Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- network. In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.
Benefits and Coverage. For a complete list of Medical Drugs to determine which require Prior Authorization please see the Presbyterian Pharmacy website at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phscontent/pel_0005273 9.pdf.
Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional,We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive.
Benefits and Coverage. In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require r Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances: Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment. Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk. Continuity –If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that special...
Benefits and Coverage. The Hospice treatment program must:
Benefits and Coverage. All benefits are provided in accordance with CMS/PACE guidelines including the requirement that such services are approved by the Interdisciplinary Team and provided by CHA PACE or its contracted service providers, unless otherwise indicated. • Adult day healthcare • Primary care, including consultation, routine care, preventive health care and physical examinations • Medical specialty services including, but not limited to, services such as gastroenterology, oncology, urology, rheumatology and dermatology (specialty services not available at Cambridge Health Alliance (CHA) will be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center) • Nursing care • Social services • Physical, occupational and speech therapies • Recreational therapy • Nutrition counseling and education • Laboratory tests, X-rays and other diagnostic procedures • Prescription drugs (only if obtained from a pharmacy designated by CHA PACE) • Prostheses and durable medical equipment when determined medically necessary by the Interdisciplinary Team • Podiatry • Vision care, including examinations, treatment and corrective devices such as eyeglasses • Psychiatry, including evaluation, consultation, diagnostic and treatment service • Audiology evaluation, hearing aids, repairs and maintenance • Ambulance • Emergency room care and treatment room services • Semi-private room and board, as available • General medical and nursing services • Medical, surgical, intensive care and coronary care unit, as necessary • Laboratory tests, x-rays and other diagnostic procedures • Prescription drugs • Blood and blood derivatives • Surgical care, including anesthesia • Use of oxygen • Physical, speech, occupational, respiratory therapies • Social services Hospital inpatient care does not include a private room, private duty nursing, and non-medical services such as telephone charges. Tertiary hospital care is not available at CHA but can be provided by CHA’s clinical affiliate, Xxxx Xxxxxx Deaconess Medical Center. • Semi-private room and board, when available • Physician and nursing services • Custodial care • Personal care and assistance • Prescription drugs • Physical, speech and occupational therapies as authorized by the Interdisciplinary team • Social services • Medical supplies and appliances • Skilled nursing services • Physical, speech and occupational therapies • Social services • Home health aide services • Homemaking services • Home-delivered meals • Emergency alert system • ...
Benefits and Coverage. Important
Benefits and Coverage. The health services available to Members upon enroll- ment and under the Plan contract.
Benefits and Coverage. (What is Covered)
Benefits and Coverage. Please see Chapter 5 to learn how to receive care if you have a medical emergency or other urgent need for care.
