What Is Essential in the Essential Health Benefits? And Will Occupational Therapy Benefit?

Hospitalization

The hospitalization category requires coverage of inpatient hospital services. Under current private insurance coverage, most services are bundled together and billed to the consumer on the basis of predetermined cost sharing for covered services received as part of the inpatient stay. Occupational therapy, when medically necessary, is currently a covered service for inpatient care under private insurance. AOTA is working to ensure that continued access to occupational therapy will be available under hospitalization as well as the new rehabilitative and habilitative services and devices category that is seen to most directly relate to occupational therapy services.

Prescription Drugs

The inclusion of the prescription drugs category is critical to the health and quality of life for millions of beneficiaries. Increases in prescription drug costs outpace other categories of health care spending and are projected to exceed the growth rates for hospital care and other professional services through 2019 (Truffer et al., 2010). Medications such as those to address pain, high blood pressure, depression, and schizophrenia are truly essential to quality comprehensive health care. Although the details of coverage remain undefined, the coverage criteria and formulary are expected to be developed through the benchmarking process, as with the other categories.

Rehabilitative and Habilitative Services and Devices

Of the 10 categories of required essential benefits under the ACA, the rehabilitative and habilitative services and devices category is the most critical to occupational therapy. The inclusion of this category in the law was a direct result of work done by AOTA with the Senate Finance Committee to ensure that there would be an appropriate focus on these issues in the law. Initially, occupational therapy was likely to be covered only under the broad categories of hospital and outpatient services, but AOTA advocacy secured the inclusion of a more focused and protective category.

This was a significant victory, but it was only the first of several steps necessary to make certain that the opportunities for the profession created by the legislation are maintained throughout the implementation and regulatory processes. A few competing factors related to how the categories will be defined make the ongoing work related to fine-tuning and establishing the essential health benefits both a challenge and an opportunity for occupational therapy.

Although the list of 10 categories is now statutorily mandated, much about how it will be implemented remains unclear: “There are significant unknowns in the ACA as well. One of these unknowns is what will be covered given that the mandate is to reduce cost” (Ulicny, 2012).

One indicator of how this benefit category will be defined is the glossary of medical terms developed by NAIC (2011). AOTA participated in the definition development process and focused heavily on rehabilitation and habilitation, and it was successful in influencing those definitions so that both explicitly list occupational therapy as an example of the covered services under each term.

Note that the definitions of both habilitation and rehabilitation services reference maintenance of function (“keep . . . skills”), language that indicates flexibility as to how the benefit may be used to meet beneficiary needs.

This glossary was designed by NAIC to inform consumers of what services and benefits they can expect related to these terms, and the glossary was approved by HHS. The explicit inclusion of occupational therapy in these sanctioned definitions aids greatly in ongoing and future advocacy efforts (NAIC, 2011; U.S. Departments of Labor, Treasury, and Health and Human Services, 2012).

Taken together, the ACA principles of benchmarking and balancing also provide a sense of what will be covered under exchange plans. It is fairly clear at this point that there will be limits to essential benefits within each category. Specifically, it is expected that visit limits will exist for the rehabilitative and habilitative services and devices category. What is not known are the exact details about the nature of those limits and how the benefit will be designed.

While AOTA continues to work with Congress and federal agencies in search of improved federal guidance, it is becoming clear that significant decisions will be left to the states. AOTA is working closely with affiliated state associations to prepare them to take up the advocacy effort at the state level. AOTA is using its experience and advocacy expertise to help state associations successfully take advantage of the opportunities created by the inclusion of rehabilitative and habilitative services and devices in federal law as it pertains to health care reform.

Mental Health and Substance Use Disorder Services, Including Behavioral Health Treatment

Several provisions in the ACA may have a major impact on mental health, substance use, and behavioral health services, notably the inclusion of these services as one of the 10 required categories of essential health benefits.

It is estimated that 3.7 million more people with severe mental illnesses (SMIs) will gain access to mental health care (Mechanic, 2012). This access will be achieved in part by the expansion of Medicaid provided for by the ACA. Expanding Medicaid to all individuals at or below 133% of the Federal Poverty Level will allow adults with mental illness to be eligible for Medicaid on the basis of their income, rather than on the basis of additional eligibility criteria such as receiving Supplemental Security Income (ACA, §2001). Other coverage expansions are likely to stem from the individual mandate and income-based subsidies for individuals and families to purchase private insurance within the exchanges.

Additional improvements in access to mental health services could be accomplished through the state health insurance exchange programs (Garfield, Zuvekas, Lave, & Donohue, 2011). However, in the absence of further regulation or meaningful guidance by HHS, states that choose benchmark plans with limited benefits may cover a limited range of mental health services such as hospitalization stays, limited clinic visits, and medications. More comprehensive community services such as rehabilitation services may not be covered (Bazelon Center for Mental Health Law, 2010).

Although coverage for substance abuse services may be expanded, the form those services take under the ACA may change significantly. The coordinated and integrated health care approach encouraged under the ACA may lead to opportunities for early identification and treatment and also greater “medicalization” of substance abuse interventions by more primary care providers with limited substance abuse specialization (Buck, 2011).

The ACA also requires that all benchmark and benchmark-equivalent state Medicaid plans must comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (part of Pub. L. 110–343). Moreover, the previous requirements are extended to ensure that all plans cover mental health and substance abuse services (Bazelon Center for Mental Health Law, 2010). Note, however, that small businesses (50 or fewer employees) continue to have an exemption (Sarata, 2011).

People with SMI and/or substance abuse disorders who have previously been denied insurance coverage because of their illness should benefit from the ACA’s prohibition on denial of coverage on the basis of preexisting conditions (Mechanic, 2012). Adults with SMI and substance abuse disorders may also benefit from the ACA’s promotion of more efficient coordination of health care through the development of medical or health homes and accountable care organizations and coverage for other care coordination services that have not been traditionally covered. This promotion of coordinated care may help facilitate more comprehensive coordination of mental health care and substance abuse services as well as better utilization of other health care services. For adults with SMI, the rising rates of metabolic syndrome and existing difficulties in accessing primary health care make any improvements in coordination and integration of mental health and primary health care resulting from ACA implementation increasingly critical.

Children and adults with autism spectrum disorders (ASDs) should benefit from the ACA in several ways. The ACA’s prohibition on lifetime caps, annual limits, and denial of coverage on the basis of preexisting conditions have been in place since 2010. Still, it is estimated that 2.8% of children with ASD are uninsured, and the rate for adults is considered to be much higher. Expanding coverage will occur through a variety of provisions under the ACA. First, young adults up to age 26 are eligible for coverage under their parents’ insurance plan. Second, the insurance industry’s practice of ending coverage for individuals with high claim rates by identifying errors in the original application for insurance, a practice called rescission, is prohibited by the ACA. Third, states with insurance mandates requiring coverage of autism services will be included as mandates in that state’s benchmark plans.

The definition and coverage of habilitation services by the states’ benchmark plans, as well as any further regulation or guidance by HHS, will be very important to individuals with ASD, their families, and service providers such as occupational therapy practitioners. The definition and administration of medical necessity standards, including evidence-based materials, will also play an important role in the extent to which ASD services are covered (Association of Maternal and Child Health Programs, 2012).