Home Care Advocacy Program Sample Clauses

Home Care Advocacy Program. (a) The Home Care Advocacy Program (HCAP) will continue to provide services in the home for medically necessary private duty nursing, home infusion therapy and durable medical equipment under the partici- pating provider component of the Empire Plan. (b) 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 will receive reimbursement at 50 per- cent of the HCAP allowance for all services, equipment and supplies upon satisfying the basic medical an- nual deductible. In addition, the basic medical out-of-pocket maximum will not apply to HCAP designated services, equipment and supplies. All other HCAP non-network benefit provisions will remain. (c) External mastectomy prostheses are a paid-in-full benefit, not subject to deductible or co-insurance. Coverage will be provided by the medical carrier as follows: • Benefits are available for one single/double mastectomy prosthesis in a calendar year. • Pre-certification through the HCAP is required for any single external prosthesis costing $1,000 or more. If a less expensive prosthesis can meet the individual’s functional needs, benefits will be available for the most cost-effective alternative.
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