Policy Attachment

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Attachment A to Policy # 10.06.01d Outpatient Speech Therapy


View the policy for this attachment here:

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NEW JERSEY STATE MANDATE BY THE DEPARTMENT OF BANKING AND INSURANCE FOR BIOLOGICALLY-BASED MENTAL ILLNESS (BBMI) REGULATIONS


For members enrolled in a New Jersey product, speech, physical, and occupational therapy services may be covered and eligible for reimbursement for the treatment of persons with a BBMI, provided that the therapy is determined by the Company to be medically necessary and not considered experimental or investigational. Coverage of speech, physical, and occupational therapy is subject to the same terms and conditions that apply to other medical or surgical benefits, including product- or group-specific limits. Benefit limits are any restriction, condition, or limitation (including, but not limited to, visit limits, dollar limits, and precertification/preapproval requirements) applied to the provision of services or benefits in a health insurance policy or health maintenance organization contract.

Members enrolled in a New Jersey product who have met the criteria in this policy and have a condition listed under the definition of BBMI by the state of New Jersey shall be subject to the same benefit terms and conditions except that the following exclusions cannot be used to discontinue speech, physical, and occupational therapy services:

Exclusions for the continued coverage of speech, physical, and occupational therapy do not apply when the therapy is provided for the treatment of the following:

• Behavioral problems
• Chronic conditions
• Developmental disorders or developmental delay
• Learning disabilities

In addition, exclusions for the continued coverage of speech, physical, and occupational therapy do not apply to therapy that is defined as follows:

• Non-restorative (ie, therapy that does not restore previously possessed function, skill, or ability)
• Provided on a long-term basis
• Rendered after a fixed period of time from an injury, procedure, or the onset of illness

As defined by the New Jersey State Mandate on BBMI, conditions included under BBMI include, but are not limited to the following:

• Autism or pervasive developmental disorder
• Bipolar disorder
• Major depressive disorder
• Obsessive-compulsive disorder
• Panic disorder
• Paranoia and other psychotic disorders
• Schizoaffective disorder
• Schizophrenia
  

  Version Effective Date: 11/13/2009