RD28 - Mandated Coverage for Habilitative Services for Children with Developmental Delays


Executive Summary:
House Bill 657 was referred to the Advisory Commission for review by the House Committee on Commerce and Labor during the 2006 Session of the General Assembly of Virginia. House Bill 657 was introduced by Delegate Kenneth R. Plum. The bill, as introduced, would add § 38.2-3418.15 to the Code of Virginia to require insurers to provide coverage for habilitative services for children under age 19 with developmental delays. These provisions would apply to insurers proposing to issue individual or group accident and sickness insurance policies providing hospital, medical or surgical, or major medical coverage on an expense-incurred basis; corporations providing individual or group accident and sickness subscription contracts; and health maintenance organizations (HMOs) providing health care plans for health care services and requires that they provide coverage for medically necessary habilitative services for persons younger than 19 years.

Subsection B defines “habilitative services” as “health and social services directed toward increasing and maintaining the physical, intellectual, emotional, and social functioning of developmentally delayed individuals, in the areas of self-care, sensory and motor development, interpersonal skills, communication, and socialization; and reduction or elimination of maladaptive behavior.” “Habilitative services” does not include services for which coverage is provided or required to be provided pursuant to §38.2-3418-5.

The proposed legislation also defines “Medically necessary habilitative services” as habilitative services that are certified by the Department of Mental Health, Mental Retardation and Substance Abuse Services (MHMRSAS) as designed to help an individual attain or retain the capability to function age appropriately within the individual’s environment and shall include habilitative services that enhance functional ability without effecting a cure.

The bill does not require an insurer, corporation, or HMO subject to this section to provide coverage for medically necessary habilitative services to the extent that such services are provided through the individual’s school; however, the exclusion from coverage does not alter or diminish the obligation of an insurer, corporation, or HMO to provide coverage for medically necessary habilitative services that are not provided through the individual’s school.

The Advisory Commission held a public hearing on October 16, 2006 in Richmond, Virginia to receive public comments on House Bill 657. The patron, Delegate Plum, spoke in support of the legislation. A representative of the Virginia Association of Health Plans (VAHP) spoke in opposition to the bill.

Written comments supporting House Bill 657 were received from nine concerned citizens, parents and relatives of children with developmental delay who require habilitative services. Another comment in support of the need for coverage of habilitative services was received from an occupational therapist in Northern Virginia who works with children requiring habilitative care.

Written comments opposing House Bill 657 was received from the VAHP and the VCC.

The Advisory Commission voted on November 20, 2006 to recommend against enactment of House Bill 657. The Advisory Commission identified three major challenges to supporting the proposal, which included, defining the scope of the benefit, namely the conditions to be remediated, current service delivery through mechanisms already in place, and the creation of prudent and appropriate policy.