Habilitation – What it is And Why it Matters to You

Most of us are familiar with the term rehabilitation and are comfortable with our role in providing “rehab” services.  Habilitation, on the other hand, may be less common. I don’t know of many SLPs who consider themselves “habilitation providers.” Audiologists may be somewhat more comfortable with the term as providers of aural habilitation, but not in other contexts.

So, what is habilitation? Basically, we are talking about services that help a person learn, keep, or improve skills and functional abilities that they may not be developing normally. Still not clear? Contrast that with services that help a person improve skills that have been lost after a stroke, head injury, illness, or other cause. The latter is rehabilitation – regaining lost skills or functioning. Habilitation refers to services for those who may not have ever developed the skill, such as a child who is not talking as expected for his or her age.  Adults can also benefit from habilitative services, particularly those with intellectual disabilities or disorders such as cerebral palsy who may benefit from services at different points in their life to address functional abilities.

Why the focus on distinguishing habilitation from rehabilitation? Anyone who has dealt with private insurance for a person needing habilitative services likely knows the answer. If you look closely at coverage descriptions for many insurance plans, you’ll likely see language specifying that services like physical therapy or speech-language pathology will be provided when skills have been lost due to illness or injury. This language automatically restricts payment for services to those who haven’t had a stroke or suffered an illness, including most children who don’t have a specific diagnosis underlying their speech, language, swallowing, or hearing problems.

Habilitation is getting national attention right now due to the implementation of the health care reform law. Part of the law stipulates that insurance plans offered through the state exchanges and Medicaid programs must provide services in 10 categories of essential health benefits (EHBs), including the category of rehabilitation and habilitation services and devices. ASHA has been anxiously awaiting the regulations regarding the EHBs and has been working particularly hard on ensuring adequate coverage for habilitative services through the Habilitation Benefits Coalition. The concern centers primarily on the fact that habilitative services are not common in “typical” employer plans, upon which the EHBs are to be based, and this lack of clarity around what habilitative services are and how they should be covered could result in continued difficulty with reimbursement for these services.

Recently, the Department of Health and Human Services (HHS) issued the Essential Health Benefits Bulletin in lieu of regulations. This bulletin is offered as guidance, but does not have the power of a regulation. Essentially, the bulletin gives the states the responsibility of determining EHBs, allowing for greater flexibility and customization to each state’s unique needs. Some highlights from this bulletin include:

  • States will have flexibility in choosing their benchmark plan and will have to supplement that plan with any of the EHB categories that are lacking
  • Plans cannot discriminate based on age, disability or life expectancy, but no specific guidance on this is offered
  • If a state doesn’t choose a plan, the default plan will be the largest small group plan based on enrollment
  • States will have to submit their choices to HHS for approval
  • Self-insured group health plans, large group plans, and grandfathered plans will not be required to cover essential health benefits at this time
  • Comments on the pre-rule bulletin are being accepted until January 31, 2012

When addressing habilitation specifically in the bulletin, HHS acknowledges that these services are less well-defined and that confusion exists over what exactly is covered by such a benefit. They have proposed two options for situations where the state chosen benchmark plan does not include habilitation. These include:

  1. Habilitative services would be offered at parity with rehabilitative services — a plan covering services such as PT, OT, and ST for rehabilitation must also cover those services in similar scope, amount, and duration for habilitation; or
  2. As a transitional approach, plans would decide which habilitative services to cover, and would report on that coverage to HHS. HHS would evaluate those decisions, and further define habilitative services in the future (p. 11)

As one can see, the issue of appropriate coverage for both rehabilitation and habilitation services is going to come down to state-level debates and decisions. ASHA will continue to monitor developments and take action, when appropriate, but the burden of the work will likely fall to the state associations and members within each state. If this issue resonates with you, we encourage you to contact your State Advocate for Reimbursement (STAR) and state association to assist in any advocacy efforts. Individuals requiring speech and hearing services, regardless of etiology, have a right to services to help them function as independently as possible. We have a tremendous opportunity now to ensure appropriate coverage for habilitative services as an essential health benefit. This is your chance to have a real impact on the future of health care.

Amy Hasselkus, M.A., CCC-SLP, is associate director of health care services in speech-language pathology at ASHA. She is also currently enrolled in a Masters degree program in communication at George Mason University, with an emphasis on health communication.