Common use of Benefits Chart Clause in Contracts

Benefits Chart. a list of the covered services you get as a member of the GHC MA Plan This section describes the medical benefits and coverage you get as a member of the GHC MA Plan. “Covered services,” means the medical care, services, supplies, and equipment that are covered by the GHC MA Plan. This section has a Benefits Chart that gives a list of your covered services and tells what you must pay for each covered service. The section that follows (Section 5) tells about services that are not covered (these are called “exclusions.”) Some general requirements apply to all covered services The covered services listed in the Benefits Chart in this section are covered only when all requirements listed below are met: • Services must be provided according to the Medicare coverage guidelines established by the Medicare program and GHC guidelines. • The medical care, services, supplies, and equipment that are listed as “covered services” must be medically necessary. Certain preventive care and screening tests are also covered. (See Section 13 for a definition of “medically necessary.”) • With few exceptions, covered services must either be provided by plan providers, be approved in advance by plan providers, or be authorized by GHC. The exceptions are care for a medical emergency, urgently needed care, and renal (kidney) dialysis you get when you are outside the plan’s service area. Some of the covered services listed in the Benefits Chart in this section are covered only if your doctor or other plan provider gets “prior authorization” (approval in advance) from GHC. Covered services that need prior authorization are marked by italics text in the Benefits Chart.