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Services Subject to a Deductible: Hospice Care, Medical Equipment, Skilled Nursing Home, and Diabetes Supplies and Services

Participating Provider Services Subject to Calendar Year Deductible
(The following introductory wording is a summary. See "Benefits and Claim Procedures: Health Insurance co-pays and deductibles: A Primer" for complete wording.)

(Typical wording*)

Subject to all Policy limitations, exclusions, applicable deductibles, co-pays and maximums, the Company agrees to pay for Policy-defined Covered Expenses for the following described services, if they are Medically Necessary:

8. Hospice Care: Services Provided to an Insured by Participating Providers for Hospice Care due to Injuries or Sickness, if:

a. such Hospice Care is provided as the result of Injury or Sickness for which Covered Expenses were incurred by said Insured for Hospital Confinement;
b. the Insured's Provider certifies the life expectancy of the Insured is six months or less; and
c. the Insured's Provider recommends a Hospice Care program.

Payment under this coverage is limited to a period of a maximum of six (6) consecutive months.

"Hospice" means a properly licensed agency to provide care, under an administered program for a terminally ill insured and his or her family, with the following services available 24 hours per day, seven days per week: (a) inpatient services, (b) home services and (c) follow-up bereavement services.

"Hospice Care" means a medically necessary, coordinated, interdisciplinary hospice-provided program for meeting the physical, psychological, spiritual and social needs of a dying individual and his or her family. This includes nursing, medical and other health services to relieve pain and provide support through home and inpatient care during the sickness and final months of life, and following death, for bereavement of the family. "Family" refers to the spouse, sons, daughters, brothers, sisters, parents, grandparents and grandchildren of an insured. Note that this coverage is available only if it is preceded by hospital confinement.

9. Medical Equipment: Rental (not to exceed the purchase price) of a wheelchair, hospital bed, or other durable portable medical equipment Provided to an Insured by Participating Providers in each event required for therapeutic treatment of Injuries or Sickness on an Outpatient basis.

 

This is self-explanatory. Note that this coverage is available only for medical equipment to be used on an outpatient basis.

10. Skilled Nursing Home: Daily room and board and miscellaneous charges for other services Provided to an Insured by Participating Providers due to Injuries or Sickness for residential care received in a Skilled Nursing Home for up to 120 days in a twelve (12) month period, if:

a. the Insured has first been Confined in a Hospital for three (3) or more consecutive days;
b. the Skilled Nursing Home stay begins within thirty (30) days after discharge from the Hospital;
c. the Skilled Nursing Home stay is for the same or related Injury or sickness as the Hospital Confinement; and
d. the Insured's Provider certifies to the need for Skilled Nursing Home Confinement.

 

A "Skilled Nursing Home" charges patients for services, is licensed, has beds for patients, is supervised by a doctor, has 24-hour nursing service supervised by an R.N. and keeps complete medical records of patients. Note the four specific requirements; especially note the requirement for confinement in a hospital for at least 3 consecutive days before this coverage will become available.

11. Supplies and Services Associated with the Treatment of Diabetes: The following Outpatient services Provided to an Insured by Participating Providers for care received for the treatment of diabetes and associated conditions:

a. Diabetes Equipment;
b. Diabetes Supplies; and
c. Diabetes Self-Management Training.

 

The policy will usually provide a very specific, detailed description of the items that will be regarded as diabetes equipment and diabetes supplies for which coverage is available. Diabetes self-management training includes:

  1. training provided after initial diagnosis, including nutritional counseling and proper use of diabetes equipment and diabetes supplies;
  2. training authorized on the diagnosis of a provider or other health care practitioner due to a significant change in the insured's symptoms or condition which necessitates changes in the self-management regime; and
  3. periodic or episodic continuing education training when prescribed by an appropriate health care practitioner as warranted by the development of new techniques and treatments for diabetes.

*Wording may vary from contract to contract and from state to state.

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