Common use of Community provider Clause in Contracts

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: $100 per Member or $200 per Family Unit per calendar year. Community Provider: $200 per Member or $400 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 70% of the Preferred Community Provider Contracted Rate or Usual, Customary and Reasonable charges; Member coinsurance share is 30%, 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 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 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. Drugs - Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies) MHCN: Covered when prescribed by a MHCN Provider, subject to the lesser of the MHCN’s charge or a $15 Copayment for generic drugs or a $30 Copayment for brand name drugs. Community Provider: Covered subject to the lesser of the allowed charge or a $20 Copayment for generic drugs or a $35 Copayment for brand name drugs.

Community provider. Describes coverage 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 is provided schedule established by a Community Provider or Preferred Community Provider on a Self-Referred basisGHO. Coverage is limited Not subject to the Preferred Community Provider Contracted Rate annual Deductible or Usual, Customary and Reasonable (UCR) charges, less any applicable Cost Share amounts as noted belowPlan Coinsurance. Benefits paid 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 Community Provider option will not be duplicated under the MHCN option. The benefits described in this well care schedule are covered subject to all provisions, limitations and exclusions set forth in the Group Medical Coverage Agreement. “Welcome” Outpatient Services Waiver Annual Deductible lesser of the MHCN: $100 per Member ’s charge or $200 per Family Unit per calendar yearany applicable outpatient services Cost Share. Community Provider: $200 per Member or $400 per Family Unit per calendar year. Not covered, except for routine mammography services which are covered at the Plan Coinsurance MHCN: Plan Coinsurance share is 80%; Member coinsurance share is 20%Coinsurance, after the annual Deductible is satisfied. Community Provider: Plan Coinsurance share is 70% of the Preferred Community Provider Contracted Rate or Usual, Customary and Reasonable charges; Member coinsurance share is 30%, after the annual Deductible is satisfied. Lifetime Maximum Hospital Rehabilitation Services MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable inpatient services Copayment and at the Plan Coinsurance for up to sixty (60) days 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 calendar year after the annual Deductible is satisfied. Preauthorization is required for scheduled admissions as set forth in (see Section IV.A. IV.G.). MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient services Copayment and at the Plan Coinsurance for up to sixty (60) visits 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 calendar year after the annual Deductible is satisfied. Outpatient 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 Section IV.A.). Sterilization (vasectomy, tubal ligation) MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient services Cost Share. Community Provider: Covered subject to the lesser of the allowed charge or the applicable Cost Share. Temporomandibular Joint (TMJ) Services MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable Copayment and at the Plan Coinsurance for up to $1,000 maximum per Member 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 $1,000 maximum per Member per calendar year after the annual Deductible is satisfied. MHCN: Covered subject up 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$5,000 per Member. Community Provider: Covered subject up to the lesser of the allowed charge or the applicable outpatient services Copayment and at the Plan Coinsurance after the annual Deductible is satisfied$5,000 per Member. Drugs - Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies) Tobacco Cessation MHCN: Covered when prescribed by a MHCN Provider, subject to the lesser of the MHCN’s charge or a $15 Copayment for generic drugs or a $30 Copayment for brand name drugsin full. Community Provider: Not covered. MHCN: Covered subject to the lesser in full when prescribed as part of the allowed charge or a $20 Copayment for generic drugs or a $35 Copayment for brand name drugsGHO-designated tobacco cessation program and dispensed through the GHO mail order service. Community Provider: Not covered.

Community provider. Describes coverage when care is provided by a Community Provider or Preferred Community Provider on a SelfNot covered. Out-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 of-Pocket Limit MHCN: Limited to an aggregate maximum of $100 2,000 per Member or $200 6,000 per Family Unit family per calendar year. Except as otherwise noted in this Allowances Schedule, the total Out-of-Pocket Expenses for the following Covered Services are included in the Out-of-Pocket Limit: Community Provider: Limited to an aggregate maximum of $200 6,000 per Member or $400 18,000 per Family Unit family per calendar year. Plan Coinsurance MHCNExcept as otherwise noted in this Allowances Schedule, the total Out-of-Pocket Expenses for the following Covered Services are included in the Out-of-Pocket Limit: Plan Coinsurance share is 80%; Member coinsurance share is 20%, after the annual Deductible is satisfied. Community Provider: Plan Coinsurance share is 70% of the Preferred Community Provider Contracted Rate or Usual, Customary and Reasonable charges; Member coinsurance share is 30%, 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. Acupuncture MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient services Copayment and at the Plan Coinsurance for Self-Referrals to a MHCN Provider up to a maximum of eight (8) visits per Member per medical diagnosis per calendar year, after the annual Deductible is satisfied. When approved by GHO, additional visits are covered. 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 Ambulance Services MHCN: Covered at the Plan Coinsurance after 80% for transport to a MHCN Facility. Not subject to the annual Deductible is satisfiedDeductible. Community Provider: Covered at the Plan Coinsurance after 80% for transport to a non-MHCN Facility. Not subject to the annual Deductible is satisfiedDeductible. MHCN: Covered at 80% for MHCN-initiated transfers, except hospital-to-hospital ground transfers covered in full. Not subject to the annual Deductible. Community Provider: Covered at 80% for transport from one medical facility to the nearest facility equipped to render further Medically Necessary treatment when prescribed by the attending physician. Not subject to the annual Deductible. Chemical Dependency MHCN: Covered subject to the lesser of the MHCN’s charge or the applicable outpatient inpatient 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 inpatient 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. Drugs - Outpatient Dental Services (including mental health drugs, contraceptive drugs and devices and diabetic suppliesaccidental injury to natural teeth) MHCN: Covered when prescribed by a MHCN ProviderNot covered, subject to the lesser of the MHCN’s charge or a $15 Copayment for generic drugs or a $30 Copayment for brand name drugs. Community Provider: Covered subject to the lesser of the allowed charge or a $20 Copayment for generic drugs or a $35 Copayment for brand name drugsexcept as set forth in Section IV.B.23.

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: $100 200 per Member or $200 600 per Family Unit per calendar year. Community Provider: $200 400 per Member or $400 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 7060% of the Preferred Community Provider Contracted Rate or Usual, Customary and Reasonable charges; Member coinsurance share is 3040%, 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 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. Drugs - Outpatient (including mental health drugs, contraceptive drugs and devices and diabetic supplies) MHCN: Covered when prescribed by a MHCN Provider, subject to the lesser of the MHCN’s charge or a $15 Copayment for generic drugs or a $30 Copayment for brand name drugs. Community Provider: Covered subject to the lesser of the allowed charge or a $20 Copayment for generic drugs or a $35 Copayment for brand name drugs.