Empire Plan Enhancements. Prosthetic wigs shall be a covered basic medical benefit and shall be reimbursed up to a lifetime maxi- mum of $1,500 not subject to deductible or co-insurance. • The Empire Plan medical carrier shall contract with Diabetes Education Centers accredited by the American Diabetes Education Recognition Program. • The lifetime maximum for travel and lodging expenses for the CRS program is eliminated. • An annual diabetic shoe benefit will be available through the Home Care Advocacy Program under the medical carrier as follows: — Network Coverage—benefits paid at 100 percent with no out-of-pocket cost up to a $500 maximum per year. — Non-network Coverage—For diabetic shoes obtained other than through the HCAP, reimbursement will be made under the basic medical component of the Empire Plan, subject to deductible and the re- mainder paid at 75 percent of the network allowance up to a maximum of $500.
Empire Plan Enhancements. In addition to the basic Empire Plan benefits, the Empire Plan for enrollees shall include:
(a) The annual and lifetime maximum for each covered person under the basic medical component shall be unlimited.
(b) Routine pediatric care including all preventive pediatric immunizations, both oral and injectable, shall be considered a covered medical expense under the participating provider component and the basic medical component. Influenza vaccine shall be on the list of pediatric immunizations, subject to appropriate protocols, under the participating provider and basic medical components of the Empire Plan
(c) The newborn care allowance under the basic medical component shall not be subject to deductible or coinsurance.
(d) Office visit charges by participating providers for well childcare shall be excluded from the office visit copayment.
(e) Charges by participating providers for professional services for allergen immunotherapy in the prescribing physician's office or institution and chronic care services for chemotherapy, radiation therapy, or hemodialysis shall be excluded from the office visit copayment.
(f) In the event that there is both an office visit charge and office surgery charge by a participating provider in any single visit, the covered individual shall be subject to a single copayment.
(g) Outpatient radiology services and laboratory services rendered during a single visit by the same participating provider shall be subject to a single copayment.
(h) The Home Care Advocacy Program (HCAP), shall continue to provide services in the home for medically necessary private duty nursing, home infusion therapy and durable medical equipment under the participating provider component of the Empire Plan.
(1) Effective April 1, 2010 language under the Home Care Advocacy Program for the purchase of Durable Medical Equipment shall be modified as follows:
(2) HCAP non-network benefit for individuals who fail to have medically necessary designated HCAP services and supplies pre-certified by calling HCAP and/or individuals who use a non-network provider shall be subject to the following provisions:
(i) All professional component charges associated with ancillary services billed by the outpatient department of a hospital for emergency care for an accident or for sudden onset of an illness (medical emergency) shall be a covered expense under the participating provider or the basic medical component of the Empire Plan not subject to deductible or coinsurance, w...
Empire Plan Enhancements. In addition to the basic Empire Plan benefits, the Empire Plan for enrollees shall include:
