Transcript Essential Health Benefits

(1)
(2)
(3)
(4)
(5)
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services,
including behavioral health treatment
(6) Prescription drugs
(7) Rehabilitative and habilitative services and devices
(8) Laboratory services
(9) Preventive and wellness services and chronic
disease management
(10) Pediatric services, including oral and vision care
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
Affordable Care Act requires Essential
Health Benefits to resemble typical small
employer plans
But most employer plans do not cover
habilitation
Private insurers lack experience in this area
Lack of actuarial data causing insurers to err
on side of caution, restricting benefit
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Arkansas
has a unique advantage over most
other states when it comes to habilitation.
Arkansas has one of the few Medicaid
programs with a long history of providing
habilitative services to all adults and children
who qualify.
We know how much it costs.
We have providers who are already licensed
and located in all areas of the state.
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DDTCS serves about 8,858 children and
adults
 CHMS serves about 4,400

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Series of meetings in late 2012/early 2013
 Plan Management Advisory
Committee
 Steering Committee
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self-help/adaptive
 sensory motor
 communication
 cognition
 social/emotional

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Eventually the committees came to
understand the importance of the
developmental services provided by nontherapists.
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 Developmental
services are training
in the acquisition or maintenance of
motor, cognitive, communication,
social/emotional and selfhelp/adaptive skills and functional
activities needed for daily living.
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
Developmental services must be
performed in a licensed or certified,
organized, multidisciplinary clinic-based
individual or group setting by a direct
support professional with a least a high
school degree under the supervision or
direction of a Qualified Developmental
Disability Professional (QDDP) or an Early
Childhood Developmental Specialist.
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
Developmental services must be
furnished under a prescription and in
accordance with the goals and
objectives in a written treatment plan
certified by the treating physician.
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Definition:
 Habilitative services are services
provided in order for a person to attain
and maintain a skill or function that was
never learned or acquired and is due to
a disabling condition.
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Coverage:
 Subject to permissible terms, conditions,
exclusions and limitations, health benefit plans,
when required to provide essential health
benefits, shall provide coverage for physical,
occupational and speech therapies,
developmental services and durable medical
equipment for developmental delay,
developmental disability, developmental
speech or language disorder, developmental
coordination disorder and mixed
developmental disorder.
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Durable Medical Equipment when prescribed by a
physician (doctor of medicine or doctor of osteopathy)
or an advanced practice nurse according to the
guidelines specified below:
a. Durable Medical Equipment is equipment which (1)
can withstand repeated use; and (2) is primarily and
customarily used to serve a medical purpose; and (3)
generally is not useful to a person in the absence of
an illness or injury; and (4) is appropriate for use in the
home.
b. Durable Medical Equipment delivery or set up
charges are included in the Allowance or Allowable
Charge for the Durable Medical Equipment.
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c. Replacement of DME is covered only when
necessitated by normal growth or when it exceeds
its useful life. Maintenance and repairs resulting
from misuse or abuse of DME are the responsibility
of the Covered Person.
d. When it is more cost effective, the Company in its
discretion will purchase rather than lease
equipment. In making such purchase, the
Company may deduct previous rental payments
from its purchase Allowance.
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Arkansas definition and coverage reported
in Insurance Commissioner Directive 12013:
http://insurance.arkansas.gov/legal.htm
Some other states:
http://www.statereforum.org/weeklyinsight/defining-habilitative-benefits
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
Insurers may not discriminate in benefit
design on basis of:
Age
Expected length of life
Present or predicted disability
Degree of medical dependency
Quality of life
Other health condition
45 C.F.R. 156.110(d)
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Prohibits benefit discrimination on the basis of
factors including:
 Race
 Color
 National origin
 Disability
 Age
 Sex,
 Gender identity and sexual orientation
Source: Section 1302(b)(4) of the Affordable Care Act and 45
CFR 156.200(e)
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QHPs must:
“Ensure an appropriate balance among
the EHB categories to ensure that benefits
are not unduly weighted toward any
category.”
Source: 45 C.F.R. 156.110(e)
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
No dollar limits -- but plans may impose
limits on days, visits, etc.
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Possible: “Parity” with rehab: 30 outpatient
visits and 60 days of inpatient habilitation –
doesn’t make sense for habilitation
 Better – 90 outpatient visits
 Best – Multiplier approach: 90 hours of
therapy or (5 x 90 = 450 hours) 90 days of
developmental services, or equivalent
combination*

*still will not cover amount of services under current
clinic based model
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 Definition
good for 2 years
 HHS/CCIO will evaluate states’
experience with habilitation
during this time and then revisit
the issue
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Problem – not enough to cover ongoing
habilitation for developmental disabilities
– individuals will run out each year
 Does not take into account lifelong
condition
 Not clear whether such approach meets
ACA non-discriminatory and “balanced”
approach
 Insurers concerned about premium
increases if have to pay for full duration

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To the extent that private plans do not
provide habilitative benefits commensurate
with Arkansas Medicaid’s state plan
coverage, this will continue to incentivize
families to depend on Medicaid.
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June 30, 2013 – Deadline for insurers to
submit plans and rates for review
 July 31, 2013 – Arkansas makes
recommendations to CMS on which
plans to certify
 Early Sept. 2013 – HHS certifies plans
 October 1, 2013 – Enrollment starts
 January 1, 2014 – Coverage begins

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