This bulletin summarizes the federal requirement that issuers offering health insurance coverage in the individual or small group market provide coverage in accordance with section 2707 (a) of the Patient Protection and Affordable Care Act (ACA). The ACA requires that a health insurance issuer offer as part of the essential health benefits package (EHB) coverage for "rehabilitative and habilitative services and devices" [ACA §1302 (b) (1) (G)].
The benchmark plan selected for Wisconsin does not include a definition of or coverage for habilitative services. In accordance with 45 C.F.R. §156.115 (a) (5) (i) and (ii), insurers may either: (i) provide parity by covering habilitative services that are similar in scope, amount, and duration to benefits covered for rehabilitative services; or (ii) report to HHS its definition of habilitative services.
When defining "habilitative services" insurers should consider that insureds are provided the Glossary of Health Insurance and Medical Terms as part of the Summary of Coverage and Benefits (as required by §2714 of the ACA), that defines "habilitative services" as:
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.
In reviewing policy form filings for individual and small group comprehensive health insurance plans, OCI will look to ensure that the habilitative services included in the policy are either on par with rehabilitative services covered by the policy or, if an issuer develops its own definition, that the coverage for habilitative services does not unfairly discriminate against individuals who may have acquired a functional deficit. Insurers acting contrary to the law may be subject to administrative action pursuant to ss. 628.34 (3) and 632.748, Wis. Stat., and s. Ins 6.67, Wis. Adm. Code.
This bulletin applies to all insurers offering comprehensive individual and small group health insurance plans beginning January 1, 2014. It is each insurer's responsibility to ensure that its policy forms and procedures are in compliance with the law. Any questions concerning this bulletin should be directed to Diane Dambach at (608) 266-0106 or
diane.dambach@wisconsin.gov.