Habilitative Services. Habilitative Services are healthcare services that help you keep, learn, or improve skills and functioning for daily living. These services are Covered and may require Prior Authorization. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Habilitative Services. A. For Members from birth to age 21.
Habilitative Services. We cover Medically Necessary habilitative services. Habilitative services are defined as health care services and devices that are designed to assist individuals acquiring, retaining or improving self-help, socialization, and adaptive skills and functioning necessary for performing routine activities of daily life successfully in their home and community-based settings. These services include physical therapy, occupational therapy, speech therapy, and Durable Medical Equipment. These services have calendar year visit limits. Plan limits are outlined in the Summary of Benefits and Coverage.
Habilitative Services. For purposes of this Benefit, "habilitative services" means Skilled Care services and devices that are part of a prescribed treatment plan or Maintenance Program to help a person with a disability to keep, learn or improve skills and functioning for daily living. We will decide if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. Therapies provided for the purpose of general well- being or conditioning in the absence of a disability are not considered habilitative services. Benefits for habilitative services for the treatment of Congenital Anomaly or genetic birth defects, include services for cleft lip and cleft palate, orthodontics, oral surgery, otologic, and audiological therapy. Habilitative services include: • Physical therapy. • Occupational therapy. • Speech therapy. • Post-cochlear implant aural therapy. • Cognitive therapy. Benefits are provided for habilitative services for both inpatient services and outpatient therapy when you have a disability when both of the following conditions are met: • Treatment is administered by any of the following: ▪ Licensed speech-language pathologist. ▪ Licensed audiologist. ▪ Licensed occupational therapist. ▪ Licensed physical therapist. ▪ Physician. • Treatment must be proven and not Experimental or Investigational. The following are not habilitative services: • Custodial Care. • Respite care. • Day care. • Therapeutic recreation. • Educational/vocational training. • Residential Treatment. • A service or treatment plan that does not help you meet functional goals. • Services solely educational in nature. • Educational services otherwise paid under state or federal law. We may require the following be provided for the treatment of Autism Spectrum Disorder: • A comprehensive evaluation of an individual by the individual’s Primary Care Physician or specialty Physician; • A prescription from an individual’s Primary Care Physician or specialty Physician that includes specific treatment goals; and • An annual review by the prescribing Primary Care Physician or specialty Physician, in consultation with the habilitative services provider, that includes: ▪ Documentation of benefit to the individual; ▪ Identification of new or continuing treatment goals; and ▪ Development of a new or continuing treatment plan. We may require the following be provided for all other conditions: • Medical records. • Other necessary data to allow us to prove th...
Habilitative Services. SAMPLE For purposes of this Benefit, "habilitative services" means Skilled Care services that are part of a prescribed treatment plan or maintenance program to help a person with a disabling condition to keep, learn or improve skills and functioning for daily living. We will decide if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. Therapies provided for the purpose of general well-being or conditioning in the absence of a disabling condition are not considered habilitative services. Habilitative services are limited to: • Physical therapy. • Occupational therapy. • Speech therapy. • Post-cochlear implant aural therapy. • Cognitive therapy. Benefits are provided for habilitative services for both inpatient services and outpatient therapy when you have a disabling condition when both of the following conditions are met: • Treatment is administered by any of the following: ▪ Licensed speech-language pathologist. ▪ Licensed audiologist. ▪ Licensed occupational therapist. ▪ Licensed physical therapist. ▪ Physician. • Treatment must be proven and not Experimental or Investigational. The following are not habilitative services: • Custodial Care. • Respite care. • Day care. • Therapeutic recreation. • Educational/vocational training. • Residential Treatment. • A service or treatment plan that does not help you meet functional goals. • Services solely educational in nature. • Educational services otherwise paid under state or federal law. We may require the following be provided: • Medical records. • Other necessary data to allow us to prove that medical treatment is needed. When the treating provider expects that continued treatment is or will be required to allow you to achieve progress we may request additional medical records. Habilitative services provided in your home by a Home Health Agency are provided as described under Home Health Care. Benefits for DME, orthotics and prosthetic devices, when used as a part of habilitative services, are described under Durable Medical Equipment (DME), Orthotics and Prosthetic Devices.
Habilitative Services. A. Members until at least the end of the month in which the Member turns nineteen (19) years old.
Habilitative Services. Benefits are provided for habilitative services when Medically Necessary, and must be recognized by the medical community as efficacious: • For partial or full development; • For keeping and learning age appropriate skills and functioning within the individual's environment; or • To compensate for a progressive physical, cognitive, and emotional Illness. Covered Services include: • Speech, occupational, physical and aural therapy services; • FDA approved devices designed to assist a Member and which require a prescription to dispense the device; and • Habilitative services received at a school-based health care center, unless delivered pursuant to federal Individuals with Disabilities Education Act of 2004 requirements, such as pursuant to an individual educational plan. Day habilitation services designed to provide training, structured activities, or specialized assistance to adults, chore services to assist with basic needs, and vocational and custodial services are not covered. NOTE: Outpatient habilitative therapy services are subject to a combined total maximum of 25 visits per Member per Calendar Year, unless provided to treat a DSM diagnosis. Home Health Care Pre-Authorization is required for home health care benefits. The patient must be homebound and require Skilled Care services. Home health care is covered when provided as an alternative to hospitalization, and prescribed by your physician. Benefits are limited to intermittent visits by a licensed home health care agency. A home health care visit is defined as: a time-limited session or encounter with any of the following home health agency Providers: • Nursing service providers (RN, LPN); • Licensed or registered physical, occupational or speech therapist (or an assistant working under the supervision of one of these providers); • Home health aide/assistant working directly under the supervision of one of the above Providers; • Licensed Social Worker (Master’s prepared); or • Registered dietician. Private duty nursing, shift or hourly care services, Custodial Care, maintenance care, housekeeping services, respite care and meal services are not covered. Additional items and expenses covered when home health care is provided include: • Approved medications and infusion therapies furnished and billed by an approved home health agency; • Durable Medical Equipment when billed by a licensed home health agency; and • Services and supplies required by the home health agency to provide the care. Home he...
Habilitative Services. We cover Medically Necessary Services, including speech therapy, occupational therapy and physical therapy, for children under the age of 21 years with a congenital or genetic birth defect, to enhance the child’s ability to function. Medically Necessary habilitative Services are those Services designed to help an individual attain or retain the capability to function age- appropriately within his or her environment, and shall include Services that enhance functional ability without effecting a cure. Congenital or genetic birth defect means a defect existing at or from birth, including a hereditary defect. Congenital or genetic birth defect means a defect existing at or from birth, including a hereditary defect. The term “congenital or genetic birth defect includes: (1) autism or an autism spectrum disorder and (2) cerebral palsy. Habilitative Services Exclusions: • Assistive technology Services and devices. • Services provided through federal, state or local early intervention programs, including school programs. • Services not preauthorized by Health Plan.
Habilitative Services. Services designed to help an individual attain or retain the capability to function age-appropriately within his or her environment, and shall include Services that enhance functional ability without effecting a cure. Health Plan: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. This EOC sometimes refers to the Health Plan as “we” or “us”.
Habilitative Services. Habilitative services are Healthcare Services that help you keep, learn, or improve skills and functioning for daily living. These services are Covered and may require Prior Authorization. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical therapy and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Autism Spectrum Disorder The diagnosis and treatment for Autism Spectrum Disorder is covered regardless of age in accordance with state mandated benefits as follows: Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well- Child or well-baby screening Diagnosis of autism; and Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children 3 to 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. Heart Artery Calcification Scan Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a Healthcare Provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible Member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible Member receives a heart artery calcium score greater than zero. Heart Artery calcification is a Covered preventive benefit with no member C...
