Tri-State Plan SPD >> Footnotes

1   Hospital/facility is a fully licensed acute-care general facility that has all of the following on its own premiises:

• a broad scope of major surgical, medical, therapeutic and diagnostic services available at all times to treat almost all illnesses, accidents and emergencies

• 24-hour general nursing service with registered nurses who are on duty and present in the hospital at all times

• a fully staffed operating room suitable for major surgery, together with anesthesia service and equipment (the hospital must perform major surgery frequently enough to maintain a high level of expertise with respect to such surgery in order to ensure quality care)

• assigned emergency personnel and a "crash cart" to treat cardiac arrest and other medical emergencies

• diagnostic radiology facilities

• a pathology laboratory

• an organized medical staff of licensed doctors.

For pregnancy and childbirth services, the definition of "hospital"includes any birthing center that has a participation agreement with either Empire or, for EPO participants, another BlueCross and/or BlueShield plan.

For physical therapy purposes, the definition of a "hospital" may include a rehabilitation facility either approved by Empire or participating with Empire or, for EPO participants, another BlueCross and/or BlueShield plan other than specified above.

For kidney dialysis treatment, a facility in New York State qualifies for in-network benefits if the facility has an operating certificate issued by the New York State Department of Health, and participates with Empire or another BlueCross and/or BlueShield plan. In other states, the facility must participate with another BlueCross and/or BlueShield plan and be certified by the state using criteria similar to New York's. Out-of-network benefits will be paid only for non-participating facilities that have an appropriate operating certificate.

For certain specified benefits, the definition of a "hospital" or "facility" may include a hospital, hospital department or facility that has a special agreement with Empire.

Empire does not recognize as hospitals: nursing or convalescent homes and institutions; rehabilitation facilities (except as noted above), institutions primarily for rest or for the aged, spas, sanitariums, infirmaries at schools, colleges or camps; and any institution primarily for the treatment of drug addiction, alcoholism or behavioral care.

2   Outpatient surgery includes hospital surgical facilities, surgeons and surgical assistants; chemotherapy and radiation therapy, including medications, in a hospital outpatient department, doctor's office or facility (medications that are part of outpatient hospital treatment are covered if they are prescribed by the hospital and filled by the hospital pharmacy). Same-day, ambulatory or outpatient surgery (including invasive diagnostic procedures) means surgery that does not require an overnight stay in a hospital and:

• is performed in a same-day or hospital outpatient surgical facility

• requires the use of both surgical operating and postoperative recovery rooms

• does not require an inpatient hospital admission, and

• would justify an inpatient hospital admission in the absence of a same-day surgery program.

3    Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) is covered in the following settings until Medicare becomes primary for end-stage renal disease dialysis (which occurs after 30 months):

• at home, when provided, supervised and arranged by a doctor and the patient has registered with an approved kidney disease treatment center (not covered: professional assistance to perform dialysis and any furniture, electrical, plumbing or other fixtures needed in the home to permit home dialysis treatment)

• in a hospital-based or free-standing facility.

4    Skilled nursing facility means a licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Skilled nursing facilities are useful when you do not need the level of care a hospital provides, but you are not well enough to recover at home. The Plan covers inpatient care in a skilled nursing facility, for up to 60 days of inpatient care per person per year. However, you must use an in-network facility and your doctor must provide a referral and written treatment plan, a projected length of stay and an explanation of the needed services and the intended benefits of care. Care must be provided under the direct supervision of a doctor, registered nurse, physical therapist or other health care professional.

5    Hospice care is for patients who are diagnosed as terminally ill (that is, they have a life expectancy of six months or less). Up to 210 days of hospice care is covered in full in-network only; there are no out-of-network hospice benefits. The Plan covers hospice services when the patient's doctor certifies that the patient is terminally ill and the hospice care is provided by a hospice organization certified by the state in which the hospice organization is located. Hospice care services include:

• up to 12 hours a day of intermittent nursing care by an RN or LPN

• medical care by the hospice doctor

• drugs and medications prescribed by the patient's doctor that are not experimental and are approved for use by the most recent "Physicians' Desk Reference"

• approved drugs and medications

• physical, occupational, speech and respiratory therapy when required

• lab tests, X-rays, chemotherapy and radiation therapy

• social and counseling services for the patient's family, including bereavement counseling visits for up to one year following the patient's death (if eligible)

• medically necessary transportation between home and hospital or hospice

• medical supplies and rental of durable medical equipment, and

• up to 14 hours of respite care a week.

6    Home health care means services and supplies including nursing care by a registered nurse (RN) or licensed practical nurse (LPN) and home health aid services. The Plan covers up to 200 home health care visits per person per year (in-network and out-of-network combined), as long as your doctor certifies that home health care is medically necessary and approves a written treatment plan. Up to four hours of care by an RN, a home health aide or a physical therapist count as one home health care visit. Benefits are payable for up to three visits a day. Home health care services include:

• part-time nursing care by an RN or LPN

• part-time home health aid services

• restorative physical, occupational or speech therapy

• medications, medical equipment and medical supplies prescribed by a doctor

• laboratory tests, and

• ambulette service when arranged by the Fund's Health Services Department.

If you use a home health care agency in the Empire Direct POS network, the agency is responsible for calling Health Services to pre-certify. If you use an out-of-network home health care agency, you are responsible for calling; otherwise, a pre-certification penalty will apply.

7    Home infusion therapy, a service sometimes provided during home health care visits, is available only in-network. The network provider must pre-certify by calling the Health Services Program. An Empire Direct POS network home health care agency or home infusion supplier may not bill you for covered services. If you receive a bill from one of these providers, contact the Member Service Center.

8    Emergency room treatment benefits are limited to the initial visit for emergency care. An in-network provider (not an emergency room of a participating hospital) must provide all follow-up care for you to receive maximum benefits. Also remember to contact the Health Services Program within 48 hours after an emergency hospital admission, as described in the "Pre-Certification" section, to pre-certify any continued stay in the hospital. If you have an emergency outside the Empire Direct POS Operating Area (see the "Hospital and Medical Benefits" section), show your Empire ID Card at the emergency room. If the hospital participates with another BlueCross and/or BlueShield program, your claim will be processed by the local BlueCross plan. If it is a non-participating hospital, you will need to file a claim in order to be reimbursed for your eligible expenses.

9    Ambulance services (land or air) are covered in an emergency and in other situations when it is medically appropriate (such as taking a patient home when the patient has a major fracture or needs oxygen during the trip home). Air ambulance service, which requires pre-certification, is covered only as a last resort (such as when you need to go to a distant hospital because the nearest hospital you can get to in a land ambulance cannot help you, or using land transportation would pose an immediate threat to your health).

10    Second surgical opinions are covered under the Plan at the full cost when you go through the Health Services Program for them. To confirm a cancer diagnosis or course of treatment, second or third opinions are paid as if they are in-network even if you use an out-of-network specialist. Please note that the specialist who provides the second or third opinion cannot perform the surgery.

11    Diabetes coverage includes diet information, management and supplies (such as blood glucose monitors, testing strips and syringes) prescribed by an authorized provider.

12    Preventive care under the Plan includes routine physicals, subject to limits shown above. Eligible expenses include X-rays, laboratory or other tests given in connection with the exam and materials for immunizations for infectious diseases. Adults are covered for immunizations if medically necessary.

13    Well-child care covers visits to a pediatrician, family practice doctor, nurse or licensed nurse practitioner. Regular checkups may include a physical examination, medical history review, developmental assessment, guidance on normal childhood development and laboratory tests. The tests may be performed in the office or a laboratory and must be within five days of the doctor's office visit. The number of well-child visits covered per year depends on your child's age, as shown in the chart in the "Hospital and Medical Benefits" section. Covered immunizations include: Diphtheria, tetanus and pertussis (DtaP), Hepatitis B, Haemophilus influenza Type B (Hib), Pneumococcus (Pcv), Polio (IPV), Measles, mumps and rubella (MMR), Varicella (chicken pox), Tetanus-diphtheria (Td), Hepatitis A & influenza for certain patients, other immunizations as determined by the American Academy of Pediatrics, Superintendent of Insurance and the Commissioner of Health in New York State or the state where your child lives.

14    Services of a certified nurse-midwife are covered if she or he is affiliated with or practicing in conjunction with a licensed facility and the services are provided under qualified medical direction.

15    Physical therapy is covered for up to 30 days of covered inpatient physical therapy per person per year (in-network and out-of-network combined). Physical therapy, physical medicine and rehabilitation services—or any combination of these—are covered as long as the treatment is prescribed by your doctor and designed to improve or restore physical functioning within a reasonable period of time. If you receive therapy on an inpatient basis, it must be short-term. Occupational, Speech and Vision therapy are covered if prescribed by your doctor and provided by a licensed therapist (occupational, speech or vision, as applicable) in your home, in a therapist's office or in an approved outpatient facility.

Up to 30 outpatient visits are covered per year for physical therapy. Speech, vision and occupational therapy combined are covered for up to 30 visits per year. You must receive any such services through a network provider in the home, office or the outpatient department of a network facility. For outpatient physical therapy, you must pre-certify from the first visit.

16    Durable medical equipment and supplies means buying, renting and/or repairing prosthetics (such as artificial limbs), orthotics and other durable medical equipment and supplies—but you generally must go in-network for them. The only exceptions are glucometers and disposable medical supplies, such as syringes, which are covered up to the allowed amount whether you get them from an in-network or out-of-network supplier. In addition to the items listed above, the Plan covers:

• prosthetics/orthotics and durable medical equipment from in-network suppliers, when prescribed by a doctor and approved by the Health Services Program, including:
   
  – artificial arms, legs, eyes, ears, nose, larynx and external breast prostheses
  – supportive devices essential to the use of an artificial limb
  – corrective braces
  – wheelchairs, hospital-type beds, oxygen equipment, sleep apnea monitors
  – replacement of covered medical equipment because of wear, damage, growth or change in patient's need, when ordered by a doctor
  – reasonable cost of repairs and maintenance for covered medical equipment.

The Network supplier must pre-certify the rental or purchase of durable medical equipment. In addition, the Plan will cover the cost of buying equipment when the purchase price is expected to be less costly than long-term rental, or when the item is not available on a rental basis.

17    Nutritional supplements include enteral formulas, which are covered if the patient has a written order from a doctor that states the formula is medically necessary and effective, and that without it the patient would become malnourished, suffer from serious physical disorders or die. Modified solid-food products will be covered for the treatment of certain inherited diseases if the patient has a written order from a doctor.

18    Cosmetic Surgery will be considered not medically necessary unless it is necessitated by injury, is for breast reconstruction after cancer surgery, or is necessary to lessen a disfiguring disease or a deformity arising from or directly related to a congenital abnormality. Cosmetic treatment includes any procedure that is directed at improving the patient’s appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease.

19    Experimental or "investigative" means treatment that, for the particular diagnosis or treatment of the enrolled person's condition, is not of proven benefit and not generally recognized by the medical community (as reflected in published literature). Government approval of a specific technology or treatment does not necessarily prove that it is appropriate or effective for a particular diagnosis or treatment of an enrolled person's condition. A claims administrator may require that any or all of the following criteria be met to determine whether a technology, treatment, procedure, biological product, medical device or drug is experimental, investigative, obsolete or ineffective:

• there is final market approval by the U.S. Food and Drug Administration (FDA) for the patient's particular diagnosis or condition, except for certain drugs prescribed for the treatment of cancer; once the FDA approves use of a medical device, drug or biological product for a particular diagnosis or condition, use for another diagnosis or condition may require that additional criteria be met

• published peer-reviewed medical literature must conclude that the technology has a definite positive effect on health outcomes

• published evidence must show that over time the treatment improves health outcomes (i.e., the beneficial effects outweigh any harmful effects)

• published proof must show that the treatment at the least improves health outcomes or that it can be used in appropriate medical situations where the established treatment cannot be used. Published proof must show that the treatment improves health outcomes in standard medical practice, not just in an experimental laboratory setting.