Page 38 - QCS.19 SPD - PPO

Habilitative services provided in your home by a Home Health Agency are provided as described under Home
Health Care.

For purposes of this Benefit, "habilitative services" means health care services that help a person keep, learn or
improve skills and functioning for daily living.
Benefits for Durable Medical Equipment and prosthetic devices, when used as a part of habilitative services, are
described under Durable Medical Equipment and Prosthetic Devices.
Other than as described under Habilitative Services above, please note that we will pay Benefits for speech
therapy for the treatment of disorders of speech, language, voice, communication and auditory processing only
when the disorder results from Injury, stroke, cancer, Congenital Anomaly, or Autism Spectrum Disorder. We will
pay Benefits for cognitive rehabilitation therapy only when Medically Necessary following a post-traumatic brain
Injury or cerebral vascular accident.

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

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

· Room and board in a Semi-Private Room
Please note that Benefits are available only if both of the following are true:

· If the first confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility was or will be a cost
effective option to an Inpatient Stay in a Hospital; and

· You will receive skilled care services that are not primarily Custodial Care.
Surgery - Outpatient Facility

Surgery and related services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician’s
office.

Benefits include certain scopic procedures. Examples of surgical scopic procedures include:
· Arthroscopy,

· Laparoscopy,
· Bronchoscopy,

· Hysteroscopy.
Benefits under this provision include the facility charge and the charge for supplies and equipment.

Therapeutic Treatments

Therapeutic treatments received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office
include:

· Dialysis (both hemodialysis and peritoneal dialysis,
· Intravenous chemotherapy or other intravenous infusion therapy,

· Radiation oncology.
Covered Health Care Services include medical education services that are provided on an outpatient basis at a
Hospital or Alternate Facility by appropriately licensed or registered health care professionals when both of the
following are true:
· Education is required for a disease in which patient self–management is a part of treatment;

· There is a lack of knowledge regarding the disease which requires the help of a trained health
professional.

Page 33 Section 5- Additional Coverage Details
PPO - 2017