Who Decides Essential Care?

The health care reform law provides categories of care that must be provided for customers of the health-insurance exchanges that are launching in 2014.  An article in today’s Wall Street Journal, “Defining Essential Care,” points out that “The next big issue for the federal health law as it moves toward implementation is how regulators will define so-called essential benefits—the basic medical services that health plans must cover under the law.”  So the details are left up to regulators who are now starting to develop the rules on what is an “essential” health care service and what is not.

Habilitative services, used by such children with Autism and other developmental disabilities, have become a particularly contentious point in the debate. The Arc’s Marty Ford provides an example of the difference between rehabilitative and habilitative services. (Visit our website to read Marty’s prior testimony on the importance of defining habilitation as an essential service.)

One thought on “Who Decides Essential Care?

  1. How can parents, caregivers and self-advocates become involved in defining essential health care services? I am a parent of a 3.5 year old child with severe delays in all areas of his development. My husband’s company recently switched to a “self-funded” plan, which I understand is subject to Department of Labor regulations and does not have to comply with Maryland’s mandate for habilitative services.Our insurance plan is focused on prevention. I view habilitative services as prevention, since they can potentially prevent or alleviate some of the devastating consequences of cerebral palsy and help a person to live a more healthy life. However, the company is focused on paying for care for the healthy person, not the person who was born with a congenital condition. If a federal definition of essential benefits is developed, will companies that decide to pay for health care directly still find loopholes around providing these benefits?

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