Page 31 - QCS.19 SPD - HSA

· Craniofacial anomalies whose abnormal or absent ear canals prevent the use of a wearable Hearing Aid;
or
· Hearing loss severe enough that it would not be remedied by a wearable Hearing Aid.

Benefits for BAHA are limited to one per Covered Person during the entire period of time the Covered Person is
enrolled under the Plan and include repairs and/or replacement only if the BAHA malfunctions

Home Health Care

Services received from a Home Health Agency that all of the following:
· Ordered by a Physician; and

· Provided in your home by a registered nurse, therapist, or provided by either a home health aide or
licensed practical nurse and supervised by a registered nurse, and
· Provided on a part-time Intermittent Care schedule.

· Provided when skilled care is required.
Hospice Care

Hospice care that is recommended by a Physician. Hospice care is an integrated program that provides comfort
and support services for the Terminally ill. It includes the following:
· Physical, psychological, social and spiritual care for the Terminally ill person.

· Short-term grief counseling for immediate family members while you are receiving hospice care.
Benefits are available when you receive hospice care from a licensed hospice agency.

Hospital - Inpatient Stay

Services and supplies provided during an Inpatient Stay in a Hospital. Benefits are available for:
· Supplies and non-Physician services received during the Inpatient Stay; and

· Room and board in a Semi-Private Room
Lab, X-Ray and Diagnostic

Services for Sickness and Injury-related diagnostic purposes, received at a Hospital or Alternate Facility or in a
Physician's office include, but are not limited to:

· Lab and radiology/X-ray; and
· Mammography.

Benefits include:
· The physician and facility charge; and

· The charge for supplies and equipment.
Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services.

Major Diagnostic and Imaging

Services for CT scans, PET scans, MRI, MRA, nuclear medicine, and major diagnostic services received at a
Hospital or Alternate Facility or in a Physician's office.

Benefits include:
· The physician and facility charge; and

· The charge for supplies and equipment

Page 26 Section 5- Additional Coverage Details
HSA - 2017