Page 47 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Emergency Health Care Services - Outpatient
Services that are required to stabilize or begin treatment in an Emergency. Emergency Health Care
Services must be received on an outpatient basis at a Hospital or Alternate Facility.
Benefits include the facility charge, supplies and all professional services required to stabilize your
condition and/or begin treatment. This includes placement in an observation bed to monitor your condition
(rather than being admitted to a Hospital for an Inpatient Stay).
Benefits are available for services to treat a condition that does not meet the definition of an Emergency.

Enteral Nutrition
Benefits are provided for enteral formulas and low protein modified food products, administered either
orally or by tube feeding as the primary source of nutrition, for certain conditions which require specialized
nutrients or formulas. Examples of conditions include:

• Metabolic diseases such as phenylketonuria (PKU) and maple syrup urine disease.
• Severe food allergies.

• Impaired absorption of nutrients caused by disorders affecting the gastrointestinal tract.
Benefits for prescription or over-the-counter formula are available when a Physician issues a prescription
or written order stating the formula or product is Medically Necessary for the therapeutic treatment of a
condition requiring specialized nutrients and specifying the quantity and the duration of the prescription or
order. The formula or product must be administered under the direction of a Physician or registered
dietitian.

For the purpose of this Benefit, "enteral formulas" include:
• Amino acid-based elemental formulas.

• Extensively hydrolyzed protein formulas.
• Modified nutrient content formulas.

For the purpose of this Benefit, "severe food allergies" mean allergies which if left untreated will result in:
• Malnourishment.

• Chronic physical disability.
• Intellectual disability; or

• Loss of life.

Habilitative Services

For purposes of this Benefit, "habilitative services" means Skilled Care services that are part of a
prescribed plan of treatment to help a person with a disabling condition to learn or improve skills and
functioning for daily living. The Claims Administrator will decide if Benefits are available by reviewing both
the skilled nature of the service and the need for Physician-directed medical management. Therapies
provided for the purpose of general well-being or conditioning in the absence of a disabling condition are
not considered habilitative services.
Habilitative services are limited to:

• Physical therapy.
• Occupational therapy.

44 Section 1: Covered Health Care Services