Page 121 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

• The service is provided to a Covered Person by an independent nurse who is hired directly by the
Covered Person or his/her family. This includes nursing services provided on an inpatient or home-
care basis, whether the service is skilled or non-skilled independent nursing.
Residential Treatment - treatment in a facility established and operated as required by law, which
provides Mental Health Care Services or Substance-Related and Addictive Disorders Services. It must
meet all of the following requirements:

• Provides a program of treatment, approved by the Mental Health/Substance-Related and Addictive
Disorders Designee, under the active participation and direction of a Physician and, approved by
the Mental Health/Substance-Related and Addictive Disorder Designee.

• Has or maintains a written, specific and detailed treatment program requiring your full-time
residence and participation.

• Provides at least the following basic services in a 24-hour per day, structured setting:

 Room and board.
 Evaluation and diagnosis.
 Counseling.

 Referral and orientation to specialized community resources.
A Residential Treatment facility that qualifies as a Hospital is considered a Hospital.

Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is a
Covered Health Care Service, the difference in cost between a Semi-private Room and a private room is
a Benefit only when a private room is Medically Necessary, or when a Semi-private Room is not available.

Service Fee - the periodic fee required for each Participant and each Enrolled Dependent, in accordance
with the terms of the Plan.

Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this SPD includes
Mental Illness or substance-related and addictive disorders, regardless of the cause or origin of the
Mental Illness or substance-related and addictive disorder.
Skilled Care - skilled nursing, skilled teaching and skilled rehabilitation services when all of the following
are true:
• Must be delivered or supervised by licensed technical or professional medical personnel in order to
obtain the specified medical outcome, and provide for the safety of the patient.
• Ordered by a Physician.

• Not delivered for the purpose of helping with activities of daily living, including dressing, feeding,
bathing or transferring from a bed to a chair.
• Requires clinical training in order to be delivered safely and effectively.

• Not Custodial Care, which can safely and effectively be performed by trained non-medical
personnel.

Skilled Nursing Facility - a Hospital or nursing facility that is licensed and operated as required by law.
Specialist - a Physician who has a majority of his or her practice in areas other than general pediatrics,
internal medicine, obstetrics/gynecology, family practice or general medicine.
Spouse - an individual to whom you are legally married.

118 Section 9: Defined Terms