Understanding the Rehabilitative and Habilitative Services Essential Health Benefit

Rehabilitative and habilitative services are one of the ten essential health benefits covered under all Affordable Care Act (ACA) insurance plans. Although they sound similar, there is a meaningful difference between them.

Generally, rehabilitative services help you return to your level of functioning prior to illness or injury. Habilitative services help you improve your level of functioning from your existing baseline. These essential benefits have a lifelong impact, so it’s best to understand the benefits of each.

What Rehabilitative and Habilitative Services Are Available?

• Physical therapy restores, improves, or maintains your movement and function.
  • This service is provided by physical therapists, or “movement experts who optimize the quality of life through prescribed exercise, hands-on care, and patient education,” according to the American Physical Therapy Association. These practitioners will use movement and other treatments to help you restore, improve, or maintain your range of motion and ability.
  • Physical therapy appointments are usually very interactive. So you will want to ask about social distancing, as well as glove and mask protocols before you attend a session. Expect to be closely guided by your physical therapist, perhaps including hands-on therapies. Also, you’ll likely get coaching on how to continue some exercises and treatments at home. Physical therapists may provide home visits, as well.
• Occupational therapy improves your ability to take part in everyday activities.
  • Occupational therapy is often thought to be the same as physical therapy, but they are quite distinct. Occupational therapists help you function better in your everyday environment. For example, while a physical therapist might help you, say, regain shoulder movement after an injury, an occupational therapist can help you do things like cooking a meal or writing.
  • These services can take place in a variety of settings, including a hospital stay, at school or at home. Be sure to check with your insurance provider about specific coverage.
• Speech therapy improves your ability to use language and communicate.
  • Speech therapists will be able to support you in key areas related to:
    • speech (how you verbally communicate);
    • language (how you process communication);
    • cognitive functioning (how you process and use information in tasks that involve memory, holding attention, and problem-solving).
  • Like other rehabilitative and habilitative services, speech therapy is provided across a variety of settings.

Note that “rehab” for substance abuse issues is actually part of the mental health essential benefit, rather than the rehabilitative services discussed here.

ACA plans are required to broadly cover rehabilitative and habilitative services. However, details such as the maximum number of visits covered or specific services that aren’t covered will vary depending on your state and your specific plan.

These therapies are considered to be “inpatient services” if they are provided after you have been admitted to a hospital or nursing facility. Otherwise, they are “outpatient services.” Plans have different coverage for each.

As always, if you get these services outside of your plan’s network of medical providers, you will likely face significant additional expenses. Also, if you enrolled in a large employer group or another non-ACA plan, these services may not be covered as robustly — or at all. 

Rehabilitative and Habilitative Devices

Rehabilitative services involve more than in-person treatment. This essential health benefit covers a number of items that are part of your rehabilitation, as well.

There are a wide variety of technologies that you may need to recover or improve, so it’s important to know what your plan covers. You may use these items during treatment sessions, such as physical therapy, or your doctor may prescribe a device that you use at home. 

Devices you use at home are called durable medical equipment (DME). You can work with your doctor to choose the best make and model covered by your insurance.

Some common examples of DME devices include walking aids, such as crutches and a cane, as well as a commode chair or a hospital bed. More complex devices, like a breathing machine, are also considered DME.

If you’re looking for coverage for a particular type of device, you’ll want to check your plan’s Summary of Benefits to see whether or not that DME is covered for your specific condition. Independent vendors of home medical devices can also help you find an appropriate item that’s covered.

Each state has a different take on what are required services under essential health benefits. Illinois, for example, has a more generous list of required services, while Alabama mandates only the bare minimum of services.

States define essential health benefits coverage by choosing an existing private plan in their state and setting it as the state’s benchmark plan. This means that all other health insurance plans in the state must meet, at a minimum, the benefits covered in the benchmark plan. Starting this year, states have more flexibility in how they cover essential health benefits, however, and some may have trimmed benefits to save money.

Although most states cover common rehabilitative services like physical, occupational, and speech therapy, many states impose limits on these services. For example, Alabama’s 2017-2021 benchmark plan, Blue Cross Blue Shield of Alabama, has a combined limit of 30 visits a year for physical, occupational, and speech therapy. In contrast, California’s benchmark plan, Kaiser Foundation Health Plan, does not cap the number of visits for these therapies.

Other states limit coverage by including specific types of services they won’t cover. Alaska’s 2017-2021 benchmark plan excludes recreational, vocational, and educational therapy from its outpatient rehabilitation services benefit. Colorado is another state that does not cover outpatient rehabilitation services, such as long-term rehabilitation.

States also have different guidelines for child rehabilitation. For example, some states have greater coverage for children with autism compared to general pediatric therapy needs.

After a serious illness or injury, rehabilitative and habilitative services can impact your recovery and performance for the rest of your life so it’s important you get the care you need. Check your Summary of Benefits or call your insurance company with specific questions to be sure you get all the sessions and equipment you need for the best possible outcome.