Perspectives on Essential Health Benefits by Institute of Medicine

Author:Institute of Medicine
Language: eng
Format: epub
Tags: Health and Medicine: Healthcare and Quality
ISBN: 9780309215466
Publisher: The National Academies Press
Published: 2012-12-18T00:00:00+00:00

Acquiring, retaining, and improving skills can be both habilitative and rehabilitative, depending specifically on the needs of that individual.10

Legislative Intent

Children and adults with disabilities and significant health needs require both habilitative and rehabilitative services and supports. Ms. Ford argued that the discrimination against children and adults who need these services denies them access to medically necessary and appropriate interventions. Members of Congress, she said, are very familiar with the term habilitation from its use in the Medicaid program, and, as indicated in floor statements, Congress clearly intended to include habilitation services and supports in the EHB package.5,6

As stated in the ACA, the category of rehabilitative and habilitative services and devices is a broad category that, since combined, indicates that acquiring and retaining function are critical aspects of the benefit category.

State Mandates

Many states, Ms. Ford noted, have “recognized the importance of habilitation” by requiring private insurers to provide these services. Of the 23 states that passed statutes requiring coverage of benefits for people with autism spectrum disorders, 14 have used the term habilitative and rehabilitative care in the legislative language (NCSL, 2010a). In many states, she said, the term habilitative is defined as “any professional counseling and guidance service and treatment program, including applied behavior analysis that is necessary to develop, maintain and restore, to the maximum extent possible, the function of an individual” (Autism Speaks, 2011). Additionally, she said, many of these state mandates specifically require coverage of a broad list of therapies including occupational, physical, speech, and behavioral therapies (NCSL, 2010b).11

Illinois and Maryland have mandated health plans to provide habilitation services to children under age 18 with congenital, genetic, or early acquired disorders (Illinois Department of Insurance, 2010; Maryland Insurance Administration, 2009). Since 2000, Maryland has tracked the economic impact of the state mandate and found that the mandate costs two dollars of the average annual group health insurance policy premium, or 0.04 percent (Rosenblatt, 2007).

Building an Evidence Base

When committee member Dr. Ho asked how, in the absence of an evidence base for some of these services, plans should make medical necessity determinations, Ms. Ford responded that rehabilitative and habilitative services are “always based on an individualized plan of care” and that medical decisions are often based on decisions by patients, their families, and their health care provider. It would therefore be a mistake, she said, to “not take clinical expertise into account” when making medical necessity determinations. Mr. Thomas supported Ms. Ford’s argument while also noting that “you go with the highest level of evidence that you have.” While the evidence base for rehabilitative services has developed significantly, it is “still a work in progress,” Mr. Thomas said. Some medical necessity determinations, he noted, are obvious even without clear evidence: a randomized controlled trial (RCT) is not necessary, for example, to understand that providing an artificial limb to someone without limbs will improve function. Level I, RCT studies are not practical for many rehabilitation services and devices, he said, so “there must be a different way to approach the evidence base.

Download

Copyright Disclaimer:
This site does not store any files on its server. We only index and link to content provided by other sites. Please contact the content providers to delete copyright contents if any and email us, we'll remove relevant links or contents immediately.