Analysis of rehabilitation and habilitation benefits in qualified health plans

We examined silver-level Marketplace plans in 24 states and the District of Columbia, 677 plans in all, analyzing how rehabilitation and habilitation services are covered in the ACA Marketplaces by reviewing Summaries of Benefits and Coverage (SBC) – short, standardized documents that allow consumers to evaluate and compare health plans.

A person looking for information about occupational therapy coverage should be able to tell:

• Whether occupational therapy is covered under rehabilitation and habilitation.
• Whether there are any quantitative limits on occupational therapy services (e.g., number of visits covered).
• Whether the deductible applies to occupational therapy.

Fewer than half of the plans we surveyed had “ideal SBCs” with all this information available.

What we found

• Fewer than half of plans (48%) list occupational therapy, physical therapy, and speech-language pathology as being covered.
• Approximately 68% of plans made the visit limit clear for both rehabilitation and habilitation.
• Almost all the SBCs we reviewed made it clear whether or not a person would need to meet their deductible before rehabilitation or habilitation coverage would take effect.

Fewer than 1% of plans combined habilitation and rehabilitation or tied benefits to age or health status, a significant improvement over earlier reports.

Habilitation lags behind

When the Essential Health Benefits were established, habilitation was a "new" benefit – most existing plans didn't cover it. Habilitation still lags behind when it comes to presenting clear and consistent information about coverage. For example, 48% of plans made it clear that occupational therapy, physical therapy, and speech-language pathology were available under both habilitative and rehabilitative services, but this percentage increased to 57% if only considering the rehabilitation benefit.

Read the report