Common use of Maternity Services Clause in Contracts

Maternity Services. We cover for pre-and post-natal Services, which includes routine and non-routine office visits, telemedicine visits, x-ray, lab and specialty tests. The Health Plan covers birthing classes and breastfeeding support, supplies, and counseling from trained providers during pregnancy and/or in the postpartum period. Services for pre-existing conditions care related to the development of a high-risk condition(s) during pregnancy, and non-routine obstetrical care are covered subject to applicable Cost Share for specialty, diagnostic, and/or treatment Services. We cover inpatient hospitalization Services for you and your enrolled newborn child for a minimum stay of at least forty-eight (48) hours following an uncomplicated vaginal delivery; and at least ninety-six (96) hours following an uncomplicated cesarean section. We also cover postpartum home care visits upon release, when prescribed by the attending provider. In consultation with your physician, you may request a shorter length of stay. In such cases, we will cover one home health visit scheduled to occur within twenty-four (24) hours after discharge, and an additional home visit if prescribed by the attending provider. Up to four (4) days of additional hospitalization for the newborn is covered if you are required to remain hospitalized after childbirth for medical reasons. Comprehensive lactation (breastfeeding) education and counseling, by trained clinicians during pregnancy and/or postpartum period in conjunction with each birth, Breastfeeding equipment is issued, per pregnancy. The breast-feeding pump (including any equipment that is required for pump functionality) is covered for six (6) months at no cost sharing to the member. See the benefit-specific exclusion immediately below for additional information Benefit-Specific Exclusion: 1. Personal and convenience supplies associated with breastfeeding equipment such as pads, bottles, and carrier cases. 2. Services for newborn deliveries performed at home Medical Foods We cover medical foods and low protein modified food products for the treatment of inherited metabolic diseases caused by an inherited abnormality of body chemistry including a disease for which the State screens newborn babies. Coverage is provided if the medical foods and low protein food products are prescribed as Medically Necessary for the therapeutic treatment of inherited metabolic diseases and are administered under the direction of a Plan Provider. Medical foods are intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and are formulated to be consumed or administered internally (i.e., by tube directly into the stomach or small intestines) under the direction of a Plan Provider. Low protein modified foods are food products that are: 1. Specially formulated to have less than one (1) gram of protein per serving; and 2. Intended to be used under the direction of a Plan Provider for the dietary treatment of an inherited metabolic disease. Amino Acid-based Elemental Formula (Drugs, Supplies and Supplements) We cover amino acid-based elemental formula, regardless of delivery method, for the diagnosis and treatment of: 1. Immunoglobulin E and non-Immunoglobulin E mediated allergies to multiple food proteins; 2. Severe food protein induced enterocolitis syndrome; 3. Eosinophilic disorders, as evidenced by the results of a biopsy; and 4. Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. Coverage shall be provided if the ordering physician has issued a written order stating that amino acid-based elemental formula is Medically Necessary for the treatment of a disease or disorder listed above. The Health Plan, or a private review agent acting on behalf of the Health Plan, may review the ordering physician’s determination of the Medical Necessity of the amino acid-based elemental formula for the treatment of a disease or disorders listed above. See the benefit-specific exclusions immediately below for additional information.

Maternity Services. We cover obstetrical Services for pre-and post-natal Services, which includes routine and non-routine office visits, telemedicine visitsServices, x-ray, lab and specialty tests. The Health Plan covers birthing classes and breastfeeding support, supplies, and counseling from trained providers during pregnancy and/or in the postpartum period. Services for pre-existing conditions care related to the development of a high-risk condition(s) during pregnancy, and non-routine obstetrical care are covered subject to applicable Cost Share for specialty, diagnostic, and/or treatment Services. We cover inpatient hospitalization Services for you and your enrolled newborn child for a minimum stay of at least forty-eight (48) hours following an uncomplicated vaginal delivery; and at least ninety-six (96) hours following an uncomplicated cesarean section. We also cover postpartum home care visits upon release, when prescribed by the attending provider. In consultation with your physician, you may request a shorter length of stay. In such cases, we will cover one home health visit scheduled to occur within twenty-four (24) hours after discharge, and an additional home visit if prescribed by the attending provider. Up to four (4) days of additional hospitalization for the newborn is covered if you are required to remain hospitalized after childbirth for medical reasons. Comprehensive lactation (breastfeeding) education and counseling, by trained clinicians during pregnancy and/or postpartum period in conjunction with each birth, Breastfeeding equipment is issued, per pregnancy. The breast-feeding pump (including any equipment that is required for pump functionality) is covered for six (6) months at no cost sharing to the member. See the benefit-specific exclusion immediately below for additional information Benefit-Specific Exclusion: 1. Personal and convenience supplies associated with breastfeeding equipment such as pads, bottles, and carrier cases. 2. Services for newborn deliveries performed at home Medical Foods We cover medical foods and low protein modified food products for the treatment of inherited metabolic diseases caused by an inherited abnormality of body chemistry including a disease for which the State screens newborn babies. Coverage is provided if the medical foods and low protein food products are prescribed as Medically Necessary for the therapeutic treatment of inherited metabolic diseases diseases, and are administered under the direction of a Plan Provider. Medical foods are intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and are formulated to be consumed or administered internally (i.e., by tube directly into the stomach or small intestines) under the direction of a Plan Provider. Low protein modified foods are food products that are: 1. Specially formulated to have less than one (1) gram of protein per serving; and 2. Intended to be used under the direction of a Plan Provider for the dietary treatment of an inherited metabolic disease. Amino Acid-based Elemental Formula (Drugs, Supplies and Supplements) We cover amino acid-based elemental formula, regardless of delivery method, for the diagnosis and treatment of: 1. Immunoglobulin E and non-Immunoglobulin E mediated allergies to multiple food proteins; 2. Severe food protein induced enterocolitis syndrome; 3. Eosinophilic disorders, as evidenced by the results of a biopsy; and 4. Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. Coverage shall be provided if the ordering physician has issued a written order stating that amino acid-based elemental formula is Medically Necessary for the treatment of a disease or disorder listed above. The Health Plan, or a private review agent acting on behalf of the Health Plan, may review the ordering physician’s determination of the Medical Necessity of the amino acid-based elemental formula for the treatment of a disease or disorders listed above. See the benefit-specific exclusions immediately below for additional information. Benefit-Specific Exclusions: 1. Medical food for treatment of any conditions other than an inherited metabolic disease. 2. Amino-acid based elemental formula for treatment of any condition other than those listed above. Medical Nutrition Therapy and Counseling Coverage is provided for unlimited Medically Necessary nutritional counseling and medical nutrition therapy provided by a licensed dietician-nutritionist, Plan Physician, physician assistant or nurse practitioner for an individual at risk due to: 1. Nutritional history; 2. Current dietary intake; 3. Medication use; or 4. Chronic illness or condition. Coverage is also provided for unlimited Medically Necessary nutrition therapy provided by a licensed dietician-nutritionist, working in coordination with a Primary Care Plan Physician, to treat a chronic illness or condition. Morbid Obesity Services We cover diagnosis and treatment of morbid obesity, including gastric bypass surgery or other surgical method, that is: 1. Recognized by the NIH as effective for long-term reversal of morbid obesity; and 2. Consistent with criteria approved by the NIH. Morbid obesity is defined as: 1. A weight that is at least one-hundred (100) pounds over or twice the ideal weight for a patient’s frame, age, height and gender, as specified in the 1983 Metropolitan Life Insurance tables; or 2. A Body Mass Index (BMI) that is equal to or greater than thirty-five (35) kilograms per meter squared with a comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary condition, sleep apnea or diabetes; or 3. A BMI of forty (40) kilograms per meter squared without such comorbidity. Body Mass Index means a practical marker that is used to assess the degree of obesity and is calculated by dividing the weight in kilograms by the height in meters squared. See the benefit-specific exclusion immediately below for additional information. Benefit-Specific Exclusion: 1. Services not preauthorized by the Health Plan. Oral Surgery We cover treatment of tumors where a biopsy is needed for pathological reasons. We also cover treatment of significant congenital defects, causing functional impairment, found in the oral cavity or jaw area which are similar to disease or which occur in other parts of the body, including Medically Necessary medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses. For the purposes of this benefit, coverage for diseases and injuries of the jaw include: 1. Fractures of the jaw or facial bones; 2. Removal of cysts of non-dental origin or tumors, including any associated lab fees prior to removal; and 3. Surgical correction of malformation of the jaw when the malformation creates significant impairment in the Member’s speech and nutrition, and when such impairments are demonstrated through examination and consultation with appropriate Plan Providers. For the purposes of this benefit, coverage of significant congenital defects causing functional impairment must be: 1. Evidenced through documented medical records showing significant impairment in speech or a nutritional deficit; and 2. Based on examination of the Member by a Plan Provider. Functional impairment refers to an anatomical function as opposed to a psychological function. The Health Plan provides coverage for cleft lip, cleft palate and ectodermal dysplasia under a separate benefit. Please see Cleft Lip, Cleft Palate or Both. See the benefit-specific exclusions immediately below for additional information. Benefit-Specific Exclusions: 1. Oral surgery Services when the functional aspect is minimal and would not in itself warrant surgery. 2. Lab fees associated with cysts that are considered dental under our standards.

Maternity Services. We cover Services for pre-and post-natal Services, which includes routine and non-routine office visits, telemedicine visits, x-ray, lab and specialty tests. The Health Plan covers birthing classes and breastfeeding support, supplies, and counseling from trained providers during pregnancy and/or in the postpartum period. “Non-routine obstetrical care” includes: 1. Services provided for pre-a condition not usually associated with pregnancy; 2. Services provided for conditions existing conditions care prior to pregnancy; 3. Services related to the development of a high-risk condition(s) during pregnancy, ; and 4. Services provided for the medical complications of pregnancy. Services for non-routine obstetrical care are covered subject to applicable Cost Share cost share for specialty, diagnostic, diagnostic and/or treatment Services. We cover inpatient hospitalization Services for you and your enrolled newborn child for a minimum stay of at least forty-eight (48) hours following an uncomplicated vaginal delivery; and at least ninety-six (96) hours following an uncomplicated cesarean section. We also cover postpartum home care health visits upon release, when prescribed by the attending provider. In consultation with your physician, you may request a shorter length of stay. In such cases, we will cover one home health visit scheduled to occur within twenty-four (24) hours after discharge, and an additional home visit if prescribed by the attending provider. Up to four (4) days of additional hospitalization for the newborn is covered if you are the enrolled mother is required to remain hospitalized after childbirth for medical reasons. Comprehensive lactation (breastfeeding) education and counseling, by trained clinicians during pregnancy and/or postpartum period in conjunction with each birth, Breastfeeding equipment is issued, per pregnancy. The breast-feeding pump (including any equipment that is required for pump functionality) is covered for six (6) months at no cost sharing to the member. See the benefit-specific exclusion immediately below for additional information Benefit-Specific Exclusion: 1. Personal and convenience supplies associated with breastfeeding equipment such as pads, bottles, and carrier cases. 2. Services for newborn deliveries performed at home Medical Foods We cover medical foods and low protein modified food products for the treatment of inherited metabolic diseases caused by an inherited abnormality of body chemistry including a disease for which the State screens newborn babies. Coverage is provided if the medical foods and low protein food products are prescribed as Medically Necessary for the therapeutic treatment of inherited metabolic diseases diseases, and are administered under the direction of a Plan Provider. Medical foods are intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and are formulated to be consumed or administered internally (i.e., by tube directly into the stomach or small intestines) under the direction of a Plan Provider. Low protein modified foods are food products that are: 1. Specially formulated to have less than one (1) gram of protein per serving; and 2. Intended to be used under the direction of a Plan Provider for the dietary treatment of an inherited metabolic disease. Amino Acid-based Elemental Formula (Drugs, Supplies and Supplements) We cover amino acid-based elemental formula, regardless of delivery method, for the diagnosis and treatment of: 1. Immunoglobulin E and non-Immunoglobulin E mediated allergies to multiple food proteins; 2. Severe food protein induced enterocolitis syndrome; 3. Eosinophilic disorders, as evidenced by the results of a biopsy; and 4. Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. Coverage shall be provided if the ordering physician has issued a written order stating that amino acid-based elemental formula is Medically Necessary for the treatment of a disease or disorder listed above. The Health Plan, or a private review agent acting on behalf of the Health Plan, may review the ordering physician’s determination of the Medical Necessity of the amino acid-based elemental formula for the treatment of a disease or disorders listed above. See the benefit-specific exclusions immediately below for additional information.and

Maternity Services. We cover for pre-and post-natal Services, which includes routine and non-routine office visits, telemedicine visits, x-ray, lab and specialty tests. The Health Plan covers birthing classes and breastfeeding support, supplies, and counseling from trained providers during pregnancy and/or in the postpartum period. Services for pre-existing conditions care related to the development of a high-risk condition(s) during pregnancy, and non-routine obstetrical care are covered subject to applicable Cost Share for specialty, diagnostic, and/or treatment Services. We cover inpatient hospitalization Services for you and your enrolled newborn child for a minimum stay of at least forty-eight (48) hours following an uncomplicated vaginal delivery; and at least ninety-six (96) hours following an uncomplicated cesarean section. We also cover postpartum home care visits upon release, when prescribed by the attending provider. In consultation with your physician, you may request a shorter length of stay. In such cases, we will cover one home health visit scheduled to occur within twenty-four (24) hours after discharge, and an additional home visit if prescribed by the attending provider. Up to four (4) days of additional hospitalization for the newborn is covered if you are required to remain hospitalized after childbirth for medical reasons. Comprehensive lactation (breastfeeding) education and counseling, by trained clinicians during pregnancy and/or postpartum period in conjunction with each birth, Breastfeeding equipment is issued, per pregnancy. The breast-feeding pump (including any equipment that is required for pump functionality) is covered for six (6) months at no cost sharing to the member. See the benefit-specific exclusion immediately below for additional information Benefit-Specific Exclusion: 1. Personal and convenience supplies associated with breastfeeding equipment such as pads, bottles, and carrier cases. 2. Services for newborn deliveries performed at home Medical Foods We cover medical foods and low protein modified food products for the treatment of inherited metabolic diseases caused by an inherited abnormality of body chemistry including a disease for which the State screens newborn babies. Coverage is provided if the medical foods and low protein food products are prescribed as Medically Necessary for the therapeutic treatment of inherited metabolic diseases and are administered under the direction of a Plan Provider. Medical foods are intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and are formulated to be consumed or administered internally (i.e., by tube directly into the stomach or small intestines) under the direction of a Plan Provider. Low protein modified foods are food products that are: 1. Specially formulated to have less than one (1) gram of protein per serving; and 2. Intended to be used under the direction of a Plan Provider for the dietary treatment of an inherited metabolic disease. Amino Acid-based Elemental Formula (Drugs, Supplies and Supplements) We cover amino acid-based elemental formula, regardless of delivery method, for the diagnosis and treatment of: 1. Immunoglobulin E and non-Immunoglobulin E mediated allergies to multiple food proteins; 2. Severe food protein induced enterocolitis syndrome; 3. Eosinophilic disorders, as evidenced by the results of a biopsy; and 4. Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. Coverage shall be provided if the ordering physician has issued a written order stating that amino acid-based elemental formula is Medically Necessary for the treatment of a disease or disorder listed above. The Health Plan, or a private review agent acting on behalf of the Health Plan, may review the ordering physician’s determination of the Medical Necessity of the amino acid-based elemental formula for the treatment of a disease or disorders listed above. See the benefit-specific exclusions immediately below for additional information.