In the August 13, 2013 Kaiser Health News, Eric Whitney reports that the Affordable Care Act has set new standards — called essential health benefits — outlining what health insurance companies must now cover. But there seems to be a catch. Insurance firms can still pick and choose to some degree which specific therapies they’ll cover within some categories of benefit. And the way insurers interpret the rules could turn out to be a big deal for people with disabilities who need ongoing therapy to improve their day-to-day lives.
The Affordable Care Act is changing the benefits for people who require “habilitative” coverage defined as ongoing care necessary for people with disabilities.
“You’re much more likely to find these benefits in a plan in the individual market [starting in 2014] than you would be today. Far more likely,” says Clemans-Cope.
“Habilitative services” are included within the 10 categories of essential health benefits the ACA will require in those new plans. Still, while some categories are straightforward — such as maternity care and preventive care — the category including habilitative services leaves more room for interpretation.
For instance, insurers could choose to cover physical therapy for someone with a broken bone, but not cover long-term support services for chronic conditions, such as speech therapy for kids with developmental delays.
Clemans-Cope says some insurers may arrange their benefits in a way that discourages people with expensive chronic conditions from signing up with them. And, she says, people who want to have specific therapies covered are going have to slog through some fine print to figure out if they’ll actually benefit from a particular policy. (The new policies will start to go on sale this fall and go into effect beginning Jan. 1, 2014.)
“This is a big improvement, but we should emphasize that it’s not totally fixed,” Clemans-Cope says. “And people are really going to have to get help to decide which plans cover the benefits they need.”
Covered California strongly recommends using a licensed, certified insurance agent to advise you on the benefits most necessary for your particular needs. Call Jeremy at (310) 486-7625 to be informed and ready for the changes with the Exchange.