Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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7 Examining Two Categories of Care in Section 1302
7 Examining Two Categories of Care in Section 1302
Pages 71-84
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From page 71... ...
Disability Policy Collaboration focused on the need to develop criteria for the EHB package that ensures people with disabilities and chronic conditions can access rehabilitative and habilitative services and devices that help them improve, maintain, and limit deterioration of function. The committee's work, these latter panelists argued, will determine whether plans in the exchanges meet the needs of people confronted with illness, injury, disability, or other health condition by enabling them to become more healthy, functional, and independent.
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Current mental health and substance abuse providers for safety-net populations will likely be the only available, initial source of care even as low-income populations transition to the private insurance market or into the expanded Medicaid program. These providers have expertise in managing this population.
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KAVITA PATEL, UCLA SEMEL INSTITUTE Dr. Patel used her experience working on health insurance policy for Senator Ted Kennedy and the Obama administration, as well as her knowledge of the Massachusetts reform efforts as an avenue for explaining the unique nature of mental health and substance use benefits.
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From page 74... ...
In particular, she said, the committee should ensure that the EHB package devote its attention to case or care management, patient education and activation, and coordination of services for patients who are vulnerable due to illness or social factors. Community-based services, which take place in churches, barber shops, or in lay worker settings, she said, have been shown to be effective in treating mental health, behavioral health, and substance use disorders.
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From page 75... ...
Wells and Patel: individuals need to be able to access the type, level, amount, and duration of care they need, including care for relapses. Thus, medical necessity criteria should reflect the chronicity of mental illness and substance abuse disorders.
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From page 76... ...
Samuels noted, ongoing support to help people manage their disease over the course of their life, services for children and families, and services that are culturally appropriate. A robust EHB package would: • Include a full range of services provided at parity with other medical/surgical benefits; • Manage benefits using good clinical judgment; • Ensure decisions about the type and amount of care are driven by the treating professional, not payers or other third parties; • Provide care to individuals and family members over their lifetime; • Use process measures, such as those developed by the NQF, and outcome measures to ensure care focuses on the patient's quality of life and ability to function; • Consider the individual treatment needs of the patient and the availability of evidence-based practices as part of medical necessity determinations; • Change the practice of unfair and inappropriate denials of care; and • Clearly define and make available to patients and providers the medical necessity criteria and reasons for denial.
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From page 77... ...
or instrumental activities of daily living (IADLs) over time.7 5 Congressman Pascrell, a co-chair of the Congressional Brain Injury Task Force, included the following in his House floor statement: "The term rehabilitative and habilitative services includes items and services used to restore functional capacity, minimize limitations on physical and cognitive functions, and maintain or prevent deterioration of functioning as a result of an illness, injury, disorder or other health condition.
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Typical Employer Plans Mr. Thomas explained that most private plans cover rehabilitation services and devices.
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From page 79... ...
The committee, he suggested, should "veer away from using Medicare as a benefit design model" for the rehabili tative and habilitative services covered in the EHB because Medicare is designed primarily for people over age 65 and its benefit design will not adequately take into account the needs of, for example, a 15-year-old who has experienced a catastrophic spinal cord injury. Role of Device Manufacturers When committee member Dr.
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MARTY FORD, THE ARC AND UNITED CEREBRAL PALSY DISABILITY POLICY COLLABORATION Ms. Ford, who spoke on behalf of the Long Term Services and Supports and Health Task Forces of the CCD, began by stating that Medicaid defines habilitative services as those services designed to assist participants in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings.8 These therapies, services, and supports, which are needed over the course of a person's lifetime, enable people with significant disabilities to learn, improve, or prevent deterioration of activities of daily living.
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From page 81... ...
Ho asked how, in the absence of an evidence base for some of these services, plans should make medical necessity determinations, Ms. Ford responded that rehabilitative and habilitative services are "always based on an individualized plan of care" and that medical decisions are often based on decisions by patients, their families, and their health care provider.
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From page 82... ...
PowerPoint Presentation to the IOM Com mittee on the Determination of Essential Health Benefits by Cindy Ehnes, Director, Maureen McKennan, Acting Deputy Director for Plan and Provider Relations, and Andrew George, Assistant Deputy Director, Help Center, California Department of Managed Health Care, Costa Mesa, CA, March 2. Eggert, L
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From page 83... ...
2010. Interim final rules under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
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