Common use of Health Insurance Premium Payment (XXXX) Reimbursement Program Clause in Contracts

Health Insurance Premium Payment (XXXX) Reimbursement Program. An individual who is eligible to enroll and who is a recipient of medical assistance under the state of Texas Medicaid Program or enrolled in CHIP, and who is a participant in the state of Texas XXXX Reimbursement Program may enroll with no enrollment period restrictions. If the individual is not eligible unless a family member is enrolled, both the individual and family member may enroll. The Effective Date of Coverage is on the first day of the month after HMO receives (i) written notice from the Texas Health and Human Services Commission, or (ii) enrollment forms, from You, provided such forms and applicable Premium payments are received by HMO within sixty (60) days after the date the individual becomes eligible for participation in the XXXX Reimbursement Program. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITS. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITS. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care, Participating Urgent Care, Retail Health Clinics, and Virtual Visits. HMO and Participating Providers do not have any financial responsibility for any services You seek or receive from a non-Participating Provider or facility, except as set forth below, unless both Your PCP and HMO have made prior Referral authorization arrangements.

Health Insurance Premium Payment (XXXX) Reimbursement Program. An individual who is eligible to enroll and who is a recipient of medical assistance under the state of Texas Medicaid Program or enrolled in CHIP, and who is a participant in the state of Texas XXXX Reimbursement Program may enroll with no enrollment period restrictions. If the individual is not eligible unless a family member is enrolled, both the individual and family member may enroll. The Effective Date of Coverage is on the first day of the month after HMO receives (i) written notice from the Texas Health and Human Services Commission, or (ii) enrollment forms, from You, provided such forms and applicable Premium payments are received by HMO within sixty (60) days after the date the individual becomes eligible for participation in the XXXX Reimbursement Program. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITS. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITS. Some Covered Services may also require Preauthorization by HMO. Preauthorization processes will be conducted in accordance with Texas Insurance Code, chapter 4201 or in accordance with the laws in the state of Texas. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care, Participating Urgent Care, Retail Health Clinics, Virtual Visits or Covered Services provided to female Members, who may directly access an Obstetrician/Gynecologist in the same Limited Provider Network as their PCP for: 1) well woman exams; 2) obstetrical care; 3) care for all active gynecological conditions; and Virtual Visits4) diagnosis, treatment, and Referral for any disease or condition within the scope of the professional practice of the Obstetrician/Gynecologist. PCPs in a Limited Provider Network will be identified in the HMO provider directory or You can call customer service at the toll-free telephone number on the back of Your identification card. HMO and Participating Providers do not have any financial responsibility for any services You seek or receive from a non-Participating Provider or facility, except as set forth below, unless both Your PCP and HMO have made prior Referral authorization arrangements. Selecting a PCP At the time You enroll, You must choose a PCP. If any Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on Member’s behalf. If Your Dependents enroll, You and Your Dependents must choose a PCP from HMO’s directory of Participating Providers in order to receive Covered Services. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may also request a written copy of the Participating Provider directory, which is updated quarterly, by calling customer service. Each directory identifies those Providers who are accepting existing patients only. HMO may assign a PCP if one has not been selected. Until a PCP is selected or assigned, benefits will be limited to coverage for Emergency Care. Your PCP may be part of a Limited Provider Network, so Your choice of a PCP may affect the network of Participating Providers available to You. For instance, if Your PCP is part of a Limited Provider Network, You may only be referred to Participating Providers who are associated with the same Limited Provider Network. (A Limited Provider Network is made up of Physicians in separate offices who form an association to provide health care services to HMO Members.) You can be referred to Participating Providers who are not associated with that group or Limited Provider Network only for Covered Services that are not available within the group or Limited Provider Network. You may be required to choose an Obstetrician or Gynecologist who belongs to the same Limited Provider Network as Your PCP, but a female Member’s right to directly access an Obstetrician or Gynecologist will not be infringed upon. PCPs in a Limited Provider Network will be identified in the HMO provider directory or You can call customer service at the toll-free telephone number on the back of Your identification card. Members who have been diagnosed with a chronic, disabling or life threatening illness may request approval to choose a Participating Specialist as a PCP using the process described in Specialist as PCP. Your PCP Your PCP coordinates Your medical care, as appropriate, either by providing treatment or by issuing Referrals to direct You to Participating Providers. Except for Emergency Care/medical emergencies or certain direct-access Specialist benefits described in this Certificate, only those services which are provided by or referred by Your PCP will be covered. It is Your responsibility to consult with the PCP in all matters regarding Your medical care. If Your PCP performs, suggests, or recommends a course of treatment for You that includes services that are not Covered Services, the entire cost of any such non-Covered Services will be Your responsibility. Changing Your PCP You may change Your PCP by calling the customer service toll-free telephone number listed on Your identification card to make the change or to request a change form or assistance in completing that form. The change will become effective on the first day of the month following HMO’s receipt and approval of the request. In the event of termination of a Participating Provider of any kind, HMO will use best efforts to provide reasonable advance notice to Members receiving care from such Participating Provider that termination is imminent. Special circumstances may render You eligible to continue receiving treatment from a Participating Provider after the effective date of termination, which is fully described in Continuity of Care.

Health Insurance Premium Payment (XXXX) Reimbursement Program. An individual who is eligible to enroll and who is a recipient of medical assistance under the state of Texas Medicaid Program or enrolled in CHIP, and who is a participant in the state of Texas XXXX Reimbursement Program may enroll with no enrollment period restrictions. If the individual is not eligible unless a family member is enrolled, both the individual and family member may enroll. The Effective Date of Coverage is on the first day of the month after HMO receives (i) written notice from the Texas Health and Human Services Commission, or (ii) enrollment forms, from You, provided such forms and applicable Premium payments are received by HMO within sixty (60) days after the date the individual becomes eligible for participation in the XXXX HIPP Reimbursement Program. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITSCovered Services and Benefits. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITSCovered Services and Benefits. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care, Participating Urgent Care, Retail Health Clinics, and or Virtual Visits. HMO and Participating Providers do not have any financial responsibility for any services You seek or receive from a non-Participating Provider or facility, except as set forth below, unless both Your PCP and HMO have made prior Referral authorization arrangements. Preauthorization Some Covered Services may also require Preauthorization by HMO. Preauthorization processes will be conducted in accordance with Texas Insurance Code, chapter 4201 or in accordance with the laws in the state of Texas. Renewal of an existing Preauthorization issued by HMO can be requested by a Physician or Health Care Provider up to 60 days prior to the expiration of the existing Preauthorization. For additional information and a current list of medical and and health care services that require Preauthorization, please visit the website at xxx.xxxxxx.xxx.

Health Insurance Premium Payment (XXXX) Reimbursement Program. An individual who is eligible to enroll and who is a recipient of medical assistance under the state of Texas Medicaid Program or enrolled in CHIP, and who is a participant in the state of Texas XXXX Reimbursement Program may enroll with no enrollment period restrictions. If the individual is not eligible unless a family member is enrolled, both the individual and family member may enroll. The Effective Date of Coverage is on the first day of the month after HMO receives (i) written notice from the Texas Health and Human Services Commission, or (ii) enrollment forms, from You, provided such forms and applicable Premium payments are received by HMO within sixty (60) days after the date the individual becomes eligible for participation in the XXXX Reimbursement Program. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITSCovered Services and Benefits. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITSCovered Services and Benefits. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care, Participating Urgent Care, Retail Health Clinics, and or Virtual Visits. HMO and Participating Providers do not have any financial responsibility for any services You seek or receive from a non-Participating Provider or facility, except as set forth below, unless both Your PCP and HMO have made prior Referral authorization arrangements. Preauthorization Some Covered Services may also require Preauthorization by HMO. Preauthorization processes will be conducted in accordance with Texas Insurance Code, chapter 4201 or in accordance with the laws in the state of Texas. Renewal of an existing Preauthorization issued by HMO can be requested by a Physician or Health Care Provider up to 60 days prior to the expiration of the existing Preauthorization. For additional information and a current list of medical and and health care services that require Preauthorization, please visit the website at xxx.xxxxxx.xxx.

Health Insurance Premium Payment (XXXX) Reimbursement Program. An individual who is eligible to enroll and who is a recipient of medical assistance under the state of Texas Medicaid Program or enrolled in CHIP, and who is a participant in the state of Texas XXXX Reimbursement Program may enroll with no enrollment period restrictions. If the individual is not eligible unless a family member is enrolled, both the individual and family member may enroll. The Effective Date of Coverage is on the first day of the month after HMO receives (i) written notice from the Texas Health and Human Services Commission, or (ii) enrollment forms, from You, provided such forms and applicable Premium payments are received by HMO within sixty (60) days after the date the individual becomes eligible for participation in the XXXX Reimbursement Program. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITSCovered Services and Benefits. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITSCovered Services and Benefits. Some Covered Services may also require Preauthorization by HMO. Preauthorization processes will be conducted in accordance with Texas Insurance Code, chapter 4201 or in accordance with the laws in the state of Texas. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care, Participating Urgent CareCare or Covered Services provided to female Members, Retail Health Clinicswho may directly access an Obstetrician/Gynecologist in the same Limited Provider Network as their PCP for: 1) well woman exams; 2) obstetrical care; 3) care for all active gynecological conditions; and 4) diagnosis, treatment, and Virtual VisitsReferral for any disease or condition within the scope of the professional practice of the Obstetrician/Gynecologist. PCPs in a Limited Provider Network will be identified in the HMO provider directory or You can call customer service at the toll-free telephone number on the back of Your identification card. HMO and Participating Providers do not have any financial responsibility for any services You seek or receive from a non-Participating Provider or facility, except as set forth below, unless both Your PCP and HMO have made prior Referral authorization arrangements. Selecting a PCP At the time You enroll, You must choose a PCP. If any Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on Member’s behalf. If Your Dependents enroll, You and Your Dependents must choose a PCP from HMO’s directory of Participating Providers in order to receive Covered Services. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may also request a written copy of the Participating Provider directory, which is updated quarterly, by calling customer service. Each directory identifies those Providers who are accepting existing patients only. HMO may assign a PCP if one has not been selected. Until a PCP is selected or assigned, benefits will be limited to coverage for Emergency Care. Your PCP may be part of a Limited Provider Network, so Your choice of a PCP may affect the network of Participating Providers available to You. For instance, if Your PCP is part of a Limited Provider Network, You may only be referred to Participating Providers who are associated with the same Limited Provider Network. (A Limited Provider Network is made up of Physicians in separate offices who form an association to provide health care services to HMO Members.) You can be referred to Participating Providers who are not associated with that group or Limited Provider Network only for Covered Services that are not available within the group or Limited Provider Network. You may be required to choose an Obstetrician or Gynecologist who belongs to the same Limited Provider Network as Your PCP, but a female Member’s right to directly access an Obstetrician or Gynecologist will not be infringed upon. PCPs in a Limited Provider Network will be identified in the HMO provider directory or You can call customer service at the toll-free telephone number on the back of Your identification card. Members who have been diagnosed with a chronic, disabling or life threatening illness may request approval to choose a Participating Specialist as a PCP using the process described in Specialist as PCP. Your PCP Your PCP coordinates Your medical care, as appropriate, either by providing treatment or by issuing Referrals to direct You to Participating Providers. The PCP can also order lab tests and x-rays, prescribe medicines or therapies, and arrange hospitalization. Except for Emergency Care/medical emergencies or certain direct-access Specialist benefits described in this Certificate, only those services which are provided by or referred by Your PCP will be covered. It is Your responsibility to consult with the PCP in all matters regarding Your medical care. If Your PCP performs, suggests, or recommends a course of treatment for You that includes services that are not Covered Services, the entire cost of any such non-Covered Services will be Your responsibility. Changing Your PCP You may change Your PCP by calling the customer service toll-free telephone number listed on Your identification card to make the change or to request a change form or assistance in completing that form. The change will become effective on the first day of the month following HMO’s receipt and approval of the request. In the event of termination of a Participating Provider of any kind, HMO will use best efforts to provide reasonable advance notice to Members receiving care from such Participating Provider that termination is imminent. Special circumstances may render You eligible to continue receiving treatment from a Participating Provider after the effective date of termination, which is fully described in Continuity of Care.

Health Insurance Premium Payment (XXXX) Reimbursement Program. An individual who is eligible to enroll and who is a recipient of medical assistance under the state of Texas Medicaid Program or enrolled in CHIP, and who is a participant in the state of Texas XXXX Reimbursement Program may enroll with no enrollment period restrictions. If the individual is not eligible unless a family member is enrolled, both the individual and family member may enroll. The Effective Date of Coverage is on the first day of the month after HMO receives (i) written notice from the Texas Health and Human Services Commission, or (ii) enrollment forms, from You, provided such forms and applicable Premium payments are received by HMO within sixty (60) days after the date the individual becomes eligible for participation in the XXXX Reimbursement Program. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITS. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITS. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care, Participating Urgent Care, Retail Health Clinics, and or Virtual Visits. HMO and Participating Providers do not have any financial responsibility for any services You seek or receive from a non-Participating Provider or facility, except as set forth below, unless both Your PCP and HMO have made prior Referral authorization arrangements. Preauthorization Some Covered Services may also require Preauthorization by HMO. Preauthorization processes will be conducted in accordance with Texas Insurance Code, chapter 4201 or in accordance with the laws in the state of Texas. Renewal of an existing Preauthorization issued by HMO can be requested by a Physician or Health Care Provider up to 60 days prior to the expiration of the existing Preauthorization. For additional information and a current list of medical and health care services that require Preauthorization, please visit the website at xxx.xxxxxx.xxx.

Health Insurance Premium Payment (XXXX) Reimbursement Program. An individual who is eligible to enroll and who is a recipient of medical assistance under the state of Texas Medicaid Program or enrolled in CHIP, and who is a participant in the state of Texas XXXX Reimbursement Program may enroll with no enrollment period restrictions. If the individual is not eligible unless a family member is enrolled, both the individual and family member may enroll. The Effective Date of Coverage is on the first day of the month after HMO receives (i) written notice from the Texas Health and Human Services Commission, or (ii) enrollment forms, from You, provided such forms and applicable Premium payments are received by HMO within sixty (60) days after the date the individual becomes eligible for participation in the XXXX Reimbursement Program. Provider Information You are entitled to medical care and services from Participating Providers including Medically Necessary medical, surgical, diagnostic, therapeutic and preventive services that are generally and customarily provided in the Service Area. Some services may not be covered. To be covered, a service that is Medically Necessary must also be described in COVERED SERVICES AND BENEFITSCovered Services and Benefits. Even though a Physician or other Health Care Professional has performed, prescribed or recommended a service does not mean it is Medically Necessary or that it is covered under COVERED SERVICES AND BENEFITSCovered Services and Benefits. Only services that are performed, prescribed, directed or authorized in advance by the PCP or HMO are covered benefits under this Certificate except Emergency Care, Participating Urgent Care, Retail Health Clinics, and or Virtual Visits. HMO and Participating Providers do not have any financial responsibility for any services You seek or receive from a non-Participating Provider or facility, except as set forth below, unless both Your PCP and HMO have made prior Referral authorization arrangements. Preauthorization Some Covered Services may also require Preauthorization by HMO. Preauthorization processes will be conducted in accordance with Texas Insurance Code, chapter 4201 or in accordance with the laws in the state of Texas. Renewal of an existing Preauthorization issued by HMO can be requested by a Physician or Health Care Provider up to 60 days prior to the expiration of the existing Preauthorization. For additional information and a current list of medical and health care services that require Preauthorization, please visit the website at xxx.xxxxxx.xxx.