Common use of Chiropractic Services Clause in Contracts

Chiropractic Services. Medical transportation not directly related to the labor or threatened labor and/or delivery of the covered unborn child. Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment related to labor with delivery or post partum care. Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility. Mechanical organ replacement devices including, but not limited to artificial heart Hospital services and supplies when confinement is solely for diagnostic testing purposes and not a part of labor with delivery Prostate and mammography screening Elective surgery to correct vision Gastric procedures for weight loss Cosmetic surgery/services solely for cosmetic purposes Out-of-network services not authorized by the Health Plan except for emergency care related to the labor with delivery of the covered unborn child. Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity Acupuncture services, naturopathy and hypnotherapy Immunizations solely for foreign travel Routine foot care such as hygienic care Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails) Corrective orthopedic shoes Convenience items Orthotics primarily used for athletic or recreational purposes Custodial care (care that assists with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a caregiver. This care does not require the continuing attention of trained medical or paramedical personnel.)

Chiropractic Services. Medical transportation not directly related to the labor or threatened labor and/or delivery of the covered unborn child. Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment related to labor with delivery or post partum care. Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility. Coverage while traveling outside of the United States and U.S. Terriotries (including Puerto Rico, U.S. Virgin Islands, Commonwealth of Northern Mariana Islands, Guam, and American Samoa). Mechanical organ replacement devices including, but not limited to artificial heart Hospital services and supplies when confinement is solely for diagnostic testing purposes and not a part of labor with delivery Prostate and mammography screening Elective surgery to correct vision Gastric procedures for weight loss Cosmetic surgery/services solely for cosmetic purposes Out-of-network services not authorized by the Health Plan except for emergency care related to the labor with delivery of the covered unborn child. Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity Acupuncture services, naturopathy and hypnotherapy Immunizations solely for foreign travel Routine foot care such as hygienic care Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails) Corrective orthopedic shoes Convenience items Orthotics primarily used for athletic or recreational purposes Custodial care (care that assists with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a caregiver. This care does not require the continuing attention of trained medical or paramedical personnel.)

Chiropractic Services. Medical transportation not directly related to the labor or threatened labor and/or delivery of the covered unborn child. • Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment related to labor with delivery or post partum care. • Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community • Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court • Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility. • Mechanical organ replacement devices including, but not limited to artificial heart • Hospital services and supplies when confinement is solely for diagnostic testing purposes and not a part of labor with delivery • Prostate and mammography screening • Elective surgery to correct vision • Gastric procedures for weight loss • Cosmetic surgery/services solely for cosmetic purposes • Out-of-network services not authorized by the Health Plan except for emergency care related to the labor with delivery of the covered unborn child. • Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity • Acupuncture services, naturopathy and hypnotherapy • Immunizations solely for foreign travel • Routine foot care such as hygienic care • Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails) • Corrective orthopedic shoes • Convenience items • Orthotics primarily used for athletic or recreational purposes • Custodial care (care that assists with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a caregiver. This care does not require the continuing attention of trained medical or paramedical personnel.)) • Housekeeping • Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities • Services or supplies received from a nurse, which do not require the skill and training of a nurse • Vision training, vision therapy, or vision services • Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered • Donor non-medical expenses • Charges incurred as a donor of an organ CHIP PERINATAL PROGRAM EXCLUSIONS FROM COVERED SERVICES FOR CHIP PERINATE NEWBORNS With the exception of the first bullet, all the following exclusions match those found in the CHIP Program. • For CHIP Perinate Newborns in families with incomes at or below 185% of the Federal Poverty Level, inpatient facility charges are not a covered benefit for the initial Perinate Newborn admission. "Initial Perinate Newborn admission" means the hospitalization associated with the birth. • Inpatient and outpatient infertility treatments or reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system • Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment of sickness or injury • Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community • Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court • Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility. • Mechanical organ replacement devices including, but not limited to artificial heart • Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless otherwise pre-authorized by Health Plan • Prostate and mammography screening • Elective surgery to correct vision • Gastric procedures for weight loss • Cosmetic surgery/services solely for cosmetic purposes • Out-of-network services not authorized by the Health Plan except for emergency care and physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section • Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan • Acupuncture services, naturopathy and hypnotherapy • Immunizations solely for foreign travel • Routine foot care such as hygienic care • Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails) • Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor • Corrective orthopedic shoes • Convenience items • Orthotics primarily used for athletic or recreational purposes • Custodial care (care that assists a child with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice services. • Housekeeping • Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities • Services or supplies received from a nurse, which do not require the skill and training of a nurse • Vision training and vision therapy • Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP • Donor non-medical expenses • Charges incurred as a donor of an organ when the recipient is not covered under this health plan CHIP & CHIP PERINATAL PROGRAM DME/SUPPLIES Note: DME/SUPPLIES are not a covered benefit for CHIP Perinate Members but are a benefit for CHIP Perinate Newborns. SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER CONTRACT PROVISIONS Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs (diabetic) X Over-the-counter supply not covered, unless RX provided at time of dispensing. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Xxx Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan. Bandages X Basal Thermometer X Over-the-counter supply. Batteries – initial X . For covered DME items Batteries – replacement X For covered DME when replacement is necessary due to normal use. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication Devices X Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent Briefs/Chux X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing Supplies/Central Line X Syringes, needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing Supplies/Decubitus X Eligible for coverage only if receiving covered home care for wound care. Dressing Supplies/Peripheral IV Therapy X Eligible for coverage only if receiving home IV therapy. Dressing Supplies/Other X Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition Supplies X Necessary supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia. Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and authorized by plan.) Physician documentation to justify prescription of formula must include: • Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: • For members who could be sustained on an age-appropriate diet. • Traditionally used for infant feeding • In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) • For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care provided by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Insulin Pump (External) Supplies X Supplies (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets, Wound Care X Eligible for coverage when used during covered home care for wound care. Irrigation Sets, Urinary X Eligible for coverage for individual with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Eligible for individuals with diabetes. Med Ejector X Needles and Syringes/Diabetic See Diabetic Supplies Needles and Syringes/IV and Central Line See IV Therapy and Dressing Supplies/Central Line. Needles and Syringes/Other X Eligible for coverage if a covered IM or SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral Nutrition/Supplies X Necessary supplies (e.g., tubing, filters, connectors, etc.) are eligible for coverage when the Health Plan has authorized the parenteral nutrition. Saline, Normal X Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. Xxxxx Sleeve X Xxxxx Socks X Suction Catheters X Syringes See Needles/Syringes. Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy Supplies X Cannulas, Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External Catheter & Supplies X Exception: Covered when used by incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan Urinary, Indwelling Catheter & Supplies X Cover catheter, drainage bag with tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When determined to be medically necessary. Urostomy supplies See Ostomy Supplies. Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-3 – Value-added Services Version 1.8 DOCUMENT HISTORY LOG STATUS1 DOCUMENT REVISION2 EFFECTIVE DATE DESCRIPTION3 Baseline n/a Initial version of Attachment B-3, Value-added Services. Revision 1.1 June 30, 2006 Contract amendment did not revise Attachment B-3, Value-added Services. Revision 1.2 September 1. 2006 Revised Physical Health Value-added Services to include Home Visits to New Mothers. Revised the certification provision by changing the start date for the 12-month provision of services.

Chiropractic Services. Medical transportation not directly related to the labor or threatened labor and/or delivery of the covered unborn child. · Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment related to labor with delivery or post partum care. · Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community · Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court · Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility. · Mechanical organ replacement devices including, but not limited to artificial heart · Hospital services and supplies when confinement is solely for diagnostic testing purposes and not a part of labor with delivery Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-2.2 – CHIP Perinatal Covered Services Version 1.7 · Prostate and mammography screening · Elective surgery to correct vision · Gastric procedures for weight loss · Cosmetic surgery/services solely for cosmetic purposes · Out-of-network services not authorized by the Health Plan except for emergency care related to the labor with delivery of the covered unborn child. · Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity · Acupuncture services, naturopathy and hypnotherapy · Immunizations solely for foreign travel · Routine foot care such as hygienic care · Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails) · Corrective orthopedic shoes · Convenience items · Orthotics primarily used for athletic or recreational purposes · Custodial care (care that assists with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a caregiver. This care does not require the continuing attention of trained medical or paramedical personnel.)) · Housekeeping · Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities · Services or supplies received from a nurse, which do not require the skill and training of a nurse · Vision training, vision therapy, or vision services · Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered · Donor non-medical expenses · Charges incurred as a donor of an organ Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) Subject: Attachment B-2.2 – CHIP Perinatal Covered Services Version 1.7 CHIP PERINATAL PROGRAM EXCLUSIONS FROM COVERED SERVICES FOR CHIP PERINATE NEWBORNS With the exception of the first bullet, all the following exclusions match those found in the CHIP Program.