SCHEDULE OF BENEFITS

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SCHEDULE OF BENEFITS

  1. 1. SCHEDULE OF BENEFITS FLEX ’99 HARRIS METHODIST TEXAS HEALTH PLAN, INC. d/b/a HARRIS METHODIST HEALTH PLAN A Federally Qualified Health Maintenance Organization 611 Ryan Plaza Drive, Ste. 900 Arlington, TX 76011-4009 817-462-7800 800-633-8598FLEX.199 FLEX 10/200/1000
  2. 2. CUSTOMER SERVICE DEPARTMENTThe Health Plan’s Customer Service Department can help You anytime You have a problem or question. Call a representative at(817) 462-7800 or 1-800-633-8598 if You: • Need to change Your Primary Care Physician • Have a benefit question • Cannot reach Your Primary Care Physician • Need any replacement documents (Member Guide, Schedule of Benefits, Certificate of Coverage, Provider Directory, etc.) • Need to replace a lost or stolen ID Card • Need to update Your name, address, or phone number • Have a complaint, problem, or suggestion • Have any other questions about Your health care coverage. WELLCALL PLUS • (817) 462-7800 or (800) 633-8598FLEX.199 Flex 10/200/1000
  3. 3. TABLE OF CONTENTSaaWELCOME.................................................................................................................................1abSCHEDULE OF BENEFITS.......................................................................................................3AMBULANCE SERVICES..............................................................................................................6CARDIAC REHABILITATION SERVICES....................................................................................17CHEMICAL DEPENDENCY SERVICES......................................................................................14DENTAL SERVICES - LIMITED...................................................................................................19DIABETIC SERVICES..................................................................................................................10DURABLE MEDICAL EQUIPMENT (DME)..................................................................................18EMERGENCY CARE SERVICES..................................................................................................5FAMILY PLANNING SERVICES....................................................................................................9HOME HEALTH SERVICES........................................................................................................15INFERTILITY SERVICES...............................................................................................................9INPATIENT FACILITY SERVICES.................................................................................................7KIDNEY DIALYSIS SERVICES....................................................................................................11MATERNITY SERVICES................................................................................................................8MENTAL HEALTH SERVICES - INPATIENT...............................................................................12MENTAL HEALTH SERVICES - OUTPATIENT...........................................................................12menzSERIOUS MENTAL ILLNESS SERVICES..........................................................................13ORGAN TRANSPLANT SERVICES............................................................................................11OSTOMY SUPPLIES...................................................................................................................17OUTPATIENT FACILITY SERVICES.............................................................................................7PHYSICIAN SERVICES.................................................................................................................4PROSTHETIC MEDICAL APPLIANCES......................................................................................18REHABILITATION SERVICES.....................................................................................................16SKILLED NURSING FACILITY SERVICES.................................................................................14SPEECH AND HEARING SERVICES..........................................................................................16VISION SERVICES - LIMITED.....................................................................................................20zyGENERAL LIMITATIONS.........................................................................................................21zzGENERAL EXCLUSIONS.........................................................................................................22FLEX.199 Flex 10/200/1000
  4. 4. WELCOMEWelcome to Harris Methodist Health Plan, referred to as “Health Plan” in this Schedule ofBenefits. We have prepared this Schedule of Benefits to help explain the coverage provided bythe Health Plan. It explains how to obtain medical care, what health services are covered, andwhat portion of the health care cost You are required to pay. You should refer to this informationwhenever You need medical services. You may request additional assistance by calling theHealth Plan’s Customer Service Department at (817) 462-7800 or (800) 633-8598.The Health Plan does not provide health care services, equipment, or supplies, but doescoordinate a health care system to finance and deliver quality, cost-effective services to You.You may choose to seek health care services outside the terms of this Schedule of Benefits;however, the Health Plan will only provide coverage for services received according to the termsof this Schedule of Benefits.SELECTING A PRIMARY CARE PHYSICIANYour Primary Care Physician (PCP) is responsible for coordinating Your total health care. Thisincludes initial care, routine care, home and office visits, and referrals. Upon enrollment, Youmust select a PCP from the Member Guide provided to You by the Health Plan, which includesphysician addresses and telephone numbers. If You do not choose a PCP, the Health Plan willselect one for You and notify You of the selection.You may change Your PCP by contacting the Health Plan’s Customer Service Department. Thechange becomes effective on the first day of the month following Your request. The Health Planmay limit Your requests to change Your PCP to four changes in any twelve month period.You may request health services by calling Your Primary Care Physician any time, day or night.OBTAINING THE SERVICES OF A SPECIALIST PHYSICIANBased on Your health care needs, Your PCP will coordinate referrals to specialists, although Youmay directly access Participating Providers for mental health services andobstetrical/gynecological services. Mental health services are coordinated through Alliance ofBehavioral Providers (ABP) whom You may contact directly by calling 817-462-6677 or1-800-374-2129. Access to OB/GYN services is described in the next section. Referrals tospecialists are valid only for the number of visits and/or time specified.If a required specialty is not represented in the Health Plan network, Your PCP may requestauthorization for referral to a Non-Participating Provider for Covered Services. All such non-emergency referrals must be authorized by the Health Plan before services are obtained.OBSTETRICAL & GYNECOLOGICAL SERVICESA referral from Your Primary Care Physician is not required for obstetrical or gynecological careprovided by a Participating Provider. You may directly contact the Participating Provider of Yourchoice for these services.FLEX.199 Flex 10/200/1000
  5. 5. ANNUAL DIAGNOSTIC EXAMINATIONSMammograms and prostate exams are covered under Your benefit plan. The Health Planrecommends that female Members receive mammograms and male Members receive prostateexams especially if You are considered to be in a high risk category. You may contact Your PCPto determine if You are considered to be in a high risk category and for the recommendedfrequency of exams.MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICESYou may access mental health and Chemical Dependency services directly by calling the HealthPlan’s mental health management services at (817) 462-6677 or (800) 374-2129, or byrequesting assistance from Your PCP.PREAUTHORIZATION & THE UTILIZATION REVIEW PROGRAMPreauthorization is the review of a requested service for Medical Necessity. This process helpsensure that You are receiving the most appropriate care available under this Schedule ofBenefits.Your Physician should contact the Health Plan before scheduling any service or admissionrequiring preauthorization. Some services which require preauthorization are: • Educational services; • Inpatient and outpatient Facility services; • Infertility services; • Cardiac Rehabilitation services; • Durable Medical Equipment; • Organ Transplant services; and • Home Health CareREGARDING REFERRALSIn some cases, the Health Plan has designated certain utilization management functions toPhysician groups or related entities. If the PCP You choose is affiliated with one of thesearrangements, prior approval for specialist referrals may be required. You may wish to consultwith Your PCP to determine if he or she is affiliated with an arrangement which requires approvalfor specialist referrals. Please refer to Your complaint and appeals procedures listed in YourSubscriber Certificate of Coverage for information regarding how to appeal any preauthorizationdecision.Your PCP may also be a part of a Limited Provider Network or association of healthprofessionals who work together to provide a full range of health care services. (A LimitedProvider Network is a subnetwork within an HMO delivery network in which contractualrelationships exist between Physicians, certain Providers, independent Physician associationsand/or Physician groups which may limit the enrollees’ access to only the Physicians, Providers,and Hospitals in the subnetwork.)FLEX.199 Flex 10/200/1000
  6. 6. SCHEDULE OF BENEFITSYou are entitled to receive benefits for Covered Services that are Medically Necessary anddescribed in this Schedule of Benefits. All services and benefits are subject to the statedCopayment amounts, Limitations, Exclusions, and provisions of the Group Health CareAgreement/Subscriber Certificate of Coverage and this Schedule of Benefits. Benefits may beadded to this Schedule of Benefits by the addition of benefit Riders.LIMITATIONS AND EXCLUSIONSAll benefits are subject to the stated Limitations and Exclusions. Each benefit section includesLimitations and Exclusions that apply to those benefits. General Limitations and Exclusions thatapply to all benefits are listed at the end of this Schedule of Benefits.REGARDING COPAYMENTSThis Schedule of Benefits shows different Copayments for different Covered Services. When aProvider performs two or more Covered Services on the same day, You pay only the higherCopayment. You would pay more than one Copayment for services on the same day if more thanone Provider is involved, such as paying a Facility Copayment to the Hospital and a PhysicianCopayment to the doctor.Copayments shown as a percentage of total charges means You pay the percentage of the ratethe Health Plan has negotiated with that Provider. If there is not a negotiated rate, You pay thepercentage of the rate charged by the Provider.COPAYMENT MAXIMUMSWhen the total Copayments applied to all Covered Services received by an individual Memberreach the Per Member Copayment maximum, no Copayment will be required for additionalCovered Services provided to that Member in the same Calendar Year.When the total Copayments applied to all Covered Services received by a family reach the PerFamily Copayment maximum, no Copayment will be required for additional Covered Servicesprovided to any Member of that family in the same Calendar Year. It is possible that a familycould reach the Per Family maximum without any one of the Members first reaching the PerMember maximum.OUT-OF-POCKET MAXIMUM YOUR COSTPer Member $1,000Per Family $2,000FLEX.199 Flex 10/200/1000
  7. 7. PHYSICIAN SERVICESBENEFITS YOUR COSTPrimary Care Physician office visits for the diagnosis, care, $10/Visitand treatment of an Illness or Injury, including, but not limitedto:• Well-child care;• Health assessments and screenings;• Routine physical examinations; and• Office surgerySpecialist Physician office visits $10/VisitAnnual well-woman examinations $10/Visit-Primary Care Physician $10/Visit-Specialist PhysicianPhysician home visits $10/Visit-Primary Care Physician $10/Visit-Specialist PhysicianPhysician visits outside of scheduled office hours $25/VisitImmunizations administered in the office without an office visit• Ages 0-6 years No Copayment• Ages 7 years and older No CopaymentInjections administered in the office without an office visit No Copayment(allergy serum is not covered).Allergy testing and diagnosis $10/VisitDiagnostic services, laboratory tests, and x-rays performed in No Copaymenta Physician’s officeProfessional radiology and pathology services No CopaymentProfessional anesthesia services No CopaymentPhysician services performed in an outpatient Facility No CopaymentPhysician services while You are confined in a Hospital or No Copaymentother inpatient FacilityPhysician services in an emergency Facility No CopaymentEXCLUSIONS♦ Reports, evaluations, or physical examinations not required for treatment of health conditions, or not directly related to medical treatment. Examples include, but are not limited to, services (including immunizations) for: compliance with a court order, employment, insurance, camp, adoption, school, travel, or government licenses.♦ Allergy serumFLEX.199 Flex 10/200/1000
  8. 8. EMERGENCY CARE SERVICESWhen faced with an emergency Illness or Injury, it is suggested You contact Your localemergency service or proceed to the nearest Emergency Care Facility. Upon arrival at theFacility or as soon as reasonably possible, You or someone You designate must contact YourPrimary Care Physician. The Health Plan will pay for Emergency Care whether it is providedinside or outside the Health Plan’s Service Area.Emergency Care means health care services provided in a Hospital emergency Facility orcomparable Facility to evaluate and stabilize medical conditions of a recent onset and severity,including but not limited to severe pain that would lead a prudent layperson, possessing anaverage knowledge of medicine and health, to believe that his or her condition, sickness, or Injuryis of such a nature that failure to obtain immediate medical care could result in: • placing the Member’s health in serious jeopardy; • serious impairment to bodily functions; • serious dysfunction of any bodily organ or part; • serious disfigurement; or • in the case of a pregnant woman, serious jeopardy to the health of the fetus.The Health Plan will pay for medical screening examinations or other evaluations provided to Youin the emergency department necessary to determine whether an emergency medical conditionexists. The Health Plan will also pay for necessary Emergency Care services originating in aHospital emergency department provided to You following stabilization of an emergency medicalcondition. The Health Plan must approve or deny coverage of post-stabilization care within thetime frame appropriate to the circumstances, but in no case to exceed one hour.Other SituationsIf the Illness or Injury is not an emergency, contact Your PCP before seeking treatment. YourPCP will direct You to the most appropriate place of service. Your PCP, or someone hedesignates, is available 24 hours per day, seven days a week.You may also contact WellCall Plus, the Health Plan’s personal health help line. Highly qualifiednurses are available 24 hours a day to assist You if You or a covered family Member is sick, hurt,or in need of medical advice. After asking questions about Your symptoms, the nurse will helpYou decide on the appropriate level of care. We suggest You contact Your PCP following a callto WellCall Plus to update him on Your medical condition. Contact WellCall Plus at1-800-633-8598 or through the Health Plan’s Customer Service Department at 817-462-7800.If You have determined that Your condition does not require Emergency Care, but does needimmediate attention from medical personnel, You may also choose to seek care from an UrgentCare center (minor emergency clinic). Urgent Care means health services provided in a situationother than in an emergency where a prudent layperson believes that the absence of treatmentwithin a reasonable time would result in a serious deterioration of a person’s health.Inpatient Admission Following Emergency Care ServicesIf You are admitted directly to an inpatient Facility from the emergency department of the sameFacility, the emergency room Facility Copayment will be waived and You will pay the appropriateinpatient Facility Copayment.FLEX.199 Flex 10/200/1000
  9. 9. EMERGENCY CARE SERVICES (cont.)BENEFITS YOUR COSTEmergency room Facility services inside or outside the $50/VisitHealth Plan’s Service AreaUrgent Care center services $25/VisitPhysician services in an emergency Facility No CopaymentLIMITATIONS♦ Benefits for Members temporarily outside the Service Area are limited to Emergency Care services. The Member must return to the Service Area to receive all other services and follow-up care from Participating Providers.♦ Coverage for services, supplies, or treatments not provided, referred, or authorized by Your PCP or the Health Plan is limited to coverage under this Emergency Care services benefit.♦ Coverage for services by Physicians, Facilities, or other Providers, who are not Participating Providers, is limited to coverage under this Emergency Care services benefit or to services preauthorized by the Health PlanAMBULANCE SERVICESBENEFITS YOUR COSTLand and air ambulance services $50 CopaymentLIMITATIONS♦ Ambulance services benefits are limited to: • services provided in relation to covered Emergency Care services; or • non-emergency services preauthorized by the Health Plan♦ Transportation or travel by means of any private or commercial carrier is limited to covered ambulance servicesFLEX.199 Flex 10/200/1000
  10. 10. INPATIENT FACILITY SERVICESBENEFITS YOUR COSTAll covered inpatient Facility services, medications, and $200 per admissionsuppliesPhysician services while You are confined in a Hospital or No Copaymentother inpatient FacilityProfessional anesthesia services No CopaymentLIMITATIONS♦ Inpatient diagnostic testing is limited to services directly related to the condition for which the hospitalization is authorized.EXCLUSIONS♦ Recreational or educational therapy♦ Private room accommodations when semi-private room accommodations are available♦ Private duty nursing in an inpatient FacilityOUTPATIENT FACILITY SERVICESBENEFITS YOUR COSTFacility services for surgery or other procedure $50/VisitPhysician services for surgery or other procedure No Copaymentperformed in an outpatient FacilityProfessional radiology and pathology services No CopaymentProfessional anesthesia services No CopaymentDiagnostic services, laboratory tests, and x-rays No Copayment(except MRI and CAT scan)MRI and CAT scan No CopaymentChemotherapy and radiation therapy $10/VisitLIMITATIONS♦ You will pay only the higher Copayment for Physician services when multiple services are performed by one or more Participating Physicians .FLEX.199 Flex 10/200/1000
  11. 11. MATERNITY SERVICESBENEFITS YOUR COSTPhysician services for obstetrical care, $10 First Visitincluding pre-natal care, post-partum care, and Medically $10 Each Subsequent VisitNecessary diagnostic servicesPhysician services for maternity care and delivery while No CopaymentYou are confined in a Hospital or inpatient Facility.Physician services for care of an eligible newborn while No Copaymentconfined in a Hospital or other inpatient Facility.All covered inpatient Facility services, medications, and $200 per admissionsuppliesMaternity education programs $10 per programLIMITATIONS♦ Coverage for maternity services received outside the Service Area before week thirty-seven (37) of the pregnancy are limited to covered Emergency Care services benefits or services preauthorized by the Health Plan.♦ You must have preauthorization from the Health Plan to travel outside the Service Area (except for travel due to emergencies) after week thirty-six (36) of the pregnancy or services received outside the Service Area will not be covered.♦ Coverage for maternity services by Non-participating Providers is limited to Members who become eligible with the Health Plan after week thirty-one (31) of the pregnancy. All services must be authorized by the Health Plan before charges are incurred. All future obstetrical/gynecological services must be performed by a Participating Provider.♦ Maternity education programs require a referral from Your Physician and include prepared childbirth, Lamaze, teen pregnancy, cesarean section, vaginal birth after cesarean (VBAC), parenting, breast-feeding, and stress management during pregnancy.♦ Ultrasounds are limited to one (1) ultrasound per pregnancy unless additional ultrasounds are determined to be Medically Necessary.EXCLUSIONS Any procedure performed solely for sex determination of the fetus. Examples include, but are not limited to: ultrasound and amniocentesis.FLEX.199 Flex 10/200/1000
  12. 12. INFERTILITY SERVICESBENEFITS YOUR COSTPhysician office visits $10/Visit-Primary Care Physician $10/Visit-Specialist PhysicianDiagnostic services, laboratory tests, and x-rays No CopaymentIntra-uterine and intra-cervical insemination with related $10 per proceduresperm washingEndometrial biopsy, hysterosalpingography, and diagnostic $50 per procedurelaparoscopyLIMITATIONS♦ Infertility services benefits are limited to intra-uterine and intra-cervical insemination and diagnostic services to determine the cause of infertility.♦ Costs associated with the collection, storage, purchase, or processing of sperm is limited to those incurred for sperm washing for an intra-uterine or intra-cervical insemination procedure.EXCLUSIONS♦ Infertility treatment, except intra-uterine and intra-cervical insemination♦ Any surgery or other procedure to correct a medical condition causing infertility for the purpose of enabling pregnancy♦ Infertility medications♦ Surrogate parenting♦ Any assisted reproductive technology (ART) procedure that enhances a woman’s ability to become pregnant, unless provided by Rider. Examples of ART procedures include, but are not limited to: GIFT procedures, ZIFT procedures, and in-vitro fertilization.FAMILY PLANNING SERVICESBENEFITS YOUR COSTPhysician office visits $10/Visit-Primary Care PhysicianIncluding testing, counseling, genetic counseling, Federal $10/Visit-Specialist PhysicianDrug Administration approved contraceptive injections, thefitting or dispensing of an IUD or diaphragm, the removal ofNorplant or similar device.Physician services for Tubal Ligation No CopaymentPhysician services for Vasectomy $10 per procedureFLEX.199 Flex 10/200/1000
  13. 13. FAMILY PLANNING SERVICES (cont.)EXCLUSIONS♦ Reversal of sterilization♦ Subsequent resterilization♦ Insertion or supply of Norplant or any similar deviceDIABETIC SERVICESBENEFITS YOUR COSTPhysician office visits for diabetic care $10/VisitDiabetic equipment and supplies $10 CopaymentDiabetic education No CopaymentLIMITATIONS♦ Medically Necessary covered diabetic equipment and supplies include: • blood glucose monitors, including monitors designed to be used by blind individuals; • insulin pumps and associated appurtenances; • insulin infusion devices; • podiatric appliances for the prevention of complications associated with diabetes; • test strips for blood glucose monitors; • visual reading and urine test strips; • lancets and lancet devices; • syringes; • insulin and insulin analogs; • injection aids; • prescriptive and nonprescriptive oral agents for controlling blood sugar levels; and • glucagon emergency kits♦ Covered diabetic education programs must be Medically Necessary and preauthorized, and include: • diabetes care and self management training; and • dietary counseling for diabetes management♦ Purchases of diabetic equipment and supplies is limited to a maximum of a thirty (30) day supply per Copayment.FLEX.199 Flex 10/200/1000
  14. 14. KIDNEY DIALYSIS SERVICESBENEFITS YOUR COSTOutpatient services $10/VisitHome Dialysis $10/Visit (continuous ambulatory peritoneal dialysis) including equipment, training, solutions, coils, and drug and surgical suppliesORGAN TRANSPLANT SERVICESThe Health Plan will provide benefits toward the following transplants when preauthorized by theHealth Plan Medical Director or his designee: • kidney transplants; • cornea transplants; • liver transplants; • pancreas transplants; • bone marrow transplants; • heart transplants; • lung transplants; and/or • any combination of these covered transplantsBENEFITS YOUR COSTAll covered inpatient Facility services, medications, and $200 per admissionsuppliesPhysician services while You are confined in a Hospital or No Copaymentother inpatient FacilityEXCLUSIONS♦ Artificial Organ Transplants♦ Cross-species whole Organ Transplants♦ Organ donor transportation or lodging costs♦ Services provided to any Member for the donation of any organ or element of the body to a non-Member recipientFLEX.199 Flex 10/200/1000
  15. 15. OUTPATIENT MENTAL HEALTH SERVICESServices for the evaluation and treatment of mental health conditions which do not require aprogram of daily treatment and for which services are provided on a per-visit basis.BENEFITS YOUR COST Maximum: 30 Days per yearCovered Services except group therapy and home health $10/VisitvisitsGroup therapy and home health visits $10/VisitMedication management $10/Visit-Primary Care Physician $10/Visit-Specialist PhysicianPsychological testing $100/VisitLIMITATIONS♦ Mental health services benefits for outpatient care services are limited to a maximum benefit of 30 visits per Calendar Year, and may include individual, family or group therapy and home health visitsINPATIENT MENTAL HEALTH SERVICESInpatient Mental Health Benefits include:• Psychiatric Day Treatment Facility/Structured Sub-acute Care - Provides treatment for individuals suffering from acute, mental and nervous disorders in a structured psychiatric program utilizing individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program. Each full day of treatment in a Psychiatric Day Treatment Facility shall be considered equal to one-half of one day of treatment of mental or emotional Illness or disorder in a Hospital or inpatient program.• Residential Treatment Center for Children and Adolescents - Provides residential care and treatment for emotionally disturbed children and adolescents and is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Hospitals, or the American Association of Psychiatric services for Children. Each two days of treatment in a residential treatment center will be considered equal to one day of treatment of mental or emotional Illness or disorder in a Hospital or inpatient program.• Crisis Stabilization Unit/Inpatient Care - Means a 24-hour residential program that is usually short-term in nature and that provides intensive supervision and highly structured activities to persons who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe proportions. Each two days in a Crisis Stabilization Unit are considered equal to one day of treatment of mental or emotional Illness or disorder in a Hospital or inpatient program.FLEX.199 Flex 10/200/1000
  16. 16. INPATIENT MENTAL HEALTH SERVICES (cont.)BENEFITS YOUR COST Maximum: 30 Days per yearCrisis Stabilization Unit/Inpatient Care Facility $200 per admissionPsychiatric Day Treatment/Structured Sub-acute Care,and/or Residential Treatment Center for Children andAdolescentsPhysician services while You are confined in a Hospital or No Copaymentother inpatient FacilityLIMITATIONS♦ Inpatient mental health services benefits are limited to a combined maximum benefit of 30 days per Calendar Year and may include evaluation, crisis intervention, and stabilization for the diagnosis and treatment of covered mental Illnesses or disorders.SERIOUS MENTAL ILLNESS SERVICESBENEFITS YOUR COSTPhysician services for Serious Mental Illness $10/VisitAll covered inpatient Facility services, medications, and $200 per admissionsuppliesPhysician services while You are confined in a Hospital or No Copaymentother inpatient FacilityOutpatient Facility services $50/VisitLIMITATIONS♦ All services must be provided in relation to a covered diagnosis or procedure♦ Treatment of Serious Mental Illness will mean treatment of the following psychiatric conditions as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM): • Schizophrenia; • Paranoia and other psychotic disorders; • Bipolar disorders (mixed, manic, depressive, and hypomanic); • Major depressive disorders (single episode or recurrent); • Depression in childhood or adolescence; • Schizo-affective disorders (bipolar or depressive); • Pervasive developmental disorders; or • Obsessive-compulsive disordersFLEX.199 Flex 10/200/1000
  17. 17. CHEMICAL DEPENDENCY SERVICESYou are entitled to coverage of necessary care and treatment for Chemical Dependency on thesame basis as that provided for any physical illness. Diagnosis and treatment for ChemicalDependency will include detoxification and/or rehabilitation on an inpatient or outpatient basis.A series of treatments is a planned, structured, and organized program to promote chemical freestatus which may include different facilities or modalities and is complete when the Member: • is discharged on medical advice; • has completed a series of these treatments without a lapse in treatment; or • fails to materially comply with the treatment program for a period of 30 daysBENEFITS YOUR COST Lifetime Maximum Benefit: Three separate series of treatmentsOutpatient Care $10/Visit-Primary Care Physician $10/Visit-Specialist PhysicianInpatient Care/Crisis Stabilization Unit or Psychiatric Day $200 per admissionTreatment Facility/Structured Sub-acute CarePhysician services while You are confined in a Hospital or No Copaymentother inpatient FacilityEXCLUSIONS♦ Services provided by or at a residential treatment centerSKILLED NURSING FACILITY SERVICESBENEFITS YOUR COST Maximum Benefit: 60 days per Calendar YearAll covered inpatient Facility services, medications, and $200 per admissionsuppliesPhysician services while You are confined in an inpatient No CopaymentFacility for the purpose of skilled nursing servicesFLEX.199 Flex 10/200/1000
  18. 18. SKILLED NURSING FACILITY SERVICES (cont.)LIMITATIONS♦ Skilled Nursing Facility services benefits are limited to: • medical conditions subject to significant clinical improvement; and • services provided instead of hospitalization, either in place of an admission or upon discharge from inpatient care, or • services determined Medically Necessary by the Health Plan based on acuity of services and patient conditionHOME HEALTH SERVICESBENEFITS YOUR COSTHome health services $10/VisitHospice (Home health service only) $10/DayGrowth hormones $10 per VialLIMITATIONS♦ Home health care services benefits are limited to services provided for: • chemotherapy; • radiation therapy; • treatment of terminal illness; • physical, occupational, respiratory, and/or speech therapy; or • treatments determined by the Health Plan to be Medically Necessary and appropriate to be rendered in a home setting♦ Hospice care received outside the home is provided under the inpatient Facility services benefitEXCLUSIONS♦ Homemaker chores or similar servicesFLEX.199 Flex 10/200/1000
  19. 19. REHABILITATION SERVICESBENEFITS YOUR COSTRehabilitative services including occupational therapy, Outpatient: $10/Visitrespiratory therapy, and/or physical therapy Inpatient: $200 per admissionPhysician services while You are confined in a Hospital or No Copaymentother inpatient FacilityLIMITATIONS♦ Rehabilitation services benefits are limited to services that: • prevent dysfunction, restore functional ability, or facilitate maximal adaption to impairment; • are directed and monitored by a Participating Physician; • are for therapy provided by a Physician or by a licensed or certified physical, occupational, or respiratory therapist; • are furnished to You by a Participating Facility or through a Participating Provider; and • are provided according to a specific, written treatment plan that details the treatment, including frequency and duration, and provides for on-going reviews.EXCLUSIONS♦ Work hardening programsSPEECH AND HEARING SERVICESBENEFITS YOUR COSTSpeech and/or hearing therapy Outpatient: $10/Visit Inpatient: $200 per admissionPhysician services while You are confined in a Hospital or No Copaymentother inpatient FacilityFLEX.199 Flex 10/200/1000
  20. 20. SPEECH AND HEARING SERVICES (cont.)LIMITATIONS♦ Speech and hearing benefits are limited to services that: • prevent dysfunction, restore functional ability, or facilitate maximal adaption to impairment; • are directed and monitored by a Participating Physician; • are for therapy provided by a Physician or by a licensed or certified speech or hearing therapist; • are furnished to You by a participating Facility or through a Participating Provider; and • are provided according to a specific, written treatment plan that details the treatment, including frequency and duration, and provides for on-going reviews.EXCLUSIONS♦ Work hardening programsCARDIAC REHABILITATION PROGRAMBENEFITS YOUR COST Maximum Benefit: 36 sessions within 12 consecutive weeks per episodeOutpatient services $10/VisitLIMITATIONS♦ Cardiac rehabilitation program benefits are limited to services provided immediately following: • a documented episode of unstable angina or myocardial infarction; or • a coronary revascularization procedure♦ Cardiac rehabilitation programs must be medically supervised and EKG monitored.OSTOMY SUPPLIESBENEFITS YOUR COST Maximum Benefit: $1,000 per Calendar YearOstomy supplies 20% of Total ChargesLIMITATIONS♦ Coverage of ostomy supplies is limited to: bags, stoma caps, skin cleanser, skin prep, paste, powder, dressings, syringes, sheaths, and gloves♦ Purchases of ostomy supplies are limited to a maximum of a thirty (30) day supply per CopaymentFLEX.199 Flex 10/200/1000
  21. 21. PROSTHETIC MEDICAL APPLIANCESBENEFITS YOUR COST Maximum Benefit: unlimited per Calendar YearInternal and external prosthetic appliances and applicable $10 per appliancehardwareLIMITATIONS♦ Prosthetic medical appliances benefits are limited to appliances that: • serve a basic physical or functional purpose; and • are obtained from a participating prosthetic medical appliance Provider♦ Repair or replacement of external prosthesis is covered only when required by marked physical changes, growth, or malfunction of the device as determined by the Health Plan♦ The purchase of an external breast prosthesis and any associated garments is limited to purchase of the initial prosthesis and bra following mastectomy without reconstructionEXCLUSIONS♦ Maintenance of any external device, appliance, equipment, or supply♦ Repairs to prosthetic medical appliances determined to be cosmetic by the Health PlanDURABLE MEDICAL EQUIPMENT (DME)BENEFITS YOUR COST Maximum Benefit: unlimited per Calendar YearRental or purchase of medical equipment $10 per deviceLIMITATIONS♦ Durable Medical Equipment (DME) benefits are limited to equipment that is: • ordered by a Participating Physician; • obtained from a participating DME Provider; • able to withstand repeated use; • primarily and customarily serve a medical purpose; • not generally useful in the absence of Illness or Injury; and • appropriate for use in the home♦ Replacement of Durable Medical Equipment is covered only when required by marked physical changes or growthFLEX.199 Flex 10/200/1000
  22. 22. DURABLE MEDICAL EQUIPMENT (DME) (cont.)♦ Breast pumps must be determined to be Medically Necessary by the Health Plan to be eligible for coverage♦ At Our option, the Health Plan maintains the right to rent or purchase approved equipment and maintains the right of possession of the equipment.EXCLUSIONS♦ Repair or maintenance of any Durable Medical EquipmentLIMITED DENTAL SERVICESBENEFITS YOUR COST Maximum Benefit: $500 per Calendar YearLimited professional dental services for repair of accidental 20% of Total ChargesInjury to Sound Natural TeethLIMITATIONS♦ Limited professional dental repair services are covered only when performed by a Participating Provider♦ Limited professional dental repair services benefits are limited to treatment: • for the repair of accidental, non-occupational Injury to Sound Natural Teeth; • begun within thirty (30) days of the accident; and • completed within one hundred eighty (180) days of the accident.♦ Anesthesia and Hospital services for any dental care are limited to those available for Members who are unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the Members Physician or the Dentist providing the dental care.EXCLUSIONS♦ Repair or replacement of any implant, pontic, bridge, or denture♦ Appliances or splints for conditions involving the teeth, jaws, or tongueFLEX.199 Flex 10/200/1000
  23. 23. LIMITED DENTAL SERVICES (cont.)♦ Dental care, including, but not limited to: • orthodontia services; • fillings or other dental repair procedures; • replacement of teeth, including fixed or removable prosthesis; • treatment for diseases of the teeth or gums; • extraction of teeth, including wisdom teeth; • treatment for malocclusion or malposition of the teeth or jaws (mandibular or maxillary hyperplasia or hypoplasia); • Inpatient or outpatient surgery required for any dental care; • prescription drugs for dental treatment; and • x-rays♦ Dental services covered by any dental benefit plan through which the Member has other coverage for dental benefitsLIMITED VISION SERVICESBENEFITS YOUR COST Maximum Benefit: $75 per Calendar YearLimited vision services following cataract surgery, No CopaymentCongenital Anomaly repair, or accidental InjuryLIMITATIONS• Limited vision services benefits are limited to the purchase and fitting of the initial set of basic eyeglasses or initial contact lens following: • cataract surgery; • repair of Congenital Anomaly; or • accidental Injury when the natural lens has not been replaced by an internal prosthetic lensEXCLUSIONS♦ Radial keratotomy (RK), photorefractive keratotomy (PRK), and other keratoplasties or keratotomiesFLEX.199 Flex 10/200/1000
  24. 24. GENERAL LIMITATIONSGeneral Limitations that apply to Your benefits are listed in this section. Limitations that normallyoccur in relation to a specific benefit have been listed in the appropriate benefit section; however,all benefits are subject to all stated Limitations in this Schedule of Benefits.1. Coverage is limited to those Covered Services that are Medically Necessary and provided in relation to a covered diagnosis or procedure.2. Reconstructive surgery is limited to the reconstruction necessary to repair a dysfunction or disfigurement resulting from Injury, Illness, or Congenital Anomaly.3. Breast reconstruction is limited to reconstruction of a breast, incident to mastectomy, to restore or achieve breast symmetry. This includes surgical reconstruction of a breast on which mastectomy surgery has been performed and surgical reconstruction of a breast on which mastectomy surgery has not been performed.4. Charges submitted by a Facility as part of an inpatient confinement are limited to services related to the condition for which the confinement was approved.5. Coverage for treatment of the temporomandibular joint (TMJ), including the jaw and the craniomandibular joint, is limited to those services for which coverage is mandated by the State of Texas. This includes only Medically Necessary diagnostic services and/or surgical treatment of conditions affecting the TMJ as determined to be Medically Necessary by the Health Plan Medical Director or his designee. All services must be provided by a Participating Provider. Surgical treatment of conditions affecting the TMJ must be preauthorized by the Health Plan. Charges related to dental services are not covered.6. Benefits for covered prescription and non-prescription drugs, medications, and pharmaceuticals are limited to those covered items purchased and administered in a clinical setting by a Participating Provider. Formulas necessary for the treatment of phenylketonuria (PKU) or other heritable diseases are covered to the same extent as for drugs available only on the orders of a Physician.7. Coverage for orthotics is limited to those services or products used in the treatment of all medical conditions other than for treatment of the foot and must be preauthorized by the Health Plan.8. Coverage for blood and blood products is limited to those units which have not been replaced by or on behalf of a Member.FLEX.199 Flex 10/200/1000
  25. 25. GENERAL EXCLUSIONSGeneral Exclusions that apply to Your benefits are listed in this section. Exclusions that normallyoccur in relation to a specific benefit have been listed in the appropriate benefit section; however,all benefits are subject to all stated Exclusions in this Schedule of Benefits. Please check anyRider(s) purchased with this Schedule of Benefits for possible coverage of any of these excludedservices.1. Any service or treatment for which You would not legally be required to pay in the absence of coverage provided by this Schedule of Benefits, except for Medicaid2. Care for conditions that state or local law requires be treated in a public Facility3. Care for military service-connected disabilities for which the Member is legally entitled to services and for which Facilities are reasonably available to the Member4. Services rendered by an immediate relative of the Member or by a person who resides in the Member’s home. An immediate relative is the spouse, child, parent, grandparent, or sibling of the Member and includes in-law and step-family relationships formed through a current or previous marriage5. Any medical, surgical, or health care procedure, service, device, or drug held to be Experimental or Investigational at the time it is performed, utilized, or administered, unless approved by the Health Plan6. Services or products not for the specific treatment of Illness or Injury, including, but not limited to: • personal, convenience, or comfort items; • personal kits provided upon admission to a Hospital; • television; • telephone; • photographs; • living accommodations or expenses, guest meals, or cots; • finance charges; and • announcements7. Alternative methods of treatment including, but not limited to: • acupuncture; • naturopathy; • psychosurgery; • megavitamin therapy; • nutritionally based alcoholism therapy; • holistic or homeopathic care, including drugs; • ecological or environmental medicine; • hypnotherapy or hypnotic anesthesia; • hippotherapy; and • sleep therapy8. Services primarily for rest, Custodial Care, Domiciliary Care, convalescent or respite care9. Transsexual surgery, including medical or psychological counseling or hormonal therapy, in preparation for or subsequent to any such surgeryFLEX.199 Flex 10/200/1000
  26. 26. GENERAL EXCLUSIONS (cont.)10. Hearing aids, batteries, and examinations for the fitting of hearing aids, unless provided by Rider11. Structural changes to a building or vehicle12. Care and treatment of the exterior surfaces of the feet, including, but not limited to: • removal or reduction of corns or calluses; • arch supports or foot orthotics; • trimming of nails; • treatment of flat feet; • braces; and • splints13. Treatment of obesity or complications of obesity treatment, regardless of associated medical or psychological condition, including, but not limited to: • intestinal or stomach bypass surgery; • gastric stapling; • wiring of the jaw; and • insertion of gastric balloons14. Services primarily to improve the Member’s appearance, which will not result in significant functional improvement, including, but not limited to: • plastic surgery; • surgical treatment of keloid formation; • rhinoplasty; • scar revision; • revision or reformation of sagging skin on any part of the body described as relating to the eyelids, face, neck, abdomen, arms, legs, or buttocks; • liposuction procedures; • procedures performed in connection with the enlargement, reduction, implantation, or appearance of a part of the body described as relating to the breast, face, lips, jaw, chin, nose, ears, or genitals; • hair replacement or transplantation; • chemical applications or peels; • abrasion of the skin; • tattoo removal or camouflage; and • electrolysis depilation15. Drugs or substances not approved by the FDA, labeled “Caution - Limited by Federal Law to Investigational use,” or considered Experimental16. Drugs used to treat hemophilia disorders17. Formulas, dietary supplements, or special diets, except enteral nutritional products when approved by the Health Plan and those for the treatment of phenylketonuria (PKU) or other heritable diseasesFLEX.199 Flex 10/200/1000
  27. 27. GENERAL EXCLUSIONS (cont.)18. Aids, appliances, or supplies that possess features not required by the Member’s condition, are not primarily medical in nature, are self-help devices, are primarily for the Member’s comfort or convenience, are for common household use, are research equipment, or are deemed Experimental by the Health Plan, including, but not limited to: • corrective orthopedic shoes or arch supports; • dentures; • contact lenses; • wigs or hair pieces; • motor-driven wheel chairs and beds; • bed boards, bathtub lifts, over-bed tables, adjustable beds, telephone arms, sauna or whirlpool baths, chairs, elevators, car seats, or standing frames; • stethoscopes, sphygmomanometers, or other blood pressure units; • exercise equipment or enrollment in health or athletic clubs; • air purifiers, air conditioners, or water purifiers; • hypo-allergenic pillows or mattresses, or water beds; • elastic stockings, garter belts, or corsets; • cervical collars, slings, or traction apparatus; • home testing kits or supplies; • over-the-counter medications; and • diapers, incontinence supplies, or other disposable supplies not otherwise specified in this Schedule of Benefits19. Excluded mental health services: • services for psychiatric conditions that are chronic or organic in nature, or that will not substantially benefit from short-term treatment; • biofeedback; • marriage, career, or financial counseling; • treatment of mental retardation or mental deficiency; • behavioral training; • remedial education; • evaluation and treatment of learning and developmental disabilities, and minimal brain dysfunction; • psychological testing or psychotherapy for the treatment of attention deficit disorders or related conditions; and • recreational or educational therapyFLEX.199 Flex 10/200/1000

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