the date the person first becomes a Dependent.] A DEVELOPMENTAL DISABILITY or DEVELOPMENTALLY DISABLED. severe, chronic disability that: is attributable to a mental or physical impairment or a combination of mental and physical impairments; is manifested before the [Member] attains age 26. is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency; reflects the for a combination and sequence of special [Member’s] need interdisciplinary or generic care, treatment or other services which are of lifelong or of extended duration and are individually planned and coordinated. Developmental disability includes but is not limited to severe disabilities attributable to intellectual disability, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments where the above criteria are met. DIAGNOSTIC SERVICES. Procedures ordered by a recognized Provider because of specific symptoms to diagnose a specific condition or disease. Some examples include, but are not limited to: radiology, ultrasound, and nuclear medicine; laboratory and pathology; and EKG's, EEG's, and other electronic diagnostic tests. DISCRETION / DETERMINATION / DETERMINE. Our right to make a decision or determination. The decision will be applied in a reasonable and non-discriminatory manner. DURABLE MEDICAL EQUIPMENT. Equipment We Determine to be: designed and able to withstand repeated use; used primarily and customarily for a medical purpose; is generally not useful to a[Member] in the absence of an Illness or Injury; and suitable for use in the home. Durable Medical Equipment includes, but is not limited to, apnea monitors, breathing equipment, hospital-type beds, walkers, and wheelchairs as well as hearing aids which are covered through age 15. Items such as walkers, wheelchairs and hearing aids are examples durable medical equipment that are also habilitative devices. Among other things, Durable Medical Equipment does not include: adjustments made to vehicles, air conditioners, air purifiers, humidifiers, dehumidifiers, elevators, ramps, stair glides, Emergency Alert equipment, handrails, heat appliances, improvements made to a[Member]'s home or place of business, waterbeds, whirlpool baths, exercise and massage equipment.
the date the person first becomes a Dependent.] DEVELOPMENTAL DISABILITY or DEVELOPMENTALLY DISABLED. A severe, chronic disability that: is attributable to a mental or physical impairment or a combination of mental and physical impairments; is manifested before the [Member] attains age 26. is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency; reflects the [Member’s] need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are of lifelong or of extended duration and are individually planned and coordinated. Developmental disability includes but is not limited to severe disabilities attributable to intellectual disability, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments where the above criteria are met. DIAGNOSTIC SERVICES. Procedures ordered by a recognized Provider because of specific symptoms to diagnose a specific condition or disease. Some examples include, but are not limited to: radiology, ultrasound, and nuclear medicine; laboratory and pathology; and EKG's, EEG's, and other electronic diagnostic tests. DISCRETION / DETERMINATION / DETERMINE. Our right to make a decision or determination. The decision will be applied in a reasonable and non-discriminatory manner. DURABLE MEDICAL EQUIPMENT. Equipment We Determine to be: designed and able to withstand repeated use; used primarily and customarily for a medical purpose; is generally not useful to a[Member] in the absence of an Illness or Injury; and suitable for use in the home. Durable Medical Equipment includes, but is not limited to, apnea monitors, breathing equipment, hospital-type beds, walkers, and wheelchairs as well as hearing aids which are covered through age 15. Items such as walkers, wheelchairs and hearing aids are examples durable medical equipment that are also habilitative devices. Among other things, Durable Medical Equipment does not include: adjustments made to vehicles, air conditioners, air purifiers, humidifiers, dehumidifiers, elevators, ramps, stair glides, Emergency Alert equipment, handrails, heat appliances, improvements made to a[Member]'s home or place of business, waterbeds, whirlpool baths, exercise and massage equipment.
HMOContract2018P.docx