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. Asthma management 0% Not Covered Hospital emergency room $200 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21, the benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) infertility treatment cycles will be covered per plan year with a total of eight (8) 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. Asthma management 0% Not Covered Hospital emergency room $200 150 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 Not Covered Hearing diagnostic testing 0% $30 Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21, 19; the benefit limit is $700 per hearing aid for a member 21 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) infertility treatment in-vitro fertilization cycles will be covered per plan year with a total of eight (8) infertility treatment 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. Asthma management 0% Not Covered Hospital emergency room $200 150 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 30 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21, the benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) infertility treatment in-vitro fertilization cycles will be covered per plan year with a total of eight (8) infertility treatment 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. Asthma management 0% Not Covered Hospital emergency room $200 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 50 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21, 19; the benefit limit is $700 per hearing aid for a member 21 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 020% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 020% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) infertility treatment in-vitro fertilization cycles will be covered per plan year with a total of eight (8) infertility treatment 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. Asthma management 0% Not Covered Hospital emergency room $200 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 21, 19; the benefit limit is $700 per hearing aid for a member 21 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) infertility treatment in-vitro fertilization cycles will be covered per plan year with a total of eight (8) infertility treatment 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. Asthma management 0% Not Covered Hospital emergency room $200 150 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 30 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 21, 19; the benefit limit is $700 per hearing aid for a member 21 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 020% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 020% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) infertility treatment cycles will be covered per plan year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. 20% - After deductible Not Covered