would be today. Far more likely," says Clemans-Cope.

This is because "habilitative services" are included within the 10 categories of essential health benefits the ACA will require in those new plans. Still, while some categories are straightforward — such as maternity care and preventive care — the category including habilitative services leaves more room for interpretation.

For instance, insurers could choose to cover physical therapy for someone with a broken bone, but not cover long-term support services for chronic conditions, such as speech therapy for kids with developmental delays