Benefits and Coverage Sample Clauses

Benefits and Coverage. For a complete list of Medical Drugs to determine which require Prior Authorization please see the Presbyterian Pharmacy website at ▇▇▇▇://▇▇▇▇.▇▇▇.▇▇▇/idc/groups/public/%40phs/%40php/documents/phscontent/pel_0005273 9.pdf.

Benefits and Coverage. In-network Practitioners and Providers cannot ▇▇▇▇ you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require r Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that special...

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers fo...

Benefits and Coverage. The Hospice treatment program must:

Benefits and Coverage. All benefits are provided in accordance with CMS/PACE guidelines including the requirement that such services are approved by the Interdisciplinary Team and provided by CHA PACE or its contracted service providers, unless otherwise indicated. • Adult day healthcare • Primary care, including consultation, routine care, preventive health care and physical examinations • Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology and dermatology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, ▇▇▇▇ ▇▇▇▇▇▇ Deaconess Medical Center) • Nursing care • Social services • Physical, occupational and speech therapies • Recreational therapy • Nutrition counseling and education • Laboratory tests, X-rays and other diagnostic procedures • Prescription drugs (only if obtained from a pharmacy designated by CHA PACE) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team • Podiatry • Vision care, including examinations, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance • Ambulance • Emergency room care and treatment room services • Semi-private room and board, as available • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary • Laboratory tests, x-rays and other diagnostic procedures • Prescription drugs • Blood and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care does not include a private room, private duty nursing, and non-medical services such as telephone charges. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, ▇▇▇▇ ▇▇▇▇▇▇ Deaconess Medical Center. • Semi-private room and board, when available • Physician and nursing services • Custodial care • Personal care and assistance • Prescription drugs • Physical, speech and occupational therapies as authorized by the Interdisciplinary team • Social services • Medical supplies and appliances • Skilled nursing services • Physical, speech and occupational therapies • Social services • Home health aide services • Homemaking services • Home-delivered meals • Emergency alert system • ...

Benefits and Coverage. You will pay a lower percentage (Coinsurance) of Covered charges when you visit our In- network Practitioners/Providers. When you receive services from Out-of-network Practitioners/Providers, the Coinsurance you pay is higher and the Coinsurance will be applied to Medicare Allowable or billed charges, whichever is less, that we allow or the particular procedure. The Out-of-network Practitioner/Provider may ▇▇▇▇ you for any amounts over the billed charges we allow and this amount does not apply to your Annual Contract Year Deductible or your Coinsurance. Covered charges for In-network Practitioner and Provider services only apply to the In-network Coinsurance limits and do not apply to the Out-of-network Coinsurance limits shown in the Summary of Benefits and Coverage. Covered charges for Out-of-network Practitioner and Provider services only apply to the Out-of- network Coinsurance limits and do not apply to the In-network Coinsurance limits shown in the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Coinsurance Amounts. Coinsurance Amounts vary by type of service and by In-network and Out-of-network Practitioners/Providers. This Plan includes an Annual Out-of-pocket Maximum amount to help protect you and your Covered Dependents from high-cost catastrophic healthcare expenses. The Annual Out-of-pocket Maximum is the most you will pay in Cost Sharing in a Contract Year for certain Covered Services. After you have met your Annual Out- of-pocket Maximum in a Contract Year, we pay 100 percent (100%) of the cost for Covered Services, for the remainder of that Contract Year, up to the maximum benefit amount, if any. Refer to your Summary of Benefits and Coverage for the Plan Annual Out-of-pocket Maximum. For single coverage, the Out-of-pocket Maximum requirement is fulfilled when one Member meets the Individual Out-of-pocket Maximum listed in the Summary of Benefits and Coverage. For double or family coverage, with two or more enrolled Members, the entire Family Out-of- pocket Maximum must be met before benefits will be paid at 100 percent (100%). However, if one (family) Member reaches the Individual Out-of-pocket maximum amount before the Family has met the Family Out-of-pocket maximum benefits will be paid at 100 percent (100%) for that Member who has met the Individual Out-of-pocket maximum. The Family and Individual Out- of-pocket maximums amounts are listed in the Summary of Benefits and Coverage.‌ You will pay less...

Benefits and Coverage. Important

Benefits and Coverage. The health services available to Members upon enroll- ment and under the Plan contract.

Benefits and Coverage. Please see Chapter 5 to learn how to receive care if you have a medical emergency or other urgent need for care.