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, Kaiser Health News reports.
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,” 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, told KHN. “They’d say patients are not recovering function, but rather developing function, and that was an education issue.”
That leaves parents having to scrounge to fill their childrents' habilitative care needs and haggle with insurers over denials.
The health law’s new coverage offers recognition of the needs of people born with serious developmental problems that require life-long attention. But advocates fear that insurers may avoid providing benefits to the extent needed by people, 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. Read more.