PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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Home Health Care Home health care services are designed to enable you or a covered family member to receive treatment for an illness or injury in your home, rather than in a hospital or an extended care facility. To receive home health care benefits you must be homebound and require skilled nursing services on an intermittent basis. Home health care benefits will be paid if: Care is pre-certified before you receive it You are homebound (unable to leave home without assistance and requiring supportive devices or special transportation), and You require skilled nursing services on an intermittent basis under the direction of your physician. Covered home health care expenses include charges for: Part-time or intermittent care by an R.N., L.P.N. or L.V.N. Physical, respiratory, occupational or speech therapy Part-time or intermittent home health aide services for you or a covered family member who is receiving covered nursing or therapy services Medical social service consultations, and Nutritional guidance by a registered dietitian and nutritional supplements such as diet substitutes administered intravenously or through hyperalimentation (if medically necessary). 22 Home health care benefits will not be paid toward the cost of: Homemaker services Maintenance therapy Dialysis treatment Food or home delivered meals Prescription or non-prescription drugs or biologicals Rental or purchase of durable medical equipment Services or supplies that are not part of the home health care plan Services of a person who usually lives with you or is a member of your family Services of a social worker, or Transportation services. Hospice Care Hospice care is specialized voluntary care for terminally ill patients who have a life expectancy of six months or less. Hospice care is designed to treat the unique physical and mental distress of terminal illness by addressing as many of the patient’s and family’s physical and emotional needs as possible. You or your covered dependent’s physician must submit documentation that: The illness is a terminal illness, and The covered person has a life expectancy of six months or less. The patient’s physician must approve his or her enrollment in the hospice program.
The PPO/DRP pays benefits if hospice care services are received from an approved provider either in your home (under a home health care program), as an outpatient, or as an inpatient in a hospital or skilled nursing facility. Services covered under the hospice care program include: Room and board in a hospice facility Services, supplies and treatment provided by a hospice in a home setting Physician services and/or nursing care by a R.N., L.P.N. or L.V.N. Physical therapy, occupational therapy, speech therapy or respiratory therapy Nutrition services Counseling services provided through a hospice Coordinated home care Medical dressings and supplies Medication, and Pain management services. Services not covered under the hospice care program include: Home delivered meals Homemaker services Respite care, and Transportation, including, but not limited to, ambulance transportation. Hospital Benefits Inpatient Hospital Services The PPO/DRP covers the following inpatient services: Semiprivate room and board charges (private room charges are not covered unless a private room is medically necessary, or the facility has only private rooms) Intensive care unit services Admission fees and other fees charged by the hospital for rendering services, supplies and treatments Use of operating, treatment and delivery rooms Anesthesia and anesthesia supplies and administration Medical and surgical dressings, casts and splints Blood transfusions Drugs and medicines X-ray and diagnostic laboratory procedures and services 23 Oxygen and other gas therapy Therapy services, and Miscellaneous hospital services and supplies during confinement. Important! Inpatient hospital admissions are subject to pre-certification. Outpatient Care The PPO/DRP covers the following outpatient services: Preadmission testing Surgery Diagnostic services Radiation therapy Chemotherapy Shock therapy, and Renal dialysis treatments if received in a hospital, dialysis facility, or in your home under the supervision of a hospital or dialysis facility. Human Organ Transplants Organ transplants are subject to pre-certification. Benefits for organ transplants are subject to following claims administrator guidelines. Benefits will be provided only for the following transplant procedures: Kidney Bone marrow Heart valve Heart Lung Heart/lung Liver Pancreas, or Pancreas/kidney human organ or tissue transplants.
Page 1 and 2: PPO/DRP Medical Plan
Page 3 and 4: PPO/DRP Medical Plan If you are an
Page 5 and 6: You also may be invited to particip
Page 7 and 8: Services In-Network Out-of-Network
Page 9 and 10: Type of Services In-Network Out-of-
Page 11 and 12: Incapacitated Dependents A child wi
Page 13 and 14: You may be able to enroll yourself
Page 15 and 16: PPO/DRP Benefits The PPO/DRP covera
Page 17 and 18: Medically Necessary Services A proc
Page 19 and 20: You must call to schedule a non-urg
Page 21: Chiropractic Care The Plan will pay
Page 25 and 26: Benefits for Newborns When you or a
Page 27 and 28: Other Covered Services Besides the
Page 29 and 30: Weight reduction or treatment of ob
Page 31 and 32: Making a Claim Filing a Claim Any c
Page 33 and 34: However, if a claim is submitted th
Page 35 and 36: The consulting health care professi
Page 37 and 38: If the claimant’s request is comp
Page 39 and 40: Other Plan Information When Medical
Page 41 and 42: Reimbursement/Subrogation You and y
Page 43 and 44: Assignment of Benefits A Qualified
Page 45 and 46: Your Benefits If you elect to conti

PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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