1. Autism Services
Coverage shall be provided for the Medically Necessary diagnosis and treatment of Autism Spectrum Disorders based on an approved treatment plan. A treatment plan will be reviewed not more than once every six months unless the Covered Person’s licensed
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Physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or as a result of changes in the Covered Person’s treatment plan.
Covered Services include:
Behavior Therapy rendered by an Autism Behavioral Therapy Provider and ordered by a licensed Physician, psychologist or clinical social worker in
accordance with a treatment plan developed by a licensed Physician, psychologist or licensed clinical social worker;
Direct psychiatric or consultative services provided by a licensed psychiatrist;
Direct psychiatric or consultative services provided by a licensed psychologist;
Physical therapy provided by a licensed physical therapist;
Speech therapy provided by a licensed speech and language pathologist; and
Occupational therapy provided by a licensed occupational therapist.
Visit limits for physical, speech and occupational therapy will not apply to Autism Spectrum Disorder services.
2. Chemotherapy for the treatment of cancer.
3. Chiropractic Therapy.
4. Early Intervention Services are provided for an eligible enrolled child from birth to age three (36 months) who is not eligible for special education and related services pursuant to Connecticut law.
Services under this section are limited to children who:
a. Are experiencing a significant developmental delay as measured by standardized diagnostic instruments and procedures, including informed clinical opinion, in one or more of the following areas:
Cognitive development;
Physical development, including vision or hearing;
Communication development;
Social or emotional development; or
Adaptive skills; or
b. Are diagnosed as having a physical or mental condition that has a high probability of resulting in a developmental delay.
For the purpose of this benefit, Early Intervention Services are services:
Designed to meet the developmental needs of an eligible Participant and the needs of his or her family related to enhancing the child’s development;
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Selected in collaboration with the parents of the eligible Participant;
Services under this section are subject to a maximum benefit of $6,400 per covered Child per Plan Year and an aggregate per child maximum benefit per child of $19,200 over a three year period.
5. Electroshock Therapy.
6. Infusion Therapy: Benefits will be provided Infusion Therapy administered in an Outpatient Hospital, Physician Office or home under the following conditions:
A plan of care for such services is prescribed in writing by a Physician (M.D.);
The plan of care is reviewed, and certified by the Physician (M.D.), and, in the case of POE Plan Members, approved by the Carrier.
Infusion Therapy is limited to:
Chemotherapy (including gamma globulin);
Intravenous antibiotic therapy;
Total parenteral nutrition;
Enteral therapy when nutrients are only available by a Physician’s prescription; and
Intravenous pain management.
Covered Services include supplies, solutions and pharmaceuticals. Exclusions and Limitations
Whether Infusion Therapy is provided in an Outpatient Hospital program, Physician’s office or a combined Outpatient Hospital and home program covered under this Benefit Plan, the benefits will not exceed the amount shown on the Schedule of Benefits.
7. Kidney Dialysis in a Hospital or free-standing dialysis center.
8. Outpatient cardiac rehabilitation therapy.
9. Outpatient physical and occupational therapy (requires Prior Authorization5);
Physical and occupational therapy is covered only when reasonable and necessary to correct a condition that is the result of a disease, injury or congenital physical deformity that inhibits normal function.
To be considered reasonable and necessary, the following conditions must be met:
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a. The services must be considered under accepted standards of medical practice to be a specific, safe, and effective treatment for the Member's condition;
b. The services must be of such a level of complexity and sophistication or the condition of the Member must be such that the services required can safely and effectively be performed only by a qualified physical therapist or by a qualified physical therapy assistant under the supervision of a qualified physical therapist, by a qualified speech-language pathologist, or by a qualified occupational therapist or a qualified occupational therapy assistant under the supervision of a qualified
occupational therapist. Services that do not require the performance or supervision of a physical therapist or an occupational therapist are not considered reasonable or necessary physical therapy or occupational therapy services, even if they are performed by or supervised by a physical therapist or occupational therapist;
c. There must be an expectation that the Member’s condition will improve materially in a reasonable (and generally predictable) period of time based on the Physician's assessment of the Member's restoration potential and unique medical condition, or the services must be necessary to establish a safe and effective maintenance program required in connection with a specific disease, or the skills of a therapist must be necessary to perform a safe and effective maintenance program. If the services are for the establishment of a maintenance program, they may include the design of the program, the instruction of the Member, family, or home health aides, and the
necessary infrequent reevaluations of the Member and the program to the degree that the specialized knowledge and judgment of a physical therapist, or occupational therapist is required; and
d. The amount, frequency, and duration of the services must be reasonable. e. For out-of network services, coverage is limited to 30 outpatient days of service per year, prior authorization may be required.
10. Short-term Inpatient physical therapy and rehabilitation services. Radiation therapy.
12. Speech therapy is a Covered Service when prescribed by a Physician (M.D.), and provided by a licensed speech pathologist for treatment resulting from autism, stroke, tumor removal, injury or congenital anomalies of the oropharynx.