Common use of Early Intervention Services (EIS) Clause in Contracts

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $150 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 Not Covered Hearing diagnostic testing $30 Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $150 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 30 Not Covered Hearing diagnostic testing $30 0% Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 020% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 020% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% Not Covered Infertility Services* Services Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization infertility treatment cycles will be covered per plan year with a total of eight (8) in-vitro fertilization infertility treatment cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $150 200 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 Not Covered Hearing diagnostic testing $30 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; 21, the benefit limit is $700 per hearing aid for a member 19 21 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% Not Covered Infertility Services* Services Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization infertility treatment cycles will be covered per plan year with a total of eight (8) in-vitro fertilization infertility treatment cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $150 200 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 Not Covered Hearing diagnostic testing $30 0% Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $150 200 The level of coverage is the same as network provider. Experimental and Investigational Services Coverage varies based on type of service. Hearing Services Hearing exam $40 50 Not Covered Hearing diagnostic testing $30 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Home Health Care* Intermittent skilled services when billed by a home health care agency. 020% - After deductible Not Covered Hospice Care Inpatient/in your home. When provided by an approved hospice care program. 020% - After deductible Not Covered Human Leukocyte Antigen Testing Human leukocyte antigen testing 0% Not Covered Infertility Services* Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered