COVERED SERVICES EXPENSE LIMITATION Sample Clauses

COVERED SERVICES EXPENSE LIMITATION. If, during any calendar year, you have paid Copayments, deductibles and/or any Coinsurance amount for Covered Services under this Certificate the total amount of which equals $1,500 per enrollee or $3,000 per family, your benefits for any additional Covered Services that you may receive during that calendar year, in­ cluding any Copayment, deductible and/or Coinsurance amounts, will be reimbursed by the Plan. Should the federal government adjust the deductible and/ or out‐of‐pocket limit amount(s) for high deductible health plans, the deductible and/or the out‐of‐pocket expense limit amount(s) in this Certificate will be adjus­ xxx accordingly. In the event your Physician or the Hospital requires you to pay any additional Co­ payments, deductible and/or Coinsurance amounts after you have met the above provision, upon receipt of properly authenticated documentation, the Plan will re­ imburse to you, the amount of those Copayments, deductibles and/or Coinsurance amounts. Copayments and deductibles required under this Certificate are not to exceed 50% of the usual and customary fee for any single service. The above Covered Services expense provisions are not applicable to the benefits described in the following sections of this Certificate: Supplemental Benefits. YOUR PROVIDER RELATIONSHIPS The choice of a Hospital, Participating IPA, Participating Medical Group, Prima­ ry Care Physician or any other Provider is solely your choice and the Plan will not interfere with your relationship with any Provider. The Plan does not itself undertake to provide health care services, but solely to arrange for the provision of health care services and to make payments to Provid­ ers for the Covered Services received by you. The Plan is not in any event liable for any act or omission of any Provider or the agent or employee of such Provider, including, but not limited to, the failure or refusal to render services to you. Pro­ fessional services which can only be legally performed by a Provider are not provided by the Plan. Any contractual relationship between a Physician and a Hospital or other Provider should not be construed to mean that the Plan is pro­ viding professional service. Each Provider provides Covered Services only to Covered Persons and does not deal with or provide any services to any Group (other than as an individual Cov­ ered Person) or any Group's ERISA Health Benefit Program. FAILURE OF YOUR PARTICIPATING IPA OR PARTICIPATING MEDICAL GROUP TO PERFORM UND...
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Related to COVERED SERVICES EXPENSE LIMITATION

  • Covered Services Services to be performed by Contractor under this Agreement may involve the performance of trade work covered by the provisions of Section 6.22(e) [Prevailing Wages] of the Administrative Code or Section 21C [Miscellaneous Prevailing Wage Requirements] (collectively, “Covered Services”). The provisions of Section 6.22(e) and 21C of the Administrative Code are incorporated as provisions of this Agreement as if fully set forth herein and will apply to any Covered Services performed by Contractor and its subcontractors.

  • Compensation for Reimbursable Expenses 11.8.1 Reimbursable Expenses are in addition to compensation for Basic, Supplemental, and Additional Services and include expenses incurred by the Architect and the Architect’s consultants directly related to the Project, as follows:

  • Travel Expense Reimbursement Pricing for services provided under this Contract are exclusive of any travel expenses that may be incurred in the performance of those services. Travel expense reimbursement may include personal vehicle mileage or commercial coach transportation, hotel accommodations, parking and meals; provided, however, the amount of reimbursement by Customers shall not exceed the amounts authorized for state employees as adopted by each Customer; and provided, further, that all reimbursement rates shall not exceed the maximum rates established for state employees under the current State Travel Management Program (xxxx://xxx.xxxxxx.xxxxx.xx.xx/procurement/prog/stmp/). Travel time may not be included as part of the amounts payable by Customer for any services rendered under this Contract. The DIR administrative fee specified in Section 5 below is not applicable to travel expense reimbursement. Anticipated travel expenses must be pre-approved in writing by Customer.

  • Non-Covered Services MCOs are not permitted to provide Medicaid excluded services that include, but are not limited to, the following:

  • Reimbursable Expenses; Maximum Total Payment; Invoicing District will make no payment until this Contract is fully executed by the authorized representatives of both parties.

  • A-E’S EXPENSE A-E will be responsible for all costs related to photo copying, telephone communications and fax communications while on COUNTY sites during the performance of work and services under this CONTRACT.

  • Non-Reimbursable Expenses In addition to the non-reimbursable items set forth above in this Policy, the following is a non-exhaustive list of expenses that will not be reimbursed by Xxxxxxxxxx County:

  • Provision of Covered Services Contractor shall undertake commercially reasonable efforts to ensure that each Participating Provider Agreement and each subcontracting arrangement entered into by each Participating Provider complies with the applicable terms and conditions set forth in this Agreement, as mutually agreed upon by Covered California and Contractor, and which may include the following:

  • Grandfathered Services Services identified in GTE Tariffs as grandfathered in any manner are available for resale only to end user customers that already have such grandfathered service. An existing end user customer may not move a grandfathered service to a new service location. Grandfathered services are subject to a resale discount.

  • Covered Benefits and Services The Contractor shall provide to its Hoosier Healthwise members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered by the IHCP, and included in the Indiana Administrative Code and under the Contract with the State. A covered service is considered medically necessary if it meets the definition as set forth in 405 IAC 5-2-17. The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services:  On the basis of criteria applied under the State plan, such as medical necessity; or  For the purpose of utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.

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