Health law covers habilitative services but will insurers comply?

by | Jan 17, 2014 | Social Security Disability

As some people in Pennsylvania may know, habilitative treatment can be an extremely helpful tool for those who live with developmental disabilities. Unlike rehabilitation, habilitation helps someone learn and retain a skill rather than helping them re-learn how to do it. For a long time, however, insurers have not been required to provide coverage for habilitation. Although the new health law says they must cover it on small group and individual plans, some people see serious problems with the law’s language — or lack thereof.

Rather than defining habilitation itself, the U.S. Department of Health and Human Services has left that task up to each individual state. If the state chooses not to create a definition, they can either require insurance companies to treat habilitation the same way they would treat rehabilitation, or they can allow insurers to decide how to handle it.

So far, more than half of states have opted for the last option, allowing insurers to decide habilitation coverage options on their own. This has created a situation that many disability advocates feared: Many people are being denied coverage for habilitation because insurance companies do not consider it medically necessary. Additionally, many people are having trouble finding out what kind of coverage their insurance company offers for habilitation services.

In two years, the health law will be reviewed, at which time many people will likely be hoping for better guidance around habilitative care. Although it is certainly a step in the right direction to have habilitation included on the list of essential health benefits, it doesn’t do much good if insurers can refuse to cover it. In the meantime, those who need habilitation may want to consider applying for Social Security disability benefits if they have not already. While it may not cover all expenses, it could help make costs a bit more manageable.

Source: Disability Scoop, “Health Law Adds Coverage For Developmental Disability Services,” Michelle Andrews, Jan. 14, 2014

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