Common use of Essential Health Benefits Clause in Contracts

Essential Health Benefits. Benefits defined by the Secretary of Health and Human Services that shall include at least the following general categories: ambulatory patient services, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and services, including oral and vision care. The designation of benefits as essential shall be consistent with the requirements and limitations set forth under the Affordable Care Act and applicable regulations as determined by the Secretary of Health and Human Services. Experimental/Investigational Services Services that meet one or more of the following:  A drug or device which cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and does not have approval on the date the service is provided  It is subject to oversight by an Institutional Review Board  There is no reliable evidence showing that the service is effective in clinical diagnosis, evaluation, management or treatment of the condition  It is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety or efficacy  Evaluation of reliable evidence shows that more research is necessary before the service can be classified as equally or more effective than conventional therapies Reliable evidence means only published reports and articles in authoritative medical and scientific literature, and assessments. Facility (Medical Facility) A hospital, skilled nursing facility, approved treatment facility for chemical dependency, state-approved institution for treatment of mental or psychiatric conditions, or hospice. Not all health care facilities are covered under this contract. Home Medical Equipment (HME) Equipment ordered by a provider for everyday or extended use to treat an illness or injury. HME may include: oxygen equipment, wheelchairs or crutches. Home Health Agency An organization that provides covered home health services to a member. Hospice A facility or program designed to provide a caring environment for supplying the physical and emotional needs of the terminally ill.

Essential Health Benefits. Benefits defined by the Secretary of Health and Human Services that shall include at least the following general categories: ambulatory patient services, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and services, including oral and vision care. The designation of benefits as essential shall be consistent with the requirements and limitations set forth under the Affordable Care Act and applicable regulations as determined by the Secretary of Health and Human Services. Experimental/Investigational Services Services that meet one or more of the following:  • A drug or device which cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and does not have approval on the date the service is provided  • It is subject to oversight by an Institutional Review Board  • There is no reliable evidence showing that the service is effective in clinical diagnosis, evaluation, management or treatment of the condition  • It is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety or efficacy  • Evaluation of reliable evidence shows that more research is necessary before the service can be classified as equally or more effective than conventional therapies Reliable evidence means only published reports and articles in authoritative medical and scientific literature, and assessments. Facility (Medical Facility) A hospital, skilled nursing facility, approved treatment facility for chemical dependency, state-approved institution for treatment of mental or psychiatric conditions, or hospice. Not all health care facilities are covered under this contract. Home Medical Equipment (HME) Equipment ordered by a provider for everyday or extended use to treat an illness or injury. HME may include: oxygen equipment, wheelchairs or crutches. Home Health Agency An organization that provides covered home health services to a member. Hospice A facility or program designed to provide a caring environment for supplying the physical and emotional needs of the terminally ill.

Essential Health Benefits. Benefits defined by the Secretary of Health and Human Services that shall include at least the following general categories: ambulatory patient services, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and services, including oral and vision care. The designation of benefits as essential shall be consistent with the requirements and limitations set forth under the Affordable Care Act and applicable regulations as determined by the Secretary of Health and Human Services. Experimental/Investigational Services Services that meet one or more of the following:  • A drug or device which cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and does not have approval on the date the service is provided  • It is subject to oversight by an Institutional Review Board  • There is no reliable evidence showing that the service is effective in clinical diagnosis, evaluation, management or treatment of the condition  • It is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety or efficacy  • Evaluation of reliable evidence shows that more research is necessary before the service can be classified as equally or more effective than conventional therapies Reliable evidence means only published reports and articles in authoritative medical and scientific literature, and assessments. Facility (Medical Facility) A hospital, skilled nursing facility, approved treatment facility for chemical dependency, state-state- approved institution for treatment of mental or psychiatric conditions, or hospice. Not all health care facilities are covered under this contract. Home Medical Equipment (HME) Equipment ordered by a provider for everyday or extended use to treat an illness or injury. HME may include: oxygen equipment, wheelchairs or crutches. Home Health Agency An organization that provides covered home health services to a member. Hospice A facility or program designed to provide a caring environment for supplying the physical and emotional needs of the terminally ill.

Essential Health Benefits. Benefits defined by the Secretary of Health and Human Services that shall include at least the following general categories: ambulatory patient services, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and services, including oral and vision care. The designation of benefits as essential shall be consistent with the requirements and limitations set forth under the Affordable Care Act and applicable regulations as determined by the Secretary of Health and Human Services. Experimental/Investigational Services Services that meet one or more of the following:  A drug or device which cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and does not have approval on the date the service is provided  It is subject to oversight by an Institutional Review Board  There is no reliable evidence showing that the service is effective in clinical diagnosis, evaluation, management or treatment of the condition  It is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety or efficacy  Evaluation of reliable evidence shows that more research is necessary before the service can be classified as equally or more effective than conventional therapies Reliable evidence means only published reports and articles in authoritative medical and scientific literature, and assessments. Facility (Medical Facility) A hospital, skilled nursing facility, approved treatment facility for chemical dependency, state-state- approved institution for treatment of mental or psychiatric conditions, or hospice. Not all health care facilities are covered under this contract. Home Medical Equipment (HME) Equipment ordered by a provider for everyday or extended use to treat an illness or injury. HME may include: oxygen equipment, wheelchairs or crutches. Home Health Agency An organization that provides covered home health services to a member. Hospice A facility or program designed to provide a caring environment for supplying the physical and emotional needs of the terminally ill.