Noblesville Schools Medical Plan 109 Section 9: Defined Terms • Non-Emergency Covered Health Care Services received at certain Network facilities by out-of- Network Physicians, when such services are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Health Service Act. For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary. The amount is based on one of the following in the order listed below as applicable: 1. An All Payer Model Agreement if adopted, 2. State law, or 3. The lesser of the qualifying payment amount as determined under applicable law or the amount billed by the provider or facility. The Recognized Amount for Air Ambulance services provided by an out-of-Network provider will be calculated based on the lesser of the qualifying payment amount as determined under applicable law or the amount billed by the Air Ambulance service provider. Note: Covered Health Care Services that use the Recognized Amount to determine your cost sharing may be higher or lower than if cost sharing for these Covered Health Care Services were determined based upon an Allowed Amount. Remote Physiologic Monitoring - the automatic collection and electronic transmission of patient physiologic data that are analyzed and used by a licensed Physician or other qualified health care professional to develop and manage a plan of treatment related to a chronic and/or acute health illness or condition. The plan of treatment will provide milestones for which progress will be tracked by one or more Remote Physiologic Monitoring devices. Remote Physiologic Monitoring must be ordered by a licensed Physician or other qualified health professional who has examined the patient and with whom the patient has an established, documented, and ongoing relationship. Remote Physiologic Monitoring may not be used while the patient is inpatient at a Hospital or other facility. Use of multiple devices must be coordinated by one Physician. Residential Treatment - a program of Mental Health Care Services or Substance-Related and Addictive Disorders Services that meets all of the following requirements: • Provides a program of treatment, under the active participation and direction of a Physician. • Offers organized treatment services that feature a planned and structured regimen of care in a 24- hour setting and provides at least the following basic services: ▪ Room and board. ▪ Evaluation and diagnosis. ▪ Counseling. ▪ Referral and orientation to specialized community resources. Residential Treatment Facility - a Hospital or facility, licensed and operated as required by law, that provides Residential Treatment. Secretary - as that term is applied in the No Surprises Act of the Consolidated Appropriations Act (P.L. 116-260). Semi-private Room - a room with two or more beds. When an Inpatient Stay in a Semi-private Room is a Covered Health Care Service, the difference in cost between a Semi-private Room and a private room is a Benefit only when a private room is Medically Necessary, or when a Semi-private Room is not available.