People with Disabilities in the Patient Protection and Affordable Care Act
November 21, 2012
Director of Research and Policy Initiatives
Texas Department of Insurance
333 Guadalupe, PO Box 149104
Austin, TX 78714
First, let me say how much TCDD appreciates the work of the Texas Department of Insurance (TDI) in preparing for the implementation of the Affordable Care Act, including the September stakeholder meeting, the analysis and side-by-side of existing health benefit plans and the opportunity for continued public input.
The Texas Council for Developmental Disabilities (TCDD) is established by federal law in the Developmental Disabilities Assistance and Bill of Rights Act. The Council’s governing board is a 27 member body, appointed by the Governor, 60 percent of whom are individuals with developmental disabilities or family members of individuals with disabilities. TCDD’s purpose in law is to encourage policy change so that people with disabilities have opportunities to be fully included in their communities and exercise control over their own lives.
TCDD strongly supports reform measures and principles that provide individuals with consistent access to patient centered, timely, unencumbered, affordable and appropriate health care and universal coverage while maintaining physicians as an integral component to providing the highest quality treatment. The following comments identify considerations for people with developmental disabilities as they relate to the default largest small employer plan, Blue Cross Blue Shield (BCBS) Small Group Best Choice PPO as presented in the TDI Analysis of Benchmark Plan Options in Texas by Required PPACA Coverage Categories and State Mandated Benefits and Offers1.
Habilitation and Rehabilitation
The TDI Analysis indicates that BCBS Small Group Best Choice covers rehabilitative and habilitative services and includes notations for limitations on the number of annual visits. For habilitation the TDI Analysis refers to notation number 44 on the chart, but this notation defines occupational therapy, which is not the same as habilitation. Habilitation is not found in the BCBS Small Group Best Choice benefit booklet; however occupational therapy is defined as “services which do not consist of traditional physical therapy modalities and which are not part of an active multi−disciplinary physical rehabilitation program designed to restore lost or impaired body function, except as may be provided under the Benefits for Autism Spectrum Disorder.” In order for habilitation and rehabilitation to be meaningful benefits for people with disabilities, the BCBS Small Group Best Choice plan more appropriate definitions to enhance these essential medical interventions.
In proposed rules, the U.S. Department of Health and Human Services (HHS) defines rehabilitation as follows: “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 rehabili-tation services in a variety of inpatient and/or outpatient settings.” Other services and devices that are often included in addition to previously listed services are rehabilitation physician and nursing services;; recreational therapy; music therapy and cognitive therapy for people with brain injuries and other conditions; psychiatric, behavioral and other developmental services and supports; durable medical equipment (DME), including complex rehabilitation technologies; orthotics and prosthetics; low vision aids; hearing aids and augmentative communication devices; and other assistive technologies and supplies.
These services and devices need to be provided in an array of settings, such as inpatient rehabilitation hospitals and other inpatient or transitional rehabilitation settings, outpatient therapy clinics, community provider offices, at a person’s home, and at various levels of intensity, duration and scope, depending on the severity of the condition and the functional impairment presented by the particular individual.
The HHS proposed rules on how plans should define habilitation is taken from the National Association of Insurance Commissioners (NAIC): “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.”2 Advocates for people with disabilities nationwide have expressed support for the NAIC definition plus the Medicaid definition: “Services designed to assist individuals in acquiring, retaining and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community based settings.”3 Ensuring that habilitation includes learning a new skill or function is a critical aspect of the definition.
How is habilitation different from rehabilitation?
While many insurance companies may not recognize habilitative services for health coverage, the same therapies, treatments, and devices are often covered under the rehabilitation benefit for people who have sustained an illness or injury. The key difference is that habilitation usually refers to acquiring or learning skills whereas rehabilitation usually involves regaining skills that have been lost or improving or preventing deterioration of skills.
|An occupational therapist teaching adults with developmental disabilities the necessary motor coordination required to dress themselves.||An occupational therapist teaching adults who have had a stroke the necessary motor skills required to re-learn how to dress themselves.|
|A speech therapist providing speech therapy to a 3-year old with autism who has never had speech.||A speech therapist providing speech therapy to a 3-year old to regain speech after a traumatic brain injury.|
|A physical therapist providing a strength training program for an individual with a congenital spine condition to prevent osteoporosis and decline in function as he ages.||A physical therapist providing a strength training program for an individual who recently acquired a spinal cord injury.|
|A physical therapist making a splint for an adult with a chronic condition, such as arthritis, to prevent hand deformities.||A physical therapist making a splint for an adult who has had hand surgery for a torn tendon.|
Medical Necessity in Habilitation and Rehabilitation
Decisions about medical necessity for habilitation and rehabilitation should defer to the practitioner actually treating the patient on an individual basis. Because the rehabilitation coverage standard definition refers to “regaining” function and habilitation is designed for people that have never attained certain skills and functions in the first place, parity among the two services requires scope and limitations specific to the respective service. Limitations of any kind should be based on the best available evidence and such decisions should be made by professionals with sufficient knowledge and expertise in the rehabilitative and habilitative fields to render informed decisions.4 In the BCBS Small Group Best Choice benefit booklet physical medicine is defined as modalities, procedures, tests, and measurements listed in the Physicians’ Current Procedural Terminology Manual (Procedure Codes 97010−97799). Two patients with the same diagnosis code may require vastly different treatments and services; therefore any diagnosis code-based guidelines should only be guidelines.
Children and adults with behavioral or mental health concerns must have access to screening, diagnosis and treatment that is not subject to arbitrary limits on coverage and integrated into the broader health care system. The limits in existing plans appear to provide children with only crisis stabilization and residential treatment. TCDD does not support residential or institutional services when effective treatments, interventions, and practices exist that can help adults, children and youth with mental health concerns succeed at home, at work, in their schools, and in their communities. TCDD supports services provided in the context of a medical home, where the clinician works in partnership with the individual and/or family to ensure that all of the medical and nonmedical needs of the person are met. Mental health parity is essential to achieving an integrated physical and mental health system.
None of the plans on the TDI analysis cover a developmental delay which misses the best opportunity to reduce future costs. Research from the Center on the Developing Child at Harvard University tells us that the neural circuits, which create the foundation for learning, behavior and health, are most flexible or “plastic” during the first three years of life5. Over time, they become increasingly difficult to change. Research indicates as many as 13% of children birth to 36 months have developmental delays that would benefit from early intervention services. Pediatric early intervention is delivered by a team of providers including credentialed early intervention specialists, speech and language pathologists, and physical and occupational therapists. And, as for mental health, the pediatric clinician that provides the medical home is the ideal person to identify these children through early and continuous screening. These services minimize the potential for developmental delay and reduce health costs.
In closing, with the delay by the federal government in issuing regulations for essential health benefits we hope TDI will conduct an additional stakeholder meeting focused on these three areas where the plans have the most differences and where supplementing coverage is most likely: rehabilitation and habilitation, mental health, and pediatric services where stakeholders could hear more details from TDI and provide more detailed comments on how to best meet the needs of populations who depend on these benefits.
Belinda Carlton, CPM
Public Policy Specialist
512 437-5414 (desk)
- Analysis of Benchmark Plan Options in Texas by Required PPACA Coverage Categories and State Mandated Benefits and Offers. 2012 Texas Department of Insurance. Retrieved 10-15-2012. ↩
- NAIC Glossary of Terms for the Affordable Care Act (PDF) ↩
- Social Security Act, Section 1915(c)(5)(A). ↩
- Letter to Centers for Medicare and Medicaid Services from Habilitation Benefit Coalition. February 17, 2012. ↩
- Center on the Developing Child at Harvard University (2008). In Brief: The science of early childhood development. Retrieved November 6, 2012. ↩