Page 53 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Physician's Office Services - Sickness and Injury
Services provided in a Physician's office for the diagnosis and treatment of a Sickness or Injury. Benefits
are provided regardless of whether the Physician's office is freestanding, located in a clinic or located in a
Hospital.
Covered Health Care Services include medical education services that are provided in a Physician's
office by appropriately licensed or registered health care professionals when both of the following are
true:

• Education is required for a disease in which patient self-management is a part of treatment.
• There is a lack of knowledge regarding the disease which requires the help of a trained health
professional.
Covered Health Care Services include Genetic Counseling.

Benefits include allergy injections.
Covered Health Care Services for preventive care provided in a Physician's office are described under
Preventive Care Services.
When a test is performed or a sample is drawn in the Physician's office, Benefits for the analysis or
testing of a lab, radiology/X-ray or other diagnostic service, whether performed in or out of the Physician's
office, are described under Lab, X-ray and Diagnostic - Outpatient.

Pregnancy - Maternity Services
Benefits for Pregnancy include all maternity-related medical services for prenatal care, postnatal care,
delivery and any related complications.

Both before and during a Pregnancy, Benefits include the services of a genetic counselor when provided
or referred by a Physician. These Benefits are available to all Covered Persons in the immediate family.
Covered Health Care Services include related tests and treatment.
The Claims Administrator also has special prenatal programs to help during Pregnancy. They are
voluntary and there is no extra cost for taking part in the program. To sign up, you should notify the
Claims Administrator during the first trimester, but no later than one month prior to the expected date of
delivery.
The Plan will pay Benefits for an Inpatient Stay of at least:
• 48 hours for the mother and newborn child following a normal vaginal delivery.

• 96 hours for the mother and newborn child following a cesarean section delivery.
If the mother agrees, the attending provider may discharge the mother and/or the newborn child earlier
than these minimum time frames.

Preventive Care Services

Preventive care services provided on an outpatient basis at a Physician's office, an Alternate Facility or a
Hospital encompass medical services that have been demonstrated by clinical evidence to be safe and
effective in either the early detection of disease or in the prevention of disease, have been proven to have
a beneficial effect on health outcomes and include the following as required under applicable law:

• Evidence-based items or services that have in effect a rating of "A" or "B" in the current
recommendations of the United States Preventive Services Task Force.

50 Section 1: Covered Health Care Services