Nebraska Administrative Code › Topic - INSURANCE, DEPARTMENT OF › Title 210 - NEBRASKA DEPARTMENT OF INSURANCE › Chapter 44 - SCOPE OF COVERAGE TO BE OFFERED BY THE NEBRASKA COMPREHENSIVE HEALTH INSURANCE POOL › Section 210-44-007 - Covered services and supplies

Current through June 17, 2024
007.01 The
				following services will be considered covered services and supplies for which a
				benefit will be payable.
007.01A Hospital
				room and board and any other hospital furnished medical services and supplies.
				Limitations and conditions may be imposed where confinement is in a private
				room or intensive-care facility.
007.01B Services of a physician.
007.01C Services of a physical, occupational
				or speech therapist acting under the direction of a physician.
007.01D Anesthetics and their
				administration.
007.01E X-ray and
				laboratory examinations.
007.01F
				Skilled nursing facility benefits, subject to the following conditions and
				limitations;
007.01F(1) Benefits payable for
				up to 30 days in a calendar year;
007.01F(2) Confinement must begin within 14
				days of discharge from hospital confinement which lasts at least three days in
				a row;
007.01F(3) Care is for the
				same condition which caused the hospital confinement; and
007.01F(4) Care is given in a skilled nursing
				facility which is a place licensed to provide skilled care to resident persons.
				It must have a registered graduate nurse (RN) on call 24 hours a day.
007.01G Ambulance
				services for:
007.01G(1) Local professional
				land and air ambulance service; and
007.01G(2) Transportation within the United
				States by a professional nonair ambulance or on a regularly scheduled flight on
				a commercial airline when:
007.01G(2)(a)
				Special and unique Covered Hospital Services are required which are not
				provided by a local hospital;
007.01G(2)(b) Transportation is medically
				necessary; and
007.01G(2)(c)
				Transportation is to the nearest hospital equipped to furnish the
				services;
007.01H The following medical supplies:
007.01H(1) blood and blood plasma;
007.01H(2) artificial eyes or prosthetic
				limbs;
007.01H(3) surgical
				dressings, casts, splints, trusses, braces, (except dental braces) crutches, or
				heart pacemakers;
007.01H(4) oxygen
				and the rental or purchase of equipment for its administration;
007.01H(5) rental or purchase of a wheelchair
				or hospital type bed or other medically necessary durable medical
				equipment;
007.01H(6) rental or
				purchase of mechanical equipment required for respiratory paralysis; and
007.01H(7) drugs and medicines
				that require a prescription are purchased upon a physicians' orders and
				dispensed by a licensed pharmacist.
007.01H(8) Where applicable the option of
				rental or purchase shall be determined by the pool.
007.01I The following services for a Hospice
				Care Program:
007.01I(1)(a) Room and board in
				a hospice while you are an inpatient;
007.01I(1)(b) Respite Care: Short-term
				Inpatient care which is necessary for you in order to give temporary relief to
				the person who regularly assists with the care at home. Respite Care must be
				provided in a Skilled or Intermediate Care Nursing facility that is affiliated
				with the Hospice that is providing services to you. Respite Care in a Skilled
				or Intermediate Care Nursing facility need not meet our normal Medical
				Necessary criteria ordinarily applied to Inpatient admissions;
007.01I(1)(c) The rental of medical
				appliances and equipment while the terminally ill covered person is in a
				hospice care program to the extent that such items would have been covered
				under the policy if the covered person had been confined in a hospital;
007.01I(1)(d) Medical, palliative,
				and supportive care, and the procedures necessary for pain control and acute
				and chronic symptom management;
007.01I(2) Such services must be provided by
				a hospital related institution, home health agency, hospice or other licensed
				facility which would be approved under Medicare or any applicable state law as
				a Hospice Care Program
007.01I(3)
				"Hospice Care Program" means a program for meeting the special needs of
				terminally ill individuals and their immediate families, by providing support
				and care during the illness and bereavement:
007.01I(3)(a) A "Terminally ill" individual
				is defined as an individual who has no reasonable prospect of cure and, as
				estimated by a physician, has a life expectancy of less than six
				months.
007.01I(4)
				Notwithstanding the provisions of any other sections of this rule, benefits for
				the above hospice care are limited as follows:
007.01I(4)(a) Benefits are payable only if
				the terminally ill person is the insured person.
007.01I(4)(b) Benefits for counseling (other
				than bereavement counseling) for the insured person's immediate family are not
				to exceed a total maximum benefit of $500. (The immediate family includes the
				insured person's spouse, children, and parents); and
007.01I(4)(c) Benefits for bereavement
				counseling for the insured person's immediate family are not to exceed a total
				maximum benefit of $100.
007.01I(5) In addition to the Exclusions and
				Limitations found in Section 006, benefits for Hospice Care will not be
				provided for:
007.01I(5)(a) Services
				performed by volunteers;
007.01I(5)(b) Pastoral services, or legal or
				financial counseling services;
007.01I(5)(c) Services which are primarily
				for the convenience of the patient, or a person other than the
				patient;
007.01I(5)(d) Home
				delivered meals;
007.01I(5)(e) Any
				maintenance therapy which is not designed to improve the insured's condition;
				or
007.01I(5)(f) Services for
				Mental illness.
007.01J Home Health Care received in lieu of
				hospitalization, furnished under a planned program by an agency licensed to
				provide home health care, and ordered or directed by a physician.
007.01K Diabetes Patient Education
				Program.
007.01L Cosmetic or
				Reconstructive Surgery, but only if required due to injuries received while the
				policy is in force or for conditions resulting from surgery for which benefits
				are paid under the policy. For a person eligible for pool benefits pursuant to
				Neb. Rev. Stat. §
										44-4221(1)(b)(i)
				 through §
										44-4221(1)(b)(iii),
				the policy will pay for such cosmetic or reconstructive surgery regardless of
				when the individual was injured, when they had the initial surgery or if the
				surgery was paid for under the policy.
007.01M Radiation therapy or
				treatment.
007.01N Ambulatory
				Surgical Facility expenses.
007.
				01OServices of a mental health practitioner.
007.01P Cardiac or pulmonary rehabilitation
				program