Common use of Community Provider Clause in Contracts

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 covered. Skilled Nursing Facility (SNF) MHCN and Community Provider benefit limits are combined and cannot be duplicated. MHCN: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Community Provider: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Preauthorization is required (see Section IV.A.). Sterilization (vasectomy, tubal ligation) MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable Cost Share. Community Provider: Covered subject to the lesser of the allowed charge or the applicable Cost Share. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services 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 Copayment and at the Plan Coinsurance for up to $1,000 maximum per Member per calendar year 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 for up to $1,000 maximum per Member per calendar year after the annual Deductible is satisfied. • Lifetime benefit maximum MHCN and Community Provider benefit limits are combined and cannot be duplicated. MHCN: Covered up to $5,000 per Member. Community Provider: Covered up to $5,000 per Member. Tobacco Cessation • Individual/group sessions MHCN: Covered in full. Community Provider: Not covered. • Approved pharmacy products MHCN: Covered in full when prescribed as part of the GHO-designated tobacco cessation program and dispensed through the GHO mail order service. Community Provider: Not covered.

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 Covered at the Plan Coinsurance to a $150 maximum per Member ($300 per Family Unit) per calendar year. Routine mammography services which are covered at the Plan Coinsurance, Coinsurance after the annual Deductible is satisfied. Coinsurance does not apply to the Out-of-Pocket Limit. 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 condition 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 condition 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 condition 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 condition per calendar year after the annual Deductible is satisfied. Sexual Dysfunction Services MHCN: Not covered. Community Provider: Not covered. Skilled Nursing Facility (SNF) MHCN and Community Provider benefit limits are combined and cannot be duplicated. MHCN: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Community Provider: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Preauthorization is required (see Section IV.A.). Sterilization (vasectomy, tubal ligation) MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable Cost Share. Community Provider: Covered subject to the lesser of the allowed charge or the applicable Cost Share. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services 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 Copayment and at the Plan Coinsurance for up to $1,000 maximum per Member per calendar year 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 for up to $1,000 maximum per Member per calendar year after the annual Deductible is satisfied. • Lifetime benefit maximum MHCN and Community Provider benefit limits are combined and cannot be duplicated. MHCN: Covered up to $5,000 per Member. Community Provider: Covered up to $5,000 per Member. Tobacco Cessation • Individual/group sessions MHCN: Covered in full. Community Provider: Not covered. • Approved pharmacy products MHCN: Covered in full when prescribed as part of the GHO-designated tobacco cessation program and dispensed through the GHO mail order service. Community Provider: Not covered.

Community Provider. Not coveredDescribes coverage when care is provided by a Community Provider or Preferred Community Provider on a Self-Referred basis. Coverage is limited to the Preferred Community Provider Contracted Rate or Usual, except Customary and Reasonable (UCR) charges, less any applicable Cost Share amounts as noted below. Benefits paid under the Community Provider option will not be duplicated under the MHCN option. The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in the presence of a non-related Group Medical Condition affecting the lower limbsCoverage Agreement. Pre-Existing Condition Covered with no wait“Welcome” Outpatient Services Waiver Not applicable. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) Annual Deductible MHCN: Covered in full when in accordance with the well care schedule established by GHO. Not subject to the annual Deductible $100 per Member 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$200 per Family Unit per calendar year. Community Provider: Not covered, except for routine mammography services which are covered at the $200 per Member or $400 per Family Unit per calendar year. Plan CoinsuranceCoinsurance MHCN: Plan Coinsurance share is 80%; Member coinsurance share is 20%, after the annual Deductible is satisfied. Rehabilitation Community Provider: Plan Coinsurance share is 70% of the Preferred Community Provider Contracted Rate or Usual, Customary and Reasonable charges; Member coinsurance share is 30%, after the annual Deductible is satisfied. Lifetime Maximum $2,000,000 per Member for Covered Services incurred, unless otherwise indicated. Up to $5,000 is restored automatically each January 1 for benefits paid by GHO during the prior calendar year. Hospital Services • Inpatient physical, occupational Covered inpatient medical and restorative speech therapy services combinedsurgical services, including services for neurodevelopmentally disabled children age six acute chemical withdrawal (6detoxification) 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 for scheduled admissions as set forth in Section IV.A. • Covered outpatient hospital surgery (see Section IV.G.). • Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6ambulatory surgical centers) 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 Outpatient Services MHCN: Not covered. Community Provider: Not covered. Skilled Nursing Facility (SNF) MHCN • Covered outpatient medical and Community Provider benefit limits are combined and cannot be duplicated. surgical services MHCN: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Community Provider: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Preauthorization is required (see Section IV.A.). Sterilization (vasectomy, tubal ligation) • Allergy testing MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable Cost Share. Community Provider: Covered subject to the lesser of the allowed charge or the applicable Cost Share. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services 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 Copayment and at the Plan Coinsurance for up to $1,000 maximum per Member 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 $1,000 maximum per Member per calendar year after the annual Deductible is satisfied. • Lifetime benefit maximum MHCN and Community Provider benefit limits are combined and cannot be duplicated. Oncology (radiation therapy, chemotherapy) MHCN: Covered up subject to $5,000 per Memberthe lesser of the MHCN’s charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Community Provider: Covered up subject to $5,000 per Memberthe lesser of the allowed charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Tobacco Cessation Drugs - Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies) • Individual/group sessions Prescription drugs, medicines, supplies and devices for a supply of thirty (30) days or less when listed in the GHO drug formulary MHCN: Covered in fullwhen prescribed by a MHCN Provider, subject to the lesser of the MHCN’s charge or a $15 Copayment for generic drugs or a $30 Copayment for brand name drugs. Community Provider: Covered subject to the lesser of the allowed charge or a $20 Copayment for generic drugs or a $35 Copayment for brand name drugs. • Over-the-counter drugs and medicines Not covered. • Approved pharmacy products MHCN: Covered in full when prescribed as part of the GHO-designated tobacco cessation program and dispensed through the GHO mail order service. Community Provider: Not covered.Allergy Serum

Community Provider. Not covered. Out-of-Pocket Limit MHCN and Community Provider maximums are not combined MHCN: Limited to an aggregate maximum of $2,000 per Member or $6,000 per family per calendar year. Except as otherwise noted in this Allowances Schedule, except the total Out-of-Pocket Expenses for the following Covered Services are included in the presence Out-of-Pocket Limit: • Plan Coinsurance • Emergency care at a MHCN Facility • Ambulance services Community Provider: Limited to an aggregate maximum of $6,000 per Member or $18,000 per family per calendar year. Except as otherwise noted in this Allowances Schedule, the total Out-of-Pocket Expenses for the following Covered Services are included in the Out-of-Pocket Limit: • Plan Coinsurance • Emergency care at 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 Facility Acupuncture 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 the applicable outpatient services Cost Share. Community Provider: Not covered, except for routine mammography services which are covered Copayment and at the Plan CoinsuranceCoinsurance for Self-Referrals to a MHCN Provider up to a maximum of eight (8) visits per Member per medical diagnosis per calendar year, after the annual Deductible is satisfied. Rehabilitation When approved by GHO, additional visits are covered. Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Ambulance Services • Emergency ground/air transport MHCN: Covered at 80% for transport to a MHCN Facility. Not subject to the annual Deductible. Community Provider: Covered at 80% for transport to a non-MHCN Facility. Not subject to the annual Deductible. • Non-emergent ground/air interfacility transfer MHCN: Covered at 80% for MHCN-initiated transfers, except hospital-to-hospital ground transfers covered in full. Not subject to the annual Deductible. Community Provider: Covered at 80% for transport from one medical facility to the nearest facility equipped to render further Medically Necessary treatment when prescribed by the attending physician. Not subject to the annual Deductible. Chemical Dependency • Inpatient physical, occupational and restorative speech therapy services combined, (including services for neurodevelopmentally disabled children age six (6Residential Treatment services) 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 Acute detoxification covered as any other medical service. Dental Services (including accidental injury to natural teeth) MHCN: Not covered. Community Provider: Not covered. Skilled Nursing Facility (SNF) MHCN and Community Provider benefit limits are combined and cannot be duplicated. MHCN: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Community Provider: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Preauthorization is required (see , except as set forth in Section IV.A.). Sterilization (vasectomy, tubal ligation) MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable Cost Share. Community Provider: Covered subject to the lesser of the allowed charge or the applicable Cost Share. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services 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 Copayment and at the Plan Coinsurance for up to $1,000 maximum per Member per calendar year 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 for up to $1,000 maximum per Member per calendar year after the annual Deductible is satisfied. • Lifetime benefit maximum MHCN and Community Provider benefit limits are combined and cannot be duplicated. MHCN: Covered up to $5,000 per Member. Community Provider: Covered up to $5,000 per Member. Tobacco Cessation • Individual/group sessions MHCN: Covered in full. Community Provider: Not covered. • Approved pharmacy products MHCN: Covered in full when prescribed as part of the GHO-designated tobacco cessation program and dispensed through the GHO mail order service. Community Provider: Not coveredIV.B.23.

Community Provider. Not coveredDescribes coverage when care is provided by a Community Provider or Preferred Community Provider on a Self-Referred basis. Coverage is limited to the Preferred Community Provider Contracted Rate or Usual, except Customary and Reasonable (UCR) charges, less any applicable Cost Share amounts as noted below. Benefits paid under the Community Provider option will not be duplicated under the MHCN option. The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in the presence of a non-related Group Medical Condition affecting the lower limbsCoverage Agreement. Pre-Existing Condition Covered with no wait“Welcome” Outpatient Services Waiver Not applicable. Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) Annual Deductible MHCN: Covered in full when in accordance with the well care schedule established by GHO. Not subject to the annual Deductible $200 per Member 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$600 per Family Unit per calendar year. Community Provider: Not covered, except for routine mammography services which are covered at the $400 per Member or $1,200 per Family Unit per calendar year. Plan CoinsuranceCoinsurance MHCN: Plan Coinsurance share is 80%; Member coinsurance share is 20%, after the annual Deductible is satisfied. Rehabilitation Community Provider: Plan Coinsurance share is 60% of the Preferred Community Provider Contracted Rate or Usual, Customary and Reasonable charges; Member coinsurance share is 40%, after the annual Deductible is satisfied. Lifetime Maximum $2,000,000 per Member for Covered Services incurred, unless otherwise indicated. Up to $5,000 is restored automatically each January 1 for benefits paid by GHO during the prior calendar year. Hospital Services • Inpatient physical, occupational Covered inpatient medical and restorative speech therapy services combinedsurgical services, including services for neurodevelopmentally disabled children age six acute chemical withdrawal (6detoxification) 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 for scheduled admissions as set forth in Section IV.A. • Covered outpatient hospital surgery (see Section IV.G.). • Outpatient physical, occupational and restorative speech therapy services combined, including services for neurodevelopmentally disabled children age six (6ambulatory surgical centers) 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 Outpatient Services MHCN: Not covered. Community Provider: Not covered. Skilled Nursing Facility (SNF) MHCN • Covered outpatient medical and Community Provider benefit limits are combined and cannot be duplicated. surgical services MHCN: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or a $5 outpatient services Copayment and at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Preauthorization is required (see Section IV.A.). Sterilization (vasectomy, tubal ligation) • Allergy testing MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable Cost Share. Community Provider: Covered subject to the lesser of the allowed charge or the applicable Cost Share. Temporomandibular Joint (TMJ) Services • Inpatient and outpatient TMJ services 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 Copayment and at the Plan Coinsurance for up to $1,000 maximum per Member 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 $1,000 maximum per Member per calendar year after the annual Deductible is satisfied. • Lifetime benefit maximum MHCN and Community Provider benefit limits are combined and cannot be duplicated. Oncology (radiation therapy, chemotherapy) MHCN: Covered up subject to $5,000 per Memberthe lesser of the MHCN’s charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Community Provider: Covered up subject to $5,000 per Memberthe lesser of the allowed charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Tobacco Cessation Drugs - Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies) • Individual/group sessions Prescription drugs, medicines, supplies and devices for a supply of thirty (30) days or less when listed in the GHO drug formulary MHCN: Covered in fullwhen prescribed by a MHCN Provider, subject to the lesser of the MHCN’s charge or a $15 Copayment for generic drugs or a $30 Copayment for brand name drugs. Community Provider: Covered subject to the lesser of the allowed charge or a $20 Copayment for generic drugs or a $35 Copayment for brand name drugs. • Over-the-counter drugs and medicines Not covered. • Approved pharmacy products MHCN: Covered in full when prescribed as part of the GHO-designated tobacco cessation program and dispensed through the GHO mail order service. Community Provider: Not covered.Injectables