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AFFORDABLE CARE ACT

Advocates fear limited coverage for habilitative services

(The following is excerpted from two separate copyrighted news releases and are posted here because of the potential impact on lymphedema patients obtaining insurance coverage under the new State-administered insurance plans)

While advocates for the disabled applaud the inclusion of habilitative services as an essential health benefit under the Affordable Care Act, they worry payers can "pick and choose" which therapies they will cover come Jan. 1, Kaiser Health News reported this week.

The essential health benefit category covering rehabilitation and habilitative services--one of 10 categories covered under the ACA--leave room for interpretation about what payers must cover, KHN reported. While physical therapy following an injury might be covered, for example, long-term support for patients needing help improving daily living skills or something like speech therapy might not, according to the article.

While buoyed that policies next year will be much more likely to cover habilitative services, the Urban Institute's Lisa Clemans-Cope told KHN she fears insurers might structure benefits "in a way that discourages people with expensive chronic conditions" from seeking policies with them. Consumers also will have to carefully read the fine print to understand what habilitative services will be covered, she said.

"This is a big improvement, but we should emphasize that it's not totally fixed," she told KHN. "And people are really going to have to get help to decide which plans cover the benefits they need."

Earlier this year Carl Schmid, deputy executive director of the AIDS Institute, expressed similar disappointment that the essential health benefits didn't spell out explicit, uniform national standards for AIDS treatment to include a broad range of drugs. "We thought the federal government would spell out essential health benefits in more detail," he said. "Under this rule, patients might have access to a total of 500 drugs in one state and more than 1,000 in another state."

The KHN article also noted that the benefits will vary by state, each of which has its own model policy.

"I certainly hope the way the Affordable Care Act is implemented is a game changer for people in the disabilities community. It can be," activist Jill Tappert of Colorado told KHN. "The opportunity is there for policy makers to vastly improve lives."

Only 2 percent of insurers currently offer all the benefits that will be required under the ACA, according to an analysis last spring of 11,100 private health insurance plans from technology company HealthPocket.

The greatest deficiencies were in coverage for maternity and newborn care, pediatric dental and vision care, mental health services and substance abuse services, the analysis found.

For more information:
- read the KHN article

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The Affordable Care Act has set new standards — called essential health benefits — outlining what health insurance companies must now cover. But there's a catch: Insurance firms can still pick and choose to some degree which specific therapies they'll cover within some categories of benefit. And the way insurers interpret the rules could turn out to be a big deal for people with disabilities who need ongoing therapy to improve their day-to-day lives.

Habilitative services are for people who can benefit from one-on-one time with a therapist to improve daily living skills. But such services can be expensive, and not all insurance plans have covered them.

The Affordable Care Act is changing that, says health economist Lisa Clemans-Cope with the Urban Institute.

"You're much more likely to find these benefits in a plan in the individual market [starting in 2014] than you would be today. Far more likely," says Clemans-Cope.

This is because "habilitative services" are included within the 10 categories of essential health benefits the ACA will require in those new plans. Still, while some categories are straightforward — such as maternity care and preventive care — the category including habilitative services leaves more room for interpretation.

For instance, insurers could choose to cover physical therapy for someone with a broken bone, but not cover long-term support services for chronic conditions, such as speech therapy for kids with developmental delays.

Clemans-Cope says some insurers may arrange their benefits in a way that discourages people with expensive chronic conditions from signing up with them. And, she says, people who want to have specific therapies covered are going have to slog through some fine print to figure out if they'll actually benefit from a particular policy. (The new policies will start to go on sale this fall and go into effect beginning Jan. 1, 2014.)

"This is a big improvement, but we should emphasize that it's not totally fixed," Clemans-Cope says. "And people are really going to have to get help to decide which plans cover the benefits they need. "

Whether a person will be able to get the new therapy benefits also depends on where they live. The level of benefits insurers have to provide in each category is based on a model policy in each state, and some of those model policies are a lot more generous than others.

Jill Tappert, an activist in Colorado for people with disabilities, says a lot of details still need to be sorted out before she'll be able to say whether the health care law has improved things much.

"I certainly hope the way the Affordable Care Act is implemented is a game changer for people in the disabilities community. It can be," says Tappert, who spent years fighting for habilitative service coverage for her daughter who has autism. "The opportunity is there for policy makers to vastly improve lives."

The new rules for what health insurance companies have to cover may still change. Federal regulators plan to review them as the health law rolls out and could make changes in 2016.

This piece is part of a reporting partnership among NPR,Colorado Public Radio and Kaiser Health News.
The full text may be found at URL: http://www.kaiserhealthnews.org/Stories/2013/August/13/Disabilities-And-Essential-Health-Benefits.aspx?p=1