Common use of Dialysis Services Clause in Contracts

Dialysis Services. Dialysis services for chronic renal failure are covered when provided in a Hospital, an outpatient facility or in the home. Pre-Authorization is required for dialysis performed in an outpatient facility or at home. Durable Medical Equipment (“DME”) is Medical Equipment, including mobility enhancing equipment that can withstand repeated use, is not disposable, is used for a medically therapeutic purpose, is generally not useful in the absence of Illness or Injury, and is appropriate for use in the home. DME may be rented or purchased at the discretion of the plan; the total cost of any DME rental may not exceed the purchase price. Repair or replacement is covered only when needed due to normal use, a change in the patient’s physical condition, or the growth of a child. Duplicate items are not covered. When more than one option exists, benefits will be limited to the least expensive model or item appropriate to treat the patient’s covered condition. Examples of DME include: • Crutches; • Oxygen and equipment for administering oxygen; • Xxxxxxx; and • Wheelchairs. This benefit also covers: • Breast Pumps; • Diabetic monitoring equipment, such as the initial cost of an insulin pump and supplies related to such equipment. Diabetic supplies such as insulin, syringes, needles, lancets, test strips, etc., are covered under the Prescription Drugs benefit; • Medical supplies needed for the treatment or care of an appropriate covered condition, including but not limited to compression garments, mastectomy bras and supplies, and ostomy supplies. Please note that supplies available over-the-counter are excluded from this benefit; • Limited Medical Vision Hardware: Benefits are provided for vision hardware for the following medical conditions of the eye: corneal ulcer, bullous keratopathy, recurrent erosion of cornea, tear film insufficiency, aphakia, Xxxxxxxx's disease, congenital cataract, corneal abrasion and keratoconus; and • State sales tax for durable medical and mobility enhancing equipment. Surgically implanted devices may be covered under the appropriate surgical benefit and are not considered DME. Benefits for DME are determined by the type of device and its intended use, and not by the entity that provides or bills for the device. DME and medical supply charges listed below are not covered: • Biofeedback equipment; • Equipment or supplies whose primary purpose is preventing Illness or Injury; • Exercise equipment; • Eyeglasses or contact lenses for conditions not listed as a covered medical condition or covered under the Pediatric Vision benefit, including routine eye care; • Items not manufactured exclusively for the direct therapeutic treatment of an Illness or Injury; • Items primarily for comfort, convenience, sports/recreational activities or use outside the home; • Off-the shelf shoe inserts and orthopedic shoes; • Over-the-counter items (except Medically Necessary crutches, walkers, standard wheelchairs, diabetic supplies and ostomy supplies are covered); • Personal comfort items including but not limited to air conditioners, lumbar rolls, heating pads, diapers, or personal hygiene items; • Phototherapy devices related to seasonal affective disorder; • Supportive equipment/environmental adaptive items including, but not limited to, hand rails, chair lifts, ramps, shower chairs, commodes, car lifts, elevators, and modifications made to the patient’s home, place of work, or vehicle; or • The following Medical Equipment/supplies: regular or special car seats or strollers, push chairs, air filtration/purifier systems or supplies, water purifiers, allergenic mattresses, orthopedic or other special chairs, pillows, bed-wetting training equipment, whirlpool baths, vaporizers, room humidifiers, hot tubs or other types of tubs, home UV or other light units, home blood testing equipment and supplies (except diabetic equipment and supplies, and home anticoagulation meters). This plan covers Emergency Care services, including supplies, outpatient charges for patient observation, Facility costs, and medical screening exams that are required for the stabilization of a patient experiencing a Medical Emergency. Emergency Care services provided by In-Network and Out-of-Network facilities are covered by this plan and include Medically Necessary detoxification services, including Chemical Dependency detoxification. Prescription medications associated with a Medical Emergency, including those purchased in a foreign country, are also covered.

Dialysis Services. This plan covers dialysis services and supplies provided when you are inpatient, outpatient or in your home and under the supervision of a dialysis program. Dialysis services for chronic renal failure supplies provided in your home are covered when provided in a Hospital, an outpatient facility or in the home. Pre-Authorization is required for dialysis performed in an outpatient facility or at homeas durable medical equipment. 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. DME is Medical Equipment, including mobility enhancing equipment that which: • can withstand repeated use, ; • is primarily and customarily used to serve a medical purpose; • is not disposable, is used for useful to a medically therapeutic purpose, is generally not useful person in the absence of Illness an illness or Injury, injury; and • is appropriate for use in the home. DME may be rented or purchased at includes supplies necessary for the discretion effective use of the plan; the total cost of any DME rental may not exceed the purchase price. Repair or replacement is covered only when needed due to normal use, a change in the patient’s physical condition, or the growth of a child. Duplicate items are not covered. When more than one option exists, benefits will be limited to the least expensive model or item appropriate to treat the patient’s covered condition. Examples of DME include: • Crutches; • Oxygen and equipment for administering oxygen; • Xxxxxxx; and • Wheelchairs. This benefit also covers: • Breast Pumps; • Diabetic monitoring equipment, such as the initial cost of an insulin pump and supplies related to such equipment. Diabetic supplies such as insulin, syringes, needles, lancets, test strips, etc., are covered under the Prescription Drugs benefit; • Medical supplies needed for the treatment or care of an appropriate covered condition, including but not limited to compression garments, mastectomy bras and supplies, and ostomy supplies. Please note that supplies available over-the-counter are excluded from this benefit; • Limited Medical Vision Hardware: Benefits are provided for vision hardware for the following medical conditions of the eye: corneal ulcer, bullous keratopathy, recurrent erosion of cornea, tear film insufficiency, aphakia, Xxxxxxxx's disease, congenital cataract, corneal abrasion and keratoconus; and • State sales tax for durable medical and mobility enhancing equipment. Surgically implanted devices may be covered under the appropriate surgical benefit and are not considered DME. Benefits for DME are determined by the type of device and its intended use, and not by the entity that provides or bills for the device. DME and medical supply charges listed below are not covered: • Biofeedback equipment; • Equipment or supplies whose primary purpose is preventing Illness or Injury; • Exercise equipment; • Eyeglasses or contact lenses for conditions not listed as a covered medical condition or covered under the Pediatric Vision benefit, including routine eye care; • Items not manufactured exclusively for the direct therapeutic treatment of an Illness or Injury; • Items primarily for comfort, convenience, sports/recreational activities or use outside the home; • Off-the shelf shoe inserts and orthopedic shoes; • Over-the-counter items (except Medically Necessary crutches, walkers, standard wheelchairs, diabetic supplies and ostomy supplies are covered); • Personal comfort items including but not limited to air conditioners, lumbar rolls, heating pads, diapers, or personal hygiene items; • Phototherapy devices related to seasonal affective disorder; • Supportive equipment/environmental adaptive items including, but not limited to, hand rails, chair lifts, ramps, shower chairs, commodes, car lifts, elevators, and modifications made to the patient’s home, place of work, or vehicle; or • The following Medical Equipment/supplies: regular or special car seats or strollers, push chairs, air filtration/purifier systems or supplies, water purifiers, allergenic mattresses, orthopedic or other special chairs, pillows, bed-wetting training equipment, whirlpool baths, vaporizers, room humidifiers, hot tubs or other types of tubs, home UV or other light units, home blood testing equipment and supplies (except diabetic equipment and supplies, and home anticoagulation meters). This plan covers Emergency Care servicesthe 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. 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. 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 replace or substitute all or part of an internal body part, including suppliescontiguous 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 charges benefit limit will apply. 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 patient observationhome use. In accordance with R.I. General Law §27-20-56, Facility costs, and medical screening exams that are required this plan covers enteral formula taken orally for the stabilization treatment of: • malabsorption caused by Crohn’s Disease; • ulcerative colitis; • gastroesophageal reflux; • chronic intestinal pseudo obstruction; and • inherited diseases of a patient experiencing a Medical Emergencyamino acids and organic acids. Emergency Care services provided by In-Network and Out-of-Network facilities Food products modified to be low protein are covered by this plan for the treatment of inherited diseases of amino acids and include Medically Necessary detoxification servicesorganic 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, including Chemical Dependency detoxification. Prescription medications associated with a Medical Emergency, including those purchased in a foreign country, supplies are also covered. 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. 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.

Dialysis Services. This plan covers dialysis services and supplies provided when you are inpatient, outpatient or in your home and under the supervision of a dialysis program. Dialysis services for chronic renal failure supplies provided in your home are covered when provided in a Hospital, an outpatient facility or in the home. Pre-Authorization is required for dialysis performed in an outpatient facility or at homeas durable medical equipment. 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. DME is Medical Equipment, including mobility enhancing equipment that which: • can withstand repeated use, ; • is primarily and customarily used to serve a medical purpose; • is not disposable, is used for useful to a medically therapeutic purpose, is generally not useful person in the absence of Illness an illness or Injury, injury; and • is appropriate for use in the home. DME may be rented or purchased at includes supplies necessary for the discretion effective use of the plan; the total cost of any DME rental may not exceed the purchase price. Repair or replacement is covered only when needed due to normal use, a change in the patient’s physical condition, or the growth of a child. Duplicate items are not covered. When more than one option exists, benefits will be limited to the least expensive model or item appropriate to treat the patient’s covered condition. Examples of DME include: • Crutches; • Oxygen and equipment for administering oxygen; • Xxxxxxx; and • Wheelchairs. This benefit also covers: • Breast Pumps; • Diabetic monitoring equipment, such as the initial cost of an insulin pump and supplies related to such equipment. Diabetic supplies such as insulin, syringes, needles, lancets, test strips, etc., are covered under the Prescription Drugs benefit; • Medical supplies needed for the treatment or care of an appropriate covered condition, including but not limited to compression garments, mastectomy bras and supplies, and ostomy supplies. Please note that supplies available over-the-counter are excluded from this benefit; • Limited Medical Vision Hardware: Benefits are provided for vision hardware for the following medical conditions of the eye: corneal ulcer, bullous keratopathy, recurrent erosion of cornea, tear film insufficiency, aphakia, Xxxxxxxx's disease, congenital cataract, corneal abrasion and keratoconus; and • State sales tax for durable medical and mobility enhancing equipment. Surgically implanted devices may be covered under the appropriate surgical benefit and are not considered DME. Benefits for DME are determined by the type of device and its intended use, and not by the entity that provides or bills for the device. DME and medical supply charges listed below are not covered: • Biofeedback equipment; • Equipment or supplies whose primary purpose is preventing Illness or Injury; • Exercise equipment; • Eyeglasses or contact lenses for conditions not listed as a covered medical condition or covered under the Pediatric Vision benefit, including routine eye care; • Items not manufactured exclusively for the direct therapeutic treatment of an Illness or Injury; • Items primarily for comfort, convenience, sports/recreational activities or use outside the home; • Off-the shelf shoe inserts and orthopedic shoes; • Over-the-counter items (except Medically Necessary crutches, walkers, standard wheelchairs, diabetic supplies and ostomy supplies are covered); • Personal comfort items including but not limited to air conditioners, lumbar rolls, heating pads, diapers, or personal hygiene items; • Phototherapy devices related to seasonal affective disorder; • Supportive equipment/environmental adaptive items including, but not limited to, hand rails, chair lifts, ramps, shower chairs, commodes, car lifts, elevators, and modifications made to the patient’s home, place of work, or vehicle; or • The following Medical Equipment/supplies: regular or special car seats or strollers, push chairs, air filtration/purifier systems or supplies, water purifiers, allergenic mattresses, orthopedic or other special chairs, pillows, bed-wetting training equipment, whirlpool baths, vaporizers, room humidifiers, hot tubs or other types of tubs, home UV or other light units, home blood testing equipment and supplies (except diabetic equipment and supplies, and home anticoagulation meters). This plan covers Emergency Care servicesthe 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. 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. 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 replace or substitute all or part of an internal body part, including suppliescontiguous 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 charges benefit limit will apply. 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 patient observationhome use. In accordance with R.I. General Law §27-20-56, Facility costs, and medical screening exams that are required this plan covers enteral formula taken orally for the stabilization treatment of: • malabsorption caused by Crohn’s Disease; • ulcerative colitis; • gastroesophageal reflux; • chronic intestinal pseudo obstruction; and • inherited diseases of a patient experiencing a Medical Emergencyamino acids and organic acids. Emergency Care services provided by In-Network and Out-of-Network facilities Food products modified to be low protein are covered by this plan for the treatment of inherited diseases of amino acids and include Medically Necessary detoxification servicesorganic 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, including Chemical Dependency detoxification. Prescription medications associated with a Medical Emergency, including those purchased in a foreign country, supplies are also covered. 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. 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 enrolled in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider. 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.