Hospitalization In the event an employee is hospitalized overnight, the employee will have access to their EIB accrual at the first day of absence due to the hospitalization. Same day surgery, if requiring five (5) or more days of recovery, may also be paid from the employee’s EIB account.
Family Planning The MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid enrollees are entitled to obtain all Medicaid covered family planning services without prior authorization through any Medicaid provider, who will bill the MCO and be paid on a FFS basis.4 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. MCOs must provide their Medicaid enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.
Health and Hospitalization Insurance Single Coverage: The School District shall contribute a sum not to exceed $284.00 per month toward the premium for individual coverage for each full-time employee employed by the School District who qualifies for and is enrolled in single coverage in the School District’s group health and hospitalization insurance plan. Any additional cost of the premium shall be borne by the employee and paid by payroll deduction.
Medical Flexible Spending Arrangement A. During January 2020 and again in January 2021, the Employer will make available two hundred fifty dollars ($250) in a medical flexible spending arrangement (FSA) account for each bargaining unit member represented by a Union in the Coalition described in RCW 41.80.020(3), who meets the criteria in Subsection 28.7(B) below.
Orthodontics We Cover orthodontics used to help restore oral structures to health and function and to treat serious medical conditions such as: cleft palate and cleft lip; maxillary/mandibular micrognathia (underdeveloped upper or lower jaw); extreme mandibular prognathism; severe asymmetry (craniofacial anomalies); ankylosis of the temporomandibular joint; and other significant skeletal dysplasias. Procedures include but are not limited to: • Rapid Palatal Expansion (RPE); • Placement of component parts (e.g. brackets, bands); • Interceptive orthodontic treatment; • Comprehensive orthodontic treatment (during which orthodontic appliances are placed for active treatment and periodically adjusted); • Removable appliance therapy; and • Orthodontic retention (removal of appliances, construction and placement of retainers).
HEALTH CARE PLANS Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.
Hospitals a. In every Hospital:
Hospitalization Insurance The Employer shall provide: HOSPITALIZATION INSURANCE Effective as soon as is practical after September 1, 2011 or date of ratification, whichever is sooner. Community Blue PPO 4$2/25/50 Prescription Drug Rider Dental Plan 2 $ Mandatory Mail-Order for Maintenance Drugs $ On Mail-Order- Pay for 2 month supply, get 3 month supply $ Mandatory Generic Drugs$ $10 Office and Chiropractic Visit Employees Contribute $10 per Pay Period for spousal coverage. Effective the first pay period after 9/1/2011 or as soon as is practicable employees hired before 9/1/11 shall pay 5% of the illustrated rate for the health and dental coverage they select. Effective 1/1/2012 employees hired before 9/1/11 shall pay 10% of the illustrated rate for the health and dental coverage they select. Effective the first pay period after 9/1/2011 or as soon as is practicable, for employees hired on or after 9/1/11, employees shall contribute 20% of the illustrated rate for the coverage the employee selects.
Medical Exams 18.1: The Sheriff's Department may require a physical and/or psychological exam by a doctor, at the Employer's expense, to determine the employee's ability to perform his/her regular duties, if deemed appropriate. The employee may obtain a second opinion, at the employee's expense, and in the event there is a dispute between the Employer's doctor and the employee's doctor, both of these doctors shall select a third doctor, whose decision shall be final and binding on the parties. The expense for the third doctor's opinion shall be split 50-50 by the Employer and the employee if not covered by the employee's insurance.
Dental Care Plan The Welfare Plan will include a Dental Care Plan which will reimburse members for expenses incurred in respect of the coverages summarized in Appendix "1". The Plan will not duplicate benefits provided now or which may be provided in the future by any government program.
