The following are excluded from coverage: • services provided by a person who is a member of the patient’s family, even when that person is a health care provider. • services provided by a person who normally resides in the patient’s house, even when that person is a health care provider. • non-skilled care, Custodial Services, and assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other services; self-care activities; homemaker services; and services primarily for rest, domiciliary or convalescent care. Home Health Care Services, for a patient who is dependent upon others for non-skilled care and/or Custodial Services, is provided only when there is a family member or caregiver present in the home at the time of the health care visit to provide the non-skilled care and/or Custodial Services.
• drugs and medicines lawfully dispensed only on the written prescription of a Physician; • laboratory services; but only to the extent such charges would have been payable under the policy if the person had remained or been Confined in a Hospital or Hospice Facility. The following charges for Hospice Care Services are not included as Covered Expenses: • services of a person who is a member of your family or your Dependent's family or who normally resides in your house or your Dependent's house; • services for any period when you or your Dependent is not under the care of a Physician; • services or supplies not listed in the Hospice Care Program; • to the extent that any other benefits are payable for those expenses under the policy; • services or supplies that are primarily to aid you or your Dependent in daily living.
HC-COV1123
01-22
Hospice Care Services Charges for services for a person diagnosed with advanced illness having a life expectancy of twelve or fewer months. Services provided by a Hospice Care Program are available to those who have ceased treatment and to those continuing to receive curative treatment and therapies. Hospice Care Programs rendered by Hospice Facilities or Hospitals include services: • by a Hospice Facility for Room and Board and Services and Supplies; • by a Hospice Facility for services provided on an outpatient basis; • by a Physician for professional services; • by a Psychologist, social worker, family counselor or ordained minister for individual and family counseling; • for pain relief treatment, including drugs, medicines and medical supplies; Hospice Care Programs rendered by Other Health Care Facilities or in the Home include services: • for part-time or intermittent nursing care by or under the supervision of a Nurse; • for part-time or intermittent services of an Other Health Professional; • physical, occupational and speech therapy; • medical supplies;
HC-COV1180
01-22
Mental Health and Substance Use Disorder Services The plan covers charges for mental health and substance use disorder services. Mental Health Disorders are conditions which consider the following factors as defined in the current version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM): • a behavioral or psychological syndrome or pattern that occurs in an individual. • reflects an underlying psychobiological dysfunction. • the consequences of which are clinically significant distress (such as a painful symptom) or disability (such as impairment in one or more important areas of functioning). • must not be merely an expected response to common stressors and losses (such as loss of a loved one) or a culturally sanctioned response to a particular event (such as trance states in religious rituals). • primarily a result of social deviance or conflicts with society. Substance Use Disorders involve patterns of symptoms caused by using a substance that an individual continues taking despite its negative effects, considering the following factors as defined in the current version of the American
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