Common use of Inpatient Care Clause in Contracts

Inpatient Care. You can get inpatient care in a specialized rehabilitative unit of a hospital. If you are already an inpatient, this benefit will start when your care becomes mainly rehabilitative. You must get prior authorization from us before you get inpatient treatment. See Prior Authorization for details. This plan covers inpatient rehabilitative therapy only when it meets these conditions:  You cannot get these services in a less intensive setting  The care is part of a written plan of treatment prescribed doctor Outpatient Care This plan covers outpatient rehabilitative services only when it meets these conditions: This plan covers the following types of outpatient therapy:  Physical, speech, hearing and occupational therapies  Chronic pain care  Cardiac and pulmonary therapy  Cochlear implants  Home medical equipment, medical supplies and devices This benefit does not cover:  Recreational, vocational or educational therapy  Exercise or maintenance-level programs  Social or cultural therapy  Treatment that the ill, injured or impaired member does not actively take part in  Gym or swim therapy  Custodial care Skilled Nursing Facility and Care This plan covers skilled nursing facility services. Covered services include room and board for a semi-private room, plus services, supplies and drugs you get while confined in a skilled nursing facility. Sometimes a patient goes from acute nursing care to skilled nursing care without leaving the hospital. When that happens, this benefit starts on the day that the care becomes primarily skilled nursing care. Skilled nursing care is covered only during certain stages of recovery. It must be a time when inpatient hospital care is no longer medically necessary, but care in a skilled nursing care facility is medically necessary. Your doctor must actively supervise your care while you are in the skilled nursing facility. We cover skilled nursing care provided after hospitalization at a long-term care facility (see Definitions) where you were residing at immediately prior to your hospitalization when your primary care provider determines that the medical care you need can be provided at that facility, and that facility satisfies our standards, terms and conditions for long-term care facilities, accepts our rates and has all applicable licenses and certifications. You must get prior authorization from us before you get treatment. See Prior Authorization for details. Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics Services must be prescribed by your physician. Not all supplies, devices or HME are a covered service and are subject to the terms and conditions as described in this plan. Documentation must be provided which includes; the prescription stating the diagnosis, the reason the service is required and an estimate of the duration of its need. For this benefit, this includes services such as prosthetic and orthotic devices, oxygen and oxygen supplies, diabetic supplies and wheelchairs. Prior Authorization is required for some medical supplies/devices, home medical equipment, prosthetics and orthotics. Please see Prior Authorization for additional information. Home Medical Equipment (HME) This plan covers rental of medical and respiratory equipment (including fitting expenses), not to exceed the purchase price, when medically necessary and prescribed by a physician for therapeutic use in direct treatment of a covered illness or injury. Benefits may also be provided for the initial purchase of equipment, in lieu of rental. In cases where an alternative type of equipment is less costly and serves the same medical purpose, we will provide benefits only up to the lesser amount. Repair or replacement of medical or respiratory equipment medically necessary due to normal use or growth of a child is covered. Medical and respiratory equipment includes, but is not limited to, wheelchairs, hospital-type beds, traction equipment, ventilators and diabetic equipment such as blood glucose monitors, insulin pumps and accessories to pumps and insulin infusion devices (including any sales tax). Medical Supplies Medical supplies include, but are not limited to, dressings, braces, splints, rib belts and crutches, as well as related fitting expenses. Also included are diabetic care supplies such as blood glucose monitor, insulin pump (including accessories), and insulin infusion devices. Medical Vision Hardware This plan covers medical vision hardware including eyeglasses, contact lenses and other corneal lenses for members age 19 and older, when such devices are required for the following:  Corneal ulcer  Bullous keratopathy  Recurrent erosion of cornea  Tear film insufficiency  Aphakia  Xxxxxxx’x disease  Congenital cataract  Corneal abrasion  Keratoconus. Medical vision hardware for members under age 19 is covered under Pediatric Vision Services.

Inpatient Care. You can get inpatient care in a specialized rehabilitative unit of a hospital. If you are already an inpatient, this benefit will start when your care becomes mainly rehabilitative. You must get prior authorization from us before you get inpatient treatment. See Prior Authorization for details. This plan covers inpatient rehabilitative therapy only when it meets these conditions:  • You cannot get these services in a less intensive setting  • The care is part of a written plan of treatment prescribed doctor Outpatient Care This plan covers outpatient rehabilitative services only when it meets these conditions: This plan covers the following types of outpatient therapy:  • Physical, speech, hearing and occupational therapies  • Chronic pain care  • Cardiac and pulmonary therapy  • Cochlear implants  • Home medical equipment, medical supplies and devices This benefit does not cover:  • Recreational, vocational or educational therapy  • Exercise or maintenance-level programs  • Social or cultural therapy  • Treatment that the ill, injured or impaired member does not actively take part in  • Gym or swim therapy  • Custodial care Skilled Nursing Facility and Care This plan covers skilled nursing facility services. Covered services include room and board for a semi-private room, plus services, supplies and drugs you get while confined in a skilled nursing facility. Sometimes a patient goes from acute nursing care to skilled nursing care without leaving the hospital. When that happens, this benefit starts on the day that the care becomes primarily skilled nursing care. Skilled nursing care is covered only during certain stages of recovery. It must be a time when inpatient hospital care is no longer medically necessary, but care in a skilled nursing care facility is medically necessary. Your doctor must actively supervise your care while you are in the skilled nursing facility. We cover skilled nursing care provided after hospitalization at a long-term care facility (see Definitions) where you were residing at immediately prior to your hospitalization when your primary care provider determines that the medical care you need can be provided at that facility, and that facility satisfies our standards, terms and conditions for long-term care facilities, accepts our rates and has all applicable licenses and certifications. You must get prior authorization from us before you get treatment. See Prior Authorization for details. Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics Services must be prescribed by your physician. Not all supplies, devices or HME are a covered service and are subject to the terms and conditions as described in this plan. Documentation must be provided which includes; the prescription stating the diagnosis, the reason the service is required and an estimate of the duration of its need. For this benefit, this includes services such as prosthetic and orthotic devices, oxygen and oxygen supplies, diabetic supplies and wheelchairs. Prior Authorization is required for some medical supplies/devices, home medical equipment, prosthetics and orthotics. Please see Prior Authorization for additional information. Home Medical Equipment (HME) This plan covers rental of medical and respiratory equipment (including fitting expenses), not to exceed the purchase price, when medically necessary and prescribed by a physician for therapeutic use in direct treatment of a covered illness or injury. Benefits may also be provided for the initial purchase of equipment, in lieu of rental. In cases where an alternative type of equipment is less costly and serves the same medical purpose, we will provide benefits only up to the lesser amount. Repair or replacement of medical or respiratory equipment medically necessary due to normal use or growth of a child is covered. Medical and respiratory equipment includes, but is not limited to, wheelchairs, hospital-type beds, traction equipment, ventilators and diabetic equipment such as blood glucose monitors, insulin pumps and accessories to pumps and insulin infusion devices (including any sales tax). Medical Supplies Medical supplies include, but are not limited to, dressings, braces, splints, rib belts and crutches, as well as related fitting expenses. Also included are diabetic care supplies such as blood glucose monitor, insulin pump (including accessories), and insulin infusion devices. Medical Vision Hardware This plan covers medical vision hardware including eyeglasses, contact lenses and other corneal lenses for members age 19 and older, when such devices are required for the following:  • Corneal ulcer  • Bullous keratopathy  • Recurrent erosion of cornea  • Tear film insufficiency  • Aphakia  • Xxxxxxx’x disease  • Congenital cataract  • Corneal abrasion  • Keratoconus. Medical vision hardware for members under age 19 is covered under Pediatric Vision Services.

Inpatient Care. You can get inpatient care in a specialized rehabilitative unit of a hospital. If you are already an inpatient, this benefit will start when your care becomes mainly rehabilitative. You must get prior authorization from us before you get inpatient treatment. See Prior Authorization for details. This plan covers inpatient rehabilitative therapy only when it meets these conditions:  • You cannot get these services in a less intensive setting  • The care is part of a written plan of treatment prescribed doctor Outpatient Care This plan covers outpatient rehabilitative services only when it meets these conditions: This plan covers the following types of outpatient therapy:  • Physical, speech, hearing and occupational therapies  • Chronic pain care  • Cardiac and pulmonary therapy  • Cochlear implants  • Home medical equipment, medical supplies and devices This benefit does not cover:  • Recreational, vocational or educational therapy  • Exercise or maintenance-level programs  • Social or cultural therapy  • Treatment that the ill, injured or impaired member does not actively take part in  • Gym or swim therapy  • Custodial care Skilled Nursing Facility and Care This plan covers skilled nursing facility services. Covered services include room and board for a semi-private room, plus services, supplies and drugs you get while confined in a skilled nursing facility. Sometimes a patient goes from acute nursing care to skilled nursing care without leaving the hospital. When that happens, this benefit starts on the day that the care becomes primarily skilled nursing care. Skilled nursing care is covered only during certain stages of recovery. It must be a time when inpatient hospital care is no longer medically necessary, but care in a skilled nursing care facility is medically necessary. Your doctor must actively supervise your care while you are in the skilled nursing facility. We cover skilled nursing care provided after following hospitalization at a the long-term care facility (see Definitions) where you were residing at immediately prior to your hospitalization when your primary care provider determines that the medical care you need can be provided at that facility, and that facility satisfies our standards, terms and conditions for long-term care facilities, accepts our rates rates, and has all applicable licenses and certifications. You must get prior authorization from us before you get treatment. See Prior Authorization for details. Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics Services must be prescribed by your physician. Not all Medically necessary supplies, devices or and HME are a covered service and are covered, subject to the terms and conditions as described in this plan. Documentation must be provided which includes; the prescription stating the diagnosis, the reason the service is required and an estimate of the duration of its need. For this benefit, this includes services such as prosthetic and orthotic devices, oxygen and oxygen supplies, diabetic supplies and wheelchairs. Apparatuses used to support, align, correct, or improve the function of moving parts are covered. Prior Authorization is required for some medical supplies/devices, home medical equipment, prosthetics and orthotics. Please see Prior Authorization for additional information. Home Medical Equipment (HME) This plan covers rental of medical and respiratory equipment (including fitting expenses), not to exceed the purchase price, when medically necessary and prescribed by a physician for therapeutic use in direct treatment of a covered illness or injury. Benefits may also be provided for the initial purchase of equipment, in lieu of rental. In cases where an alternative type of equipment is less costly and serves the same medical purpose, we will provide benefits only up to the lesser amount. Repair or replacement of medical or respiratory equipment medically necessary due to normal use or growth of a child is covered. Medical and respiratory equipment includes, but is not limited to, wheelchairs, hospital-type beds, traction equipment, ventilators and diabetic equipment such as blood glucose monitors, insulin pumps and accessories to pumps and insulin infusion devices (including any sales tax). Medical Supplies Medical supplies include, but are not limited to, to dressings, braces, splints, rib belts and crutches, as well as related fitting expenses. Also included are diabetic care supplies such as blood glucose monitor, insulin pump (including accessories), and insulin infusion devices. Medical Vision Hardware This plan covers medical vision hardware including eyeglasses, contact lenses and other corneal lenses for members age 19 and older, older when such devices are required for the following:  • Corneal ulcer  • Bullous keratopathy  • Recurrent erosion of cornea  • Tear film insufficiency  • Aphakia  • Xxxxxxx’x disease  • Congenital cataract  • Corneal abrasion  • Keratoconus. Medical vision hardware for members under age 19 is covered under Pediatric Vision Services.

Inpatient Care. You can get inpatient care in a specialized rehabilitative unit of a hospital. If you are already an inpatient, this benefit will start when your care becomes mainly rehabilitative. You must get prior authorization from us before you get inpatient treatment. See Prior Authorization for details. This plan covers inpatient rehabilitative therapy only when it meets these conditions:  You cannot get these services in a less intensive setting  The care is part of a written plan of treatment prescribed doctor Outpatient Care This plan covers outpatient rehabilitative services only when it meets these conditions: This plan covers the following types of outpatient therapy:  Physical, speech, hearing and occupational therapies  Chronic pain care  Cardiac and pulmonary therapy  Cochlear implants  Home medical equipment, medical supplies and devices This benefit does not cover:  Recreational, vocational or educational therapy  Exercise or maintenance-level programs  Social or cultural therapy  Treatment that the ill, injured or impaired member does not actively take part in  Gym or swim therapy  Custodial care Skilled Nursing Facility and Care This plan covers skilled nursing facility services. Covered services include room and board for a semi-private room, plus services, supplies and drugs you get while confined in a skilled nursing facility. Sometimes a patient goes from acute nursing care to skilled nursing care without leaving the hospital. When that happens, this benefit starts on the day that the care becomes primarily skilled nursing care. Skilled nursing care is covered only during certain stages of recovery. It must be a time when inpatient hospital care is no longer medically necessary, but care in a skilled nursing care facility is medically necessary. Your doctor must actively supervise your care while you are in the skilled nursing facility. We cover skilled nursing care provided after following hospitalization at a the long-term care facility (see Definitions) where you were residing at immediately prior to your hospitalization when your primary care provider determines that the medical care you need can be provided at that facility, and that facility satisfies our standards, terms and conditions for long-term care facilities, accepts our rates rates, and has all applicable licenses and certifications. You must get prior authorization from us before you get treatment. See Prior Authorization for details. Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics Services must be prescribed by your physician. Not all Medically necessary supplies, devices or and HME are a covered service and are covered, subject to the terms and conditions as described in this plan. Documentation must be provided which includes; the prescription stating the diagnosis, the reason the service is required and an estimate of the duration of its need. For this benefit, this includes services such as prosthetic and orthotic devices, oxygen and oxygen supplies, diabetic supplies and wheelchairs. Apparatuses used to support, align, correct, or improve the function of moving parts are covered. Prior Authorization is required for some medical supplies/devices, home medical equipment, prosthetics and orthotics. Please see Prior Authorization for additional information. Home Medical Equipment (HME) This plan covers rental of medical and respiratory equipment (including fitting expenses), not to exceed the purchase price, when medically necessary and prescribed by a physician for therapeutic use in direct treatment of a covered illness or injury. Benefits may also be provided for the initial purchase of equipment, in lieu of rental. In cases where an alternative type of equipment is less costly and serves the same medical purpose, we will provide benefits only up to the lesser amount. Repair or replacement of medical or respiratory equipment medically necessary due to normal use or growth of a child is covered. Medical and respiratory equipment includes, but is not limited to, wheelchairs, hospital-type beds, traction equipment, ventilators and diabetic equipment such as blood glucose monitors, insulin pumps and accessories to pumps and insulin infusion devices (including any sales tax). Medical Supplies Medical supplies include, but are not limited to, to dressings, braces, splints, rib belts and crutches, as well as related fitting expenses. Also included are diabetic care supplies such as blood glucose monitor, insulin pump (including accessories), and insulin infusion devices. Medical Vision Hardware This plan covers medical vision hardware including eyeglasses, contact lenses and other corneal lenses for members age 19 and older, older when such devices are required for the following:  Corneal ulcer  Bullous keratopathy  Recurrent erosion of cornea  Tear film insufficiency  Aphakia  Xxxxxxx’x disease  Congenital cataract  Corneal abrasion  Keratoconus. Medical vision hardware for members under age 19 is covered under Pediatric Vision Services.