Summary Plan Description
90% Network and 80% Non-Network
The benefits described below are provided for rehabilitative care when prescribed by the patient's attending physician and are medically necessary to improve or restore function previously normal but lost due to illness, injury or surgery.
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. This benefit maximum includes physician visits, medical supplies, and the services of the physical, speech, respiratory, and occupational therapist, and applies to habilitative and rehabilitative services combined. All care must be part of a written plan of multidisciplinary treatment prescribed and periodically reviewed by the attending physician. Precertification is required for a separate inpatient admission or for an admission that is part of a continuous inpatient stay that began with acute care. Inpatient care is only covered when services cannot be provided in a less intensive setting.
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 30 outpatient visits. This benefit maximum applies to habilitative and rehabilitative services combined. All care must be part of a formal program prescribed by the attending physician. Therapy must be provided under the physician's supervision and the patient 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.
Biofeedback is covered within the provisions of the outpatient rehabilitative care benefit (included in the annual 30 outpatient visit maximum) but only when it is 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.
Exercise programs for cardiac patients, commonly referred to as "cardiac rehabilitation," are covered within the provisions of the outpatient care benefit (included in the 30 outpatient visit annual maximum). Benefits are provided for phase II cardiac rehabilitation up to a maximum of 12 weeks or 30 sessions when provided by a hospital outpatient department or in a physician-directed clinic. Cardiac rehabilitation program benefits are available only for patients 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.
Benefits are not provided for:
- Nonmedical self-help or related testing; work hardening; recreational, cognitive, behavioral, or vocational therapy; neuromuscular reevaluation; or gym or pool therapy.
- Social or cultural therapy.
- Acupressure or massage therapy.
- Therapy elected by the patient but not prescribed by the attending physician prior to commencement of treatment.
- Services related to activities intended to promote overall fitness, sports conditioning or overuse, flexibility or sense of well being without direct relationship to restoration of a functional loss related to illness, injury or surgery.
- Therapy provided to patients who have achieved their therapeutic goals; or therapy provided to patients whose progress in strength and mobility has reached a plateau, except as necessary to prevent deterioration.
- Self-correcting dysfunction such as hoarseness, language therapy for young children with natural dysfluency, or oral myofunctional therapy; stammering and stuttering; sensory integration therapy; state-required medical assessments for specialized educational programs; or services or supplies required by law to be provided by any school system.
- Feeding therapy.
- Biofeedback for muscle tension states, psychosomatic conditions, tension and anxiety states, headaches, chronic pain, Raynaud's disease, or hypertension.
- Physical, speech or occupational therapy for Autism Spectrum Disorder/Pervasive Developmental Disorder, except as provided under Behavioral Health Services.
These exclusions apply to both inpatient and outpatient services.
Related Health & Security Content
- 2017 Summary of Material Modifications (1/31/2017)
- 2017 Summary of Material Modifications (1/1/2017)
- 2016 Summary of Material Modifications
- 2014 Summary of Material Modifications
2017 Summary of Benefits and Coverage
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