I:\Legal\LEGAL\ST PATRICK HOSPITAL-Medical\Plan Document ...

Medical BenefitsGENETIC AND INFERTILITY TESTING AND COUNSELING BENEFITBenefit Limits apply as stated in the Schedule of Medical Benefits.Coverage under this benefit includes charges for genetic counseling and testing relating to infertility, andscreening for Pregnancy-related genetic anomalies.DENTAL SERVICES BENEFIT (MEDICAL PLAN)Coverage under this benefit includes charges for dental treatment required because of accidental bodilyInjury to natural teeth. Conditions related to trauma must be diagnosed within six (6) months of Injury andtreatment must begin with twelve (12) months of the date of accident.ORTHOGNATHIC SERVICESBenefit Limits apply as stated in the Schedule of Medical Benefits.Coverage under this benefit includes charges for orthognathic services, including medical and surgicaltreatment fo TMJ, only when there is significant evidence of pathology as a result of an Illness or Injury.Illness refers to a neoplastic process, degenerative disease, or infection.HOME HEALTH CARE BENEFITCoverage under this benefit includes charges made by a Home Health Care Agency for care inaccordance with a Home Health Care Plan for the following services:1. Part-time or intermittent nursing care by a Registered Nurse (R.N.) or by a Licensed PracticalNurse (L.P.N.), a vocational nurse, or public health nurse who is under the direct supervision of aRegistered Nurse;2. Home health aides;3. Medical supplies, drugs and medicines prescribed by a Physician, and laboratory servicesprovided by or on behalf of a Hospital.“Home Health Care Agency” means an organization that provides skilled nursing services and therapeuticservices (home health aide services, physical therapy, occupational therapy, speech therapy, medicalsocial services) on a visiting basis, in a place of residence used as the Covered Person’s home. Theorganization must be Medicare certified and licensed within the state in which home health care servicesare provided.“Home Health Care Plan” means a program for continued care and treatment administered by a Medicarecertified and licensed Home Health Care Agency, for the Covered Person who may otherwise have beenconfined as an Inpatient in a Hospital or Skilled Nursing Facility or following termination of a Hospitalconfinement as an Inpatient and is the result of the same related condition for which the Covered Personwas hospitalized and is approved in writing by the Covered Person's attending Physician.Home Health Care specifically excludes the following:1. Services and supplies not included in the approved Home Health Care Plan.2. Services of a person who ordinarily resides in the home of the Covered Person, or who is a CloseRelative of the Covered Person who does not regularly charge the Covered Person for services.3. Services of any social worker.Western Montana Providence Health & Services - SPD 24Group #2000204 - January 1, 2011