Agreement of Coverage. The Eligible Person and/or Dependent loses eligibility under Medicaid or Children's Health Insurance Program (CHIP). Coverage will begin only if SHL receives the completed enrollment form and any required Premium within 60 days of the date coverage ended. Any other event which affects a Dependent’s eligibility. If the Subscriber fails to give notice which would have resulted in termination of coverage, SHL shall have the right to terminate coverage. A Dependent’s coverage terminates on the same day as the Subscriber.
Agreement of Coverage. Divorce. Transfer of residence outside HPN’s Service Area. The Eligible Person and/or Dependent loses eligibility under Medicaid or Children's Health Insurance Program (CHIP). Coverage will begin only if HPN receive the completed enrollment form and any required premium within sixty (60) days of the date coverage ended. Any other event which affects a Dependent’s eligibility. If the Subscriber fails to give notice which would have resulted in termination of coverage, HPN shall have the right to terminate coverage. A Dependent’s coverage terminates on the same day as the Subscriber.
Agreement of Coverage. 5.23 Self-Management and Treatment of Diabetes Coverage includes medication, equipment, supplies and appliances that are for the treatment of diabetes. Diabetes includes type I, type II and gestational diabetes. Covered Services include: supplies, training and education provided to a Member for the care and management of diabetes, after he is initially diagnosed with diabetes, to include counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes; supplies, training and education which is necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the Member and which requires modification of his program of self-management of diabetes; and supplies, training and education which is necessary because of the development of new techniques and treatment for diabetes.
Agreement of Coverage. If a Subscriber fails to make premium payments within thirty-one (31) days of the premium due date, coverage will be terminated on the first day of the month for which a premium was due and not received by HPN. With thirty (30) days written notice, if the Member allows his, or any other Member's, HPN ID Card to be used by any other person, or uses another person's ID Card. The Member will be liable to HPN for all costs incurred as a result of the misuse of the HPN Member ID Card. If the Member performs an act or practice that constitutes fraud, or makes any intentional misrepresentation of material fact, as prohibited by the terms of coverage, HPN has the right to rescind coverage and declare coverage under the Plan null and void as follows: for a material breach that occurred in the application process, rescission of coverage back to the original Effective Date of Coverage, with a refund any applicable premium; or for any other act of fraud, termination effective no earlier than the date that the fraud had taken place. Thirty (30) days written notice shall be provided to the Member prior to any rescission of coverage. A Member has the right to appeal any such rescission. Except as specifically provided in Section 1.3, on the last day of the calendar month in which a Member no longer meets the requirements of Section 1. If the Member fails to give written notice within thirty-one (31) days of the loss of eligibility, HPN will terminate coverage retroactively and refund any corresponding premium. When a Subscriber moves his primary residence outside HPN’s Service Area or when a Dependent moves his primary residence outside HPN's Service Area, Subscriber must notify HPN within thirty-one (31) days of the change. When information provided to HPN in the application form is determined to be untrue, inaccurate, or incomplete, in lieu of termination of coverage. HPN shall have the right to retroactively increase past premium payments to the maximum rate allowed that would have been billed if such untrue, inaccurate, or incomplete information had not been provided. If the revised premium rate is not received by HPN within thirty (30) days of the letter of notification, coverage will be terminated as of the paid-to date.
Agreement of Coverage. 2. A Subscriber's newborn natural child is covered for the first thirty-one (31) days following birth. Coverage continues after thirty- one (31) days only if the Subscriber makes application for the child as a Dependent and pays any premium within sixty (60) days of the date of birth.
Agreement of Coverage. Immunizations(1) that have in effect a recommendation from the Advisory Committee on Immunizations Practices of the Centers for Disease Control and Prevention; With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”); and With respect to women, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the HRSA, as long as they are not otherwise addressed by the recommendations of the USPSTF. For a complete list of Preventive Services, including all FDA approved contraceptives, go to xxxx://xxx.xx.xxx/Healthcare- Reform/Individuals-Families/Preventive-Care/.
Agreement of Coverage. The Member has signed a statement of consent before his participation in the clinical trial or study indicating that he has been informed of: The procedure to be undertaken; Alternative methods of treatment; and The risks associated with participation in the clinical trial or study. Benefit coverage for medical treatment received during a clinical trial or study is limited to the following Covered Services: The initial consultation to determine whether the Member is eligible to participate in the clinical trial or study; Any drug or device that is approved for sale by the FDA without regard to whether the approved drug or device has been approved for use in the medical treatment of the Member, if the drug or device is not paid for by the manufacturer, distributor, or Provider: Services normally covered under this Plan that are required as a result of the medical treatment or related complications provided in the clinical trial or study when not provided by the sponsor of the clinical trial or study; Services required for the clinically appropriate monitoring of the Member during the clinical trial or study when not provided by the sponsor of the clinical trial or study. Benefits for Covered Services in connection with a clinical trial or study are payable under this Plan to the same extent as any other Illness or Injury. Services must be provided by an HPN Plan Provider. In the event an HPN Plan Provider does not offer a clinical trial with the same protocol as the one the Member’s Plan Provider recommended, the Member may select a Non-Plan Provider performing a clinical trial with that protocol within the State of Nevada. If there is no Provider offering the clinical trial with the same protocol as the one the Member’s Plan Provider recommended in Nevada, the Member may select a clinical trial outside of Nevada but within the United States of America. In no event will HPN pay more than the maximum payment allowance established in the HPN Reimbursement Schedule. HPN will require a copy of the clinical trial or study certification approval, the Member’s signed statement of consent and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment.
Agreement of Coverage. Nursery charges for newborns. Reimbursement for Covered Services provided by a Non-Plan Provider outside HPN’s Service Area to a newborn natural child or adopted child is limited to HPN’s Eligible Medical Expenses, or the Recognized Amount when applicable, for similar Covered Services provided in HPN's Service Area. Services and Supplies. Covered Services and supplies provided by a Hospital, Ambulatory Surgical Facility, Skilled Nursing Facility, Residential Treatment Center or Hospice Care Facility include: • non-surgical Provider visits; • operating, recovery, and treatment rooms and equipment (Hospital and Ambulatory Surgical Facility only); • delivery and labor rooms and equipment (Hospital and Ambulatory Surgical Facility only); • anesthesia materials and anesthesia administration by Hospital staff (Hospital and Ambulatory Surgical Facility only); • clinical pathology and laboratory services and supplies; • services and supplies for diagnostic tests required to diagnose Member's Illness, Injury or other conditions but only when charges for the services and/or supplies are made by the facility (Hospital, Skilled Nursing Facility and Ambulatory Surgical Facility only); • drugs consumed at the time and place dispensed which have been approved for general marketing in the United States by the Food and Drug Administration (FDA); • dressings, splints, casts and other supplies for medical treatment provided by the Hospital from a central sterile supply department; • oxygen and its administration; • non-replaced blood, blood plasma, blood derivatives, and their administration and processing; • intravenous injections and solutions; • private duty nursing; • supportive services for a Hospice patient's family, including care for the patient which provides a respite from the stresses and responsibilities that result from the daily care of the patient and bereavement services provided to the family after the death of the patient (Hospice Care Facility only); and • Sterilization procedures.
Agreement of Coverage or a family member of a Member or the Member’s treating provider only when the Member is unable to provide consent. Adverse determinations eligible for External Review set forth in this section are only those relating to Medical Necessity, appropriateness of service, healthcare service, healthcare setting, or level of care or effectiveness of a healthcare service. HPN will provide the Member notice of such an adverse determination which will include the following statement: HPN has denied your request for the provision or payment of a requested healthcare service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the Medical Necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested, by submitting a request for External Review to the Office for Consumer Health Assistance. Additionally, as per applicable law and regulations, the notice will provide the Member the information outlined herein as well as the following: • The telephone number for the Office for Consumer Health Assistance for the state of jurisdiction of the health carrier and the state in which the Member resides. • The right to receive correspondence in a culturally and linguistically appropriate manner. The notice to the Member or the Member’s Authorized Representative will also include • a HIPAA compliant authorization form by which the Member or the Member’s Authorized Representative can authorize HPN and the Member’s Physician to disclose protected health information (“PHI”), including medical records, that are pertinent to the External Review, • and any other forms as required by Nevada law or regulation. The Member or the Member’s Authorized Representative may submit a request directly to OCHA for an External Review of an adverse determination by an Independent Review Organization (“IRO”) within four (4) months of the Member or the Member’s Authorized Representative receiving notice of such determination. The IRO must be certified by the Nevada Division of Insurance. Requests for an External Review must be made in writing and submitted to OCHA at the address below and should include the signed HIPAA authorization form, authorizing the release of your medical records. The entire External Review process and any associated medical records are confidential. Address Office for Consumer...
Agreement of Coverage. A pharmacy may refuse to fill or refill a prescription order when, in the professional judgment of the pharmacist, the prescription should not be filled. Benefits are not payable if the Member is directed to a Designated Plan Pharmacy and chooses not to obtain the Covered Drug from that Designated Plan Pharmacy. If HPN determines that the Member may be using Prescription Drugs in a harmful or abusive manner, or with harmful frequency, the Member’s selection of Plan Pharmacies may be limited. If this happens, HPN may require the Member to select a single Plan Pharmacy that will provide and coordinate all future pharmacy services. Benefit coverage will be paid only if the Member uses the assigned single Plan Pharmacy. If a selection is not made by the Member within thirty-one (31) days of the date of notification, then HPN will select a single Plan Pharmacy for the Member. Certain Specialty Prescription Drugs may be dispensed by the Designated Pharmacy in fifteen (15) day supplies up to ninety (90) days and at a pro-rated Copayment or Coinsurance. The Member will receive a fifteen (15) day supply of the Specialty Prescription Drug Product to determine if the Member will tolerate the Specialty Prescription Drug Product prior to purchasing a full supply. The Designated Pharmacy will contact the Member each time prior to dispensing the fifteen (15) day supply to confirm if the Member is tolerating the Specialty Prescription Drug Product. The list of these certain Specialty Prescription Drugs is available through review of the HPN Prescription Drug List (PDL). If a Prescription Drug is excluded from coverage, the Member or representative may request an exception to gain access to the excluded Prescription Drug. Exceptions do not apply to drugs that are considered benefit exclusions, such as drugs for sexual dysfunction, cosmetic products and infertility. To make a request, contact HPN in writing or call the toll-free number on your ID card. Please note, if the request for an exception is approved by HPN, the Member may incur the cost of the excepted Prescription Drug at the highest tier. If the request requires immediate action and a delay could significantly increase a health risk or the ability regain maximum function, call HPN as soon as possible. HPN will provide a written or electronic determination within twenty-four (24) hours. If the Member is not satisfied with HPN determination of the exclusion exception, they may request an External Review. ...
