Carpenters Health and Security Plan
90% Network and 80% Non-Network
Habilitative care refers to health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical, speech and occupational therapy, and other services for individuals with disabilities in a variety of inpatient and/or outpatient settings.
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 a calendar year maximum of 15 inpatient days. If charges for more than 15 inpatient days are submitted, those charges will be denied. Inpatient care is only covered when services cannot be provided in a less intensive setting. The annual inpatient maximum applies to habilitative and rehabilitative services combined.
Benefits are provided with a calendar year maximum of 30 outpatient visits. visits. If, however, the ordering physician determines additional visits are medically necessary, a fully documented request can be made to the plan. Up to an additional 30 visits may be allowed (a total of 60 visits per calendar year) based on the information provided by the ordering physician to the plan. This benefit maximum applies to habilitative and rehabilitative services combined.
Benefits are not provided for:
- Respite care, education services, chore services to assist with basic needs, social services, recreational care, residential treatment, vocational training or custodial services.
- Self-correcting dysfunction such as hoarseness.
- State-required medical assessments for specialized educational programs; or services or supplies required by law to be provided by any school system.
- Feeding therapy.
These exclusions apply to inpatient and outpatient care.
Last Updated: 11/23/2021