The inclusion of habilitative services as an essential health benefit (EHB) in the Affordable Care Act (ACA) was a major success, brought about in part because of the advocacy efforts of AOTA and its allies. However, that was only the first step to ensure that occupational therapy clients have access to necessary habilitative services. A lengthy implementation process has been ongoing for years to determine the regulatory framework under which this provision of the law will take effect. AOTA and state OT associations have been continuously monitoring the situation and advocating for definitions and coverage requirements that are favorable for OT practitioners and consumers. AOTA staff drafted a FAQ-style fact sheet (available here), with the assistance of a workgroup composed of OT practitioners and educators, to summarize the basic background and current status of this issue. For a thorough examination of the background, see this AJOT article and posts on this blog with "habilitation" tags. 

To determine the requirements for coverage of habilitative services in your state, there are several resources available. AOTA created a chart last year summarizing the best information available at that time (available to download below). Much of the information populating AOTA's chart was acquired by reviewing summaries the federal government produced and made available here. However, it's important to note that some information in the summaries produced by the federal government was incomplete or inaccurate. Coverage of habilitative OT services in 2014 health plans sold on federally-facilitated marketplaces may be reviewed in some cases by accessing the summaries of benefits and coverage available through this database. AOTA will be doing additional analysis of this information this summer to compile a more user-friendly summary of how plans are actually covering habilitative OT services. 

There have also been a variety of recent developments not addressed by the resources listed above. For example, Arkansas released its requirements for health plan certification for 2015 in April. Those requirements include a more expansive definition of coverage requirements for habilitative services (see last page of the document). AOTA has partnered with state OT associations to do advocacy work in an effort to address some of the inadequacies and compliance issues we have identified around the country. One successful example from Colorado is described here. There remains a lot of work to do in order to fully realize the intended benefit of having habilitative services included in the ACA as an EHB. For example, as can be seen in this article that appeared in a Tennessee newspaper last month, habilitative services are supposed to have separate visit limits from rehabilitative services according to a spokeswoman for the Tennessee Department of Insurance. However, an initial review of Tennessee plans by AOTA staff revealed that some plans are not complying with that requirement. AOTA will be working with the Tennessee OT association to advocate for improved enforcement in the state.