The Patient Protection and Affordable Care Act (ACA), Pub. L. 111-148, lists ten benefit categories that must be covered by new individual and small group plans that participate in health exchanges beginning in 2014. These 10 benefit categories, known as “essential health benefits,” or EHBs, must include rehabilitation services and devices that restore or maintain the ability of an individual to function after an injury, illness or ongoing health condition.
The Department of Health and Human Services’ (HHS) has instructed states to select an existing plan as a benchmark for their essential health benefits package from one of the following options:
- the largest small group market plan in the state,
- any of the largest three State employee health benefit plans,
- any of the largest three Federal Employee Health Benefit plans,or
- the largest non-Medicaid HMO in the state.
States must enhance or “plus-up” the chosen plan where it does not cover all 10 of the required benefit categories.
Rehabilitative services encompass a wide range of benefits, including but not limited to physical, occupational, speech, language and hearing therapies; cognitive, psychiatric and behavioral therapies; durable medical equipment, orthotics and prosthetics, low-vision aids, hearing aids and augmentative communication devices. While these benefits are crucial to the well-being, functional ability and health status of individuals with chronic conditions and disabilities, rehabilitative services and devices are often not considered “life saving” by insurers. They, therefore, may be covered to a lesser degree than other services and devices.
Plans should not limit visits for therapy services, or coverage for durable medical equipment, orthotics and prosthetics. If so, any limitations should be set based on medical necessity to be determined by the beneficiary’s health care provider rather than the insurer.
As part of the process of establishing and evaluating essential health benefits, states must ensure that plans appropriately cover rehabilitative services and devices in a balanced manner, so that one category is not disadvantaged over another and so that plans do not discriminate based on an individual’s disability or health status.