The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Hearing Aids and
Tests for Hearing
Aids
Home Health Care
Home Infusion
Therapy
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
You pay 25% You pay 45% Hearing aids are covered for a dependent child under age 13 who has a
hearing loss due to a congenital loss of hearing that cannot be corrected by
other covered procedures. Coverage is limited to $1,000 paid by the
plan per ear every third plan year and includes the hearing aid, dispensing
fee, molds, impressions, batteries and repairs. Replacements are not
covered if lost.
You pay 25% You pay 45%
No coverage for tests for hearing aids.
To be covered, skilled care must be prescribed by a physician and
provided by a Medicare approved or other pre-approved licensed
home health agency. Coverage is limited to $15,000 paid by the plan per
plan year. $15,000 limit does not include lab and x-ray charges, drugs or
Durable Medical Equipment purchased through home health care provider.
See “Durable Medical Equipment (DME) and Medical Supplies” in this
chart. Services for custodial care, non-skilled care, services of a nonmedical
nature, private duty nursing, rest cures and mental health are not
covered.
You pay 25% You pay 45% To be covered, care must be ordered by a physician and provided by a
Medicare approved or other pre-approved licensed home health
agency. Covered services include solutions and pharmaceutical additives,
pharmacy compounding and dispensing services, durable medical
equipment and supplies, nursing services to train you or your caregiver to
monitor your therapy, and collection, analysis and reporting of lab tests.
Infusion services do not apply to the Home Health Care maximum.
Hospice Care You pay 25% You pay 45% Hospice care for terminally ill patients provided by a Medicare-certified
hospice provider or other pre-approved hospice.
Coverage for inpatient and outpatient hospital care, routine and continuous
home nursing care, home health aide visits, physical therapy, speech
therapy, language therapy, occupational therapy, social worker visits,
dietary/nutritional counseling, durable medical equipment, routine medical
supplies and other supportive services provided to meet the physical,
psychological, spiritual, and social needs of the dying patient.
Coverage includes patient care instructions, respite care and other
supportive services for the family, both before and after the death of the
patient.
Coverage for respite care is limited to 10 days paid by the plan during the
episode of hospice care. To be eligible for hospice care, a physician must
document that according to best medical judgment, the patient has six
months or less to live, and the patient/family must agree not to pursue
curative treatment. Inpatient care in a hospice or hospital is covered
under Hospital Inpatient Services. Take-home drugs will process under
this benefit level. Medical care services unrelated to the terminal illness
may be covered according to other Plan benefits and requirements.
Eligible services provided by a skilled nursing facility are covered but are
separate from the hospice benefit. (See Skilled Nursing under “Hospital
Inpatient Services” in this chart.)
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
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