Services Subject to a Deductible: Outpatient Therapy and Home Health Care

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Jun 19, 2018

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Participating Provider Services Subject to Calendar Year Deductible
(The following introductory wording is a summary. See “Benefits and Claim Procedures: Health Insurance co-pays and deductibles: A Primer” for complete wording.)

(Typical wording*):

Subject to all Policy limitations, exclusions, applicable deductibles, co-pays and maximums, the Company agrees to pay for Policy-defined Covered Expenses for the following described services, if they are Medically Necessary:

6. Outpatient Therapy: Services Provided by Participating Providers, Hospitals, or other medical facilities in connection with the following types of therapy received on an Outpatient basis by an Insured due to Injuries or Sickness:

a. Radiation therapy;
b. Chemotherapy;
c. Occupational therapy;
d. Physical therapy – not to exceed 25 treatments or a maximum Benefit of $2,000 per Calendar Year per Insured;
e. Rehabilitation therapy; and
f. Speech therapy.

7. Home Health Care: Services Provided to an Insured by participating Providers due to Injuries or Sickness for the care specified in a Home Health Care Plan, up to a Covered Expense maximum per day of 50% of the amount of the semi-private room rate of either (i) the Hospital where such Insured was Confined immediately prior to the development of the Home Health Care Plan, or (ii) the Skilled Nursing Home where said Insured was a resident immediately prior to the development of the Home Health Care Plan. Such expenses incurred by an Insured as the result of a Home Health Care Plan are payable for an Insured, if:

a. The Insured had first been Confined in a Hospital or was a resident at a Skilled Nursing Home due to an Injury or Sickness;
b. The Home Health Care Plan of the Insured begins no later than thirty (30) days after discharge from the Hospital or Skilled Nursing Home; and
c. The Home Health Care Plan is for the same or related Injury or Sickness at the Hospital or Skilled Nursing Home Confinement.

The applicable Provider must certify that the Insured would have to be in a Hospital or Skilled Nursing Home (and receive a level of care greater than Custodial Care) if Home Health Care Plan services had not been available.

Payment under this coverage is limited to a period of a maximum of 120 days during a twelve (12) consecutive month period.

The outpatient therapy section is fairly self-explanatory – coverage for many types of therapy is provided. In fact, if you have a need for some other type of therapy not specifically listed, but similar in nature to one of the listed types, it would be well worth your while to inquire of the company as to whether they will cover it under this provision. Coverage is constantly evolving as new methods of treatment are accepted by the medical profession as valid and legitimate. It is possible that the company may be on the verge of covering a new type of therapy. Technically, under the express terms of the policy, the company is not required to provide coverage for a type of therapy not listed. But, it doesn’t hurt to ask.

A “Home Health Care Plan’ is a medically necessary program of care, established by an insured’s provider, taking place in a residential setting.

A “Skilled Nursing Home” is a facility which:

  1. charges patients for their services;
  2. is legally licensed;
  3. has beds for patients who need medical and skilled care;
  4. operates under a doctor’s supervision;
  5. has continuous 24-hour nursing service supervise by an R.N.; and
  6. keeps complete medical records on each patient.

“Custodial Care” means care given mainly to meet personal needs. It may be provided by persons without professional skills or training.

You will note that home health care plan coverage is only available if the plan provides for more than custodial care, immediately follows confinement in a hospital or residence in a skilled nursing home, and is for the same or a related condition. There are also limitations on the amount and duration of benefits available.

*Wording may vary from contract to contract and from state to state.

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