Page 42 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

• From a short-term acute care facility to the closest Network long-term acute care facility (LTAC),
Network Inpatient Rehabilitation Facility, or other Network sub-acute facility where the required
Covered Health Care Services can be delivered.
For the purpose of this Benefit the following terms have the following meanings:

 "Long-term acute care facility (LTAC)" means a facility or Hospital that provides care to
people with complex medical needs requiring long-term Hospital stay in an acute or critical
setting.
 "Short-term acute care facility" means a facility or Hospital that provides care to people with
medical needs requiring short-term Hospital stay in an acute or critical setting such as for
recovery following a surgery, care following sudden Sickness, Injury, or flare-up of a chronic
Sickness.

 "Sub-acute facility" means a facility that provides intermediate care on short-term or long-
term basis.

Cellular and Gene Therapy
Cellular Therapy and Gene Therapy received on an inpatient or outpatient basis at a Hospital or on an
outpatient basis at an Alternate Facility or in a Physician's office.
Benefits for CAR-T therapy for malignancies are provided as described under Transplantation Services.

Clinical Trials
Routine patient care costs incurred while taking part in a qualifying clinical trial for the treatment of:

• Cancer or other life-threatening disease or condition. For purposes of this Benefit, a life-threatening
disease or condition is one which is likely to cause death unless the course of the disease or
condition is interrupted.
• Cardiovascular disease (cardiac/stroke) which is not life threatening, when the Claims
Administrator determines the clinical trial meets the qualifying clinical trial criteria stated below.
• Surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, when
the Claims Administrator determines the clinical trial meets the qualifying clinical trial criteria stated
below.
• Other diseases or disorders which are not life threatening, when the Claims Administrator
determines the clinical trial meets the qualifying clinical trial criteria stated below.
Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat
complications arising from taking part in a qualifying clinical trial.
Benefits are available only when you are clinically eligible, as determined by the researcher, to take part
in the qualifying clinical trial.
Routine patient care costs for qualifying clinical trials include:

• Covered Health Care Services for which Benefits are typically provided absent a clinical trial.
• Covered Health Care Services required solely for the following:
 The provision of the Experimental or Investigational Service(s) or item.

 The clinically appropriate monitoring of the effects of the service or item, or
 The prevention of complications.

39 Section 1: Covered Health Care Services