Cost Sharing Provisions. PHP agrees to comply with all cost sharing restrictions imposed on FHKC participants by federal or state laws and regulations, including the following specific provisions:
A. Special Populations Enrollees identified by FHKC to PHP as Native Americans or Alaskan Natives are prohibited from paying any cost sharing amounts.
B. Cost Sharing Limited to No More than Five Percent of Family's Income FHKC may identify to PHP other enrollees who have met federal requirements regarding maximum out of pocket expenditures. Enrollees identified by FHKC as having met this threshold are not required to pay any further cost sharing for covered services for a time specified by FHKC.
C. PHP is responsible for informing its providers of these provisions and ensuring that enrollees under this section incur no further out of pocket costs for covered services and are not denied access to services. FHKC will provide these enrollees with a letter indicating that they may not incur any cost sharing obligations.
Cost Sharing Provisions. The following co-payments will apply at the time services are to be rendered. OUTPATIENT SERVICES COPAYMENTS
1. No statement by the Subscriber in the Enrollment/Change Form shall void his coverage hereunder or be used in any legal proceedings hereunder unless such Enrollment/Change Form or an exact copy thereof is included in or attached to his Member Handbook. All statements made by the Subscriber shall be deemed representations and not warranties.
2. All Covered Services provided by the Plan shall be paid directly to the Plan Provider, unless a reimbursement is being paid to the Covered Person. The Covered Person must pay directly to the plan Provider any co-payments due for specified services at the time services are to be rendered. Refer to co-payment schedule for applicable co-payments.
3. No action at law or in equity shall be brought to recover on this Agreement prior to the expiration of 60 days following a final appeal in accordance with requirements of this Agreement. No such action may be brought after the expiration of the applicable statute of limitations. The statute of limitations applicable to any action relative to this appeal shall commence from the date of treatment.
4. No interest in this Agreement issued pursuant hereto is assignable without written consent of the Plan being first obtained.
5. Only the Covered Person is entitled to benefits.
6. The Covered Person shall present his or her Subscriber Identification Card provided by the Plan when applying for benefits.
7. Any notice required or permitted under this Agreement shall be deemed given if hand delivered or if mailed by United States Mail, postage prepaid, and addressed as set forth below. Such notice shall be deemed effective as of the date delivered or so deposited in the mail.
a. If to the Plan, mailed to the address printed on the Application for Individual Service Agreement.
b. If to a Covered Person, mailed to the last address provided by the Covered Person.
8. This Agreement shall be governed by and construed in accordance with the laws of the state of Florida, and the exclusive and sole venue for any action arising hereunder shall be in Dade County, Florida.
9. This Agreement in writing and the Application for Enrollment constitute the entire contract between the Plan and the Individual. No agent of the Plan other than a corporate officer can change or waive any of the provision of the Agreement. No change or amendment shall be valid unless evidenced by an endorsement, r...
Cost Sharing Provisions. INSURER shall comply with all cost sharing restrictions imposed on Enrollees by federal or state laws and regulations, including the following specific provisions:
A. Special Populations FHKC shall provide to INSURER on a monthly basis those Enrollees identified as Native Americans or Alaskan Natives who are prohibited from paying any cost sharing amounts, including co-payments.
B. Cost Sharing Limited to No More than Five Percent (5%) of Family’s Income FHKC will also identify to INSURER other Enrollees who have met federal requirements regarding maximum out of pocket expenditures. Enrollees identified by FHKC as having met this threshold are not required to pay any further cost sharing for covered services for a time specified by FHKC. INSURER is responsible for informing its Providers of these provisions and ensuring that such Enrollees incur no further out of pocket costs for covered services and are not denied access to services. FHKC will provide these Enrollees with a letter indicating that they may not incur any cost sharing obligations.
Cost Sharing Provisions. 5.1 In consideration of the services provided by Manager, each of GLR and Senior Care LLC agree to contribute to the operating costs and expenses of Manager in proportion to the extent to which they and their respective subsidiaries make use of Manager’s services, with the intention that each year 100%, but no more than 100%, of the costs and expenses of the Manager are recouped from GLR and Senior Care LLC on such a proportional basis. In other words, it is intended that Manager be operated on a break even basis, and not as a profit center for GLR. Such amounts shall be funded by GLR and Senior Care LLC monthly in arrears, as billed by Manager, as determined by Manager in its sole discretion, in accordance with this Agreement. All payments shall be made not less than thirty (30) days of billing. Notwithstanding the above, Manager may elect to maintain cash reserves so as to have at all times not less than one nor more than three months working capital available to it, in which case the amounts needed to fund such working capital reserve shall be paid by GLR and Senior Care LLC within thirty (30) days of demand by Manager, such amounts to be funded in proportion to the allocation ratios of GLR and Senior Care LLC then in effect.
5.2 Initially, for the period through December 31, 2005, the costs and expenses of Manager will be allocated 35% to GLR and 65% to Senior Care LLC; provided, however, that in the event of any extraordinary matter requiring a greater than expected expenditure of resources by Manager, the costs and expenses related to such matter may be billed directly to GLR or Senior Care LLC, as the case may be, and without reference to any general cost sharing allocation then in effect.
5.3 Not later than September 30 of each year, beginning September 30, 2005, the Contract Management Committee will meet and confer in order to determine the projected budget and cost allocation for the following year, commencing as of January 1st of each such year. Any such budget and allocation will be subject to the reasonable review and approval of GLR’s independent outside directors. On January 1st, any working capital reserve will be adjusted to reflect such agreed upon going forward cost allocation, with the party receiving a reduced allocation receiving a proportionate working capital refund and the party receiving an increased allocation being obligated to make a proportionate increased contribution to such working capital reserves.
5.4 Not later than Marc...
Cost Sharing Provisions. INSURER agrees to comply with all Cost Sharing restrictions imposed on FHKC Participants by federal or state laws and regulations, including the following specific provisions:
A. Special Populations AMERIGROUP FLORIDA, INC. Effective Date: October 1, 2005 Enrollees identified by FHKC to INSURER as Native Americans or Alaskan Natives are prohibited from paying any Cost Sharing amounts.
B. Cost Sharing Limited to No More than Five Percent of Family's Income FHKC may identify to INSURER other Enrollees who have met federal requirements regarding maximum out-of-pocket expenditures. Enrollees identified by FHKC as having met this threshold are not required to pay any further Cost Sharing for covered services for a time specified by FHKC.
C. INSURER is responsible for informing its providers of these provisions and ensuring that Enrollees under this section incur no further out-of-pocket-costs for covered services and are not denied access to services. FHKC will provide these Enrollees with a letter indicating that they may not incur any Cost Sharing obligations and shall provide written notification to INSURER of any such Participants.
Cost Sharing Provisions. INSURER agrees to comply with all Cost Sharing restrictions imposed on FHKC Participants by federal or state laws and regulations, including the following specific provisions:
A. Special Populations HEALTHEASE AND STAYWELL HMO Effective Date: October 1, 2005 Enrollees identified by FHKC to INSURER as Native Americans or Alaskan Natives are prohibited from paying any Cost Sharing amounts.
