Hospital Expense Benefits

If an individual, while covered under the Plan, has incurred covered Hospital Expenses for treatment of an illness or injury, the Plan shall pay the amount(s) and/or percentage(s) indicated in the Schedule of Benefits section. Hospital Expense Benefits are subject to all limitations and conditions of the Plan, including Usual, Reasonable and Customary Charges.

IN-PATIENT HOSPITAL CHARGES (GENERAL HOSPITALS)
If a Covered Person incurs necessary expenses which are recommended and approved by a Physician for hospital care for diagnosis or treatment of an illness or injury, the Plan shall pay hospital charges not exceeding the maximum amount specified in the Schedule of Benefits for such charges.

a. Room and Board - General Nursing Care: The Plan shall pay the Semi-Private or Intensive/Coronary/Acute Care Charge for a Covered Person who is confined on an inpatient basis for the treatment of an illness or injury not to exceed the amounts indicated in the Schedule of Benefits. (The allowance for a private room shall be an amount equal to the hospital's most common semi-private room rate.)

b. Hospital Miscellaneous Charges: The Plan shall pay the usual, reasonable and customary amounts charged by the hospital for necessary services, medicines, blood (if not replaced) and plasma, and supplies for diagnosis and treatment of the illness or injury for which the Covered Person is confined (except services of a Physician, Dentist, special nursing in any form, or drugs or supplies not consumed or used in the hospital). Hospital Miscellaneous Charges shall be payable for all days of hospitalization for which the hospital's room and board charges are payable.

c. Charges by a birthing center shall be considered eligible charges to the extent such charges would have been covered if provided by a hospital as part of an in-patient confinement.

d. Coverage is provided for such period as is determined by the attending physician in consultation with the patient to be medically appropriate after such person has undergone a lymph node dissection or a lumpectomy for the treatment of breast cancer or a mastectomy.

SKILLED NURSING FACILITY
Conditions for Skilled Nursing Facility Care: The Plan will pay for care in a Skilled Nursing Facility described below when the following conditions are met:

a. Care in a skilled nursing facility must be medically necessary. Care is medically necessary when it must be furnished by skilled personnel to assure the safety of the patient and achieve the medically desired result. Custodial care, which is primarily assistance with the activities of daily living, is not covered. In order to determine whether care is medically necessary, the guidelines used by the Federal government’s Medicare program will be applied. The Managed Benefits Program Coordinator, in conference with the patient’s Physician, will verify medical necessity and establish when skilled nursing facility care is appropriate and eligible for benefits.

b. Coverage will only be provided for as long as in-patient hospital care would have been required if care in a skilled nursing facility were not provided.

Kind of Skilled Nursing Facility. The facility must be either:

a. accredited as a skilled nursing facility by the Joint Commission on Accreditation of Hospitals; or

b. certified as a participating skilled nursing facility under Medicare.

Covered Services. The Plan will pay the charges of a skilled nursing facility for:

a. a semi-private room (if a private room is occupied, the Plan will pay an amount equal to the facility's most common charge for a semi-private room);

b. physical, occupational and speech therapy;

c. medical social services;

d. drugs, biologicals, supplies, appliances and equipment furnished for use in the facility and which are ordinarily provided by the facility to patients; and

e. other services necessary for the patient’s health which are generally provided by the facility.

OUT-PATIENT HOSPITAL/SURGICAL CENTER CHARGES
Hospital charges for out-patient services are covered in full, subject to URC and deductible, when: the patient is physically present; they are for the diagnosis or treatment of illness or injury; they are ordered by a Physician; and they are billed by the hospital.

a. Emergency condition: Benefits are payable for outpatient or emergency room charges (Physician's charges are covered under the Medical Expense Benefits portion of the Plan) for care given by a professional provider in or outside of a hospital for an emergency condition.

b. Surgery and Radiation Therapy. Benefits are payable for out-patient hospital charges (excluding Physician charges) related to the performance of a surgical operation or radiation therapy.

c. Diagnostic X-Rays and Laboratory Charges: Benefits are payable for out-patient hospital charges (excluding Physician charges) for diagnostic X-ray examinations and laboratory tests, including such examinations and tests performed as part of pre-admission testing for a proposed, covered hospitalization.

d. Pre-Admission Testing: Hospital services for pre-admission testing in the out-patient department of a hospital are covered, when:

• the testing is ordered by a Physician as a planned preliminary to the patient's admission as a registered bed patient for surgery in the same hospital;

• the testing is necessary for, and consistent with, the diagnosis and treatment of the condition for which the surgery is to be performed;

• the reservations for a hospital bed and an operating room have been made before the tests are performed; and

• the patient is physically present at the hospital for the tests.

e. Physical Therapy. Benefits are payable for physical therapy performed in the out-patient department of a hospital and billed by the hospital, provided: such therapy is in connection with a condition which necessitated hospitalization or surgery; treatment begins within six months from the date of the hospital discharge or surgery; and treatment is received within one year of the hospital discharge or surgery.

f. Hemodialysis Treatment Benefits are payable for hemodialysis treatment performed in the out-patient department of a hospital and billed by the hospital.

EMERGENCY HOSPITAL AMBULANCE SERVICE
The Plan will pay for emergency ambulance service under the following conditions: the ambulance service must be owned and operated by the hospital and it is billed for by the hospital; there is an emergency and you need an ambulance; and you are taken to the nearest hospital which provides the necessary emergency out-patient care you need or if you are admitted to that hospital as a registered bed patient.

HOME HEALTH CARE
Benefits are payable for Home Health Care treatment stated in a Home Health Care Plan, performed while the individual is under the care of the Physician approving the Home Health Care Plan.

Type of Home Health Care Agency. The Plan will pay for home care visits provided by a home care agency certified or licensed under Article 36 of the New York State Public Health Law. If the home care is provided outside of New York State, the provider of care must have an appropriate operating certificate or license issued by the appropriate state agency where the care is rendered. The provider outside of New York State must be a hospital or non-profit or public home health service or agency.

Conditions for Home Health Care: The Plan will pay for home care visits only if the following conditions are met:

a. If the patient did not receive home health care visits, the patient would have to be hospitalized in a hospital or cared for in a skilled nursing facility. In other words, the home health care visits are a substitution for hospital care or care in a skilled nursing facility.

b. A Plan for the patient’s home health care is established in writing, ordered or approved by the patient’s Physician.

Home Health Care Services Covered. Payment will be made for the following home care services:

a. Part-time or intermittent home nursing care by or under the supervision of a Registered Nurse (R.N.).

b. Part-time or intermittent home health aid services which consist primarily of caring for the patient.

c. Physical, occupational and speech therapy if the home care agency or hospital provides those services.

d. Medical supplies, drugs and medications prescribed by a Physician, but only if the Plan would have paid for those items if the patient was in a hospital or confined in a skilled nursing facility.

e. Laboratory services provided by or on behalf of the home care agency or hospital.
Number of Home Care Visits: Each visit by a member of a home care team is counted as one home care visit. Four hours of home health aide services are counted as one home care visit. Each Covered Person is limited to 200 home health care visits per calendar year.

HOSPICE CARE
Hospice Organizations: The Plan will pay for hospice care provided by a hospice organization which has an operating certificate issued by the New York State Department of Health. If the hospice care is provided outside of New York State, the hospice organization must have an operating certificate issued under criteria similar to those issued in New York by a state agency in the state where the hospice care is provided.

Hospice Care Covered: Hospice care is covered during the period when the hospice has accepted the patient for its hospice program. The following services provided by the hospice organization are covered:

a. Bed-patient care either in a designated hospice unit or in a regular hospital bed.

b. Home care and out-patient services which are provided by the hospice and for which the hospice charges the patient. The services may include at least the following:

• Intermittent nursing care by an R.N., L.P.N. or home health aides.

• Physical, speech, occupational and respiratory therapy.

• Social services.

• Nutritional services.

• Laboratory tests and X-ray examinations.

• Chemotherapy and radiation therapy, when required for control of symptoms.

• Medical supplies.

• Drugs and medications prescribed by a Physician and which are considered approved under the appropriate Governmental authorities. The Plan will not pay when the drug or medication is of an experimental nature.

• Bereavement services provided to your family during your illness and until one year after death.

CHEMICAL DEPENDENCE TREATMENT BENEFIT
Benefits are payable, up to the number of days specified in the Schedule of Benefits, for chemical dependence treatment provided by a General or Public Hospital, or a Chemical Dependence Treatment Facility, on an in-patient basis.

Out-patient treatment by a Chemical Dependence Treatment Facility (as defined by the Plan) shall be subject to the maximum number of days as specified in the Schedule of Benefits under the separate Out-Patient Chemical dependence Services/Treatment benefit.

MEDICAL CONDITIONS RESULTING IN INFERTILITY
Benefits are payable for charges for hospital care, surgical or medical procedures or prescription drugs which would correct malformation, disease or dysfunction resulting in infertility, diagnostic tests and procedures, including prescription drugs necessary to determine infertility or that are necessary in connection with hospital care or surgical or medical procedures to correct malformation, disease or dysfunction resulting in infertility, including hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy, sonohysterogram, post coital tests, testis biopsy, semen analysis, blood tests and ultrasound. Coverage shall not include diagnosis or treatment in connection with in vitro fertilization, gamete intrafallopian tube transfers or zygote intrafallopian tube transfers, the reversal of sterilization, sex change procedures, cloning or procedures or services that are experimental. Coverage is limited to individuals whose ages range from twenty-one (21) through forty-four (44) years.