BENEFITS AND COVERAGES Sample Clauses

BENEFITS AND COVERAGES. All the benefits provided for in this Agreement are detailed in “Schedule A – Benefit Coverage”, and subject to the following terms and conditions: 1. In case of Out-Patient, the MEMBER can go directly to the primary physician of any accredited hospital/clinic for out-patient consultation. The primary physician will request for laboratory or diagnostic examinations or refer the MEMBER to a specialist. The MEMBER may avail of services from any accredited hospital/clinic of his/her choice upon issuance by MediCard of the Out-Patient Consultation Form or Laboratory Request Form. 2. For In-Patient services, all limits are inclusive of room and board, operating room charges, professional fees and other incidental expenses relative to the procedure. A Letter of Authorization (LOA) together with other necessary documents shall be issued by MediCard prior to confinement. The maximum benefit limit and annual benefit limit shall be inclusive of consultations, diagnostic procedures and hospitalization. Before being discharged from the Hospital, a Member must fill up the prescribed discharge form and settle that portion of the medical bill not covered by the Agreement. That portion of the bill covered by the Agreement shall be settled directly by the HMO with the hospital and/or Attending Physician(s). 3. All procedures or benefits are subject to the limitations on pre-existing conditions as stated in this Agreement. 4. Non-emergency confinement or surgery (elective cases) shall be subject to prior review and approval by the MediCard review board. MediCard reserves the right to direct the MEMBERS to other physicians or specialists for further opinions as needed so as to protect the interest of both the MEMBER and MediCard. 5. In all circumstances of Emergency Care Services, MediCard reserves the right to validate whether treatment received is emergency in nature and/or the illness or condition is covered under the provisions of this Agreement. 6. In case a MEMBER is simultaneously covered under more than one corporate or group health maintenance agreements with MediCard, the ASO Fund in Schedule B for which are paid by the COMPANY and/or Principal Member, the MEMBER on a per confinement basis, shall only avail of the benefits accruing from one agreement. The MEMBER must choose which agreement will apply and his/her confinement will be governed by the terms and conditions and the limits of the agreement of his/her choice. The provision is without prejudice to the other...

BENEFITS AND COVERAGES. After you reach your Out-of-Pocket Limit (including any required Deductible), your Contract pays 100% of the Maximum Allowable Amount for the remainder of the calendar year. Out-of-pocket Limits are accumulated separately for In-Network and Out-of-Network Providers. There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist you in understanding the Maximum Allowed Cost (MAC) language as described below, please refer to the definition of In-Network Provider, Out-of-Network Provider and Non- Preferred Provider contained in the Definitions section of this booklet.

BENEFITS AND COVERAGES. The District’s health and prescription plan is provided by Medical Mutual under policy number CMS1331800000423-00756. Copies of health and prescription plan certificates of coverage have been provided to OAPSE. See Exhibit A for more information regarding the District’s health and prescription plans.

BENEFITS AND COVERAGES. After you reach your Out-of-Pocket Limit (including any required Deductible), your Contract pays 100% of the Maximum Allowable Amount for the remainder of the calendar year. Out-of-pocket Limits are accumulated separately for In-Network and Out-of-Network Providers. There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist you in understanding the Maximum Allowed Cost (MAC) language as described below, please refer to the definition of In-Network Provider, Out-of-Network Provider and Non- Preferred Provider contained in the Definitions section of this booklet. This section describes how we determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by In-Network and Out-of-network Providers is based on this plan’s Maximum Allowed Cost (MAC)Cost (MAC) for the Covered Service that you receive. The Maximum Allowed Cost (MAC) Cost for this plan is the maximum amount of reimbursement Alliant will pay for services and supplies: • that meet our definition of Covered Services, to the extent such services and supplies are covered under Your Plan and are not excluded; • that are Medically Necessary; and • that is provided in accordance with all applicable preauthorization, utilization management (i.e., coverage certification) or other requirements set forth in Your Plan. You will be required to pay a portion of the Maximum Allowed Cost (MAC) Cost to the extent you have not met your Deductible nor have a Copayment or Coinsurance. In addition, when you receive Covered Services from an Out-of-network Provider, you may be responsible for paying any difference between the Maximum Allowed Cost (MAC) and the Provider’s actual charges. This amount can be significant. 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 Maximum Allowed Cost (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...

BENEFITS AND COVERAGES. HMO agrees to arrange for preventive, diagnostic and treatment services from HMO Medical Service Units and within HMO Accredited Hospitals or HMO Medical Centers to all qualified and accepted MEMBERS, subject to the following terms and conditions: Care by HMO Medical Service Units/Teams A. The following Preventive Health Care Services will be provided to MEMBERS by designated HMO Medical Service Units:  Annual Physical Examination (APE) for MEMBERS below Vice President to include: Complete Blood Count Urinalysis (urine examination) Fecalysis (stool examination) Chest X-ray Electrocardiogram (for members 35 years old and above, or if prescribed) Pap smear (for women 35 years old and above, or if prescribed) Eye Refraction Prostate cancer screening (Prostate Specific Antigen) for male age 40 and above, or if prescribed Mammography (for female 40 years old and above, or if prescribed) Blood typing/chemistry (FBS, HDL, LDL, VLDL) All items in the APE Chest X-ray (PA-L view) Blood chemistry – total cholesterol, triglycerides, SGOT, SGPT, BUN, CREA, Uric Acid, Serum Electrolytes (Na+, K+, Cl-, Ca++), Thyroid Function Test (TSH, FT3, FT4) Treadmill Exercise Test Gastroscopy Proctosigmoidoscopy Ultrasound of the whole abdomen (liver, gall bladder, pancreas, spleen, kidney)  Management of Health Problems  Routine Immunization (except cost of vaccines)  Counseling on health habits, diets and Family Planning  Record keeping of Medical History Once a year, APE shall be conducted at the clinic of HMO or at the PDIC premises through a HMO Mobile Medical Team on a scheduled basis for a minimum of 50 Principal MEMBERS. B. The following Out-Patient Services will be provided to MEMBERS in any HMO accredited hospital:  Referral to specialists  Regular consultation and treatment (except prescribed medicines)  Eye, Ear, Nose and Throat treatment  Treatment of minor injuries and surgery not requiring confinement  X-ray and laboratory examinations prescribed by HMO physician  Physical, occupational and speech therapy up to the annual benefit limit per MEMBER per year  Laser treatment for all eye illnesses and injuries up to P30,000.00 per MEMBER per year  Pre and post natal consultations excluding laboratory examinations  First dose of anti-rabies, anti-tetanus and anti-venom  Cauterization of warts including facial warts up to P1,000.00 per MEMBER per year  Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) study on any part of the body  Echocard...

BENEFITS AND COVERAGES. If you would like more information on WHCRA benefits, call your Plan Administrator. If you would like more information on WHCRA benefits, call your Plan Administrator.