Member Handbook for Parkland KIDSfirst and Parkland CHIP ...

• serious impairment to bodily functions;
• serious dysfunction of any bodily organ or part;
• serious disfigurement; or
• in the case of a pregnant woman, serious jeopardy to the health of the fetus.
“Emergency Services” and “Emergency Medical Care” means health care services provided in an
in-network or out-of-network hospital emergency department or other comparable facility by innetwork
or out-of network physicians, providers, or facility staff to evaluate and stabilize medical
conditions. Emergency services also include, but are not limited to, any medical screening
examination or other evaluation required by state or federal law that is necessary to determine
whether an emergency condition exists.
There is no lifetime maximum on benefits; however, 12-month period or lifetime limitations do
apply to certain services, as specified in the following chart. Co-pays apply until a family reaches
its specific cost-sharing maximum. Co-pays do not apply to the Parkland CHIP Perinate
Newborn members.
Type of Benefit Description of Benefit Limitations Co-Pay
Inpatient General
Acute and Inpatient
Rehabilitation
Hospital Services
Medically necessary services
include, but are not limited to,
the following:
• Hospital-provided
physician or provider
services
• Semi-private room and
board (or private if
medically necessary as
certified by attending)
• General nursing care
• Special duty nursing
when medically
necessary
• ICU and services
• Patient meals and special
diets
• Operating, recovery and
other treatment rooms
• Anesthesia and
administration (facility
technical component)
• Surgical dressings, trays,
casts, splints
• Drugs, medications and
biologicals, Blood or
blood products not
provided free-of-charge
to the patient and their
administration,
• X-rays, imaging and
other radiological tests
PKF-M100708R 10
• For Parkland CHIP
Perinate Newborns in
families with incomes at or
below 185% of the Federal
Poverty Level (FPL) the
facility charges are not a
covered benefit for the
initial Perinate Newborn
admission. Facility charges
are a covered benefit after
the initial Perinate
Newborn admission.
• For Parkland CHIP
Perinate Newborns in
families with incomes at or
below 185% of the Federal
Poverty Level, professional
service charges are a
covered benefit for the
initial Perinate Newborn
admission and subsequent
admissions.
• Requires prior authorization
for non-emergency care and
following stabilization of an
emergency condition
• Requires prior authorization
for in-network or out-ofnetwork
facility for a mother
and her newborn(s) after 48
hours following an
uncomplicated vaginal
Applicable level
of inpatient copay
applies for
CHIP Program
Members
No co-pays
required for
CHIP Perinate
Newborn
Members