COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.
Hospice Services Services are available for a Member whose Attending Physician has determined the Member's illness will result in a remaining life span of six months or less.
Surgery Services This plan covers surgery services to treat a disease or injury when: • the operation is not experimental or investigational, or cosmetic in nature; • the operation is being performed at the appropriate place of service; and • the physician is licensed to perform the surgery. This plan covers reconstructive surgery and procedures when the services are performed to relieve pain, or to correct or improve bodily function that is impaired as a result of: • a birth defect; • an accidental injury; • a disease; or • a previous covered surgical procedure. Functional indications for surgical correction do not include psychological, psychiatric or emotional reasons. This plan covers the procedures listed below to treat functional impairments. • abdominal wall surgery including panniculectomy (other than an abdominoplasty); • blepharoplasty and ptosis repair; • gastric bypass or gastric banding; • nasal reconstruction and septorhinoplasty; • orthognathic surgery including mandibular and maxillary osteotomy; • reduction mammoplasty; • removal of breast implants; • removal or treatment of proliferative vascular lesions and hemangiomas; • treatment of varicose veins; or • gynecomastia.
Community Service Leave Community service leave is provided for in the NES.
Training Services Training Services may include pre-packaged training Products, and/or the development or customization of training programs as requested, including Live Training, Computer Based/Multi-Media Training which encompasses Internet-Delivered Training, and/or Video Based Training.
Software Services If elected by Customer, the following Software Services will be made available for Customer’s use.
2.1. Core HR Software Service is a system of interactive web pages to assist Customer in its human resource related recordkeeping and reporting. Customer shall ensure the accuracy of its Customer Data. The HR Software Services shall function in accordance with the Documentation, as may be amended from time to time, and provide features to aid Customer with its compliance with federal and state laws and regulations applicable to Human Resources (except as stated otherwise in the Documentation).
2.2. Recruiting Software Service is a system of interactive web pages to assist Customer in posting job requisitions, storing candidates, recording job applications, and the related recordkeeping and reporting. Customer shall ensure the accuracy of its Customer Data. The Recruiting Software Service shall function in accordance with the Documentation which may be amended from time to time.
Educational Services Any service or supply for education, training or retraining services or testing including: special education, remedial education; cognitive remediation; wilderness/outdoor treatment, therapy or adventure programs (whether or not the program is part of a Residential Treatment facility or otherwise licensed institution); job training or job hardening programs; educational services and schooling or any such related or similar program including therapeutic programs within a school setting.
Community Engagement Integration Activities The SP will support the HSP to engage the community of diverse persons and entities in the area where it provides health services when setting priorities for the delivery of health services and when developing plans for submission to the LHIN including but not limited to CAPS and integration proposals.
Counseling Services Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment your counselor will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ABO may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that ABO cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the counselor you select. If you have questions about the procedures used or conclusions made by your counselor at ABO, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things that are discussed both during your sessions and on your own. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. The initial assessment will last from one to four sessions. During this time, you and your counselor can both decide if she/he is the best person to provide the services you need in order to meet your treatment goals. If you choose to begin psychotherapy, your counselor will usually schedule one meeting at a time you each agree on. Once an appointment is scheduled, you will be expected to attend unless you provide advance notice of cancellation. If you need to cancel an appointment, it is your responsibility to contact us to cancel. Fees will be collected when services are rendered.*In addition to therapy services fees may include assessment administration, scoring, and reporting; creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. We understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and your therapist is happy to contact you for a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location, we can help you keep your regularly scheduled appointment. If you still must change or cancel your counseling appointment, please know: • Cancellations must be made during business hours. • Cancellations must be made within 48 hours of session time if using our online scheduling program. • We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. • We may not accommodate cancellations made after hours or on holidays to our main number as we cannot check voice mail regularly. If you have an appointment on a Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment. • Cancellations with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. • *After two no-shows/late cancellations, you will pre-pay a retainer before scheduling any future appointments. • Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. • Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. • It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer may be forfeited. If proper notice is given, the retainer will be refunded. • Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $250 per hour, rounded to the nearest 15 minute increment. You (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your xxxx first, then contact your insurance company regarding reimbursement. We answer our main office number 9:00 AM – 5:00 PM Monday through Friday (except holidays). You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: • We do not provide therapy/counseling via email or text messaging. • Text messaging and email will be used for administrative tasks only (as defined above). • Therapists may not acknowledge or return emails or text messages that are not administrative. This includes emergency texts and emails. • If your therapist leaves for an extended period of time you will be given the information for another licensed therapist with whom you may schedule if you need an appointment during your therapist’s absence. You may need to fill out other paperwork if therapist is in another practice.
Money Market Fund Compliance Testing and Reporting Services Subject to the authorization and direction of the Trust and, in each case where appropriate, the review and comment by the Trust’s independent accountants and legal counsel, and in accordance with procedures that may be established from time to time between the Trust and the Administrator, the Administrator will: