NCPA - National Center for Policy Analysis

Defining Essential Benefits under Health Law Proves Difficult

March 2, 2011

The new health reform legislation gives 10 categories of "essential" care that plans must provide for customers of the health insurance exchanges that are launching in 2014.  But the law leaves details up to regulators, who are now starting to develop the rules, says the Wall Street Journal.  

  • Habilitative services have become a contentious point in the debate.
  • Unlike rehabilitation, which helps patients recover skills they have lost, habilitation helps patients acquire new skills.
  • Such services can be costly because the process can take years and insurers haven't typically covered many of them, sometimes labeling them educational or experimental.

The debate over exactly what habilitative services to include in the new rules -- and how much of them -- exemplifies the challenge of defining what health benefits are truly essential.  Insurers say they want the flexibility to design plans for consumers with different needs.  Patient advocates say that consumers shouldn't have to pay extra for habilitative coverage.

  • Habilitative services have been particularly contentious because they can be costly and difficult to define.
  • For example, a three-year-old child who lost speech after a brain injury would require rehabilitation.
  • But a three-year-old child with autism who has never learned to speak would require habilitation.

Source: Avery Johnson, "Defining 'Essential' Care Regulators Move to Specify Coverage Under Health Law; Insurers Seek Flexibility," Wall Street Journal, February 28, 2011.

For text:


Browse more articles on Health Issues