Habilitative Services
Page 1 of 4
UnitedHealthcare West Benefit Interpretation Policy
Effective 12/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
UnitedHealthcare
®
West
Benefit Interpretation Policy
Habilitative Services
Policy Number: BIP201.I
Effective Date: December 1, 2023
Instructions for Use
Table of Contents Page
Federal/State Mandated Regulations .......................................... 1
State Market Plan Enhancements ................................................ 2
Covered Benefits ........................................................................... 2
Not Covered ................................................................................... 3
Definitions ...................................................................................... 3
References ..................................................................................... 3
Policy History/Revision Information ............................................. 3
Instructions for Use ....................................................................... 4
Federal/State Mandated Regulations
California Code of Regulations, Title 28, § 1300.67. Scope of Basic Health Care Services.
Section 1300.67 - Scope of Basic Health Care Services, Cal. Code Regs. tit. 28 § 1300.67 | Casetext Search + Citator
The basic health care services required to be provided by a health care service plan to its enrollee’s shall include, where
medically necessary, subject to any copayment, deductible, or limitation of which the Director may approve:
(c) Ambulatory care services, (outpatient hospital services) which shall include diagnostic and treatment services, physical
therapy, speech therapy, occupational therapy services as appropriate and those hospital services, which can reasonably
be provided on an ambulatory basis. Such services may be provided at a hospital, any other appropriate licensed facility, or
any appropriate facility which is not required by law to be licensed, if the professionals delivering such services are licensed
to practice, are certified, or practice under the authority of the plan, a medical group, or individual practice association or
other authority authorized by applicable California law.
Rehabilitation and Habilitative Services and Therapy
Rehabilitation and Habilitative Services and therapy will be provided only as Medically Necessary and are provided by a
Participating Provider acting within the scope of his or her license or as authorized under California law and are either limited or
not covered, as follows:
Speech, occupational or physical therapy is not covered when medical or mental health documentation does not support
the Medical Necessity because of the Member’s inability to progress toward the treatment plan goals or when a Member
has already met the treatment goals.
Speech therapy is limited to Medically Necessary therapy to treat speech disorders caused by an illness, including Mental
Disorders and Severe Mental Illness and Serious Emotional Disturbances of a Child, injury or surgery (for example, cleft
palate repair) and are provided by a Participating Provider acting within the scope of his or her license or as authorized
under California law.
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 of California (HMO)
UnitedHealthcare Benefits Plan of California (EPO/POS)
Habilitative Services
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UnitedHealthcare West Benefit Interpretation Policy
Effective 12/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
State Market Plan Enhancements
None
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 individual or group:
• 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 with a disabling
condition, including autism spectrum disorder and pervasive developmental disorder when both of the following conditions are
met:
The treatment is ordered/performed by a physician and is administered by a licensed therapy provider, or qualified autism
service provider, or other provider licenses or by a provider acting within the scope of his or her license or as certified or
otherwise authorized under California law.
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.
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 or in an
organized multidisciplinary rehabilitation day-treatment program).
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.
Habilitative Services
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UnitedHealthcare West Benefit Interpretation Policy
Effective 12/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
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 recreation, vocational training and residential treatment.
In the absence of a disabling condition, services to improve general physical condition are excluded from coverage.
Coverage can be discontinued when the treatment plan goals and objectives are achieved or no longer appropriate.
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.
Activities that are solely recreational, social or for general fitness such as, gym and fitness club memberships and fees,
health club fees, dancing classes, exercise equipment or supplies.
Biofeedback services are excluded on most plans. Refer to the member specific benefit documents.
Hypnotherapy
Cognitive behavioral therapy, unless medically necessary and provided by a Participating Provider acting within the scope
of his or her license or as authorized under California law.
Vocational habilitation
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.
Work Hardening/Work Rehabilitation: Work Hardening/rehabilitation 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 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.
Policy History/Revision Information
Date
Summary of Changes
12/01/2023
Definitions
Removed definition of:
o Custodial Care
o Habilitative Services
Habilitative Services
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UnitedHealthcare West Benefit Interpretation Policy
Effective 12/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
Date
Summary of Changes
Updated definition of:
o Congenital Anomaly/Defect (also commonly referred to as Congenital Anomalies, Birth Defects,
Congenital Disorders, Congenital Malformations, or Congenital abnormalities)
o Work Hardening/Work Rehabilitation
Supporting Information
Added
References
section
Archived previous policy version BIP201.H
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.
