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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR 411.15 and 411.15(o).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health plan contract says that if you have been diagnosed by a qualified provider with certain chronic conditions and you meet certain criteria, you may be eligible for additional benefits. Additional benefits include: You have up to $240 every 3 months ($960 yearly). This is a quarterly allowance for healthy food purchases and/or for help with your phone, water and/or electricity bill payments. The allotted amount by the plan is to be used in combination for these services. This is a maximum amount allowance to combine the four (4) services mentioned above. The Health Plan will cover up to a maximum amount of money quarterly. Once that maximum amount is reached, the benefit will not be available until the next quarter. Unused allowance amount cannot be carried over to the next quarter. The quarterly periods are from January to March; from April to June; from July to September; and from October to December. If the service you receive exceeds the quarterly amount allotted by the plan, you must pay the difference in price, if any. Water, electricity, and phone bills must be in the member's name in order to access the benefit. The benefit cannot be used to buy alcoholic beverages nor tobacco, or its derivatives. The Health Plan is not responsible of any product or item defects. If any defect is found, you must contact the service provider directly or the product manufacturer, accordingly. The allowance cannot be redeemed for cash. Applies only through contracted suppliers. Reimbursement does not apply. Certain limitations and rules may apply.
Eligibility requirements: To be eligible for these additional benefits, you must meet the following requirements: You must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning -see the list of applicable conditions below. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. Eligible chronic conditions: Chronic alcohol and other drug dependence; Autoimmune disorders limited to: Polyarteritis nodosa, Polymyalgia rheumatica, Polymyositis, Rheumatoid arthritis, and Systemic lupus erythematosus; Cancer, excluding pre-cancer conditions or in-situ status; Cardiovascular disorders limited to: Cardiac arrhythmias, Coronary artery disease, Peripheral vascular disease, and Chronic venous thromboembolic disorder; Chronic heart failure; Dementia; Diabetes mellitus; End-stage liver disease; End-stage renal disease (ESRD) requiring dialysis; Severe hematologic disorders limited to: Aplastic anemia, Hemophilia, Immune thrombocytopenic purpura, Myelodysplatic syndrome, Sickle-cell disease (excluding sickle-cell trait), and Chronic venous thromboembolic disorder; HIV/AIDS; Chronic lung disorders limited to: Asthma, Chronic bronchitis, Emphysema, Pulmonary fibrosis, and Pulmonary hypertension; ?Chronic and disabling mental health conditions limited to: Bipolar disorders, Major depressive disorders, Paranoid disorder, Schizophrenia, and Schizoaffective disorder; Neurologic disorders limited to: Amyotrophic lateral sclerosis (ALS), Epilepsy, Extensive paralysis (i.e., hemiplegia, quadriplegia, paraplegia, monoplegia), Huntington's disease, Multiple sclerosis, Parkinson's disease, Polyneuropathy, Spinal stenosis, and Stroke-related neurologic deficit; and Stroke. You can find this information in Chapter 4 on pages 118-122 of the plan's 2020 Evidence of Coverage.