Hospice Services Services are available for a Member whose Attending Physician has determined the Member's illness will result in a remaining life span of six months or less.
COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.
Rehabilitation Program The company agrees to the implementation of an agreed worker’s compensation rehabilitation policy. The operation of this policy shall be reviewed on a regular basis. The parties commit to ensuring that the rehabilitation of injured workers is an accepted practice, and that suitable duties are provided when available. No employee will be terminated whilst on workers compensation during the first 12 months without prior consultation with the union. The parties agree that the person responsible for the management of rehabilitation cases must be adequately trained to do the job. If such a person is not available within the company, then the services of an agreed building industry rehabilitation coordination service will be used. The parties to this Agreement shall ensure that any employee who sustains a work related injury, illness or disease, will be afforded every assistance in utilising a rehabilitation program aimed at returning that employee to meaningful employment within the industry.
Cardiac Rehabilitation This plan covers services provided in a cardiac rehabilitation program up to the benefit limit shown in the Summary of Medical Benefits.
Supportive Services The program staff will be trained in and maintain professional development opportunities in how to best assess and identify when support services are needed to ensure client success. Prior to using funds for these services, GMSI will assist the client in exploration of personal resources and other community programs and in making plans for addressing ongoing needs. Although in some cases supportive services are necessary in order for customer’s to obtain and retain a job. When necessary, GMSI will provide transportation assistance, emergency childcare, clothing and emergency housing. Supportive services should be used as a tool for work. The need for these items should not interfere with a customer being successfully employed.
Outpatient emergency and urgicenter services within the service area The emergency room copay applies to all outpatient emergency visits that do not result in hospital admission within twenty-four (24) hours. The urgicenter copay is the same as the primary care clinic office visit copay.
Core Services The Company agrees to provide those Core Services to the Municipality as set forth in Schedule “A” and further agrees to the process contained in Schedule “A”.
Ambulance Services Ground Ambulance This plan covers local professional or municipal ground ambulance services when it is medically necessary to use these services, rather than any other form of transportation as required under R.I. General Law § 27-20-55. Examples include but are not limited to the following: • from a hospital to a home, a skilled nursing facility, or a rehabilitation facility after being discharged as an inpatient; • to the closest available hospital emergency room in an emergency situation; or • from a physician’s office to an emergency room. Our allowance for ground ambulance includes the services rendered by an emergency medical technician or paramedic, as well as any drugs, supplies and cardiac monitoring provided. Air and Water Ambulance This plan covers air and water ambulance services when: • the time needed to move a patient by land, or the instability of transportation by land, may threaten a patient’s condition or survival; or • if the proper equipment needed to treat the patient is not available from a ground ambulance. The patient must be transported to the nearest facility where the required services can be performed and the type of physician needed to treat the patient’s condition is available. Our allowance for the air or water ambulance includes the services rendered by an emergency medical technician or paramedic, as well as any drugs, supplies and cardiac monitoring provided.
Educational Services Any service or supply for education, training or retraining services or testing including: special education, remedial education; cognitive remediation; wilderness/outdoor treatment, therapy or adventure programs (whether or not the program is part of a Residential Treatment facility or otherwise licensed institution); job training or job hardening programs; educational services and schooling or any such related or similar program including therapeutic programs within a school setting.
Surgery Services This plan covers surgery services to treat a disease or injury when: • the operation is not experimental or investigational, or cosmetic in nature; • the operation is being performed at the appropriate place of service; and • the physician is licensed to perform the surgery. Preauthorization may be required for certain surgical services. Reconstructive Surgery for a Functional Deformity or Impairment This plan covers reconstructive surgery and procedures when the services are performed to relieve pain, or to correct or improve bodily function that is impaired as a result of: • a birth defect; • an accidental injury; • a disease; or • a previous covered surgical procedure. Functional indications for surgical correction do not include psychological, psychiatric or emotional reasons. This plan covers the procedures listed below to treat functional impairments. • abdominal wall surgery including panniculectomy (other than an abdominoplasty); • blepharoplasty and ptosis repair; • gastric bypass or gastric banding; • nasal reconstruction and septorhinoplasty; • orthognathic surgery including mandibular and maxillary osteotomy; • reduction mammoplasty; • removal of breast implants; • removal or treatment of proliferative vascular lesions and hemangiomas; • treatment of varicose veins; or • gynecomastia. Preauthorization may be required for these services.
