Early Intervention Services (EIS). In accordance with Rhode Island General Law §27-20-50, this agreement provides coverage for Early Intervention Service. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The children must have been certified by the Rhode Island Department of Human Services to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. We cover Early Intervention Services as defined by the Rhode Island Department of Human Services including, but not limited to, the following: • speech and language therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices. See the Summary of Medical Benefits for the maximum benefit limit and the amount that you pay.
Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Education - Asthma Asthma management 0% - After deductible 40% - After deductible
Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% 20% - After deductible Emergency Room Services Hospital emergency room $200 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $50 20% - After deductible Hearing diagnostic testing 0% 20% - After deductible Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21, the benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible 20% - After deductible
Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Education - Asthma Asthma management 0% - After deductible Not Covered Emergency Room Services Hospital emergency room 0% - After deductible Not Covered Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 0% - After deductible Not Covered
Early Intervention Services (EIS). In accordance with Rhode Island General Law §27-20-50, this agreement provides coverage for Early Intervention Service. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six
Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO The level of coverage is the same as network provider. The level of coverage is the same as network provider. Education Asthma Management $0 NO 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $40 NO 40% YES Diagnostic Testing 20% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 20% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 20% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 20% YES 40% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 20% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycl...
Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $200 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21, the benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% Not Covered Infertility Services Inpatient/outpatient/in a physician’s office. Three (3) infertility treatment cycles will be covered per plan year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. 20% - After deductible Not Covered
Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $150 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 Not Covered Hearing diagnostic testing $30 Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered
Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Education - Asthma Asthma management 0% 20% - After deductible Emergency Room Services Hospital emergency room $200 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 20% - After deductible Hearing diagnostic testing 0% 20% - After deductible Hearing aids - The benefit limit is $1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible 20% - After deductible
Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Education - Asthma Asthma management $50 - After deductible 40% - After deductible Emergency Room Services Hospital emergency room $200 - After deductible The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $50 - After deductible 40% - After deductible Hearing diagnostic testing 0% - After deductible 40% - After deductible Hearing aids - The benefit limit is $1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 0% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible 40% - After deductible Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 40% - After deductible Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% - After deductible 40% - After deductible Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 0% - After deductible 40% - After deductible Infusion Therapy - Administration Services Outpatient - facility 0% - After deductible 40% - After deductible In the physician’s office/in your home 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient Services General hospital or specialty hospital services* - Unlimited Days 0% - After deductible 40% - After deductible Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible 40% - After deductible Physician hospital visits 0% - After deductible 40% - After deductible Mastectomy Services Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible 40% - After deductible Surgery services - includes mastectomy and re...
