AUTISM SPECTRUM DISORDERS any of the pervasive developmental disorders defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, or its successor, including autistic disorder, Asperger’s disorder and pervasive developmental disorder not otherwise specified.
AUTISM SPECTRUM DISORDERS. Covered Services include Medically Necessary services that are generally recognized and accepted procedures for screening, diagnosing and treating Autism Spectrum Disorders for Insureds under the age of 18 or, if enrolled in high school, until such Insured reaches the age of 22. Covered Services must be provided by a duly licensed physician, psychologist or Behavior Analyst (including an Assistant Behavior Analyst and/or Autism Behavior Interventionist) or other provider that is supervised by the licensed physician, psychologist or behavior analyst and are subject to SHL’s Managed Care Program. With the exception of the specific limitation on benefits for Applied Behavior Analysis (“ABA”) as outlined in Attachment A Benefit Schedule, benefits for all Covered Services for the treatment of Autism Spectrum Disorders are payable to the same extent as other Covered Services and Covered Drugs under the Plan. Covered Services for the treatment of Autism Spectrum Disorder do not include services provided by: • an early intervention agency or school for services delivered through early intervention, or • school services.
AUTISM SPECTRUM DISORDERS. The Outline of Coverage specifies Autism Spectrum Disorder coverage and how it applies. When Autism Spectrum Disorder coverage is applicable, refer to the following: For Participants under twenty-one (21) years of age or as indicated on the Outline of Coverage, coverage will be provided for the diagnostic assessment of Autism Spectrum Disorders and for the treatment of Autism Spectrum Disorders up to a Maximum benefit of $36,000* or as indicated on the Outline of Coverage per Participant per Benefit Period. Once the Benefit Period Maximum has been reached, no additional Covered Services are available under the agreement for the remainder of the Benefit Period for the diagnostic assessment and/or treatment of the Participant's Autism Spectrum Disorder. When a Provider renders Medical Care for treatment of a health condition unrelated to or distinguishable from the Participant's Autism Spectrum Disorder, payment for such Medical Care will be based on the medical Covered Services available and will not be applied toward this dollar Maximum. No coverage is provided for Participants age twenty-one (21) and over or as indicated on the Outline of Coverage. Treatment of Autism Spectrum Disorders shall be identified in a Treatment Plan for ASD and shall include any of the following Medically Necessary services: Pharmacy Care, Psychiatric Care, Psychological Care, Rehabilitative Care, and Therapeutic Care that is:
AUTISM SPECTRUM DISORDERS. The treatment is administered by a licensed speech-language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist and • the initial or continued treatment must be proven and not Experimental or Investigational. Coverage for Habilitative Services does not apply to those services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential treatment are not Habilitative Services. A service that does not help the Insured to meet functional goals in a treatment plan within a prescribed time frame is not a habilitative service. When the Insured reaches his maximum level of improvement or does not demonstrate continued progress under a treatment plan, a service that was previously habilitative is no longer habilitative. SHL may require that a treatment plan be provided, request medical records, clinical notes, or other necessary data to allow us to substantiate that initial or continued medical treatment is needed and that the Insured’s condition is Form No. SHL-Ind_AOC(2015) Page 17
