Noblesville Schools Medical Plan 114 Clinical Programs and Resources Coverage for transplant and transplant-related services are based on your health plan's terms, exclusions, limitations and conditions, including the plan's eligibility requirements and coverage guidelines. Participation in this program is voluntary. Your Plan Sponsor is providing you with Travel and Lodging assistance. Refer to the Complex Medical Conditions Travel and Lodging Assistance Program. Complex Medical Conditions Travel and Lodging Assistance Program for the Covered Health Services Described Below Your Plan Sponsor may provide you with Travel and Lodging assistance for certain Covered Health Care Services. Travel and Lodging assistance is only available for you or your eligible family member if you meet the qualifications for the benefit, including receiving care at a Designated Provider and the requisite distance from your home address to the facility is at least 50 miles. Allowed Amounts are reimbursed after the expense forms have been completed and submitted with the appropriate receipts. If you have specific questions regarding the Travel and Lodging Assistance Program, please call the number on your ID card. Travel and Lodging Expenses The Plan covers expenses for travel and lodging for the Covered Person and a travel companion, provided the Covered Person is not covered by Medicare as follows: • Transportation of the Covered Person and one companion who is traveling on the same day(s) to and/or from the site of the qualified procedure provided by a Designated Provider for care related to one of the programs listed below. • The Allowed Amount for lodging for the Covered Person (while not a Hospital inpatient) and one companion. • If the Covered Person is an enrolled Dependent minor child, the transportation expenses of two companions will be covered. • Travel and lodging expenses are only available if the Covered Person resides at least 50 miles from the Designated Provider. • Reimbursement for certain lodging expenses for the Covered Person and his/her companion(s) may be included in the unearned taxable income of the Plan participant if the reimbursement exceeds the per diem rate. • The cancer, congenital heart disease and transplant programs offer a combined overall lifetime maximum of $10,000 per Covered Person for all transportation and lodging expenses incurred by you and reimbursed under the Plan in connection with all qualified procedures. Lodging Reimbursement Assistance • A per diem rate, up to $50.00 per day, for the Covered Person or the caregiver if the Covered Person is in the Hospital. • A per diem rate, up to $100.00 per day, for the Covered Person and one caregiver. When a child is the Covered Person, two persons may accompany the child. Decision Support In order to help you make informed decisions about your health care, the Claims Administrator has a program called Decision Support. This program targets specific conditions as well as the treatments and procedures for those conditions. This program offers: