| HMO | Occupational Therapy |
| Aetna US Healthcare | Covers: Occupational therapy for non-chronic conditions, illnesses, and injuries.
Limits: Covers treatment for a 60-day period per incident of illness or injury. Requires referral of PCP and prior approval by Aetna. Cost Sharing Copayment applies. Excludes: Vocational rehabilitation or employment counseling. |
| Blue Cross Blue Shield | Covers: Outpatient short-term rehabilitation services for conditions which are expected to show significant improvement through short-term therapy, as determined by the PCP.
Limits: Limited to a maximum of 30 visits per calendar year. Cost Sharing: Copayment applies. |
| CIGNA / Healthsource | Covers: Short-term services for conditions that are expected to show significant improvement within a 60-day period, as determined by CHCNC.
Limits: Visit limits apply. Cost Sharing: Copayment applies |
| Doctors Health Plan | Covers: Occupational therapy for conditions expected to show significant improvement, as determined by Doctors Health Plan.
Limits: Limited to 20 visits per illness per injury. Requires precertification or prior authorization from Doctors and must be provided by participating provider or facility unless there is no participating provider available. |
| Generations | Covers: Short-term occupational therapy to restore self-care and the ability to function in the activities of daily living (such as dressing, feeding, bathing, etc.)
Limits: Only covers services determined to be medically necessary by Generations’ Medical Management Department. Benefits limited to maximum of 30 visits per incident per contract year. Exclusions: Therapy to correct impairment resulting from a functional disorder. Excludes vocational rehabilitative services. |
| Optimum Choice | Covers: Medically necessary and treatable short-term occupational therapy. Services covered to restore an individual’s loss of function due to an injury, or sickness.
Limits: Therapy is limited to conditions which are subject to significant improvement in the member’s condition. Rehabilitative therapy is limited to a combined treatment period of 60 days per condition. For inpatient rehabilitative services, one day equals one visit. Cost Sharing: Copayments may apply. |
| PARTNERS | Covers: Inpatient and outpatient, short-term physical therapy for treatment expected by Partners to result in significant improvement of member’s condition.
Limits: Limited to 24 visits per spell of illness for acute conditions. (Acute defined as medical condition resulting from a sudden onset of disease or injury.) Coverage may also include up to 12 visits (as part of maximum of 24) per calendar year for patients with developmental abnormalities (e.g. cerebral palsy), primarily for parental instruction and monitoring. Excludes: Therapy for chronic conditions, long-term physical therapy. |
| Coventry/Principal Health Care of the Carolinas | Covers: Short- term occupational therapy to restore normal physical functions due to trauma, stroke or a surgical procedure.
Limits: Therapy is limited to conditions that are expected to show significant improvement in 60 days. Benefits for therapy and/or treatment will be discontinued if it is determined within the first two weeks of therapy that the member’s condition will not significantly improve. |
| QualChoice | Covers: Medically necessary occupational therapy services in a licensed therapist’s office or in a hospital. May impose visit limits. |
| The Wellness Plan of North Carolina, Inc. | Covers: Short-term restorative rehabilitation services for conditions that are expected to show significant improvement through short-term therapy, as determined by TWP-NC.
Limits: Occupational therapy limited to 20 sessions per illness or injury. Prior authorization is required. |
| United HealthCare | Covers: Short-term occupational therapy provided under the direction of a participating provider.
Limits: Limited to 20 visits per member per calendar year. Requires prior approval. Inpatient services are covered under the medical inpatient benefits. Cost Sharing: Copayments may apply. |
| WellPath | Covers: Occupational therapy if WellPath determines the condition is expected to significantly improve within 60 days. Also covers short-term inpatient therapy if the member is already receiving inpatient care and services can only be provided on an inpatient basis.
Limits: Must be provided by a participating provider with prior approval from WellPath. Limited to maximum treatment period of 60 consecutive days per illness or injury. If services for the same condition are received on both an inpatient and outpatient basis, total coverage for both is limited to a maximum treatment period of 60 consecutive days. Cost Sharing: Copayment applies. |