Community Provider. Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Covered with no wait. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) MHCN: Covered in full when in accordance with the well care schedule established by GHO. Not subject to the annual Deductible or any applicable Plan Coinsurance. Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Services provided during a preventive care visit which are not in accordance with the well care schedule are covered subject to the lesser of the MHCN’s charge or any applicable outpatient services Cost Share. Community Provider: Not covered, except for routine mammography services which are covered at the Plan Coinsurance, after the annual Deductible is satisfied. Rehabilitation Services • Inpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under MHCN and Community Provider benefit limits are combined and cannot be duplicated. MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable inpatient services Copayment and at the Plan Coinsurance for up to sixty (60) days per calendar year after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or the applicable inpatient services Copayment and at the Plan Coinsurance for up to sixty (60) days per calendar year after the annual Deductible is satisfied. Preauthorization is required (see Section IV.G.). • Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6) and under MHCN and Community Provider benefit limits are combined and cannot be duplicated. MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient services Copayment and at the Plan Coinsurance for up to sixty (60) visits per calendar year after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services Copayment and at the Plan Coinsurance for up to sixty (60) visits per calendar year after the annual Deductible is satisfied. Sexual Dysfunction Services MHCN: Not covered. Community Provider: Not cover...
Community Provider. Covered Services received from a Community Provider are subject to the annual Deductible as set forth in the Allowances Schedule. Charges subject to the annual Deductible shall be borne by the Subscriber during each calendar year until the annual Deductible is met. There is an individual annual Deductible amount for each Member and a maximum aggregate annual Deductible amount for each Family Unit. Once the aggregate annual Deductible amount is reached for a Family Unit in a calendar year, the individual annual Deductibles are also deemed reached for each Member during that same calendar year.
Community Provider. After the annual Deductible is satisfied, Members shall be required to pay the Plan Coinsurance for Covered Services as set forth in the Allowances Schedule. A benefit-specific coinsurance may apply to some Covered Services, as set forth in the Allowances Schedule. Services that are subject to the benefit-specific coinsurance are not subject to the Plan Coinsurance.
Community Provider. Not covered.
Community Provider. Covered subject to the lesser of the allowed charge or the applicable Copayment and at the Plan Coinsurance up to a $350,000 lifetime benefit maximum (including organ acquisition, matching and donor costs up to $50,000) after the annual Deductible is satisfied, subject to a six (6) month benefit wait period. Plastic and Reconstructive Services (plastic surgery, cosmetic surgery) • Surgery to correct a congenital disease or anomaly, or conditions following an injury or resulting from surgery MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or the applicable Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. • Cosmetic surgery, including complications resulting from cosmetic surgery MHCN: Not covered.
Community Provider. Community provider" means a governmental or nongovernmental entity that provides services to students or families, including but not limited to temporary and permanent housing, case management, immigration and language services and social, behavioral health, occupational training and legal services. [PL 2021, c. 445, §2 (NEW).]
