2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 51
ELIGIBLE MEDICAL EXPENSES
Eligible expenses shall be the charges actually made for services provided to the Covered Person and will be
considered eligible only if the expenses are:
Due to Illness or Injury;
Ordered or performed by a Physician;
Medically Necessary; and
Usual and Customary charges.
Reimbursement for eligible expenses will be made directly to the provider of the service, unless a receipt showing
payment is submitted. All eligible expenses Incurred at a Participating Provider will be reimbursed to the provider.
Allergy Services: Allergy testing, treatment, serum and injections. Eligible expenses will be payable as
shown in the Medical Schedule of Benefits.
Ambulance Service: Local Medically Necessary professional ground or air ambulance service to transport
the Covered Person:
To the nearest Hospital or Skilled Nursing Facility equipped to treat the specific Illness or Injury in an
emergency situation; or
To another Hospital in the area when the first Hospital did not have services required and/or facilities
to treat the Covered Person; or
When Medically Necessary.
Professional ground or air ambulance charges for convenience are not covered. Air ambulance is covered
only when terrain, distance or condition warrants.
Eligible expenses will be payable as shown in the Medical Schedule of Benefits.
Ambulatory Surgery Center: Services and supplies provided by an Ambulatory Surgery Center.
Anesthetics: Anesthetics and their professional administration.
Attention Deficit Disorder: Diagnosis, testing and treatment for Attention Deficit Disorder / Attention Deficit
Hyperactivity Disorder (ADD/ADHD).
Autism: Charges for diagnosis, care and treatment of autism and autistic spectrum disorders.
Blood and Blood Derivatives: Blood, blood plasma or blood components not donated or replaced.
Breast Pump: This expense will be covered as Durable Medical Equipment. Covered items may include: (a)
a standard electric pump (non-hospital-grade) while you are pregnant or for the duration of breastfeeding,
once every 3 years, or (b) a manual breast pump while pregnant or for the duration of breastfeeding, if you
have not received an electric or a manual breast pump in the last 3 years, and (c) another set of breast pump
supplies if you get pregnant again before you are eligible for a new pump.
Cardiac Rehabilitation: Cardiac rehabilitation services which are rendered: (a) under the supervision of a
Physician; and (b) in connection with a myocardial infarction, coronary occlusion or coronary bypass Surgery
or any other medical condition if medically appropriate; and (c) initiated within 12 weeks after other treatment
for the medical condition ends; and (d) in a medical care facility.
Expenses in connection with Phase III cardiac rehabilitation, including, but not limited to occupational therapy
or work hardening programs will not be considered eligible. Phase III is defined as the general maintenance