Essential Health Benefits Sample Clauses

Essential Health Benefits. Each QHP offered by Contractor under the terms of this Agreement shall provide essential health benefits in accordance with the Benefit Plan Design requirements described in the Covered California Patient-Centered Benefit Plan Designs as approved by the Board for the applicable Plan Year, and as required under this Agreement, and applicable laws, rules and regulations, including California Health and Safety Code § 1367.005, California Insurance Code § 10112.27, California Government Code § 100503(e), and as applicable, 45 C.F.R. § 156.200(b).
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Essential Health Benefits. (“Pediatric Benefits”). For the purpose of this Part, Essential Health Benefits are certain pediatric oral services that are required to be included under the Affordable Care Act. The services considered to be Essential Health Benefits are determined by state and federal agencies and are available for Eligible Pediatric Individuals.
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Essential Health Benefits. Benefits defined by the Secretary of Health and Human Services that shall include at least the following general categories: ambulatory patient services, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and services, including oral and vision care. The designation of benefits as essential shall be consistent with the requirements and limitations set forth under the Affordable Care Act and applicable regulations as determined by the Secretary of Health and Human Services. Experimental/Investigational Services Services that meet one or more of the following:  A drug or device which cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and does not have approval on the date the service is provided  It is subject to oversight by an Institutional Review Board  There is no reliable evidence showing that the service is effective in clinical diagnosis, evaluation, management or treatment of the condition  It is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety or efficacy  Evaluation of reliable evidence shows that more research is necessary before the service can be classified as equally or more effective than conventional therapies Reliable evidence means only published reports and articles in authoritative medical and scientific literature, and assessments. Facility (Medical Facility) A hospital, skilled nursing facility, approved treatment facility for chemical dependency, state-approved institution for treatment of mental or psychiatric conditions, or hospice. Not all health care facilities are covered under this contract. Home Medical Equipment (HME) Equipment ordered by a provider for everyday or extended use to treat an illness or injury. HME may include: oxygen equipment, wheelchairs or crutches. Home Health Agency An organization that provides covered home health services to a member. Hospice A facility or program designed to provide a caring environment for supplying the physical and emotional needs of the terminally ill.
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Essential Health Benefits. This contract covers all essential health benefits. Essential health benefits are subject to some limitations or exclusions under this contract.
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Essential Health Benefits. (EHB) –are, for the purposes of this coverage, pediatric dental services that Alliant is required to cover under the Patient Protection and Affordable Care Act and any other applicableregulations. EHB and its provisions apply to Members through age 18 only.‌ Provider – is any Physician, health care practitioner, pharmacy, supplier or facility, including, but not limited to, a Hospital, clinical laboratory, Ambulatory Surgery Center, Retail Health Clinic, Skilled Nursing Facility, Long Term Acute Care facility, or Home Health Care Agency holding all licenses required by law to provide health care services. Plan – refers to the Alliant Health Plans’ SoloCare medical health insurance plan You have chosen for the 2023 Calendar year. DENTAL PROVIDERS AND CLAIMS PAYMENT You have the freedom to choose the Dentist You want for Your dental care. However, Your choice of Dentist can make a difference in the benefits You receive and the amount You pay. You may have additional out-of-pocket costs if Your Dentist does not accept the reimbursement amount determined by Alliant. Payments are made by Alliant only when the Covered Services have been completed. Your Plan may require additional information from You or Your Provider before a claim can be considered complete and ready for processing. In order to properly process a claim, Your Provider may be requested to submit a corrected claim. For example, if your Dentist submits a claim for an adult dental cleaning when the service performed was a pediatric dental cleaning, Alliant will deny the claim and request that the dentist submit a corrected claim. Xxxxxxxxx claims previously processed will be denied. This section describes how Alliant determines the amount of reimbursement for Covered Services. Reimbursement for dental services rendered by a Dentists is based on the Maximum Allowed Amount for the type of service performed. The Maximum Allowed Amount is the maximum amount of reimbursement Alliant will pay for Covered Services, as defined in this Schedule, by a Dentist or Member. You will be required to pay a portion of the Maximum Allowed Amount to the extent You have not met Your Deductible or have a Coinsurance. In addition, when You receive Covered Services from a Dentist, You may be responsible for paying any difference between the Maximum Allowed Amount and the Dentist’s actual charges. When You receive Covered Services from a Dentist, Alliant will apply processing rules to the claim submitted for those Covered S...
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Essential Health Benefits. 3.2.2 Patient-Centered Standard Benefit Designs 4.2.2 Patient-Centered Standard Benefit Designs
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Related to Essential Health Benefits

  • 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.

  • Medical Benefits The Company shall reimburse the Employee for the cost of the Employee's group health, vision and dental plan coverage in effect until the end of the Termination Period. The Employee may use this payment, as well as any other payment made under this Section 6, for such continuation coverage or for any other purpose. To the extent the Employee pays the cost of such coverage, and the cost of such coverage is not deductible as a medical expense by the Employee, the Company shall "gross-up" the amount of such reimbursement for all taxes payable by the Employee on the amount of such reimbursement and the amount of such gross-up.

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