Network Covered Services Clause Samples

Network Covered Services. When Members under the same Family Coverage have Incurred $13,700 in Deductible, Copayment and Coinsurance expenses for Network Covered Services furnished to the Members in one (1) Benefit Period, the benefits payable for claims received by the Plan thereafter for all Members under that same Family Coverage during the remainder of the Benefit Period will increase to one hundred percent (100%) of the Plan Allowance. In the case of family coverage, no individual Member may contribute cost-sharing expenses greater than their Individual Out-of-Pocket Maximum. However, as each Member reaches their Individual Out-of-Pocket Maximum, the benefits payable for that Member will increase to 100% of the Plan Allowance for the remainder of the Benefit Period, whether or not the Family Out-of-Pocket Maximum has been met. The dollar amount specified shall not include amounts in excess of the Plan Allowance.

Network Covered Services. When members under the same family coverage have incurred $8,000, in coinsurance expense for network covered services furnished to the members in one (1) benefit period, the benefits payable for claims received by the Plan thereafter for all members under that same family coverage during the remainder of the benefit period will increase to one hundred percent (100%) of the plan allowance. In the case of family coverage, benefits for any individual will not increase to one hundred percent (100%) of the plan allowance until the entire Family Out-of-Pocket Limit has been satisfied. The dollar amount specified shall not include any amounts paid for deductibles or amounts in excess of the plan allowance.