Opinion ID: 777312
Heading Depth: 2
Heading Rank: 1

Heading: The Mt. Sinai/Oxford Point-of-Service Plan (the Plan)

Text: 4 The Plan describes coverage for participants as follows: 5 A Member shall be entitled to receive the following medical care and services of Physicians, Surgeons, and other Plan Providers as set forth in Attachment A, including medical, surgical, diagnostic, therapeutic, and preventive services, which are generally and customarily provided in the area, which are determined by Health Plan to be Medically Necessary AND WHICH ARE PERFORMED, PRESCRIBED, DIRECTED OR AUTHORIZED IN ADVANCE BY MEMBER'S PRIMARY CARE PHYSICIAN, OR HEALTH PLAN. 6 The body of the Plan sets out the details of plan administration, including eligibility, termination of coverage, and limitations of coverage, and provides definitions of key terms like Medically Necessary 2 and Medical Director. 3 The specific details of the Plan's coverage appear in Attachment A's Schedule of Benefits and Exclusions. Introducing these benefits, Attachment A first explains that all services and benefits under this Certificate are available ... only if and to the extent that they are Medically Necessary and are provided, authorized or directed by Member's Primary Care Physician or Health Plan. The Attachment then establishes the parameters for several key aspects of the Plan's health care coverage. 7 Attachment A defines Medical Care as including Medically Necessary medical care and services, including office visits and consultations, Hospital and Skilled Nursing Facility visits, and periodic physical examinations ... when authorized in advance by Member's Primary Care Physician and/or Oxford as required under the terms of this Certificate. It also expressly defines Home Health Care to include (1) house calls and, (2) home care, further defined as: 8 [c]are in the home by Physician-supervised health professionals other than Physicians, provided by a state licensed or certified Home Health Agency within the Service Area when authorized in advance by Member's Primary Care Physician and Health Plan. Such care shall be limited to two hundred (200) home care visits per contract year. For the purpose of this Certificate, a visit is defined as treatment of up to 4 hours by an eligible home health provider. Home care includes (i) part-time or intermittent home nursing care by or under the supervision of a registered professional nurse (R.N.), (ii) part-time or intermittent home health aide services which consist primarily of caring for the Member, (iii) physical, occupational, or speech therapy where provided by the home health service or agency, and (iv) medical supplies, drugs and medications prescribed by a Participating Physician, and laboratory services by or on behalf of a certified home health agency to the extent such items would have been covered or provided hereunder if the Member had been hospitalized or confined in a Skilled Nursing Facility. 9 The Attachment then explains that Skilled Nursing Facility (SNF) services may include non-custodial care which is Medically Necessary for 200 days per Member per calendar year, but not [c]ustodial, convalescent or domiciliary care in an SNF or elsewhere. 10 Having detailed these available areas of coverage, Attachment A next sets out several explicit exclusions, including [p]rivate or special duty nursing, i.e., full-time, in-home care. Specifically, the Plan states, [e]xcept as specifically provided in any Attachment hereto, the following services and benefits are excluded from coverage hereunder.... (13)[p]rivate or special duty nursing, unless determined to be Medically Necessary and approved in advance by Health Plan. 11 Attachment C to the Plan outlines the Grievance Procedure, which consists of four elements: (1) the Member who is dissatisfied files a complaint with a Customer Service Associate, who investigates and attempts to achieve a resolution, and notifies the Member of such resolution within fifteen days; (2) if the Member is still dissatisfied, she may file a written complaint with the Issues Resolution Department (IRD), which conducts a review and provides a written response within fifteen days; (3) if still dissatisfied, the Member may file a formal written grievance with the Grievance Review Board, composed of a committee of Health Plan employees designated by the Health Plan's Board of Directors, that issues a decision within fifteen days; and (4) if still dissatisfied, the Member may appeal in writing to the Board of Directors by letter to the Secretary of the Grievance Review Board. An appeals committee designated by the Board of Directors reviews the final appeal, holding a hearing if the Member so desires. The appeals committee issues a final ruling within fifteen days.