COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.
Hospice Services Services are available for a Member whose Attending Physician has determined the Member's illness will result in a remaining life span of six months or less.
Clinical Management for Behavioral Health Services (CMBHS) System
1. request access to CMBHS via the CMBHS Helpline at (000) 000-0000.
2. use the CMBHS time frames specified by System Agency.
3. use System Agency-specified functionality of the CMBHS in its entirety.
4. submit all bills and reports to System Agency through the CMBHS, unless otherwise instructed.
Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.
Core Services The Company agrees to provide to the Municipality the Core Services set forth in Schedule “A”. The Company and the Municipality may amend Schedule “A” from time to time upon mutual agreement.
Educational Services Any service or supply for education, training or retraining services or testing including: special education, remedial education; cognitive remediation; wilderness/outdoor treatment, therapy or adventure programs (whether or not the program is part of a Residential Treatment facility or otherwise licensed institution); job training or job hardening programs; educational services and schooling or any such related or similar program including therapeutic programs within a school setting.
Software Services If elected by Customer, the following Software Services will be made available for Customer’s use.
2.1. Core HR Software Service is a system of interactive web pages to assist Customer in its human resource related recordkeeping and reporting. Customer shall ensure the accuracy of its Customer Data. The HR Software Services shall function in accordance with the Documentation, as may be amended from time to time, and provide features to aid Customer with its compliance with federal and state laws and regulations applicable to Human Resources (except as stated otherwise in the Documentation).
2.2. Recruiting Software Service is a system of interactive web pages to assist Customer in posting job requisitions, storing candidates, recording job applications, and the related recordkeeping and reporting. Customer shall ensure the accuracy of its Customer Data. The Recruiting Software Service shall function in accordance with the Documentation which may be amended from time to time.
Home Health Care This plan covers the following home care services when provided by a certified home healthcare agency: • nursing services; • services of a home health aide; • visits from a social worker; • medical supplies; and • physical, occupational and speech therapy.
Healthcare Section 1. Bargaining unit employees with one (1) year or more of service will be provided coverage for the duration of this contract through the “Full Coverage” Team Care Plan (“Team Care MM200”), which includes dental, vision, life, short term disability, medical and prescription drug benefits. Prior to January 1, 2020, bargaining unit employees with less than one (1) year of service will be provided coverage through the “Medical Only” plan. On January 1, 2020, all bargaining unit employees enrolled in the Medical Only plan shall be enrolled in the Full Coverage plan, and the Medical Only plan will eliminated. The rates for 2019 and a further description of the plan and rates are referenced
Use of Verizon Telecommunications Services 2.1 Verizon Telecommunications Services may be purchased by Z-Tel under this Resale Attachment only for the purpose of resale by Z-Tel as a Telecommunications Carrier. Verizon Telecommunications Services to be purchased by Z-Tel for other purposes (including, but not limited to, Z-Tel’s own use) must be purchased by Z-Tel pursuant to other applicable Attachments to this Agreement (if any), or separate written agreements, including, but not limited to, applicable Verizon Tariffs.
2.2 Z-Tel shall not resell:
2.2.1 Residential service to persons not eligible to subscribe to such service from Verizon (including, but not limited to, business or other nonresidential Customers);
2.2.2 Lifeline, Link Up America, or other means-tested service offerings, to persons not eligible to subscribe to such service offerings from Verizon;
2.2.3 Grandfathered or discontinued service offerings to persons not eligible to subscribe to such service offerings from Verizon; or
2.2.4 Any other Verizon service in violation of a restriction stated in this Agreement (including, but not limited to, a Verizon Tariff) that is not prohibited by Applicable Law.
2.2.5 In addition to any other actions taken by Z-Tel to comply with this Section 2.2, Z-Tel shall take those actions required by Applicable Law to determine the eligibility of Z-Tel Customers to purchase a service, including, but not limited to, obtaining any proof or certification of eligibility to purchase Lifeline, Link Up America, or other means-tested services, required by Applicable Law. Z-Tel shall indemnify Verizon from any Claims resulting from Z-Tel’s failure to take such actions required by Applicable Law.
2.2.6 Verizon may perform audits to confirm Z-Tel’s conformity to the provisions of this Section 2.2. Such audits may be performed twice per calendar year and shall be performed in accordance with Sections 4.4.2 through 4.4.4 of the General Terms and Conditions.
2.3 Z-Tel shall be subject to the same limitations that Verizon’s Customers are subject to with respect to any Telecommunications Service that Verizon grandfathers or discontinues offering. Without limiting the foregoing, except to the extent that Verizon follows a different practice for Verizon Customers in regard to a grandfathered Telecommunications Service, such grandfathered Telecommunications Service: (a) shall be available only to a Customer that already has such Telecommunications Service; (b) may not be moved to a new service location; and, (c) will be furnished only to the extent that facilities continue to be available to provide such Telecommunications Service.
2.4 Z-Tel shall not be eligible to participate in any Verizon plan or program under which Verizon Customers may obtain products or services which are not Verizon Telecommunications Services, in return for trying, agreeing to purchase, purchasing, or using, Verizon Telecommunications Services.
2.5 In accordance with 47 CFR § 51.617(b), Verizon shall be entitled to all charges for Verizon Exchange Access services used by interexchange carriers to provide service to Z-Tel Customers.
