Rehabilitation and Habilitation Services and Devices

Information sourced and provided  to us by Jennifer Falk, MSW, CPHM, in Miami, Florida

This fact sheet is intended to help Navigators answer specific questions that people with disabilities might ask about rehabilitation and habilitation services and devices benefits when they are considering buying health insurance through the Marketplace

Click here for a pdf version of this Fact Sheet
Click here for a pdf version of a 2 page summary of this Fact Sheet

A. Health plans available through the Marketplace must offer rehabilitation and habilitation services and devices as essential health benefits. These services speed your recovery after an illness or injury and reduce the likelihood that you will need to be hospitalized again. They also might help to slow the progression of your disability or enable you to gain new functional or communication skills. They also help to improve your health, strengthen your ability to participate in the community, and maintain function long-term. Equally important, such services can improve the likelihood that you can return to work and maintain a good quality of life.

These categories of services and benefits are grouped together here and also in federal law because they are interdependent and might be used at the same time to ensure recovery or to meet a specific clinical or functional goal. For example, an occupational therapist might help a person who wishes to learn a new way of dressing because they have a new wheelchair with arm rests that are harder to grip than those on the older chair. At the same time, the person could be working with a physical therapist to maintain upper mobility functions in muscles that were overused with the older chair, thereby prompting the need for a new chair. Rehabilitation and habilitation devices and services often complement one another as components in a comprehensive treatment plan.

A. Rehabilitation typically includes services you might need to regain function after an injury or illness and include acute clinical care in the hospital or treatment in a rehabilitation hospital or residential rehabilitation facility. Services might also include treatment you might need from a day treatment program, outpatient clinic, other outpatient setting, or that a home health agency provides. Rehabilitation benefits covered by a health plan might also pay your specialist physician to manage your care over time. Examples of covered services you might need include physical, occupational, and speech-language therapy, cognitive therapy, recreational therapy, and psychological and behavioral evaluation.

A. Habilitation focuses on helping you or a family member attain, keep or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age or teaching adults with developmental disabilities the fine motor coordination required to groom and dress themselves. Habilitation services include physical, occupational, and speech-language therapy, various treatments related to pain management, and audiology and other services that are offered in both hospital and outpatient locations. The benefits of these therapies can include, for example, improved socialization skills, which reduces developmental delays for children with developmental disabilities. Adults and older people with certain disabilities can also benefit, for example, from therapies that prevent muscle loss and thus mobility, or that increase fine motor coordination so that independent living tasks such as dressing and bathing are made easier.

A. You or a family member might also need certain equipment so you can benefit from habilitation and/or rehabilitation therapy services or that meet other clinical or functional needs. Examples include walkers, canes, and crutches, glucose monitors and infusion pumps, prosthetics and orthotics, low vision aids, augmentative communication devices, and complex rehabilitation technologies such as motorized wheelchairs and assistive breathing machines. These are devices that you might need to aid in your recovery after an injury or illness, maintain function or prevent its loss, sustain your health or help you gain new skills for independence.

A. Although individual and small group health plans sold either inside or outside the Health Insurance Marketplace must offer rehabilitation and habilitation services and devices, the scope of the benefits available will vary from plan to plan. For example, in order to determine what and how many therapy benefits are offered by plans, states have picked as a model a typical plan sold in that state. Plans offered in the Marketplace must provide benefits substantially equal to those provided in their state’s model plan.

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