Page 64 - Aegion Value Plan SPDs
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Should the newborn require other than routine nursery care, the baby will be admitted to the Hospital in his
or her own name. See “Changing Coverage (Adding a Dependent)” to add a newborn to Your coverage.
Under federal law, the Plan may not restrict the length of stay to less than the 48/96-hour periods or require
Precertification for either length of stay. The length of hospitalization which is Medically Necessary will be
determined by the Member’s attending Physician in consultation with the mother. Should the mother or
infant be discharged before 48 hours following a normal delivery or 96 hours following a cesarean section
delivery, the Member will have access to two post-discharge follow-up visits within the 48- or 96-hour period.
These visits may be provided either in the Physician’s office or in the Member’s home by a Home Health
Care Agency. The determination of the medically appropriate place of service and the type of Provider
rendering the service will be made by the Member’s attending Physician.
Elective Abortion - Regardless of Medical Necessity, the Plan pays Covered Services from a Provider for
elective abortion accomplished by any means.
Contraceptive Benefits
Benefits include oral contraceptive Drugs, injectable contraceptive Drugs and patches. Benefits also
include contraceptive devices such as diaphragms, intra uterine devices (IUDs), and implants. Certain
contraceptives are covered under the “Preventive Care” benefit. Please see that section for further details.
Sterilization Services
Benefits include sterilization services and services to reverse a non-elective sterilization that resulted from
an illness or injury. Reversals of elective sterilizations are not covered. Sterilizations for women are
covered under the “Preventive Care” benefit.
Mental Health (Behavioral Health) / Substance Abuse Services
Coverage for the diagnosis and treatment of Behavioral Health Care and Substance Abuse
Treatment on an Inpatient or Outpatient basis will not be subject to Deductibles or Coinsurance
provisions that are less favorable than the Deductibles or Coinsurance provisions that apply to a
physical illness as covered under this Benefit Booklet.
Covered Services include the following:
Inpatient Services in a Hospital or any facility that must be covered by law. Inpatient benefits include
psychotherapy, psychological testing, electroconvulsive therapy, and Detoxification.
Residential Treatment in a licensed Residential Treatment Center that offers individualized and
intensive treatment and includes:
observation and assessment by a psychiatrist weekly or more often; and
rehabilitation, therapy, and education.
Outpatient Services including office visits, therapy and treatment, Partial Hospitalization/Day
Treatment Programs, and Intensive Outpatient Programs
Online Visits when available in Your area. Covered Services include a medical visit with the Doctor
using the internet by a webcam, chat or voice. Online visits do not include reporting normal lab or other
test results, requesting office visits, getting answers to billing, insurance coverage or payment
questions, asking for referrals to doctors outside the online care panel, benefit precertification, or Doctor
to Doctor discussions.
Examples of Providers from whom You can receive Covered Services include:
Psychiatrist,
Psychologist,
Licensed clinical social worker (L.C.S.W.),
Mental health clinical nurse specialist,
Licensed marriage and family therapist (L.M.F.T.),
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or her own name. See “Changing Coverage (Adding a Dependent)” to add a newborn to Your coverage.
Under federal law, the Plan may not restrict the length of stay to less than the 48/96-hour periods or require
Precertification for either length of stay. The length of hospitalization which is Medically Necessary will be
determined by the Member’s attending Physician in consultation with the mother. Should the mother or
infant be discharged before 48 hours following a normal delivery or 96 hours following a cesarean section
delivery, the Member will have access to two post-discharge follow-up visits within the 48- or 96-hour period.
These visits may be provided either in the Physician’s office or in the Member’s home by a Home Health
Care Agency. The determination of the medically appropriate place of service and the type of Provider
rendering the service will be made by the Member’s attending Physician.
Elective Abortion - Regardless of Medical Necessity, the Plan pays Covered Services from a Provider for
elective abortion accomplished by any means.
Contraceptive Benefits
Benefits include oral contraceptive Drugs, injectable contraceptive Drugs and patches. Benefits also
include contraceptive devices such as diaphragms, intra uterine devices (IUDs), and implants. Certain
contraceptives are covered under the “Preventive Care” benefit. Please see that section for further details.
Sterilization Services
Benefits include sterilization services and services to reverse a non-elective sterilization that resulted from
an illness or injury. Reversals of elective sterilizations are not covered. Sterilizations for women are
covered under the “Preventive Care” benefit.
Mental Health (Behavioral Health) / Substance Abuse Services
Coverage for the diagnosis and treatment of Behavioral Health Care and Substance Abuse
Treatment on an Inpatient or Outpatient basis will not be subject to Deductibles or Coinsurance
provisions that are less favorable than the Deductibles or Coinsurance provisions that apply to a
physical illness as covered under this Benefit Booklet.
Covered Services include the following:
Inpatient Services in a Hospital or any facility that must be covered by law. Inpatient benefits include
psychotherapy, psychological testing, electroconvulsive therapy, and Detoxification.
Residential Treatment in a licensed Residential Treatment Center that offers individualized and
intensive treatment and includes:
observation and assessment by a psychiatrist weekly or more often; and
rehabilitation, therapy, and education.
Outpatient Services including office visits, therapy and treatment, Partial Hospitalization/Day
Treatment Programs, and Intensive Outpatient Programs
Online Visits when available in Your area. Covered Services include a medical visit with the Doctor
using the internet by a webcam, chat or voice. Online visits do not include reporting normal lab or other
test results, requesting office visits, getting answers to billing, insurance coverage or payment
questions, asking for referrals to doctors outside the online care panel, benefit precertification, or Doctor
to Doctor discussions.
Examples of Providers from whom You can receive Covered Services include:
Psychiatrist,
Psychologist,
Licensed clinical social worker (L.C.S.W.),
Mental health clinical nurse specialist,
Licensed marriage and family therapist (L.M.F.T.),
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