Common use of Discharge Planning Clause in Contracts

Discharge Planning. If further care at home or in another facility is appropriate following discharge from the Hospital, Blue Shield or Blue Shield’s MHSA will work with the Member, the attending Physician and the Hospital discharge planners to determine the most appropriate and cost effective way to provide this care. Case Management The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. Palliative Care Services In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Discharge Planning. If further care at home or in another facility is appropriate following discharge from the Hospital, Blue Shield or Blue Shield’s MHSA will work with the Member, the attending Physician and the Hospital discharge planners to determine the most appropriate and cost effective way to provide this care. Case Management The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. Palliative Care Services In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Discharge Planning. If further care at home or in another facility is appropriate following discharge from the Hospital, Blue Shield or Blue Shield’s MHSA will work with the Member, the attending Physician and the Hospital discharge planners to determine the most appropriate and cost effective way to provide this care. Case Management The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. Palliative Care Services In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Acupuncture Benefits Benefits are provided for acupuncture evaluation and treatment by a Doctor of Medicine or licensed acupuncturist. Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification. Allergy Testing and Treatment Benefits Benefits are provided for allergy testing and treatment, including allergy serum. Ambulance Benefits Benefits are provided for (1) ambulance services (ground and air) when used to transport a Member from place of illness or injury to the closest medical facility where appropriate treatment can be received; or (2) authorized ambulance transportation to or from Covered Services. Ambulatory Surgery Center Benefits Benefits are provided for surgery performed in an Ambulatory Surgery Center.

Discharge Planning. If further care at home or in another facility is appropriate following discharge from the Hospital, Blue Shield or Blue Shield’s MHSA will work with the Member, the attending Physician and the Hospital discharge planners to determine the most appropriate and cost effective way to provide this care. Case Management The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. Palliative Care Services In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. Unless otherwise authorized by Blue Shield or the MHSA, all Benefits must be provided by Participating Providers or MHSA Participating Providers. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- cost-effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Discharge Planning. If further care at home or in another facility is appropriate following discharge from the Hospital, Blue Shield or Blue Shield’s MHSA will work with the Member, the attending Physician and the Hospital discharge planners to determine the most appropriate and cost effective way to provide this care. Case Management The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. Palliative Care Services In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Acupuncture Benefits Benefits are provided for acupuncture evaluation and treatment by a Doctor of Medicine or licensed acupuncturist. Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification. Allergy Testing and Treatment Benefits Benefits are provided for allergy testing and treatment, including allergy serum. Ambulance Benefits Benefits are provided for (1) ambulance services (ground and air) when used to transport a Member from place of illness or injury to the closest medical facility where appropriate treatment can be received; or (2) authorized ambulance transportation to or from Covered Services.

Discharge Planning. If further care at home or in another facility is appropriate following discharge from the Hospital, Blue Shield or Blue Shield’s MHSA will work with the Member, the attending Physician and the Hospital discharge planners to determine the most appropriate and cost effective way to provide this care. Case Management The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. Palliative Care Services In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the treatment can be received; or (2) authorized ambulance transportation to or from Covered Services. Ambulatory Surgery Center Benefits Benefits are provided for surgery performed in an Ambulatory Surgery Center. illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.