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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

Up to sixty (60) combined (physical, speech and occupational therapy and rehabilitation services) visits are allowed per calendar year without preauthorization. Any visits after the first sixty (60) may be covered, upon preauthorization by the medical plan, if such visits continue to be medically necessary. All therapy is subject to plan limitations.

Covered as a prescribed course of therapy by an appropriate health care provider as medically necessary when all of the following criteria are met:

Physical Therapy

  • The program is designed to improve lost or impaired physical function or reduce pain resulting from illness, injury, congenital defect or surgery;
  • The program is expected to result in significant therapeutic improvement over a clearly defined period of time; and
  • The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals.

 

Speech Therapy

Covered for either of the following:

  • Member has severe impairment of speech/language; and an evaluation has been completed by a certified speech-language pathologist that includes age-appropriate standardized tests that measure the extent of the impairment, performance deviation, and language and pragmatic skills assessment levels.
  • Member has a significant voice disorder that is the result of anatomic abnormality, neurological condition, or injury (e.g., vocal nodules or polyps, vocal cord paresis or paralysis, post-operative vocal cord surgery).

Criteria

  • The therapy requires the one-to-one intervention and supervision of a speech-language pathologist;
  • The therapy plan includes specific tests and measures that will be used to document significant progress every two weeks;
  • Meaningful improvement is expected from the therapy; and
  • The therapy includes a transition from one-to-one supervision to an individual or caregiver provided maintenance program upon discharge.

 

Occupational Therapy

Criteria

  • The program is designed to improve or compensate for lost or impaired physical functions, particularly those affecting activities of daily living, resulting from illness, injury, congenital defect, or surgery.
  • The program is expected to result in significant therapeutic improvement over a clearly defined period of time.
  • The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals.

 


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