114 Covered Services Health care services, supplies, or treatment described in this Booklet that are given to you by a Provider. To be a Covered Service the service, supply or treatment must be: • Medically Necessary or specifically included as a benefit under this Booklet. • Within the scope of the Provider’s license. • Given while you are covered under the Plan. • Not Experimental / Investigational, excluded, or limited by this Booklet, or by any amendment or rider to this Booklet. • Approved by us before you get the service if prior authorization is needed. A charge for a Covered Service will apply on the date the service, supply, or treatment was given to you. The date for applying Deductible and other cost shares for an Inpatient stay is the date of you enter the Facility.” Covered Services do not include services or supplies not described in the Provider records. Custodial Care Any type of care, including room and board, that (a) does not require the skills of professional or technical workers; (b) is not given to you or supervised by such workers or does not meet the rules for post - Hospital Skilled Nursing Facility care; (c) is given when you have already reached the greatest level of physical or mental health and are not likely to improve further. Custodial Care includes any type of care meant to help you with activities of daily living that does not require the skill of trained medical or paramedical workers. Examples of Custodial Care include: • Help in walking, getting in and out of bed, bathing, dressing, eating, or using the toilet, • Changing dressings of non - infected wounds, after surgery or chronic conditions, • Preparing meals and/or special diets, • Feeding by utensil, tube, or gastrostomy, • Common skin and nail care, • Supervising medicine that you can take yourself, • Catheter care, general colostomy or ileostomy care, • Routine services which we decide can be safely done by you or a non - medical person without the help of trained medical and paramedical workers, • Residential care and adult day care, • Protective and supportive care, including education, • Rest and convalescent care. Care can be Custodial even if it is recommended by a professional or performed in a Facility, such as a Hospital or Skilled Nursing Facility, or at home. Deductible The amount you must pay for Covered Services before benefits begin under this Plan. For example, if your Deductible is $1,000, your Plan won’t cover anything until you meet the $1,000 Deductible. The Deductible may not apply to all Covered Services. Ple ase see the “Schedule of Benefits” for details. Dependent