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. • 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 • 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. • 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 • 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 • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services • 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/PACE guidelines including the requirement that such your home care services are approved by the Interdisciplinary Team and provided by CHA PACE or its contracted service providerstrans- portation schedules. Services include: • Social day care • Congregate meals • Activities/ recreation • Personal care and supportive services, unless otherwise indicated. • Adult day healthcare 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 • 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/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 • 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 • Medical supplies and appliances • Alcohol and substance abuse services • Mental health services Skilled nursing home services are provided through a private room, private duty nursing, facility that is contracted and non-medical services such as telephone chargescoordinated with Eddy SeniorCare. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. 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 • 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 • 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. • Medical supplies • Transportation to CHA PACE authorized medical appointments • Skilled nursing transportation and escort services • Social services and environmental supports • Home health aide services Translation language services, if necessary • Medical supplies • Prescription drugs • Xxxxxxx services • 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. 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. • 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 • 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. • 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 • 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 • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services • 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 Many kinds of care are provided 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 you what is best for your needs. Services you may receive from Serenity Care PACE are: • Physician and Specialist Care • Dental Care • Home Healthcare • Durable Medical Equipment • Health-Related Services • Outpatient Health Services • Ambulance Transportation • Emergency Room Care • Treatment Room Services • Hospital Inpatient Care • Drug, Alcohol and Mental Health Counseling • Nursing Home Care • Assisted Living Care • Respite Care • End of Life Care • Pastoral Care Participants in accordance with CMS/Serenity Care PACE guidelines including receive all of their routine medical services through the requirement that such 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 are approved must be authorized by the Interdisciplinary Team and provided IDT in order to have the costs covered by CHA PACE or its contracted service providers, unless otherwise indicatedSerenity Care PACE. • Adult day healthcare • Primary care, including consultation, routine care, preventive health Specialist care and physical examinations • Medical specialty services includingmay include, but is not limited to, services such as gastroenterology, oncology, urology, rheumatology and dermatology : • Anesthesiology • Audiology • Cardiology • Dermatology • Gastroenterology • Gynecology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHAwomen’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Centerhealth specialist) • Nursing care Internal medicine • Social services Nephrology • PhysicalNeurosurgery • Oncology • Ophthalmology • Oral Surgery • Orthopedic surgery • Otorhinolaryngology (ear, occupational nose, 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 PACEthroat) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team Plastic Surgery • Podiatry • Vision carePsychiatry • Pulmonary Disease • Radiology • Rheumatology • General Surgery • Thoracic and Vascular surgery • Urology 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, including examinationsyou will get a dental check-up within the first three months of your enrollment. After that, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic you will be given a check-up and treatment service as needed every year. Dental services may include: • Audiology evaluationExams, hearing aids, repairs and maintenance • 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, 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 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. • 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 • 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 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 • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services • Oral examsequipment is made by the IDT. At the time of enrollment if you currently have equipment that is rented, cleanings, fillings • X-rays • Some oral surgery it may be replaced by Serenity Care 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.

Benefits and Coverage. All ESP of HHSI covers all of the items and services covered under Medicare and MassHealth. We also cover other services if the Interdisciplinary Team determines they are necessary to improve and/or maintain your health status. The following benefits are provided in accordance with CMS/PACE guidelines including the requirement that such services are fully covered when approved by the Interdisciplinary Team and provided by CHA PACE ESP of HHSI staff or its contractors and in ESP OF HHSI contracted service providers, unless otherwise indicatedfacilities. • Adult day healthcare • Approval or pre-approval is not required for emergency services. Primary care, Care Physician services including consultation, routine care, preventive health care and physical examinations • Medical specialty Physical therapy, speech therapy and occupational therapy Personal Care Supportive services including: social services, transportation Nutrition Counseling and education Meals Recreational therapy Outpatient Health Services Physician Specialists 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 • Home Health Care Laboratory tests, X-rays and other diagnostic procedures • services Physical therapy, speech therapy and occupational therapy Prosthetics and Orthotics Personal Care Attendant services Prescription drugs (only if obtained from a pharmacy designated by CHA PACEESP OF HHSI except when provided for emergency services or authorized post emergency or urgent care services) • Prostheses and durable 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 • Ambulance • Emergency room care and treatment room services • Non-emergency ambulance transportation, if medically necessary Inpatient Hospital Care Semi-private room and board, as available • (or private room if medically necessary) Meals including special diets General medical and nursing services • Medical, surgical, and special care such as intensive care and coronary care unit, as necessary • unit Laboratory tests, x-rays and other radiology services Other diagnostic procedures • Prescription drugs • Use of appliances such as wheelchairs Drugs and biologicals Rehabilitative Care Blood and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care Please note: ESP of HHSI does not include a cover private room, room and private duty nursing, and nonunless determined medically necessary by the IDT. Non-medical services items for your personal convenience such as telephone charges. Tertiary hospital care is charges and radio or television rental are not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. • 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 • 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 • Skilled nursing services • Social services • Home health aide services • Medical supplies • Prescription drugs • Xxxxxxx services • Oral exams, cleanings, fillings • X-rays • Some oral surgery (such as removal of impacted teeth, biopsies, soft tissue surgery, and extractions) • Anesthesia • Denturescovered.

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. 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: • Primary care clinic visits (with {PACE guidelines Organization} physician, nurse practitioner and/or nurse) • Routine physicals and preventive health evaluations and care (including the requirement that such pap smears, mammograms, immunizations, and all generally accepted cancer screening tests). These services are approved by the Interdisciplinary Team and provided by CHA PACE or its contracted service providers, unless otherwise indicateddo not require prior authorization. • Adult day healthcare Sensitive Services, which are services related to sexually transmitted diseases and HIV testing. These services do not require prior authorization. • Primary care, including consultation, routine care, preventive Consultation with medical specialists • Kidney dialysis • Outpatient surgical services • Outpatient mental health care and physical examinations • 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. 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 • 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 (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 careMedical/Surgical, including examinationsIntensive Care, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance • 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 unitCoronary Care Unit, as necessary • Laboratory testsKidney dialysis • Dressings, xcasts, supplies • Operating room and recovery room • Oxygen and anesthesia • Organ and bone marrow transplants (non-rays experimental and other diagnostic procedures non- investigative) • Prescription drugs Use of appliances, such as a wheelchair • Blood Rehabilitation services, such as physical, occupational, speech and respiratory therapy • Radiation therapy • Blood, blood plasma, blood factors and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social Medical social services Hospital inpatient care and discharge planning {PACE Organization} does not include a cover private room, room and private duty nursingnursing unless medically necessary, and nor any non-medical services items for which there is an additional charge, 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 Centercharges or television rental. • 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 • 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 social services {PACE Program’s} comfort care program is available to CHA PACE authorized medical appointments • Skilled nursing 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 • 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.