BENEFITS AND COVERAGES Sample Clauses

BENEFITS AND COVERAGES. All the benefits provided for in this Agreement are detailed in “Schedule A – Benefit Coverage”, and subject to the following terms and conditions:

BENEFITS AND COVERAGES. The District’s health and prescription plan is provided by Medical Mutual under policy number CMS1331800000423-00756. Copies of health and prescription plan certificates of coverage have been provided to OAPSE. See Exhibit A for more information regarding the District’s health and prescription plans.

BENEFITS AND COVERAGES. After you reach your Out-of-Pocket Limit (including any required Deductible), your Contract pays 100% of the Maximum Allowable Amount for the remainder of the calendar year. Out-of-pocket Limits are accumulated separately for In-Network and Out-of-Network Providers. See the Summary of Benefits and Coverage’s to determine if you have an In-Network Coinsurance amount and In-Network Out-of-Pocket Limit. Annual and Lifetime Limits There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. What Your Plan Pays In order to assist you in understanding the Maximum Allowed Cost (MAC) language as described below, please refer to the definition of In-Network Provider, Out-of-Network Provider and Non- Preferred Provider contained in the Definitions section of this booklet. Maximum Allowed Cost (MAC)

BENEFITS AND COVERAGES. After you reach your Out-of-Pocket Limit (including any required Deductible), your Contract pays 100% of the Maximum Allowable Amount for the remainder of the calendar year. Out-of-pocket Limits are accumulated separately for In-Network and Out-of-Network Providers. See the Summary of Benefits and Coverage’s to determine if you have an In-Network Coinsurance amount and In-Network Out-of-Pocket Limit. Annual and Lifetime Limits There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. What Your Plan Pays In order to assist you in understanding the Maximum Allowed Cost (MAC) language as described below, please refer to the definition of In-Network Provider, Out-of-Network Provider and Non- Preferred Provider contained in the Definitions section of this booklet. Maximum Allowed Cost (MAC) Cost (MAC)‌ General‌ This section describes how we determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by In-Network and Out-of-network Providers is based on this plan’s Maximum Allowed Cost (MAC)Cost (MAC) for the Covered Service that you receive. The Maximum Allowed Cost (MAC) Cost for this plan is the maximum amount of reimbursement Alliant will pay for services and supplies: • that meet our definition of Covered Services, to the extent such services and supplies are covered under Your Plan and are not excluded; • that are Medically Necessary; and • that is provided in accordance with all applicable preauthorization, utilization management (i.e., coverage certification) or other requirements set forth in Your Plan. You will be required to pay a portion of the Maximum Allowed Cost (MAC) Cost to the extent you have not met your Deductible nor have a Copayment or Coinsurance. In addition, when you receive Covered Services from an Out-of-network Provider, you may be responsible for paying any difference between the Maximum Allowed Cost (MAC) and the Provider’s actual charges. This amount can be significant. 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 Maximum Allowed Cost (MAC). Our application of these rules does not mean that the Covere...

BENEFITS AND COVERAGES. HMO agrees to arrange for preventive, diagnostic and treatment services from HMO Medical Service Units and within HMO Accredited Hospitals or HMO Medical Centers to all qualified and accepted MEMBERS, subject to the following terms and conditions: Care by HMO Medical Service Units/Teams

BENEFITS AND COVERAGES. If you would like more information on WHCRA benefits, call your Plan Administrator. If you would like more information on WHCRA benefits, call your Plan Administrator.