Outpatient Medical Self-Care Programs
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Defines Aetna's coverage stance for outpatient self-care programs (e.g., diabetes education, cardiac/pulmonary rehabilitation, back school) including required program elements and limitations; applies to Aetna members where plan benefits allow.
No material clinical or coverage changes in this revision.
Coverage Criteria for Outpatient Medical Self-Care Programs
Medical Necessity Criteria
Aetna considers the following interventions medically necessary when ALL conditions are met:
See related CPBs for program-specific criteria
Includes dietitians and respiratory therapists when required by law or criteria met
Charges should be billed by the doctor or hospital employer or provided under supervision of a recognized facility or home health agency.
Work hardening programs are excluded (vocational rehabilitation); participation is generally considered medically necessary once per lifetime unless another episode of illness occurs.
Coverage is not extended for outpatient self-care programs that: (1) are available to the general public without charge; (2) are general health or lifestyle education programs not related to the member's diagnosis or condition; or (3) consist of services not generally accepted as necessary and appropriate for management of the disease or injury.
Work hardening programs are not considered covered outpatient self-care programs under Aetna medical plans because their primary goal is return to work rather than treatment of a disease or injury; these programs are a form of vocational rehabilitation and therefore excluded.
Provider Responsibilities, Documentation, and Billing
Verify plan coverage and coordination requirements
Coverage for outpatient medical self-care programs is subject to the member's plan coverage definitions and limitations; providers must check the member's benefit plan description for details and any coordination requirements with Aetna Patient Management for network plans.
Obtain physician prescription and confirm billing responsibility
Ensure the program is prescribed by the attending physician for a member with a medical condition amenable to self-care and that charges are billed by the doctor or hospital employer; confirm services are covered under the member's policy before proceeding.
Required documentation, supervision, and billing
Document that the program is prescribed by the attending physician, directed and supervised by a physician, delivered by recognized health care professionals, and billed by the doctor or hospital employer (or provided under the supervision of a recognized facility or home health agency). For Aetna network plans, coordinate the program with Aetna's Patient Management Department.
- Program prescribed by attending physician for the member's specific medical condition.
- Program directed and supervised by a physician.
- Services provided by recognized professionals (doctors, RNs, social workers, PTs, dietitians, respiratory therapists, etc.) and billed by their employer.
- Coordinate with Aetna Patient Management for Aetna network plans.
Avoid billing non-covered programs
Do not bill or seek coverage for programs that are available to the general public without charge, are general health or lifestyle education not related to the member's diagnosis, or consist of services not generally accepted as necessary and appropriate for management of the disease or injury — such programs are non-covered and may trigger claim denials.
- Programs available to the general public without charge.
- General health or lifestyle education programs not related to the member's diagnosis.
- Services not generally accepted as necessary and appropriate for disease or injury management.
Definitions
Background
Outpatient medical self-care programs are structured, evidence-informed interventions designed to teach and support patients in day-to-day management of chronic conditions. Typical components include education on diet, exercise, medication administration, monitoring of disease, activity modification and guidance on obtaining appropriate follow-up care. These programs must be prescribed by the attending physician, directed and supervised by a physician, and delivered by recognized health care professionals (for example, dietitians or respiratory therapists when required), and they are intended to improve disease control and self-management rather than provide vocational training. Participation for a particular illness is generally considered medically necessary once per lifetime unless another episode of illness justifies an additional program.
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