Daniel Brown; Habilitative Services: An Essential Health Benefit and an Opportunity for Occupational Therapy Practitioners and Consumers. Am J Occup Ther 2014;68(2):130–138. https://doi.org/10.5014/ajot.2014.682001
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Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care (§ 1302(b)(1)).
The term rehabilitative and habilitative services includes items and services used to restore functional capacity, minimize limitations on physical and cognitive functions, and maintain or prevent deterioration of functioning as a result of an illness, injury, disorder or other health condition. Such services also include training of individuals with mental and physical disabilities to enhance functional development. (IOM, 2011b, p. 77, italics added)
Rehabilitation Services—Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech–language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.Habilitation Services—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. (National Association of Insurance Commissioners, 2011)
Rehabilitation Services—Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech–language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Habilitation Services—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. (National Association of Insurance Commissioners, 2011)
Clearly the rehabilitation and habilitation benefits required under the ACA must include full coverage of occupational therapy… It is essential to the effectiveness and quality of a reformed health care system to ensure that beneficiaries receive comprehensive care from acute to post-acute and from prevention to rehabilitation. Occupational therapy is a key part of the health care solution because it is a critical link between acute, post-acute, rehabilitative and preventive care. (AOTA, 2011, p. 2).
that about 70 percent of small group products offer at least limited coverage of habilitative services. Physical therapy (PT), occupational therapy (OT), and speech therapy (ST) for habilitative purposes may be covered under the rehabilitation benefit of health insurance plans. (CCIIO, 2011, p. 6)
Habilitative services would be offered at parity with rehabilitative services—a plan covering services such as PT, OT and ST for rehabilitation must also cover those services in similar scope, amount, and duration for habilitation; or [a]s a transitional approach, plans would decide which habilitative services to cover, and would report on that coverage to HHS. HHS would evaluate those decisions, and further define habilitative services in the future (CCIIO, 2011, p. 11).
For example, a plan could offer coverage consistent with a benchmark plan offering up to 20 covered physical therapy visits and 10 covered occupational therapy visits by replacing them with up to 10 covered physical therapy visits and up to 20 covered occupational therapy visits, assuming actuarial equivalence and the other criteria are met. (CMS, 2012, p. 3)
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