Primary Care Clinic Employees and each of their covered dependents must individually elect a primary care clinic within the network of providers offered by the plan administrator chosen by the employee. Employees and their dependents may elect to change clinics within their clinic’s Benefit Level as often as the plan administrator permits and as outlined above.
Vision Care Plan The County agrees to provide a Vision Care Plan for all employees and dependents. The Plan will be the Vision Service Plan - Plan A with benefits at 12/12/24 month intervals and with twenty dollar ($20.00) deductible for examinations and twenty dollar ($20.00) deductible for materials. The County will fully pay the monthly premium for the employee and dependents and pick up inflationary costs during the term of the Agreement.
Newborn Care A newborn child will be covered from the moment of birth provided that the newborn child is eligible for coverage and properly enrolled. Covered Services will consist of coverage for injury or illness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, premature birth and transportation costs to the nearest facility appropriately staffed and equipped to treat the newborn's Condition, when such transportation is Medically Necessary. Circumcisions are provided for up to one year from the date of birth.
Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.
Child Care A. Employees employed as of March 1 who meet the following criteria shall be eligible for a lump sum payment each year. Eligible employees may apply for this payment between March 1 and April 15 of each year. Payment shall be made within thirty (30) days of receipt of the completed application. Any application received after April 15 will be considered on a case by case basis and shall not be arbitrarily rejected.
Emergency Care Services If you experience a medical emergency while traveling outside our service area, go to the nearest emergency or urgent care facility. When you receive Out-of-Area covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for the Out-of-Area Covered healthcare services, if not a flat dollar copayment, is calculated based on the lower of: • the billed charges for your Out-of-Area covered healthcare services; or • the negotiated price that the Host Blue makes available to us. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.
Urgent Care Services All Medically Necessary Covered Services received in Urgent Care Centers, Retail Clinics or your Primary Care Physician’s office after-hours to treat an Urgent Medical Condition will be covered by AvMed. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.
Provider Network The Panel of health service Providers with which the Contractor contracts for the provision of covered services to Members and Out-of-network Providers administering services to Members.
Health Care Operations Health Care Operations shall have the meaning set out in its definition at 45 C.F.R. § 164.501, as such provision is currently drafted and as it is subsequently updated, amended or revised.
Covered Health Care Services We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.
