Essential Health Benefits Proposed Rule Released
The long anticipated “essential health benefit” (EHB) proposed rule has been released by the U.S. Department of Health & Human Services (HHS). For the most part, it conforms with the general trend of providing states with significant flexibility and decision-making authority. It permits a state to define habilitative services when its benchmark plan does not provide sufficient coverage.
However, in the absence of state action, health plans will be permitted to define habilitative services. AOTA has serious concerns with allowing health plans to define this benefit. We advocate for definitions of rehabilitative and habilitative services such as those produced by the National Association of Insurance Commissioners, which include the concept of maintenance of function.
Another issue that is addressed by the proposed rule is that substitution of benefits will be limited to the 10 broad EHB categories. AOTA favored that option as compared to the alternative that HHS had been considering, which would have allowed substituting benefits across categories. While the proposal ensures rehabilitative and habilitative services and devices will be protected as a category, it remains important to ensure occupational therapy maintains its place as a required benefit within that category.
AOTA will be commenting on the proposed rule, and working with state occupational therapy associations to advocate for the profession. States will continue to have an opportunity to submit or change EHB benchmark plan selections, as well as formulate rules governing issues such as those described above. AOTA State Affairs staff will provide additional analysis and resources in the coming weeks.