Common use of Habilitative Services Clause in Contracts

Habilitative Services. For purposes of this Benefit, "habilitative services" means Skilled Care services and devices that are part of a prescribed treatment plan or Maintenance Program to help a person with a disability to keep, learn or improve skills and functioning for daily living. We will decide if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. Therapies provided for the purpose of general well- being or conditioning in the absence of a disability are not considered habilitative services. Benefits for habilitative services for the treatment of Congenital Anomaly or genetic birth defects, include services for cleft lip and cleft palate, orthodontics, oral surgery, otologic, and audiological therapy. Habilitative services include: • Physical therapy. • Occupational therapy. • Speech therapy. • Post-cochlear implant aural therapy. • Cognitive therapy. Benefits are provided for habilitative services for both inpatient services and outpatient therapy when you have a disability when both of the following conditions are met: • Treatment is administered by any of the following: ▪ Licensed speech-language pathologist. ▪ Licensed audiologist. ▪ Licensed occupational therapist. ▪ Licensed physical therapist. ▪ Physician. • Treatment must be proven and not Experimental or Investigational. The following are not habilitative services: • Custodial Care. • Respite care. • Day care. • Therapeutic recreation. • Educational/vocational training. • Residential Treatment. • A service or treatment plan that does not help you meet functional goals. • Services solely educational in nature. • Educational services otherwise paid under state or federal law. We may require the following be provided for the treatment of Autism Spectrum Disorder: • A comprehensive evaluation of an individual by the individual’s Primary Care Physician or specialty Physician; • A prescription from an individual’s Primary Care Physician or specialty Physician that includes specific treatment goals; and • An annual review by the prescribing Primary Care Physician or specialty Physician, in consultation with the habilitative services provider, that includes: ▪ Documentation of benefit to the individual; ▪ Identification of new or continuing treatment goals; and ▪ Development of a new or continuing treatment plan. We may require the following be provided for all other conditions: • Medical records. • Other necessary data to allow us to prove that medical treatment is needed. When the Treating Provider expects that continued treatment is or will be required to allow you to achieve progress we may request additional medical records. Habilitative services provided in your home by a Home Health Agency are provided as described under Home Health Care. Benefits for DME, Orthotics and prosthetic devices, when used as a part of habilitative services, are described under