2005

RI 73-445

M-CARE www.mcare.org

A Health Maintenance Organization

Serving: Southeastern Michigan and Flint area Enrollment in this plan is limited. You must live in our Geographic service area to enroll. See page 6 for requirements.

For changes in benefits see page 7.

This Plan has excellent accreditation from NCQA. See the 2005 Guide for more information on accreditation.

Enrollment code for this Plan: EG1 Self Only EG2 Self and Family

CALL - THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 658-8878 or write to us at M-CARE, Customer Service, 2301 Commonwealth Boulevard, Ann Arbor, MI 48105. You may also request replacement cards through our Web site at www.mcare.org .

Where you get covered care

You get care from "Plan providers" and "Plan facilities." You will only pay copayments and you will not have to file claims .

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members . Our M-CARE provider network recruitment process is a very selective process. Our physician screening and credentialing is rigorous and comprehensive. For credentialing, we verify state licensure, hospital privileges, board certification, and whether there is adequate malpractice coverage.

We list Plan providers in the provider directory, which we update periodically. The list is also on our Web site.

Plan facilities

Plan facilities are hospital s and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our Web site.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. You must choose a primary care physician from the primary care physicians listed in the M-CARE Provider Directory. You can select a primary care physician from M-CARE’s Provider Directory or by calling us at (800) 658-8878 for help with choosing or changing your primary care physician.

Primary care

Your primary care physician can be a family practitioner, internist, or pediatrician.Your primary care physician will provide most of your health care, or give you a referral to see a specialist. If you have not chosen a M-CARE pediatrician to be your child’s PCP and want to take your child to a M-CARE pediatrician for routine services, you can without a referral. M-CARE may assign that pediatrician to be your child’s PCP.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care

Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, a female member may see her M-CARE OB/GYN for routine services, without referral.

Here are some other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with us and Plan specialists to develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else. Please contact the Plan to authorize and coordinate this care.

If you have a chronic and disabling condition and lose access to your specialist because we:

- Terminate our contract with your specialist for other than cause; or

- Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program Plan; or

- Reduce our service area and you enroll in another FEHB Plan.

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days. Please contact the Plan to authorize and coordinate this care.

Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (800) 658-8878. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or

The day your benefits from your former plan run out; or

The 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment .

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process pre-authorization. Your physician must obtain pre-authorization for the following services.

All non-emergency inpatient hospitalization

Outpatient/ambulatory surgery

Skilled nursing facility admissions

Home health care services

Hospice

Durable medical equipment

Orthopedic and prosthetic devices

Selected medications

Physical/Occupational/Speech therapy

Growth Hormone Therapy (GHT)

Our pre-authorization process is as follows:

Your primary care physician determines a need for an elective admission or other medically necessary service that requires pre-authorization.

Your primary care physician contacts M-CARE’s Authorization Department.

Your primary care physician, or specialist with the primary care physician’s approval, notifies a participating hospital or facility of the need for this procedure.

If there are any questions related to admission, care setting, benefit, coverage, or medical necessity, M-CARE’s Utilization Management Department will contact your primary care physician or treating physician directly.

You are responsible for obtaining authorization for mental health and substance abuse services from the Central Diagnostic and Referral (CDR) unit assigned to you before seeking treatment. Your CDR authorizes and coordinates all of your mental health and substance abuse care. Simply call the CDR phone number that is listed on the front of your M-CARE identification card. You do not need a referral from your primary care physician. M-CARE will not cover unauthorized care. If you need additional information or the phone number of your CDR, please call M-CARE Customer Service.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.

Deductible

We do not have a deductible.

Coinsurance

Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 50% of the allowable charges for durable medical equipment.

Your catastrophic protection out-of-pocket maximum

After your copayments total $4,000 per person or $8,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments for prescription drugs do not count toward your catastrophic protection out-of-pocket maximum , and you must continue to pay copayments for these services.

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions , limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary .

Plan physicians must provide or arrange your care.

We do not have a calendar year deductible.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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Professional services of physicians

In physician’s office

Office medical consultations

Second surgical opinion

$10 per office visit

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility

Nothing

At home

Note: We cover house calls within the service area if your doctor determines that such care is necessary and appropriate.

$10 per house call

Tests, such as:

Blood tests

Urinalysis

Non-routine pap test s

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $10 per office visit

Routine screenings, such as:

Total Blood Cholesterol-once every three years

Colorectal Cancer Screening , including

- Fecal occult blood test

- Sigmoidoscopy, screening – every five years starting at age 50

- Double contrast barium enema – every five years starting at age 50

- Colonoscopy screening – every ten years starting at age 50

$10 per office visit

Routine Prostate Specific Antigen (PSA) test – one annually for men age 40 and older

$10 per office visit

Routine pap test

Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

$10 per office visit

Routine mammogram – covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year

At age 65 and older, one every two consecutive calendar years

$10 per office visit

Routine immunization s, such as:

Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine-annually, age 50 and over

Pneumococcal vaccine, age 65 and over

$10 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, travel, or to obtain a marriage license.

All charges

Childhood immunizations recommended by the American Academy of Pediatrics

$10 per office visit

Well-child care charges for routine examinations, immunizations and care

Examinations, such as:

- Eye exams through age 17 to determine the need for vision correction

- Ear exams through age 17 to determine the need for hearing correction

- Examinations done on the day of immunizations

Nothing for well-child visits through age 6

$10 per office visit after age 6

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary .

We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

We cover one routine ultrasound per low-risk pregnancy.

Nothing

Not covered: Multiple sonograms to determine fetal age, size or sex.

All charges

A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures Section 5 (b))

Surgically implanted contraceptive s (such as Norplant)

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Genetic counseling

Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

Not covered:

Reversal of voluntary surgical sterilization.

All charges

Diagnosis and treatment of infertility such as:

Artificial insemination:

- intravaginal insemination (IVI)

- intracervical insemination (ICI)

- intrauterine insemination (IUI)

$10 per office visit

Fertility drugs

Note: We typically cover injectible fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. However, there are some self-injected infertility drugs covered under the prescription drug benefits.

50% copay per prescription unit or refill for fertility drugs to induce ovulation

Not covered:

Assisted reproductive technology (ART) procedures, such as:

- in vitro fertilization

- embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

All charges

Testing and treatment

Allergy injections

$10 per office visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplant s is limited to those transplants listed under Organ/Tissue Transplants on page xx.

Respiratory and inhalation therapy

Dialysis – hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: – We only cover GHT when we preauthorize the treatment and it is documented that the member has a growth hormone deficiency. Call (800) 658-8878 for prior authorization. We cover GHT under the plan’s prescription drug benefit.

We will ask you to submit information that establishes that the GHT is medically necessary . Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

Nothing if you receive these treatments during your visit; otherwise, $10 copay per office visit

Up to 60 visits for any combination of physical or occupational therapy services per condition. Coverage applies to the services of each of the following:

qualified physical therapists and

occupational therapists

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury. We will only cover short-term rehabilitative therapy where significant improvement can be expected within two months.

Note: This benefit is renewable after surgery.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to six consecutive weeks.

Nothing

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges

20 visits per condition per calendar year for medically necessary speech therapy services with qualified speech pathologists.

Nothing

Not covered:

Evaluations and treatments covered in a school program or public agency.

Foreign accent reduction or English as a second language spoken at home.

Maintenance therapy, i.e., treatment that does not require the use of a qualified speech therapist to perform.

Treatment for disorders that are self-correcting as determined by the member’s PCP/specialist and speech therapist.

All charges

Hearing testing

$10 per office visit

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges

In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye, we cover an annual refraction (to provide a written lens prescription) by a plan provider.

Nothing

Not covered:

Eyeglasses or contact lenses (except immediately following cataract surgery).

Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$10 per office visit

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above.

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery).

All charges

Artificial limbs and eyes; stump hose

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: Internal prosthetic devices are paid as hospital benefits; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b) for coverage of the surgery to insert the device.

Foot orthotics

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. Limited to one per member per lifetime.

Note: Your plan physician must write the prescription and we must authorize the equipment. We base our decision on medical necessity. You must obtain authorized equipment from a plan contracted provider. We reserve the right to require use of the least costly medically-effective device.

50% coinsurance per item

Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

Nothing

Not covered:

Orthopedic and corrective shoes

Arch supports

Heel pads and heel cups

Wigs, prosthetic hair, or hair transplants

Lumbosacral supports

Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than 3 years after the last one we covered

All charges

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds

Wheelchairs ; (the type depends on your illness)

Crutches

Walkers

50% coinsurance per item

Blood glucose monitors

Insulin pumps

Diabetic supplies including glucose test tablets and test tape

Benedict’s solution or equivalent, and acetone test tablets

Note: Your plan physician must write the prescription and we must authorize the equipment. We base our decision on medical necessity. You must obtain authorized equipment from a plan contracted DME provider. We reserve the right to require use of the least costly medically-effective device.

Nothing

Not covered:

Over-the-counter medical supplies such as gauze, bandages, tape, and dressings

Over-the counter or non-medically necessary custom-fitted braces

Bathroom items

Athletic or exercise equipment

Personal convenience items

Air conditioner, humidifiers, etc.

All charges

Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

$5 per office visit

Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient’s family;

Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges

No Benefit

All charges

No Benefit

We do not cover services such as:

Naturopathy

Hypnotherapy

Biofeedback

Acupuncture

All charges

Coverage is limited to:

Health education classes including childbirth preparation, breastfeeding nutrition, CPR, first aid, and smoking cessation classes are limited to one per category per calendar year. Classes must be provided at a plan provider.

Free access to the University of Michigan Health System’s Health Education Resource Center to borrow a variety of health-related videos, audiotapes, and books.

Asthma, cardiovascular health, depression, diabetes, and heart failure management programs.

A limited number of visits for nutritional counseling provided by a registered dietician are covered when ordered by the member’s PCP for the following medical diagnoses:

- Hyperlipidemia, Hypertension, Heart Failure, and Previously diagnosed diabetes (four visits per year);

- Newly diagnosed diabetes (six visits the first year following diagnosis);

- Gestational diabetes (four visits per pregnancy).

Nothing

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions , limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary .

Plan physicians must provide or arrange your care.

We do not have a calendar year deductible.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital , surgical center, etc.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see reconstructive surgery )

Surgical treatment of morbid obesity -- a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over

Insertion of internal prosthetic devices . See 5(a) – Orthopedic and prosthetic devices for device coverage information

Voluntary sterilization (e.g., Tubal ligation, Vasectomy)

Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit; nothing if performed in a hospital

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges

Surgery to correct a functional defect

Surgery to correct a condition caused by injury or illness if:

- the condition produced a major effect on the member’s appearance and

- the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

- surgery to produce a symmetrical appearance of breasts;

- treatment of any physical complications, such as lymphedemas;

- breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

$10 per office visit; nothing if performed in a hospital

Not covered:

Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit; nothing if performed in a hospital

Not covered:

Oral implants and transplants

Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingival, and alveolar bone)

All charges

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single – Double

Pancreas

Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplant s (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin’s lymphoma; advanced non-Hodgkin’s lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

Note: The Plan’s providers participate with the United Network Organ Sharing (UNOS) and the National Marrow Donor Program.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

Nothing

Not covered:

Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs

Transplants not listed as covered

Travel and lodging expenses

All charges

Professional services provided in –

Hospital (inpatient)

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Physician’s office

Nothing

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions , limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary .

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

We do not have a calendar year deductible.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification

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Room and board , such as

Semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semi-private room rate.

Nothing

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Blood or blood plasma, if not donated or replaced

Dressings , splints , casts , and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber s