The U.S. Office of Personnel Management (OPM) is charged with administering the Multi-State Plan Program (MSPP). You can read more on that here. Last fall, the Habilitation Benefits (HAB) Coalition Steering Committee, on which AOTA has representation, met with staff from OPM to request the inclusion of an exceptions process for habilitative services. In other words, the HAB Coalition requested that OPM require that MSPP health plans have a procedure in place that would allow plan beneficiaries to request coverage of habilitative services beyond the visit limits or other utilization restrictions established by the plan. The rationale underlying this request was that habilitative services is a new benefit category for most health plans in most states and as a result, there is insufficient experience to determine what appropriate limits on habilitative services are at this point. A similar exceptions process was included in the essential health benefits' regulation that applies to prescription drugs, so there is also that precedent, which the HAB Coalition cited. 

The HAB Coalition's advocacy efforts produced a positive effect. Though not the requirement it sought, OPM did encourage MSPP plans to include an exceptions process for habilitative services. The following explanation was included in OPM's letter calling for applications from insurance carriers for the MSPP:

"We recognize that coverage of habilitative services as an essential health benefit is evolving. Lacking a standard definition, many issuers have begun by offering habilitation in parity with rehabilitative services. However, the duration and scope of services an individual may need to acquire skills for the first time may differ from what a person may need to regain function after illness or injury. To accommodate such unique circumstances, we encourage MSP issuers to provide a reasonable 'exceptions process' to consider requests for additional habilitative services when such services are medically necessary to achieve a therapeutic milestone or avoid significant deterioration in health status."

While more advocacy is necessary to ensure access to all medically necessary habilitative OT services, this is a positive step that we can cite in our future efforts.