Common use of Hospital Services Clause in Contracts

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 100% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  ✓ You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  ✓ The result of the test will directly impact the current treatment being delivered to you; and  ✓ After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 100% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 10080% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  ✓ You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  ✓ The result of the test will directly impact the current treatment being delivered to you; and  ✓ After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 10075% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 10075% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  ✓ You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  ✓ The result of the test will directly impact the current treatment being delivered to you; and  ✓ After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 10080% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 10080% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:.

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 10070% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  ✓ You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  ✓ The result of the test will directly impact the current treatment being delivered to you; and  ✓ After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 10070% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:

Hospital Services. Inpatient Hospital Services. • Inpatient hospital and residential treatment facility services for mental and substance use disorders. • Outpatient hospital services, ambulatory care or surgical facility services. • Outpatient hospital, partial hospital, and rehabilitation services in a day hospital program for mental and substance use disorders. • Telemedicine. • Medically necessary genetic testing determined by PIC to be covered services, as described below:  You display clinical features, or are at direct risk of inheriting the mutation in question (presymptomatic); and  The result of the test will directly impact the current treatment being delivered to you; and  After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. 10070% of eligible charges after the deductible. 50% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and non- participating residential treatment facilities are limited to a combined maximum of 120 calendar days per member per calendar year. * In the case of health care services (other than emergency services) furnished by a non-participating provider with respect to a visit at a hospital or ambulatory surgical center which is a participating provider:.