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Understanding the Rehabilitative and Habilitative Services Essential Health Benefit

Health Policy

Last updated March 18th, 2020

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Rehabilitative and habilitative services are one of the ten essential health benefits covered under all Affordable Care Act (ACA) insurance plans. This benefit includes services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.

soccer | rehabilitative services

Generally speaking, rehabilitative services help you return to your level of functioning prior to illness or injury. Habilitative services help you improve your level of functioning from your existing baseline. These essential benefits have lifelong benefits.

What Are Rehabilitative and Habilitative Services?

  • Physical therapy restores, improves, or maintains your movement and ability.
    • This service is provided by physical therapists, or “movement experts who optimize quality of life through prescribed exercise, hands-on care, and patient education,” according to the American Physical Therapy Association. These practitioners will use movement and other treatments to help you restore, improve, or maintain your range of motion and ability.
    • Physical therapy appointments are usually very interactive. you can expect to be closely guided by your physical therapist during the visit, and you’ll likely get coaching on how to continue some treatments at home. Physical therapists may provide home visits, as well.
  • Occupational therapy improves your ability to take part in everyday activities.
    • Occupational therapy is often thought to be the same as physical therapy, but they are quite distinct. Occupational therapists help you function better in your everyday environments. For example, while a physical therapist might help with something like regaining shoulder movement after an injury, an occupational therapist can help with something like cooking a meal or writing.
    • These services can take place in a variety of settings, like during a hospital stay, at school, or at home. Be sure to check with your insurance provider about specific coverage.
  • Speech therapy improves your ability to use language and communicate.
    • Speech therapists will be able to support you in key areas related to:
      • speech (how you verbally communicate)
      • language (how you process communication), and
      • cognitive functioning (how you process and use information in tasks that involve memory, holding attention, and problem-solving).
    • Like other rehabilitative and habilitative services, speech therapy is provided across a variety of settings.

Note that “rehab” for substance abuse issues is actually part of the mental health essential benefit, instead of the rehabilitative services benefit discussed in this article.

ACA plans are required to broadly cover rehabilitative and habilitative services. However, details such as the maximum number of visits covered or specific services that aren’t covered will vary depending on the state you live in and your specific plan.

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These therapies are considered inpatient services if they are provided during your stay in a hospital or intensive nursing facility. Otherwise, they are considered outpatient services. Plans will have different coverage for each.

As always, if you get these services outside of your plan’s network of medical providers, you will likely have additional expenses. Additionally, if you receive insurance through a large employer group or another non-ACA plan, these services are not required to be covered.

Rehabilitative and Habilitative Devices

Rehabilitative services involve more than in-person treatment. The other half of this essential health benefit takes care of items that are part of your rehabilitation.

There is a wide variety of technologies that you may need for your treatment, so it’s important to know what is covered under your plan. You may use these items during treatment sessions, such as physical therapy, or your doctor may prescribe you a device for at-home use.

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If you need a device for at-home use, then it’s considered durable medical equipment (DME). You can work with your doctor to choose what make and model of device works with your insurance.

Some common examples of DME devices include walking aids, such as crutches or a cane. More complex devices, like a breathing machine, are also considered DME.

If you’re looking for coverage for a particular type of device, you’ll want to check your plan’s Summary of Benefits to see whether or not that DME is covered for your specific condition. Independent vendors of home medical devices will also be willing to help you find an appropriate item that’s covered.

Differences in Coverage Across States

Each state defines required services under essential health benefits differently, and states can decide which essential health benefits get more coverage.

That’s why it’s still important that you reach out to your insurance company to understand how your plan covers rehabilitative services.

States define essential health benefits coverage by choosing an existing private plan in their state and setting it as the state’s benchmark plan. This means that all other health insurance plans in the state must meet, at a minimum, the benefits covered in the benchmark plan. Starting in 2020, states will have even more flexibility in how they cover essential health benefits.

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For most states, rehabilitative services include things like physical, occupational, and speech therapy, and many states have different limits on these services. For example, Alabama’s 2017-2021 benchmark plan, Blue Cross Blue Shield of Alabama, has a combined limit of 30 visits for physical, occupational, and speech therapy. In contrast, California’s benchmark plan (Kaiser Foundation Health Plan) does not include any cap on the number of visits for these therapies.

Other states limit coverage by including specific types of services they won’t cover. Alaska’s 2017-2021 benchmark plan excludes recreational, vocational, and educational therapy from its outpatient rehabilitation services benefit. Colorado is another state that won’t cover some outpatient rehabilitation services, such as long-term rehabilitation.

States have different guidelines for child rehabilitation, as well. For example, some states have greater coverage for children with autism compared to general pediatric therapy needs.

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