Covered Benefits. Benefits for Bone Mass Measurement for the prevention, diagnosis, and treatment of osteoporosis are covered when requested by a Health Care Provider for a Qualified Individual.
Covered Benefits. A Member shall be entitled to the Covered Benefits as specified below, in accordance with the terms and conditions of this Certificate. Unless specifically stated otherwise, in order for benefits to be covered, they must be Medically Necessary. For the purpose of coverage, HMO may determine whether any benefit provided under the Certificate is Medically Necessary, and HMO has the option to only authorize coverage for a Covered Benefit performed by a particular Provider. Preventive care, as described below, will be considered Medically Necessary. ALL SERVICES ARE SUBJECT TO THE EXCLUSIONS AND LIMITATIONS DESCRIBED IN THIS CERTIFICATE. To be Medically Necessary, the service or supply must: • be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; • be care or services related to diagnosis or treatment of an existing illness or injury, except for covered periodic health evaluations and preventive and well baby care, as determined by HMO; • be a diagnostic procedure, indicated by the health status of the Member and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; • include only those services and supplies that cannot be safely and satisfactorily provided at home, in a Physician’s office, on an outpatient basis, or in any facility other than a Hospital, when used in relation to inpatient Hospital services; and • as to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests. In determining if a service or supply is Medically Necessary, HMO’s Patient Management Medical Director or its Physician designee will consider: • information provided on the Member's health status; • reports in peer reviewed medical literature; • reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; • professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment; • the opinion of Health Profession...
Covered Benefits. We will provide coverage for Covered Benefits to Members subject to the terms and conditions of this Group Agreement. Coverage will be provided in accordance with the reasonable exercise of Our business judgment, consistent with applicable law. Members covered under this Group Agreement are subject to all of the conditions and provisions contained herein and in the incorporated documents.
Covered Benefits. Those Medically Necessary Services and supplies set forth in this Certificate, which are covered subject to all of the terms and conditions of the Group Agreement and Certificate.
Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid covered services as detailed in 405 IAC 5. Contract Exhibit 3 provides a general description of the covered benefits. The Contractor must cover, at minimum, all benefits and services deemed medically necessary and reasonable and covered under the Hoosier Care Connect program in accordance with the terms of the Contract. A covered service is medically necessary if, in a manner consistent with accepted standards of medical practice, it is reasonably expected to: Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor is prohibited from paying for items or services (other than an emergency item or service, not including items or services furnished in an emergency room or a hospital): With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(3), the Contractor must furnish covered services in an amount, duration or scope reasonably expected to achieve the purpose for which the services are furnished. The Contractor may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of medical necessity criteria for the purpose of utilization contro...
Covered Benefits. “Covered Benefits” shall mean any benefit or payment from the Holding Company or any affiliate or any successor in interest to any of the foregoing that will be (or in the opinion of Tax Counsel (as defined below) might reasonably be expected to be) subject to any excise tax (the “Excise Tax”) imposed under Section 4999 of the Internal Revenue Code of 1986, as amended (the “Code”). In the event that at any time during or after the Term of Employment the Executive shall receive any Covered Benefits, the Holding Company shall pay to the Executive an additional amount (the “Gross-Up Payment”) such that the net amount retained by the Executive from the Gross-Up Payment, after deduction of any federal, state and local income taxes, Excise Tax, and FICA and Medicare withholding taxes on the Gross-Up Payment, shall be equal to the Excise Tax on the Covered Benefits. For purposes of determining the amount of such Excise Tax on the Covered Benefits, the amount of the Covered Benefits that shall be taken into account in calculating the Excise Tax shall be equal to (i) the Covered Benefits, minus (ii) the amount of such Covered Benefits that, in the opinion of tax counsel selected by the Holding Company and reasonably acceptable to the Executive (“Tax Counsel”), are not parachute payments (within the meaning of Section 280G(b)(1) of the Code).
Covered Benefits. Dental benefits will be provided to repair or replace Sound Natural Teeth that have been damaged or lost due to injury if the injury did not arise while or as a result of biting or chewing, and treatment is commenced within six (6) months of the injury or, if due to the nature of the injury, treatment could not begin within six (6) months of the injury, treatment began within six (6) months of the earliest date that it would be medically appropriate to begin such treatment. As used in this provision, accidental injury means an injury to Sound Natural Teeth as a result of an external force or trauma resulting in damage to a tooth or teeth, surrounding bone and/or jaw.
Covered Benefits. Benefits will be provided for the costs associated with the coordination of care for the Qualifying Individual’s medical conditions, including:
Covered Benefits. The Covered Benefits section of the Certificate is amended to add the following provision:
Covered Benefits. Benefits that are covered under the terms of the applicable Sponsor’s Plan, subject to the limitations and exclusions of such Plan. See explanation in Addendum.
