Common use of Habilitative Services Clause in Contracts

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. • 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 health care listed below is not covered: • Custodial Care; • Private duty nursing; • Housekeeping or meal services; • Maintenance care; or • Shift or hourly care services. and special needs of a patient-family unit during the final stages of illness and dying. Hospice care is provided at a variety of levels to meet the individual needs of the patient-family unit. Levels offered are: • Intermittent in-home visits, provided on an as needed basis by the hospice team, which includes health care professionals, support staff, and a 24 hour a day “on-call” registered nurse. This level of care does not cover room and board while a Member resides in a Skilled Nursing Facility, adult family home, or assisted living facility. • Inpatient Hospice care is needed and care cannot be managed where the patient resides. Care will be provided at an inpatient Facility until the patient’s condition stabilizes. • Continuous home care, provided when a medical crisis occurs where the patient resides and care can be provided at the residence. During such periods, the hospice team can provide around-the-clock care for up to 5 days. • Inpatient and outpatient respite care is available to provide continuous care and to give the patient’s caregiver a rest from the duties of caring for the patient. Respite care is limited to a total of 14 days, inpatient or outpatient, per Subscriber’s lifetime. When respite care is provided for the patient at an inpatient facility, room and board costs are also covered. When provided within the above defined Levels of Care, additional covered expenses include: • Approved medications and infusion therapies furnished and billed by an approved hospice agency; • Durable Medical Equipment when billed by a licensed hospice care program; and • Services and supplies required by the hospice agency to provide the care. Any charges for hospice care that qualify under this benefit, and under any other benefit of this plan, will be covered under the most appropriate benefit as determined by CHPW. Hospice care listed below is not covered: • Custodial Care or maintenance care, except palliative care to the terminally ill patient subject to the stated limits; • Financial or legal counseling services; • Housekeeping or meal services; • Services by a Subscriber or the patient’s Family or Volunteers; • Services not specifically listed as covered hospice services under this plan; • Supportive equipment such as handrails or ramps; or • Transportation.

Habilitative Services. Benefits are provided for habilitative services when Medically Necessary, 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 • and  To compensate for a progressive physical, cognitive, and emotional Illness. Covered Services include: • 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 school‐based health care center, center unless delivered pursuant to federal Individuals with Disabilities Education Act of 2004 requirements, such as requirements pursuant to an individual educational plan. plan Day habilitation services designed to provide training, structured activities, or activities and 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 member per Calendar Year, unless provided to treat a DSM diagnosis. •  Nursing service providers services (RN, LPN); •  Licensed or registered physical, occupational or speech therapist (or an assistant working under the supervision of one of these providers)therapist; •  Home health aide/assistant working directly under the supervision of one of the above Providers; • or  Licensed Social Worker (Master’s preparedMSW); 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 Home Health agency; •  Durable Medical Equipment when billed by a licensed home health agency; and •  Services and supplies required by the home health Home Health agency to provide the care. Home health care listed below is not covered: •  Custodial Care; •  Private duty nursing; •  Housekeeping or meal services; •  Maintenance care; or •  Shift or hourly care services. and special needs of a patient-family unit during the final stages of illness and dying. Hospice care is provided at a variety of levels to meet the individual needs of the patient-family unit. Levels offered are: •  Intermittent in-home visits, in‐home visits are provided on an as needed basis by the hospice team, which includes health care professionals, support staff, and a 24 twenty‐four (24) hour a day “on-callon‐call” registered nurse. This level of care does not cover room and board while a Member resides in a Skilled Nursing Facility, adult family home, or assisted living facility. • ;  Inpatient Hospice care is needed and when care cannot be managed where the patient resides. Care The care will be provided at an inpatient Facility until the patient’s condition stabilizes. • ;  Continuous home care, care is provided when a medical crisis occurs where the patient resides and care can be provided at the residence. During such periods, the hospice team can provide around-the-clock around‐the‐clock care for up to 5 days. • ; and  Inpatient and outpatient respite care is available to provide continuous care and to give the patient’s caregiver a rest from the duties of caring for the patient. Respite care is limited to a total of 14 days, days of inpatient or outpatient, outpatient respite care per Subscriber’s lifetime. When respite care is provided for the patient at an inpatient facility, room and board costs are also covered. When provided within the above defined Levels of Care, additional covered expenses include: •  Approved medications and infusion therapies furnished and billed by an approved hospice agency; •  Durable Medical Equipment when billed by a licensed hospice care program; and •  Services and supplies required by the hospice Hospice agency to provide the care. Any charges for hospice care that qualify under this benefit, and under any other benefit of this plan, will be covered under the most appropriate benefit as determined by CHPW. Hospice care listed below is not covered: •  Custodial Care or maintenance care, except palliative care to the terminally ill patient subject to the stated limits; •  Financial or legal counseling services; •  Housekeeping or meal services; •  Services by a Subscriber or the patient’s Family or Volunteers; •  Services not specifically listed as covered hospice services under this plan; •  Supportive equipment such as handrails or ramps; or •  Transportation.