Essential Health Benefits Sample Clauses

Essential Health Benefits. Each QHP offered by Contractor under the terms of this Agreement shall provide essential health benefits in accordance with the Benefit Plan Design requirements described in the Covered California Patient-Centered Benefit Plan Designs as approved by the Board for the applicable Plan Year, and as required under this Agreement, and applicable laws, rules and regulations, including California Health and Safety Code § 1367.005, California Insurance Code § 10112.27, California Government Code § 100503(e), and as applicable, 45 C.F.R. § 156.200(b).
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Essential Health Benefits. (“Pediatric Benefits”). For the purpose of this Part, Essential Health Benefits are certain pediatric oral services that are required to be included under the Affordable Care Act. The services considered to be Essential Health Benefits are determined by state and federal agencies and are available for Eligible Pediatric Individuals.
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Essential Health Benefits. Benefits defined by the Secretary of Health and Human Services that shall include at least the following general categories: ambulatory patient services, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and services, including oral and vision care. The designation of benefits as essential shall be consistent with the requirements and limitations set forth under the Affordable Care Act and applicable regulations as determined by the Secretary of Health and Human Services. Experimental/Investigational Services Services that meet one or more of the following:  A drug or device which cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and does not have approval on the date the service is provided  It is subject to oversight by an Institutional Review Board  There is no reliable evidence showing that the service is effective in clinical diagnosis, evaluation, management or treatment of the condition  It is the subject of ongoing clinical trials to determine its maximum tolerated dose, toxicity, safety or efficacy  Evaluation of reliable evidence shows that more research is necessary before the service can be classified as equally or more effective than conventional therapies Reliable evidence means only published reports and articles in authoritative medical and scientific literature, and assessments. Facility (Medical Facility) A hospital, skilled nursing facility, approved treatment facility for chemical dependency, state-approved institution for treatment of mental or psychiatric conditions, or hospice. Not all health care facilities are covered under this contract. Home Medical Equipment (HME) Equipment ordered by a provider for everyday or extended use to treat an illness or injury. HME may include: oxygen equipment, wheelchairs or crutches. Home Health Agency An organization that provides covered home health services to a member. Hospice A facility or program designed to provide a caring environment for supplying the physical and emotional needs of the terminally ill.
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Essential Health Benefits. This contract covers all essential health benefits. Essential health benefits are subject to some limitations or exclusions under this contract.
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Essential Health Benefits. Samaritan Health Plans covers the ten categories of benefits defined by the Secretary of U.S. Department of Health and Human Services. Please note that pediatric dental is not covered by Samaritan Health Plans. Contact your dental carrier or your Plan Sponsor for more information. The categories include: • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and chemical dependency/substance abuse disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services (vision care) Gastric bypass – Or any other bariatric surgery is not covered. Genetic testing – Is covered as determined through our prior authorization process. Samaritan Health Plans requires prior authorization for genetic testing, except for standard prenatal testing which includes (but is not limited to) genetic testing for cystic fibrosis and Verifi®. Hearing aids – Are covered. Repairs or accessories to hearing aids will be paid through the annual limit. Batteries are not covered. This benefit is limited to 1 every 48 months for each impaired ear. High-tech imaging – Imaging services such as MRI, CT scans, PET scans and/or SPECT scans are considered high-tech imaging. [These specific radiological services are categorized to have a separate member cost share than our benefit category, Radiology.] Please carefully review your Benefit Schedule for cost share information. Some of these services will also require an authorization. Please see Prior Authorization list for more information. Home health – Is covered. See your Benefit Schedule for cost share information. Services provided during your home health visit can apply to other benefits and other cost shares will apply. For example, physical therapy can be done in your home. This service will be paid under the physical therapy benefit. Hospice – Is covered. Respite care is covered with a maximum of 5 consecutive days and 30 days lifetime. Infusion – Is covered and is paid by the Plan based on the type of infusion you receive and where you receive it. You can have pharmacy costs for the drugs used during your infusion services. See Prescription drug benefits for more information. Injections – Can be done by your Primary care provider or a specialist provider in an office setting. If you are receiving an injection...
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Essential Health Benefits. 3.2.2 Patient-Centered Standard Benefit Designs 4.2.2 Patient-Centered Standard Benefit Designs
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Related to Essential Health Benefits

  • Health Benefits The method for determining the Employer bi-weekly contributions to the cost of employee health insurance programs under the Federal Employees Health Benefits Program (FEHBP) will be as follows:

  • Vision Benefits The County provides vision benefits to full-time active employees and their dependent(s), and computer vision care benefits to full-time active employees, with no employee contribution. Part-time employees will be enrolled automatically in the vision benefit and the County shall contribute to part-time eligible employees on a pro-rated basis, in accordance with Article 5.2.6. Benefit provisions, co-payments and deductibles are outlined in the Summary Plan Description or Evidence of Coverage.

  • Medical Benefits The Company shall reimburse the Employee for the cost of the Employee's group health, vision and dental plan coverage in effect until the end of the Termination Period. The Employee may use this payment, as well as any other payment made under this Section 6, for such continuation coverage or for any other purpose. To the extent the Employee pays the cost of such coverage, and the cost of such coverage is not deductible as a medical expense by the Employee, the Company shall "gross-up" the amount of such reimbursement for all taxes payable by the Employee on the amount of such reimbursement and the amount of such gross-up.

  • Compensation and Benefits As compensation for all services performed by the Executive under and during the term hereof and subject to performance of the Executive’s duties and of the obligations of the Executive to the Company and its Affiliates, pursuant to this Agreement or otherwise:

  • Program Benefits The Participating Contractor will be eligible for contractor incentives, its customers will have access to financing offered through the Program, and income-eligible households will be eligible to receive Program incentives.

  • Extended Health Benefits (i) The Employer, by means of a policy issued by the insurance company, provides extended health benefits to all eligible faculty members. The monthly premium for this benefit is assumed totally by the Employer for each eligible faculty member, spouse/common-law spouse and his/her dependants. Plan benefits will be paid in accordance with the schedule of benefits listed in the plan and will be subject to the limitations specified in the plan including eligibility requirements.

  • In-Training Employment 1. The Employer may designate specific positions, groups of positions, or all positions in a job classification or series as in-training. The Employer will document the training program, including a description and length of the program.

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