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. If a Member: 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 family cost share attributable to such services is a Covered Charge under this Contract. The deductible, coinsurance or copayment as applicable to a physician visit for treatment of an Illness or Injury will apply to the family cost share. The therapy services a Member receives through New Jersey Early Intervention do not reduce the therapy services otherwise available under this Diagnosis and Treatment of Autism and Other Disabilities provision. NOTE: ANY SERVICES AND SUPPLIES A [MEMBER] RECEIVES AS [NETWORK] SERVICES AND SUPPLIES WILL REDUCE THE BENEFITS AVAILABLE AS A [NON-NETWORK] COVERED CHARGE. Fertility Services Subject to Our Pre-Approval We cover charges for procedures and Prescription Drugs to enhance fertility, except where specifically excluded in the Contract. We cover charges for: artificial insemination; and standard dosages, lengths of treatment and cycles of therapy of Prescription Drugs used to stimulate ovulation for artificial insemination or for unassisted conception. The Prescription Drugs noted in this section are subject to the terms and conditions of the Prescription Drugs section of the Contract. We will reduce benefits by 50% with respect to charges for Fertility Services which are not Pre-Approved by Us provided that benefits would otherwise be payable under the Contract. Preventive Care We cover charges for routine physical examinations including related laboratory tests and x-rays. We also cover charges for immunizations and vaccines, well baby care, pap smears, mammography , screening tests, bone density testing and Nicotine Dependence Treatment. [But We limit what We pay each [Calendar] [Plan] Year to: $750 per [Member] for a Dependent child from birth until the end of the [Calendar] [Plan] Year in which the Dependent child attains age 1, and $500 per [Member] for all other [Member]s.] These charges are not subject to any Copayment, Cash Deductible or Coinsurance. [The $750 and $500 limits do not apply to services from a Network Provider.] [Carriers may elect to cover non-network preventive care without any dollar limits.]
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. If a Member: 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 family cost share attributable to such services is a Covered Charge under this Contract. The deductible, coinsurance or copayment as applicable to a physician visit for treatment of an Illness or Injury will apply to the family cost share. The therapy services a Member receives through New Jersey Early Intervention do not reduce the therapy services otherwise available under this Diagnosis and Treatment of Autism and Other Disabilities provision. NOTE: ANY SERVICES AND SUPPLIES A [MEMBER] RECEIVES AS [NETWORK] SERVICES AND SUPPLIES WILL REDUCE THE BENEFITS AVAILABLE AS A [NON-NETWORK] COVERED CHARGE. Fertility Services Subject to Our Pre-Approval We cover charges for procedures and Prescription Drugs to enhance fertility, except where specifically excluded in the Contract. We cover charges for: artificial insemination; and standard dosages, lengths of treatment and cycles of therapy of Prescription Drugs used to stimulate ovulation for artificial insemination or for unassisted conception. The Prescription Drugs noted in this section are subject to the terms and conditions of the Prescription Drugs section of the Contract. We will reduce benefits by 50% with respect to charges for Fertility Services which are not Pre-Approved by Us provided that benefits would otherwise be payable under the Contract. Preventive Care We cover charges for routine physical examinations including related laboratory tests and x-rays. We also cover charges for immunizations and vaccines, well baby care, pap smears, mammography , screening tests, bone density testing and Nicotine Dependence Treatment. [But We limit what We pay each [Calendar] [Plan] Year to: $750 per [Member] for a Dependent child from birth until the end of the [Calendar] [Plan] Year in which the Dependent child attains age 1, and $500 per [Member] for all other [Member]s.] These charges are not subject to any Copayment, Cash Deductible or Coinsurance. [The $750 and $500 limits do not apply to services from a Network Provider.] [Carriers may elect to cover non-network preventive care without any dollar limits.]
hmo_pos_eoc.docx