Proposed Rule Mandates Coverage of Habilitation Services If the rule becomes final, health plans would be required to provide speech-language and other services to people across the range of ages and disabilities. Policy Analysis
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Policy Analysis  |   February 01, 2015
Proposed Rule Mandates Coverage of Habilitation Services
Author Notes
  • Tim Nanof, MSW, is director of ASHA health care policy and advocacy. tnanof@asha.org
    Tim Nanof, MSW, is director of ASHA health care policy and advocacy. tnanof@asha.org×
  • Daneen Grooms, MHSA, is director of ASHA health reform analysis and advocacy. dgrooms@asha.org
    Daneen Grooms, MHSA, is director of ASHA health reform analysis and advocacy. dgrooms@asha.org×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   February 01, 2015
Proposed Rule Mandates Coverage of Habilitation Services
The ASHA Leader, February 2015, Vol. 20, 24-26. doi:10.1044/leader.PA.20022015.24
The ASHA Leader, February 2015, Vol. 20, 24-26. doi:10.1044/leader.PA.20022015.24
Speech-language pathology is included in the definition of “habilitation services” in proposed 2016 federal regulations for health plans under the Affordable Care Act. If included in the final rule, these provisions would broaden access to speech-language treatment—particularly for children and for people of all ages with developmental disabilities—and open the door to continued advocacy for improved audiology coverage.
The ACA requires health plans to offer a set of essential health benefits that include rehabilitative and habilitative services and devices. The proposed rule, published by the Centers for Medicare and Medicaid Services in November 2014, creates a nationwide definition for habilitative services that explicitly lists speech-language pathology, occupational therapy and physical therapy as examples of services covered in both categories. It also creates the opportunity for coverage of additional services, including rehabilitative and habilitative audiology and related devices.
The habilitation definition was crafted in 2010 by the National Association of Insurance Commissioners with significant ASHA input and support. ASHA initially proposed the definition to the NAIC committee that established a glossary of terms designed to inform consumers about health plan details. It defines habilitative services as:
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Rehabilitative services differ in that they help a person regain skills and functioning lost to illness or trauma.
Why a national definition?
Under current policy, states are allowed to define the habilitative benefit—and if they don’t, individual health plans can choose how to provide habilitation coverage. Many states have not defined habilitation and many plans, therefore, opted to restrict coverage to a narrow list of specific conditions and a narrow list of treatments.
If the rule becomes final as written, it would establish this definition as a national standard that states and health plans must meet.
In addition, a national standard provides leverage for continued advocacy. With a national mandate in hand, national and local professional and consumer associations, as well as individual clinicians and patients, can reference federal definitions and requirements when advocating with state regulators and health plan administrators on the coverage of audiology and speech-language pathology services in health care exchanges (see sidebar below).
Other provisions
In addition to defining habilitation, the proposed rule also requires that habilitation and rehabilitation be provided as distinct—not combined—benefits, and that the habilitation benefit must be provided at least in the same amount as rehabilitative coverage. Health plans, therefore, could not cover habilitation simply by adding it to the rehabilitation benefit without increasing the restrictions.
For example, a provider that offers a 12-visit rehabilitation benefit may not expand the benefit to include habilitation and rehabilitation unless the provider also increases the number of covered visits. Health plans could establish visit limits, but separately for both habilitation and rehabilitation, and would have to factor in beneficiary needs and medical necessity.
Finally, the proposed rule prohibits discrimination based on a person’s age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions. The rule states, “For example, it would be arbitrary to limit a hearing aid to enrollees who are 6 years of age and younger since there may be some older enrollees for whom a hearing aid is medically necessary.”
These provisions can potentially affect coverage of hearing aids for adults and also the scope and range of audiology and speech-language services available to people of all ages with a variety of medical conditions and functional impairments. The ACA mandates nondiscrimination, stating that “health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or of the individuals’ present or predicted disability, degree of medical dependency, or quality of life ... ”
Despite this language, previous regulations and guidance had no enforceable standards to ensure that health plans implemented it. Together, the definition and the nondiscrimination rules would help to ensure that beneficiaries receive needed services for medical conditions and functional impairments—regardless of the underlying causes.
A long road
Initial versions of the ACA legislation did not include rehabilitation/habilitation services and devices as essential health benefits, covering them under the broader hospitalization and ambulatory care category, with little chance for consistent coverage. Through the Consortium for Citizens With Disabilities, ASHA worked with the American Physical Therapy Association, the American Occupational Therapy Association and a host of other groups to press Congress to include rehabilitation/habilitation as essential health benefits.
As part of this advocacy effort, ASHA founded the Habilitation Coalition, bringing together more than 30 national associations. ASHA worked independently and with the coalition, and secured ASHA representation on the NAIC workgroup that created the definition in the proposed rule.
But including rehabilitation/habilitation services as one of 10 essential health benefit categories in the ACA was just the first—albeit critical—step. Unlike the other nine categories, habilitation/rehabilitation services lacked specific benefit and coverage information. There was no federal guidance because the rules for implementing ACA plans were based on those of private health plans—and private plan coverage of habilitation was extremely rare. Many plans limited coverage to only children with autism and only one treatment—applied behavior analysis.
ASHA and the Habilitation Coalition argued that these types of limits did not meet the requirements of the statute or create a meaningful essential health benefit, and worked with federal agencies to create rules that would require states and health plans to meet the ACA obligations.
The proposed regulation is only the beginning; ASHA continues to work to ensure that the final rule includes all of these important provisions and that states and health plans interpret and implement them appropriately. The final rule is expected in the spring.
For updates on the status of essential health benefits and other policy information, follow ASHA Advocacy on Facebook or sign up to receive Headlines policy e-mails (send a blank e-mail with the subject “subscribe to Headlines” to emailsupport@asha.org).
Health Insurance Exchanges

The Affordable Care Act mandates the creation of federal- and state-run health insurance exchanges (or marketplaces), where consumers can shop for health insurance coverage in person with the help of enrollment navigators or, more commonly, online.

There are several types of exchanges, and states have options in structuring and establishing exchanges. They must, however, have an exchange operating within the state, even if they choose not to operate it. Each exchange has a minimum set of benefits (established in a benchmark plan) that all qualified plans must offer. The variation among exchanges is related to how the benchmark plans are chosen and how beneficiaries enroll.

The options include:

  • State-based exchange: States perform all exchange functions, including establishing benchmark plans, determining coverage options and enrolling beneficiaries.

  • State-partnership exchange: States provide some consumer assistance, but the U.S. Department of Health and Human Services performs the remaining functions. Consumers enroll through healthcare.gov.

  • Federally supported state-based exchange: States perform all exchange functions, but use a federal website structure. Consumers enroll through healthcare.gov.

  • Federally facilitated exchange: The U.S. Department of Health and Human Services performs all functions and consumers enroll through healthcare.gov.

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February 2015
Volume 20, Issue 2