Do You Rely on Health Insurance to Cover Pediatric Therapies?
Our country is going through a pivotal time in regards to insurance. While our federal legislators are working on yet another healthcare bill, on a personal level we sometimes don’t take understand which parts of insurance regulations are important for our families. Speech & Occupational Therapy of North Texas has provided pediatric therapy in Collin County for 17 years. And we have worked with many major insurance companies throughout this period. To better serve our families, we have tried to keep abreast of important insurance changes that impact our young clients.
The proposed American Healthcare Act (AHCA), sometimes referred to as Trump Care or Ryan Care, is the current effort to repeal and replace the Affordable Care Act (ACA) also known as Obamacare.
Both the ACA and the proposed AHCA are complex and cover many areas, impacting not only commercial insurance but Medicaid as well. Right now instead of debating for or against either healthcare plan, let’s take a look at the importance of one aspect of the ACA that is remaining, at least for now, in the proposed AHCA. These are the Essential Health Benefits (EHBs), which many conservative legislators want removed before they will support the new proposed plan. For this reason, it is important to understand this component of healthcare so you can let your concerns be known to your federal elected officials if you don’t want to lose EHBs.
What are Essential Health Benefits?
Essential Health Benefits (EHBs), are a set of 10 benefits that individual and small group plans must cover in the private and Health Insurance Marketplace. They are as follows:
Ambulatory patient services. [outpatient care]
Hospitalization. [inpatient care]
Mental health and substance use disorder services, including behavioral health treatment.
Rehabilitative and habilitative services and devices.
For specifics about Texas’ EHB visit: http://www.tdi.texas.gov/health/documents/fhrpage-ehbsu.pdf
How Do Essential Health Benefits Impact You and Your Family?
Whether your plan has ESB requirements will be determined by the kind of policy you have. ERISA plans, which are employer funded plans – along with fully funded large group plans, are not subject to state insurance laws. This makes them exempt from providing the EHB requirements. According to 2011 data from the Employee Benefit Research Institute (ebri), 68.3% of Texas employer group plans with over 50 members are self-funded, and of Texas employer group plans with over 1000 members, the self-funded plans make up 88.7% of these larger group plans. This percentage actually has climbed in response to the ACA’s essential health benefits requirement, because employers are trying to find ways to lower their insurance expense. However, we have seen many large employers with either fully funded or ERISA plans incorporate certain benefits into their plans that are known to attract and keep skilled employees
What Can You Do if Your Policy is Exempt from EHB Requirement?
If your plan is exempt, what does this mean if you have a child in need of therapies? It means that you must to be direct with your HR department about your needs. Share information about your child’s disorder and data about the importance of intervention. Employee advocacy is often key to getting better benefits that help everyone. You also need to ask very direct questions of your insurance company representative and be sure you have a benefits book and take the time to study it. You may be told that your plan covers speech therapy and occupational therapy and find later this only applies to disorders that result from a later occurring illness or injury. Families must always ask insurance representatives if treatment is covered for developmental disabilities and to what extent since these are frequently policy exclusions or there may be a low cap on annual visits. It is also important to ask your insurance company to provide you with their criteria for determining medical necessity.
Is an Individual Policy Important to Your Family?
We have learned many things through working with families who depend on insurance to pay for therapies. And we have seen a trend towards families supplementing ERISA plans by purchasing individuals plans for their child with unique challenges, such as autism spectrum disorder and Down syndrome. These plans typically cover many therapies due to the habilitation benefit. Families have been able to purchase these plans because of the EHB that are part of the Affordable Care Act. These individual plans have been challenging to work with and are also expensive for families. However, depending on your state’s defined habilitation benefit (one of the essential health benefits), many families are able to get specialized therapies, such as speech, occupational therapy, and ABA covered for their child. It is important to ask your insurance many questions about coverage to insure that the plan you are considering will cover your therapies. For more information about EHB requirements in Texas,
Do You Need the Essential Health Benefits? Call Your Federal Representatives!
Right now, these Essential Health Benefits are carrying forward from the ACA as part of the proposed American Healthcare Act. If any of the 10 benefits – like the habilitation benefit, is critically important for your family or your child, and they are not covered under your ERISA plan, it would be wise to call your federal legislator and tell them you need the EHBs kept in whatever healthcare laws.
As pediatric therapy providers it has been heartbreaking for us to tell families yes their child needs and qualifies for treatment based on an in-depth evaluation only to have the services denied as a non-covered benefit. As expensive as it may be, having the option to purchase and individual plan that will insure a child gets the therapies they need may be worth the cost. Do we want to lose this option for our children?
If concerned, families can call Senator Paul Ryan’s office at 202-225-0600 and express the importance of keeping the essential health benefits for their families. Families in Collin County can also call Congressman Sam Johnson’s office as well, since he is our local representative. His number is 202-225-4201.
If your child has a significant disability, you might want to tell these legislators that you do not want Medicaid block grants or per capita caps as part of the AHCA. These models will lead to cuts in current services and significantly slow the move of individuals from our state interest lists.
For more information about block grants and per capital caps, visit:
To learn more about Employee Benefit Research, visit: