Georgia Health Insurance - Affordable Health Insurance Quotes in Georgia

Covered Services

Services for which your Traditional Health Coverage will pay benefits include the following hospital and medical services and supplies for treatment of an injury or disease. Most services received from providers who offer discounts will be covered at 90% of discounted fees. Most services received from providers who do not offer discounts will be covered at 60% of Reasonable and Customary charges (as determined by the Plan Administrator). Only those services, supplies and treatments that are for the treatment of an injury or disease, Medically Necessary (as determined by the Plan Administrator) and rendered by a licensed provider are covered, according to Lumenos plan provisions.

This section provides a detailed description of services covered under Traditional Health Coverage. Services for which your Traditional Health Coverage will pay benefits include the following:

• Professional Services
• Maternity Care
• Mental Health and Chemical Dependency
• Hospital and Facility Services

Professional Services

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

Allergy Care - Injections and Tests
Allergy care is covered when administered by a physician, allergist, or specialist. Serum is covered only when received and administered within the provider's office. If received from a pharmacy, the serum may be covered under the pharmaceutical benefit. The following services are covered:

• Allergy Injections
• Allergy Tests

Allergy Injections- Immunotherapy
Also called allergy desensitization or allergy shots; immunotherapy is given to increase a person's tolerance to the substances that provoke allergy symptoms (allergens). Allergy shots reduce the sensitivity to certain substances but do not cure allergies.

Allergy Tests

• An allergy skin test, also called a scratch test, is used to identify the substances that are causing allergy symptoms. It is the application of the allergen extract to the skin, and then scratching or pricking the skin to allow exposure, and evaluating the skin's reaction.
• Scratch Test - In this test, one or more small scratches or superficial cuts are made in the skin, and a minute amount of the substance to be tested is inserted in the scratches and allowed to remain there for a short time. If no reaction has occurred after 30 minutes, the substance is removed and the test is considered negative. If there is redness or swelling at the scratch sites, the test is considered positive.
• RAST (radioallergosorbent test) is a blood test used to identify the substances that are causing allergy symptoms and to estimate a relative sensitivity.

Ambulance
Professional ground transportation ambulance services are covered in the following circumstances:

• When used to transport the patient from the place of accidental injury or serious medical incident to the nearest facility where treatment can be given.
• To transport a patient from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the patient.
• To transport a patient from hospital to home, skilled nursing facility or nursing home when the patient cannot be safely or adequately transported in another way without endangering the individual's health, whether or not such other transportation is actually available.
• To transport a patient from home to hospital for Medically Necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the patient.
• To transport a patient upon medical stabilization from a non-discounted facility to a discounted facility when they were admitted due to a medical emergency to a non- discounted facility.
Coverage is provided for air ambulance transport for medical emergencies in the following circumstances:

• Patient requires transport to a hospital or from one hospital to another because the first hospital does not have the required services and/or facilities to treat the patient; and ground transportation is not medically appropriate because of the distance involved,
• Or because the patient has an unstable condition requiring medical supervision and rapid transport.

Notification is required except in a life threatening circumstance. Ambulance services are covered at 90% of discounted fees for providers who offer discounts, and 90% of charges for providers who do not offer discounts.

Anesthesia
The administration of anesthesia, other than local infiltration anesthesia, in connection with a covered surgical procedure, and provided the anesthesia is administered and charged for by a physician other than the operating surgeon or his assistant.

BioFeedback
Biofeedback is a process by which a person learns to influence involuntary bodily processes by watching a monitoring device that feeds back relevant physiologic information to them, such as skin temperature, muscle tone, brain waves, or respiration. Biofeedback can be used to treat a wide variety of conditions and diseases ranging from stress, alcohol and other addictions, sleep disorders, epilepsy, respiratory problems, and fecal and urinary incontinence, muscle spasms, partial paralysis or muscle dysfunction caused by injury, migraine headaches, hypertension, and a variety of vascular disorders.

Blood Transfusions
Coverage is provided for blood transfusions to maintain or replace blood volume, to provide deficient blood elements and improve coagulation, to maintain or improve transport of oxygen, and in exchange for blood that has been removed in the treatment of Rh incompatibility in the newborn, liver failure in which toxins accumulate in the blood, or in some other types of toxemia.

Coverage is included for the following:

• Autologous
• Direct Donation
• Regular Administration
• Blood Products

Cardiac Rehabilitation Therapy
Coverage for cardiac rehabilitation therapy is provided in two phases. Phase I begins during/after the acute event (i.e. by-pass surgery, myocardial infarction, angioplasty). It includes nursing services, physical therapy and teaching the patient how to deal with his/her condition. Phase II is a hospital based outpatient program after inpatient hospital discharge. It is physician directed with active treatment and EKG monitoring at a frequency of three (3) times per week for approximately twelve (12) weeks. Benefits are limited to 40 visits per person per Plan year.

Chiropractic
Chiropractic services are defined as those services for the detection and correction by manual or mechanical means of nerve interference resulting from or related to misalignment or partial dislocation of or in the vertebral column. Coverage includes initial consultation and treatment. Benefits for chiropractic treatment are limited to a maximum of 20 visits per person per Plan year.

Dental Services and Oral Surgery
Charges for care rendered by a physician or dentist, which are required as a result of an accidental injury to the jaws, sound natural teeth, mouth or face, provided care commences within 90 days of the accident. Injury as a result of chewing or biting will not be considered an accidental injury.

Charges for surgical benefits for cutting procedures for the treatment of disease, injuries, fractures and dislocations of the jaw when the service is performed by a physician or dentist are also considered covered services.

NOTE: Normal extraction and care of teeth and structures directly supporting the teeth are not covered.

Diagnostic Labs and X-rays
Coverage is provided when services are performed to diagnose specific symptoms or rule out medical conditions. Services include:
• Diagnostic X-ray, consisting of radiology, ultrasound, nuclear medicine and magnetic resonance imaging.
• Diagnostic laboratory and pathology tests.
• Diagnostic medical procedures consisting of EKG, EEG, and other electronic diagnostic medical procedures.
• Pre-admission presurgical tests which are made prior to a covered person's inpatient or outpatient surgery.
For pre-admission and/or post-release testing to be covered under the Lumenos plan, your doctor must specify required tests and approve the facility for testing. In most cases, the tests can be performed in the outpatient department of a hospital, at an independent medical testing laboratory or in your doctor's office.

Pre-admission tests will be covered even if hospitalization is delayed, postponed or cancelled.

NOTE: Lab and x-ray services received in the absence of a diagnosis are not covered, with the exception of those specifically noted in the preventive care section.

Durable Medical Equipment
Coverage is provided for rental or, at the discretion of the Plan, purchase of Durable Medical Equipment, which is prescribed by a professional provider and required for therapeutic use. If purchased, charges for repair or Medically Necessary replacement of Durable Medical Equipment will be considered a covered expense.

Includes, but not limited to crutches, commodes, hospital beds, nebulizers, monitoring equipment, wheelchairs, glucometers and blood pressure monitors with a provider's prescription and an applicable diagnosis.

NOTE: Coverage for replacement of durable medical equipment due to growth of the individual is also provided.

Coverage for DME does not include exercise equipment, equipment that is not solely for the use of the patient, comfort items, routine maintenance, or DME for the convenience of the patient. Consumable supplies are not covered, except for those that are Medically Necessary for the function of the authorized DME.

Family Planning
Coverage for family planning is provided for:
• D & C/Abortion - therapeutic or voluntary
• Diaphragm - Device and/or fitting
• IUD - Device and/or insertion and removal
• Tubal ligation
• Vasectomy
• Sterilization
Contraceptives administered in a doctor's office are covered, such as Depo-Provera.

Note: Reversal of sterilization is not a covered service.

Foreign Claims
Claims for services rendered while you are out of the country are reimbursed at 90% for emergent care, and 60% for non-emergent care.

All monetary conversions and rate of exchange are calculated based on the date of service. Hearing Exam
Routine hearing exams to detect/prevent auditory deterioration are limited to one exam per person per Plan year.

Home Health Care
Home Health Care expenses are covered if the services are provided by a licensed Home Health Care Agency, and:
• The charge is made by a Home Health Care Agency
• The care is given according to a Home Health Care treatment plan
• The care is given to a person in his or her home
Home Health expenses are charges for:
• Part-time or intermittent care by an R.N. or by an L.P.N. if an R.N. is not available
• Part-time or intermittent home health aide services for patient care
• Physical, occupational and speech therapy
• The following to the extent they would have been covered under this Plan if the person had been confined in a hospital or convalescent facility:


Medical supplies
Drugs and medicines provided by a physician
Lab services provided by a home health care agency
The following expenses are not considered payable under Home Health Care:
• Services or supplies that are not part of the home health care treatment plan
• Services of a person who usually lives with the patient or who is a member of the patient's family
• Services of a social worker
• Transportation

Hospice Care
Hospice is a health care program providing a coordinated set of services rendered at home, in an outpatient setting or in an institutional setting for those suffering from a condition that has a terminal prognosis.

To be covered, the Hospice program must be licensed and the attending physician must certify that the terminally ill covered person has a life expectancy of six months or less. Charges incurred during periods of remission are not eligible under the provision of the Plan.

Hospice care for you and your eligible dependents is covered for up to six (6) months. A Personal Health Coach is available to coordinate coverage beyond six (6) months.

Services and supplies typically provided and billed by a Hospice are: Inpatient care;
• Nutrition counseling and special meals;
• Part-time nursing;
• Homemaker services;
• Bereavement counseling for immediate family members during the six month period following the date of death, limited to a combined maximum of $500 per episode (Immediate family members include husband, wife, and children);
• Respite care - limited to 5 days per episode;
• Physical and chemical therapy.

Infertility Treatment
Coverage is provided for the initial evaluation treatment and correction of the underlying condition only.

Procedures that may produce a pregnancy, but do not correct the underlying cause of the infertility are not covered.

Not Covered Treatments:
• Artificial Insemination
• Drug Therapy
• In-vitro fertilization
• Gamete (GIFT) and zygote (ZIFT) intrafallopian transfer procedures
• Drugs related to the inducement of pregnancy

Medical Supplies
Medical supplies that are prescribed by a licensed provider for a medical condition or diagnosis are covered, except for over the counter supplies. Over the counter supplies are excluded from the Lumenos plan.

Examples of medical supplies are diabetic supplies (lancets, glucometers, syringes, if not covered under the pharmacy benefit), injectables and ostomy supplies (including medical equipment and supplies directly related to ostomy care when surgery creates an opening for drainage from the kidney, the small intestines or the colon). Glucomoters and blood pressure monitors with a provider's prescription and an applicable diagnosis are also covered.

Orthotic Devices Coverage is provided for orthotic devices (a rigid or semi-rigid supportive device which restricts or eliminates motion for a weak or diseased body part), including custom shoes and custom molded inserts, if prescribed by a physician. Orthopedic shoes are only covered when an integral part of a brace.

Podiatry
Coverage is provided for certain surgical podiatry services, including incision and drainage of infected tissue of the foot, removal of lesions of the foot, removal or debridement of infected toenails, and treatment of fractures and dislocations of bones of the foot. Podiatry services not covered are those procedures considered to be a part of a routine foot care, or of a cosmetic nature, such as treatment of corns, calluses, non-surgical care of toenails, fallen arches and other symptomatic complaints of the feet.

Preventive Care
The Lumenos plan covers preventive services based on guidelines from the U. S. Preventive Services Task Force, American Cancer Society, the Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. The preventive benefit includes screening tests, immunizations and counseling services designed to detect and treat medical conditions to prevent avoidable premature injury, illness and death.

All discounted rates will be paid by the Plan at 100% up to $500 per person per Plan year for providers who offer discounts, with no out-of-pocket responsibility for preventive services. Services that fall outside of the Preventive Care Benefit and other services performed during a preventive office visit will be considered for coverage under your account and/or Traditional Health Coverage portion of your plan.

Well Baby and Well Child Care

Baby/Child Preventive Care Office Visits
• Six (6) visits the first year
• Three (3) visits the second year
• Annual visit from ages 2 through 18
Baby/Child Screening Tests (annually, unless otherwise indicated):
• Lead Level Tests (once between 9 and 12 months)
• Vision screenings
• Hearing screenings
• Routine pelvic exam, Pap test and contraceptive management (screen all females who are 18, or have been sexually active, whichever comes first)
Baby/ Child Immunizations
Note: Actual dosing regimen to be determined by physician.

• Hepatitis A
• Hepatitis B
• Diphtheria, Tetanus, Pertussis (DtaP)
• H. Influenza type b
• Polio
• Measles, Mumps, Rubella (MMR)
• Varicella (chicken pox)
• Influenza - flu shot (Over age 6 months. Doctor may give this vaccine if the child is at high risk or to reduce the risk of the child getting the flu)
• Pneumococcal Conjugate (pneumonia)

Adult Preventive Care

Adult Preventive Care Office Visits
• Periodic preventive visit (up to one annual visit, after age 18)
Adult Screening Tests (annually, unless otherwise indicated):
• Coronary Artery Disease: Periodic cholesterol and lipid screening for men beginning at age 35 and women age 45
• Clinical breast exam and mammogram - annual starting at age 40
• Routine pelvic exam, Pap test and contraceptive management (screen all females who are 18, or have been sexually active, whichever comes first)
• Colorectal Cancer Screenings: Annual fecal occult blood testing or flexible sigmoidoscopy every 3-5 years or colonoscopy every 10 years - starting at age 50
• Prostate Cancer Screenings: Digital rectal examination (DRE) and Prostate Specific Antigen (PSA) at discretion of physician and patient - starting at age 50
• Diabetes (Type II Diabetes) Screening - Periodic blood glucose testing for high-risk individuals (e.g. hypertension, hyperlipidemia)
• Osteoporosis Screening - Periodic bone density screening for women over age 65 and for women over age 60 with increased risk for osteoporotic fractures
Adult Immunizations
• Influenza
• Pneumococcal Conjugate (pneumonia)
• Tetanus /Diphtheria (DtaP)
• Measles, Mumps, Rubella (MMR) - for individuals under the age of 50 without previous immunization
• Hepatitis A - Recommended for high risk groups, such as international travelers, workers in food service or health care industry
• Hepatitis B and Varicella - Recommended for high risk individuals
• Meningococcal - Considered for college students who live in dormitories and have a slightly increased risk of getting meningococcal disease

Private Duty Nursing
Coverage is provided for the services of a private duty nurse on an outpatient basis only. Nursing services must be rendered by a nurse who does not reside in the patient's home, or who is not a member of the immediate family. To be covered, the physician in charge of the case must certify that the patient's condition requires the requested care, which can only be provided by an RN or LPN. Private duty nursing applies only for care given in the patient's home and not part of the home health care agency's plan of treatment.

Professional Services
Professional services are those services billed by a provider's office rather than by a facility - such as office visits and inpatient hospital visits. Covered professional services are:
• Office Visits - Visits made by patients to health service providers' offices for diagnosis, treatment, and follow-up.
• Inpatient Hospital Visit - A visit by a provider for persons admitted to health facilities which provide room and board, for the purpose of observation, care, diagnosis or treatment.
• Home Visit - Visit made by a provider to a patient's home for diagnosis, treatment and follow-up.

Prosthetics
Coverage is provided for the purchase and fitting of external prosthetic appliances which are used as a replacement or substitute for a missing body part, and are necessary for the alleviation or correction of illness, injury, or congenital defect.

Replacement or repair, as appropriate, of external prosthetic appliances is covered if necessitated by such circumstances as normal anatomical growth, physical changes which render the device ineffective, or excessive wear.

Coverage for internal prosthetic appliances includes the purchase, maintenance, or repair of permanent or temporary internal aids and supports for defective body parts, specifically, intraocular lenses, artificial heart valves, cardiac pacemakers, artificial joints, and other surgical materials such as screw nails, sutures and wire mesh.

Second Surgical Opinion
Coverage is provided for an opinion provided by a second physician, when one physician recommends surgery to an individual. Second opinions will be covered at 90% for providers who offer discounts, and 60% for providers who do not offer discounts.

Surgery
Coverage is provided for surgery rendered in both inpatient and outpatient settings for the treatment of disease or injury. Separate payment will not be made for pre-operative care or post-operative care normally provided by the surgeon as part of the surgical procedure.

NOTE: Prior authorization is required for:
• Medical necessity for procedures that could be considered cosmetic
• Transplants

Breast reconstruction coverage
Other covered services also include breast reconstruction - for you and your covered dependents - if you or your family members received benefits for a mastectomy, and/or elected breast reconstruction in connection with the mastectomy. As long as the breast reconstruction is performed in a manner determined by the patient in consultation with the attending physician, benefits include:
• Reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedemas.

Surgical Services
Coverage is provided for the following surgical services:
• Assistant Surgeon
• Bilateral Surgical Procedures
• Co-surgeon
• Multiple Surgical Procedures

Assistant Surgeon
Benefits may be provided for services of a physician who actively assists the operating surgeon when it is determined that the condition of the patient or the type of surgical service requires such assistance.

When considered necessary by the surgeon, the service of an assistant surgeon is a covered service. The benefit payable for the assistant surgeon's services is 20% of the benefit payable for the primary surgeon.

Bilateral Surgical Procedures
Bilateral surgical procedures are defined as more than one procedure associated with a single surgical event. For bilateral procedures, the plan considers 50% of the eligible benefit for the primary surgical procedure.

Co-Surgeon
A co-surgeon is usually a surgeon who is in the operating room performing a different surgery than the other surgeon who is present at the same time. Also, a co-surgeon is allowed in complicated surgeries (such as heart surgery) due to the length of time of the operation. The co-surgeons have the same responsibility. Co-surgeon services are covered at 50% of the eligible benefit of the surgeon's fee.

Multiple Surgical Procedures
For multiple surgeries (related operations or procedures performed through the same incision or in the same operative field, performed at the same operative session), the plan considers as an eligible expense 100% of the eligible surgical allowance for the highest paying procedure plus 50% of the eligible surgical allowance for the second highest paying procedure and 50% of the eligible surgical allowance for each additional procedure. For example, if the benefit normally pays 90%, the primary surgical procedure would be paid at 90%, the remaining surgical procedures would be paid at 50% of the 90% benefit.

Temporomandibular Joint Dysfunction (TMJ)
Coverage is provided for surgical treatment of temporomandibular joint dysfunction if due to accident, congenital defect or developmental defect. Appliances are limited to a $1,100 lifetime maximum.

Therapy Services
Coverage is provided for therapy services when used for the treatment of a condition, sickness or injury to promote the recovery of the covered person. To be covered, the therapy services must be rendered in accordance with a physician's written treatment plan. Services covered under the Lumenos plan include:
• Chemotherapy - the treatment of malignant disease by chemical or biological antineoplastic agents. The cost of the antineoplastic agent is included.
• Dialysis Treatment - the treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body, to include hemodialysis or peritoneal dialysis.
• Occupational Therapy - the treatment of a physically disabled person by means of constructive activities designed and adapted to promote the functional restoration of the person's abilities lost or impaired by disease or accidental injury, to satisfactorily accomplish the ordinary tasks of daily living. Occupational therapy is limited to 40 visits per person per Plan year.
• Physical Therapy - the treatment by physical means, hydrotherapy, heat, or similar modalities; physical agents; bio-mechanical and neuro-physical principles; and devices to relieve pain, restore maximum function lost or impaired by disease or accidental injury, and prevent disability following disease, injury or loss of body part. Physical therapy is limited to 40 visits per person per Plan year.
• Radiation Therapy - the treatment of disease by X-ray, gamma ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes.
• Respiratory Therapy - the introduction of dry or moist gases into the lungs for treatment purposes.
• Speech Therapy - Speech therapy is covered to restore speech loss or correct impairment due to a congenital defect, illness or injury; such as stroke, head injury or vocal cord injury. Speech therapy is limited to 40 visits per person per Plan year.

Transplant Services
Coverage is provided for the expenses for human to human organ or tissue transplants including:
• Kidney
• Heart/lung
• Cornea
• Liver
• Bone marrow/Stem cell
• Pancreas
• Heart
• Lung
• Kidney/pancreas
• Liver/small bowel
• Small bowel
Covered expenses incurred by the donor of an organ or tissue for transplant to a recipient who is a covered person under this Plan are covered the same as any other sickness when the donor is a covered person under this Plan.

Covered expenses incurred by the donor of an organ or tissue for transplant when the donor is not a covered person under this Plan are covered to the extent of any benefits remaining after payment of the covered person's expenses as a recipient, when the donor's expenses are not covered under any group or individual insurance policy or benefit plan and are charged to the recipient.

Covered expenses include:
• Organ or tissue procurement from a cadaver consisting of removing, preserving and transporting the donated part;
• Services and supplies furnished by a facility provider;
• Treatment and surgery by a professional provider; and
• Drug therapy treatment to prevent rejection of the transplanted organ or tissue.
Surgical, storage and transportation costs directly related to the procurement of an organ or tissue used in a transplant described above will be covered for each such procedure completed. If an organ or tissue is sold rather than donated, no benefits will be available for the purchase price of such organ or tissue. If a covered transplant procedure is not done as scheduled due to the intended recipient's medical condition or death, benefits will be paid for charges incurred for organ or tissue procurement as described above.

You must contact the plan in order for care to be precertified prior to services occurring. Benefits for transplants are limited to $500,000 lifetime maximum for all services other than kidney or cornea transplant.

Coverage is provided for transplant recipients and family members for the cost of travel and lodging. There is a combined episodic maximum of $10,000 per covered person. This maximum applies to all associated transportation, lodging and meal expenses incurred by the transplant recipient and companion(s). Benefits for transplant - transportation and lodging are covered at 100% of charges only when treatment is rendered in a facility that offers discounts.

The Lumenos plan covers the following expenses:
• Transportation for the patient and a companion traveling on the same day(s) to and/or from the site of the transplant for the evaluation, transplant procedure, or necessary post-discharge follow-up.
• Reasonable and necessary expenses for lodging and meals for the patient (while not hospitalized) and companion. Benefits are paid at a rate of up to $50 per day for one person. If the patient is a dependent child, the transportation expenses of two companions will be covered, and lodging and meal expenses will be reimbursed up to $100 each day.
• Travel and lodging expenses - but only if the transplant recipient resides more than 50 miles from the designated transplant facility.

Maternity Care

Benefits are payable for pregnancy-related expenses of female employees or eligible spouses/dependents on the same basis as a covered illness. The expenses must be incurred while the person is covered under the Lumenos plan.

If you become pregnant, you are invited to enroll in the FutureFootsteps maternity program provided by FutureHealth. The Lumenos plan has important information to help you have a healthy pregnancy. Depending on your needs, a nurse will follow you throughout your pregnancy to provide support and help you carry out your doctor's instructions.

Also covered are services rendered in a birthing facility, provided that the physician in charge is acting within the scope of his license and the birthing facility meets all legal requirements; and midwife delivery services provided that the state in which such services are performed has legally recognized midwife delivery, and provided the midwife is licensed at the time delivery is performed.

NOTE: Home births are not covered, even if attended by a mid-wife.

Nursery facility charges for a baby will be covered under the enrolled mother until discharge from the nursery. Only charges for a nursery will be considered. Children admitted to or transferred to a more intensive level of care including, but not limited to, ICU, PICU, NICU are not covered under the Plan unless they are enrolled.

In order for any additional costs (including, but not limited to physician charges, labs, drugs) to be considered, the baby must be enrolled as per the Plan's enrollment and eligibility guidelines. No coverage exists until enrollment is completed.

Contact your payroll location to add the baby.

NOTE: Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Mental Health/Chemical Dependency

The Lumenos plan provides coverage for both mental health and chemical dependency care services. For mental health and chemical dependency services, the Lumenos plan pays 90% of discounted fees for providers who offer discounts or 60% Reasonable and Customary charges for providers who do not offer Discounts.

Services covered under your mental health and chemical dependency coverage include:

• Inpatient Mental Health and Chemical Dependency Confinement
• Outpatient Mental Health and Chemical Dependency Treatment


Inpatient and Residential Treatment Center Mental Health and Chemical Dependency Confinement
An acute inpatient hospitalization is described as treatment that includes 24-hour nursing and daily, active treatment under the direction of a psychiatrist, or for children and adolescents, a board certified/eligible child and adolescent psychiatrist.

Charges of a facility and/or professional provider related to or because of psychiatric illness are covered as follows:
• Inpatient facility charges;
• Individual Psychotherapy;
• Group Psychotherapy;
• Psychological Testing;
• Family Counseling (counseling with family members to assist in the covered person's diagnosis and treatment);
• Electro-Convulsive Therapy (electroshock treatment) or convulsive drug therapy, including anesthesia when administered concurrently with the treatment by the same professional provider.
Benefits for mental health and chemical dependency inpatient confinement are limited to 30 days per person per Plan year combined on an aggregate basis.

Outpatient Mental Health and Chemical Dependency Treatment
Outpatient mental health treatment and chemical dependency treatment is described as the diagnosis or treatment of a mental disease, disorder, or condition listed in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, as revised, whether or not the cause of the disease, disorder, or condition is physical, chemical, or mental in nature or origin. Care must be provided by a physician or licensed mental health/chemical dependency provider. Covered services include but are not limited to:
• Assessment
• Diagnosis
• Individual, group, family or conjoint p
sychotherapy,
• Medication management
• Psychological testing and assessment,
• Electroconvulsive treatment (ECT)
• Crisis intervention
• Rehabilitation (drug and alcohol related)
ECT, medication management, biofeedback treatments for mental health, and methadone maintenance treatments are covered under this benefit, but do not apply to the outpatient mental health/chemical dependency limits.

Outpatient services are limited to 30 visits per Plan year for individual and group therapy combined. The 30-visit maximum applies to outpatient mental health treatment and outpatient chemical dependency treatment combined.

Alternative Levels of Care
Alternative levels of care are covered as follows and apply toward annual inpatient day limits:
• Acute Partial Hospitalization: This is treatment that includes daily nursing and active treatment in a structured treatment program lasting 5-7 days per week and delivering at least 20 hours of active treatment per week, with patients going home each evening and/or weekend.
• Intensive Outpatient Treatment (IOP): IOP is a structured program that includes combinations of individual and group process therapy, meeting at least three times per week, and delivering at least 4 hours of treatment per week.

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.

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