Outpatient If you receive dialysis services in a hospital's outpatient unit or in a dialysis facility, we cover the use of the treatment room, related supplies, solutions, drugs, and the use of the dialysis machine. In Your Home If you receive dialysis services in your home and the services are under the supervision of a hospital or outpatient facility dialysis program, we cover the purchase or rental (whichever is less, but never to exceed our allowance for purchase) of the dialysis machine, related supplies, solutions, drugs, and necessary installation costs. Related Exclusions If you receive dialysis services in your home, this agreement does NOT cover: • installing or modifying of electric power, water and sanitary disposal or charges for these services; • moving expenses for relocating the machine; • installation expenses not necessary to operate the machine; or • training you or members of your family in the operation of the machine. This agreement does NOT cover dialysis services when received in a doctor's office.
Emergency Medical Treatment I grant the Releasees permission to authorize emergency medical treatment as they deem appropriate, and agree that such action by the Releasees shall be subject to the terms of this Agreement. I understand and agree that the Releasees assume no responsibility for any injury or damage that might result from such emergency medical treatment.
Behavioral Health Services – Mental Health and Substance Use Disorder Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Cardiac Rehabilitation Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible Chiropractic Services In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Dental Services - Accidental Injury (Emergency) Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services- Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. 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% - After deductible The level of coverage is the same as network provider. Education - Asthma Asthma management 0% - After deductible 40% - After deductible Emergency Room Services Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.
Medical Treatment Undersigned understands that the Released Parties do not have medical personnel available at the location of the activities. Undersigned hereby grants the Released Parties permission to administer first aid or to authorize emergency medical treatment, if necessary. Undersigned understands and agrees that any such action by the Released Parties shall be subject to the terms of this agreement and release, including any liability arising from the negligence of the Released Parties when administering first aid or authorizing others to do so. Undersigned understands and agrees that the Released Parties do not assume responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment.
Consent to Transportation and Medical Treatment I consent to the use of first aid treatment and the use of generic and over-the-counter medications and treatments as directed by manufacturer labels, whether administered by the Released Parties or first aid personnel. In an emergency, I understand the Released Parties may try to contact the individual listed below as an emergency contact. If an emergency contact cannot be reached promptly, I hereby authorize the Released Parties to act as an agent for me to consent to any examination, testing, x-rays, medical, dental or surgical treatment for me as advised by a physician, dentist or other health care provider. This includes, but is not limited to, my assessment, evaluation, medical care and treatment, anesthesia, hospitalization, or other health care treatment or procedure as advised by a physician, dentist or other health care provider. I also authorize the Released Parties to arrange for transportation of me as deemed necessary and appropriate in their discretion. I, the Volunteer, do hereby release, forever discharge and hold harmless the Released Parties from any liability, claim, demand, and action whatsoever brought by me or on my behalf which arises or may hereafter arise on account of any transportation, first aid, assessment, care, treatment, response or service rendered in connection with my Activities with any of the Released Parties. If the Volunteer is less than 18 years of age, the parent(s) having legal custody and/or the legal guardian(s) of the Volunteer also hereby release, forever discharge and hold harmless the Released Parties from any liability, claim, demand and action whatsoever brought by such volunteer or on his/her behalf which arises or may hereafter arise on account of the decision by any representative or agent of the Released Parties to exercise the power to transport, administer first aid, and consent to assessment, examination, x-rays, medical, dental, surgical or other such health care treatment as set forth in the Parental Authorization for Treatment of, and Travel With, a Minor Child.
Community Mental Health Center Services Assertive Community Treatment Staffing Full Time Equivalents Community Mental Health Center March 2021 December 2020 Nurse Masters Level Clinician/or Functional Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner 01 Northern Human Services - Wolfeboro 1.00 0.00 0.00 0.57 6.81 0.27 8.27 0.25 01 Northern Human Services - Berlin 0.34 0.31 0.00 0.00 3.94 0.14 4.17 0.14 01 Northern Human Services - Littleton 0.00 0.14 0.00 0.00 3.28 0.29 3.31 0.29 02 West Central Behavioral Health 0.60 1.00 0.00 0.00 5.40 0.30 5.90 0.30 03 Lakes Region Mental Health Center 1.00 1.00 0.00 1.00 5.00 0.40 7.00 0.38 04 Riverbend Community Mental Health Center 0.50 1.00 6.90 1.00 10.40 0.50 10.50 0.50 05 Monadnock Family Services 1.91 2.53 0.00 1.12 11.17 0.66 10.32 0.62 06 Greater Nashua Mental Health 1 1.00 1.00 3.00 1.00 7.65 0.15 8.50 0.15 06 Greater Nashua Mental Health 2 1.00 1.00 4.00 1.00 8.65 0.15 8.50 0.15 07 Mental Health Center of Greater Manchester-CTT 1.33 10.64 2.00 0.00 19.95 1.17 21.61 1.21 07 Mental Health Center of Greater Manchester-MCST 1.33 9.31 3.33 1.33 19.95 1.17 25.27 1.21 08 Seacoast Mental Health Center 1.00 1.10 5.00 1.00 10.10 0.60 10.10 0.60 09 Community Partners 0.50 0.00 3.40 0.88 7.28 0.70 7.41 0.70 10 Center for Life Management 1.00 0.00 2.28 1.00 6.71 0.46 6.57 0.46 Total 12.51 29.03 29.91 9.33 126.29 6.96 137.43 6.96 2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies Community Mental Health Center Substance Use Disorder Treatment Housing Assistance Supported Employment March 2021 December 2020 March 2021 December 2020 March 2021 December 2020 01 Northern Human Services - Wolfeboro 1.27 1.27 5.81 6.30 0.00 0.40 01 Northern Human Services - Berlin 0.74 0.74 3.29 3.29 0.00 0.23 01 Northern Human Services - Littleton 1.43 1.29 2.14 2.14 1.00 1.00 02 West Central Behavioral Health 0.20 0.20 4.00 0.40 0.60 0.60 03 Lakes Region Mental Health Center 1.00 3.00 5.00 7.00 2.00 2.00 04 Riverbend Community Mental Health Center 0.50 0.50 9.40 9.50 0.50 0.50 05 Monadnock Family Services 1.69 1.62 4.56 4.48 0.95 1.18 06 Greater Nashua Mental Health 1 6.15 7.15 5.50 6.50 1.50 1.50 06 Greater Nashua Mental Health 2 5.15 5.15 6.50 6.50 0.50 0.50 07 Mental Health Center of Greater Manchester-CCT 14.47 15.84 13.96 15.62 2.66 2.66 07 Mental Health Center of Greater Manchester-MCST 6.49 7.86 15.29 19.28 1.33 2.66 08 Seacoast Mental Health Center 2.00 2.00 5.00 5.00 1.00 1.00 09 Community Partners 1.20 1.20 4.50 4.50 1.00 1.00 10 Center for Life Management 2.14 2.14 5.42 5.28 0.29 0.29 Total 44.43 49.96 90.37 99.39 13.33 15.52 Revisions to Prior Period: None. Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report. Notes: Data compiled 04/26/2021. For 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, but rather the quantity of staff available to provide each service. If staff are trained to provide multiple service types, their entire FTE value is credited to each service type.
Surgery Services and Mastectomy Related Treatment This plan provides benefits for mastectomy surgery and mastectomy-related services in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Law 27-20-29 et seq. For the member receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician, physician assistant, or an advance practice registered nurse and the patient, for: • all stages of reconstruction of the breast on which the mastectomy was performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance; • prostheses; and • treatment of physical complications at all stages of the mastectomy, including lymphedema. See the Summary of Medical Benefits for the amount you pay.
Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services.
Mental Health Services This agreement covers medically necessary services for the treatment of mental health disorders in a general or specialty hospital or outpatient facilities that are: • reviewed and approved by us; and • licensed under the laws of the State of Rhode Island or by the state in which the facility is located as a general or specialty hospital or outpatient facility. We review network and non-network programs, hospitals and inpatient facilities, and the specific services provided to decide whether a preauthorization, hospital or inpatient facility, or specific services rendered meets our program requirements, content and criteria. If our program content and criteria are not met, the services are not covered under this agreement. Our program content and criteria are defined below.
Substance Abuse Treatment Information Substance abuse treatment information shall be maintained in compliance with 42 C.F.R. Part 2 if the Party or subcontractor(s) are Part 2 covered programs, or if substance abuse treatment information is received from a Part 2 covered program by the Party or subcontractor(s).
