Medically Frail Clause Samples

The 'Medically Frail' clause defines the criteria or conditions under which an individual is considered medically frail for the purposes of a contract or policy. Typically, this clause outlines specific health conditions, disabilities, or limitations that qualify a person as medically frail, such as chronic illnesses, severe physical or mental impairments, or the need for institutional care. By clearly establishing who is deemed medically frail, the clause ensures that individuals with significant health vulnerabilities receive appropriate accommodations, protections, or benefits, and it helps prevent disputes over eligibility or coverage.
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Medically Frail. The Contractor shall provide HIP State Plan services to members who meet the definition of medically frail. Consistent with 42 CFR §440.315(f), an individual will be considered medically frail if he or she has one or more of the following: ▪ Disabling mental disorder; ▪ A chronic substance abuse disorder; ▪ Serious and complex medical conditions; ▪ Physical, intellectual, or developmental disability that significantly impair the individuals’ ability to perform one or more activities of daily living; or ▪ A disability determination based on Social Security Administration criteria.
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Related to Medically Frail

  • Medically Necessary In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Contract.

  • Hospice Individuals whose permanent residence and principal work location are outside the State of Minnesota and outside of the service areas of the health plans participating in Advantage. If these individuals use the plan administrator’s national preferred provider organization in their area, services will be covered at Benefit Level Two. If a national preferred provider is not available in their area, services will be covered at Benefit Level Two through any other provider available in their area. If the national preferred provider organization is available but not used, benefits will be paid at the POS level described in paragraph “i” below. All terms and conditions outlined in the Summary of Benefits will apply.

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  • Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services. This plan covers dental care for members until the last day of the month in which they turn nineteen (19). This plan covers services only if they meet all of the following requirements: • listed as a covered dental care service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered dental care service under this plan. • dentally necessary, consistent with our dental policies and related guidelines at the time the services are provided. • not listed in Exclusions section. • received while a member is enrolled in the plan. • consistent with applicable state or federal law. • services are provided by a network provider.

  • Preventive Care This plan covers preventive care as described below. “