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Hospital Services and More from Lumenos Georgia Health Insurance

Hospital and Facility Services

This section provides a detailed description of the eligible hospital and facility services. Most services received from hospitals and facilities that offer discounts will be covered at 90% of discounted fees or 60% of charges for providers who do not offer discounts.

This section provides a detailed description of services covered under Traditional Health Coverage. To make it easier for you to find, the list of eligible services are listed in alphabetical order within the following categories:

• Emergency Room Care
• Emergency Room Care for Non-Emergencies
• Inpatient Medical Facility
• Inpatient Rehabilitation Facility
• Outpatient Facility
• Skilled Nursing Facility
• Urgent Care Center

Emergency Room Care

Facility and professional provider services and supplies for the initial treatment of traumatic bodily injuries resulting from an accident are covered.

Emergency medical care meeting the following definition is also covered: Facility and professional provider services and supplies for the initial treatment of a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention could result in:

• Permanently placing the covered person's health in jeopardy,
• Causing other serious medical consequences,
• Causing serious impairment to bodily functions, or
• Causing serious and permanent dysfunction of any bodily organ or part.

If the emergency room visit results in a hospital admission, you should notify the plan within 48 hours of the admission.

Emergency room care as described above will be reimbursed at 90% of discounted fees for providers who offer discounts and 90% of charges for providers who do not offer discounts.

Emergency Room Care for Non-Emergencies

Emergency room care for non-emergencies will be reimbursed at 60% of discounted fees for providers who offer discounts and 60% of charges for providers who do not offer discounts. Care for non-emergencies is defined as care received in an emergency room for a service or condition that does not meet the prudent layperson's assessment of emergency (see description above in Emergency Room Care section).

Inpatient Medical Facility

The Lumenos plan pays benefits toward the cost of the following types of inpatient hospital care services:

• Inpatient Room & Board
• Inpatient Ancillary Services

Inpatient Room and Board

Coverage provided for room and board is limited to the Semi-Private room rate. Private room, intensive care, coronary care and other specialized care units of a facility are covered when such special care or isolation is consistent with professional standards for the care of the patient's condition.

When room and board for other than Semi-Private care is at the convenience of the patient, payment will be made only for Semi-Private accommodations.

Inpatient Ancillary Charges

Coverage is provided for necessary services and supplies including, but not limited to admission fees, use of operating, delivery, and treatment rooms; prescribed drugs; whole blood, administration of blood, blood processing, and blood derivatives (to the extent blood or blood derivatives are not donated or otherwise replaced); anesthesia, anesthesia supplies and the administration of anesthesia by an employee of the facility; medical and surgical dressings, supplies, casts and splints; diagnostic services; and therapy services; but not services of a physician, or drugs or supplies not consumed or used in the facility.

Inpatient Rehabilitation Facility

Coverage is provided for Inpatient Rehabilitation Facilities. Most people who are admitted to an Inpatient Rehabilitation Facility are recovering from injuries or illnesses that severely impair their physical functioning or understanding. These include strokes, spinal cord injuries, traumatic brain injuries, chronic pulmonary problems, neurological disorders and other debilitating conditions.

Administered by treatment teams, individual patient programs can include these services:

• Behavioral medicine
• Case management
• Dialysis
• Nutrition services
• Neuropsychology
• Occupational therapy (OT)
• On-site orthotic and prosthetic services
• Physical therapy (PT)
• Psychology
• Recreation therapy
• Rehabilitation engineering and technology
• Rehabilitation nursing
• Social work
• Speech and language therapy
• Vocational and community re-entry services

Mental health/chemical dependency rehab is not covered under this benefit but rather under the MH/CD benefit.

Outpatient Facility

Outpatient facility charges are covered only when required for a covered service or procedure. Coverage is provided for necessary services and supplies including, but not limited to use of operating, delivery, and treatment rooms; prescribed drugs; whole blood, administration of blood, blood processing, and blood derivatives (to the extent blood or blood derivatives are not donated or otherwise replaced); anesthesia, anesthesia supplies and the administration of anesthesia by an employee of the facility; medical and surgical dressings, supplies, casts and splints; diagnostic services; and therapy services; but not services of a physician, or drugs or supplies not consumed or used in the facility.

Urgent Care Center

Coverage is provided at an emergency medical service center, which is separate from any other hospital or medical facility.