Page 49 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

• Expected treatment goals.

• Frequency of treatment plan updates.
Habilitative services provided in your home by a Home Health Agency are provided as described under
Home Health Care. Habilitative services provided in your home other than by a Home Health Agency are
provided as described under this section.
Benefits for DME and prosthetic devices, when used as a part of habilitative services, are described
under Durable Medical Equipment (DME), Orthotics and Supplies and Prosthetic Devices.

Hearing Aids

Hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive
sound which may range from slight to complete deafness). These are electronic amplifying devices
designed to bring sound more effectively into the ear. These consist of a microphone, amplifier and
receiver.

Benefits are available for a hearing aid that is purchased due to a written recommendation by a
Physician. Benefits are provided for the hearing aid and associated fitting charges and testing.
If more than one type of hearing aid can meet your functional needs, Benefits are available only for the
hearing aid that meets the minimum specifications for your needs. If you purchase a hearing aid that
exceeds these minimum specifications, the Plan will pay only the amount that the Plan would have paid
for the hearing aid that meets the minimum specifications, and you will be responsible for paying any
difference in cost.

Benefits do not include bone anchored hearing aids. Bone anchored hearing aids are a Covered Health
Care Service for which Benefits are available under the applicable medical/surgical Covered Health Care
Services categories in this SPD. They are only available if you have either of the following:

• Craniofacial anomalies whose abnormal or absent ear canals prevent the use of a wearable
hearing aid.

• Hearing loss severe enough that it would not be remedied by a wearable hearing aid.

Home Health Care

Services received from a Home Health Agency that are all of the following:

• Ordered by a Physician.
• Provided in your home by a registered nurse, or provided by either a home health aide or licensed
practical nurse and supervised by a registered nurse.

• Provided on a part-time, Intermittent Care schedule.
• Provided when Skilled Care is required.

The Claims Administrator will determine if Benefits are available by reviewing both the skilled nature of
the service and the need for Physician-directed medical management.

Hospice Care
Hospice care that is recommended by a Physician. Hospice care is an integrated program that provides
comfort and support services for the terminally ill. It includes the following:
• Physical, psychological, social, spiritual and respite care for the terminally ill person.

46 Section 1: Covered Health Care Services