Appendix C - Habilitative Services

Appendix C: Habilitative Services Benefit Data Elements
Table 1
Habilitative
Services

Covered
Inpatient

Covered
Outpatient

Limits

Physical Therapy

Y/N

Y/N

Occupational
Therapy

Y/N

Y/N

Describe
Limits
Describe
Limits

Speech-Language Y/N
Pathology

Y/N

Other Services –
please list all
other services
covered

Free text

Free text

Exclusions
(incl. diagnosis
exclusions)
Describe
Exclusions
Describe
Exclusions
Describe
Exclusions

Describe
Limits

Describe
Exclusions

Table 2
Habilitative
Devices
Durable Medical
Equipment

Covered?

Limits

Y/N

Describe
Limits

Prosthetics

Y/N

Orthotics

Y/N

Describe
Limits
Describe
Limits
Describe
Limits
Describe
Limits
Describe
Limits

Mobility Equipment Y/N
Supplies

Y/N

Other Devices Describe
please list all other additional
Devices
device types
covered for
habilitative
purposes

Exclusions (incl.
diagnosis exclusions)
Describe Exclusions

Describe Exclusions
Describe Exclusions
Describe Exclusions
Describe Exclusions
Describe Exclusions