Covered Lumenos Georgia Health Insurance 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