limitations described under Outpatient Therapy Services Maximum shown in The Schedule.
for services or supplies that are primarily to aid you or your Dependent; in daily living.
HC-COV863
01-20
HC-COV6
04-10
V1
Hospice Care Services charges made for a person who has been diagnosed as having six months or fewer to live, due to Terminal Illness, for the following Hospice Care Services provided under a Hospice Care Program: by a Hospice Facility for Bed 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; by an Other Health Care Facility for: part-time or intermittent nursing care by or under the supervision of a Nurse; part-time or intermittent services of an Other Health Care Professional; physical, occupational and speech therapy; medical supplies; drugs and medicines lawfully dispensed only on the written prescription of a Physician; and 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: for the 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; for any period when you or your Dependent is not under the care of a Physician; for services or supplies not listed in the Hospice Care Program; for any curative or life-prolonging procedures; to the extent that any other benefits are payable for those expenses under the policy;
Mental Health and Substance Use Disorder Services Mental Health Services are services that are required to treat a disorder that impairs the behavior, emotional reaction or thought processes. In determining benefits payable, charges made for the treatment of any physiological conditions related to Mental Health will not be considered to be charges made for treatment of Mental Health. Substance Use Disorder is defined as the psychological or physical dependence on alcohol or other mind-altering drugs that requires diagnosis, care, and treatment. In determining benefits payable, charges made for the treatment of any physiological conditions related to rehabilitation services for alcohol or drug abuse or addiction will not be considered to be charges made for treatment of Substance Use Disorder. Inpatient Mental Health Services Services that are provided by a Hospital while you or your Dependent is Confined in a Hospital for the treatment and evaluation of Mental Health. Inpatient Mental Health Services include Mental Health Residential Treatment Services. Mental Health Residential Treatment Services are services provided by a Hospital for the evaluation and treatment of the psychological and social functional disturbances that are a result of subacute Mental Health conditions. Mental Health Residential Treatment Center means an institution which specializes in the treatment of psychological and social disturbances that are the result of Mental Health conditions; provides a subacute, structured, psychotherapeutic treatment program, under the supervision of Physicians; provides 24-hour care, in which a person lives in an open setting; and is licensed in accordance with the laws of the appropriate legally authorized agency as a residential treatment center. A person is considered confined in a Mental Health Residential Treatment Center when she/he is a registered bed patient in a Mental Health Residential Treatment Center upon
the recommendation of a Physician. Outpatient Mental Health Services
Services of Providers who are qualified to treat Mental Health when treatment is provided on an outpatient basis, while you or your Dependent is not Confined in a Hospital, and is provided in an individual, group or Mental Health Partial Hospitalization or Intensive Outpatient Therapy Program. Covered services include, but are not limited to, outpatient
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