DIAGNOSIS AND TREATMENT OF AUTISM AND OTHER DEVELOPMENTAL DISABILITIES. We provide coverage for charges for the screening and diagnosis of autism and other developmental disabilities. If a Member’s primary diagnosis is autism or another developmental disability We provide coverage for the following medically necessary therapies as prescribed through a treatment plan. These are habilitative services in that they are provided to develop rather than restore a function. The therapy services are subject to the benefit limits set forth below:
DIAGNOSIS AND TREATMENT OF AUTISM AND OTHER DEVELOPMENTAL DISABILITIES. We provide coverage for charges for the screening and diagnosis of autism and other developmental disabilities. If a Member’s primary diagnosis is autism or another Developmental Disability We provide coverage for the following medically necessary therapies as prescribed through a treatment plan. These are habilitative services in that they are provided to develop rather than restore a function. The therapy services are subject to the benefit limits set forth below: occupational therapy where occupational therapy refers to treatment to develop a Member’s ability to perform the ordinary tasks of daily living; physical therapy where physical therapy refers to treatment to develop a Member’s physical function; and speech therapy where speech therapy refers to treatment of a Member’s speech impairment. Coverage for occupational therapy and physical therapy combined is limited to 30 visits per [Calendar] [Plan] Year for the treatment of conditions other than autism. Coverage for speech therapy is limited to 30 visits per [Calendar] [Plan] Year for the treatment of conditions other than autism. These therapy services are covered whether or not the therapies are restorative. The therapy services covered under this provision do not reduce the available therapy visits available under the Therapy Services provision. . If a Member’s primary diagnosis is autism, in addition to coverage for the therapy services as described above, We also cover medically necessary behavioral interventions based on the principles of applied behavior analysis and related structured behavioral programs as prescribed through a treatment plan. The treatment plan(s) referred to above must be in writing, signed by the treating physician, and must include: a diagnosis, proposed treatment by type, frequency and duration; the anticipated outcomes stated as goals; and the frequency by which the treatment plan will be updated. We may request additional information if necessary to determine the coverage under the Contract. We may require the submission of an updated treatment plan once every six months unless We and the treating physician agree to more frequent updates. Member Person: is eligible for early intervention services through the New Jersey Early Intervention System; and has been diagnosed with autism or other Developmental Disability; and receives physical therapy, occupational therapy, speech therapy, applied behavior analysis or related structured behavior services the portion of the f...
