l****k
发帖数: 48 | 1 它COVER的有：
Rehabilitation Services Outpatient Therapy and Manipulative Treatment
Short‑term outpatient rehabilitation services for:
● Physical therapy;
● Occupational therapy;
● Manipulative treatment
● Speech therapy;
· Cognitive rehabilitation therapy;
● Pulmonary rehabilitation
therapy; and
● Cardiac rehabilitation therapy.
For all rehabilitation services, a licensed therapy provider, under the
direction of a Physician, must perform the services.
Benefits can be denied or shortened for Covered Persons who are not
progressing in goal-directed rehabilitation services or if rehabilitation
goals have previously been met.
$30 copay per visit then 100% of eligible expenses.
Any combination of Network and Non-Network Benefits is limited as follows:
● 60 visits of physical, occupational, manipulative and speech therapy
combined per calendar year.
● 36 visits of pulmonary rehabilitation therapy per calendar year.
● 36 visits of cardiac rehabilitation therapy per calendar year.
· 20 visits of cognitive rehabilitation therapy per calendar year.
70% of eligible expenses after satisfying $2,000 deductible.
Any combination of Network and Non-Network Benefits is limited as follows:
● 60 visits of physical, occupational, manipulative and speech therapy
combined per calendar year.
● 36 visits of pulmonary rehabilitation therapy per calendar year.
● 36 visits of cardiac rehabilitation therapy per calendar year.
· 20 visits of cognitive rehabilitation therapy per calendar year.
Notification Required
If you don't notify us, Benefits will be subject to a $400
Neurobiological Disorders - Mental Health Services for Autism Spectrum
Disorders
The Plan pays Benefits for psychiatric services for Autism Spectrum
Disorders that are both of the following:
● Provided by or under the
direction of an experienced psychiatrist and/or an experienced licensed
psychiatric provider; and
● Focused on treating
maladaptive/stereotypic behaviors that are posing danger to self, others and
property and impairment in daily functioning.
These Benefits describe only the psychiatric component of treatment for
Autism Spectrum Disorders. Medical treatment of Autism Spectrum Disorders is
a Covered Health Service for which Benefits are available as described
under the Enhanced Autism Spectrum Disorders benefit below.
Benefits include the following services provided on either an outpatient or
inpatient basis:
● diagnostic evaluations
and assessment;
● treatment planning;
● referral services;
● medication management;
● individual, family,
therapeutic group and provider-based case management services; and
● crisis intervention
Benefits include the following services provided on an inpatient basis:
● Partial
Hospitalization/Day Treatment;
● services at a Residential
Treatment Facility;
Benefits include the following services provided on an outpatient basis:
● Intensive Outpatient
Treatment.
Services received on an inpatient basis in a Hospital or Alternate Facility:
$500 copay per admission, then 100% of eligible expenses.
Services received on an outpatient basis in a provider’s office or at an
Alternate Facility:
$15 copay per visit then 100% of eligible expenses.
You are not required to provide pre-service notification when you seek these
services from Network providers. Network providers are responsible for
notifying the Mental Health/Substance Use Disorder Administrator before they
provide these services to you.
Network provider ONLY will be responsible for obtaining the following
notification requirements:
● Neurobiological Disorders - Mental Health Services for Autism Spectrum
Disorder - inpatient services (including Partial Hospitalization/Day
Treatment and services at a Residential Treatment facility).
For a scheduled admission, Network provider must notify the Mental Health/
Substance Use Disorder Administrator prior to the admission, or as soon as
is reasonably possible for non-scheduled admissions (including Emergency
admissions).
Services received on an inpatient basis in a Hospital or Alternate Facility:
70% of eligible expenses after $500 per admission and satisfying the $2,000
deductible.
Services received on an outpatient basis in a provider’s office or at an
Alternate Facility:
70% of eligible expenses after satisfying $2,000 deductible.
Notification Required
You must provide pre-service notification as described below.
When Benefits are provided for any of the services listed below, the
following services require notification:
● Neurobiological Disorders - Mental Health Services for Autism Spectrum
Disorder - inpatient services (including Partial Hospitalization/Day
Treatment and services at a Residential Treatment facility).
For a scheduled admission, you must notify the Mental Health/Substance Use
Disorder Administrator prior to the admission, or as soon as is reasonably
possible for non-scheduled admissions (including Emergency admissions).
Exclusions listed directly below apply to services described under Mental
Health Services, Neurobiological Disorders - Mental Health Services for
Autism Spectrum Disorders and/or Substance Use Disorders
The following services are not covered:
● Services performed in connection with conditions not classified in the
current edition of the Diagnostic and Statistical Manual of the American
Psychiatric Association;
● services or supplies for the diagnosis or treatment of
Mental Illness, alcoholism or substance use disorders that, in the
reasonable judgment of the Mental Health/Substance Use Disorder
Administrator, are any of the following:
● not consistent with generally accepted standards of
medical practice for the treatment of such conditions;
● not consistent with services backed by credible
research soundly demonstrating that the services or supplies will have a
measurable and beneficial health outcome, and therefore considered
experimental;
● not consistent with the Mental Health/Substance
Use Disorder Administrator’s level of care guidelines or best practices as
modified from time to time; or
● not clinically appropriate for the patient’s mental
illness, substance use disorder or condition based on generally accepted
standards of medical practice and benchmarks.
● Mental Health Services as treatments for V-code
conditions as listed within the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association;
● Mental Health Services as treatment for a primary
diagnosis of insomnia, other sleep disorders, sexual dysfunction disorders,
feeding disorders, neurological disorders and other disorders with a known
physical basis;
● Treatments for the primary diagnoses of learning disabilities, conduct
and impulse control disorders, personality disorders and, paraphilias (
sexual behavior that is considered deviant or abnormal);
● educational/behavioral services that are focused on
primarily building skills and capabilities in communication, social
interaction and learning;
● tuition for or services that are school-based for
children and adolescents under the Individuals with Disabilities Education
Act;
● learning, motor skills and primary communication
disorders as defined in the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association;
● mental retardation as a primary diagnosis defined in the current
edition of the Diagnostic and Statistical Manual of the American Psychiatric
Association;
● methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol),
Cyclazocine, or their equivalents for drug addiction;
● intensive behavioral therapies such as applied
behavioral analysis for Autism Spectrum Disorders;
● any treatments or other specialized services designed
for Autism Spectrum Disorder that are not backed by credible research
demonstrating that the services or supplies have a measurable and beneficial
health outcome and therefore considered Experimental or Investigational or
Unproven Services | l****k
发帖数: 48 | 2 抱歉打了这么多，主要是它明确表明不会支持ABA，还有其他的以增加功能和交流能力
为主的基础性训练。然后如果是跨网络的话，我还要缴纳2000然后每次拿到百分之七十
的报销。我觉得整个PLAN都很恶心，就这样也舔着大脸跟我说EVERYTHING HAS BEEN
TAKEN CARE OF? 如果我不要这份保险，有办法跟公司要别的么？或者让这个保险公司
加东西？
这个是BLUE PLAN的，我不明白美国的保险，这是啥意思？
谢谢大家。我在国内看到这个火很大。 | g*********9
发帖数: 3528 | 3 如果你的公司有其他保险的话，找找看其他保险的条例看看。否则也没有选择了。至于
保险这个东西，你比较一下单独买外面的保险，再看看公司给你付了多少。好一点的保
险，全价买的话一般family一家$1000+/月。保险是要赚钱的，铁定赔本的生意不会做。
至于保险不支持ABA，不是最后一条还开了一些口子么，你仔细研究研究，也许能争取
到一些治疗。
【在 l****k 的大作中提到】
: 抱歉打了这么多，主要是它明确表明不会支持ABA，还有其他的以增加功能和交流能力
: 为主的基础性训练。然后如果是跨网络的话，我还要缴纳2000然后每次拿到百分之七十
: 的报销。我觉得整个PLAN都很恶心，就这样也舔着大脸跟我说EVERYTHING HAS BEEN
: TAKEN CARE OF? 如果我不要这份保险，有办法跟公司要别的么？或者让这个保险公司
: 加东西？
: 这个是BLUE PLAN的，我不明白美国的保险，这是啥意思？
: 谢谢大家。我在国内看到这个火很大。
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