Essential Health Benefits Update
The Biden administration’s first Affordable Care Act (ACA) marketplace proposed rule has some good news for AOTA’s ongoing work to show that OT is essential to a meaningful package of benefits. Meaningful benefits include services that help to attain and maintain, not just regain, skills and functioning for daily living. The proposed rule would change the standards for approving waivers of state individual health insurance market rules, rescinding a Trump administration policy that allowed state waivers promoting plans that aren’t required to cover essential health benefits (EHBs), such as rehabilitation and habilitation.
AOTA will be submitting comments on the proposed rule. We also asked the U.S. Secretary of Health and Human Services (HHS) to revise this policy in a letter from the Habilitation Benefits Coalition (HAB Coalition). AOTA is on the steering committee of the coalition, which works to ensure access to habilitation within the EHB category known as “rehabilitative and habilitative services and devices.”
The HAB letter to HHS also urged the agency to reconsider a policy giving states flexibility to select a narrower EHB-benchmark plan (states determine the specific services included in each EHB category by choosing a benchmark plan). The Acting Director of the Center for Consumer Information & Insurance Oversight (CCIIO), the branch of HHS that oversees the ACA marketplaces, responded that, “We will remain vigilant to ensure states provide sufficient habilitative coverage in the EHB-benchmark plans.”
AOTA and HAB Coalition advocacy helped convince the federal government to clarify this benefit category by codifying a uniform definition of habilitative services in federal regulations. The uniform definition, established in the 2016 Notice of Benefit and Payment Parameters, specifically lists occupational therapy. The regulation also prohibited combined visit limits for habilitation and rehabilitation and clarified that health plans can’t impose limits on habilitation that are less favorable than those imposed on rehab.
The uniform definition was meant to minimize variability across states and reduce uncertainty for children and adults who need OT and other habilitative services. But AOTA research on state ACA marketplace offerings has showed that hasn’t always been the case.
AOTA welcomes the opportunity to work with CCIIO and our coalition partners to ensure that consumers get the habilitative services promised by the ACA.