Manipulative Therapy ................................................................................................................................... 28 Massage Therapy ........................................................................................................................................... 29 Maternity and Pregnancy ............................................................................................................................... 29 Mental Health and Wellness .......................................................................................................................... 30 Naturopathy ................................................................................................................................................... 31 Newborn Services ......................................................................................................................................... 31 Nutritional Counseling .................................................................................................................................. 32 Nutritional Therapy ....................................................................................................................................... 32 Obesity Related Surgical Services................................................................................................................. 32 On the Job Injuries or Illnesses ..................................................................................................................... 33 Oncology ....................................................................................................................................................... 33 Optical (vision) .............................................................................................................................................. 34 Oral Surgery .................................................................................................................................................. 35 Outpatient Services ....................................................................................................................................... 35 Plastic and Reconstructive Surgery ............................................................................................................... 36 Podiatry ......................................................................................................................................................... 36 Preventive Services ....................................................................................................................................... 36 Rehabilitation and Habilitative Care (occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy .................................................................................. 38 Reproductive Health ...................................................................................................................................... 39 Sexual Dysfunction ....................................................................................................................................... 40 Skilled Nursing Facility................................................................................................................................. 40 Sterilization ................................................................................................................................................... 40 Substance Use Disorder................................................................................................................................. 41 Telehealth Services ....................................................................................................................................... 43 Temporomandibular Joint (TMJ) .................................................................................................................. 44 Tobacco Cessation ......................................................................................................................................... 44 Transplants .................................................................................................................................................... 44 Urgent Care ................................................................................................................................................... 45 V. General Exclusions ...................................................................................................................................... 45 VI. Eligibility, Enrollment and Termination ................................................................................................... 48 A. Eligibility. .............................................................................................................................................. 48 B. Enrollment for subscribers and dependents. ........................................................................................... 49 C. Medicare Eligibility and Enrollment. ..................................................................................................... 52 D. When Medical Coverage Begins. ........................................................................................................... 52 E. Making changes ..................................................................................................................................... 53 F. When medical coverage ends ................................................................................................................. 59 G. General provisions for eligibility and enrollment .................................................................................. 61 H. Appeal rights .......................................................................................................................................... 62 I. Relationship to law and regulations ....................................................................................................... 62 VII. Grievances .................................................................................................................................................... 62 VIII. Appeals ......................................................................................................................................................... 63 IX. Claims ........................................................................................................................................................... 64 X. Coordination of Benefits ............................................................................................................................. 65 Definitions. .................................................................................................................................................... 65 Order of Benefit Determination Rules........................................................................................................... 67 PEBB HMOHSA 2024 4