Essential Health Benefit Benchmark Plan Coverage of Rehabilitation, Habilitation, and Autism Services

Transcription

1 Essential Health Benefit Benchmark Plan Coverage of Rehabilitation, Habilitation, and Autism Services This information is derived from CCIIO s supplementary materials referenced in Appendix A of the EHB final rule. All information in this chart that is not from those materials has a link, a statutory reference, or is bracketed. Many fields are paraphrased. Under the exclusions column, if it indicates none, that only means none were listed in CCIIO s materials, or the information seemed more appropriate for another column. Other rehabilitative and habilitative services are covered under many plans inpatient, SNF, and home health benefits, but for the most part, those are not referenced in this chart. In the analysis column, there is no mention of inadequate visit limits, even though many plans visit limits are quite low. 17 states benchmark plans have little or no distinction between their coverage of rehabilitative and habilitative services. Approximately 10 states benchmark plans (data isn t clear) have no coverage of habilitative services, and those states have not taken action to define coverage requirements. Alabama (default) Alaska (default) State Rehabilitation Habilitation Exclusions Definitions Analysis 30 combined visits per See rehab None None No distinction person per year of between rehab PT/SLP/OT for rehab and and hab hab combined 45 visits per year for rehab and hab combined See rehab 1) Recreational, vocational, or educational therapy, exercise, or maintenance-level programs 2) Social or cultural therapy 3) Treatment that isn't actively engaged in by the ill, injured, or impaired member None No distinction between rehab and hab Maintenance explicitly excluded

2 4) Gym or swim therapy 5) Custodial care Arizona 60 visits per year No coverage None None **No hab coverage** No specific mention of covered therapies Arkansas 30 procedures per year (depends on the type of outpatient services) Limit to 30 aggregate visits per member per contract year. All therapies combined in the limit. See definitions None Definition of Habilitative Services: Services provided in order for a person to attain and maintain a skill or function that was never learned or acquired and is due to a disabling condition. Coverage of Habilitative Services: Subject to permissible terms, conditions, exclusions and limitations, health benefit plans, when required to provide essential health benefits, shall provide coverage for physical, ABA covered under Other (Excludes Sensory Integration, LOVAAS Therapy and Music Therapy) Reasonably good hab coverage (e.g. distinct, no age limits, mentions therapies, parity, mentions maintenance) ABA covered under Other 2

3 California PT/OT/SLP See definitions Rehab: none Hab: Certain limitations on types of care givers for behavioral health treatment as described in H&S Code section [includes a variety of professionals including OT/PT/SLP and BCBAs] CA Health and Safety occupational and speech therapies, developmental services and durable medical equipment for developmental delay, developmental disability, developmental speech or language disorder, developmental coordination disorder and mixed developmental disorder. The Arkansas Insurance Department (AID) will continue to develop criteria by which AID will evaluate the EHB habilitative services coverage. At a minimum, criteria will be at parity with EHB rehabilitative services coverage. Habilitative services means medically necessary health care services and health care devices that assist an individual in partially or fully acquiring or improving skills and functioning and that are necessary to address a health condition, to the maximum extent practical. These services address the skills and abilities needed for functioning in interaction Definition of hab, in part, by explicit and broad exclusions Excludes maintenance under hab Confusing use of necessity in hab definition 3

4 Colorado PT/OT/SLP 20 visits per year per therapy type Code sec (Stats 2012, ch. 854) requires that individual or small group health care service plans provide habilitative services, to the extent required under state law and as required by federal rules and regulations in section 1302(b) of the ACA. with an individual's environment. Examples of health care services that are not habilitative services include, but are not limited to, respite care, day care, recreational care, residential treatment, social services, custodial care, or education services of any kind, including, but not limited to, vocational training. Habilitative services shall be covered under the same terms and conditions applied to rehabilitative services under the policy. See definitions None "Habilitative services are services that help a person retain, learn, or improve skills and functioning for daily living that are offered in parity with, and in addition to, any rehabilitative services offered in Colorado's EHB benchmark plan. Parity in this context means of like type and substantially equivalent in scope, amount, and duration." Defining habilitative benefits in this manner provides habilitative benefits on par with those currently offered in Solid coverage (e.g. covers maintenance under hab, parity, distinct, no age or condition limits, explicit mention of therapy types) ASD (no mention of specific services) covered under Other 4

5 Connecticut 40 combined visits per year of PT/OT/SLP Medically necessary short term outpatient rehabilitative therapy (including those services rendered at a day program facility and in an office). No coverage Unless provided under Autism Services Rehab: Services are limited to short-term physical, occupational and speech therapy necessary to restore a function lost through or to eliminate an abnormal function that has developed due to injury or illness. Speech therapy for developmental speech delays, stuttering, lisps, and other non-injury or non-illness related speech impediments are not covered, except as provided in the Autism Services or Birth To Three Program (Early Intervention Services) provisions of Other Outpatient Services subsection C. Postoperative physical therapy for temporomandibular joint (TMJ) dysfunction surgery is covered when the TMJ surgery rehabilitation and reflects current utilization in the rehabilitative arena. Autism Services covered with no quantitative limits, but other unspecified limitations Hab not covered except for unspecified Autism Services 5

6 Delaware 30 combined visits per year of PT/OT/SLP See definitions DC OT/PT/SLP Defined in DC Code for children 21 and under is covered under this Plan. This physical therapy must be obtained during the 90- day period beginning on the date of the covered TMJ surgery and it must be Pre- Authorized by us as part of the surgical procedure. Other unspecified exclusions None Delaware will require that coverage for habilitative services be on parity with those for rehabilitative services as outlined in the state s Essential Health Benefit benchmark. Habilitative services means services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child's ability to function. (D.C. Code (3)) Adopted the NAIC definition of habilitation and supplemented it with ABA. DC Exchange Work group made the following recommendations: Recommendations: i. That there be no age 6

7 restriction on eligibility for habilitative services. ii. That the National Association of Insurance Commissioner s (NAIC) definition of habilitative services be adopted, Habilitation Services - Health care services that help a person 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. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. iii. That coverage of applied behavior analysis (ABA) be 7

8 included as part of habilitative services. Florida (default) 35 visits per year or benefit period No coverage Other unspecified exclusions DC Exchange Executive Board adopted the NAIC definition, and supplemented it with ABA coverage. None **No hab coverage** Georgia (default) PT/OT/SLP, respiratory therapy and cardiac rehabilitation combined for rehab and hab. 20 visit limit for PT/OT combined; Separate 20 visit limit for SLP; Separate 20 visit limit for Respiratory Therapy. See rehab Outpatient rehab and hab: Hypnotherapy; Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetics therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin None No mention of specific therapies covered No distinction between rehab and hab Inpatient rehab and mental/behavioral exclusions are very broad 8

9 abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment of nicotine addiction, and carbon dioxide. Self-Help - Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing. Inpatient Rehabilitation - Inpatient rehabilitation in the Hospital or Hospitalbased rehabilitation facility, when the Participant is medically stable and does not require skilled nursing care or the constant availability of a Physician or: the 9

10 treatment is for maintenance therapy; or the Participant has no restorative potential; or the treatment is for congenital learning or neurological disability/disorder; or the treatment is for communication training, educational training or vocational training. Mental/Behavioral Outpatient: Educational services and treatment of behavioral disorders, together with services for remedial education including evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral training, and cognitive rehabilitation. This includes services, treatment or educational testing and training related to 10

11 behavioral (conduct) problems, Developmental Delay (when it is less than two standard deviations from the norm as defined by standardized, validated developmental screening tests, such as the Denver Developmental Screening Test), including but not limited to services for conditions related to autistic disease of childhood (except to the same extent that the Contract provides for neurological disorders), hyperkinetic syndromes, including attention deficit disorder and attention deficit hyperactivity disorder, learning disabilities, behavioral problems, and mental retardation. Special education, including lessons in sign language to instruct a Participant, whose 11

12 ability to speak has been lost or impaired, to function without that ability, is not covered. Self-Help - biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing. Hawaii PT/OT/SLP No coverage Rehab: Maintenance therapy, defined as activities that preserve present functional level and prevent regression, are not covered. Idaho (default) PT/ OT/SLP services are for the purpose of restoring certain functional losses due to disease, illness or injury PT/OT/SLP services related to developmental and rehabilitative care, with reasonable expectation that the services will produce measurable improvement in the Insured s None None 20 visit limit is combined for all three therapies. Outpatient Rehabilitation and Habilitative services are a combined limit. Covered Services are for the purpose of restoring certain functional losses due to disease, illness or injury only and do not include maintenance services. **No coverage of hab** Maintenance explicitly excluded for rehab No distinction between rehab and hab Maintenance explicitly excluded Reasonable period of time requirement in hab coverage concerning 12

13 Illinois Covered with no description Separate descriptions of coverage for OT/PT/SLP (see exclusions) condition in a reasonable period of time. See definitions and exclusions Rehab: other unspecified exclusions OT: Covered when these services are rendered by a registered Occupational Therapist under the supervision of a Physician. This therapy must be furnished under a written plan established by a Physician and regularly reviewed by the therapist and Physician. The plan must be established before treatment begins and must relate to the type, frequency and duration of therapy and indicate anticipated goals and diagnosis. Your benefits for Habilitative Services for persons with a Congenital, Genetic, or Early Acquired Disorder are the same as your benefits for any other condition if all of the following conditions are met: 1. A Physician has diagnosed the Congenital, Genetic, or Early Acquired Disorder; and 2. Treatment is administered by a licensed speech language pathologist, Audiologist, Occupational Therapist, Physical Therapist, Physician, licensed nurse, Optometrist, licensed nutritionist, Clinical Social Worker, or Psychologist upon the referral of a Physician; and; 3. Treatment must be Medically Necessary and therapeutic and not Investigational. Limitations on hab somewhat vague Coverage of ASD services under Other PT: Covered when rendered by a registered professional Physical Therapist under the supervision Habilitative services for children. (a) As used in this Section, "habilitative services" means occupational therapy, 13

14 of a Physician. The therapy must be furnished under a written plan established by a Physician and regularly reviewed by the therapist and the Physician. The plan must be established before treatment begins and must relate to the type, frequency and duration of therapy and indicate anticipated goals and diagnosis. Preventive physical therapy for Multiple Sclerosis patients is covered as mandated. SLP: Covered when these services are rendered by a licensed Speech Therapist or Speech Therapist certified by the American Speech and Hearing Association. Inpatient Speech Therapy benefits will be provided only if Speech Therapy is not physical therapy, speech therapy, and other services prescribed by the insured's treating physician pursuant to a treatment plan to enhance the ability of a child to function with a congenital, genetic, or early acquired disorder. A congenital or genetic disorder includes, but is not limited to, hereditary disorders. An early acquired disorder refers to a disorder resulting from illness, trauma, injury, or some other event or condition suffered by a child prior to that child developing functional life skills such as, but not limited to, walking, talking, or selfhelp skills. Congenital, genetic, and early acquired disorders may include, but are not limited to, autism or an autism spectrum disorder, cerebral palsy, and other disorders resulting from early childhood illness, trauma, or injury. (215 Ill. Comp. Stat. 5/356z.15(a)) (existing statutory definition not pursuant to ACA or specific to EHB) 14

15 the only reason for admission. Hab: Benefit available only for Congenital, Genetic or Early Acquired Disorders diagnoses. Habilitative Services that are solely educational in nature or otherwise paid under State or Federal law for purely educational services are excluded. Treatment for Autism Spectrum Disorder(s) shall include the following care when prescribed, provided or ordered for an individual diagnosed with an Autism Spectrum Disorder by (a) a Physician or a Psychologist who has determined that such care is medically necessary, or, (b) a certified, registered, or licensed health care professional with expertise in treating Autism Spectrum Disorder(s) and when such care is determined to be medically necessary and ordered by a Physician or a Psychologist: psychiatric care, including diagnostic services; psychological assessments and treatments; habilitative or rehabilitative treatments; therapeutic care, including behavioral Speech, Occupational and Physical Therapies that provide treatment in the following areas: a) self care and feeding, b) pragmatic, receptive and expressive language, c) cognitive functioning, d) applied 15

16 Indiana (default) PT/OT/SLP, pulmonary therapy and cardiac rehabilitation. Separate annual 20 visit limit for PT/ OT/ SLP, Pulmonary Rehab; 36 annual visit limit for Cardiac Rehab. Benefit limits are shared between rehabilitation and habilitation services. See rehab OT does not include diversional, recreational, vocational therapies (e.g., hobbies and crafts). Non Covered Services include: supplies (looms, ceramic tiles, leather, utensils); therapy to improve or restore functions that could be expected to improve as the patient resumes normal activities again; general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions behavior analysis (ABA), intervention and modification, e) motor planning and f) sensory processing. ASD: Coverage is provided for the treatment of pervasive developmental disorders. No distinction between rehab and hab ASD services covered under Other 16

17 to the home such as rampways, door widening, automobile adaptors, kitchen adaptation and other types of similar equipment. PT: Non Covered Services include: maintenance therapy to delay or minimize muscular deterioration in patients suffering from a chronic disease or illness; repetitive exercise to improve movement, maintain strength and increase endurance (including assistance with walking for weak or unstable patients); range of motion and passive exercises that are not related to restoration of a specific loss of function, but are for maintaining a range of motion in paralyzed extremities; general exercise programs; diathermy, ultrasound and heat 17

18 treatments for pulmonary conditions; diapulse; work hardening. Iowa (default) Covered with no description, except to say it includes cardiac rehab Separate descriptions of coverage for OT/PT/SLP OT: Services to treat the upper extremities, which mean the arms from the shoulders to the finders. SLP: Rehabilitative Speech Therapy services when related to a specific illness, injury, or impairment. See definitions and exclusions Additional exclusions for cardiac rehab. Hab: Therapies rendered primarily for job training and therapy services related to general conditioning of the patient. Any habilitation not related to developmental delay is not covered. The following exclusions are specific to the therapy types, but not specific to the rehab and hab categories: Habilitative services driven by congenital disorders/ developmental delays are covered. Coverage of hab is vague Coverage of OT limited to upper extremities Occupational therapy supplies and occupational therapy provided as an inpatient in the absence of a separate medical condition that requires hospitalization. 18

19 Speech therapy services not provided by a licensed or certified Speech Pathologist. Speech therapy to treat certain developmental, learning, or communication disorders such as: stuttering and stammering. Kansas Covered with no description, except 90 annual visits of SLP See definitions Physical therapy as provided as an inpatient in the absence of a separate medical condition that requires hospitalization. Rehab: Vocational Rehabilitation, Cognitive Therapy. Potentially other unspecified exclusions The EHB plan has welldefined rehabilitative services and using the parity approach will ensure greater consistency among issuers. No explicit mention of therapy types for rehab or hab, except for SLP Kentucky PT/OT/SLP, pulmonary therapy and cardiac rehabilitation. Separate 20 annual visit limit for PT/OT/SLP, See rehab OT Non Covered Services include: supplies (looms, ceramic tiles, leather, utensils); therapy to improve or restore KY State Mandate: Services for Autism Spectrum Disorders including Medical Care, Habilitative or Rehabilitative care, Pharmacy care, Psychiatric No distinction between rehab and hab ASD services covered under 19

20 Pulmonary Rehab; 36 visit limit for Cardiac Rehab. Benefit limits are shared between rehabilitation and habilitation services. functions that could be expected to improve as the patient resumes normal activities again general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home such as rampways, door widening, automobile adaptors, kitchen adaptation and other types of similar equipment. care, Psychological care, Therapeutic care, Applied Behavior Analysis. Other PT Non Covered Services include: maintenance therapy to delay or minimize muscular deterioration in patients suffering from a chronic disease or illness; repetitive 20

21 Louisiana (default) Inpatient or Outpatient services for OT/PT/SLP, and/or Chiropractic Services. The Member must be able to tolerate a minimum of 3 hours of active therapy per day. See rehab (and analysis) exercise to improve movement, maintain strength and increase endurance (including assistance with walking for weak or unstable patients); range of motion and passive exercises that are not related to restoration of a specific loss of function, but are for maintaining a range of motion in paralyzed extremities; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse; work hardening. Other exclusions: Visual therapy; lifestyle/habit changing clinics and/or programs; recreational therapy; primarily to enhance athletic abilities; and/or Inpatient pain rehabilitation and pain control programs. An Inpatient rehabilitation Autism Spectrum Disorders (ASD) Benefits include, but are not limited to the Medically Necessary assessment, evaluations, or tests performed for diagnosis, habilitative or rehabilitative care, pharmacy care, psychiatric care, psychological care, and therapeutic care. Members who have not yet reached their 17 th birthday are eligible No distinction between rehab and hab (verbatim same for rehab and hab) OT/PT/SLP and/or chiro ASD services covered under Other 21

22 Maine (default) PT/OT/SLP, respiratory therapy and cardiac rehabilitation. 60 visit/year limit applies to PT/OT/SLP combined. Benefit limits are shared between rehabilitation and habilitation services. See rehab Admission must be Authorized prior to the Admission and must begin within 72 hours following the discharge from an Inpatient Hospital Admission for the same or similar condition. Day Rehabilitation Programs for Rehabilitative Care may be Authorized in place of Inpatient stays for rehabilitation. Day Rehabilitation Programs must be Authorized prior to beginning the program and must begin within 72 hours following discharge from an Inpatient Admission for the same or similar condition. We do not provide Benefits for health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment, or facilities for Applied Behavior Analysis, when Company determines it is Medically Necessary ASD: We provide coverage for members who are five years of age or under for any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an Autism Spectrum Disorder. No distinction between rehab and hab Maintenance explicitly excluded ASD services covered under 22

23 used for developing or maintaining physical fitness, even if ordered by a Physician. This exclusion also applies to health spas. No Benefits are provided for treatments such as: massage therapy, paraffin baths, hot packs, whirlpools, or moist/dry heat applications unless in conjunction with an active course of treatment. We do not provide Benefits for maintenance services, treatments or therapy. We do not provide speech therapy benefits for deficiencies resulting from mental retardation and/or dysfunctions that are self-correcting, such as language treatment for young children with natural dysfluency or developmental articulation errors. We do not provide Benefits for vision therapy, Treatment of Autism Spectrum Disorders is covered when it is determined by a licensed physician or licensed psychologist that the treatment is Medically Necessary Health Care, as defined in the Certificate of Coverage. A licensed physician or licensed psychologist may be required to demonstrate ongoing medical necessity for coverage at least annually. ABA is covered for children under 5, as are early intervention services for members ages birth to 36 months of age with an identified developmental disability or delay. Other 23

24 Maryland 30 visits per condition per contract year for each of PT/OT/SLP For Members from birth to age 19, habilitative services means services, including OT/PT/SLP, orthodontics, oral surgery, otologic and audiological therapy for the treatment of children with congenital and genetic birth defects to enhance the child's ability to function. For Members age 19 and above, habilitative services means habilitative services in including treatment such as vision training, orthoptics, eye training, or eye exercises. None Habilitative benefits in the State's EHB benchmark require plans to cover habilitative services benefits for members age 19 and above in parity with benefits covered for rehabilitative services. Habilitative services means services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child s ability to function. (Md. Code Ins (a)(3)) (existing statutory definition not pursuant to ACA or specific to EHB) Reasonably good coverage (e.g. distinct, explicit mention of therapies, parity) 24

25 Massachusetts Michigan 60 visits per year of OT/PT (unclear whether the visit limits are distinct for OT/PT and rehab/hab) 30 visits a year apply to all rehab services (potentially combined with chiropractic) parity with rehabilitative services: 30 visits per condition per contract year for each of PT/OT/SLP See rehab None No limit applies to autism, home health care, and speech/hearing disorders. See definitions None Habilitative Services are defined as health care services that help a person 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. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities. No distinction between rehab and hab Only state where verbatim NAIC definition is listed under hab in CCIIO s materials No explicit mention of therapies covered under rehab Chiropractic visits combined with rehab benefit? The Commissioner has determined that habilitative services encompasses many types of services, including but not limited to applied behavioral analysis (ABA) for the treatment of autism 25

26 Minnesota (default) Mississippi Covered with no description PT/OT combined 20 annual visit limit; SLP separate 20 annual visit limit Covered with no description See rehab and definitions spectrum disorder. ABA is defined by Michigan law as the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. None None No actual descriptions of Therapy services related to general conditioning of the patient; therapies rendered primarily for job training; pulmonary rehabilitation; speech therapy for learning disabilities and developmental problems; Rehab: Benefits for the coordinated use of medical, social, educational or vocational services, beyond the acute care stage of disease or injury, for the purpose of upgrading the physical functional ability of a patient disabled by disease or injury so that the patient may independently carry out ordinary daily activities. coverage No distinction between rehab and hab Missouri (default) PT/OT/SLP, pulmonary therapy and cardiac See rehab OT Non Covered Services include: Hab: Covered as defined by Rehabilitation Services. ASD: Benefits include Medically Necessary Covered No distinction between rehab 26

27 rehabilitation. Separate 20 visit limit for PT/OT, Pulmonary Rehab; 36 visit limit for Cardiac Rehab. Benefit limits are shared between rehabilitation and habilitation services. supplies (looms, ceramic tiles, leather, utensils); therapy to improve or restore functions that could be expected to improve as the patient resumes normal activities again; general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home such as rampways, door widening, automobile adaptors, kitchen adaptation and other types of similar equipment. Non-Covered Services for physical medicine and rehabilitation include, but are not Services to diagnose and treat Autism Spectrum Disorders when prescribed or ordered for a Member diagnosed with an Autism Spectrum Disorder by a licensed Physician or licensed Psychologist. Covered Services include the following: Diagnosis of Autism Spectrum Disorders Medically Necessary assessments, evaluations, or tests in order to diagnose whether an individual has an Autism Spectrum Disorder; Habilitative or rehabilitative care Professional, counseling, and guidance services and treatment programs, including Applied Behavior Analysis from a licensed Autism service Provider or Line Therapist under the direct supervision of a licensed Behavioral Analyst, which are necessary to develop the functioning of the Member; Psychiatric care Direct or consultative services provided by a licensed Psychiatrist; Psychological and hab ASD services covered under Other 27

28 limited to: admission to a Hospital mainly for physical therapy; long term rehabilitation in an Inpatient setting. Services, supplies and equipment for gastric electrical stimulation, hippotherapy, intestinal rehabilitation therapy, prolotherapy, recreational therapy, sensory integration therapy. PT Non Covered Services include: maintenance therapy to delay or minimize muscular deterioration in patients suffering from a chronic disease or illness; repetitive exercise to improve movement, maintain strength and increase endurance (including assistance with walking for weak or unstable patients); range of motion and passive exercises that are not related to restoration of a specific care Direct or consultative services provided by a licensed Psychologist; Therapeutic care Services provided by licensed Speech Therapists, Occupational Therapists, or Physical Therapists; Equipment Medically Necessary equipment for the treatment of Autism Spectrum Disorders; Pharmacy care Prescription Drugs used to address symptoms of an Autism Spectrum Disorder prescribed by a licensed Physician, and any health-related services deemed Medically Necessary to determine the need or effectiveness of the Prescription Drugs if those Prescription Drugs are covered by this Certificate. Pharmacy benefits will be reimbursed under the Prescription Drug benefit. Benefits for Applied Behavior Analysis are covered for dependents up to age

29 loss of function, but are for maintaining a range of motion in paralyzed extremities; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse; work hardening. Montana (default) OT/PT/SLP and cardiac therapy See definitions Additional exclusions for cardiac and pulmonary rehab. Custodial care, diagnostic admissions, maintenance, nonmedical self-help or vocational educational therapy, social or cultural rehabilitation, learning and developmental disabilities and visual, speech or auditory disordered because of learning and developmental disabilities. A specialized, intense and comprehensive program of therapies and treatment services, including but not limited to physical, occupational and speech therapy, provided by a multidisciplinary team for treatment of an injury or physical deficit. A Rehabilitation Therapy program is provided by a rehabilitation facility in an inpatient care or outpatient setting; provided under the direction of a qualified physician and according to a formal written treatment plan with specific goals; Scope of hab coverage unclear Maintenance specifically excluded 29

30 designed to restore the patient's maximum function and independence; and medically necessary to improve or restore bodily function and the member must continue to show measurable progress. For Autism Spectrum Disorders (autistic disorder, Asperger's Disorder, Pervasive Developmental Disorder) covered services include: habilitative or rehabilitative care, including, but not limited to professional, counseling and guidance services and treatment programs; Applied Behavioral Analysis (ABA): discrete trail training, pivotal response training, intensive intervention programs and early intensive behavioral intervention; medications; psychiatric or psychological care; and therapeutic care provided by a speechlanguage pathologist, audiologist, occupational therapist or physical therapist. ABA Therapy is available for 30

31 Nebraska (default) Nevada New Hampshire 45 annual visits of PT/OT/SLP (not clear if visits are combined), 18 sessions of Cardiac rehab, pulmonary rehab 60 visits per year (limit combined with inpatient rehab) PT/OT/SLP, respiratory therapy and cardiac rehabilitation. Separate 20 visit/year limit applies to PT/OT/SLP. Benefit limits are shared between rehabilitation and habilitation services. Covered with no description (see rehab?) Therapies rendered primarily for job training. members with an Autism, Asperger's or Pervasive Developmental Disorder and are under 19 years of age None See definitions None Nevada will require habilitative services to be offered at parity with rehabilitative services. See rehab Non covered services include, but are not limited to: on-going or life-long exercise and education programs intended to maintain fitness, including voice fitness, or to reinforce lifestyle changes, including lifestyle changes affecting the voice. No Benefits are available for voice therapy, vocal retraining, preventive therapy or therapy None No distinction between rehab and hab? No actual description of hab coverage No explicit mention of therapies covered ASD services covered under Other No distinction between rehab and hab Some troubling language in exclusions ASD services covered under Other (refers to them as mental health services) 31

32 provided in a group setting. No Benefits are available for educational reasons or for Developmental Disabilities, except for Early Intervention Services. No Benefits are available for sport, recreational or occupational reasons. Physical therapy for TMJ disorders is not covered. No Benefits are available for health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment, or facilities used for developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to health spas. No Benefits are available for rehabilitation services primarily intended to improve the level of 32

33 New Jersey (default) 30 visits per year combined for PT/OT, 30 visits per year for SLP; 30 additional visits a year for PT/OT for autism or developmental disabilities, 30 additional visits per year for SLP for autism or developmental disabilities Pre-approval required. Separate from services provided through home health care benefits. See rehab and definitions physical functioning for enhancement of job, athletic, or recreational performance. No Benefits are available for programs such as, but not limited to, work hardening programs and programs for general physical conditioning. None Habilitations as provided through rehabilitation services are covered. Habilitation services are subject to the limits applicable to rehabilitation services, other therapies, services and supplies. See Explanation. The benefit limit for the standard small group plans is a combined 30 visit limit for PT and OT, but for the standard individual market, the benefit limit is 30 visits each for PT and OT. No distinction between rehab and hab ASD services covered under Other (but mentioned as habilitative and rehabilitative) The benefit limit for the standard small group plans is combined for speech and cognitive therapy for a total 33

34 New Mexico Covered with no description Covered with no description New York PT/OT/SLP 60 visits per condition Separately described autism spectrum disorder screening, diagnosis and treatment (including ABA) of 30 visits, but for the standard individual plan market, the limit is 30 visits each for speech and cognitive therapy. Therapy need not be restorative. Therapy received through Early Intervention Services does not reduce these therapy benefits. ABA for members under 21 available to treat primary diagnosis of autism None None No actual description of coverage See definitions None New York will set habilitative services at modified parity with rehabilitative services. The intent is to set the habilitative benefit at parity with the rehabilitative benefit in the outpatient setting only. Further, in New York s Base Benchmark Plan, the rehabilitative services benefit is covered only if the services are provided on a post-hospitalization or postsurgical basis. By setting habilitative services at parity Reasonably good rehab and hab coverage, but not many details ASD services (including ABA) covered under Other 34

35 North Carolina (default) 30 visits per year combined for PT/OT and chiropractic, 30 visits per year for SLP, 30 visits per year for cardiac rehab, one course of pulmonary rehab per year No coverage?? (see definitions) Cognitive therapy Speech therapy for stuttering is not covered. North Dakota 30 treatments per year No coverage Services provided in the Members home for convenience, that are not expected to make measurable or sustainable with rehabilitative services, New York will require the same types of services and the same number of covered days for both benefits, but New York does not consider the post-hospitalization and post-surgical requirements for rehabilitative services to be requirements for habilitative services. Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking, talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. (included in benefit description of hab, but states no coverage) None **No coverage of hab??** (see definitions) **No coverage of hab** No mention of specific therapies covered 35

36 Ohio (default) PT/OT/SLP, pulmonary therapy and cardiac rehabilitation. Separate 20 visit limits for PT/OT/ST, Pulmonary Rehab; 36 visit limit for Cardiac Rehab. See definitions improvement within a reasonable period of time including therapy for chronic and/or recurring symptoms including but not limited to arthritis, back pain, and fibromyalgia; hot/cold pack therapy including polar ice therapy and water circulating devices; Speech therapy for the purpose of correcting speech impediments (stuttering or lisps), or assisting the initial development of verbal facility or clarity; voice training and voice therapy. OT Does not include coverage for diversional, recreational, vocational therapies (e.g., hobbies, arts and crafts). Non Covered Services include: supplies (looms, ceramic tiles, leather, utensils); therapy to improve or restore Habilitative services benefits shall be determined by the individual plans and must include, but shall not be limited to, Habilitative Services to children (0 to 21) with a medical diagnosis of Autism Spectrum disorder which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services Required hab coverage specific only to autism diagnosis Hab coverage is SLP and/or OT 36

37 functions that could be expected to improve as the patient resumes normal activities again; general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home such as rampways, door widening, automobile adaptors, kitchen adaptation and other types of similar equipment. PT Non Covered Services include: maintenance therapy to delay or minimize muscular deterioration in patients suffering from a chronic disease or illness; repetitive including (a) Speech and Language therapy and/or Occupational therapy, performed by a licensed therapists, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention defined as therapies supported by empirical evidence, which include but are not limited to Applied Behavioral Analysis, provided by or under the supervision of a professional who is licensed, certified, or registered by an appropriate agency of this state to perform the services in accordance with a treatment plan, 20 hours per week; (2) Mental/Behavioral Health Outpatient Services performed by a licensed Psychologist, Psychiatrist, or Physician to provide consultation, assessment, development and oversight of treatment plans, 30 visits per year total. 37

38 exercise to improve movement, maintain strength and increase endurance (including assistance with walking for weak or unstable patients); range of motion and passive exercises that are not related to restoration of a specific loss of function, but are for maintaining a range of motion in paralyzed extremities; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse; work hardening. Pulmonary rehabilitation in the acute Inpatient rehabilitation setting is not a Covered Service. Cardiac Rehab Home programs, on-going conditioning and maintenance are not covered. 38

39 Oklahoma (default) Oregon 25 visits per year - Combination of PT/OT and Manipulative Therapy. Same Benefit as habilitation Chiropractic Benefit Below. Chiropractic office Visits are not limited to 25, only PT is limited. Same benefit as combination of PT/OT and Manipulative Therapy and habilitation. Services provided by a licensed PT/OT/SLP, physician, or other practitioner licensed to provide PT/OT/SLP. Services must be prescribed in writing by a licensed physician, dentist, podiatrist, nurse practitioner, or physician assistant. The prescription must include site, modality, Non-Covered Services for physical medicine and rehabilitation include, but are not limited to: admission to a Hospital mainly for physical therapy; long term rehabilitation in an Inpatient setting. See rehab None None No distinction between rehab and hab Defined by the State of Oregon. Parity with rehabilitation services. See "other" for inpatient habilitation services Also see rehab and definitions Hab: Functional capacity evaluations, work hardening programs, vocational habilitation, community reintegration services, and driving evaluations and training programs. Motion analysis, including videotaping and 3-D kinematics, dynamic surface and fine wire For purposes of the essential health benefits benchmark plan for the State of Oregon, and subject to carrier-specific requirements; including eligibility, medical necessity, preauthorization, provider credentialing/accreditation standards, etc.; the provisions of the EHB Benchmark Plan relating to rehabilitation medical services define the coverage requirements for habilitation Chiro included in rehab/hab? Not clearly described Reasonably good hab coverage (e.g. distinct, parity, maintenance, mentions therapies) 39

40 duration, and frequency of treatment. Only treatment of neurologic conditions (e.g., stroke, spinal cord injury, head injury, pediatric neurodevelopmental problems, and other problems associated with pervasive developmental disorders for which rehabilitative services would be appropriate for children under 18 years of age) may be considered for additional benefits, not to exceed 30 visits per condition, when criteria for supplemental services are met. electromyography, including physician review. medical services when such services are medically necessary for the maintenance, learning, or improving skills and function for daily living. Pennsylvania (default) Rhode Island Services for speech therapy will only be allowed when needed to correct stuttering, hearing loss, peripheral speech mechanism problems, and deficits due to neurological disease or injury. 30 annual visits PT/OT, 30 annual visits SLP PT/OT/SLP No quantitative limit No coverage None None **No coverage of hab** PT/OT/SLP Maintenance therapy is not covered No quantitative Habilitative services must be comprehensive and measured as per member per Relatively good coverage with the exception of 40

41 limit Also see definitions month cost of rehabilitation serviced covered under the plan. Issuer will be required to attach filing as an Exhibit that identifies the habilitative services covered by the plan; includes an actuarial memorandum estimating the per member per month cost of the habilitative and rehabilitative services covered; and, includes in the actuarial memo the calculation and analysis used to develop the identified cost. All should happen no later than 90 days after the end of each calendar year. Issuer must also file with OHIC an actuarial memo, using the best available claims data and compare such claims and expense experience with the approved rate factor. The Plan must cover habilitative services as approved by the Commissioner, in accordance with the following: Habilitative services covered under the Plan must be defined by scope, and must exclusion of maintenance 41

42 South Carolina (default) PT and pulmonary rehab only? 30 visits per benefit period for PT No coverage (however includes limitation to physical therapy?) South Dakota Covered with no description Covered with no description Other unspecified exclusions be at least as comprehensive (measured by per member per month cost) as the per member per month cost of rehabilitation services covered under the plan. Service visit limitations or other durational or quantitative limitations will be approved by the Commissioner only if the filer can demonstrate that no other qualitative, evidencedbased limitations less burdensome to the consumer (e.g. a process for developing limitations based on individual assessments of need) are feasible and appropriate. (pg. 6) None **No coverage of hab??** Only coverage of PT for rehab?? None None No actual description of coverage 42

43 Tennessee (default) 20 annual for each OT/PT/SLP Cardiac and pulmonary rehab Outpatient, home health or office therapeutic and rehabilitative services that are expected to result in significant and measurable improvement in Your condition resulting from an Acute disease, injury, autism in children under age 12, or cleft palate. The services must be performed by, or under the direct supervision of a licensed therapist, upon written authorization of the treating Practitioner; Therapeutic/Rehabilitative Services include: (1) physical therapy; (2) speech therapy for restoration of speech; (3) occupational therapy; (4) manipulative therapy; and (5) cardiac and pulmonary rehabilitative services; (1) Speech therapy is Covered only for disorders of articulation and swallowing, See rehab Treatment beyond what can reasonably be expected to significantly improve health, including therapeutic treatments for ongoing maintenance or palliative care; Enhancement therapy that is designed to improve Your physical status beyond Your pre-injury or pre-illness state; Complementary and alternative therapeutic services; Modalities that do not require the attendance or supervision of a licensed therapist; Behavioral therapy, play therapy, communication therapy, and therapy for self-correcting language dysfunctions as part of speech None No distinction between rehab and hab Maintenance explicitly excluded Includes chiro under rehab?? 43

44 Texas (default) resulting from Acute illness, injury, stroke, autism in children under age 12, or cleft palate Coverage is limited to: The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner s office, outpatient facility or home health setting; Services received during an inpatient hospital, skilled nursing or rehabilitative facility stay are Covered as shown in the inpatient hospital, skilled nursing and rehabilitative facility section, and are not subject to the therapy visit limits. 35 visits per year (includes chiro) therapy, physical therapy or occupational therapy programs. Behavioral therapy and play therapy for behavioral health diagnoses may be Covered under the Behavioral Health Rider (if applicable); Duplicate therapy. See rehab None PT/OT/SLP for treatment of autism for children up to age 10 is described as a habilitative service Diagnosis of autism is described as a mental or behavioral health service Hab limited to ASD and TBI services Specific therapies covered not mentioned Utah 20 annual visits of PT/OT/SLP (includes hab with a combined limit) See rehab None None No distinction between rehab and hab Vermont 30 outpatient sessions No coverage?? None None **No coverage of 44