AOTA works to ensure that occupational therapy is valued and protected in the health insurance marketplaces created by the Affordable Care Act (ACA).
The 2010 health care reform law expanded access to health insurance coverage for millions of Americans by expanding eligibility for Medicaid and developing health insurance marketplaces where eligible consumers can shop for coverage and apply for subsidies to make private health plans more affordable.
The ACA identifies 10 broad categories of services—including rehabilitative and habilitative services and devices, preventive and wellness services, and mental health and substance use disorder services—that certain health insurance plans must cover. These services are called essential health benefits (EHBs). Individual and small group plans, as well as plans covering the population that became eligible for Medicaid under the ACA, are required to cover the EHBs.
In the individual and small group markets, states establish the specific services covered in each EHB category by selecting a benchmark plan. States may update their benchmark each year, which could result in more or less generous occupational therapy benefits.
AOTA advocacy helped ensure that both services that help keep, learn, or improve skills and functioning for daily living (habilitation) and services that help keep, get back, or improve skills and functioning for daily living that have been lost or impaired (rehabilitation) were included in the EHBs. For example, an occupational therapy practitioner teaching a child who had a stroke in utero the fine motor skills to groom and dress would be providing habilitative services, whereas a therapist helping a 10-year-old who had a stroke relearn how to groom and dress would be providing rehabilitative services.
The Notice of Benefit and Payment Parameters is the annual regulation governing the Marketplaces created by the Affordable Care Act. CMS finalized changes related to consumer cost sharing, provider network strength, and the scope of covered benefits that will decrease barriers to occupational therapy services.
Research from AOTA examines how ACA Marketplace plans cover the EHB category of rehabilitative and habilitative services and devices.
Checklist from AOTA, APTA, and ASHA helps evaluate habilitative and rehabilitative insurance benefits.