Closed Panel Plan Clause Samples

Closed Panel Plan. Closed Panel Plan is a Plan that provides health care benefits to Covered Persons primarily in the form of services through a panel of providers that have contracted with or are employed by the Plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member.
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Closed Panel Plan. A closed panel plan is a plan that provides health care benefits to Members primarily in the form of Services through a panel of providers that has contracted with or is employed by the Plan, and that excludes coverage for Services provided by other providers, except in cases of emergency or referral by a contracted provider. This Plan is not a closed panel provider plan. A custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the Dependent child resides more than one half of the Calendar Year excluding any temporary visitation.] When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows: • The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits of any other plan. Except as provided in the bullet below, a plan that does not contain a COB provision that is consistent with the State of Oregon’s COB regulations is always primary unless the provisions of both plans state that the complying plan is primary. • Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage shall be excess to any other parts of the plan provided by the contract holder. Examples of these types of situations are major medical coverage that are superimposed over base plan Hospital and surgical benefits, and insurance type coverage that are written in connection with a Closed panel plan to provide out-of-network benefits. A plan can consider the benefits paid or provided by another plan in calculating payment of its benefits only when it is secondary to that other plan. The plan that covers a Member other than as a Dependent, for example as an employee, Subscriber or retiree is the primary plan and the plan that covers the Member as a Dependent is the secondary plan. However, if the Member is a Medicare beneficiary, and as a result of federal law, Medicare is secondary to the plan covering the Member as a Dependent; and primary to the plan covering the Member as other than a Dependent (e.g. a retired employee); then the order of benefits between the two plans is reversed so that the plan covering the Member as an employee, subscriber or retiree is the secondary plan and the other plan is the primary plan. Unless there is a court decree stating otherwise, when a Member is a Dependent c...
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Related to Closed Panel Plan

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