Page 48 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

• Manipulative Treatment.

• Speech therapy.
• Post-cochlear implant aural therapy.
• Cognitive therapy.

Benefits are provided for habilitative services for both inpatient services and outpatient therapy when you
have a disabling condition when both of the following conditions are met:

• Treatment is administered by any of the following:
 Licensed speech-language pathologist.

 Licensed audiologist.
 Licensed occupational therapist.

 Licensed physical therapist.
 Physician.

• Treatment must be proven and not Experimental or Investigational.
The following are not habilitative services:

• Custodial Care.
• Respite care.

• Day care.
• Therapeutic recreation.

• Vocational training.
• Residential Treatment.

• A service that does not help you meet functional goals in a treatment plan within a prescribed time
frame.

• Services solely educational in nature.
• Educational services otherwise paid under state or federal law.

The Claims Administrator may require the following be provided:
• Treatment plan.

• Medical records.
• Clinical notes.

• Other necessary data to allow the Claims Administrator to prove that medical treatment is needed.
When the treating provider expects that continued treatment is or will be required to allow you to achieve
progress that is capable of being demonstrated, the Claims Administrator may request a treatment plan
that includes:

• Diagnosis.
• Proposed treatment by type, frequency, and expected duration of treatment.

45 Section 1: Covered Health Care Services