Page 33 - QCS.19 SPD - PPO

· Any other services that are consistent with the follow-up care recommended in the protocols and
guidelines developed by national organizations that represent pediatric, obstetric, and nursing
professionals.

Benefits apply to services provided in a medical setting or through home health care visits. Benefits apply to a
home health care visit only if the health care provider who conducts the visit is knowledgeable and experienced in
maternity and newborn care.

When the mother and her Physician decide to shorten the length of the Inpatient Stay to less than the number of
hours required under this maternity benefit and the newborn well baby care benefit, we will provide Benefits for all
follow-up care that is provided within 72 hours after discharge.

When the mother or newborn receives at least the number of hours of inpatient care required to be covered, we
will only provide Benefits for follow-up care that is determined to be Medically Necessary by the health care
provider responsible for discharging the mother or newborn.

Newborn Well Baby Care

Benefits for newborn well baby care are provided on the same basis as Benefits for a Sickness.
We will provide Benefits for newborn well baby care that meets the definition of a preventive care service.

We will provide Benefits for newborn well baby care according to:
· Guidelines established by the American Academy of Pediatrics; or

· Any other established professional medical association.
Newborn well baby care services include:

· Hospital nursery room, board and miscellaneous services and supplies provided and billed by the
Hospital on its own behalf;

· Physician charges for circumcision; and
· Physician charges for the first routine exam of the child before discharge from the Hospital.
We will provide Benefits for newborn well baby care for up to:

· 48 hours of the child's life for a vaginal delivery; or

· 96 hours of the child's life for a cesarean section,
However, we will never provide benefits for newborn well baby care after the mother is discharged from the
Hospital.

For multiple births, the 48 or 96 hours begin at the time of the last child's delivery.
If delivery happens outside of a Hospital, the 48 or 96 hours begin when the newborn is admitted to the Hospital
for the birth. A determination of whether to admit the newborn to a Hospital is made by the Physician.
For purposes of this provision, a Physician is a person who is:
· Licensed under applicable state law to provide pediatric care;

· Directly responsible for providing pediatric care to the child; and

· Providing the care.
IMPORTANT: To provide coverage for the child, (Including Newborn Well Baby Care), you must enroll the child
under the plan as required under adding new dependents in Section 2, Introduction sub-section When Coverage
Begins. Failure to enroll will result in no coverage for the newborn under this plan.

Page 28 Section 5- Additional Coverage Details
PPO - 2017