published Monday, May 5th, 2014

A step up: New ACA coverage seen as advance for disability community

Five-year-old Jeremiah Williams reaches for a plastic donut while working on balance and mobility skills at the Siskin Hospital for Physical Rehabilitation.
Five-year-old Jeremiah Williams reaches for a plastic donut while working on balance and mobility skills at the Siskin Hospital for Physical Rehabilitation.
Photo by Dan Henry.
  • photo
    Occupational therapist assistant Kate McMahon, left, and Dr. Emily Gavlick work with Jeremiah on balance.
    Photo by Dan Henry.
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WHAT’S THE DIFFERENCE?

Habilitative Services: “Health care services that help you 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.”

Rehabilitative Services: “Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled.”

Source: Kate Abernathy, spokeswoman for the Tennessee Dept. of Commerce and Insurance

ESSENTIAL HEALTH BENEFITS

1. Outpatient care.

2. Trips to the emergency room

3. Inpatient care.

4. Maternity and newborn care.

5. Mental health and substance use disorder services

6. Prescription drugs

7. Habilitative and rehabilitative care.

8. Lab tests.

9. Preventive services including counseling, screenings, and vaccines.

10. Dental care and vision care for children.

Source: Healthcare.gov

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Editor’s note: This is the fourth in an occasional series on the 10 essential health benefits required by the Affordable Care Act.

Even the subtlest motions that 5-year-old Jeremiah Williams makes in the therapy room are loaded with importance.

Shifting his weight on a swing. Rolling a beach ball across the floor. Learning to push a small walker. To his therapists at Siskin Hospital for Physical Rehabilitation, each exercise builds a bridge in the little boy’s brain, forging a network of skills that most people take for granted: Balance. Hand-eye coordination. The ability to adjust the weight of his 40-pound body on his feet, so he can take one step — and another.

Jeremiah cannot walk on his own. He is completely deaf, has chronic lung disease. Since birth he has had a developmental delay that doctors are still trying to understand.

He’s been in and out of therapy since he was 3, but just started at Siskin a couple of weeks ago. From physical therapy, he’ll head to occupational therapy to work on tasks like brushing his teeth and dressing himself. From there, he goes to speech therapy to learn sign language.

The sooner he gains traction with these, the better his outlook for independence, his therapists say.

“They think he will be able to walk and eat again one day,” said Raven Williams, his mother.

While Jeremiah is receiving therapy at a hospital known for its rehabilitative services, the kind of care he is getting is technically called “habilitative” care.

Rehabilitative services are defined as therapies that restore functions that have been lost because of illness or injury, explained Kelly Paulk, director of product strategy at BlueCross BlueShield of Tennessee.

Habilitative services are essentially the same kinds of therapies, but geared toward people who have never had certain functions in the first place — often because of a disability.

Siskin works with those who need both kinds of therapy, often using similar methods for both.

But in the insurance world, the two types of services have not been treated the same. Traditionally, insurers have included rehabilitative care in their policies, while leaving habilitative care out.

“In my 20 years of experience in this field, [habilitative care] is just not something that’s been included in an insurance plan,” Paulk said.

Before last year, Tennessee had no? requirements for insurers to include habilitative services, said Kate Abernathy, spokeswoman with the Tennessee Department of Commerce and Insurance.

But the Affordable Care Act has changed that with the establishment of its 10 essential health benefits that are now required in every insurance plan.

Jeremiah’s therapy has so far been covered by TennCare, so the ACA does not immediately affect his situation.

But the inclusion of habilitative services in new insurance plans is a significant step for the disability community, said Sarah Sampson, spokeswoman for the Tennessee Disability Coalition.

“It is well-documented that habilitative services can not only enhance people’s lives, but they can really reduce the cost of serving that individual later in life,” said Sampson.

Even more important, she said, is the fact that the ACA does not allow insurers to deny coverage based on pre-existing conditions.

“That’s really addressing this population,” Sampson said. “Someone who knew they would need these services for the rest of their lives would have been in a real struggle getting insurance coverage, let alone something that included habilitative services.”

But families that tried to select a plan during the open enrollment period that ended March 31 had a tough time finding out exactly what coverage was offered, she said.

Habilitative services vary from state to state. The ACA required each state to pick a benchmark insurance plan that would serve as a basic model for all new plans on the individual market, meaning each state could decide which specific services would be covered.

In Tennessee, that benchmark plan — BlueCross’ small group PPO plan — includes 20 visits for physical therapy, 20 visits for occupational therapy, 20 visits for chiropractic care, 20 visits for speech therapy and 36 visits for cardiac and pulmonary therapy.

The coverage levels must be the same for both rehabilitative and habilitative services, and each has separate limits, Abernathy said.

Still, one key type of habilitative treatment is noticeably absent in Tennessee, Sampson said: Applied behavioral analysis, a behavior therapy program that has been found to be especially effective for children on the autism spectrum.

Still, she said, just having habilitative services considered “essential” is a big step.

The 10 essential health benefits are required in all plans in the individual and small group markets except for grandfathered plans — policies in place before the health law took effect in March 2010 and that don’t violate the rules of grandfathering.

Contact staff writer Kate Harrison at kharrison @timesfreepress.com or 423-757-6673.

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