1980 002 Ordinance - Laserfiche WebLink

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Convalescent Nursing Home Eligible charges for room and board and other services and supplies made by a convalescent nursing home other than charges for professional services will be paid when: a. A covered person is first confined in a hospital for at least three consecutive days, b. A doctor recommends nursing home confinement of the person for a convalescense from a condition which caused that hospital stay, or a related condition, c. Nursing home confinement begins within 15 days after discharge from that hospital stay, or within 15 days after a related convalescent nursing home stay, d. The person is under continuous care of a doctor who certifies that the person must have 24-hour-a-day nursing care. Charges for each day for a maximum of 60 days of convalescent nursing home confinement due to the same or related causes are eligible up to one-half the standard semi-private room daily rate in the last hospital in which the person was confined prior to the convalescent nursing home confinement (or, if the hospital has no semi-private rooms, 40% of the hospital's lowest private room daily rate). Home Health Care This benefit is provided in certain states and certain charges may be subject to a deductible and co- insurance. The booklet-certificate will give the details if the benefit is included. Generally a doctor prescribes a home health care plan for care and treatment of your illness at home, and certifies that otherwise you would have to be in a hospital. Services of nurses, therapists and home health aides, and supplies needed for your care usually are included for a limited number of home health care visits during a calendar year. ~. Other benefits (Subject to a Deductible) After satisfying a S 100 per person calendar year deductible, the plan pays 80% " of eligible charges, in and out of the hospital, which are not otherwise payable under the plan and are for: • Anesthetics and their administration Local ambulance service • Doctor's services' • Surgeon's services • Private duty, professional nursing care (except by a close relative) Oxygen and rental of equipment for its administration • X-ray and laboratory examinations • Physiotherapy (except by a close relative) Treatment by X-ray, radium or other radioactive substances • Surgical dressings, casts, splints, trusses, braces and crutches • Drugs and medicines • Speech therapy for certain conditions (except by a close relative) • Electronic heart pacemaker • Blood and blood plasma • Artificial limbs, larynx and eyes • Rental of wheelchair, hospital bed or iron lung Services and supplies furnished by a hospital for medical care, other than room, board and professional services. "For all doctors' visits in connection with mental, psychoneurotic or personality disorders not made during a hospital stay or in connection with treatment by convulsive therapy, Prudential pays 50% of eligible charges after the deductible has been satisfied. Eligible charges are limited to 50 calls per calendar year and S20 per call. Pregnancy Benefits (For Complications Only) Benefits for pregnancy are provided under A. and B. above, for services and supplies connected only with certain complications of pregnancy for a covered female. Details are shown in the booklet-certificate. Complications of pregnancy are covered, as described in the booklet-certificate, whether or not the Maternity Benefits are included in the plan. Deductible • Applies only once per person during a calendar year. • If two or more covered members of your family are injured in a common accident, only one deductible will apply to their combined eligible expenses resulting from that accident during a calendar year. • When any two members of your covered family have satisfied their deductibles in a calendar year, each other covered family member will be considered to have then satisfied his or her deductible for the rest of that calendar year. • Any eligible charges incurred in the last three months of any calendar year which are used toward satisfying the deductible in that year may also be used toward satisfying the deductible in the next year. 7