Common use of Long Term Care Services Clause in Contracts

Long Term Care Services. Respite Care Services, except as specifically mentioned under Hospice Care Benefits. — Services or supplies received during an Inpatient stay when the stay is solely related to behavioral, social maladjustment, lack of discipline or other anti­ social actions which are not specifically the result of Mental Illness. This does not include services or supplies provided for the treatment of an injury resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). — Special education therapy such as music therapy or recreational therapy, ex­ cept as specifically provided for in this Certificate. — Cosmetic Surgery and related services and supplies, except for the correc­ tion of congenital deformities or for conditions resulting from accidental injuries, tumors or disease. — Services or supplies received from a dental or medical department or clinic maintained by an employer, labor union or other similar person or group. — Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar cov­ erage. — Charges for failure to keep a scheduled visit or charges for completion of a Claim form or charges for the transfer of medical records. — Personal hygiene, comfort or convenience items commonly used for other than medical purposes such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones. — Special braces, splints, specialized equipment, appliances, ambulatory appa­ ratus or, battery implants except as specifically stated in this Certificate. — Prosthetic devices, special appliances or surgical implants which are for cos­ metic purposes, the comfort or convenience of the patient or unrelated to the treatment of a disease or injury. — Nutritional items such as infant formula, weight‐loss supplements, over‐the‐ counter food substitutes, non‐prescription vitamins and herbal supplements, except as stated in this Certificate. — Blood derivatives which are not classified as drugs in the official formu­ laries. — Hypnotism. — Inpatient and Outpatient Private Duty Nursing Service. — Routine foot care, except for persons diagnosed with diabetes. — Maintenance Occupational Therapy, Maintenance Physical Therapy and Maintenance Speech Therapy, except as specifically mentioned in this Cer­ tificate. — Maintenance Care. — Self‐management training, education and medical nutrition therapy, except as specifically stated in this Certificate. — Habilitative Services that are solely educational in nature or otherwise paid under State or Federal law for purely educational services. — Services or supplies which are rendered for the care, treatment, filling, re­ moval, replacement or artificial restoration of the teeth or structures directly supporting the teeth except as specifically stated in this Certificate. — Repair or replacement of appliances and/or devices due to misuse or loss, except as specifically mentioned in this Certificate. — Treatment of temporomandibular joint syndrome with intraoral prosthetic devices or any other method which alters vertical dimension or treatment of temporomandibular joint dysfunction not caused by documented organic joint disease or physical trauma. — Services or supplies rendered for human organ or tissue transplants except as specifically provided for in this Certificate. — Wigs (also referred to as cranial prostheses). — Services or supplies rendered for infertility treatment except as specifically provided for in this Certificate. — Eyeglasses, contact lenses or hearing aids, except as specifically provided for this Certificate. — Dental care, except as directly required for the treatment of a medical condi­ tion or as otherwise provided for in this Certificate. — Any services and/or supplies provided to you outside the United States, un­ less they are received for an Emergency Condition, not withstanding any provision in the Certificate to the contrary. COORDINATION OF BENEFITS Coordination of Benefits (COB) applies to this Benefit Program when you or your covered dependent has health care coverage under more than one Benefit Program. COB does not apply to the Outpatient Prescription Drug Program Bene­ fits. The order of benefit determination rules should be looked at first. Those rules de­ termine whether the benefits of this Benefit Program are determined before or after those of another Benefit Program. The benefits of this Benefit Program:

Long Term Care Services. Respite Care Services, except as specifically mentioned under Hospice Care Benefits. — Services or supplies received during an Inpatient stay when the stay is solely related to behavioral, social maladjustment, lack of discipline or other anti­ social actions which are not specifically the result of Mental Illness. This does not include services or supplies provided for the treatment of an injury resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). — Special education therapy such as music therapy or recreational therapy, ex­ cept as specifically provided for in this Certificate. — Cosmetic Surgery and related services and supplies, except for the correc­ tion of congenital deformities or for conditions resulting from accidental injuries, tumors or disease. — Services or supplies received from a dental or medical department or clinic maintained by an employer, labor union or other similar person or group. — Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar cov­ erage. — Charges for failure to keep a scheduled visit or charges for completion of a Claim form or charges for the transfer of medical records. — Personal hygiene, comfort or convenience items commonly used for other than medical purposes such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones. — Special braces, splints, specialized equipment, appliances, ambulatory appa­ ratus ap­ paratus or, battery implants except as specifically stated in this Certificate. — Prosthetic devices, special appliances or surgical implants which are for cos­ metic purposes, the comfort or convenience of the patient or unrelated to the treatment of a disease or injury. — Nutritional items such as infant formula, weight‐loss supplements, over‐the‐ counter over‐the‐counter food substitutes, non‐prescription vitamins and herbal supplementssup­ plements, except as stated in this Certificate. — Blood derivatives which are not classified as drugs in the official formu­ lariesformular­ ies. — Hypnotism. — Inpatient and Outpatient Private Duty Nursing Service. — Routine foot care, except for persons diagnosed with diabetes. — Maintenance Occupational Therapy, Maintenance Physical Therapy and Maintenance Speech Therapy, except as specifically mentioned in this Cer­ tificate. — Maintenance Care. IL‐G‐H‐OF‐2016 90 — Self‐management training, education and medical nutrition therapy, except as specifically stated in this Certificate. — Habilitative Services that are solely educational in nature or otherwise paid under State or Federal law for purely educational services. — Services or supplies which are rendered for the care, treatment, filling, re­ moval, replacement or artificial restoration of the teeth or structures directly supporting the teeth except as specifically stated in this Certificate. — Repair or replacement of appliances and/or devices due to misuse or loss, except as specifically mentioned in this Certificate. — Treatment of temporomandibular joint syndrome with intraoral prosthetic devices or any other method which alters vertical dimension or treatment of temporomandibular joint dysfunction not caused by documented organic joint disease or physical trauma. — Services or supplies rendered for human organ or tissue transplants except as specifically provided for in this Certificate. — Wigs (also referred to as cranial prostheses). — Services or supplies rendered for infertility treatment except as specifically provided for in this Certificate. — Eyeglasses, contact lenses lenses, which are not medically necessary, or hearing aids, except as specifically provided for this this Certificate. — Acupuncture. — Reversal of vasectomies. — Services and supplies rendered or provided outside of the United States, if the purpose of the travel to the location was for receiving medical services, supplies or drugs. — Dental care, except as directly required for the treatment of a medical condi­ tion or as otherwise provided for in this Certificate. — Any services and/or supplies provided to you outside the United States, un­ less they are received for an Emergency Condition, not withstanding any provision in the Certificate to the contrary. COORDINATION OF BENEFITS Coordination of Benefits (COB) applies to this Benefit Program when you or your covered dependent has health care coverage under more than one Benefit Program. COB does not apply to the Outpatient Prescription Drug Program Bene­ fits. The order of benefit determination rules should be looked at first. Those rules de­ termine whether the benefits of this Benefit Program are determined before or after those of another Benefit Program. The benefits of this Benefit Program:IL‐G‐H‐OF‐2016 91

Long Term Care Services. Respite Care Services, except as specifically mentioned under Hospice Care Benefits. — Services or supplies received during an Inpatient stay when the stay is solely related to behavioral, social maladjustment, lack of discipline or other anti­ social actions which are not specifically the result of Mental Illness. This does not include services or supplies provided for the treatment of an injury resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). — Special education therapy such as music therapy or recreational therapy, ex­ cept as specifically provided for in this Certificate. — Cosmetic Surgery and related services and supplies, except for the correc­ tion of congenital deformities or for conditions resulting from accidental injuries, tumors or disease. — Services or supplies received from a dental or medical department or clinic maintained by an employer, labor union or other similar person or group. — Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar cov­ erage. — Charges for failure to keep a scheduled visit or charges for completion of a Claim form or charges for the transfer of medical records. — Personal hygiene, comfort or convenience items commonly used for other than medical purposes such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones. — Special braces, splints, specialized equipment, appliances, ambulatory appa­ ratus or, battery implants except as specifically stated in this Certificate. — Prosthetic devices, special appliances or surgical implants which are for cos­ metic purposes, the comfort or convenience of the patient or unrelated to the treatment of a disease or injury. — Nutritional items such as infant formula, weight‐loss supplements, over‐the‐ counter food substitutes, non‐prescription vitamins and herbal supplements, except as stated in this Certificate. — Blood derivatives which are not classified as drugs in the official formu­ laries. — Hypnotism. — Inpatient and Outpatient Private Duty Nursing Service. — Routine foot care, except for persons diagnosed with diabetes. — Maintenance Occupational Therapy, Maintenance Physical Therapy and Maintenance Speech Therapy, except as specifically mentioned in this Cer­ tificate. — Maintenance Care. — Self‐management training, education and medical nutrition therapy, except as specifically stated in this Certificate. — Habilitative Services that are solely educational in nature or otherwise paid under State or Federal law for purely educational services. — Services or supplies which are rendered for the care, treatment, filling, re­ moval, replacement or artificial restoration of the teeth or structures directly supporting the teeth except as specifically stated in this Certificate. — Repair or replacement of appliances and/or devices due to misuse or loss, except as specifically mentioned in this Certificate. — Treatment of temporomandibular joint syndrome with intraoral prosthetic devices or any other method which alters vertical dimension or treatment of temporomandibular joint dysfunction not caused by documented organic joint disease or physical trauma. — Services or supplies rendered for human organ or tissue transplants except as specifically provided for in this Certificate. — Wigs (also referred to as cranial prostheses). — Services or supplies rendered for infertility treatment except as specifically provided for in this Certificate. — Eyeglasses, contact lenses or hearing aids, except as specifically provided for in this Certificate. — Dental care, except as directly required for the treatment of a medical condi­ tion or as otherwise provided for in this Certificate. — Any services and/or supplies provided to you outside the United States, un­ less they are received for an Emergency Condition, not withstanding any provision in the Certificate to the contrary. COORDINATION OF BENEFITS Coordination of Benefits (COB) applies to this Benefit Program when you or your covered dependent has health care coverage under more than one Benefit Program. COB does not apply to the Outpatient Prescription Drug Program Bene­ fits. The order of benefit determination rules should be looked at first. Those rules de­ termine whether the benefits of this Benefit Program are determined before or after those of another Benefit Program. The benefits of this Benefit Program:

Long Term Care Services. Respite Care Services, except as specifically mentioned under Hospice Care Benefits. — Services or supplies received during an Inpatient stay when the stay is solely related to behavioral, social maladjustment, lack of discipline or other anti­ social actions which are not specifically the result of Mental Illness. This does not include services or supplies provided for the treatment of an injury resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). — Special education therapy such as music therapy or recreational therapy, ex­ cept as specifically provided for in this Certificate. — Cosmetic Surgery and related services and supplies, except for the correc­ tion of congenital deformities or for conditions resulting from accidental injuries, tumors or disease. — Services or supplies received from a dental or medical department or clinic maintained by an employer, labor union or other similar person or group. — Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar cov­ erage. — Charges for failure to keep a scheduled visit or charges for completion of a Claim form or charges for the transfer of medical records. — Personal hygiene, comfort or convenience items commonly used for other than medical purposes such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones. — Special braces, splints, specialized equipment, appliances, ambulatory appa­ ratus or, battery implants except as specifically stated in this Certificate. — Prosthetic devices, special appliances or surgical implants which are for cos­ metic purposes, the comfort or convenience of the patient or unrelated to the treatment of a disease or injury. — Nutritional items such as infant formula, weight‐loss supplements, over‐the‐ counter food substitutes, non‐prescription vitamins and herbal supplements, except as stated in this Certificate. — Blood derivatives which are not classified as drugs in the official formu­ laries. — Hypnotism. — Inpatient and Outpatient Private Duty Nursing Service. — Routine foot care, except for persons diagnosed with diabetes. — Maintenance Occupational Therapy, Maintenance Physical Therapy and Maintenance Speech Therapy, except as specifically mentioned in this Cer­ tificate. — Maintenance Care. — Self‐management training, education and medical nutrition therapy, except as specifically stated in this Certificate. — Habilitative Services that are solely educational in nature or otherwise paid under State or Federal law for purely educational services. — Services or supplies which are rendered for the care, treatment, filling, re­ moval, replacement or artificial restoration of the teeth or structures directly supporting the teeth except as specifically stated in this Certificate. — Repair or replacement of appliances and/or devices due to misuse or loss, except as specifically mentioned in this Certificate. — Treatment of temporomandibular joint syndrome with intraoral prosthetic devices or any other method which alters vertical dimension or treatment of temporomandibular joint dysfunction not caused by documented organic joint disease or physical trauma. — Services or supplies rendered for human organ or tissue transplants except as specifically provided for in this Certificate. — Wigs (also referred to as cranial prostheses). — Services or supplies rendered for infertility treatment except as specifically provided for in this Certificate. — Outpatient prescription drugs or medicines. — Outpatient contraceptive devices and services. — Eyeglasses, contact lenses or hearing aids, except as specifically provided for in this Certificate. — Dental care, except as directly required for the treatment of a medical condi­ tion or as otherwise provided for in this Certificate. — Any services and/or supplies provided to you outside the United States, un­ less they are received for an Emergency Condition, not withstanding any provision in the Certificate to the contrary. COORDINATION OF BENEFITS Coordination of Benefits (COB) applies to this Benefit Program when you or your covered dependent has health care coverage under more than one Benefit Program. COB does not apply to the Outpatient Prescription Drug Program Bene­ fits. The order of benefit determination rules should be looked at first. Those rules de­ termine whether the benefits of this Benefit Program are determined before or after those of another Benefit Program. The benefits of this Benefit Program:

Long Term Care Services. Respite Care Services, except as specifically mentioned under Hospice Care Benefits. — Services or supplies received during an Inpatient stay when the stay is solely related to behavioral, social maladjustment, lack of discipline or other anti­ social actions which are not specifically the result of Mental Illness. This does not include services or supplies provided for the treatment of an injury resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). — Special education therapy such as music therapy or recreational therapy, ex­ cept as specifically provided for in this Certificate. — Cosmetic Surgery and related services and supplies, except for the correc­ tion of congenital deformities or for conditions resulting from accidental injuries, tumors or disease. — Services or supplies received from a dental or medical department or clinic maintained by an employer, labor union or other similar person or group. — Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar cov­ erage. — Charges for failure to keep a scheduled visit or charges for completion of a Claim form or charges for the transfer of medical records. — Personal hygiene, comfort or convenience items commonly used for other than medical purposes such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones. — Special braces, splints, specialized equipment, appliances, ambulatory appa­ ratus or, battery implants except as specifically stated in this Certificate. — Prosthetic devices, special appliances or surgical implants which are for cos­ metic purposes, the comfort or convenience of the patient or unrelated to the treatment of a disease or injury. — Nutritional items such as infant formula, weight‐loss supplements, over‐the‐ counter food substitutes, non‐prescription vitamins and herbal supplements, except as stated in this Certificate. — Blood derivatives which are not classified as drugs in the official formu­ laries. — Hypnotism. — Inpatient and Outpatient Private Duty Nursing Service. — Routine foot care, except for persons diagnosed with diabetes. — Maintenance Occupational Therapy, Maintenance Physical Therapy and Maintenance Speech Therapy, except as specifically mentioned in this Cer­ tificate. — Maintenance Care. — Self‐management training, education and medical nutrition therapy, except as specifically stated in this Certificate. — Habilitative Services that are solely educational in nature or otherwise paid under State or Federal law for purely educational services. — Services or supplies which are rendered for the care, treatment, filling, re­ moval, replacement or artificial restoration of the teeth or structures directly supporting the teeth except as specifically stated in this Certificate. — Repair or replacement of appliances and/or devices due to misuse or loss, except as specifically mentioned in this Certificate. — Treatment of temporomandibular joint syndrome with intraoral prosthetic devices or any other method which alters vertical dimension or treatment of temporomandibular joint dysfunction not caused by documented organic joint disease or physical trauma. — Services or supplies rendered for human organ or tissue transplants except as specifically provided for in this Certificate. — Wigs (also referred to as cranial prostheses). — Services or supplies rendered for infertility treatment except as specifically provided for in this Certificate. — Eyeglasses, contact lenses or hearing aids, except as specifically provided for in this Certificate. — Dental care, except as directly required for the treatment of a medical condi­ tion or as otherwise provided for in this Certificate. — Any services and/or supplies provided to you outside the United States, un­ less they are received for an Emergency Condition, not withstanding any provision in the Certificate to the contrary. COORDINATION OF BENEFITS Coordination of Benefits (COB) applies to this Benefit Program when you or your covered dependent has health care coverage under more than one Benefit Program. COB does not apply to the Outpatient Prescription Drug Program Bene­ fits. The order of benefit determination rules should be looked at first. Those rules de­ termine whether the benefits of this Benefit Program are determined before or after those of another Benefit Program. The benefits of this Benefit Program: