Neurodevelopmental
Therapy – 90%
Benefits are provided for
medically necessary neurodevelopmental therapy prescribed by a physician to
restore and improve function for children age six and under. There is an annual
maximum benefit of $1,500. If expenses exceed this $1,500 annual maximum, this
plan will not pay the additional costs. This benefit includes maintenance
services for identifiable underlying causes when significant deterioration of
the child’s condition would result without the service.
The
child’s physician must
preauthorize
treatment with the Trust Office and must
periodically review the written treatment plan specifically describing the
neurodevelopmental therapy services provided. Progress notes may be required by
the Trust Office.
Benefits
are provided as follows:
- Services
and supplies for physical, speech and occupational therapy when performed by a
physician or a physical, speech or occupational therapist in the office, clinic
or outpatient hospital department.
- Inpatient
hospital and skilled nursing facility services and supplies for an inpatient
neurodevelopmental therapy admission when care cannot safely be provided on an
outpatient basis.
Benefits
are not
provided for:
- Custodial
or maintenance care (except as specified above), nonmedical self-help or related
testing, recreational, educational, cognitive, behavioral, or vocational
therapy; gym or pool therapy; or sensory integration therapy.
- Speech
therapy for self-correcting dysfunction, such as hoarseness or language therapy
for young children with natural dysfluency; oral myofunctional therapy;
stammering and stuttering; or tongue thrust. Developmental articulation errors
that are self-correcting are also not covered.
- State-required
medical assessments for specialized educational programs; services or supplies
required by law to be provided by any school system; or treatment for learning
disabilities. This exclusion applies regardless of the recommendation of the
attending physician.
- Neurodevelopmental
therapy and rehabilitation care for the same condition.
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