Common use of Benefits and Coverage Clause in Contracts

Benefits and Coverage. for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total ⮚ Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section. • Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. ⮚ Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section. • Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and

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 visit limitationscenter as listed on the inside cover of this booklet at any time. Prior Auth Required o The treatment plans that define expected Significant Improvement must Our plan provides ready access to a whole array of professionals and health care services. Upon enrollment you will be established assigned a PCP at the initial visitcenter where you will receive services. The treatment plan requires Prior Authorization. Therapy treatments must All benefits are covered by FHCN PACE and will be provided and/or directed according to your needs as assessed by a licensed physical your IDT, in accordance with professionally recognized standards. If you would like more specific information about how we authorize or occupational therapistdeny health care services, please request this from the Social Worker. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and Benefits include: ● Services in the presence therapistPACE center, your home, the community, hospitals, and nursing facilities ● Primary care clinic visits (with FHCN PACE physician, nurse practitioner and/or nurse) ● Routine physicals and preventive health evaluations and care (including pap smears, mammograms, immunizations, and all generally accepted cancer screening tests). of a licensed physical or These services do not require prior authorization. ● Sensitive Services, that are services related to sexually transmitted diseases and HIV testing. ● Consultation with medical specialists ● Kidney dialysis ● Outpatient surgical services ● Outpatient mental health ● Medical social services/case management ● Health education and counseling ● Rehabilitation therapy (physical, occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Shortspeech) ● Personal care ● Recreational therapy ● Social and cultural activities {intergenerational (if applicable)} ● Nutritional counseling and hot meals ● Transportation, including escort ● Ambulance service ● X-term Rehabilitation physical therapy program. Refer to your Summary of Benefits rays ● Laboratory procedures ● Emergency coverage anywhere in the United States and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means languageits territories ● Durable medical equipment ● Prosthetic and orthotic appliances ● Routine podiatry ● Prescribed drugs and medicines ● Vision care (prescription eyeglasses, dysphagia (difficulty swallowingcorrective lenses after cataract surgery) ● Hearing exams and hearing therapyaids ● Dental care from the FHCN PACE dentist, with the goal of restoring participant oral function to a condition that will help maintain optimal nutritional and health status. Speech therapy Dental services include Preventive Care (initial and yearly examinations, radiographs, prophylaxis, and oral hygiene instructions); Basic Care (fillings and extractions); and Major Care (treatment that is Covered when 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. ● Diagnosis and treatment of male erectile dysfunction provided that the care is from FHCN PACE staff physician or a physician specialist under contract to FHCN PACE, and that such care is authorized by a licensed or certified speech therapistthe IDT. Coverage is subject to ● Mastectomy, lumpectomy, lymph node dissection, prosthetic devices, and reconstructive surgery. ● Necessary materials, supplies and services for the following limitations: Your Primary management of diabetes mellitus. Home Services ● Home Care Physician must determineo Personal care (i.e., grooming, dressing, assistance in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary using the bathroom) o Homemaker/chore services o Rehabilitation maintenance o Evaluation of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through 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 Services● 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 ● 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 (non-experimental and non- investigative) ● Use of appliances, such as a wheelchair ● Rehabilitation services, such as physical, occupational, speech and respiratory therapy ● Radiation therapy ● Blood, blood plasma, blood factors and blood derivatives ● Medical social services and discharge planning FHCN PACE will only cover private room and private duty nursing, or any non-medical items that have an additional charge, such as telephone charges or television rental, when authorized by the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and CoverageIDT. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total ⮚ Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section. • Room ● Semi-private room and board ● Physician and nursing services ● Custodial care ● All meals ● Personal care and assistance ● Prescribed drugs and biologicals ● Necessary medical supplies and appliances, such as a wheelchair ● Physical, occupational, speech and respiratory therapy ● Medical social services End of Life Care {PACE Program’s} comfort care program is available to care for the terminally ill. If needed, your PCP and other necessary clinical experts on your IDT will work with you and your family to provide these services furnished by directly or through contracts with local hospice providers. If you want to receive the Medicare hospice benefit, you will need to disenroll from our program and enroll in a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. ⮚ Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section. • Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andMedicare-certified Hospice provider.

Benefits and Coverage. for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total ⮚  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section. •  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. ⮚  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section. •  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and