Health & Security Plan > SPD > Hospital Services and Supplies – 90%

Summary Plan Description

Hospital Services and Supplies—90%

Inpatient Hospital

Inpatient Admissions Must Be Precertified With the Medical Review Agency

Benefits are provided for a semiprivate room and hospital services and supplies to treat an illness or injury. Intensive and coronary care units are also covered when medically necessary. All inpatient hospital admissions must be precertified. Covered hospital services and supplies include:

  • Operating rooms and equipment.
  • Nursing services (other than the services of a private-duty nurse or attendant).
  • Diagnostic or therapeutic items or services that are ordinarily furnished by the hospital for the care and treatment of the patient.
  • Anesthesia including administration and materials.
  • Drugs, biologicals, supplies, appliances, and equipment for use in the hospital that are ordinarily furnished by the hospital for the care and treatment of the patient.

Benefits are not provided for a bed or room set aside for a patient while the patient is in a special care unit.

Helpful Hint

If your physician recommends an inpatient hospital admission, you must call the medical review agency as soon as possible but no later than 48 hours before the scheduled admission. Please see "Preadmission Certification Program" on pages 37-38 for details.

Outpatient Hospital

Benefits are provided for:

  • Services and supplies otherwise provided on an inpatient hospital basis.
  • Facility fees for outpatient surgery, a same-day surgical center or an ambulatory surgical center.
  • Treatment including x-ray, radium therapy and other radioactive substances, chemotherapy, and laboratory and diagnostic radiology and imaging.
  • Care in a hospital emergency room. There is a $50 copayment for each visit to the emergency room. The $50 copayment is waived if the patient is admitted as an inpatient directly following treatment in the emergency room.

Key Point

Care in an emergency room is expensive. An emergency room should only be used when the patient's condition requires immediate medical attention. You may want to identify an urgent care facility near your home or work which can be used in less emergent situations.

Key Point

Fees for a hospital, ambulatory surgical center or other surgical facility for surgical services commonly and primarily performed in a clinic or physician's office are not deemed medically necessary and will be denied. Please see page 78 for a partial list of applicable surgical procedures or call the Trust Office.