Habilitative Services: OK, OR, TX, WA – UnitedHealthcare West Benefit Interpretation Policy

Habilitative Services

Page 1 of 10

UnitedHealthcare West Benefit Interpretation Policy

Effective 12/01/2023

UnitedHealthcare

West

Benefit Interpretation Policy

Habilitative Services

Policy Number: BIP202.I

Effective Date: December 1, 2023



Instructions for Use

Table of Contents Page

Federal/State Mandated Regulations .......................................... 1

State Market Plan Enhancements ................................................ 8

Covered Benefits ........................................................................... 8

Not Covered ................................................................................... 9

Definitions ...................................................................................... 9

References ................................................................................... 10

Policy History/Revision Information ........................................... 10

Instructions for Use ..................................................................... 10

Federal/State Mandated Regulations

Oklahoma

Oklahoma Department of Insurance 365:40-5-20 (4): Basic Health Care Services

https://www.law.cornell.edu/regulations/oklahoma/OAC-365-40-5-20

(2) Outpatient services and inpatient hospital services including short-term rehabilitation services and physical therapy which

the HMO expects can result in the significant improvement of an enrollee's condition within two months.

(12) Inpatient and outpatient care for treatment of the birth defect known as cleft lip or cleft palate or both including medically

necessary oral surgery, orthodontics and otologic, audiological, and speed/language treatment.

365:40-5-21 Supplemental Health Care Services

http://www.oar.state.ok.us/viewhtml/365_40-5-21.htm

https://www.law.cornell.edu/regulations/oklahoma/OAC-365-40-5-21

Supplemental health care services of an HMO may include the following:

(5) Long-term physical therapy and rehabilitative services

Oregon

1. For UnitedHealthcare of Oregon (Clark County, Washington) Members Only

RCW 48.44.450, Neurodevelopmental Therapies

https://app.leg.wa.gov/rcw/default.aspx?cite=48.44.450

1. Each employer-sponsored group contract for comprehensive health care service which is entered into, or renewed, on

or after twelve months after July 23, 1989, shall include coverage for neurodevelopmental therapies for covered

individual’s age six and under.

2. Benefits provided under this section shall cover the services of those authorized to deliver occupational therapy,

speech therapy, and physical therapy. Benefits shall be payable only where the services have been delivered pursuant

Related Benefit Interpretation Policies

• Biofeedback

• Cognitive Rehabilitation

• Durable Medical Equipment (DME), Prosthetics,

Corrective Appliances/Orthotics (Non Foot

Orthotics) and Medical Supplies

• Experimental and Investigational Services

• Home Health Care

• Rehabilitation Services (Physical, Occupational, and

Speech Therapy)

• Skilled Nursing Facility (SNF): Skilled Nursing

Facility (SNF) Care

UnitedHealthcare Benefits of Texas, Inc.

UnitedHealthcare of Oklahoma, Inc.

UnitedHealthcare of Oregon, Inc.

UnitedHealthcare of Washington, Inc.

Habilitative Services

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UnitedHealthcare West Benefit Interpretation Policy

Effective 12/01/2023

to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or where

covered services have been rendered by such licensee. Nothing in this section shall prohibit a health care service

contractor from requiring that covered services be delivered by a provider who participates by contract with the health

care service contractor unless no participating provider is available to deliver covered services. Nothing in this section

shall prohibit a health care service contractor from negotiating rates with qualified providers.

3. Benefits provided under this section shall be for medically necessary services as determined by the health care service

contractor. Benefits shall be payable for services for the maintenance of a covered individual in cases where significant

deterioration in the patient's condition would result without the service. Benefits shall be payable to restore and

improve function.

4. It is the intent of this section that employers purchasing comprehensive group coverage including the benefits required

by this section, together with the health care service contractor, retain authority to design and employ utilization and

cost controls. Therefore, benefits delivered under this section may be subject to contractual provisions regarding

deductible amounts and/or copayments established by the employer purchasing coverage and the health care service

contractor. Benefits provided under this section may be subject to standard waiting periods for preexisting conditions,

and may be subject to the submission of written treatment plans.

5. In recognition of the intent expressed in subsection (4) of this section, benefits provided under this section may be

subject to contractual provisions establishing annual and/or lifetime benefit limits. Such limits may define the total

dollar benefits available or may limit the number of services delivered as agreed by the employer purchasing coverage

and the health care service contractor.

Note: Neurodevelopmental therapies are services rendered to children age six (6) and under, who have developmental

delay due to diagnosable medical cause such as autism, prematurity, or cerebral palsy. Benefits provided will cover the

services of those authorized to deliver occupational therapy, speech therapy and physical therapy. Benefits will be payable

to restore and improve function and for the maintenance of a condition where significant deterioration in the child's

condition would result without the service. Inpatient or residential neurodevelopmental programs in the absence of a

medical condition requiring acute medical care are never covered.

For regulatory guidance, Refer to the

Washington State Department of Social and Health Services' Division of

Developmental Disabilities.

For specific visit limitations, refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) or contact the

Customer Service Department.

2. Habilitative Services: Short-term habilitative services are covered for members with a disabling condition when both of the

following conditions are met:

o The treatment is administered by a licensed health care professional, as long as the services are performed within the

licensed health care professional’s scope of practice and are commensurate with the licensed health care

professional’s post-secondary education, training, and supervised experience including a licensed speech-language

pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed

nutritionist, licensed social worker or licensed psychologist, licensed behavior analyst or assistant behavior analyst or

autism technician licensed under the laws of the state of Oregon to perform the specific service commensurate with

the licensed health care professional’s post-secondary education, training and supervised experience.

o The initial or continued treatment must be proven and not an Experimental or Investigational Treatment.

Covered services for habilitative services do not apply to those services that are solely educational in nature or otherwise

paid under state or federal law for purely educational services. Custodial care, respite care, day care, therapeutic

recreation, vocational training and residential treatment are not habilitative services. A service that does not help the

member meet functional goals in a treatment plan within a prescribed time frame is not a habilitative service.

We may require that a treatment plan be provided, request medical records, clinical notes, or other necessary data to allow

us to substantiate the initial or continued medical treatment is needed. When the treating provider anticipates that

continued treatment is or will be required to permit the member to achieve demonstrable progress, we may request a

treatment plan consisting of diagnosis, proposed treatment type, frequency the treatment plan will be updated. For

purposes of this Benefit “habilitative services” means healthcare services that help a person keep, learn or improve skills

and functioning for a daily living.

Habilitative Services

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UnitedHealthcare West Benefit Interpretation Policy

Effective 12/01/2023

ORS 743A.190 Children with Pervasive Developmental Disorder

https://www.oregonlaws.org/ors/743A.190

A health benefit plan, as defined in ORS 743B.005 must cover for a child enrolled in the plan who is under 18 years of age and

who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are

medically necessary and are otherwise covered under the plan.

(2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other

provisions of the health benefit plan that apply to covered services, including but not limited to:

(a) Deductibles, copayments or coinsurance;

(b) Prior authorization or utilization review requirements; or

(3) As used in this section:

(a) "Medically necessary" means in accordance with the definition of medical necessity that is specified in the policy,

certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health

benefit plan.

(b) "Pervasive developmental disorder" means a neurological condition that includes autism spectrum disorder,

developmental delay, developmental disability or mental retardation.

improve function.

(4) The provisions of ORS 743A.001

do not apply to this section.

(5) The definition of "pervasive developmental disorder" is not intended to apply to coverage required under ORS 743A.168 or

section 2, chapter 771, Oregon Laws 2013. [2007 c.872 §2; 2013 c.771 §7]

Note: The amendments to 743A.190

by section 20, chapter 771, Oregon Laws 2013, become operative January 2, 2022. See

section 24, chapter 771, Oregon Laws 2013. The text that is operative on and after January 2, 2022, is set forth for the user’s

convenience.

743A.190

(1) A health benefit plan, as defined in ORS 743B.005 must cover for a child enrolled in the plan who is under 18 years of age

and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation

services, that are medically necessary and are otherwise covered under the plan.

(2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other

provisions of the health benefit plan that apply to covered services, including but not limited to:

(a) Deductibles, copayments or coinsurance;

(b) Prior authorization or utilization review requirements; or

(3) As used in this section:

(a) "Medically necessary" means in accordance with the definition of medical necessity that is specified in the policy,

certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health

benefit plan.

(b) "Pervasive developmental disorder" means a neurological condition that includes autism spectrum disorder,

developmental delay, developmental disability or mental retardation.

improve function.

(4) The provisions of ORS 743A.001

do not apply to this section.

(5) The definition of "pervasive developmental disorder" is not intended to apply to coverage required under ORS 743A.168

Texas

Texas Insurance Code, Title 8, Subtitle E, Chapter 1367, Subchapter E.: Developmental Delays

https://statutes.capitol.texas.gov/DocViewer.aspx?DocKey=IN%2fIN.1367&Phrases=1367.201&HighlightType=1&ExactPhrase=

False&QueryText=1367.201

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UnitedHealthcare West Benefit Interpretation Policy

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Sec. 1367.201 Definition

In this subchapter, rehabilitative and habilitative therapies include:

1) Occupational therapy evaluations and services;

2) Physical therapy evaluations and services;

3) Speech therapy evaluations and services; and

4) Dietary or nutritional evaluations.

Sec. 1367.202 Applicability of Subchapter

https://statutes.capitol.texas.gov/DocViewer.aspx?DocKey=IN%2fIN.1367&Phrases=1367.202&HighlightType=1&ExactPhrase=

False&QueryText=1367.202

This subchapter applies only to a health benefit plan that:

1) Provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness,

including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service

contract, or an individual or group evidence of coverage that is offered by:

(A) An insurance company;

(B) A group hospital service corporation operating under Chapter 842;

(D) A stipulated premium company operating under Chapter 884;

(E) A health maintenance organization operating under Chapter 843; or

(F) A multiple employer welfare arrangement subject to regulation under Chapter 846;

2) Is offered by an approved nonprofit health corporation that holds a certificate of authority under Chapter 844

; or

3) Provides health and accident coverage through a risk pool created under Chapter 172, Local Government Code,

notwithstanding Section 172.014, Local Government Code, or any other law.

Sec. 1367.203 Exception

https://statutes.capitol.texas.gov/DocViewer.aspx?DocKey=IN%2fIN.1367&Phrases=1367.203&HighlightType=1&ExactPhrase=

False&QueryText=1367.203

This subchapter does not apply to:

1) A plan that provides coverage:

(A) Only for a specified disease or for another limited benefit;

(B) Only for accidental death or dismemberment;

sickness or injury;

(D) As a supplement to a liability insurance policy;

(E) For credit insurance;

(F) Only for dental or vision care; or

(G) Only for indemnity for hospital confinement;

2) A small employer health benefit plan written under Chapter 1501

;

3) A Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

4) A workers' compensation insurance policy;

5) Medical payment insurance coverage provided under a motor vehicle insurance policy; or

6) A long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines

that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section

1367.202

Sec. 1367.204 Offer of Coverage Required

https://statutes.capitol.texas.gov/DocViewer.aspx?DocKey=IN%2fIN.1367&Phrases=1367.204&HighlightType=1&ExactPhrase=

False&QueryText=1367.204

a) A health benefit plan issuer must offer coverage that complies with this subchapter.

b) The individual or group policy or contract holder may reject coverage required to be offered under this section.

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UnitedHealthcare West Benefit Interpretation Policy

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Sec. 1367.205 Coverage of Certain Therapies

https://statutes.capitol.texas.gov/DocViewer.aspx?DocKey=IN%2fIN.1367&Phrases=1367.205&HighlightType=1&ExactPhrase=

False&QueryText=1367.205

a) A health benefit plan that provides coverage for rehabilitative and habilitative therapies under this subchapter may not

prohibit or restrict payment for covered services provided to a child and determined to be necessary to and provided in

accordance with an individualized family service plan issued by the Interagency Council on Early Childhood Intervention

under Chapter 73

, Human Resources Code.

b) Rehabilitative and habilitative therapies described by Subsection (a) must be covered in the amount, duration, scope, and

service setting established in the child's individualized family service plan.

c) A child is entitled to benefits under this subchapter if the child, as a result of the child's relationship to an insured or

enrollee in a health benefit plan, would be entitled to coverage under an accident and health insurance policy under

Section 1201.061, 1201.062, 1201.063, or 1201.064

Sec. 1367.206 Prohibited Actions

https://statutes.capitol.texas.gov/DocViewer.aspx?DocKey=IN%2fIN.1367&Phrases=1367.206&HighlightType=1&ExactPhrase=

False&QueryText=1367.206

Under the coverage required to be offered under this subchapter, a health benefit plan issuer may not:

1) Apply the cost of rehabilitative and habilitative therapies described by Section 1367.205

(a) to an annual or lifetime

maximum plan benefit or similar provision under the plan; or

2) Use the cost of rehabilitative or habilitative therapies described by Section 1367.205(a) as the sole justification for:

(A) Increasing plan premiums; or

(B) Terminating the insured's or enrollee's participation in the plan.

Sec. 1367.207 Rules

https://statutes.capitol.texas.gov/DocViewer.aspx?DocKey=IN%2fIN.1367&Phrases=1367.207&HighlightType=1&ExactPhrase=

False&QueryText=1367.207

The commissioner may adopt rules necessary to implement this subchapter.

Texas Insurance Code, Title 8, Subtitle C. Managed Care, Chapter 1271. Benefits Provided By Health

Maintenance Organizations, Sec. 1271.156

https://statutes.capitol.texas.gov/DocViewer.aspx?DocKey=IN%2fIN.1271&Phrases=1271.156&HighlightType=1&ExactPhrase=

False&QueryText=1271.156

Benefits for Rehabilitation Services and Therapies

a) If benefits are provided for rehabilitation services and therapies under an evidence of coverage, the provision of a

rehabilitation service or therapy that, in the opinion of a physician, is medically necessary may not be denied, limited, or

terminated if the service or therapy meets or exceeds treatment goals for the enrollee.

b) For an enrollee with a physical disability, treatment goals may include maintenance of functioning or prevention of or

slowing of further deterioration

Washington

RCW 48.43.045, Health Plan Requirements-Annual Reports-Exemptions

https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.045

(1) Every health plan delivered, issued for delivery, or renewed by a health carrier, 1996, shall:

a. Permit every category of health care provider to provide health services or care included in the basic essential health

benefits benchmark plan established by the commissioner consistent with RCW 48.43.715,to the extent that:

(i) The provision of such health services or care is within the health care provider's permitted scope of practice;

(ii) The providers agree to abide by standards related to:

(A) Provision, utilization review, and cost containment of health services

(B) Management and administrative procedures and

(iii) The plan covers such services or care in the essential health benefits benchmark plan. The reference to the

essential health benefits does not create a mandate to cover a service that is otherwise not a covered benefit.

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UnitedHealthcare West Benefit Interpretation Policy

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RCW 18.74.010

https://app.leg.wa.gov/rcw/default.aspx?cite=18.74.010

(8) Physical therapist" means a person who meets all the requirements of this chapter and is licensed in this state to practice

physical therapy

(a) (9) "Physical therapist assistant" means a person who meets all the requirements of this chapter and is licensed as a

physical therapist assistant and who performs physical therapy procedures and related tasks that have been

selected and delegated only by the supervising physical therapist. However, a physical therapist may not delegate

sharp debridement to a physical therapist assistant.

(b) "Physical therapy aide" means an unlicensed person who receives ongoing on-the-job training and assists a physical

therapist or physical therapist assistant in providing physical therapy patient care and who does not meet the definition

of a physical therapist or physical therapist assistant or other assistive personnel. A physical therapy aide may directly

assist in the implementation of therapeutic interventions, but may not alter or modify the plan of therapeutic

interventions and may not perform any procedure or task which only a physical therapist may perform under this

chapter.

subsection, who perform specific designated tasks related to physical therapy and within their license, scope of

practice or formal education, under the supervision of a physical therapist, including but not limited to licensed

massage therapists, athletic trainers, and exercise physiologists. At the direction of the supervising physical therapist,

and if properly credentialed and not prohibited by any other law, other assistive personnel may be identified by the title

specific to their training or education.

(10) “Physical therapy" means the care and services provided by or under the direction and supervision of a physical therapist

licensed by the state. Except as provided in RCW 18.74.190

the use of Roentgen rays and radium for diagnostic and

therapeutic purposes, the use of electricity for surgical purposes, including cauterization, and the use of spinal

manipulation, or manipulative mobilization of the spine and its immediate articulations, are not included under the term

"physical therapy" as used in this chapter.

(11) “Practice of physical therapy" is based on movement science and means:

a. Examining, evaluating, and testing individuals with mechanical, physiological, and developmental impairments,

functional limitations in movement, and disability or other health and movement-related conditions in order to

determine a diagnosis, prognosis, plan of therapeutic intervention, and to assess and document the ongoing effects of

intervention;

b. Alleviating impairments and functional limitations in movement by designing, implementing, and modifying therapeutic

interventions that include therapeutic exercise; functional training related to balance, posture, and movement to

facilitate self-care and reintegration into home, community, or work; manual therapy including soft tissue and joint

mobilization and manipulation; therapeutic massage; assistive, adaptive, protective, and devices related to postural

control and mobility except as restricted by (c) of this subsection; airway clearance techniques; physical agents or

modalities; mechanical and electrotherapeutic modalities; and patient-related instruction;

c. Training for, and the evaluation of, the function of a patient wearing an orthosis or prosthesis as defined in RCW

18.200.010. Physical therapists may provide those direct-formed and prefabricated upper limb, knee, and ankle-foot

orthoses, but not fracture orthoses except those for hand, wrist, ankle, and foot fractures, and assistive technology

devices specified in RCW 18.200.010 as exemptions from the defined scope of licensed orthotic and prosthetic

services. It is the intent of the legislature that the unregulated devices specified in RCW 18.200.010 are in the public

domain to the extent that they may be provided in common with individuals or other health providers, whether

unregulated or regulated under Title 18 RCW, without regard to any scope of practice;

d. Performing wound care services that is limited to sharp debridement, debridement with other agents, dry dressings,

wet dressings, topical agents including enzymes, hydrotherapy, electrical stimulation, ultrasound, and other similar

treatments. Physical therapists may not delegate sharp debridement. A physical therapist may perform wound care

services only by referral from or after consultation with an authorized health care practitioner;

e. Performing intramuscular needling;

f. Reducing the risk of injury, impairment, functional limitation, and disability related to movement, including the

promotion and maintenance of fitness, health, and quality of life in all age populations; and

g. Engaging in administration, consultation, education, and research.

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UnitedHealthcare West Benefit Interpretation Policy

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RCW 18.74.012

https://app.leg.wa.gov/rcw/default.aspx?cite=18.74.012

A consultation and periodic review by an authorized health care practitioner is not required for treatment of neuromuscular or

musculoskeletal conditions

RCW 48.44.450, Neurodevelopmental Therapies – Employer-Sponsored Group Contracts

https://app.leg.wa.gov/rcw/default.aspx?cite=48.44.450

(1) Each employer-sponsored group contract for comprehensive health care service which is entered into, or renewed, on or

after twelve months after July 23, 1989, shall include coverage for neurodevelopmental therapies for covered individual’s

age six and under.

(2) Benefits provided under this section shall cover the services of those authorized to deliver occupational therapy, speech

therapy, and physical therapy. Benefits shall be payable only where the services have been delivered pursuant to the

referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or where covered

services have been rendered by such licensee. Nothing in this section shall prohibit a health care service contractor from

requiring that covered services be delivered by a provider who participates by contract with the health care service

contractor unless no participating provider is available to deliver covered services. Nothing in this section shall prohibit a

health care service contractor from negotiating rates with qualified providers.

(3) Benefits provided under this section shall be for medically necessary services as determined by the health care service

contractor. Benefits shall be payable for services for the maintenance of a covered individual in cases where significant

deterioration in the patient's condition would result without the service. Benefits shall be payable to restore and improve

function.

(4) It is the intent of this section that employers purchasing comprehensive group coverage including the benefits required by

this section, together with the health care service contractor, retain authority to design and employ utilization and cost

controls. Therefore, benefits delivered under this section may be subject to contractual provisions regarding deductible

amounts and/or copayments established by the employer purchasing coverage and the health care service contractor.

Benefits provided under this section may be subject to standard waiting periods for preexisting conditions, and may be

subject to the submission of written treatment plans.

(5) In recognition of the intent expressed in subsection (4) of this section, benefits provided under this section may be subject

to contractual provisions establishing annual and/or lifetime benefit limits. Such limits may define the total dollar benefits

available or may limit the number of services delivered as agreed by the employer purchasing coverage and the health care

service contractor.

Note: Neurodevelopmental therapies are services rendered to children age six (6) and under, who have developmental delay

due to diagnosable medical cause such as autism, prematurity, or cerebral palsy. Benefits provided will cover the services of

those authorized to deliver occupational therapy, speech therapy and physical therapy. Benefits will be payable to restore and

improve function and for the maintenance of a condition where significant deterioration in the child's condition would result

without the service. Inpatient or residential neurodevelopmental programs in the absence of a medical condition requiring acute

medical care are never covered.

For regulatory guidance, Refer to the

Washington State Department of Social and Health Services' Division of Developmental

Disabilities.

For specific visit limitations, refer to the member's Schedule of Benefits (SOB) or contact the Customer Service Department.

a. Habilitative Services: Short-term Habilitative Services are covered on an outpatient basis for members with a Congenital,

genetic, or early acquired disorder when both of the following conditions are met:

o The treatment is administered by a licensed speech-language pathologist, licensed audiologist, licensed occupational

therapist, licensed physical therapists, or Physician.

o The initial or continued treatment must be proven and not an Experimental and/or Investigational Procedure, Item and

Treatment.

Covered Services for Habilitative Services do not apply to those services that are solely educational in nature or otherwise paid

under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation,

vocational training and residential treatment are not Habilitative Services. A service that does not help the member meet

Habilitative Services

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functional goals in a treatment plan within a prescribed time frame is not a Habilitative Service. When the member reaches

his/her maximum level of improvement or does not demonstrate continued progress under a treatment plan, a service that was

previously Habilitative is no longer Habilitative.

We may require that a treatment plan be provided, request medical records, clinical notes, or other necessary data to allow us

to substantiate the initial or continued medical treatment is needed and that the member’s condition is clinically improving as a

result of the Habilitative Service. When the treating Provider anticipates that continued treatment is or will be required to permit

the member to achieve demonstrable progress, we may request a treatment plan consisting of diagnosis, proposed treatment

type, frequency the treatment plan will be updated.

State Market Plan Enhancements

Texas

Members may have additional supplemental benefit coverage for rehabilitative and Habilitative Services for dependent children

under the age of three with developmental delays as deemed necessary to and in accordance with an individualized family

service plan issued by the Interagency Council on Early Childhood Intervention under Chapter 73, Human Resources Code.

Refer to the state-specific mandated coverage in the

Federal/State Mandated Regulations

section.

Covered Benefits

Important Note: Covered benefits are listed in

Federal/State Mandated Regulations

State Market Plan

Enhancements

, and

Covered Benefits

sections. Always refer to the

Federal/State Mandated Regulations

and

State Market Plan

Enhancements

sections for additional covered services/benefits not listed in this section.

Refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) to determine coverage eligibility.

Benefits for outpatient Habilitative Services include:

• Physical therapy

• Occupational therapy

• Post-cochlear implant aural therapy

• Cognitive habilitative therapy

• Manipulative treatment

• Speech therapy

For plans that provide Essential Health Benefits, benefits are provided for Habilitative Services for members to help a member

with a disabling condition to keep, learn, or improve skills and functioning for daily living when both of the following conditions

are met:

• The treatment is ordered by a physician and is performed by a licensed speech-language pathologist, licensed audiologist,

licensed occupational therapist, licensed physical therapist, physician, licensed nutritionist, licensed social worker or

licensed psychologist, a licensed behavioral analyst, or assistant behavioral analyst or autism technician licensed under the

laws of the state and

• The services must be provided in a physician's office or on an outpatient basis at a hospital or alternate facility (such as

health care facility that provides outpatient rehabilitative services).

We may require that a treatment plan be provided, request medical records, clinical notes, or other necessary data to allow us

to substantiate that initial or continued medical treatment is needed. When the treating provider anticipates that continued

treatment is or will be required to permit the member to achieve demonstrable progress, we may request a treatment plan

consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, the anticipated goals of

treatment, and how frequently the treatment plan will be updated.

Coverage of durable medical equipment and prosthetic devices, when used as a component of Habilitative Services, may

require a separate review. Check the member specific benefit document.

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Additional Information

• Habilitative Services received while in an inpatient setting, e.g. inpatient hospital, inpatient rehabilitation facility or skilled

nursing facility are covered as part of that benefit. Depending on the inpatient setting, benefits are the same as the

applicable inpatient benefit category (hospital inpatient, skilled nursing facility/inpatient rehabilitation facility benefit.).

• Eligible physical therapy and occupational therapy received in the home from a home health agency is covered under the

Home Health Care

section of the plan. The home health care benefit only applies to services that are rendered by a home

health agency.

• Eligible physical therapy and occupational therapy received in the home from an independent physical or occupational

therapist (a physical or occupational therapist that is not affiliated with a home health agency) is covered under the

Habilitative Services benefit.

• Benefits for Habilitative Services provided by the plan do not affect or reduce any obligation to provide services under an

individualized education program per the education code or individualized service plan as described in the Welfare and

Institutions Code or Disabilities Education Act.

Cardiac and pulmonary therapy are covered under the rehabilitation services benefit. These are not Habilitative Services.

Not Covered

• Services that are solely educational or vocational in nature or otherwise paid under state or federal law for purely

educational services. A service that does not help the member to meet or maintain functional goals in a treatment plan

within a prescribed time frame is not a Habilitative Service.

• When the member does not meet criteria for coverage as indicated in the

Covered Benefits

section above and member

specific benefit document.

• If the service is considered by UnitedHealthcare to be unproven, investigational or experimental.

• Custodial care, respite care, day care, therapeutic recreational care, vocational training and residential treatment.

• In the absence of a disabling condition, services to improve general physical condition are excluded from coverage.

• Once the treatment plan goals are met.

• Physiological modalities and procedures that result in similar or redundant therapeutic effects when performed on the

same body region during the same visit or office encounter. An example includes, but is not limited to, the same day

combined use of hot packs, ultrasound and iontophoresis in the treatment of strain.

• Programs that do not require the supervision of physician and/or a licensed therapy provider.

• Work Hardening.

• Confinement, treatment, services or supplies that are required: a) only by a court of law, or b) only for insurance, travel,

employment, and school or camp purposes. Refer to the member specific benefit document and state mandates.

• Services beyond any visit limits, if any, if specified in the member specific benefit document.

• Gym and fitness club memberships and fees, health club fees, exercise equipment or supplies.

• Biofeedback services. Refer to the member specific benefit documents.

• Therapies provided for the purpose of general well-being or conditioning in the absence of a disabling condition.

• Social services

Definitions

Congenital Anomaly/Defect (also commonly referred to as Congenital anomalies, birth defects, congenital disorders,

congenital malformations, or congenital abnormalities): are conditions of prenatal origin that are present at birth, potentially

impacting an infant's health, development and/or survival.

Habilitative Services: health care services that help a person 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

and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient

and/or outpatient settings.

Work Hardening: Work Hardening is an interdisciplinary program consisting of physical therapy, occupational therapy and

counseling professionals for injured workers or other adults whose injuries or disease processes interfere with their ability to

Habilitative Services

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UnitedHealthcare West Benefit Interpretation Policy

Effective 12/01/2023

work. It provides structured treatment designed to progressively improve physical function as a transition between acute care

and return to work.

References

DeSilva M, Munoz FM, Mcmillan M, Kawai AT, Marshall H, Macartney KK, Joshi J, Oneko M, Rose AE, Dolk H, Trotta F, Spiegel

H, Tomczyk S, Shrestha A, Kochhar S, Kharbanda EO; Brighton Collaboration Congenital Anomalies Working Group.

Congenital anomalies: Case definition and guidelines for data collection, analysis, and presentation of immunization safety

data. Vaccine. 2016 Dec 1;34(49):6015-6026. doi: 10.1016/j.vaccine.2016.03.047. Epub 2016 Jul 18. PMID: 27435386; PMCID:

PMC5139892.

“Habilitative/Habilitation Services - Glossary” (n.d.). HealthCare.gov, Department of Health & Human Services.

https://www.healthcare.gov/glossary/habilitative-habilitation-services/. Accessed September 29, 2023.

Policy History/Revision Information

Date

State(s) Affected

Summary of Changes

12/01/2023 All

Definitions

Removed definition of “Custodial Care”

Updated definition of:

o Congenital Anomaly/Defect (also commonly referred to as Congenital

Anomalies, Birth Defects, Congenital Disorders, Congenital Malformations,

or Congenital abnormalities)

o Habilitative Services

Supporting Information

Added

References

section

• Archived previous policy version BIP202.H

Washington

Federal/State Mandated Regulations

Revised language pertaining to

Revised Code of Washington 18.74.010

Instructions for Use

Covered benefits are listed in three (3) sections:

Federal/State Mandated Regulations

State Market Plan

Enhancements

, and

Covered Benefits

. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage,

limitations, and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a

discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.