Common use of Benefits and Coverage Clause in Contracts

Benefits and Coverage. All benefits are provided in accordance with CMS/PACE guidelines including the requirement that such services are approved by the Interdisciplinary Team and provided by CHA PACE or its contracted service providers, unless otherwise indicated. Health Services • Adult day healthcare • Primary care, including consultation, routine care, preventive health care and physical examinations • Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology and dermatology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) • Nursing care • Social services • Physical, occupational and speech therapies • Recreational therapy • Nutrition counseling and education • Laboratory tests, X-rays and other diagnostic procedures • Prescription drugs (only if obtained from a pharmacy designated by CHA PACE) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team • Podiatry • Vision care, including examinations, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance Hospital Inpatient Care • Ambulance • Emergency room care and treatment room services • Semi-private room and board, as available • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary • Laboratory tests, x-rays and other diagnostic procedures • Prescription drugs • Blood and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care does not include a private room, private duty nursing, and non-medical services such as telephone charges. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. Nursing Facility Care • Semi-private room and board, when available • Physician and nursing services • Custodial care • Personal care and assistance • Prescription drugs • Physical, speech and occupational therapies as authorized by the Interdisciplinary team • Social services • Medical supplies and appliances Home Health Care and Transportation • Skilled nursing services • Physical, speech and occupational therapies • Social services • Home health aide services • Homemaking services • Home-delivered meals • Emergency alert system • Medical supplies • Transportation to CHA PACE authorized medical appointments End of Life Services • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services Dental Care • Oral exams, cleanings, fillings • X-rays • Some oral surgery (such as removal of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Dentures

Benefits and Coverage. All benefits are provided in accordance with CMS/PACE guidelines including the requirement that such services are approved by the Interdisciplinary Team and provided by CHA PACE ESP or its contracted service providers, unless otherwise indicated. Health Services • Adult day healthcare • Primary care, including consultation, routine care, preventive health care and physical examinations • Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology and dermatology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) • Nursing care • Social services • Physical, occupational and speech therapies • Recreational therapy • Nutrition counseling and education • Laboratory tests, X-rays and other diagnostic procedures • Prescription drugs (only if obtained from a pharmacy designated by CHA PACEESP) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team • Podiatry • Vision care, including examinations, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance Hospital Inpatient Care • Ambulance • Emergency room care and treatment room services • Semi-private room and board, as available • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary • Laboratory tests, x-rays and other diagnostic procedures • Prescription drugs • Blood and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care does not include a private room, private duty nursing, and non-medical services such as telephone charges. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. Nursing Facility Care • Semi-private room and board, when available • Physician and nursing services • Custodial care • Personal care and assistance • Prescription drugs • Physical, speech and occupational therapies as authorized by the Interdisciplinary team • Social services • Medical supplies and appliances Home Health Care and Transportation • Skilled nursing services • Physical, speech and occupational therapies • Social services • Home health aide services • Homemaking services • Home-delivered meals • Emergency alert system • Medical supplies • Transportation to CHA PACE ESP authorized medical appointments End of Life Services • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services Dental Care • Oral exams, cleanings, fillings • X-rays • Some oral surgery (such as removal of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Dentures

Benefits and Coverage. All benefits There are provided in accordance with CMS/PACE guidelines including the requirement that such services are approved by the Interdisciplinary Team and many kinds of care provided by CHA PACE. Your interdisciplinary team knows about the kind of services available and will decide with you what is best to meet your needs and care preferences. CHA PACE provides a comprehensive benefit package, which includes all of the services traditionally provided by Medicare and/or Medicaid/MassHealth. The majority of services are provided directly by CHA PACE program staff. CHA PACE has contracted with a number of specialists and health care facilities for specialty care. A list of these providers is available upon request. CHA PACE guarantees access to services, but not to a specific provider. The following benefits are fully covered when the interdisciplinary team determines that they are necessary and approves them prior to delivery. Approval is not required for emergencies within the United States and its territories. PACE Interdisciplinary Care All participants receive an initial comprehensive assessment and care plan upon enrollment and are reassessed on a semi-annual basis or more often, as necessary. The care plan is revised and updated upon reassessment. CHA PACE provides interdisciplinary care at home and at its contracted service providersPACE Center in Cambridge, unless otherwise indicatedand some care at its Alternative Care Setting in Malden. Health Services Please note all services may not be available at all sites, at home, etc. Interdisciplinary care includes: • Primary medical care, including physician and nursing services • Social and mental health services • Restorative therapies, including physical and occupational therapies • Adult day healthcare • Primary care, including consultation, routine care, preventive health Activity and recreation therapy • Nutritional counseling and meals • Personal care and physical examinations support services • Care coordination and casework Healthcare Provided by Non-PACE Staff (Outpatient Care) Medical specialty services includinginclude, but are not limited to: anesthesiology, services such as cardiology, dentistry, dermatology, gastroenterology, gynecology, internal medicine, nephrology, neurosurgery, oncology, ophthalmology, oral surgery, orthopedic surgery, otorhinolaryngology, rheumatology, psychiatry, pulmonology, radiology, rheumatology, general surgery, thoracic and vascular surgery, and urology, rheumatology and dermatology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) • Nursing care • Social services • Physical, occupational and speech therapies • Recreational therapy • Nutrition counseling and education . • Laboratory tests, X-rays rays, and other diagnostic procedures • Prescription drugs (only if and over-the-counter drug items as ordered by a network provider and obtained from through a pharmacy designated by network pharmacy. Note, once you enroll, CHA PACE) PACE becomes your Part D prescription drug plan • Prostheses Pharmacy consulting services • Prostheses, orthotics, and durable medical equipment when determined medically necessary by the Interdisciplinary Team and repairs • Podiatry and routine foot care • Mental health services, including substance use disorders • Vision care, including examinations, treatment and corrective devices such as eyeglasses • PsychiatryAudiology, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance Hospital Inpatient Care (Inpatient) Services • Ambulance • Emergency room care and Hospital inpatient services means diagnostic or treatment room services • Semiprovided in a hospital to a CHA PACE participant admitted to that hospital. This includes semi-private room and board, as available board • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary unit • Emergency room care and treatment room services • Laboratory tests, x-rays and other diagnostic procedures • Prescription drugs Drugs and biologicals • Blood and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social Medical social services and discharge planning • Ambulance Hospital inpatient care does not include a private room, private duty nursing, and or non-medical services such as telephone charges, unless authorized by the interdisciplinary team. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. Nursing Facility Care • Semi-private room and board, when available • Physician and nursing services • Custodial care • Personal care and assistance • Prescription drugs • Physical, speech and occupational therapies as authorized by the Interdisciplinary team • Social services • Medical supplies and appliances Home Health Care and Transportation • Skilled nursing services • Physical, speech and occupational therapies • Social services • Home health aide services • Homemaking services • Home-delivered meals • Emergency alert system • Medical supplies • Transportation to CHA PACE authorized medical appointments End of Life Services • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services Dental Care • Oral exams, cleanings, fillings • X-rays • Some oral surgery (such as removal of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Dentures.

Benefits and Coverage. All Eddy SeniorCare provides comprehensive benefits that include all of the services tra- ditionally provided by Medicare and Medicaid. The majority of services are provided directly by Eddy SeniorCare staff. Eddy SeniorCare has contracted with a number of medical specialists and health care facilities for specialty care. A listing of these pro- viders and facilities as part of Eddy SeniorCare's Provider Network is provided to you prior to enrollment. The following benefits are fully covered when the interdisciplinary team determines that they are medically necessary and approves them prior to delivery. (Please see Section 7 Exclusions and Limitations. Prior approval is not required for Emergency Services as described in Section 5). An adult social day care program is provided Monday through Friday in accordance the PACE Center. Individual schedules are de- veloped as part of a plan of care to coincide with CMS/your home care services and trans- portation schedules. Services include: PACE guidelines including the requirement that such services are approved by the Interdisciplinary Team and provided by CHA PACE or its contracted service providers, unless otherwise indicated. Health Center Services • Adult Social day healthcare care • Congregate meals • Activities/ recreation • Personal care and supportive services, if necessary • Primary care, care physician services and nurse practitioner • Nutrition services including consultation, routine care, preventive health care counseling and physical examinations • Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology and dermatology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) • Nursing care • Social services • Physical, occupational and speech therapies education • Recreational therapy • Nutrition counseling Restorative therapies including physical therapy, occupational therapy, and education speech-language pathology • Laboratory tests, X-rays and other diagnostic procedures Nursing services • Prescription drugs (only if obtained from a pharmacy designated by CHA PACE) Social work services • Prostheses and durable medical equipment when determined Transportation to medically necessary by the Interdisciplinary Team • Podiatry • Vision care, including examinations, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance Hospital Inpatient Care • Ambulance • Emergency room care and treatment room services • Semi-private room and board, as available • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary Outpatient Services • Laboratory tests, x-rays and other diagnostic procedures • Prescription drugs/over the counter drugs and medical supplies • Prostheses and durable medical equipment, medical/surgical supplies, orthotics • Medical specialty services including but not limited to: anesthesiology, audiol- ogy, cardiology, dentistry, dermatology, gastroenterology, gynecology, internal medicine, nephrology, neurosurgery, oncology, ophthalmology, oral surgery, or- thopedic surgery, otorhinolaryngology, plastic surgery, pharmacy consulting services, podiatry, psychiatry, pulmonary disease, radiology, rheumatology, sur- xxxx, thoracic and vascular surgery, and urology • Eye care and low vision services • Alcohol and substance abuse services • Mental health services Acute Inpatient Care • Inpatient hospital care • Ambulance • Emergency room care and treatment room services • Semiprivate hospital room and board • General medical and nursing services • Medical surgical/ intensive care/ coronary care unit • Laboratory tests, x-rays, and other diagnostic procedures • Drugs and biologicals • Blood and blood derivatives • Surgical care, including the use of anesthesia • Use of oxygen • Physical, speech, occupational, occupational and respiratory therapies • Speech-language pathology • Social services Hospital inpatient care does not include a private room, private duty nursing, • Medical supplies and non-medical appliances • Alcohol and substance abuse services such as telephone charges. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. • Mental health services Nursing Facility Care Skilled nursing home services are provided through a facility that is contracted and coordinated with Eddy SeniorCare. Services include: • Semi-private Semiprivate room and board, when available board • Physician and skilled nursing services • Custodial care • Personal care and assistance • Prescription drugs Drugs and biologicals • Physical, speech occupational, speech, respiratory and occupational therapies as authorized by the Interdisciplinary team recreational therapies, if necessary • Social services • Medical supplies and appliances Home Health Care and Transportation Services • Skilled nursing Physician home visits • Nursing services • Physical, occupational, speech and occupational therapies respiratory therapy services • Social Medical social services • Home health aide aide/personal care services • Homemaking services Nutrition • Home-delivered meals with special diets, if necessary • Personal Emergency alert system Response Services (Life Line) • Durable medical equipment (DME) and hearing aids • Prescription, over-the-counter drugs and medical supplies as ordered by a physician Consumer Directed Personal Assistance Services (CDPAS) • CDPAS enables self-directing participants (or their designated representative) receiving home care services greater flexibility and freedom of choice in obtain- ing services. The scope of services that may be authorized through CDPAS in- clude tasks provided by a Personal Care Aide, Home Health Aide, Licensed Practical Nurse or Registered Professional Nurse. Health Related Services • Medical supplies transportation and escort services • Transportation to CHA PACE authorized medical appointments Social and environmental supports • Translation language services, if necessary End of Life Services • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services Dental Care • Oral exams, cleanings, fillings • X-rays • Some oral surgery (such as removal The interdisciplinary team remains involved with your care for the remainder of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Denturesyour life. This includes providing comfort care during end of life circumstanc- es. Benefits cannot be transferred from the enrollee to any other person or organization.

Benefits and Coverage. Please see Chapter 5 to learn how to receive care if you have a medical emergency or other urgent need for care. What Do I Do if I Need Care? All you need to do is call your center as listed on the inside cover of this booklet at any time. Our plan provides ready access to a whole array of professionals and health care services. Upon enrollment you will be assigned a PCP at the center where you will receive services. All benefits are covered by {PACE Organization} and will be provided according to your needs as assessed by your IDT, in accordance with CMS/PACE guidelines including professionally recognized standards. If you would like more specific information about how we authorize or deny health care services, please request this from the requirement that such services are approved by Social Worker. Benefits include: Services in the Interdisciplinary Team Center and provided by CHA PACE or its contracted service providers, unless otherwise indicated. Health Services • Adult day healthcare the Community • Primary carecare clinic visits (with {PACE Organization} physician, including consultation, routine care, nurse practitioner and/or nurse) • Routine physicals and preventive health evaluations and care (including pap smears, mammograms, immunizations, and physical examinations all generally accepted cancer screening tests). These services do not require prior authorization. • Sensitive Services, which are services related to sexually transmitted diseases and HIV testing. These services do not require prior authorization. • Consultation with medical specialists • Kidney dialysis • Outpatient surgical services • Outpatient mental health • Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology social services/case management • Health education and dermatology counseling • Rehabilitation therapy (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) • Nursing care • Social services • Physicalphysical, occupational and speech therapies speech) • Personal care • Recreational therapy • Nutrition Social and cultural activities {intergenerational (if applicable)} • Nutritional counseling and education hot meals • Transportation, including escort • Ambulance service • X-rays • Laboratory procedures • Emergency coverage anywhere in the United States and its territories • Durable medical equipment • Prosthetic and orthotic appliances • Routine podiatry • Prescribed drugs and medicines • Vision care (prescription eyeglasses, corrective lenses after cataract surgery) • Hearing exams and hearing aids • Dental care from the {PACE Organization} dentist, with the goal of restoring participant oral function to a condition which will help maintain optimal nutritional and health status. Dental services include Preventive Care (initial and yearly examinations, radiographs, prophylaxis and oral hygiene instructions); Basic Care (fillings and extractions); and Major Care (treatment which is determined by the condition of the mouth, for example, the amount of remaining supporting bone, the participant’s ability to comply with instruction, and the participant’s motivation to pursue oral health care). Major Care includes temporary crowns, full or partial dentures and root canals. Not included under dental care is: cosmetic dentistry. • Diagnosis and treatment of male erectile dysfunction provided that the care is from {PACE Organization} staff physician or a physician specialist under contract to {PACE Organization}, and that such care is deemed medically necessary. The Plan does not cover treatment, including medication, devices and surgery, which is deemed harmful to the participant or which is deemed to be for cosmetic or recreational purposes and not medically necessary. • Mastectomy, lumpectomy, lymph node dissection, prosthetic devices and reconstructive surgery. • Necessary materials, supplies and services for the management of diabetes mellitus. Home Services • Home Care o Personal care (i.e., grooming, dressing, assistance in using the bathroom) o Homemaker/chore services o Rehabilitation maintenance o Evaluation of home environment • Home Health o Skilled nursing services o Physician visits (at discretion of physician) o Medical social services o Home health aide service Hospital Inpatient Care • Semi-private room and board • General medical and nursing services • Psychiatric services • Meals • Prescribed drugs, medicines and biologicals • Diagnostic or therapeutic items and services • Laboratory tests, X-rays and other diagnostic procedures • Prescription drugs Medical/Surgical, Intensive Care, Coronary Care Unit, as necessary • Kidney dialysis • Dressings, casts, supplies • Operating room and recovery room • Oxygen and anesthesia • Organ and bone marrow transplants (only if obtained from a pharmacy designated by CHA PACEnon-experimental and non- investigative) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team • Podiatry • Vision careUse of appliances, including examinations, treatment and corrective devices such as eyeglasses a wheelchair • PsychiatryRehabilitation services, including evaluationsuch as physical, consultationoccupational, diagnostic speech and treatment service respiratory therapy • Audiology evaluationRadiation therapy • Blood, hearing aidsblood plasma, repairs blood factors and maintenance Hospital Inpatient Care blood derivatives • Ambulance • Emergency Medical social services and discharge planning {PACE Organization} does not cover private room care and treatment room services private duty nursing unless medically necessary, nor any non-medical items for which there is an additional charge, such as telephone charges or television rental. Skilled Nursing Facility • Semi-private room and board, as available • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary • Laboratory tests, x-rays and other diagnostic procedures • Prescription drugs • Blood and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care does not include a private room, private duty nursing, and non-medical services such as telephone charges. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. Nursing Facility Care • Semi-private room and board, when available board • Physician and nursing services • Custodial care • All meals • Personal care and assistance • Prescription Prescribed drugs and biologicals • Necessary medical supplies and appliances, such as a wheelchair • Physical, speech and occupational therapies as authorized by the Interdisciplinary team • Social services • Medical supplies and appliances Home Health Care and Transportation • Skilled nursing services • Physicaloccupational, speech and occupational therapies • Social services • Home health aide services • Homemaking services • Home-delivered meals • Emergency alert system respiratory therapy • Medical supplies • Transportation to CHA PACE authorized medical appointments social services End of Life Services • Skilled nursing Care {PACE Program’s} comfort care program is available to care for the terminally ill. If needed, your Physician and other clinical experts on your IDT will work with you and your family to provide these services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services Dental Care • Oral examsdirectly or through contracts with local hospice providers. If you want to receive the Medicare hospice benefit, cleanings, fillings • Xyou will need to disenroll from our program and enroll in a Medicare-rays • Some oral surgery (such as removal of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Denturescertified Hospice provider.

Benefits and Coverage. Please see Chapter 5 to learn how to receive care if you have a medical emergency or other urgent need for care. What Do I Do if I Need Care? All you need to do is call your center as listed on the inside cover of this booklet at any time. Our plan provides ready access to a whole array of professionals and health care services. Upon enrollment you will be assigned a PCP at the center where you will receive services. All benefits are covered by {PACE Organization} and will be provided according to your needs as assessed by your IDT, in accordance with CMS/professionally recognized standards. If you would like more specific information about how we authorize or deny health care services, please request this from the Social Worker. Benefits include: Services in the Center and the Community Primary care clinic visits (with {PACE guidelines including the requirement that such services are approved by the Interdisciplinary Team Organization} physician, nurse practitioner and/or nurse) Routine physicals and provided by CHA PACE or its contracted service providers, unless otherwise indicated. Health Services • Adult day healthcare • Primary care, including consultation, routine care, preventive health evaluations and care (including pap smears, mammograms, immunizations, and physical examinations • all generally accepted cancer screening tests). These services do not require prior authorization. Sensitive Services, which are services related to sexually transmitted diseases and HIV testing. These services do not require prior authorization. Consultation with medical specialists Kidney dialysis Outpatient surgical services Outpatient mental health Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology social services/case management Health education and dermatology counseling Rehabilitation therapy (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) • Nursing care • Social services • Physicalphysical, occupational and speech therapies • speech) Personal care Recreational therapy • Nutrition Social and cultural activities {intergenerational (if applicable)} Nutritional counseling and education • hot meals Transportation, including escort Ambulance service X-rays Laboratory procedures Emergency coverage anywhere in the United States and its territories Durable medical equipment Prosthetic and orthotic appliances Routine podiatry Prescribed drugs and medicines Vision care (prescription eyeglasses, corrective lenses after cataract surgery) Hearing exams and hearing aids Dental care from the {PACE Organization} dentist, with the goal of restoring participant oral function to a condition which will help maintain optimal nutritional and health status. Dental services include Preventive Care (initial and yearly examinations, radiographs, prophylaxis and oral hygiene instructions); Basic Care (fillings and extractions); and Major Care (treatment which is determined by the condition of the mouth, for example, the amount of remaining supporting bone, the participant’s ability to comply with instruction, and the participant’s motivation to pursue oral health care). Major Care includes temporary crowns, full or partial dentures and root canals. Not included under dental care is: cosmetic dentistry. Diagnosis and treatment of male erectile dysfunction provided that the care is from {PACE Organization} staff physician or a physician specialist under contract to {PACE Organization}, and that such care is deemed medically necessary. The Plan does not cover treatment, including medication, devices and surgery, which is deemed harmful to the participant or which is deemed to be for cosmetic or recreational purposes and not medically necessary. Mastectomy, lumpectomy, lymph node dissection, prosthetic devices and reconstructive surgery. Necessary materials, supplies and services for the management of diabetes mellitus. Home Services Home Care Personal care (i.e., grooming, dressing, assistance in using the bathroom) Homemaker/chore services Rehabilitation maintenance Evaluation of home environment Home Health Skilled nursing services Physician visits (at discretion of physician) Medical social services Home health aide service Hospital Inpatient Care Semi-private room and board General medical and nursing services Psychiatric services Meals Prescribed drugs, medicines and biologicals Diagnostic or therapeutic items and services Laboratory tests, X-rays and other diagnostic procedures • Prescription drugs Medical/Surgical, Intensive Care, Coronary Care Unit, as necessary Kidney dialysis Dressings, casts, supplies Operating room and recovery room Oxygen and anesthesia Organ and bone marrow transplants (only if obtained from a pharmacy designated by CHA PACEnon-experimental and non-investigative) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team • Podiatry • Vision careUse of appliances, including examinations, treatment and corrective devices such as eyeglasses • Psychiatrya wheelchair Rehabilitation services, including evaluationsuch as physical, consultationoccupational, diagnostic speech and treatment service • Audiology evaluationrespiratory therapy Radiation therapy Blood, hearing aidsblood plasma, repairs blood factors and maintenance Hospital Inpatient Care • Ambulance • Emergency blood derivatives Medical social services and discharge planning {PACE Organization} does not cover private room care and treatment room services • private duty nursing unless medically necessary, nor any non-medical items for which there is an additional charge, such as telephone charges or television rental. Skilled Nursing Facility Semi-private room and board, as available • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary • Laboratory tests, x-rays and other diagnostic procedures • Prescription drugs • Blood and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care does not include a private room, private duty nursing, and non-medical services such as telephone charges. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. Nursing Facility Care • Semi-private room and board, when available • board Physician and nursing services • Custodial care • All meals Personal care and assistance • Prescription Prescribed drugs • and biologicals Necessary medical supplies and appliances, such as a wheelchair Physical, occupational, speech and occupational therapies as authorized by the Interdisciplinary team • Social respiratory therapy Medical social services • Medical supplies and appliances Home Health Care and Transportation • Skilled nursing services • Physical, speech and occupational therapies • Social services • Home health aide services • Homemaking services • Home-delivered meals • Emergency alert system • Medical supplies • Transportation to CHA PACE authorized medical appointments End of Life Services • Skilled nursing Care {PACE Program’s} comfort care program is available to care for the terminally ill. If needed, your Physician and other clinical experts on your IDT will work with you and your family to provide these services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services Dental Care • Oral examsdirectly or through contracts with local hospice providers. If you want to receive the Medicare hospice benefit, cleanings, fillings • Xyou will need to disenroll from our program and enroll in a Medicare-rays • Some oral surgery (such as removal of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Denturescertified Hospice provider.

Benefits and Coverage. All benefits are provided in accordance The Hospice treatment program must: • Be recognized as an approved Hospice program by Alliant; • Include support services to help covered family members deal with CMS/PACE guidelines including the requirement patient’s death; and • Be directed by a Physician and coordinated by an RN with a treatment plan that: o Provides an organized system of home care; o Uses a Hospice team; and o Has around-the-clock care available. The following conditions apply: • To qualify for Hospice care, the attending Physician must certify that such services are approved by the Interdisciplinary Team patient is not expected to live more than six months. • The Physician must design and provided by CHA PACE or its contracted service providersrecommend a Hospice Care Program; and • The Physician’s statement and recommended program should obtain a Prior Authorization. For In-Network Care, unless otherwise indicatedyour Physician must arrange your hospital admission. Health Inpatient‌ Inpatient Hospital Services • Adult day healthcare • Primary care, including consultation, routine care, preventive health care and physical examinations • Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology and dermatology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) • Nursing care • Social services • Physical, occupational and speech therapies • Recreational therapy • Nutrition counseling and education • Laboratory tests, X-rays and other diagnostic procedures • Prescription drugs (only if obtained from a pharmacy designated by CHA PACE) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team • Podiatry • Vision care, including examinations, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance Hospital Inpatient Care • Ambulance • Emergency room care and treatment room services • Semi-private charges. Covered Services include semiprivate room and board, as available • General medical and general nursing services • Medical, surgical, intensive care and coronary care unitintensive or cardiac care. If you stay in a private room, Covered Services are based on the Hospital’s prevalent semiprivate rate. If you are admitted to a Hospital that has only private rooms, Covered Services are based on the Hospital’s prevalent room rate. Prior Authorization is required for all Hospital admissions. Services and Supplies • Services and supplies provided and billed by the Hospital while you are an Inpatient, including the use of operating, recovery and delivery rooms. Laboratory and diagnostic examinations, intravenous solutions, basal metabolism studies, electrocardiograms, electroencephalograms, x-ray examinations, and radiation and speech therapy are also covered. • Convenience or comfort items (such as necessary radios, TV’s, telephones, visitors’ meals, etc.) are not covered. Length of Stay • Laboratory Determined by Medical Necessity. Outpatient‌ Outpatient Services • Your Contract provides Covered Services when the following outpatient services are Medically Necessary: Pre- admission tests, surgery, diagnostic x-rays and other diagnostic laboratory services. Certain procedures require Prior Authorization. • Prescription drugs • Blood and blood derivatives • Surgical careRefer to Emergency Room Services/Emergency Medical Services definition. HOW TO OBTAIN CARE AFTER NORMAL BUSINESS HOURS‌ If you need medical attention after normal office hours because you need Urgent or Emergency Medical Services, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care does not include a private room, private duty nursing, and nonyou can find an in-medical services such as telephone charges. Tertiary hospital care is not available network facility by contacting Customer Service at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. Nursing Facility Care • Semi(000) 000-private room and board, when available • Physician and nursing services • Custodial care • Personal care and assistance • Prescription drugs • Physical, speech and occupational therapies as authorized by the Interdisciplinary team • Social services • Medical supplies and appliances Home Health Care and Transportation • Skilled nursing services • Physical, speech and occupational therapies • Social services • Home health aide services • Homemaking services • Home-delivered meals • Emergency alert system • Medical supplies • Transportation to CHA PACE authorized medical appointments End of Life Services • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services Dental Care • Oral exams, cleanings, fillings • X-rays • Some oral surgery (such as removal of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Dentures0000 or visiting XxxxxxxXxxxx.xxx.

Benefits and Coverage. All benefits Many kinds of care are provided in accordance by Serenity Care PACE. The Serenity Care PACE program covers all of the items covered under original Medicare and Medicaid. We also cover services that may not be available under the original Medicare and Medicaid. The IDT will decide along with CMS/you what is best for your needs. Services you may receive from Serenity Care PACE guidelines including the requirement that such services are approved by the Interdisciplinary Team are: • Physician and provided by CHA PACE or its contracted service providers, unless otherwise indicated. Specialist Care • Dental Care • Home Healthcare • Durable Medical Equipment • Health-Related Services • Outpatient Health Services • Adult day healthcare Ambulance Transportation • Primary care, including consultation, routine care, preventive health care and physical examinations Emergency Room Care • Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology and dermatology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) Treatment Room Services • Nursing care • Social services • Physical, occupational and speech therapies • Recreational therapy • Nutrition counseling and education • Laboratory tests, X-rays and other diagnostic procedures • Prescription drugs (only if obtained from a pharmacy designated by CHA PACE) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team • Podiatry • Vision care, including examinations, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance Hospital Inpatient Care • Ambulance Drug, Alcohol and Mental Health Counseling • Emergency room Nursing Home Care • Assisted Living Care • Respite Care • End of Life Care • Pastoral Care The following benefits are fully covered when approved by the interdisciplinary team and provided by Serenity Care PACE staff or contractors and in Serenity Care PACE contracted facilities. Approval or pre-approval is not required for emergency services. Physician and Specialist Care Participants in Serenity Care PACE receive all of their routine medical services through the day center, in-home service programs, and contracted specialists. In other words, program participants usually see their doctors and nurses at the day center instead of going to the doctor’s office. The PACE program doctors will serve as the participant’s primary care physician. If the IDT believes a special type of care is needed (for example, a participant may see a cardiologist for heart problems), the IDT will arrange for specialist care. Remember all services must be authorized by the IDT in order to have the costs covered by Serenity Care PACE. Specialist care may include, but is not limited to: • Anesthesiology • Audiology • Cardiology • Dermatology • Gastroenterology • Gynecology (women’s health specialist) • Internal medicine • Nephrology • Neurosurgery • Oncology • Ophthalmology • Oral Surgery • Orthopedic surgery • Otorhinolaryngology (ear, nose, and throat) • Plastic Surgery • Podiatry • Psychiatry • Pulmonary Disease • Radiology • Rheumatology • General Surgery • Thoracic and Vascular surgery • Urology Dental Care Our first priority for dental care is to treat pain and acute infection. Our second priority is to keep your mouth healthy so you can eat and drink without any problems. The Serenity Care PACE program provides care according to need and appropriateness as determined by the interdisciplinary team. When you first join Serenity Care PACE, you will get a dental check-up within the first three months of your enrollment. After that, you will be given a check-up and treatment room as needed every year. Dental services may include: • Semi-private room and boardExams, as available • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary • Laboratory tests, or x-rays to see what your needs are • Cleaning and other diagnostic procedures instructions in keeping your teeth and gums as healthy as possible • Prescription drugs Fillings and crowns • Blood Complete or partial dentures to help you eat or drink • Pulling teeth (called “extracting”) or the removal or repair of soft and blood derivatives • Surgical care, including anesthesia • Use hard gum tissue Home Healthcare Some services are delivered right in your own home; they may be any of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care does not include a private room, private duty nursing, and non-medical services such as telephone charges. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. Nursing Facility Care • Semi-private room and board, when available • Physician and nursing services • Custodial care • Personal care and assistance • Prescription drugs • Physical, speech and occupational therapies as authorized by the Interdisciplinary team • Social services • Medical supplies and appliances Home Health Care and Transportation • following depending on your needs: Skilled nursing services • Physical, speech speech, and occupational therapies • Social Medical social services • Home health aide or personal care worker services • Homemaking Homemaker/Chore services • Home-Home delivered meals • Emergency alert system with special diets • Medical supplies • Transportation and equipment Durable Medical Equipment (DME) The Serenity Care PACE program rehabilitation department assesses the need for all medical equipment (wheelchairs, walkers, hospital beds, canes, etc.). All equipment issued is the property of Serenity Care PACE or its contracting providers and will be returned to CHA Serenity Care PACE authorized upon disenrollment. The final decision to issue medical appointments End equipment is made by the IDT. At the time of Life Services • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services Dental enrollment if you currently have equipment that is rented, it may be replaced by Serenity Care • Oral exams, cleanings, fillings • X-rays • Some oral surgery PACE based upon evaluation for medical or functional need. It is your responsibility (such as removal or your caregiver’s) to inform Serenity Care PACE of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Denturesany rented equipment.