Noblesville Schools Medical Plan 44 Section 1: Covered Health Care Services amount that the Plan would have paid for the item that meets the minimum specifications, and you will be responsible for paying any difference in cost. DME and Supplies Examples of DME and supplies include: ▪ Equipment to help mobility, such as a standard wheelchair. ▪ A standard Hospital-type bed. ▪ Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks). ▪ Negative pressure wound therapy pumps (wound vacuums). ▪ Mechanical equipment needed for the treatment of long term or sudden respiratory failure (except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters and personal comfort items are excluded from coverage). ▪ Burn garments. ▪ Insulin pumps and all related needed supplies as described under Diabetes Services. ▪ External cochlear devices and systems. Benefits for cochlear implantation are provided under the applicable medical/surgical Benefit categories in this SPD. ▪ Shoe inserts, arch supports and shoe orthotics when prescribed by a Physician. ▪ Shoes (standard or custom), lifts and wedges. Benefits include lymphedema stockings for the arm as required by the Women's Health and Cancer Rights Act of 1998. Benefits also include dedicated speech-generating devices and tracheo-esophageal voice devices required for treatment of severe speech impairment or lack of speech directly due to Sickness or Injury. Benefits for the purchase of these devices are available only after completing a required three-month rental period. Benefits are limited as stated in the Schedule of Benefits. Orthotics Orthotic braces, including needed changes to shoes to fit braces. Braces that stabilize an injured body part and braces to treat curvature of the spine are a Covered Health Care Service. The Claims Administrator will decide if the equipment should be purchased or rented. Benefits are available for repairs and replacement, except as described in Section 2: Exclusions and Limitations, under Medical Supplies and Equipment. These Benefits apply to external DME. Unless otherwise excluded, items that are fully implanted into the body are a Covered Health Care Service for which Benefits are available under the applicable medical/surgical Covered Health Care Service categories in this SPD. Emergency Health Care Services - Outpatient Services that are required to stabilize or begin treatment in an Emergency. Emergency Health Care Services must be received on an outpatient basis at a Hospital or Alternate Facility. Benefits include the facility charge, supplies and all professional services required to stabilize your condition and/or begin treatment. This includes placement in an observation bed to monitor your condition (rather than being admitted to a Hospital for an Inpatient Stay). Benefits are available for services to treat a condition that does not meet the definition of an Emergency.