Member Input Sought: Support for “Maintenance of Function” as a Covered Service
AOTA policy staff have been closely following developments to define the “essential health benefits” that must be included in the state-run health insurance purchasing exchanges mandated by the Patient Protection and Affordable Care Act (ACA). Habilitation and rehabilitation services are considered “essential health benefits” under statute, but the Department of Health & Human Services (HHS) has yet to determine how rehabilitation and habilitation services will be defined (i.e., what type of care will be covered, under what circumstances, and by what provider types). The Institute of Medicine released a report, Essential Health Benefits: Balancing Coverage and Cost (October 7, 2011), that covers some of the logistical aspects of defining these benefits (see: AOTA release, AOTA analysis) and just last week, HHS followed up with its Essential Health Benefits Bulletin, issued by the Center for Consumer Information and Insurance Oversight (CCIIO) (December 16, 2011), available here. This bulletin is not a final regulation, but a plan for subregulatory guidance that requests comments and feedback. Specifically, the bulletin asks for the following:
“… the advantages and disadvantages of including maintenance of function as part of the definition of habilitative services. We are considering two options if a benchmark plan does not include coverage for habilitative services:
(1) Habilitative services would be offered at parity with rehabilitative services – a plan covering services such as PT, OT, and ST for rehabilitation must also cover those services in similar scope, amount, and duration for habilitation; or
(2) As a transitional approach, plans would decide which habilitative services to cover, and would report on that coverage to HHS. HHS would evaluate those decisions, and further define habilitative services in the future.”
Source: Essential Health Benefits Bulletin, p. 11.
We are drafting comments, but we need your help identifying language and research on the maintenance of function / benefits of habilitation. Executive summaries of research with citations, case studies, along with other persuasive guidance or material are sought. Comments are due January 31, 2012 so we ask that you please send materials to AOTA’s Reimbursement and Regulatory Policy Department at rrpd@aota.org by January 20, 2012.
