Medicaid therapy coverage
After a covered injury, illness or surgery, therapy services are generally a covered benefit.
- Physical therapy, cardiac rehabilitation, pulmonary therapy, occupational therapy, and speech therapy for treatment of medical diagnosis is covered if due to an injury, illness, or a congenital defect for which the patient has received corrective surgery.
- Therapy is limited to a 90-day period; services beyond 90 days require review for medical necessity. Use the Medical prior authorization form.
Rehabilitative medicine services
Short-term rehabilitative medicine services are covered if ALL of the following criteria are met:
- Services are received in an outpatient setting or in the home
- Services cannot be provided by any federal or state agency or by any local political subdivision, including school districts, when a member is not liable for the costs in the absence of insurance
- The therapy is restorative in nature and there is meaningful improvement within 90 days in the member's ability to perform functional day-to-day activities that are significant in the member's life and roles
- A physician refers, directs, and monitors the services.
Rehabilitative services provided in the home must be provided by a certified home care agency and based on medical policy.
Exclusions: Therapies not covered
Autism/developmental delay/cognitive disorder therapies
Therapies for developmental delays and cognitive disorders, including physical, occupational, speech, cognitive and sensory integration therapy, are not covered. Autism spectrum disorder services are covered by the State of Michigan and must be billed through Michigan Department of Community Mental Health. See the Autism Spectrum Disorders medical policy 91615.
Developmental delay and learning disability testing and evaluations should be requested and conducted by the child's school district.
Intelligence, developmental delay and learning disability testing and evaluations should be requested and conducted by the child's school district.
School-based services are excluded. They can be obtained through your local school system and include:
- Remedial education, including evaluation or treatment of learning disabilities, developmental and learning disorders, and behavioral training
- Services, treatment or diagnostic testing related to learning disabilities or developmental delays
- Education testing or training
- Services and supplies for mental retardation
- Physical, occupational, speech, cognitive and sensory integration therapy for developmental delay, apraxia and cognitive disorders
- Cognitive rehabilitation
- Scholastic/educational testing
Maintaining physical condition or maintenance therapy for a chronic condition is not a covered benefit. Maintenance therapies include:
- Maintenance therapy for patients with spinal cord injuries
- Therapy which is long-term in patients with cerebral palsy
- Long-term treatment for chronic (non-acute) musculoskeletal aches and pains