Mental Health or Substance Use Disorder (“MH/SUD”) (Cont’d) O.S.T. v. Regence Does the contract provide benefits for neurodevelopment therapies? BlueShield, No. Must provide benefits for mental health diagnoses (Diagnoses listed in the DSM) without any Therapy 88940-6 (WN October 9, 2014). limitations” (e.g., age six and under) “blanket Services covered must include physical, speech, and occupational therapies. RCW 48.21.310(2) Benefits shall be payable only where the services have been delivered pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or where covered services have been rendered by such licensee. Benefits shall be provided to restore and improve function, and for the maintenance of a RCW 48.21.310(3) covered individual in cases where significant deterioration in the patient's condition would result without the service. Benefits must be for medically necessary services. Benefits may not be subject to annual or lifetime dollar limits, but may be subject to visit limits, RCW 48.21.310(4) deductible, cost sharing, and requirements for written treatment plans. The contract may not exclude or limit coverage for assessment or testing to determine the amount and type of neurodevelopmental therapy needed. Pharmacy This section applies only to plans that cover prescription drugs. If the plan does not cover prescription drugs, you can skip this section and go on to the next section, PKU coverage.
Mental Health or Substance Use Disorder (“MH/SUD”) (Cont’d) Therapy O.S.T. v. Regence BlueShield, No. 88940-6 (WN October 9, 2014). RCW 48.21.310(2) RCW 48.21.310(3) RCW 48.21.310(4) Does the contract provide benefits for neurodevelopment therapies? Must provide benefits for mental health diagnoses (Diagnoses listed in the DSM) without any “blanket limitations” (e.g., age six and under) Services covered must include physical, speech, and occupational therapies. Benefits shall be payable only where the services have been delivered pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or where covered services have been rendered by such licensee. Benefits shall be provided to restore and improve function, and for the maintenance of a covered individual in cases where significant deterioration in the patient's condition would result without the service. Benefits must be for medically necessary services. Benefits may not be subject to annual or lifetime dollar limits, but may be subject to visit limits, deductible, cost sharing, and requirements for written treatment plans. The contract may not exclude or limit coverage for assessment or testing to determine the amount and type of neurodevelopmental therapy needed. Pharmacy This section applies only to plans that cover prescription drugs. If the plan does not cover prescription drugs, you can skip this section and go on to the next section, PKU coverage.
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