Currentharvard pilgrim health carePolicy N/A

Habilitative services coverage under the ACA

Governs coverage requirements for habilitative services and devices under the Affordable Care Act for Harvard Pilgrim non-grandfathered, fully insured individual and small group plans; describes billing modifiers and coding practices for identifying habilitative services.

Policy Summary

Payerharvard pilgrim health care

PolicyHabilitative services coverage under the ACA

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2016

Next Review DateN/A

Key ActionBill habilitative service diagnosis codes in the primary position with GO/GP in first position and use the SZ modifier to identify habilitative services for tracking limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2016ACA coverage requirement start date for habilitative services

Parity with rehabilitativeParity requirement

Since Jan 1, 2017Combined limits prohibited

Cost sharingMember financial responsibility

GO/GP, SZRequired billing modifiers

Habilitative Services Coverage

Habilitative services coverage criteria

Coverage is required for habilitative services and devices under the ACA for applicable plans, with specific billing identification requirements.

Non-grandfathered, fully insured individual and small group plans must cover habilitative services and devices as an Essential Health Benefit.

Plans may not impose limits on habilitative services/devices that are less favorable than limits on rehabilitative services/devices.

For plan years beginning on or after Jan 1, 2017, plans may not impose combined limits on habilitative and rehabilitative services and devices.

All habilitative service diagnosis codes must be billed in the primary position with the GO/GP modifier in the first position and the SZ modifier used to identify the service as habilitative for tracking separate limits.

Policy Summary

Payerharvard pilgrim health care

PolicyHabilitative services coverage under the ACA

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2016

Next Review DateN/A

Key ActionBill habilitative service diagnosis codes in the primary position with GO/GP in first position and use the SZ modifier to identify habilitative services for tracking limits.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing Codes, Modifiers, and Limits

Required modifiersModifierCovered

GO/GP	Modifiers to indicate government or group health plan; required in first position per policy for habilitative services
SZ	Modifier to identify services as habilitative for tracking separate limits

Limit parity and combined limits

Parity with rehabilitative servicesPlans may not impose limits on habilitative services and devices that are less favorable than limits on rehabilitative services and devices (effective Jan 1, 2016).

Prohibition on combined limitsFor plan years beginning on or after Jan 1, 2017, plans may not impose combined limits on habilitative and rehabilitative services and devices.

Member cost sharingHarvard Pilgrim members have cost sharing responsibilities for both habilitative and rehabilitative services.

Key Definitions

Habilitative services — definition and examples

DefinitionHabilitative services are health care services that help a person keep, learn, or improve skills and functioning for daily living.

Common examplesTherapy for a child who is not walking or talking at the expected age.

Service typesMay include physical therapy, occupational therapy, and speech-language pathology provided in inpatient and outpatient settings.

Grandfathered employer groups

Grandfathered employer groupsEmployer groups maintaining 'grandfathered' or 'grandmothered' status under the ACA are not required to offer Essential Health Benefits (EHB).

ScopeThe ACA EHB requirement for habilitative services applies to non-grandfathered, fully insured individual and small group plans.

Implication for coverageGrandfathered status means the employer group may lawfully decline to provide EHB-level habilitative services coverage required of non-grandfathered plans.

OpenPayer

Habilitative services coverage under the ACA

Habilitative Services Coverage

Billing Codes, Modifiers, and Limits

Billing and Submission Requirements

Key Definitions