Your Cost Share. This plan has two levels of hospital benefits. You will pay a highercostsharewhen you receivecertaininpatient services at or by “higher cost share hospitals.” See the chart on the opposite page for your cost share amounts.
Your Cost Share. This plan has two levels of hospital benefits. You will pay a higher cost share when you receive certain inpatient services at or by “higher cost share hospitals”. See the chart on opposite page for cost share amounts. Please note: If your PCP refers you to another provider for covered services (such as a specialist), it is important to check whether the provideryouare referred to is affiliated withone of the higher cost share hospitals listed below. Your cost will be greater when you receive inpatient services at or by these hospitals, even if your PCP refers you.
Your Cost Share. You pay the following copayment or coinsurance for each Service: · No charge This External Prosthetic and Orthotic Devices Rider is subject to all the terms and conditions of the Group Evidence of Coverage to which this Rider is attached. This Rider does not change any of those terms and conditions, unless specifically stated in this Rider. By: Xxxx Xxxxxxxx Vice President, Marketing, Sales & Business Development KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. 0000 Xxxx Xxxxxxxxx Xxxxxx, Xxxxxxxxx, Xxxxxxxx 00000 EXTENEDED INFERTILITY SERVICES RIDER GROUP EVIDENCE OF COVERAGE This Extended Infertility Services Rider (herein called “Rider”) is effective as of the date of your Group Agreement and Group Evidence of Coverage and shall terminate as of the date your Group Agreement and Group Evidence of Coverage terminates. The following benefits, limitations, and exclusions for extended infertility Services are hereby added to the Benefits Section of the Group Evidence of Coverage (herein referred to as the Group EOC) in consideration of the application and payment of the additional Dues for such Services.
Your Cost Share. Refer to the Summary of Benefits and Cost Shares in the Group EOC for cost share information. The cost shares for “Infertility Services” in the Summary of Benefits and Cost Shares in the Group EOC also apply to the Services covered under this Rider. This Extended Infertility Services Rider is subject to all the terms and conditions of the Group Evidence of Coverage to which this Rider is attached. This Rider does not change any of those terms and conditions, unless specifically stated in this Rider. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. By: Xxxx Xxxxxxxx Vice President, Marketing, Sales & Business Development XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. AMENDMENT RIDER TO GROUP AGREEMENT AND EVIDENCE OF COVERAGE (Non-Grandfathered Group Plan) The Group Agreement and Evidence of Coverage (hereinafter severally and collectively referred to as the “Agreement”) to which this amendment rider is attached are amended as described below. Definitions Capitalized terms shall have the meaning ascribed to them in the Agreement unless defined in this amendment rider. The following definitions have the following meanings in this amendment rider:
Your Cost Share. You pay the following copayment or coinsurance for each visit: · You pay $30 per visit. This Rider is subject to all the terms and conditions of the Group Agreement, and Group Evidence of Coverage, to which this Rider is attached. This Rider does not change any of those terms and conditions, unless specifically stated in this Rider. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. By: Xxxxx X. Xxxxxxx Vice President, Marketing, Sales & Business Development ALL-GRP-CAM(01/11) 1 HMO KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. 0000 Xxxx Xxxxxxxxx Xxxxxx Xxxxxxxxx, Xxxxxxxx 00000 (000) 000-0000 HMO DENTAL RIDER This HMO Dental Rider is effective as of the date of your Group Agreement and Group Evidence of Coverage (EOC) and shall terminate as of the date your Group Agreement and Group Evidence of Coverage (EOC) terminates. The following dental services shall be added to the Group Evidence of Coverage (EOC) to which this HMO Dental Rider (Rider) is attached, in consideration of Group’s application and payment of Premium for such Services.
Your Cost Share. You pay the following copayment or coinsurance for each Service: · No charge This External Prosthetic and Orthotic Devices Rider is subject to all the terms and conditions of the Group Evidence of Coverage to which this Rider is attached. This Rider does not change any of those terms and conditions, unless specifically stated in this Rider. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. By: Xxxxx X. Xxxxxxx Vice President, Marketing, Sales & Business Development KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. 0000 Xxxx Xxxxxxxxx Xx., Xxxxxxxxx, XX 00000 301-816-2424 COMPLEMENTARY ALTERNATIVE MEDICINE SERVICES RIDER GROUP EVIDENCE OF COVERAGE This Complementary Alternative Medicine Services Rider (herein called “Rider”) is effective as of the date of your Group Agreement and Group Evidence of Coverage and shall terminate as of the date that your Group Agreement and Group Evidence of Coverage terminate. The following benefits, limitations, and exclusions are hereby added to the “Benefits” Section of the Group Evidence of Coverage, in consideration of the Group application and payment of the additional Premium for the Services pursuant to this Rider. Complementary Alternative Medicine Services
Your Cost Share. No charge This External Prosthetic and Orthotic Devices Rider is subject to all the terms and conditions of the Group Evidence of Coverage to which this Rider is attached. This Rider does not change any of those terms and conditions, unless specifically stated in this Rider. By: Xxxx Xxxxxxxx Vice President, Marketing, Sales & Business Development KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. 0000 Xxxx Xxxxxxxxx Xx., Xxxxxxxxx, XX 00000 301-816-2424 HEARING SERVICES RIDER GROUP EVIDENCE OF COVERAGE This Hearing Services Rider (herein called “Rider”) is effective as of the date of your Group Agreement and Group Evidence of Coverage and shall terminate as of the date your Group Agreement and Group Evidence of Coverage terminates. The following benefits, limitations, and exclusions are hereby added to the “Benefits” Section of the Group Evidence of Coverage (herein referred to as the Group EOC), in consideration of the application and payment of the additional Premium for such Services.
Your Cost Share. Covered Services under this Rider are not subject to the Deductible and the Out-of-Pocket Maximum in the Group EOC to which this Rider is attached. You pay the following copayment or coinsurance for each Service: (When the Service received is in accordance with an approved referral from a Plan Provider)
Your Cost Share. Refer to the Summary of Benefits and Cost Shares in the Group EOC for cost share information. The cost shares for “Infertility Services” in the Summary of Benefits and Cost Shares in the Group EOC also apply to the Services covered under this Rider. This Extended Infertility Services Rider is subject to all the terms and conditions of the Group Evidence of Coverage to which this Rider is attached. This Rider does not change any of those terms and conditions, unless specifically stated in this Rider. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. By: Xxxx Xxxxxxxx Vice President, Marketing, Sales & Business Development XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. AMENDMENT RIDER TO GROUP AGREEMENT AND EVIDENCE OF COVERAGE (Grandfathered Group Plan with Preventive Care) The Group Agreement and Evidence of Coverage (hereinafter severally and collectively referred to as the “Agreement”) to which this amendment rider is attached is amended as described below.
Your Cost Share. Refer to the Summary of Benefits and Cost Shares in the Group EOC for cost share information. The cost shares for “Infertility Services” in the Summary of Benefits and Cost Shares in the Group EOC also apply to the Services covered under this Rider. This Extended Infertility Services Rider is subject to all the terms and conditions of the Group Evidence of Coverage to which this Rider is attached. This Rider does not change any of those terms and conditions, unless specifically stated in this Rider. XXXXXX FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. By: Xxxxx X. Xxxxxxx Vice President, Marketing, Sales & Business Development KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. 2100 Xxxx Xxxxxxxxx Xx., Xxxxxxxxx, XX 00000 001-816-2424 COMPLEMENTARY ALTERNATIVE MEDICINE SERVICES RIDER GROUP EVIDENCE OF COVERAGE This Complementary Alternative Medicine Services Rider (herein called “Rider”) is effective as of the date of your Group Agreement and Group Evidence of Coverage and shall terminate as of the date that your Group Agreement and Group Evidence of Coverage terminate. The following benefits, limitations, and exclusions are hereby added to the “Benefits” Section of the Group Evidence of Coverage, in consideration of the Group application and payment of the additional Premium for the Services pursuant to this Rider. Complementary Alternative Medicine Services
