Common use of Habilitative Services Clause in Contracts

Habilitative Services. Habilitative services are healthcare services that help you keep, learn, or improve skills and functioning for daily living. These services are Covered and may require Prior Authorization. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical therapy and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient/outpatient settings. Autism Spectrum Disorder‌‌ The diagnosis and treatment for Autism Spectrum Disorder is covered regardless of age in accordance with state mandated benefits as follows: • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well- Child or well-baby screening and/or • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children 3 to 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. This benefit has one or more exclusions as specified in the Exclusions Section. Home Health Care Services are Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. Home Health Care Services shall include Medically Necessary skilled intermittent Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services. Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. The following Home Health Care Services will be Covered when we approve a Prior Authorization request:‌ • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider • Total parenteral and enteral nutrition as the sole source of nutrition • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the Member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs may require a Prior Authorization and some must be obtained through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy website at ▇▇▇▇://▇▇▇▇.▇▇▇.▇▇▇/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. o You may call our Presbyterian Customer Service Center for more information at (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. This benefit has one or more exclusions as specified in the Exclusions Section.

Habilitative Services. Habilitative services are healthcare services Healthcare Services that help you keep, learn, or improve skills and functioning for daily living. These services are Covered and may require Prior Authorization. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical therapy and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient/inpatient and/or outpatient settings. Autism Spectrum Disorder‌‌ The diagnosis and treatment for Autism Spectrum Disorder is covered regardless of age in accordance with state mandated benefits as follows: • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well- Child or well-baby screening and/or • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the federal Individuals with Disabilities Education Improvement Act ages of 2004 45-65 years and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children 3 to 22 years have an intermediate risk of age who have Autism Spectrum Disorder are not Covered under this Plan. This benefit has one or more exclusions developing coronary heart disease as specified determined by a Healthcare Provider based upon a score calculated from an evidence-based algorithm widely used in the Exclusions Sectionmedical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible Member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible Member receives a heart artery calcium score greater than zero. Heart Artery calcification is a Covered preventive benefit with no member Cost-Sharing. Home Health Care Services are Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. Home Health Care Services shall include Medically Necessary skilled intermittent Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services. Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. The following Home Health Care Services will be Covered when we approve a Prior Authorization request:‌ request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider • Total parenteral and enteral nutrition as the sole source of nutrition • Medical Drugs: Drugs (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the Member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs may require a Prior Authorization and some must be obtained through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy website at ▇▇▇▇://▇▇▇▇.▇▇▇.▇▇▇/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. o You may call our Presbyterian Customer Service Center for more information at (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. This benefit has one or more exclusions as specified in the Exclusions Section.):

Habilitative Services. Habilitative services are healthcare services Healthcare Services that help you keep, learn, or improve skills and functioning for daily living. These services are Covered and may require Prior Authorization. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical therapy and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient/inpatient and/or outpatient settings. Autism Spectrum Disorder‌‌ The diagnosis and treatment for Autism Spectrum Disorder is covered regardless of age in accordance with state mandated benefits as follows: •  Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well- Child or well-baby screening and/or •  Diagnosis of autism; and  Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children 3 to 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. This benefit has one or more exclusions Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as specified determined by a Healthcare Provider based upon a score calculated from an evidence-based algorithm widely used in the Exclusions Sectionmedical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible Member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible Member receives a heart artery calcium score greater than zero. Heart Artery calcification is a Covered preventive benefit with no member Cost-Sharing. Home Health Care Services are Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. Home Health Care Services shall include Medically Necessary skilled intermittent Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services. Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. The following Home Health Care Services will be Covered when we approve a Prior Authorization request:‌ • request:  Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider •  Total parenteral and enteral nutrition as the sole source of nutrition •  Medical Drugs: Drugs (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the Member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs may require a Prior Authorization and some must be obtained through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy website at ▇▇▇▇://▇▇▇▇.▇▇▇.▇▇▇/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. o You may call our Presbyterian Customer Service Center for more information at (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. This benefit has one or more exclusions as specified in the Exclusions Section.):

Habilitative Services. Habilitative services are healthcare services that help you keep, learn, or improve skills and functioning for daily living. These services are Covered and may require Prior Authorization. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical therapy and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient/outpatient settings. Autism Spectrum Disorder‌‌ The diagnosis and treatment for Autism Spectrum Disorder is covered regardless of age in accordance with state mandated benefits as follows: • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well- Child or well-baby screening screening; and/or • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children 3 to 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years old and that have an intermediate risk of developing coronary heart disease as determined by a healthcare provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five (5) years if an eligible member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible member receives a heart artery calcium score greater than zero. This benefit has one or more exclusions as specified in the Exclusions Section. Home Health Care Services are Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. Home Health Care Services shall include Medically Necessary skilled intermittent Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services. Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. The following Home Health Care Services will be Covered when we approve a Prior Authorization request:‌ request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider • Total parenteral and enteral nutrition as the sole source of nutrition • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the Membermember's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs may require a Prior Authorization and some must be obtained through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy website at ▇▇▇▇://▇▇▇▇.▇▇▇.▇▇▇/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. o You may call our Presbyterian Customer Service Center for more information at (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇, Monday through Friday Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. This benefit has one or more exclusions as specified in the Exclusions Section.