Common use of Calendar Year Medical Deductible Clause in Contracts

Calendar Year Medical Deductible. The Calendar Year Medical Deductible is the amount an individual or a Family must pay for Covered Services each year before Blue Shield begins payment in accordance with this EOC. The Calendar Year Medical Deductible does not apply to all plans. When applied, this Deductible accrues to the Calendar Year Out-of-Pocket Maximum. Information specific to the Member’s plan is provided in the Summary of Benefits. The Summary of Benefits indicates whether or not the Calendar Year Medical Deductible applies to a particular Covered Service. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Medical Deductible whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Medical Deductible amounts. The individual Medical Deductible applies when an individual is covered by the plan. The Family Medical Deductible applies when a Family is covered by the plan. There is also an individual Medical Deductible within the Family Medical Deductible. This means Blue Shield will pay Benefits for any Family member who meets the individual Medical Deductible amount before the Family Medical Deductible is met. Once the respective Deductible is reached, Covered Services are paid as Allowed Charges, less any applicable Copayment or Coinsurance, for the remainder of the Calendar Year. The Calendar Year Out-of-Pocket Maximum is the highest Deductible, Copayment and Coinsurance amount an individual or Family is required to pay for designated Covered Services each year. If a benefit plan has any Calendar Year Medical Deductible, it will accumulate toward the Calendar Year Out-of-Pocket Maximum. The Summary of Benefits indicates whether or not Copayment and Coinsurance amounts for a particular Covered Service accrue to the Calendar Year Out-of-Pocket Maximum. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Out-of-Pocket Maximum whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Out-of-Pocket Maximum amounts. The individual Calendar Year Out-of-Pocket Maximum applies when an individual is covered by the plan. The Family Calendar Year Out-of-Pocket Maximum applies when a Family is covered by the plan. There is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means that any Family member who meets the individual Out-of-Pocket Maximum will receive 100% Benefits for Covered Services, before the Family Out-of-Pocket Maximum is met. The Summary of Benefits provides the Calendar Year Out-of-Pocket Maximum amounts. When the respective maximum is reached, Covered Services will be paid by Blue Shield at 100% of the Allowed Charges or contracted rate for the remainder of the Calendar Year. Charges for services that are not covered and charges in excess of the Allowed Charges or the contracted rate do not accrue to the Calendar Year Out-of-Pocket Maximum and continue to be the Member’s responsibility after the Calendar Year Out-of-Pocket Maximum is reached. As described in Role of the Primary Care Physi- cian and adjacent sections above, in general all ser- vices must be prior authorized by the Primary Care Primary Care Physician’s Medical Group/IPA; and

Calendar Year Medical Deductible. The Calendar Year Medical Deductible is the amount an individual or a Family must pay for Covered Services each year before Blue Shield begins payment in accordance with this EOCEOC and Health Service Agreement. The Calendar Year Medical Deductible does not apply to all plans. When applied, this Deductible accrues to the Calendar Year Out-of-Pocket Maximum. Information specific to the Member’s plan is provided in the Summary of Benefits. The Summary of Benefits indicates whether or not the Calendar Year Medical Deductible applies to a particular Covered Service. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Medical Deductible whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Medical Deductible amounts. The individual Medical Deductible applies when an individual is covered by the plan. The Family Medical Deductible applies when a Family is covered by the plan. There is also an individual Medical Deductible within the Family Medical Deductible. This means Blue Shield will pay Benefits for any Family member who meets the individual Medical Deductible amount before the Family Medical Deductible is met. Once the respective Deductible is reached, Covered Services are paid as Allowed Charges, less any applicable Copayment or Coinsurance, for the remainder of the Calendar Year. The Calendar Year Out-of-Pocket Maximum is the highest Deductible, Copayment and Coinsurance amount an individual or Family is required to pay for designated Covered Services each year. If a benefit plan has any Calendar Year Medical Deductible, it will accumulate toward the applicable Calendar Year Out-of-Pocket Maximum. The Summary of Benefits indicates whether or not Copayment and Coinsurance amounts for a particular Covered Service accrue to the Calendar Year Out-of-Pocket Maximum. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Out-of-Pocket Maximum whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Out-of-Pocket Maximum amounts. The individual Calendar Year Out-of-Pocket Maximum applies when an individual is covered by the plan. The Family Calendar Year Out-of-Pocket Maximum applies when a Family is covered by the plan. There is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means that any Family member who meets the individual Out-of-Pocket Maximum will receive 100% Benefits for Covered Services, before the Family Out-of-Pocket Maximum is met. The Summary of Benefits provides the Calendar Year Out-of-Pocket Maximum amounts. When the respective maximum is reached, Covered Services will be paid by Blue Shield at 100% of the Allowed Charges or contracted rate for the remainder of the Calendar Year. Charges for services that are not covered and charges in excess of the Allowed Charges or the contracted rate do not accrue to the Calendar Year Out-of-Pocket Maximum and continue to be the Member’s responsibility after the Calendar Year Out-of-Pocket Maximum is reached. As described in Role of the Primary Care Physi- cian and adjacent sections above, in general all ser- vices must be prior authorized by the Primary Care Primary Care Physician’s Physician or Medical Group/IPA; and. In addition, as designated in Prior Authorization, under Mental Health and Substance Use Services above, non- emergency inpatient and Other Outpatient Mental Health and Substance Use Disorder Services must be prior authorized by the MHSA. However, a Member will not be responsible for payment of covered Mental Health and Substance Use Ser- vices requiring prior authorization solely because an MHSA Participating Provider fails to obtain prior authorization. The following services do not require prior autho- rization by the Member’s Primary Care Physician, Medical Group/IPA, or the MHSA:

Calendar Year Medical Deductible. The Calendar Year Medical Deductible is the amount an individual or a Family must pay for Covered Services each year before Blue Shield begins payment in accordance with this EOCEvidence of Coverage and Health Service Agreement. The Calendar Year Medical Deductible does not apply to all plans. When applied, this Deductible accrues accumulates to the Calendar Year Out-of-Pocket Maximum. Information specific to the Member’s plan is provided in the Summary of Benefits. The Summary of Benefits indicates whether or not the Calendar Year Medical Deductible applies to a particular Covered Service. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Medical Deductible whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Medical Deductible amountsamounts for both Participating Providers and Non-Participating Providers. Deductible amounts for Covered Services provided by Participating Providers only accrue to the Participating Provider Medical Deductible. Deductible amounts paid for Covered Services provided by Non-Participating Providers accrue only to the Non-Participating Provider Medical Deductible. The individual Medical Deductible applies when an individual is covered by the plan. The Family Medical Deductible applies when a Family is covered by the plan. There is also an individual Medical Deductible within , and the Family Medical Deductible. This means Blue Shield will pay Benefits for any Family member who meets the individual Medical Deductible amount before the entire Family Medical Deductible is metmust be met before Blue Shield begins payment for Covered Services for any Member with Family coverage. Once the respective Deductible is reached, Covered Services are paid as Allowed Chargesat the Allowable Amount, less any applicable Copayment or and Coinsurance, for the remainder of the Calendar Year. For Covered Services received from Non- Participating Providers, the Member is responsible for the applicable Copayment and Coinsurance and for amounts billed in excess of Blue Shield’s Allowable Amount. Charges in excess of Blue Shield’s Allowable Amount do not accrue to the Calendar Year Medical Deductible. The Calendar Year Medical Deductible also applies to a newborn child or a child placed for adoption who is covered for the first 31 days, even if application is not made to add the child as a Dependent on the plan. While coverage for this child is being provided, the Family Medical Deductible will apply. The Calendar Year Out-of-Pocket Maximum is the highest Deductible, Copayment Copayment, and Coinsurance amount an individual or Family is required to pay for designated Covered Services each year. There are separate maximums for Participating Providers and Non-Participating Providers. If a benefit plan has any Calendar Year Medical Deductible, it will accumulate toward the applicable Calendar Year Out-of-Pocket Maximum. The Summary of Benefits indicates whether or not Copayment and Coinsurance amounts for a particular Covered Service accrue to the Calendar Year Out-of-Pocket Maximum. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Out-of-Pocket Maximum whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Out-of-Pocket Maximum amountsamounts for both Participating Providers and Non-Participating Providers. Deductible, Copayment and Coinsurance amounts paid for Covered Services provided by Participating Providers accrue only to the Participating Provider Out-of-Pocket Maximum. Deductible, Copayment and Coinsurance amounts paid for Covered Services provided by Non-Participating Providers accrue only to the Non-Participating Provider Out-of- Pocket Maximum. The individual Calendar Year Out-of-Pocket Maximum applies when an individual is covered by the plan. The Family Calendar Year Out-of-of- Pocket Maximum applies when a Family is covered by the plan. There is an individual , and the entire Family Calendar Year Out-of-Pocket Maximum within must be met by any one or combination of Members covered by the Family Out-of-Pocket Maximum. This means that any Family member who meets the individual Out-of-Pocket Maximum will receive 100% Benefits for Covered Services, before the Family Out-of-Pocket Maximum is metplan. The Summary of Benefits provides the Calendar Year Out-of-Pocket Maximum amountsamounts for Participating Providers and Non-Participating Providers at both the individual and Family levels. When the respective maximum Out-of-Pocket Maximum is reached, Covered Services will be are paid by Blue Shield at 100% of the Allowed Charges Allowable Amount or contracted rate for either the individual or the entire Family for the remainder of the Calendar Year. Charges for services that are not covered and covered, charges in excess of the Allowed Charges Allowable Amount or contracted rate, and additional charges assigned to the contracted rate Member under the Benefits Management Program do not accrue to the Calendar Year Out-Out- of-Pocket Maximum and continue to be the Member’s responsibility after the Calendar Year Out-of-Pocket Maximum is reached. As described Participating Providers will submit claims for payment directly to Blue Shield, however, there may be times when Members and Non- Participating Providers need to submit claims. Except in Role the case of Emergency Services, Blue Shield will pay Members directly for Covered Services rendered by a Non-Participating Provider. Claims for payment must be submitted to Blue Shield within one year after the month services were provided. Blue Shield will notify the Member of its determination within 30 days after receipt of the Primary Care Physi- cian claim. To submit a claim for payment, send a copy of your itemized bill, along with a completed Blue Shield claim form to the Blue Shield address listed on the last page of this Evidence of Coverage. Claim forms are available online at xxx.xxxxxxxxxxxx.xxx or Members may call Blue Shield Customer Service. At a minimum, each claim submission must contain the Subscriber, name, home address, contract number, Subscriber’s number, a copy of the provider’s billing showing the services rendered, dates of treatment and adjacent sections abovethe patient’s name. Members should submit their claims for all Covered Services even if the Calendar Year Deductible has not been met. Blue Shield will keep track of the Deductible for the Member. Blue Shield also provides an Explanation of Benefits to describe how the claim was processed and to inform the Member of any financial responsibility. Out of Area Programs Benefits will be provided for Covered Services received by Subscribers and their Dependent(s) who are temporarily traveling outside of California within the United States, Puerto Rico and U.S. Virgin Islands. (Temporarily traveling is defined as a Subscriber or Dependent(s) who spends in general all ser- vices must the aggregate not more than 180 days each Calendar Year outside the State of California.) Blue Shield of California calculates the Subscriber’s copayment as a percentage of the Allowable Amount, as defined in this booklet. When Covered Services are received in another state, the Subscriber’s copayment will be prior authorized based on the local Blue Cross and/or Blue Shield plan’s arrangement with its providers. See the Blue Card Program section in this booklet. If you do not see a Participating Provider through the Blue Card Program, you will have to pay for the entire bill for your medical care and submit a claim to the local Blue Cross and/or Blue Shield plan or to Blue Shield of California for payment. Blue Shield of California will notify you of its determination within thirty (30) days after the receipt of the claim. Blue Shield of California will pay you at the Non-Preferred Provider benefit level. Remember that your copayment is higher when you see a Non-Preferred Provider. You will be responsible for paying the entire difference between the amount paid by Blue Shield of California and the amount billed. Charges for services which are not covered, and charges by Non-Preferred Providers in excess of the amount covered by the Primary Care Primary Care Physicianplan, are the Subscriber’s Medical Group/IPA; andresponsibility and are not included in copayment calculations. To receive the maximum benefits of your plan, please follow the procedure below. When you require Covered Services while temporarily traveling outside of California:

Calendar Year Medical Deductible. The Calendar Year Medical Deductible is the amount an individual or a Family must pay for Covered Services each year before Blue Shield begins payment in accordance with this EOC. The Calendar Year Medical Deductible does not apply to all plans. When applied, this Deductible accrues to the Calendar Year Out-of-Pocket Maximum. Information specific to the Member’s plan is provided in the Summary of Benefits. The Summary of Benefits indicates whether or not the Calendar Year Medical Deductible applies to a particular Covered Service. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Medical Deductible whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Medical Deductible amounts. The individual Medical Deductible applies when an individual is covered by the plan. The Family Medical Deductible applies when a Family is covered by the plan. There is also an individual Medical Deductible within the Family Medical Deductible. This means Blue Shield will pay Benefits for any Family member who meets the individual Medical Deductible amount before the Family Medical Deductible is met. Once the respective Deductible is reached, Covered Services are paid as Allowed Charges, less any applicable Copayment or Coinsurance, for the remainder of the Calendar Year. The Calendar Year Out-of-Pocket Maximum is the highest Deductible, Copayment and Coinsurance amount an individual or Family is required to pay for designated Covered Services each year. If a benefit plan has any Calendar Year Medical Deductible, it will accumulate toward the Calendar Year Out-of-Pocket Maximum. The Summary of Benefits indicates whether or not Copayment and Coinsurance amounts for a particular Covered Service accrue to the Calendar Year Out-of-Pocket Maximum. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Out-of-Pocket Maximum whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Out-of-Pocket Maximum amounts. The individual Calendar Year Out-of-Pocket Maximum applies when an individual is covered by the plan. The Family Calendar Year Out-of-Pocket Maximum applies when a Family is covered by the plan. There is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means that any Family member who meets the individual Out-of-Pocket Maximum will receive 100% Benefits for Covered Services, before the Family Out-of-Pocket Maximum is met. The Summary of Benefits provides the Calendar Year Out-of-Pocket Maximum amounts. When the respective maximum is reached, Covered Services will be paid by Blue Shield at 100% of the Allowed Charges or contracted rate for the remainder of the Calendar Year. Charges for services that are not covered and charges in excess of the Allowed Charges or the contracted rate do not accrue to the Calendar Year Out-of-Pocket Maximum and continue to be the Member’s responsibility after the Calendar Year Out-of-Pocket Maximum is reached. As described in Role of the Primary Care Physi- cian and adjacent sections above, in general all ser- vices must be prior authorized by the Primary Care Primary Care Physician’s Medical Group/IPA; andCare

Calendar Year Medical Deductible. The Calendar Year Medical Deductible is the amount an individual or a Family must pay for Covered Services each year before Blue Shield begins payment in accordance with this EOCEOC and Health Service Agreement. The Calendar Year Medical Deductible does not apply to all plans. When applied, this Deductible accrues to the Calendar Year Out-of-Pocket Maximum. Information specific to the Member’s plan is provided in the Summary of Benefits. The Summary of Benefits indicates whether or not the Calendar Year Medical Deductible applies to a particular Covered Service. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Medical Deductible whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Medical Deductible amounts. The individual Medical Deductible applies when an individual is covered by the plan. The Family Medical Deductible applies when a Family is covered by the plan. There is also an individual Medical Deductible within the Family Medical Deductible. This means Blue Shield will pay Benefits for any Family member who meets the individual Medical Deductible amount before the Family Medical Deductible is met. Once the respective Deductible is reached, Covered Services are paid as Allowed Charges, less any applicable Copayment or Coinsurance, for the remainder of the Calendar Year. The Calendar Year Out-of-Pocket Maximum is the highest Deductible, Copayment and Coinsurance amount an individual or Family is required to pay for designated Covered Services each year. If a benefit plan has any Calendar Year Medical Deductible, it will accumulate toward the applicable Calendar Year Out-of-Pocket Maximum. The Summary of Benefits indicates whether or not Copayment and Coinsurance amounts for a particular Covered Service accrue to the Calendar Year Out-of-Pocket Maximum. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Out-of-of- Pocket Maximum whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Out-of-Pocket Maximum amounts. The individual Calendar Year Out-of-Pocket Maximum applies when an individual is covered by the plan. The Family Calendar Year Out-of-Pocket Maximum applies when a Family is covered by the plan. There is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means that any Family member who meets the individual Out-of-Pocket Maximum will receive 100% Benefits for Covered Services, before the Family Out-of-Pocket Maximum is met. The Summary of Benefits provides the Calendar Year Out-of-Pocket Maximum amounts. When the respective maximum is reached, Covered Services will be paid by Blue Shield at 100% of the Allowed Charges or contracted rate for the remainder of the Calendar Year. Charges for services that are not covered and charges in excess of the Allowed Charges or the contracted rate do not accrue to the Calendar Year Out-of-Pocket Maximum and continue to be the Member’s responsibility after the Calendar Year Out-of-Pocket Maximum is reached. As described in Role of the Primary Care Physi- cian and adjacent sections above, in general all ser- vices must be prior authorized by the Primary Care Primary Care Physician’s Physician or Medical Group/IPA; and. In addition, as designated in Prior Authorization, under Mental Health and Substance Use Services above, non- emergency inpatient and Other Outpatient Mental Health and Substance Use Disorder Services must be prior authorized by the MHSA. However, a Member will not be responsible for payment of covered Mental Health and Substance Use Ser- vices requiring prior authorization solely because an MHSA Participating Provider fails to obtain prior authorization. The following services do not require prior autho- rization by the Member’s Primary Care Physician, Medical Group/IPA, or the MHSA:

Calendar Year Medical Deductible. The Calendar Year Medical Deductible is the amount an individual or a Family must pay for Covered Services each year before Blue Shield begins payment in accordance with this EOCEOC and Health Service Agreement. The Calendar Year Medical Deductible does not apply to all plans. When applied, this Deductible accrues to the Calendar Year Out-of-Pocket Maximum. Information specific to the Member’s plan is provided in the Summary of Benefits. The Summary of Benefits indicates whether or not the Calendar Year Medical Deductible applies to a particular Covered Service. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Medical Deductible whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Medical Deductible amounts. The individual Medical Deductible applies when an individual is covered by the plan. The Family Medical Deductible applies when a Family is covered by the plan. There is also an individual Medical Deductible within the Family Medical Deductible. This means Blue Shield will pay Benefits for any Family member who meets the individual Medical Deductible amount before the Family Medical Deductible is met. Once the respective Deductible is reached, Covered Services are paid as Allowed Charges, less any applicable Copayment or Coinsurance, for the remainder of the Calendar Year. The Calendar Year Out-of-Pocket Maximum is the highest Deductible, Copayment and Coinsurance amount an individual or Family is required to pay for designated Covered Services each year. If a benefit plan has any Calendar Year Medical Deductible, it will accumulate toward the applicable Calendar Year Out-of-Pocket Maximum. The Summary of Benefits indicates whether or not Copayment and Coinsurance amounts for a particular Covered Service accrue to the Calendar Year Out-of-Pocket Maximum. Covered Services received at a facility that is a Plan Provider will accrue to the Calendar Year Out-of-of- Pocket Maximum whether Services are provided by a health professional who is a Plan Provider or non-Plan Provider. There are individual and Family Calendar Year Out-of-Pocket Maximum amounts. The individual Calendar Year Out-of-Pocket Maximum applies when an individual is covered by the plan. The Family Calendar Year Out-of-Pocket Maximum applies when a Family is covered by the plan. There is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means that any Family member who meets the individual Out-of-Pocket Maximum will receive 100% Benefits for Covered Services, before the Family Out-of-Pocket Maximum is met. The Summary of Benefits provides the Calendar Year Out-of-Pocket Maximum amounts. When the respective maximum is reached, Covered Services will be paid by Blue Shield at 100% of the Allowed Charges or contracted rate for the remainder of the Calendar Year. Charges for services that are not covered and charges in excess of the Allowed Charges or the contracted rate do not accrue to the Calendar Year Out-of-Pocket Maximum and continue to be the Member’s responsibility after the Calendar Year Out-of-Pocket Maximum is reached. As described in Role of the Primary Care Physi- cian and adjacent sections above, in general all ser- vices must be prior authorized by the Primary Care MHSA. However, a Member will not be responsible for payment of covered Mental Health and Substance Use Ser- vices requiring prior authorization solely because an MHSA Participating Provider fails to obtain prior authorization. The following services do not require prior autho- rization by the Member’s Primary Care Physician’s , Medical Group/IPA; and, or the MHSA: