BLUE CROSS OF CALIFORNIA
 
UCLA MEDICAL CENTER HOUSE STAFF
January 1, 2008

 
 
 
 
 
 
 
 
 
 
 
MedCall
Your plan includes MedCall, a 24-hour nurse assessment service to help you make decisions about your medical care. When you call MedCall toll free at 800-977-0027, be prepared to provide your name, the patient's name (if you're not calling for yourself), the subscriber's social security number, and the patient's phone number.
The nurse will ask you some questions to help determine your health care needs. Based on the information you provide, the advice may be:
· Home self-care. A follow-up phone call may be made to determine how well home self-care is working.
· Schedule a routine appointment within the next two weeks, or an appointment at the earliest time available (within 64 hours), with your physician. If you do not have a physician, the nurse will help you select one by providing a list of physicians who are participating providers in your geographical area.
 
· Call your physician for further discussion and assessment.
 
· To go to an emergency room in a participating provider hospital.
 
· Instructions to immediately call 911.
   
In addition to providing a nurse to help you make decisions about your health care, MedCall gives you free unlimited access to its Audio Health Library featuring recorded information on more than 100 health care topics. To access the Audio Health Library, call toll free 800-977-0027 and follow the instructions given.
We have made arrangements with an independent company to make MedCall available to you as a special service. It may be discontinued without notice.
Note: MedCall is an optional service. Remember, the best place to go for medical care is your physician.
 
 
 
 
 
 
 
 
 
 
 
 
COMBINED EVIDENCE OF COVERAGE
AND DISCLOSURE FORM
Blue Cross of California
21555 Oxnard Street
Woodland Hills, California 91367
This Combined Evidence of Coverage and Disclosure (Evidence of Coverage) Form is a summary of the important terms of your health plan. The health plan contract must be consulted to determine the exact terms and conditions of coverage. Your employer will provide you with a copy of the health plan contract upon request.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TYPES OF PROVIDERS
 
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. IF YOU HAVE SPECIAL HEALTH CARE NEEDS, YOU SHOULD CAREFULLY READ THOSE SECTIONS THAT APPLY TO THOSE NEEDS. THE MEANINGS OF WORDS AND PHRASES IN ITALICS ARE DESCRIBED IN THE SECTION OF THIS BOOKLET ENTITLED DEFINITIONS.
Participating Providers. We have established a network of various types of "Participating Providers". These providers are called "participating" because they have agreed to participate in our preferred provider organization program (PPO), which we call the Prudent Buyer Plan. They have agreed to provide our members with health care at a special low cost. The amount of benefits payable under this plan will be different for non-participating providers than for participating providers. See the definition of "Participating Providers" in the DEFINTIIONS section for a complete list of the types of providers which may be participating providers.
We publish a directory of Participating Providers. You can get a directory from your plan administrator (usually your employer).
Non-Participating Providers. Non-participating providers are providers which have not agreed to participate in our Prudent Buyer Plan network. They have not agreed to the negotiated rates and other provisions of a Prudent Buyer Plan contract.
Contracting and Non-Contracting Hospitals. Another type of provider is the "contracting hospital". This is different from a hospital which is a participating provider. As a health care service plan, we have traditionally contracted with most hospitals to obtain certain advantages for patients covered by us. While only some hospitals are participating providers, all eligible California hospitals are invited to be contracting hospitals and most--over 90%--accept. For those which do not (called non-contracting hospitals), there is a significant benefit penalty in your plan.
Physicians. "Physician" means more than an M.D. Certain other practitioners are included in this term as it is used throughout the plan. This doesn't mean they can provide every service that a medical doctor could; it just means that we'll cover expenses you incur from them when they're practicing within their specialty the same as we would if the care were provided by a medical doctor. As with the other terms, be sure to read the definition of "Physician" to determine which providers' services are covered. Only providers listed in the definition are covered as physicians.
 
Other Health Care Providers. "Other Health Care Providers" are neither physicians nor hospitals. They are mostly free-standing facilities or service organizations, such as ambulance companies. See the definition of "Other Health Care Providers" in the DEFINITIONS section for a complete list of those providers. Other health care providers are not part of our Prudent Buyer Plan provider network.
Reproductive Health Care Services. Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective physician or clinic, or call us at the customer service telephone number listed on your ID card to ensure that you can obtain the health care services that you need.
Member Rights. We have a commitment to treat you in a manner that respects your rights. You have the right to:
 
· Obtain all medically necessary care covered under the plan;
· Be treated with consideration, courtesy, and respect for personal privacy and dignity;
 
· Discuss medically necessary treatment options for your conditions, regardless of cost or benefit coverage;
 
· Be involved in decision-making regarding your treatment;
 
· Confidential treatment of your illness and health records;
 
· Receive information about the plan, participating providers and your rights and responsibilities;
 
· Voice complaints about the participating providers or the care provided; and
 
· Appeal decisions made by the Health Plan.
 
Member Responsibilities. To assist providers in meeting these obligations, it is your responsibility to:
 
Centers of Expertise Transplant Facilities. We have established a Centers of Expertise (COE) network of transplant facilities to provide services for specified organ transplants (heart, liver, lung, heart-lung, kidney-pancreas, or bone marrow, including autologous bone marrow transplant, peripheral stem cell replacement and similar procedures).
 
These procedures are covered only at a COE. These "COE" agree to accept the COE negotiated rate as payment in full for covered services. A participating provider in the Prudent Buyer Plan network is not necessarily a Centers of Expertise transplant facility.
 
 
 
 
 
 
 
SUMMARY OF BENEFITS
 
THE BENEFITS OF THIS PLAN ARE PROVIDED ONLY FOR THOSE SERVICES THAT WE DETERMINE TO BE MEDICALLY NECESSARY. THE FACT THAT A PHYSICIAN PRESCRIBES OR ORDERS A SERVICE DOES NOT, IN ITSELF, MEAN THAT THE SERVICE IS MEDICALLY NECESSARY OR THAT THE SERVICE IS A COVERED EXPENSE. CONSULT THIS BOOKLET OR TELEPHONE US AT THE NUMBER SHOWN ON YOUR IDENTIFICATION CARD IF YOU HAVE ANY QUESTIONS REGARDING WHETHER SERVICES ARE COVERED.
 
THIS PLAN CONTAINS MANY IMPORTANT TERMS (SUCH AS "MEDICALLY NECESSARY" AND "COVERED EXPENSE") THAT ARE DEFINED IN THE DEFINITIONS SECTION. WHEN READING THROUGH THIS BOOKLET, CONSULT THE DEFINITIONS SECTION TO BE SURE THAT YOU UNDERSTAND THE MEANINGS OF THESE ITALICIZED WORDS.
For your convenience, this summary provides a brief outline of your benefits. You need to refer to the entire Combined Evidence of Coverage and Disclosure (Evidence of Coverage) Form for more complete information, and you must consult your employer's health plan contract with us to determine the exact terms and conditions of your coverage.
 
Second Opinions. If you have a question about your condition or about a plan of treatment which your physician has recommended, you may receive a second medical opinion from another physician. This second opinion visit will be provided according to the benefits, limitations, and exclusions of this plan. If you wish to receive a second medical opinion, remember that greater benefits are provided when you choose a participating provider. You may also ask your physician to refer you to a participating provider to receive a second opinion.
All benefits are subject to coordination with benefits under certain other plans.
The benefits of this plan are subject to the REIMBURSEMENT FOR ACTS OF THIRD PARTIES section.
 
 
MEDICAL BENEFITS
 
Deductibles
 
Plan Year Deductibles
(Plan Year begins on July 1st and ends on the following June 30th)
     
· Member Deductible $300
· Family Deductible $600
     
Additional Deductibles
     
· ·Non-Certification Deductible $500
Exceptions: In certain circumstances, one or more of these deductibles may not apply, as described below:
 
- The Plan Year Deductible will not apply to facility based care provided on an outpatient basis or to outpatient physician services for the treatment of mental or nervous disorders.
- The Plan Year Deductible will not apply to the following services provided by a participating provider: (a) physician's services for routine examinations and immunizations under the Well Baby and Well Child Care benefit; (b) physician's services for routine examinations and services provided under the Preventive Care Benefits; and (c) Hepatitis B and Varicella Zoster immunizations for dependent children.
 
- The Plan Year Deductible will not apply to transplant travel expenses authorized by us. See MEDICAL MANAGEMENT PROGRAMS: AUTHORIZATION PROGRAM for information on how to obtain prior authorization.
 
- The Non-Certification Deductible will not apply to emergency admissions or services, nor to the services provided by a participating provider. See MEDICAL MANAGEMENT PROGRAMS.
   
Co-Payments
 
Co-Payments.* After you have met your Plan Year Deductible, and any other applicable deductible, you will be responsible for the following percentages of covered expense you incur:
 
· Participating Providers 20%
· Other Health Care Providers 20%
· Non-Participating Providers 50%
Note: In addition to the Co-Payment shown above, you will be required to pay any amount in excess of covered expense for the services of an other health care provider or non-participating provider.
*Exceptions:
 
- Your Co-Payment for a routine examination provided by a participating provider under the Well Baby and Well Child Care benefit will be $25. This Co-Payment will not apply toward the satisfaction of any deductible, nor will it apply toward satisfaction of the Out-of-Pocket Amount. There will be no Co-Payment for immunizations provided by a participating provider under the Well Baby and Well Child Care benefit, nor for Hepatitis B and Varicella Zoster immunizations provided by a participating provider for dependent children.
- Your Co-Payment for a routine examination and any other related services provided by a participating provider under the Preventive Care Benefit will be $25. This Co-Payment will not apply toward the satisfaction of any deductible, nor will it apply toward satisfaction of the Out-of-Pocket Amount.
- Your Co-Payment for the following non-participating providers will be 20%, plus charges in excess of covered expense:
   
· A skilled nursing facility; and
· A home health agency.
- Your Co-Payment for non-participating providers will be the same as for participating providers for the following services. You may be responsible for charges which exceed covered expense.
 
a. Emergency services provided by other than a hospital;
b. The first 48 hours of emergency services provided by a hospital (the participating provider Co-Payment will continue to apply to a non-participating provider beyond the first 48 hours if you, in our judgment, cannot be safely moved);
c. An authorized referral from a physician who is a participating provider to a non-participating provider (see MEDICAL MANAGEMENT PROGRAMS: AUTHORIZATION PROGRAM);
d. Charges by a type of physician not represented in the Prudent Buyer Plan network (for example, an audiologist); or
e. Cancer Clinical Trials.
- Your Co-Payment for specified organ transplants (heart, liver, lung, heart-lung, kidney-pancreas, or bone marrow, including autologous bone marrow transplant, peripheral stem cell replacement and similar procedures) authorized by us and performed at a designated COE will be the same as for participating providers. Services for specified organ transplants are not covered when performed at other than a designated COE. See MEDICAL MANAGEMENT PROGRAMS: AUTHORIZATION PROGRAM.
- No Co-Payment will be required for the transplant travel expenses authorized by us. See medical MEDICAL MANAGEMENT PROGRAMS: AUTHORIZATION PROGRAM.
   
Out-of-Pocket Amount*. After you have made the following total out-of-pocket payments for covered expense you incur during a plan year, you will no longer be required to pay a Co-Payment for the remainder of that plan year, but you remain responsible for costs in excess of covered expense.
One member
 
· Participating providers and other health care providers $1,500
· Non-participating providers $5,000
Two or more members of the same family
· Other health care providers $3,000
· Non-participating providers $10,000
Note: Out-of-pocket amounts will apply to both participating providers and other health care providers and non-participating providers out-of-pocket amounts.
*Exceptions:
- Any Co-Payments you make for the treatment of mental or nervous disorders or substance abuse will not be applied toward the satisfaction of your Out-of-Pocket Amount. In addition, you will be required to continue to pay your Co-Payment for such treatment even after you have reached that amount.
- Any Co-Payments you make for routine examinations under the Well Baby and Well Child Care benefit or Preventive Care Benefits, when such care is provided by a participating provider, will not be applied toward the satisfaction of your Out-of-Pocket Amount. In addition, you will be required to continue to pay your Co-Payment for such care even after you have reached that amount.
- Expense which is applied toward any deductible, which is incurred for non-covered services or supplies, or which is in excess of the amount of covered expense, will not be applied toward your Out-of-Pocket Amount, and is always your responsibility.
 
Non-Contracting Hospital Penalty. Covered expense is reduced by 25% for services and supplies provided by a non-contracting hospital. This penalty will be deducted from covered expense prior to calculating your Co-Payment amount, and any benefit payment by us will be based on such reduced covered expense. You are responsible for paying this extra expense. This reduction will be waived only for emergency services. To avoid this penalty, be sure to choose a contracting hospital.
 
 
 
MEDICAL BENEFIT MAXIMUMS
 
We will pay for the following services and supplies, up to the maximum amounts, or for the maximum number of days or visits shown below:
 
Skilled Nursing Facility
 
· For covered skilled nursing facility care 120 days
 per plan year
     
Home Health Care
 
· For covered home health services

100 visits
per plan year
     
Home Infusion Therapy
 
· · For all covered services and supplies received during any one day

$600*

     
*Non-participating providers only
     
Prosthetic Devices
 
· For covered services and supplies (except breast prostheses following a mastectomy or prosthetic devices following a laryngectomy)

$1,000
per plan year

     
Durable Medical Equipment
 
· For covered charges for rental or purchase

$1,000
per plan year

     
Mental or Nervous Disorders or Substance Abuse
 
· For covered physician's services (this includes services provided by an M.F.T., L.C.S.W or a psychologist)

40 visits
per plan year

     
Well Baby and Well Child Care (Dependent Children Under Age 19)
 
· For physician's services for each routine examination

$20*
 
· For each immunization $12*
 
  *Non-participating providers only
     
Hepatitis B and Varicella Zoster Immunizations
(Dependent Children)
· For each immunization (non-participating providers only)

$12
     
Preventive Care Benefits (for members age 19 and over)
· For all covered services

$250
per plan year

     
Physical Therapy, Physical Medicine and Occupational Therapy
· For covered outpatient services

24
visits per plan year

· For each covered visit when provided by a non-participating provider $25
per visit
     
Acupuncture
· For all covered services

$25
per visit, for up to 12 visits per plan year

     
Transplant travel Expense
· For the Recipient and One Companion per Transplant Episode (limited to 6 trips per episode)
 
- For transportation to the COE

$250
per trip
for each person for round trip coach airfare

   
- For hotel accommodations $100
per day,
for up to 21 days per trip, limited to one room, double occupancy
 
- For expenses such as meals $25
per day
for each person, for up to 21 days per trip
         
· For the Donor per Transplant Episode (limited to one trip per episode)
 
- For transportation to the COE

$250
for round trip coach airfare

- For hotel accommodations $100
per day,
for up to 7 days
 
- For expenses such as meals $25
per day,
up to 7 days
         
Lifetime Maximum
· For all medical benefits

$1,000,000
per member during each member's lifetime

     
 
     
     
     
     
     
   
YOUR MEDICAL BENEFITS
 
HOW COVERED EXPENSE IS DETERMINED
 
We will pay for covered expense you incur under this plan. A charge is incurred when the service or supply giving rise to the charge is rendered or received. Covered expense for medical benefits is based on a maximum charge for each covered service or supply that will be accepted by us for each different type of provider. It is not necessarily the amount a provider bills for the service.
 
Participating Providers and COE. The maximum covered expense for services provided by a participating provider or COE will be the lesser of the billed charge or the negotiated rate. Participating providers and COE have agreed not to charge you more than the negotiated rate for covered services. When you choose a participating provider, you will not be responsible for any amount in excess of the negotiated rate. If you receive an authorized, specified organ transplant at a COE, you will not be responsible for any amount in excess of the COE negotiated rate for the covered services of a COE.
If you go to a hospital which is a participating provider, you should not assume all providers in that hospital are also participating providers. To receive the greater benefits afforded when covered services are provided by a participating provider, you should request that all your provider services be performed by participating providers whenever you enter a hospital.
If you are planning to have outpatient surgery, you should first find out if the facility where the surgery is to be performed is an ambulatory surgical center. An ambulatory surgical center is licensed as a separate facility even though it may be located on the same grounds as a hospital (although this is not always the case). If the center is licensed separately, you should find out if the facility is a participating provider before undergoing the surgery.
 
Non-Participating Providers and Other Health Care Providers. The maximum covered expense for services provided by a non-participating or other health care provider will always be the lesser of the billed charge or (1) for a physician, the customary and reasonable charge or (2) for other than a physician, the reasonable charge. You will be responsible for any billed charge which exceeds the customary and reasonable charge or the reasonable charge.
The maximum covered expense for non-participating providers for services and supplies provided in connection with Cancer Clinical Trials will be the lesser of the billed charge or the amount that ordinarily applies when services are provided by a participating provider.
Exception: If Medicare is the primary payor, covered expense does not include any charge:
 
1. By a hospital, in excess of the approved amount as determined by Medicare; or:
2. By a physician or other health care provider, in excess of the lesser of the maximum covered expense stated above, or:
 
a. For providers who accept Medicare assignment, the approved amount as determined by Medicare; or
 
b. For providers who do not accept Medicare assignment, the limiting charge as determined by Medicare.
 
You will always be responsible for expense incurred which is not covered under this plan.
 
WARNING! Reduction of Covered Expense for Non-Contracting Hospitals. A small percentage of hospitals which are non-participating providers are also non-contracting hospitals. Except for emergency care, covered expense is reduced by 25% for all services and supplies provided by a non-contracting hospital. You will be responsible for paying this amount. You are strongly encouraged to avoid this additional expense by seeking care from a contracting hospital. You can call the customer service number on your identification card to locate a contracting hospital.
 
 
 
DEDUCTIBLES, CO-PAYMENTS, OUT-OF-POCKET AMOUNTS AND MEDICAL BENEFIT MAXIMUMS
 
After we subtract any applicable deductible and your Co-Payment, we will pay benefits up to the amount of covered expense, not to exceed the applicable Medical Benefit Maximum. The Deductible amounts, Co-Payments, Out-Of-Pocket Amounts and Medical Benefit Maximums are set forth in the SUMMARY OF BENEFITS.
 
Deductibles
 
Each deductible under this plan is separate and distinct from the other. Only charges that are considered covered expense will apply toward satisfaction of any deductible.
 
Plan Year Deductible. Each plan year, you will be responsible for satisfying the member's Plan Year Deductible before we begin to pay benefits.
 
Family Deductible. If, during a plan year, enrolled members of a family pay a deductible expense equal to the Family Deductible amount shown in the summary of benefits, then the Deductible for all family members is considered to have been met. No further Plan Year Deductible expense will be required for any enrolled member of that family.
Covered expense incurred from April through June and applied toward the Plan Year Deductible for that plan year, also counts toward the Plan Year Deductible for the next plan year.
 
Additional Deductible. Each time you are admitted to a hospital or residential treatment center or have outpatient surgery at an ambulatory surgical center without properly obtaining certification, you are responsible for paying the Non-Certification Deductible. This deductible will not apply to an emergency admission or procedure, nor to services provided at a participating provider. Certification is explained in MEDICAL MANAGEMENT PROGRAMS:UTILIZATION REVIEW PROGRAM..
 
 
Co-Payments
 
After you have satisfied any applicable deductible, we will subtract your Co-Payment from the amount of covered expense remaining.
If your Co-Payment is a percentage, we will apply the applicable percentage to the amount of covered expense remaining after any deductible has been met. This will determine the dollar amount of your Co-Payment.
 
 
Out-of-Pocket Amount
 
Satisfaction of the Out-of-Pocket Amount. If, after you have met your Plan Year Deductible, you pay Co-Payments equal to your Out-of-Pocket Amount per member or per family during a plan year, you will no longer be required to make Co-Payments for any covered expense you incur during the remainder of that plan year, other than for covered expense incurred for treatment of mental or nervous disorders or substance abuse, and routine examinations provided by a participating provider under the Well Baby and Well Child Care or Preventive Care Benefits.
 
Charges Which Do Not Apply Toward the Out-of-Pocket Amount. The following charges will not be applied toward satisfaction of an Out-of-Pocket Amount:
 
· Charges which are not considered covered expense;
· Any expense applied to a deductible;
· Charges for services for the treatment of mental or nervous disorders or substance abuse;
· Charges for routine examinations provided by a participating provider under the Preventive Care Benefit; and
· Charges for routine examinations provided by a participating provider under the Well Baby and Well Child Care benefit.
In addition, you will continue to be required to pay your Co-Payment for the treatment of mental or nervous disorders or substance abuse and for routine examinations provided by a participating provider under the Well Baby and Well Child Care or Preventive Care Benefits, even after the Out-of-Pocket Amount is reached.
 
 
Medical Benefit Maximums
 
We do not make benefit payments for any member in excess of any of the Medical Benefit Maximums. Your Lifetime Maximum under this plan will be reduced by any benefits we paid to you or on your behalf under any other health plan provided by Blue Cross, or any of its affiliates, which is sponsored by the group.
 
Prior Plan Maximum Benefits. If you were covered under the prior plan, any benefits paid to you under the prior plan will reduce any maximum amounts you are eligible for under this plan which apply to the same benefit.
 
 
 
CONDITIONS OF COVERAGE
 
The following conditions of coverage must be met for expense incurred for services or supplies to be considered as covered expense.
 
1. You must incur this expense while you are covered under this plan. Expense is incurred on the date you receive the service or supply for which the charge is made.
2. The expense must be for a medical service or supply furnished to you as a result of illness or injury or pregnancy, unless a specific exception is made.
3. The expense must be for a medical service or supply included in medical care that is covered. Additional limits on covered expense are included under specific benefits and in the SUMMARY OF BENEFITS.
4. The expense must not be for a medical service or supply listed in MEDICAL CARE THAT IS NOT COVERED. If the service or supply is partially excluded, then only that portion which is not excluded will be considered covered expense.
5. The expense must not exceed any of the maximum benefits or limitations of this plan.
6. Any services received must be those which are regularly provided and billed by the provider. In addition, those services must be consistent with the illness, injury, degree of disability and your medical needs. Benefits are provided only for the number of days required to treat your illness or injury.
7. All services and supplies must be ordered by a physician.
 
   
   
 
MEDICAL CARE THAT IS COVERED
 
Subject to the Medical Benefit Maximums in the SUMMARY OF BENEFITS, the requirements set forth under CONDITIONS OF COVERAGE and the exclusions or limitations listed under MEDICAL CARE THAT IS NOT COVERED, we will provide benefits for the following services and supplies:
 
Hospital
 
1. Inpatient services and supplies, provided by a hospital. Covered expense will not include charges in excess of the hospital's prevailing two-bed room rate unless there is a negotiated per diem rate between us and the hospital, or unless your physician orders, and we authorize, a private room as medically necessary.
2. Services in special care units.
3. Outpatient services and supplies provided by a hospital, including outpatient surgery.
 
Skilled Nursing Facility. Inpatient services and supplies provided by a skilled nursing facility, for up to 120 days per plan year. The amount by which your room charge exceeds the prevailing two-bed room rate of the skilled nursing facility is not considered covered expense. For the purpose of care provided for the treatment of mental or nervous disorders, severe mental disorders, or substance abuse, the term "skilled nursing facility" includes residential treatment center.
Skilled nursing facility services and supplies are subject to prior authorization to determine medical necessity. Please refer to MEDICAL MANAGMENT PROGRAMS for information on how to obtain the proper reviews.
Home Health Care. The following services provided by a home health agency:
 
1. Services of a registered nurse or licensed vocational nurse under the supervision of a registered nurse or a physician.
2. Services of a licensed therapist for physical therapy, occupational therapy, speech therapy, or respiratory therapy.
3. Services of a medical social service worker.
4. Services of a health aide who is employed by (or who contracts with) a home health agency. Services must be ordered and supervised by a registered nurse employed by the home health agency as professional coordinator. These services are covered only if you are also receiving the services listed in 1 or 2 above.
5. Medically necessary supplies provided by the home health agency.
 
In no event will benefits exceed 100 visits during a plan year. A visit of four hours or less by a home health aide shall be considered as one home health visit.
Home health care services are subject to prior authorization to determine medical necessity. Please refer to MEDICAL MANAGMENT PROGRAMS: AUTHORIZATION PROGRAM: for information on how to obtain the proper reviews.
Home health care services are not covered if received while you are receiving benefits under the "Hospice Care" provision of this section.
Hospice Care. The services and supplies listed below are covered when provided by a hospice for the palliative treatment of pain and other symptoms associated with a terminal disease. You must be suffering from a terminal illness for which the prognosis of life expectancy is one year or less, as certified by your physician and submitted to us. Covered services are available on a 24-hour basis for the management of your condition.
1. Interdisciplinary team care with the development and maintenance of an appropriate plan of care.
2. Short-term inpatient hospital care when required in periods of crisis or as respite care. Coverage of inpatient respite care is provided on an occasional basis and is limited to a maximum of five consecutive days per admission.
3. Skilled nursing services provided by or under the supervision of a registered nurse. Certified home health aide services and homemaker services provided under the supervision of a registered nurse.
4. Social services and counseling services provided by a qualified social worker.
5. Dietary and nutrition