The plan covers the following services as outpatient: • Outpatient surgery at a hospital • Short-stay obstetric (childbirth) services (released within 24 hours of admission) • Surgery and procedures performed at an ambulatory surgery center ALERT! All surgeries must follow the plan’s coverage rules. We recommend that you contact UMP Customer Service before any procedure to ask if it is covered or requires preauthorization. Temporomandibular joint (TMJ) disorder treatment The plan covers diagnosis and medically necessary treatment of temporomandibular joint (TMJ) disorders, including surgery and non-surgical services. Treatment must follow the plan’s medical policy and requires preauthorization. Treatment that is experimental or investigational, or primarily for cosmetic purposes, is not covered. Therapy: Habilitative and Rehabilitative Note: The total limit for therapies for inpatient habilitative and inpatient rehabilitative services is a combined limit of 60 days annually. The total limit for therapies for outpatient habilitative and outpatient rehabilitative services is a combined limit of 60 visits annually. Habilitative (Neurodevelopmental) Services The plan covers inpatient and outpatient habilitative (neurodevelopmental) services to assist a person to keep, learn, or improve skills and functioning for daily living. This could be related to issues such as: • A congenital anomaly (such as cleft lip or palate). • Conditions of developmental delay, including autism. For the purposes of this benefit, developmental delay means a significant lag in achieving skills such as: • Cognitive (thinking). • Language (speech, reading, writing). • Motor (crawling, walking, feeding oneself). • Social (getting along with others). You must have a prescription for occupational, physical, and speech therapy services from a covered provider type (see the “Covered and noncovered provider types” section), such as a physician. Inpatient habilitative services Preauthorization is required for inpatient habilitative admissions. The plan covers therapy services when they are provided during inpatient habilitative admission, up to 60 days combined per calendar year, counting all types of therapies listed here (see definition of “Limited benefit”). You must pay your coinsurance for inpatient services. Outpatient habilitative services The plan covers medically necessary outpatient occupational, physical, and speech therapy services up to 60 visits combined per calendar year, counting all types of therapies listed here (see definition of “Limited benefit”). 74 2024 UMP CDHP (PEBB) Certificate of Coverage