210 Neb. Admin. Code, ch. 44, § 007

Current through September 17, 2024

Section 210-44-007 - Covered services and supplies

007.01 The following services will be considered covered services and supplies for which a benefit will be payable.

007.01A Hospital room and board and any other hospital furnished medical services and supplies. Limitations and conditions may be imposed where confinement is in a private room or intensive-care facility.

007.01B Services of a physician.

007.01C Services of a physical, occupational or speech therapist acting under the direction of a physician.

007.01D Anesthetics and their administration.

007.01E X-ray and laboratory examinations.

007.01F Skilled nursing facility benefits, subject to the following conditions and limitations;

007.01F(1) Benefits payable for up to 30 days in a calendar year;

007.01F(2) Confinement must begin within 14 days of discharge from hospital confinement which lasts at least three days in a row;

007.01F(3) Care is for the same condition which caused the hospital confinement; and

007.01F(4) Care is given in a skilled nursing facility which is a place licensed to provide skilled care to resident persons. It must have a registered graduate nurse (RN) on call 24 hours a day.

007.01G Ambulance services for:

007.01G(1) Local professional land and air ambulance service; and

007.01G(2) Transportation within the United States by a professional nonair ambulance or on a regularly scheduled flight on a commercial airline when:

007.01G(2)(a) Special and unique Covered Hospital Services are required which are not provided by a local hospital;

007.01G(2)(b) Transportation is medically necessary; and

007.01G(2)(c) Transportation is to the nearest hospital equipped to furnish the services;

007.01H The following medical supplies:

007.01H(1) blood and blood plasma;

007.01H(2) artificial eyes or prosthetic limbs;

007.01H(3) surgical dressings, casts, splints, trusses, braces, (except dental braces) crutches, or heart pacemakers;

007.01H(4) oxygen and the rental or purchase of equipment for its administration;

007.01H(5) rental or purchase of a wheelchair or hospital type bed or other medically necessary durable medical equipment;

007.01H(6) rental or purchase of mechanical equipment required for respiratory paralysis; and

007.01H(7) drugs and medicines that require a prescription are purchased upon a physicians' orders and dispensed by a licensed pharmacist.

007.01H(8) Where applicable the option of rental or purchase shall be determined by the pool.

007.01I The following services for a Hospice Care Program:

007.01I(1)(a) Room and board in a hospice while you are an inpatient;

007.01I(1)(b) Respite Care: Short-term Inpatient care which is necessary for you in order to give temporary relief to the person who regularly assists with the care at home. Respite Care must be provided in a Skilled or Intermediate Care Nursing facility that is affiliated with the Hospice that is providing services to you. Respite Care in a Skilled or Intermediate Care Nursing facility need not meet our normal Medical Necessary criteria ordinarily applied to Inpatient admissions;

007.01I(1)(c) The rental of medical appliances and equipment while the terminally ill covered person is in a hospice care program to the extent that such items would have been covered under the policy if the covered person had been confined in a hospital;

007.01I(1)(d) Medical, palliative, and supportive care, and the procedures necessary for pain control and acute and chronic symptom management;

007.01I(2) Such services must be provided by a hospital related institution, home health agency, hospice or other licensed facility which would be approved under Medicare or any applicable state law as a Hospice Care Program

007.01I(3) "Hospice Care Program" means a program for meeting the special needs of terminally ill individuals and their immediate families, by providing support and care during the illness and bereavement:

007.01I(3)(a) A "Terminally ill" individual is defined as an individual who has no reasonable prospect of cure and, as estimated by a physician, has a life expectancy of less than six months.

007.01I(4) Notwithstanding the provisions of any other sections of this rule, benefits for the above hospice care are limited as follows:

007.01I(4)(a) Benefits are payable only if the terminally ill person is the insured person.

007.01I(4)(b) Benefits for counseling (other than bereavement counseling) for the insured person's immediate family are not to exceed a total maximum benefit of $500. (The immediate family includes the insured person's spouse, children, and parents); and

007.01I(4)(c) Benefits for bereavement counseling for the insured person's immediate family are not to exceed a total maximum benefit of $100.

007.01I(5) In addition to the Exclusions and Limitations found in Section 006, benefits for Hospice Care will not be provided for:

007.01I(5)(a) Services performed by volunteers;

007.01I(5)(b) Pastoral services, or legal or financial counseling services;

007.01I(5)(c) Services which are primarily for the convenience of the patient, or a person other than the patient;

007.01I(5)(d) Home delivered meals;

007.01I(5)(e) Any maintenance therapy which is not designed to improve the insured's condition; or

007.01I(5)(f) Services for Mental illness.

007.01J Home Health Care received in lieu of hospitalization, furnished under a planned program by an agency licensed to provide home health care, and ordered or directed by a physician.

007.01K Diabetes Patient Education Program.

007.01L Cosmetic or Reconstructive Surgery, but only if required due to injuries received while the policy is in force or for conditions resulting from surgery for which benefits are paid under the policy. For a person eligible for pool benefits pursuant to Neb. Rev. Stat. § 44-4221(1)(b)(i) through § 44-4221(1)(b)(iii), the policy will pay for such cosmetic or reconstructive surgery regardless of when the individual was injured, when they had the initial surgery or if the surgery was paid for under the policy.

007.01M Radiation therapy or treatment.

007.01N Ambulatory Surgical Facility expenses.

007. 01OServices of a mental health practitioner.

007.01P Cardiac or pulmonary rehabilitation program

210 Neb. Admin. Code, ch. 44, § 007