Summary Plan Description

Habilitative Care

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.

Inpatient Care

Inpatient Admissions Must Be Precertified Unless the Patient Is a Medicare-Eligible Retiree

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 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.

Outpatient Care

Benefits are provided with an annual maximum of 30 visits. If charges for more than 30 visits are submitted, those charges will be denied. The annual outpatient maximum applies to habilitative and rehabilitative services combined.

Benefits are not provided for:

  1. Respite care, education services, chore services to assist with basic needs, social services, recreational care, residential treatment, vocational training or custodial services.
  2. Self-correcting dysfunction such as hoarseness.
  3. State-required medical assessments for specialized educational programs; or services or supplies required by law to be provided by any school system.
  4. Feeding therapy.

These exclusions apply to inpatient and outpatient care.