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).
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.
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. 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. 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. Equipment ordered by a provider for everyday or extended use to treat an illness or injury. HME may include: oxygen equipment, wheelchairs or crutches. An organization that provides covered home health services to a member. A facility or program designed to provide a caring environment for supplying the physical and emotional needs of the terminally ill.
Essential Health Benefits. This contract covers all essential health benefits. Essential health benefits are subject to some limitations or exclusions under this contract.
Essential Health Benefits. (EHB) –are, for the purposes of this coverage, pediatric dental services that Alliant is required to cover under the Patient Protection and Affordable Care Act and any other applicableregulations. EHB and its provisions apply to Members through age 18 only. You have the freedom to choose the Dentist You want for Your dental care. However, Your choice of Dentist can make a difference in the benefits You receive and the amount You pay. You may have additional out-of-pocket costs if Your Dentist does not accept the reimbursement amount determined by Alliant. Payments are made by Alliant only when the Covered Services have been completed. Your Plan may require additional information from You or Your Provider before a claim can be considered complete and ready for processing. In order to properly process a claim, Your Provider may be requested to submit a corrected claim. For example, if your Dentist submits a claim for an adult dental cleaning when the service performed was a pediatric dental cleaning, Alliant will deny the claim and request that the dentist submit a corrected claim. Xxxxxxxxx claims previously processed will be denied. This section describes how Alliant determines the amount of reimbursement for Covered Services. Reimbursement for dental services rendered by a Dentists is based on the Maximum Allowed Amount for the type of service performed. The Maximum Allowed Amount is the maximum amount of reimbursement Alliant will pay for Covered Services, as defined in this Schedule, by a Dentist or Member. You will be required to pay a portion of the Maximum Allowed Amount to the extent You have not met Your Deductible or have a Coinsurance. In addition, when You receive Covered Services from a Dentist, You may be responsible for paying any difference between the Maximum Allowed Amount and the Dentist’s actual charges. When You receive Covered Services from a Dentist, Alliant will apply processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the dental procedure. Applying these rules may affect Alliant’s determination of the Maximum Allowed Amount. Here are two examples of scenarios to illustrate when the Maximum Allowed Amount may change, according to claims processing rules.
Essential Health Benefits. Patient-Centered Standard Benefit Designs 4.2.2 Patient-Centered Standard Benefit Designs
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. 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 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 drug at a pharmacy, only your pharmacy benefit will be applied. See Prescription drug benefits for more information. Allergy injections and growth hormone injections are covered. Inpatient hospital – Medically necessary hospital inpatient services are covered. Charges for a semi-private hospital room are covered, and charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for septicemic-caused isolation. Please see the Prior Authorization list of this document.
