119 See the “Schedule of Benefits” for details. Your Coinsurance will not be reduced by any refunds, rebates, or any other form of negotiated post-payment adjustments. Consolidated Appropriations Act of 2021 Please refer to the “Consolidated Appropriations Act of 2021 Notice” at the front of this Booklet for details. Copayment A fixed amount you pay toward a Covered Service. You normally have to pay the Copayment when you get health care. The amount can vary by the type of Covered Service you get. For example, you may have to pay a $15 Copayment for an office visit, but a $150 Copayment for Emergency Room Services. See the “Schedule of Benefits” for details. Your Copayment will be the lesser of the amount shown in the Schedule of Benefits or the Maximum Allowed Amount. Covered Procedure Please see the “Human Organ and Tissue Transplant (Bone Marrow / Stem Cell), Cellular and Gene Therapy Services” benefit in the “What’s Covered” section. 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,