Dental Surgery and Prosthesis. Dental surgery, orthodontia work, dental prosthesis (including repair).
Dental Surgery and Prosthesis Sample Clauses
Related to Dental Surgery and Prosthesis
Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) This plan covers durable medical equipment and supplies, prosthetic devices and enteral formula or food as described in this section. Durable Medical Equipment (DME) DME is equipment which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. DME includes supplies necessary for the effective use of the equipment. This plan covers the following DME: • wheelchairs, hospital beds, and other DME items used only for medical treatment; and • replacement of purchased equipment which is needed due to a change in your medical condition or if the device is not functional, no longer under warranty, or cannot be repaired. DME may be classified as a rental item or a purchased item. In most cases, this plan only pays for a rental DME up to our allowance for a purchased DME. Repairs and supplies for rental DME are included in the rental allowance. Preauthorization may be required for certain DME and replacement or repairs of DME. Medical Supplies Medical supplies are consumable supplies that are disposable and not intended for re- use. Medical supplies require an order by a physician and must be essential for the care or treatment of an illness, injury, or congenital defect. Covered medical supplies include: • essential accessories such as hoses, tubes and mouthpieces for use with medically necessary DME (these accessories are included as part of the rental allowance for rented DME); • catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and • respiratory therapy equipment. Diabetic Equipment and Supplies This plan covers diabetic equipment and supplies for the treatment of diabetes in accordance with R.I. General Law §27-20-30. Covered diabetic equipment and supplies include: • therapeutic or molded shoes and inserts for custom-molded shoes for the prevention of amputation; • blood glucose monitors including those with special features for the legally blind, external insulin infusion pumps and accessories, insulin infusion devices and injection aids; and • lancets and test strips for glucose monitors including those with special features for the legally blind, and infusion sets for external insulin pumps. The amount you pay differs based on whether the equipment and supplies are bought from a durable medical equipment provider or from a pharmacy. See the Summary of Pharmacy Benefits and the Summary of Medical Benefits for details. Coverage for some diabetic equipment and supplies may only be available from either a DME provider or from a pharmacy. Visit our website to determine if this is applicable or call our Customer Service Department. Prosthetic Devices Prosthetic devices replace or substitute all or part of an internal body part, including contiguous tissue, or replace all or part of the function of a permanently inoperative or malfunctioning body part and alleviate functional loss or impairment due to an illness, injury or congenital defect. Prosthetic devices do not include dental prosthetics. This plan covers the following prosthetic devices as required under R.I. General Law § 27-20-52: • prosthetic appliances such as artificial limbs, breasts, larynxes and eyes; • replacement or adjustment of prosthetic appliances if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired; • devices, accessories, batteries and supplies necessary for prosthetic devices; • orthopedic braces except corrective shoes and orthotic devices used in connection with footwear; and • breast prosthesis following a mastectomy, in accordance with the Women’s Health and Cancer Rights Act of 1998 and R.I. General Law 27-20-29. The prosthetic device must be ordered or provided by a physician, or by a provider under the direction of a physician. When you are prescribed a prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the outpatient benefit limit will apply. Enteral Formulas or Food (Enteral Nutrition) Enteral formula or food is nutrition that is absorbed through the intestinal tract, whether delivered through a feeding tube or taken orally. Enteral nutrition is covered when it is the sole source of nutrition and prescribed by the physician for home use. In accordance with R.I. General Law §27-20-56, this plan covers enteral formula taken orally for the treatment of: • malabsorption caused by Crohn’s Disease; • ulcerative colitis; • gastroesophageal reflux; • chronic intestinal pseudo obstruction; and • inherited diseases of amino acids and organic acids. Food products modified to be low protein are covered for the treatment of inherited diseases of amino acids and organic acids. Preauthorization may be required. The amount that you pay may differ depending on whether the nutrition is delivered through a feeding tube or taken orally. When enteral formula is delivered through a feeding tube, associated supplies are also covered. Hair Prosthesis (Wigs) This plan covers hair prosthetics (wigs) worn for hair loss suffered as a result of cancer treatment in accordance with R.I. General Law § 27-20-54 and subject to the benefit limit and copayment listed in the Summary of Medical Benefits. This plan will reimburse the lesser of the provider’s charge or the benefit limit shown in the Summary of Medical Benefits. If the provider’s charge is more than the benefit limit, you are responsible for paying any difference. Early Intervention Services (EIS) This plan covers Early Intervention Services in accordance with R.I. General Law §27- 20-50. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The child must be certified by the Rhode Island Department of Human Services (DHS) to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. Members not living in Rhode Island may seek services from the state in which they reside; however, those services are not covered under this plan. Early Intervention Services as defined by DHS include but are not limited to the following: • speech and language therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices.
Professional Growth and Improvement Plans A. Professional growth and improvement plans shall be developed as follows:
STAFF ORIENTATION 4101 The Employer shall provide an appropriate orientation program for nurses newly employed. The orientation program shall include such essential information as policies, nursing procedures, the location of supplies and equipment, fire, safety and disaster plans. Where necessary, orientation shall be provided for nurses moving to a new area of practice. 4102 The Employer shall provide a program of inservice education for nurses pertinent to patient care. 4103 The Employer shall provide, access to reference materials as is required in relation to maintaining current knowledge of general nursing care. APPENDIX "A" - SALARIES A1. Effective April 1, 2013 - Monthly salaries include a 2% general increase. - Hourly salary is calculated as (monthly salary x 12) ÷ annual hours. Nurse Classification Annual Hours Start Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 20 Year 1 Licensed Practical Nurse 2015 Hourly 25.198 26.022 26.836 27.825 28.732 29.745 30.804 31.420 Monthly 4,231.164 4,369.528 4,506.212 4,672.281 4,824.582 4,994.681 5,172.505 5,275.942 Annual 50,773.970 52,434.330 54,074.540 56,067.375 57,894.980 59,936.175 62,070.060 63,311.300 Nurse II 2015 Hourly 32.917 34.066 35.218 36.419 37.593 38.811 39.587 Monthly 5,527.313 5,720.249 5,913.689 6,115.357 6,312.491 6,517.014 6,647.317 Annual 66,327.755 68,642.990 70,964.270 73,384.285 75,749.895 78,204.165 79,767.805 Nurse II (20 Year Scale) 2015 Hourly 33.575 34.747 35.923 37.148 38.345 39.587 Monthly 5,637.802 5,834.600 6,032.070 6,237.768 6,438.765 6,647.317 Annual 67,653.625 70,015.205 72,384.845 74,853.220 77,265.175 79,767.805 Nurse III 2015 Hourly 34.168 35.321 36.523 37.697 38.787 39.975 41.201 42.025 Monthly 5,737.377 5,930.985 6,132.820 6,329.955 6,512.984 6,712.469 6,918.335 7,056.698 Annual 68,848.520 71,171.815 73,593.845 75,959.455 78,155.805 80,549.625 83,020.015 84,680.375 Nurse III (20 Year Scale) 2015 Hourly 34.851 36.027 37.254 38.451 39.563 40.775 42.025 Monthly 5,852.064 6,049.534 6,255.568 6,456.564 6,643.287 6,846.802 7,056.698 Annual 70,224.765 72,594.405 75,066.810 77,478.765 79,719.445 82,161.625 84,680.375 Nurse IV 2015 Hourly 35.340 36.649 37.959 39.387 41.024 42.612 44.273 45.158 Monthly 5,934.175 6,153.978 6,373.949 6,613.734 6,888.613 7,155.265 7,434.175 7,582.781 Annual 71,210.100 73,847.735 76,487.385 79,364.805 82,663.360 85,863.180 89,210.095 90,993.370 Nurse IV (20 Year Scale) 2015 Hourly 36.047 37.382 38.718 40.175 41.844 43.464 45.158 Monthly 6,052.892 6,277.061 6,501.398 6,746.052 7,026.305 7,298.330 7,582.781 Annual 72,634.705 75,324.730 78,016.770 80,952.625 84,315.660 87,579.960 90,993.370 Nurse V 2015 Hourly 37.305 38.733 40.369 41.957 43.690 45.388 47.157 48.100 Monthly 6,264.131 6,503.916 6,778.628 7,045.280 7,336.279 7,621.402 7,918.446 8,076.792 Annual 75,169.575 78,046.995 81,343.535 84,543.355 88,035.350 91,456.820 95,021.355 96,921.500 Nurse V (20 Year Scale) 2015 Hourly 38.051 39.508 41.177 42.797 44.564 46.296 48.100 Monthly 6,389.397 6,634.052 6,914.305 7,186.330 7,483.038 7,773.870 8,076.792 Annual 76,672.765 79,608.620 82,971.655 86,235.955 89,796.460 93,286.440 96,921.500 Nurse Practitioner 2015 Hourly 42.515 45.635 47.511 49.385 51.408 52.437 Monthly 7,138.977 7,662.877 7,977.889 8,292.565 8,632.260 8,805.046 Annual 85,667.725 91,954.525 95,734.665 99,510.775 103,587.120 105,660.555 Nurse Practitioner (20 Year Scale) 2015 Hourly 43.365 46.548 48.461 50.373 52.437 Monthly 7,281.706 7,816.185 8,137.410 8,458.466 8,805.046 Annual 87,380.475 93,794.220 97,648.915 101,501.595 105,660.555 Weekend Worker Rates Annual Hours Start Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 20 Year 1 Weekend Worker - Licensed Practical Nurse 2015 Hourly 28.977 29.925 30.861 31.999 33.042 34.206 35.425 36.133 Monthly 4,865.721 5,024.906 5,182.076 5,373.165 5,548.303 5,743.758 5,948.448 6,067.333 Annual 58,388.655 60,298.875 62,184.915 64,477.985 66,579.630 68,925.090 71,381.375 72,807.995 Weekend Worker - Nurse II 2015 Hourly 37.855 39.176 40.501 41.882 43.232 44.633 45.526 Monthly 6,356.485 6,578.303 6,800.793 7,032.686 7,259.373 7,494.625 7,644.574 Annual 76,277.825 78,939.640 81,609.515 84,392.230 87,112.480 89,935.495 91,734.890 Weekend Worker - Nurse II (20 Year Scale) 2015 Hourly 38.612 39.959 41.311 42.720 44.097 45.526 Monthly 6,483.598 6,709.782 6,936.805 7,173.400 7,404.621 7,644.574 Annual 77,803.180 80,517.385 83,241.665 86,080.800 88,855.455 91,734.890 Weekend Worker - Nurse III 2015 Hourly 39.293 40.619 42.002 43.352 44.605 45.971 47.381 48.329 Monthly 6,597.950 6,820.607 7,052.836 7,279.523 7,489.923 7,719.297 7,956.060 8,115.245 Annual 79,175.395 81,847.285 84,634.030 87,354.280 89,879.075 92,631.565 95,472.715 97,382.935 Weekend Worker - Nurse III (20 Year Scale) 2015 Hourly 40.079 41.431 42.842 44.219 45.497 46.891 48.329 Monthly 6,729.932 6,956.955 7,193.886 7,425.107 7,639.705 7,873.780 8,115.245 Annual 80,759.185 83,483.465 86,326.630 89,101.285 91,676.455 94,485.365 97,382.935 Weekend Worker - Nurse IV 2015 Hourly 40.641 42.146 43.653 45.295 47.177 49.003 50.914 51.932 Monthly 6,824.301 7,077.016 7,330.066 7,605.785 7,921.805 8,228.420 8,549.309 8,720.248 Annual 81,891.615 84,924.190 87,960.795 91,269.425 95,061.655 98,741.045 102,591.710 104,642.980 Weekend Worker - Nurse IV (20 Year Scale) 2015 Hourly 41.454 42.989 44.526 46.201 48.121 49.983 51.932 Monthly 6,960.818 7,218.570 7,476.658 7,757.918 8,080.318 8,392.979 8,720.248 Annual 83,529.810 86,622.835 89,719.890 93,095.015 96,963.815 100,715.745 104,642.980 Weekend Worker - Nurse V 2015 Hourly 42.900 44.543 46.425 48.251 50.244 52.196 54.230 55.315 Monthly 7,203.625 7,479.512 7,795.531 8,102.147 8,436.805 8,764.578 9,106.121 9,288.310 Annual 86,443.500 89,754.145 93,546.375 97,225.765 101,241.660 105,174.940 109,273.450 111,459.725 Weekend Worker - Nurse V (20 Year Scale) 2015 Hourly 43.758 45.434 47.353 49.216 51.249 53.240 55.315 Monthly 7,347.698 7,629.126 7,951.358 8,264.187 8,605.561 8,939.883 9,288.310 Annual 88,172.370 91,549.510 95,416.295 99,170.240 103,266.735 107,278.600 111,459.725 1 Eligibility for the 20 Year increment is determined in accordance w ith Article 2105.
Prosthodontics We Cover prosthodontic services as follows: • Removable complete or partial dentures, for Members 15 years of age and above, including six (6) months follow-up care; • Additional services including insertion of identification slips, repairs, relines and rebases and treatment of cleft palate; and • Interim prosthesis for Members five (5) to 15 years of age. We do not Cover implants or implant related services. Fixed bridges are not Covered unless they are required: • For replacement of a single upper anterior (central/lateral incisor or cuspid) in a patient with an otherwise full complement of natural, functional and/or restored teeth; • For cleft palate stabilization; or • Due to the presence of any neurologic or physiologic condition that would preclude the placement of a removable prosthesis, as demonstrated by medical documentation.
Durable Medical Equipment (DME), Medical Supplies Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) • Items typically found in the home that do not need a prescription and are easily obtainable such as, but not limited to: o adhesive bandages; o elastic bandages; o gauze pads; and o alcohol swabs. • DME and medical supplies prescribed primarily for the convenience of the member or the member’s family, including but not limited to, duplicate DME or medical supplies for use in multiple locations or any DME or medical supplies used primarily to assist a caregiver. • Non-wearable automatic external defibrillators. • Replacement of durable medical equipment and prosthetic devices prescribed because of a desire for new equipment or new technology. • Equipment that does not meet the basic functional need of the average person. • DME that does not directly improve the function of the member. • Medical supplies provided during an office visit. • Pillows or batteries, except when used for the operation of a covered prosthetic device, or items for which the sole function is to improve the quality of life or mental wellbeing. • Repair or replacement of DME when the equipment is under warranty, covered by the manufacturer, or during the rental period. • Infant formula, nutritional supplements and food, or food products, whether or not prescribed, unless required by R.I. Law §27-20-56 for Enteral Nutrition Products, or delivered through a feeding tube as the sole source of nutrition. • Corrective or orthopedic shoes and orthotic devices used in connection with footwear, unless for the treatment of diabetes. Experimental or Investigational Services • Treatments, procedures, facilities, equipment, drugs, devices, supplies, or services that are experimental or investigational except as described in Section 3. Gender Reassignment Services • Reversal of gender reassignment surgery.
Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services.
Minority and Women’s Business Enterprises Compliance Award of this Contract was based, in part, on the Minority and/or Women’s Business Enterprise (“MBE” and/or “WBE”) participation plan as detailed in the Minority and Women’s Business Enterprises Subcontractor Commitment Form, commonly referred to as “Attachment A” in the procurement documentation and incorporated by reference herein. Therefore, any changes to this information during the Contract term must be approved by MWBE Compliance and may require an amendment. It is the State’s expectation that the Contractor will meet the subcontractor commitments during the Contract term. The following MBE/WBE Division (“Division”) certified MBE and/or WBE subcontractors will be participating in this Contract: [Add additional MBEs and WBEs using the same format.] MBE or WBE COMPANY NAME PHONE EMAIL OF CONTACT PERSON PERCENT Briefly describe the MBE and/or WBE service(s)/product(s) to be provided under this Contract and include the estimated date(s) for utilization during the Contract term: A copy of each subcontractor agreement must be submitted to the Division within thirty (30) days of the effective date of this Contract. The subcontractor agreements may be uploaded into Pay Audit (Indiana’s subcontractor payment auditing system), emailed to XXXXXxxxxxxxxx@xxxx.XX.xxx, or mailed to MWBE Compliance, 000 X. Xxxxxxxxxx Street, Indianapolis IN 46204. Failure to provide a copy of any subcontractor agreement may be deemed a violation of the rules governing MBE/WBE procurement and may result in sanctions allowable under 25 IAC 5-7-8. Requests for changes must be submitted to XXXXXxxxxxxxxx@xxxx.XX.xxx for review and approval before changing the participation plan submitted in connection with this Contract. The Contractor shall report payments made to Division certified subcontractors under this Contract on a monthly basis using Pay Audit. The Contractor shall notify subcontractors that they must confirm payments received from the Contractor in Pay Audit. The Pay Audit system can be accessed on the IDOA webpage at: xxx.xx.xxx/xxxx/xxxx/xxxxxxxx.xxx. The Contractor may also be required to report Division certified subcontractor payments directly to the Division, as reasonably requested and in the format required by the Division. The Contractor’s failure to comply with the provisions in this clause may be considered a material breach of the Contract.
Pharmacy Benefits - Prescription Drugs and Diabetic Equipment or Supplies from a Pharmacy This plan covers prescription drugs listed on our formulary and diabetic equipment or supplies bought from a pharmacy as a pharmacy benefit. These benefits are administered by our Pharmacy Benefit Manager (PBM). Our formulary includes a tiered copayment structure and indicates that certain prescription drugs require preauthorization. If a prescription drug is not on our formulary, it is not covered. For specific coverage information or a copy of the most current formulary, please visit our website or call our Customer Service Department. Prescription drugs and diabetic equipment or supplies are covered when dispensed using the following guidelines: • the prescription must be medically necessary, consistent with the physician’s diagnosis, ordered by a physician whose license allows him or her to order it, filled at a pharmacy whose license allows such a prescription to be filled, and filled according to state and federal laws; • the prescription must consist of legend drugs that require a physician’s prescription under law, or compound medications made up of at least one legend drug requiring a physician’s prescription under law; • the prescription must be dispensed at the proper place of service as determined by our Pharmacy and Therapeutics Committee. For example, certain prescription drugs may only be covered when obtained from a specialty pharmacy; and • the prescription is limited to the quantities authorized by your physician not to exceed the quantity listed in the Summary of Pharmacy Benefits. Prescription drugs are subject to the benefit limits and the amount you pay shown in the Summary of Pharmacy Benefits.
Orthodontics We Cover orthodontics used to help restore oral structures to health and function and to treat serious medical conditions such as: cleft palate and cleft lip; maxillary/mandibular micrognathia (underdeveloped upper or lower jaw); extreme mandibular prognathism; severe asymmetry (craniofacial anomalies); ankylosis of the temporomandibular joint; and other significant skeletal dysplasias. Procedures include but are not limited to: • Rapid Palatal Expansion (RPE); • Placement of component parts (e.g. brackets, bands); • Interceptive orthodontic treatment; • Comprehensive orthodontic treatment (during which orthodontic appliances are placed for active treatment and periodically adjusted); • Removable appliance therapy; and • Orthodontic retention (removal of appliances, construction and placement of retainers).
Prosthetics Crowns and Bridges (Plan B) paying for 60% of the approved Schedule of Fees.
