Community provider. Describes coverage when care is provided by a Community Provider or Preferred Community Provider on a Self-Referred basis. Coverage is limited to the Preferred Community Provider Contracted Rate or Usual, Customary and Reasonable (UCR) charges, less any applicable Cost Share amounts as noted below. Benefits paid under the Community Provider option will not be duplicated under the MHCN option. The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in the Group Medical Coverage Agreement. “Welcome” Outpatient Services Waiver Annual Deductible MHCN: $200 per Member or $600 per Family Unit per calendar year. Community Provider: $400 per Member or $1,200 per Family Unit per calendar year. Plan Coinsurance MHCN: Plan Coinsurance share is 80%; Member coinsurance share is 20%, after the annual Deductible is satisfied. Community Provider: Plan Coinsurance share is 60% of the Preferred Community Provider Contracted Rate or Usual, Customary and Reasonable charges; Member coinsurance share is 40%, after the annual Deductible is satisfied. Lifetime Maximum Hospital Services MHCN: Covered at the Plan Coinsurance after the annual Deductible is satisfied. Community Provider: Covered at the Plan Coinsurance after the annual Deductible is satisfied. Preauthorization is required for scheduled admissions as set forth in Section IV.A. MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Outpatient Services MHCN: Covered at the Plan Coinsurance after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or a $5 outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied. MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient services Copaym...
Community provider. Community provider" means a governmental or nongovernmental entity that provides services to students or families, including but not limited to temporary and permanent housing, case management, immigration and language services and social, behavioral health, occupational training and legal services. [PL 2021, c. 445, §2 (NEW).]
Community provider. Covered Services received from a Community Provider are subject to the annual Deductible as set forth in the Allowances Schedule.
Community provider. After the annual Deductible is satisfied, Members shall be required to pay the Plan Coinsurance for Covered Services as set forth in the Allowances Schedule.
Community provider. Not covered.
Community provider. Not covered, except in the presence of a non-related Medical Condition affecting the lower limbs. Pre-Existing Condition Preventive Services (well adult and well child physicals, immunizations, pap smears, mammograms and prostate/colorectal cancer screening) MHCN: Covered in full when in accordance with the well care schedule established by GHO. Not subject to the annual Deductible or any applicable Plan Coinsurance. Eye refractions are not included under preventive care. Physicals for travel, employment, insurance or license are not covered. Services provided during a preventive care visit which are not in accordance with the well care schedule are covered subject to the lesser of the MHCN’s charge or any applicable outpatient services Cost Share. Community Provider: Covered at the Plan Coinsurance to a $150 maximum per Member ($300 per Family Unit) per calendar year. Routine mammography services are covered at the Plan Coinsurance after the annual Deductible is satisfied. Coinsurance does not apply to the Out-of-Pocket Limit. Rehabilitation Services MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable inpatient services Copayment and Plan Coinsurance for up to sixty (60) days per condition per calendar year after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or the applicable inpatient services Copayment and at the Plan Coinsurance for up to sixty (60) days per condition per calendar year after the annual Deductible is satisfied. Preauthorization is required (see Section IV.G.). MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient services Copayment and Plan Coinsurance for up to sixty (60) visits per condition per calendar year after the annual Deductible is satisfied. Community Provider: Covered subject to the lesser of the allowed charge or the applicable outpatient services Copayment and at the Plan Coinsurance for up to sixty (60) visits per condition per calendar year after the annual Deductible is satisfied. Sexual Dysfunction Services MHCN: Not covered. Community Provider: Not covered. Skilled Nursing Facility (SNF) MHCN: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Community Provider: Covered at the Plan Coinsurance for up to sixty (60) days per Member per calendar year after the annual Deductible is satisfied. Preauthorization is required (see Sec...
Community provider. Covered subject to the lesser of the allowed charge or the applicable Copayment and at the Plan Coinsurance up to a $350,000 lifetime benefit maximum (including organ acquisition, matching and donor costs up to $50,000) after the annual Deductible is satisfied, subject to a six (6) month benefit wait period. • Surgery to correct a congenital disease or anomaly, or conditions following an injury or resulting from surgery • Cosmetic surgery, including complications resulting from cosmetic surgery
