Habilitation Services Monte Dugas Joanna Lutman Kelsey Wolff

Habilitation Services Monte Dugas, Joanna Lutman, Kelsey Wolff

What are Habilitation Services? Health care services that help an individual • acquire, • keep, • learn, or • improve • skills and functioning for communication and daily living. Examples: • therapy for a child who isn't walking or talking at the expected age • prevocational services • educational services • supported employment services (New York State Speech-Language-Hearing Association, New York Physical Therapy Association, & New York State Occupational Therapy Association, 2012)

What are Habilitation Services? Similarities to Rehabilitation: • restores functional capacity for daily living • minimizes limitations on physical and cognitive functions • maintains or prevents deterioration of functioning • trains individuals with disabilities to enhance functional development Key Differences: Rehabilitation addresses skills and functioning that have been lost or impaired because a person was sick, injured or disabled. Habilitation can take place at any point during an individual’s life and addresses skills that have not yet been gained or mastered. Habilitation focuses on learning. Rehabilitation focuses on re-learning. (Brown, 2014)

What are Habilitation Services? Specific services can include: • physical therapy • occupational therapy • speech-language pathology • audiology • ABA therapy • psychology • other additional services Delivery can take place in a variety of inpatient and outpatient settings. (Habilitative/Habilitation Services, n. d. )

History of Habilitation Services Habilitation has always been part of the occupational therapy mindset. Habilitation has not always been reimbursable. In 1989, Medicaid added habilitation services to its list of benefits. In 2000, Maryland passed the Habilitative Services mandate, which required insurance providers to offer habilitative services to children under age 19 with congenital or genetic birth defects, though most states still have no such legislation. In 2002 this law was amended to explicitly include autism spectrum disorder and cerebral palsy. In 2012 the Maryland law was amended again specifically to include intellectual disability, Down syndrome, spina bifida, hydroencephalocele and congenital or genetic developmental disabilities. (A Brief History, n. d. )

History of Habilitation Services In 2012, because of the Affordable Care Act, all plans sold on state and federally run health insurance exchanges are required to include habilitation coverage. Beginning in 2014, all individual and small group health policies sold outside the exchange have to cover habilitative services as well. Presently, “habilitative services” is still open to interpretation, and different states offer varying degrees of coverage. (Ollove, 2013)

Impact on Occupational Therapy Practice The Affordable Care Act (ACA) identifies 10 essential health benefits (EHBs) that insurance companies are required to cover. EHB #7 is “Rehabilitative and habilitative services and devices. ” The inclusion of habilitative services as an EHB has opened the door for habilitative services to take a growing role in healthcare. AOTA is now vigilantly keeping watch to identify plans that are non-compliant with the ACA’s habilitation requirements. As the role of habilitation in health care [hopefully] expands, OTs can confidently fight for more therapy for their clients, based on the requirements of the ACA. (American Occupational Therapy Association, 2014 a)

Impact on Occupational Therapy Practice • • • Ironically, there is no official definition of habilitation services articulated in federal legislation that can be used to bring uniformity to coverage plans. • (note: Medicaid operates under its own definition of habilitation services, which does not necessarily correspond with what is offered by private insurance companies). Defining “habilitative services” is left to the discretion of state governments. • Louisiana law does not define habilitative services Individual states may also determine the degree to which habilitation services must be offered and to which populations. • Louisiana only legally requires habilitation services for autism spectrum disorder (Center for Consumer Information and Insurance Oversight, 2011; Louisiana- State Required Benefits, n. d. )

OT’s Role/Taking Advantage of the Trend • • • Become familiar with your state’s EHB benchmark coverage requirements and definition of habilitation services. Share with practitioners, clients, and referral sources the new regulatory requirements for coverage of habilitation services. Assist clients who have experienced denials of coverage of habilitation services by helping them determine if their plan is subject to the EHBs and whether their plan’s coverage is in compliance with the state’s benchmark, and if applicable, the state’s definition of habilitation services. Encourage consumers to file appeals with insurers or complaints with the state health insurance marketplace or department of insurance in cases when health plans seem to be out of compliance. Also, communicate with your state’s OT association and AOTA about these instances to inform current and future advocacy efforts. Educate decision makers (e. g. , your state legislators and insurance regulators) about the difference between rehabilitation and habilitation services and the fact that OT practitioners are skilled providers of both. Stay informed and assist with local advocacy efforts by becoming a member of your state OT association and AOTA, and by developing relationships with potential allies, such as speech therapists and organizations that advocate for people with disabilities. (American Occupational Therapy Association, 2014 b)

AOTA Blog: most recent info on ACA

Thank you, Lobbyists! “The American Occupational Therapy Association’s (AOTA’s) congressional lobbying efforts were instrumental in obtaining the inclusion of habilitative services in the ACA’s EHB requirements to reduce the likelihood that insurance carriers could continue to exclude habilitative occupational therapy services from coverage under their health plans. ” (Brown, 2014)

Conclusion What is habilitation? Health care services that help an individual • acquire, • keep, • learn, or • improve • skills and functioning for communication and daily living. Habilitation focuses on learning. Rehabilitation focuses on re-learning. We as OTs are skilled providers of both rehabilitation and habilitation services. It’s our job to familiarize ourselves with the ins and outs of services, and then promote and advocate for them to best serve our clients.

References American Occupational Therapy Association (2014 a). Analysis of Rehabilitation and Habilitation Benefits in Qualified Health Plans. Retrieved from http: //www. aota. org/-/media/Corporate/Files/Advocacy/Health-Care-Reform/Essential-Benefits/EHB-researchproject. pdf American Occupational Therapy Association (2014 b). Habilitative services are essential health benefits: An opportunity for occupational therapy practitioners and consumers. Retrieved from https: //www. aota. org/-/media/Corporate/Files/Advocacy/Health-Care. Reform/Essential-Benefits/Habilitative%20 Services%20 Fact%20 Sheet. pdf Brief History of Maryland’s Habilitative Services Mandate (n. d. ) Retrieved from http: //www. pathfindersforautism. org/resources/understanding-insurance/mandate-history Brown, D. (2014). Health Policy Perspectives—Habilitative services: An essential health benefit and an opportunity for occupational therapy practitioners and consumers. American Journal of Occupational Therapy, 68, 130– 138. doi: http: // dx. doi. org/10. 5014/ajot. 2014. 682001 Center for Consumer Information and Insurance Oversight (2011). Essential Health Benefits Bulletin. Retrieved from https: //www. cms. gov/CCIIO/Resources/Files/Downloads/essential_health_benefits_bulletin. pdf Habilitative/Habilitation Services (n. d. ). Retrieved from https: //www. healthcare. gov/glossary/habilitative-habilitation-services/ Louisiana- State Required Benefits (n. d. ). Retrieved from https: //www. cms. gov/CCIIO/Resources/Data-Resources/Downloads/la-staterequired-benefits. pdf New York State Speech-Language-Hearing Association, New York Physical Therapy Association, & New York State Occupational Therapy Association (2012). New York State benchmark plan recommendations. Retrieved from http: //www. healthcarereform. ny. gov/timeline/2012 -08 -02_exchange_stakeholder/docs/nys_ot_pt_speech. pdf Ollove, M. (2013). ‘Habilitation’ among new Obamacare benefits. USA Today. Retrieved from http: //www. usatoday. com/story/news/nation/2013/10/24/stateline-obamacare-habilitation/3177503/