White Plains, NY (Law Firm Newswire) February 28, 2013 - The Affordable Care Act (ACA) has a provision that expands coverage of certain treatments for autism, cerebral palsy and other developmental disabilities, but a lack of specificity in the law means that it can still be difficult to pin insurers down on exactly what will be covered.
Policies purchased on the new health insurance exchanges are required by law to cover ten essential health benefits. Among these are “rehabilitative and habilitative services and devices.” This revision is beneficial for people with developmental disabilities; many insurance policies did not previously cover habilitative services.
The new coverage comes from a revised understanding of the distinction between rehabilitative and habilitative services. Rehabilitative services, such as physical or occupational therapy after a stroke or accident, may help people recover functional ability. These services have traditionally been covered under many health insurance policies. Habilitative services may be very similar to them, but, by definition, they help people (including people with developmental disabilities) to learn or maintain functions that were never lost. Insurance policies often denied coverage for such services, arguing that they fell under education issues and were not medically necessary.
Now, insurance policies purchased under the new exchanges must provide these services. Other insurance policies, including large employer group plans, are not subject to the new requirements, but a ripple effect may cause insurers to bring those plans in line with ACA rules eventually.
However, advocates for people with disabilities are still disappointed with the lack of clear coverage definitions. Rather than spell the coverage requirements out, the Department of Health and Human Services is allowing states and insurance companies to decide. States may define habilitative services themselves, require insurance policies to cover those services on “parity” with rehabilitative services or let insurers decide how to provide each benefit. Unfortunately, this system causes a lot of uncertainty for individuals attempting to find out whether specific habilitative services will be covered by a particular plan.
One service that is particularly important to people with autism is behavioral therapy (specifically, applied behavior analysis or ABA treatment). This is one of the treatments that may or may not be included in state determinations of what is required. Fortunately, according to the nonprofit Autism Speaks, ABA coverage has been specifically mandated by 18 states, including New York.
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