Rehabilitative
Care – 90%
The benefits
described below are provided for rehabilitative care when prescribed by the
individual’s attending physician and medically necessary to improve or
restore function previously normal but lost due to illness, injury or surgery.
Benefits are provided only for services and supplies received within 12 months
from the onset of the illness or injury or from the date of the surgery that
made rehabilitation necessary. If treatment is received 12 months after the
illness or injury onset date, this plan will not pay the costs.
Inpatient
Rehabilitative Care
Benefits are
provided for a semiprivate room in a hospital with a rehabilitation department
or a rehabilitation hospital. Inpatient admissions are covered for physical,
speech, respiratory, and occupational therapy services and supplies, with an
annual maximum of $24,000. If expenses exceed this $24,000 annual maximum, this
plan will not pay the additional costs. This benefit maximum includes physician
visits, medical supplies and the services of the physical, speech, respiratory,
and occupational therapist. All care must be part of a written plan of
multidisciplinary treatment prescribed and periodically reviewed by the
attending
physician.
Preadmission certification is required for a separate inpatient admission or for
an admission that is part of a continuous inpatient stay that began with acute
care (non-Medicare individuals
only). Inpatient care is only
covered when services cannot be provided in a less intensive
setting.
Outpatient
Rehabilitative Care
Benefits are
provided for physical, speech, respiratory, and occupational therapy when
performed by a physician or physical, speech, respiratory, or occupational
therapist in the office, clinic or outpatient hospital department, with an
annual maximum of $2,000. If expenses exceed this $2,000 annual maximum, this
plan will not pay the additional costs. All outpatient rehabilitation must be
part of a written treatment plan provided by the attending physician. Therapy
must be provided under the physician’s supervision and the individual must
continue under the care of the physician during the time the therapy is
provided. In addition, the physician must periodically evaluate the treatment
plan and certify that continuing therapy is required. The initial claim must be
submitted with the physician’s prescription for the rehabilitative
care. Biofeedback
is covered within the provisions of the outpatient rehabilitative care benefit
but only when it is reasonable and necessary for muscle reeducation of specific
muscle groups or
for treating
pathological muscle abnormalities of spasticity, incapacitating muscle spasm or
weakness (i.e., incontinence), and more conventional treatments (i.e., heat,
cold, massage, exercise, and support) have not been successful. Biofeedback is
not
covered for muscle tension states, psychosomatic conditions, tension and anxiety
states, tension headaches, or
hypertension. Exercise
programs for cardiac patients, commonly referred to as “cardiac
rehabilitation,” are covered within the provisions of the outpatient
rehabilitative care benefit. Benefits are provided for phase II cardiac
rehabilitation up to a maximum of 12 weeks or 36 sessions when provided by a
hospital outpatient department or in a physician-directed clinic. Cardiac
rehabilitation program benefits are available only for individuals with a clear
medical need who are referred by their attending physician and (1) have a
documented diagnosis of acute myocardial infarction within the preceding 12
months, or (2) have had coronary bypass surgery, or (3) have stable angina
pectoris. Phase III cardiac rehabilitation is not covered.
Inpatient or
outpatient benefits are
not
provided for:
- Custodial
care; nonmedical self-help or related testing; work hardening; recreational,
educational, cognitive, behavioral, or vocational therapy; neuromuscular
reevaluation; gym or swim therapy; or therapy or maintenance which is solely for
the purpose of slowing body degeneration rather than restoring functional
improvement.
- Social
or cultural therapy.
- Acupressure
or services of a massage therapist.
- Therapy
prescribed by a chiropractor or a physical, speech, respiratory, or occupational
therapist; or therapy elected by the individual but not prescribed by the
attending physician prior to commencement of treatment.
- Services
related to activities intended to promote overall fitness, flexibility or sense
of well being without direct relationship to restoration of a functional loss
related to illness, injury or surgery.
- Repetitive
exercises to improve or maintain gait or strength and endurance; range of motion
and passive exercises not related to restoration of a specific loss of function
but useful only in maintaining range of motion in paralyzed extremities; and
assisted walking such as that provided in support for feeble or unstable
individuals.
- Maintenance
provided to individuals who have achieved their therapeutic goals; or
maintenance therapy provided to individuals whose progress in strength and
mobility has reached a plateau.
- Inpatient
or outpatient rehabilitation care received more than 12 months after the illness
or injury onset date or from the date of the surgery that made rehabilitation
necessary.
- Therapy
to assist in the initial development of a motor or sensory skill including
speech therapy for developmental disorders of articulation, except as provided
for under Neurodevelopmental Therapy;
self-correcting dysfunction such as hoarseness, or language therapy for young
children with natural dysfluency, or therapy to correct developmental or
emotional language delays; oral myofunctional therapy; stammering and
stuttering; tongue thrust; sensory integration therapy; state-required medical
assessments for specialized educational programs; services or supplies required
by law to be provided by any school system; or treatment of learning
disabilities or developmental delays. This exclusion applies regardless of the
recommendation of the attending physician.
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