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Atlantis Outpatient Centers


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In-Plan Benefits

Subject to the applicable Exclusions, limitations, Delivery System Rules, Medical Utilization Review Provisions, and other conditions of the Plan, Covered Persons are entitled to the benefits in this Benefits section for Covered Services. Covered Services must be rendered by a Hospital, Physician or other Provider during each Plan Year. Benefits will only be provided for services, supplies and care that are Medically Necessary and consistent with the diagnosis and treatment of an illness or injury, in the amounts specified in the ´┐ŻSUMMARY OF BENEFITS".

Except for emergency services, as defined below, most services must be provided at or through the Member´┐Żs Participating Primary Care Provider's office, by providers upon written referral from the PCP, or by participating providers, subject to the conditions below. Female Members however have direct access to primary and preventive obstetric and gynecological care from a Participating Provider of OB/GYN Care without a referral from their PCP. See Section VI Primary and Preventive Care Services ´┐Ż´┐ŻRoutine Gynecological Services´┐Ż.

Care by out-of-Plan providers, except for emergency services, must be arranged and approved by the Plan. Coverage is subject to any co-payment or benefit limits shown in the SUMMARY OF BENEFITS. See also Section IX ´┐ŻReferrals´┐Ż for more information on how to access these benefits.

Pre-existing Conditions for which medical care, diagnosis or treatment was recommended or received within the six-month period ending on the Enrollment Date are not covered under the Group Contract for a period of 11 months. However, the Plan will credit the time the Covered Person was covered under other Creditable Coverage if the coverage was continuous to a date not more than 63 days prior to the Enrollment Date of this Plan. Waiting periods and Affiliation Periods are not considered a break in coverage. The exclusion period for coverage for a Preexisting Condition does not apply to pregnancy, genetic information or newborn children or adopted children before the age of 18 if they are covered under the Contract within 30 days of the date of birth, the date the child is legally placed for adoption, or the date the child is legally adopted.

Refer to the Exclusions section of this Certificate of Coverage for information on health conditions and services that are permanently excluded form coverage under this Plan.

The services described in this section will be provided to Members when they are Medically Necessary.

A. EMERGENCY SERVICES

1. Emergency Services are defined as care for the treatment of:

´┐ŻA medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

(a) Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of the person or others in serious jeopardy; or

(c) Serious dysfunction of any bodily organ or part of such person; or

(d) Serious disfigurement of such person´┐Ż.

Emergency Services are covered 24 hours a day within or outside of the Service Area, from participating or non-participating providers. Prior approval is not required if the services meet the definition above. You will be charged a co-payment, according to your SUMMARY OF BENEFITS.

If you need treatment, but it is not an emergency, you should call your Primary Care Provider. Your PCP will provide you with instructions about what to do.

For emergency services, go directly to the nearest provider of Emergency Services. Emergency Services, as defined in the paragraph above, do not require prior approval by the Plan or your PCP. However, you or your representative must notify the Plan of the emergency service within forty-eight (48) hours, or as soon as it is reasonably possible.

Some examples of emergencies, included, but not limited to:

´┐Ż Severe Chest Pains

´┐Ż Loss of Consciousness

´┐Ż Poisoning

´┐Ż Shortness of Breath

´┐Ż Uncontrolled Bleeding

1. Emergency Services Outside of the Service Area

Emergency Services are covered outside of the Service Area if care is required for an emergency medical condition that meets the definition of an emergency as stated above. You must notify the Plan of the Emergency Service visit or admission within 48 hours or as soon as it is reasonably possible. You will be responsible for co-payments.

Non-Emergency Use of the Emergency Room

You will be responsible for Emergency Services charges, including all related charges, for care for conditions that normally are treated on a non-emergency basis and do not meet the definition above.

Some examples of situations that are usually NOT emergencies:

´┐Ż Colds, Coughs, & Sore Throats

´┐Ż Earaches

´┐Ż Fatigue

´┐Ż Pink Eye

´┐Ż Poison Ivy

´┐Ż Sprains & Strains

B. PROFESSIONAL AND OFFICE SERVICES

1. Diabetes Services

Covered services include the following diabetic equipment and supplies:

(a) Blood glucose monitors

(b) Blood glucose monitors for the legally blind

(c) Data management systems

(d) Test strips for glucose monitors

(e) Visual reading and urine testing strips

(f) Insulin

(g) Injection aids

(h) Cartridges for the legally blind

(i) Syringes

(j) Insulin pumps and appurtenances thereto

(k) Insulin infusion devices

(l) Oral agents for controlling blood sugar

(m) Additional Medically Necessary equipment and supplies, as may be required by the New York State Department of Health.

Coverage is also provided for diabetes self-management education to ensure that Members with diabetes are educated on the proper self-management and treatment of their diabetic condition, to include information on proper diets.

Self-management education is limited to Medically Necessary visits where a physician diagnoses a significant change in the Member's symptoms or condition, which requires changes in self-management, or where reeducation or refresher education is necessary. The education may be provided by a physician, other licensed health care provider legally authorized to prescribe under title eight of the education law, or their staffs, as part of an office visit for diabetes diagnosis or treatment. A certified diabetes nurse educator, certified nutritionist, certified dietician or registered dietician may also provide education after a referral from the treating physician or other provider. The education must be provided in a group setting, when practicable. Coverage also includes home visits when Medically Necessary.

Refer to your "SUMMARY OF BENEFITS" for any applicable co-payment.

2. Family Planning and Reproductive Health Services

Covered services include consultation, tubal ligations, removal of an intrauterine device, and vasectomy.

Coverage does not include treatment for any artificial means to achieve pregnancy, to include invitro fertilization, Gamete Intra Fallopian Transfer (GIFT), ZIFT, injectables, and reversal of voluntary induced sterilization.

Birth control devices and items, such as Norplant, IUDs, diaphragms, condoms and birth control pills are excluded except as may be included in prescription drug riders.

3. Home Health Care

Home health care is a covered service with prior authorization and when the attending physician certifies that:

(a) Confinement in a skilled nursing facility or hospital would otherwise be required if home health care were not provided; and

(b) The plan covering the home health service is established and approved in writing by the physician; and

(c) The home health services are provided or coordinated by a state certified home health agency or a licensed home care services agency.

Home health care shall consist of one or more of the following:

´┐Ż Part-time or intermittent home nursing care by or under the supervision of a registered professional nurse (R.N.),

´┐Ż Part-time or intermittent home health aide services which consist primarily of caring for the patient,

´┐Ż Physical, occupational or speech therapy if provided by the home health service or agency, and or

´┐Ż Medical supplies, drugs and medications prescribed by a 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 if hospitalized or confined in a skilled nursing facility.

Each visit by a member of a home care team shall be considered as one home care visit. Four hours of home health aide service shall be considered as one home care visit.

Refer to your "SUMMARY OF BENEFITS" for coverage limitations.

4. Primary and Preventive Care Services

Covered primary care services include office visits, home visits and Hospital visits provided by your PCP for consultations, diagnosis and treatment of injury and disease. Preventive care services include the following:

(a) Well Child Visits

Periodic visits to your child´┐Żs Primary Care Provider are covered in full without a co-payment. These routine visits cover the following services: a medical history, complete physical examination, developmental assessment, anticipatory guidance, laboratory tests, hearing screenings, vision screenings and Medically Necessary immunizations and boosters.

Co-payments are waived for visits per the following schedule, as recommended by the American Academy of Pediatrics:

Newborn: 2 to 4 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months

Ages 2 ´┐Ż 19: One visit per year

(b) Periodic Health Evaluations

Covered services include routine physical examinations (except when solely to meet the
requirements of a party other than the Member, such as school or insurance physicals), pelvic
examinations, routine ear and hearing examinations, routine allergy injections, adult
immunizations (not solely for travel), and routine eye examinations.

(c) Routine Gynecological Services

Female Members are entitled to receive primary and preventive obstetric and gynecological services from a qualified participating provider of such services up to twice per calendar year, as well as care related to pregnancy, without a referral from your Primary Care Provider. You may also self-refer for primary and preventive obstetric and gynecological follow-up services required because of such visits, or because of an acute gynecological condition. We recommend that you and/or your OB/GYN keep your PCP informed of any services that you have been provided.

Routine services include an annual pelvic examination, cervical cytology screening for cervical cancer (Pap smear) for woman aged 18 and older, breast examination and mammogram screening for breast cancer subject to the following guidelines:

1. One baseline mammogram for women aged 35 through 39.

2. Mammogram once every two years, or more frequently upon the recommendation of the Atlantis Health Plan provider, for women aged 40 through 49.

3. Annually for women aged 50 and over.

4. Women at high risk for breast cancer should consult their doctor about beginning screening mammography before age 40 and to determine if more frequent mammograms need to be done in their 40s. A high risk for developing breast cancer is associated with one or more of the following conditions:

´┐Ż Having a prior history of breast cancer

´┐Ż Laboratory evidence that the woman is carrying a specific mutation or genetic change that increases her susceptibility to breast cancer

´┐Ż Having a mother, sister or daughter with a history of breast cancer, or having two or more close relatives, such as cousins, with a history of breast cancer

´┐Ż Having had a diagnosis of other types of breast disease (not cancer but a condition that may predispose cancer) on a breast exam, or having two or more breast biopsies for benign disease, even if no atypical cells are found

´┐Ż Having dense breast tissue (above 75%) on a previous mammography examination that a clear reading is difficult

´┐Ż Having a first delivery and birth at age 30 or older

Mammography screening means an x-ray examination of the breast, using dedicated equipment, including x-ray tube, filter, compression device, screens, films and cassettes, with an average glandular radiation dose less than 0.5 rem per view, per breast. Only one routine screening will be covered each year.

5. Pregnancy Care

Medical care during pregnancy is covered for the Subscriber and the Subscriber´┐Żs covered spouse and dependent children. Pregnancy benefits include inpatient hospital care and prenatal and post-natal care, to include complications of pregnancy, rendered by the Member´┐Żs participating provider. Routine newborn nursery care is also covered.

Hospital inpatient benefits include a minimum stay of 48 hours following a vaginal delivery and 96 hours following a cesarean section for mother and newborn. Services of a licensed midwife are also covered if they do not duplicate the attending physician´┐Żs services. Maternity care coverage also includes parent education; assistance and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments.

The mother can choose to be discharged earlier than the above time frames. If so, one home care visit will be provided. This visit is in addition to the Home Health Care benefits of this Certificate of Coverage. The visit must be requested within 48 hours of the time of delivery (96 hours in the case of a cesarean). The home visit, by a Registered Nurse (RN) will occur within 24 hours after discharge, or of the time of the mother's request, whichever is later. There is no co-payment for the home care visit nor will it be counted against available Home Health Care benefits.

Medical care is also provided for miscarriages and Medically Necessary terminations of pregnancy. Coverage for elective abortions is limited to one occurrence per calendar year.

C. SPECIALTY CARE SERVICES

Specialty care is covered when received from a participating provider with appropriate referral from the Primary Care Provider. Participating providers include Physicians, Psychologists, Social Workers, Chiropractors, and Podiatrists. If specialty care is not available from a Participating Provider, prior authorization from Atlantis Health Plan is required to see a nonparticipating provider. See also Section X ´┐ŻIn-Plan Referrals´┐Ż.

Ambulatory care in physicians´┐Ż offices includes services for diagnostic x-rays, radiation therapy, laboratory and pathological examinations, and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy. See Chemotherapy services.

Co-payments are listed in the ´┐ŻSUMMARY OF BENEFITS´┐Ż.

Other specialty services follow:

1. Chiropractic Care Coverage is provided for the services of a licensed Participating Doctor of Chiropractic for the detection and correction by manual or mechanical means of structural imbalance, distortion of subluxation in the human body for the purpose of removing nerve interference, and effects thereof, caused by or related to distortion, misalignment or subluxation of or in the vertebral column. Refer to the "SUMMARY OF BENEFITS" for coverage limitations.

2. Surgical and Anesthesia Services

Medically Necessary surgical services are covered on an inpatient as well as outpatient basis. The benefit includes pre-admission testing, the services of a surgeon, specialist, an assistant and an anesthetist or anesthesiologist as necessary and appropriate. All covered services include pre-operative and post-operative care.

Reconstructive surgery is covered when such service is incidental to or follows a surgery resulting from trauma, infection or other disease of the involved part. Surgery to correct a congenital disease or anomaly of a covered dependent child, which has resulted in a functional defect, is also provided.

Inpatient hospital care is provided for a lymph node dissection or a lumpectomy for the treatment of breast cancer or a mastectomy. Hospitalization will be approved for as long as medically appropriate as determined by the attending physician in consultation with the Member. In the case of a covered mastectomy, breast reconstruction, to include implanted breast prosthesis, is provided as well as surgery on the healthy breast to restore or achieve symmetry.

See also Second Opinions for related benefits. Refer to the "SUMMARY OF BENEFITS" for applicable co-payments.

3. Second Opinions

There may be instances when you will disagree with a provider's recommended course of treatment or surgical recommendation. In such cases, you may receive a second opinion or second surgical opinion from another appropriate board-certified specialist within the Network. You must pay the normal office visit co-payment for second opinions that you request.

If the first opinion concerns a diagnosis of cancer (either negative or positive) or a recurrence of cancer or a recommendation for a course of treatment for cancer, you may request a referral to a non-Network specialist for a second opinion, including a specialist affiliated with a specialty care center for the treatment of cancer. This visit will be provided at no additional cost beyond the normal office visit co-payment.

In some instances, we may require a second opinion before pre-authorizing certain procedures. There is no cost to you when we request a second opinion.

4. Chemotherapy

Covered services include radiation therapy and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy provided that they are (1) related to and necessary for the treatment and diagnosis of the patient´┐Żs illness or injury, and (2) ordered by a physician. Ambulatory services may be received in a physician´┐Żs office or an approved outpatient hospital facility.

Refer to the "SUMMARY OF BENEFITS" for any applicable co-payment.

5. Pre-admission Testing

Services are provided for pre-admission testing performed in hospital facilities prior to scheduled surgery in the same hospital provided that:

´┐Ż Tests are necessary for and consistent with the diagnosis and treatment of the condition for which surgery is to be performed,

´┐Ż Reservations for a hospital bed and for an operating room have been made prior to the performance of the tests,

´┐Ż Surgery actually takes place within 7 days of such pre-surgical tests, and

´┐Ż The Member is physically present at the hospital for the tests.

6. Dental Services

We will not provide coverage for dental care or treatment, except for dental care or treatment due to accidental injury to sound natural teeth within twelve ´┐Ż (12) months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly.

7. Hemodialysis Services

Hemodialysis services are a covered benefit. See Hospital Inpatient and Outpatient Services.

D. HOSPITAL, SKILLED NURSING AND HOSPICE SERVICES

1. Hospital Inpatient and Outpatient Services

Inpatient and outpatient hospital services are covered when provided by a hospital or freestanding surgical facility.

Inpatient hospital services for acute-care include:

(a) Daily room and board in a semi-private, ward, intensive care or coronary care room, including general nursing care, meals and special diets if Medically Necessary. A private room will only be covered if Medically Necessary.

(b) Hospital services and supplies determined to be Medically Necessary, to include: use of operating room and facilities; anesthesia and oxygen services; laboratory and other diagnostic tests; x-ray services; administered drugs, biologicals, chemotherapy; radiation therapy; inhalation therapy; whole blood and blood products and their administration; cardiac rehabilitation, and short-term physical, speech and occupational therapy. Take-home drugs dispensed prior to release from confinement, whether billed directly or separately by the hospital are not covered.

(c) Non-emergency Inpatient participating hospital confinement days are covered with prior authorization from Atlantis Health Plan through a participating physician.

(d) Non-emergency Inpatient non-participating hospital confinement days are covered with prior authorization from Atlantis Health Plan.

(e) Emergency Inpatient days are covered. Atlantis Health Plan should be notified within 48 hours of admission, or as soon, as is reasonably possible.

Outpatient hospital services include ambulatory care, services and supplies, including drugs, when incurred for the following reasons:

(a) Emergency Department treatment provided in accordance with the Emergency Care provisions of this Certificate of Coverage. A participating physician should provide follow-up care, not the Emergency Department.

(b) Regularly scheduled treatment services such as inhalation therapy, radiation therapy, cardiac rehab, physical therapy and hemodialysis and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy.

(c) Diagnostic testing which includes pathological examinations, laboratory, and x-rays.

(d) Pre-admission testing.

(e) Ambulatory surgery and anesthesia.

Refer to the "SUMMARY OF BENEFITS" for any applicable co-payments.

2. Skilled Nursing Facility

Skilled nursing care is covered in participating facilities when Medically Necessary and services constitute Skilled Nursing care as defined by Medicare law. To qualify, you must:

(a) Require daily skilled care which, as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis.

(b) Have been in a hospital for at least three (3) consecutive days (not counting the day of discharge) before entering a skilled nursing facility that is certified by Medicare.

(c) Require skilled nursing services for the same condition for which you were treated in the hospital.

(d) Be certified by a medical professional and Pre-authorized by Atlantis as needing skilled nursing or skilled rehabilitation services on a daily basis.

Refer to the ´┐ŻSUMMARY OF BENEFITS´┐Ż for coverage limitations.

3. Hospice Care

Care by a certified Hospice organization is available to Members whose primary attending physician has certified that they have a life expectancy of six months or less. A total of 210 days of coverage is provided, for inpatient hospice care in a hospice or in a hospital, and, home care and outpatient services provided by the hospice, including drugs and medical supplies.

Up to five visits per family are provided for bereavement counseling for family Members as relate to the use of this benefit. 

E. REHABILITATION SERVICES

1. Physical Therapy, Speech Therapy and Occupational Therapy

Rehabilitation services are available on an inpatient or outpatient basis. Services are provided for conditions, which, in the judgement of Atlantis, are subject to significant clinical improvement through relatively short-term therapy.

Outpatient occupational or speech/language pathology therapy is covered only when necessary to correct a condition that is the result of disease, injury or a congenital condition for which surgery has been performed. Covered services must begin within six months of:

(a) The date of the injury or illness that caused the need for the therapy;

(b) The date the Member is discharged from a hospital where surgical treatment was rendered; or

(c) The date outpatient surgical care is rendered.

In no event will benefits be provided after 365 days from the hospital discharge or date of surgery.

Refer to the "SUMMARY OF BENEFITS´┐Ż for coverage limitations.

2. Cardiac Rehabilitation

Cardiac rehabilitation is covered when part of an approved inpatient program. Maintenance therapy is not covered. Phase II Cardiac Rehabilitation services must be approved, in advance, by Atlantis Health Plan and provided in the outpatient department of a hospital, in a medical center, or clinic program. This benefit applies only to Members with a recent history of:

´┐Ż Heart attack

´┐Ż Coronary bypass surgery

´┐Ż Onset of angina pectoris

´┐Ż Heart valve surgery

´┐Ż Onset of unstable angina, or

´┐Ż Percutaneous transitional angioplasty

Benefits are payable only for Members who begin an exercise program immediately, or as soon as medically indicated, following a hospital confinement for one of the conditions above.

F. OTHER SERVICES

1. Ambulance

Ambulance services for emergency medical conditions are covered in full. Ambulance services for non-emergency services are covered when Medically Necessary and approved, in advance, by the Plan. This includes transportation to and from the hospital, between hospitals and between a hospital and skilled nursing facility. Transportation for non-medical reasons, for convenience or for physician office visits is excluded.

2. Durable Medical Equipment, Supplies and Prosthetic Devices

Durable medical equipment and disposable medical supplies are covered when received from a Participating Provider or other provider authorized by Atlantis Health Plan, and when ordered or prescribed by a Participating Provider. We will determine whether the equipment should be rented or purchased. To be considered durable medical equipment, the equipment must be:

Able to withstand repeated use;
Primarily and customarily used to serve a medical purpose;
Not generally useful except for the treatment of bodily injury or sickness; and,
Appropriate for use in the home.

Surgically implanted prosthetic devices and special appliances are covered if they improve or restore the function of an internal body part, which has been removed or damaged due to disease or injury.

Benefits are available for the initial acquisition of prosthesis to temporarily or permanently replace an external body part after accidental injury, surgical removal or birth defect. Covered prostheses are standard type artificial limbs (arms, legs, ears, noses and hooks). Replacements are only covered when the body's growth necessitates the replacement.

Orthotic devices are excluded from coverage.

3. Behavioral Health Care

Coverage is available for the services of a physician, psychiatrist, psychologist or certified social worker in the diagnosis and treatment of mental, nervous or emotional disorders and ailments. Treatment consists of evaluation and short-term therapy, crisis intervention, and Medically Necessary inpatient hospitalization.

Coverage is also provided for the diagnosis and treatment of alcoholism and alcohol abuse and substance abuse and substance dependence. Services include inpatient detoxification and outpatient visits for rehabilitation. Up to twenty (20) of the outpatient visits may be used by covered family Members, even if the person in need of treatment has not received or is not receiving treatment for alcoholism or substance abuse. Coverage for family Members includes visits for remediation, through counseling and education, of the adverse effects on the physical and mental health of family Members resulting from a close relationship with the covered person receiving or in need of treatment for alcoholism or substance abuse.

Inpatient rehabilitation services for alcohol or substance abuse are not covered unless benefits have been added by a rider to the Group Contract.

Members with a primary diagnosis of alcohol abuse or alcoholism must be treated in a facility certified by the Division of Alcoholism and Alcohol Abuse. Substance abuse or dependency may only be treated in a facility approved by the Division of Substance Abuse Services.

Refer to the ´┐ŻSUMMARY OF BENEFITS´┐Ż for coverage limitations and applicable co-payments.

4. Radiology and Laboratory Services

Inpatient and outpatient x-ray and laboratory procedures and materials are covered when ordered by a Participating Provider. Services include x-ray, x-ray therapy, therapeutic radiology, fluoroscopy, electrocardiograms and laboratory tests.

See related benefits: Primary and Preventive Care, Chemotherapy, Pre-Admission Testing, Specialty Services and Hospital, Skilled Nursing and Hospice Services.

Refer to the "SUMMARY OF BENEFITS" for applicable co-payments.

2. Durable Medical Equipment, Supplies and Prosthetic Devices

Durable medical equipment and disposable medical supplies are covered when received from a Participating Provider or other provider authorized by Atlantis Health Plan, and when ordered or prescribed by a Participating Provider. We will determine whether the equipment should be rented or purchased. To be considered durable medical equipment, the equipment must be:

Able to withstand repeated use;
Primarily and customarily used to serve a medical purpose;
Not generally useful except for the treatment of bodily injury or sickness; and,
Appropriate for use in the home.

Surgically implanted prosthetic devices and special appliances are covered if they improve or restore the function of an internal body part, which has been removed or damaged due to disease or injury.

Benefits are available for the initial acquisition of prosthesis to temporarily or permanently replace an external body part after accidental injury, surgical removal or birth defect. Covered prostheses are standard type artificial limbs (arms, legs, ears, noses and hooks). Replacements are only covered when the body's growth necessitates the replacement.

Orthotic devices are excluded from coverage.

3. Behavioral Health Care

Coverage is available for the services of a physician, psychiatrist, psychologist or certified social worker in the diagnosis and treatment of mental, nervous or emotional disorders and ailments. Treatment consists of evaluation and short-term therapy, crisis intervention, and Medically Necessary inpatient hospitalization.

Coverage is also provided for the diagnosis and treatment of alcoholism and alcohol abuse and substance abuse and substance dependence. Services include inpatient detoxification and outpatient visits for rehabilitation. Up to twenty (20) of the outpatient visits may be used by covered family Members, even if the person in need of treatment has not received or is not receiving treatment for alcoholism or substance abuse. Coverage for family Members includes visits for remediation, through counseling and education, of the adverse effects on the physical and mental health of family Members resulting from a close relationship with the covered person receiving or in need of treatment for alcoholism or substance abuse.

Inpatient rehabilitation services for alcohol or substance abuse are not covered unless benefits have been added by a rider to the Group Contract.

Members with a primary diagnosis of alcohol abuse or alcoholism must be treated in a facility certified by the Division of Alcoholism and Alcohol Abuse. Substance abuse or dependency may only be treated in a facility approved by the Division of Substance Abuse Services.

Refer to the ´┐ŻSUMMARY OF BENEFITS´┐Ż for coverage limitations and applicable co-payments.

4. Radiology and Laboratory Services

Inpatient and outpatient x-ray and laboratory procedures and materials are covered when ordered by a Participating Provider. Services include x-ray, x-ray therapy, therapeutic radiology, fluoroscopy, electrocardiograms and laboratory tests.

See related benefits: Primary and Preventive Care, Chemotherapy, Pre-Admission Testing, Specialty Services and Hospital, Skilled Nursing and Hospice Services.

Refer to the "SUMMARY OF BENEFITS" for applicable co-payments.

5. Organ Transplants

Coverage at a Participating facility is provided for Medically Necessary organ transplants. Authorized medical hospital expenses of a transplant recipient and a donor (or prospective donor) are covered only when:

(a) The recipient is a Plan Member and the services are Pre-authorized by a Participating Provider and the Atlantis Medical Director.

(b) The procedure used to accomplish the transplant is not considered experimental or investigative as determined by the Federal Drug Administration and/or American Medical Association.

Note: Should you disagree with the determination, please refer to Section XII. Utilization Review, of this Certificate of Coverage.

If the donor is not a Plan Member, covered serves for the donor are limited to those services and supplies directly related to the transplant procedure itself and are covered only to the extent that those services are not covered by other health insurance. Living donor transportation costs and expenses are not covered even when the donor is a Member. Cadaver organ transportation costs are not covered even when the donor is not a Member.

Diagnostic Screening for Prostate Cancer

Upon the prescription of a health care provider legally authorized to prescribe under title eight of the Education Law, the following coverage for diagnostic screening for prostatic cancer is covered:

(a) Standard diagnostic testing including, but not limited to, a rectal examination and a prostate-specific antigen test at any age for men having a prior history of prostate cancer; and

(b) An annual standard diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific antigen test for men age fifty and over who are asymptomatic and for men age forty and over with a family history of prostate cancer or other prostate cancer risk factors.Such coverage may be subject to annual deductibles and coinsurance as may be deemed appropriate by the Superintendent and as are consistent with those established for other benefits within a given policy.

Access to End of Life Care

Atlantis Health Plan shall provide an enrollee diagnosed with advance cancer (with no hope of reversal of primary disease and fewer than sixty days to live, as certified by the patient´┐Żs attending health care practitioner) with coverage for acute care services at an acute care facility (or program) licensed pursuant to Article Twenty-Eight of the Public Health Law specializing in the treatment of (the) terminally ill patients, if the patient´┐Żs attending health care practitioner, in consultation with the medical director of the facility (or program), determines that the enrollee´┐Żs care could appropriately be provided by the facility (or program). In the event that Atlantis Health Plan disagrees with the admission of or provision or continuation of care for the enrollee by the facility (or program), Atlantis Health Plan shall initiate an expedited external appeal in accordance with the provisions of paragraph three of subsection (b) of section four thousand nine hundred fourteen of this chapter, and until such decision is rendered, the admission of or provision or continuation of the care by the facility shall not be denied by Atlantis Health Plan. The decision of the external appeal agent shall be binding on all parties. Atlantis Health Plan shall provide reimbursement for those services at rates negotiated between Atlantis Health Plan and the facility (or program). In absence of agreed upon rates the provisions of § 4805 (c) shall
apply. Payment by Atlantis Health Plan to the facility (or program) shall be payment in full to the
facility (or program) for services provided to the enrollee. The facility (or program) shall not seek
or have any recourse against an enrollee for services provided except for the collection of visit
fees and co-payments, coinsurance or deductibles (See Section XIV, Co-payments,
Coinsurance and Deductibles) defined in the "SUMMARY OF BENEFITS'.

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