Page 129 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Your Plan Sponsor is providing you with Travel and Lodging assistance. Refer to the Travel and Lodging
Assistance Program.

Transplant Resource Services (TRS) Program
Your Plan offers Transplant Resource Services (TRS) program to provide you with access to one of the
nation's leading transplant programs. Receiving transplant services through this program means your
transplant treatment is based on a "best practices" approach from health care professionals with
extensive expertise in transplantation.
To learn more about Transplant Resource Services, visit www.myoptumhealthcomplexmedical.com or call
the number on your ID card.

Coverage for transplant and transplant-related services are based on your health plan's terms,
exclusions, limitations and conditions, including the plan's eligibility requirements and coverage
guidelines. Participation in this program is voluntary.
Your Plan Sponsor is providing you with Travel and Lodging assistance. Refer to the Travel and Lodging
Assistance Program.

Travel and Lodging Assistance Program

Your Plan Sponsor is providing you with Travel and Lodging assistance. Travel and Lodging assistance is
only available for you or your eligible family member if you meet the qualifications for the benefit,
including receiving care at a Designated Provider and the distance from your home address to the facility.
Allowed Amounts are reimbursed after the expense forms have been completed and submitted with the
appropriate receipts.
If you have specific questions regarding the Travel and Lodging Assistance Program, please call the
Travel and Lodging office at 1-800-842-0843.

Travel and Lodging Expenses
The Plan covers expenses for travel and lodging for the patient, provided he or she is not covered by
Medicare, and a companion as follows:
• Transportation of the patient and one companion who is traveling on the same day(s) to and/or
from the site of the qualified procedure provided by a Designated Provider for the purposes of an
evaluation, the procedure or necessary post-discharge follow-up.

• The Allowed Amount for lodging for the patient (while not a Hospital inpatient) and one companion.
• If the patient is an Enrolled Dependent minor child, the transportation expenses of two companions
will be covered.
• Travel and lodging expenses are only available if the patient resides more than 50 miles from the
Designated Provider.
• Reimbursement for certain lodging expenses for the patient and his/her companion(s) may be
included in the taxable income of the Plan participant if the reimbursement exceeds the per diem
rate.

• The bariatric, cancer, congenital heart disease and transplant programs offer a combined overall
lifetime maximum of $10,000 per Covered Person for all transportation and lodging expenses
incurred by you and reimbursed under the Plan in connection with all qualified procedures.

• The spine and joint program provides a maximum of $2,000 per Covered Person per procedure for
all transportation and lodging expenses incurred by you and reimbursed under the Plan in
connection with all qualified procedures.

126 Clinical Programs and Resources