How to Use This Health Plan Sample Clauses

How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Choice of Providers This Blue Shield health plan is designed for Members to obtain services from Blue Shield Participating Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most services. Covered Services obtained from Non-Participating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Participating Provider or an MHSA Participating Provider may change. It is the Member’s obligation to verify whether the provider chosen is a Participating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Participating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Programs section for services outside of California. Blue Shield Participating Providers Blue Shield Participating Providers include primary care Physicians, specialists, Hospitals, Alternate Care Services Providers, and Other Providers that have a contractual relationship with Blue Shield. Participating Providers are listed in the Participating Provider directory.
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How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge at the telephone number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below on
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How to Use This Health Plan. PLEASE READ THE FOLLOWING INFORMA- TION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Choice of Providers This Blue Shield Health Plan is designed for Mem- bers to obtain services from Blue Shield Participat- ing Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most ser- vices. Covered Services obtained from Non-Par- ticipating Providers will usually result in a higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Partic- ipating Provider or an MHSA Participating Provider may change. It is the Member’s obliga- tion to verify whether the provider chosen is a Par- ticipating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Par- ticipating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Services section for services outside of California. Blue Shield Participating Providers Blue Shield Participating Providers include pri- xxxx care Physicians, specialists, Hospitals, and Alternate Care Services Providers that have a con- tractual relationship with Blue Shield. Participat- ing Providers are listed in the Participating Provider directory. Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, Coinsur- ance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Ser- vices, except as provided under the Exception for Other Coverage and the Reductions – Third Party Liability sections. This is not true of Non-Partici- pating Providers. If a Member receives services from a Non-Partici- pating Provider, Blue Shield’s payment for that service may be substantially less than the amount billed. The Subscriber is responsible for the differ- ence between the amount Blue Shield pays and the amount billed by the Non-Participating Provider. If a Member receives services at a facility that is a Participating Provider, Blue Shield’s payment for Covered Services provided by a health profes- sional at the Participating Provider facility will be paid at the Participating Provider level of Benefits, w...
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Related to How to Use This Health Plan

  • Health Plan An appropriately licensed entity that has entered into a contract with Subcontractor, either directly or indirectly, under which Subcontractor provides certain administrative services for Health Plan pursuant to the State Contract. For purposes of this Appendix, Health Plan refers to UnitedHealthcare Insurance Company.

  • CONTRACTOR California Department of General Services Use Only CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.) BY (Authorized Signature) ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING ADDRESS STATE OF CALIFORNIA AGENCY NAME BY (Authorized Signature) ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING Exempt per: ADDRESS Exhibit A Project Summary & Scope of Work

  • Registration Data Directory Services Until ICANN requires a different protocol, Registry Operator will operate a WHOIS service available via port 43 in accordance with XXX 0000, and a web-­‐based Directory Service at <whois.nic.TLD> providing free public query-­‐based access to at least the following elements in the following format. ICANN reserves the right to specify alternative formats and protocols, and upon such specification, the Registry Operator will implement such alternative specification as soon as reasonably practicable. Registry Operator shall implement a new standard supporting access to domain name registration data (SAC 051) no later than one hundred thirty-­‐five (135) days after it is requested by ICANN if: 1) the IETF produces a standard (i.e., it is published, at least, as a Proposed Standard RFC as specified in RFC 2026); and 2) its implementation is commercially reasonable in the context of the overall operation of the registry.

  • Extended Health Plan (a) The Employer will pay 100% of the monthly premiums for the extended health care plan that will cover the employee, their spouse and dependent children, provided they are not enrolled in another plan.

  • Supplier Diversity Seller shall comply with Xxxxx’s Supplier Diversity Program in accordance with Appendix V.

  • Pregnancy and Maternity Services This plan covers physician services and the services of a licensed midwife for prenatal, delivery, and postpartum care. The first office visit to diagnose a pregnancy is not included in prenatal services. This plan covers hospital services for mother and newborn child for at least forty-eight

  • Behavioral Health Services Behavioral health services include the evaluation, management, and treatment for a mental health or substance use disorder condition. For the purpose of this plan, substance use disorder does not include addiction to or abuse of tobacco and/or caffeine. Mental health or substance use disorders are those that are listed in the most updated volume of either: • the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; or • the International Classification of Disease Manual (ICD) published by the World Health Organization. This plan provides parity in benefits for behavioral healthcare services. Please see Section 10 for additional information regarding behavioral healthcare parity. Inpatient This plan covers behavioral health services if you are inpatient at a general or specialty hospital. See Inpatient Services in Section 3 for additional information. Residential Treatment Facility This plan covers services at behavioral health residential treatment facilities, which provide: • clinical treatment; • medication evaluation management; and • 24-hour on site availability of health professional staff, as required by licensing regulations. Intermediate Care Services This plan covers intermediate care services, which are facility-based programs that are: • more intensive than traditional outpatient services; • less intensive than 24-hour inpatient hospital or residential treatment facility services; and • used as a step down from a higher level of care; or • used a step-up from standard care level of care. Intermediate care services include the following: • Partial Hospital Program (PHP) – PHPs are structured and medically supervised day, evening, or nighttime treatment programs providing individualized treatment plans. A PHP typically runs for five hours a day, five days per week. • Intensive Outpatient Program (IOP) – An IOP provides substantial clinical support for patients who are either in transition from a higher level of care or at risk for admission to a higher level of care. An IOP typically runs for three hours per day, three days per week.

  • Diagnostic Services Procedures ordered by a recognized Provider because of specific symptoms to diagnose a specific condition or disease. Some examples include, but are not limited to:

  • Surgery Services This plan covers surgery services to treat a disease or injury when: • the operation is not experimental or investigational, or cosmetic in nature; • the operation is being performed at the appropriate place of service; and • the physician is licensed to perform the surgery. Preauthorization may be required for certain surgical services. Reconstructive Surgery for a Functional Deformity or Impairment This plan covers reconstructive surgery and procedures when the services are performed to relieve pain, or to correct or improve bodily function that is impaired as a result of: • a birth defect; • an accidental injury; • a disease; or • a previous covered surgical procedure. Functional indications for surgical correction do not include psychological, psychiatric or emotional reasons. This plan covers the procedures listed below to treat functional impairments. • abdominal wall surgery including panniculectomy (other than an abdominoplasty); • blepharoplasty and ptosis repair; • gastric bypass or gastric banding; • nasal reconstruction and septorhinoplasty; • orthognathic surgery including mandibular and maxillary osteotomy; • reduction mammoplasty; • removal of breast implants; • removal or treatment of proliferative vascular lesions and hemangiomas; • treatment of varicose veins; or • gynecomastia. Preauthorization may be required for these services.

  • Medical Verification The Town may require medical verification of an employee’s absence if the Town perceives the employee is abusing sick leave or has used an excessive amount of sick leave. The Town may require medical verification of an employee’s absence to verify that the employee is able to return to work with or without restrictions.

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