State of Illinois - HealthLink

Section III - Covered Medical Expenses
The plan covers the contracted or negotiated rate, or usual and customary (U&C) charges
applicable typically only to non-participating health care providers, incurred by a covered
individual for the services and supplies in the following list, provided they are performed or
prescribed by a licensed physician, are required in connection with the medically necessary
treatment of an illness or injury (or are specifically covered preventive care), are pre-certified
when required under the Medical Management program, and are not listed in the section called
Exclusions and Limitations. An expense is incurred on the date the service or supply is actually
rendered or received. Covered expenses include the following:
1. Hospital room and board and general nursing services or special charges for intensive care
confinement. This benefit requires pre-certification.
2. Other inpatient hospital charges for medical care, services and supplies.
3. Medical care services and supplies for treatment received as an outpatient at a contracted
hospital or contracted urgent care facility or the use of a contracted licensed ambulatory
surgical center. Some services may require pre-certification.
4. Contracted physician fees for other medical care and services in the office, home or
contracted hospital.
5. A cardiac rehabilitation program, when prescribed by a contracted treating physician and
provided through a recognized contracted medical facility.
6. Anesthesia charges from a contracted physician or certified registered nurse anesthetist
(CRNA). Services provided by a registered nurse first assistant (RNFA) or certified
registered nurse first assistant (CRNFA) if medically necessary and appropriate for care.
7. Nursing charges from a registered nurse (RN), licensed practical nurse (LPN) or certified
nursing aide, provided he or she is not a close relative. A close relative includes you and
your spouse and the following relations to either of you: parents, brothers, sisters or
children. (Custodial services, or services that a family or friend can be trained to perform,
are not covered.)
8. Professional service charges for medical care and services provided by a contracted
radiologist and contracted pathologist.
9. Maternity coverage is for maternity care provided to a female employee, enrolled spouse of
a male employee and enrolled dependent daughter. No coverage is provided for a child of
an enrolled dependent daughter.
10. Routine services as defined under “Preventive” in your Summary Plan Description. Routine services
must be performed by a Tier I (HMO) contracted provider or Tier II (PPO) contracted provider.
11. Human Papillomavirus (HPV) vaccine (female employees/dependents from age 11 to 26;
male employees/dependents from age 9 to 26).
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