Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- network. In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.
Benefits and Coverage. In-network Practitioners and Providers cannot xxxx 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 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 that yo r Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for Refer to payment. Please refer to the Authorization requirements. Prior Authorization Section for more information on Prior If the 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 BEFORE services 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 ...
Benefits and Coverage. For a complete list of Medical Drugs to determine which require Prior Authorization please see the Presbyterian Pharmacy website at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phscontent/pel_0005273 9.pdf.
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. Health Services • 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, Xxxx Xxxxxx 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 Hospital Inpatient Care • 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, Xxxx Xxxxxx Deaconess Medical Center. Nursing Facility Care • 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 Home Health Care and Transportation • Skilled nursing services • Physical, speech and occupational therapies • Social services • ...
Benefits and Coverage. The Hospice treatment program must: • Be recognized as an approved Hospice program by Alliant; • Include support services to help covered family members deal with the patient’s death; and • Be directed by a Physician and coordinated by an RN with a treatment plan that: o Provides an organized system of home care; o Uses a Hospice team; and o Has around-the-clock care available. The following conditions apply: • To qualify for Hospice care, the attending Physician must certify that the patient is not expected to live more than six months; • The Physician must design and recommend a Hospice Care Program; and • The Physician’s certification statement and plan of care.
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 bill 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. Annual Out-of-pocket Maximum This Plan includes an Annual Out-of-pocket Maximum amount to help protect you and your Covered Dependents from high-cost catastrophic health care 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% 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%. 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% 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 out of your...
Benefits and Coverage. Important
Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total ⮚ Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section. • Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. ⮚ Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section. • Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and
Benefits and Coverage. The health services available to Members upon enroll- ment and under the Plan contract.
Benefits and Coverage. The Employer agrees to provide regular Employees, including part time Employees who are regularly scheduled to work thirty
