2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 56
One amniocentesis test per pregnancy.
Up to 2 ultrasounds per Pregnancy (more than 2 only when it is determined to be Medically Necessary).
Breast pump: See number (8) under Eligible Medical Expenses.
Hospital stays in connection with childbirth for either the mother or newborn may not be limited to less than
48 hours following a vaginal delivery or 96 hours following a cesarean section. These requirements can only
be waived by the attending Physician in consultation with the mother. The Covered Person or provider is not
required to precertify the maternity admission, unless the stay extends past the applicable 48 or 96 hour stay.
A Hospital stay begins at the time of delivery or for deliveries outside the Hospital, the time the newborn or
mother is admitted to a Hospital following birth, in connection with childbirth.
If a newborn remains hospitalized beyond the time frames specified above, the confinement must be
precertified or a penalty may be applied.
Eligible expenses will be payable as shown in the Medical Schedule of Benefits.
(30) Medical and Surgical Supplies: Casts, splints, trusses, braces, crutches, dressings, orthotics (excluding foot
orthotics), and other Medically Necessary supplies ordered by a Physician.
(31) Mental Disorders: Charges for inpatient and outpatient treatment of Mental Disorders, including emergency
care, transition day treatment, partial hospitalization, telemedicine services and transitional rehabilitation will
be payable as shown in the Medical Schedule of Benefits.
(32) Morbid Obesity: Charges for the care and treatment of Morbid Obesity (including surgical treatment). Surgical
treatment for Morbid Obesity will only be covered if all the following conditions are met:
The Covered Person has either (1) a body mass index (BMI) of 40 or greater or (2) a BMI of 35 or
greater in conjunction with a severe co-morbidity, such as obesity hypoventilation, sleep apnea,
diabetes, hypertension, cardiomyopathy or musculoskeletal dysfunction.
The Covered Person has at least a 24-month history of Morbid Obesity as documented in such person’s
The Covered Person has failed to achieve and maintain significant weight loss and such person has
participated in a Physician-supervised nutrition and exercise program for at least 6 months (occurring
within the 24-month period prior to the proposed surgical treatment) and such participation is
documented in his or her medical records.
The Covered Person must be evaluated by a licensed professional counselor, psychologist or
psychiatrist within 12 months prior to the proposed surgical treatment. The evaluation should document
that there is no significant psychological problem that would limit the ability of the Covered Person
to understand the procedure and comply with any medical and/or surgical recommendations;
any psychological co-morbidities that may be contributing to the Covered Person’s inability to lose
weight or a diagnosed eating disorder; and
the Covered Person’s willingness to comply with the preoperative and postoperative treatment
(33) Nutritional Supplements: Physician-prescribed nutritional supplements or other enteral supplementation
necessary to sustain life, including rental or purchase of equipment used to administer nutritional supplements
or other enteral supplementation.