October 22, 2014

Essential Health Benefits – Habilitation and Rehabilitation Services

Learn What's Happening in the Policy Arena for CYSHCN.  Read Washington DC UpdateEssential Health Benefits – Habilitation and Rehabilitation Services

While the ACA spells out ten “Essential Health Benefits” (EHB) that must be included in health plans, the statute is very general. An important item for children and youth with special health care needs is the benefit “rehabilitative and habilitative services and devices.”  Unfortunately, the regulations regarding “habilitative services” are very loose. They allow each state to determine its own definition of “habilitative services,” or if a state chooses not to do so, then each health care plan must either provide those services in “parity” with rehabilitative services or establish another definition and report it to HHS. Advocates have been pushing HHS to develop a federal standard based on either the Medicaid definition or the definition developed by the National Association of Insurance Commissioners (NAIC).


Since each state or each health plan may have a different definition, it has been difficult for consumers and advocates to pin down what rehabilitation and habilitation benefits people are entitled to. Fortunately, the American Occupational Therapy Association (AOTA) has put together some valuable information, including new plan-by-plan information for each state (Analysis of Rehabilitation and Habilitation Benefits in Qualified Health Plans, 2014) and a state-by-state chart of  rehabilitative and habilitative benefits (2013). Other helpful links can be accessed from this AOTA blog post.