Appendix C - Data Elements for Habilitative Services Data Elements

Appendix C - Habilitative Services Data Requirements
Pursuant to 45 CFR 156.110(f), if the base-benchmark plan did not include coverage of
habilitative services, the State would be permitted to determine the services included in
the habilitative services category. If States did not define the habilitative services
category, plans would be required to provide these benefits as defined in 45 CFR
156.115(a)(4). As an alternative to the transitional approach outlined in 45 CFR
156.115(a)(4), if the EHB benchmark plan does not include coverage for habilitative
services and the State does not determine habilitative benefits, a health insurance
issuer must either provide parity by covering habilitative services benefits that are
similar in scope, amount, and duration to benefits covered for rehabilitative services or
decide which habilitative services to cover and report on that coverage to HHS. HHS
expects that the data collection will collect benefit information from 50 issuers. The
following lays out the specifics of the data elements to be collected:
Habilitative Servcies Benefit Data Elements
Table 1
Habilitative
Services

Covered
Inpatient

Covered
Outpatient

Limits

Physical Therapy

Y/N

Y/N

Occupational
Therapy

Y/N

Y/N

Describe
Limits
Describe
Limits

Speech-Language
Pathology

Y/N

Y/N

Other Services –
please list all other
services covered

Free text

Free text

Exclusions (incl.
diagnosis
exclusions)
Describe
Exclusions
Describe
Exclusions
Describe
Exclusions

Describe
Limits

Table 2
Page 1

Describe
Exclusions

Habilitative Devices

Covered?

Limits

Durable Medical
Equipment

Y/N

Describe
Limits

Prosthetics

Y/N

Orthotics

Y/N

Mobility Equipment

Y/N

Supplies

Y/N

Other Devices please list all other
device types covered
for habilitative
purposes

Describe
additional
Devices

Describe
Limits
Describe
Limits
Describe
Limits
Describe
Limits
Describe
Limits

1.

Page 2

Exclusions (incl.
diagnosis exclusions)
Describe Exclusions
Describe Exclusions
Describe Exclusions
Describe Exclusions
Describe Exclusions
Describe Exclusions