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OAC 365:10

INSURANCE DEPARTMENT

expenses for medically necessary emergency hospital, physician and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first sixty (60) consecutive days of each trip outside the United States, subject to a calendar year deductible of two hundred fifty dollars ($250), and a lifetime maximum benefit of fifty thousand dollars ($50,000). For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.

(9)

Preventive Medical Care Benefit. Coverage for the following preventive health

services not covered by Medicare:

(A)

An annual clinical preventive medical history and physical examination that

may include tests and services from subparagraph (B) of this paragraph and patient education to address preventive health care measures. (B) Preventive screening tests or preventive services, the selection and frequency of which is determined to be medically appropriate by the attending physician. Reimbursement shall be for the actual charges up to one hundred percent (100%) of the Medicare-approved amount for each service, as if Medicare were to cover the

service

as

identified

in

American

Medical

Association

Current

Procedural

Terminology (AMA CPT) codes, to a maximum of ($120) annually under this benefit. This benefit shall

one hundred twenty dollars not include payment for any

(10)

procedure covered by Medicare. At-Home Recovery Benefit. Coverage

for services to provide

short term, at-home

assistance with activities of daily living for those recovering from an illness, injury or

surgery.

  • (A)

    For purposes of this benefit, the following definitions shall apply:

    • (i)

      "Activities of daily living" include, but are not limited to, bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings.

    • (ii)

      "Care provider" means a duly qualified or licensed home health aide/homemaker, personal care aide or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses registry.

    • (iii)

      "Home" shall mean any place used by the insured as a place of residence, provided that such place would qualify as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility shall not be considered the insured's place of residence.

    • (iv)

      "At-home recovery visit" means the period of a visit required to provide at home recovery care, without limit on the duration of the visit, except each consecutive 4 hours in a 24-hour period of services provided by a care provider is one visit.

  • (B)

    Coverage requirements and limitations are as follows:

    • (i)

      At-home recovery services provided must be primarily services which assist in activities of daily living.

    • (ii)

      The insured's attending physician must certify that the specific type

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