Medical and Surgical Clause Samples

Medical and Surgical. Network (a) Doctor's Office Visits Doctor's office visits will be covered for the treatment of illness or injury and for designated screening services. Outpatient x-ray, lab and pathology services provided during an office visit will also be covered. The first 15 doctor's office visits provided on a network basis per covered individual, per health insurance contract year will be covered subject to a $10 copayment. Outpatient x-ray, lab and pathology services provided during the first 15 visits will be covered in full. Beginning with the sixteenth visit per covered individual per health insurance contract year, doctor's office visits and outpatient x-ray, lab and pathology services provided during the visit will be reimbursed at 80 percent of allowable expenses after the $100 per person annual deductible. Pursuant to the Patient Protection and Affordable Care Act (PPACA), effective January 1, 2012 the $100 per person annual deductible is now combined for hospital, medical and mental health and substance abuse. Visits by the employee to the Student Health Center will not count toward the 15 visit limit and will not be subject to a copayment, deductible or coinsurance. (b) Routine Health Exams The plan shall pay up to $60 for a routine physical once every two years for employees under the age of 40, and annually for employees 40 years of age or older, not subject to the office visit copayment or annual 15 visit limit. The Joint Committee on Health Benefits shall discuss the viability of the $60 cap throughout the course of the contract. Effective September 1, 2014, or as soon thereafter as practicable, pursuant to PPACA, covered preventive care services will be paid in full when received from a participating provider. Outpatient x-ray, lab and pathology screening services provided on a different date from a doctor's office visit or in a different location, other than the Student Health Center, will be subject to a $10 copayment for the first 15 occurrences and reimbursed at 80 percent of allowable expenses after the combined $100 per person annual deductible beginning with the sixteenth occurrence. (c) Mammograms and Cervical Cytology Screening Coverage for cervical cytology screening once each health insurance contract year will be provided subject to the doctor's office limit and either a $10 copayment or deductible and coinsurance. Services for the examination of the Pap smear on a different date or at a different location than the office visit will result...