The functional assessment of the member as related to the continuation of rehabilitation services is performed by one or more rehabilitation professionals.

Rehabilitation in an inpatient, outpatient or home health setting enables the member to achieve a high level of functional independence. Rehabilitation programs common to hospital settings (inpatient or outpatient) include:

Institutional and professional services provided for inpatient and outpatient rehabilitation are covered. Refer to the Health Net Provider Participation Agreement (PPA) for financial responsibility information.

The program is considered medically necessary and reasonable only for a member with a clear medical need and who is referred by their attending physician. The member must have one of the following:

The Health Net Medicare Advantage (MA) and Cal MediConnect plans cover cardiac rehabilitation when services are provided in an outpatient department of a hospital or a physician-directed clinic.

Services that may be covered include diagnostic stress testing, electrocardiogram (ECG) rhythm strips, therapeutic psychotherapy and psychological diagnostic testing, physical and occupational therapy, and member education services.

The duration of the cardiac rehabilitation program may be considered reasonable and necessary for up to 36 sessions (usually three sessions a week in a single 12-week period). Services may be covered only when supported by the attending physician's documentation.

Cardiac rehabilitation in excess of 12 weeks is covered only on a case-by-case basis.

To receive home health services, a member must be confined to the home, under the care of a participating provider and be in need of physical therapy (PT), respiratory therapy (RT), speech therapy (ST), occupational therapy (OT), or nursing services.

These services must relate directly and specifically to an active treatment plan written by the participating provider after the physician consults with a qualified therapist. The therapy must be reasonable and necessary to the treatment of the member's illness or injury.

Neuromuscular rehabilitation programs are directed by a physician experienced or trained in neuromuscular rehabilitation, and supported by rehabilitative nursing. The ancillary services of physical therapy (PT) and occupational therapy (OT) are necessary for all of the programs cited. Psychological and social services should be provided depending on the member's need. In addition to these basic services, the stroke rehabilitation program may require PT and OT, and the pulmonary rehabilitation program may require inhalation therapy.

For Health Net Medicare Advantage (MA) and Cal MediConnect plans, the following Medicare guidelines are provided for assistance in authorizing neuromuscular rehabilitation services:

Services related to activities for the general good and welfare of members, for example, general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute PT or OT services for Medicare purposes and, consequently, are not covered.

While coverage for standard rehabilitation therapy is based on continuous functional improvement in response to the treatment plan that is demonstrated by objective evidence, the optional coverage requires only that the services improve the condition or relieve symptoms and maintain or increase the member's level of functional independence.

After a maximum of one year of optional rehabilitative therapy, coverage returns to the standard benefit. Thereafter, additional therapy is covered only if there is continuous functional improvement in response to the treatment plan, as demonstrated by objective evidence.

Providers must use the Urgent Request for Continuing Occupational, Physical or Speech Therapy (PDF) concurrent review form for HMO/POS, PPO, EPO, and Medicare Advantage members continuing physical, occupational or speech therapy and home health services. Completed forms must be faxed to the Health Net Prior Authorization Department.