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 individual’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 be safely provided on an
outpatient
basis.
Benefits
are
not
provided for:
- Custodial
care; maintenance (except as specified above), nonmedical self-help or related
testing, recreational, educational, cognitive, behavioral, or vocational
therapy; gym or swim 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 rehabilitative care for the same condition.
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