Noblesville Schools Medical Plan 52 Section 1: Covered Health Care Services Rehabilitation services must be performed by a Physician or by a licensed therapy provider. Benefits include rehabilitation services provided in a Physician's office or on an outpatient basis at a Hospital or Alternate Facility. Rehabilitative services provided in your home by a Home Health Agency are provided as described under Home Health Care. Rehabilitative services provided in your home other than by a Home Health Agency are provided as described under this section. Benefits can be denied or shortened when either of the following applies: • You are not progressing in goal-directed rehabilitation services. • Rehabilitation goals have previously been met. Benefits are not available for maintenance/preventive treatment. Scopic Procedures - Outpatient Diagnostic and Therapeutic Diagnostic and therapeutic scopic procedures and related services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office. Diagnostic scopic procedures are those for visualization, biopsy and polyp removal. Examples of diagnostic scopic procedures include: • Colonoscopy. • Sigmoidoscopy. • Diagnostic endoscopy. Please note that Benefits do not include surgical scopic procedures, which are for the purpose of performing surgery. Benefits for surgical scopic procedures are described under Surgery - Outpatient. Benefits include: • The facility charge and the charge for supplies and equipment. • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for all other Physician services are described under Physician Fees for Surgical and Medical Services.) Benefits that apply to certain preventive screenings are described under Preventive Care Services. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Services and supplies provided during an Inpatient Stay in a Skilled Nursing Facility or Inpatient Rehabilitation Facility. Benefits are available for: • Supplies and non-Physician services received during the Inpatient Stay. • Room and board in a Semi-private Room (a room with two or more beds). • Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Please note that Benefits are available only if both of the following are true: • If the first confinement in a Skilled Nursing Facility or Inpatient Rehabilitation Facility was or will be a cost effective option to an Inpatient Stay in a Hospital. • You will receive Skilled Care services that are not primarily Custodial Care. The Claims Administrator will determine if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. Benefits can be denied or shortened when either of the following applies: • You are not progressing in goal-directed rehabilitation services.