How the Plan Works. This Section explains how your Health Benefit Plan works, how to access your Primary Care Practitioner to get Health Care Services, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. This plan is an “HMO” (Health Maintenance Organization). People who receive Health Care Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive to work closely with Subscribers, their Covered Dependents, and their health care Practitioners/Providers to prevent illness and provide quality, cost-effective health care. Because of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health plan. This pl n is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHP. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Some preventive benefits are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PHP and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxx://xxx.xxxxxxx.xxx/offices/public-affairs/hsa. We require that: You must physically live in the State of New Mexico (our Service Area) unless you are a Dependent and meet all of the terms and conditions for such Coverage as outlined in the Refer to Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. You and/or your Dependents cannot be eligible for Medicare due to age, illness or disability. Refer to All of your healthcare services are provided by In-Network Contract Practitioner/Providers, except for Urgent and Emergency Health Care Services situations. Please refer to the Benefits Section Accidental Injury / Urgent Care / Emergency Health Care Services / Observation / Trauma Services. You select a Primary Care Physician (PCP) from the Provider Directory to coordinate all of your care. Refer to You pay your pre-determined Cost Sharing (Deductible, Coinsurance and/or Copayment) at the time you receive Covered Services. We will reimburse the Practitioner/Provider the balance for Covered Se vices based upon Total Allowable Charges (some services may not require a Cost Sharing Deductible, Coinsurance and/or Copayment). Refer to your Summary of
Appears in 1 contract
Samples: Presbyterian Health Plan
How the Plan Works. This Section explains how your Health Benefit Plan works, how to access your Primary Care Practitioner to get Health Care Services, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. This plan is an “HMO” (Health Maintenance Organization). People who receive Health Care Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive to work closely with Subscribers, their Covered Dependents, and their health care Practitioners/Providers to prevent illness and provide quality, cost-effective health care. Because of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health plan. This pl n plan is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHP. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Some preventive benefits Preventive benefits, as defined by the Affordable Care Act (ACA) are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met et the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical s rgical benefits available to you. HSAs are not administered by PHP and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxx://xxx.xxxxxxx.xxx/offices/public-affairs/hsa. We require that: You must physically live or work (commuting daily) in the State of New Mexico (our Service Area) unless you are a Dependent and meet all of the terms and conditions for Refer to such Coverage as outlined in the Refer to Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. You and/or your Dependents cannot be eligible for Medicare due to ageEffective Dates, illness or disability. Refer to All of your healthcare services Health Care Services are provided by In-Network Contract Refer to Practitioner/ProvidersProviders in our Service Area, except for Urgent and Emergency Health Care Services situations. Please refer to the Benefits Section Accidental Injury / Urgent Care / Emergency Health Care Services / Observation / Trauma Services. You select a Primary Care Physician (PCP) from the Provider Directory to coordinate all of your care. Refer to You pay your pre-determined Cost Sharing (Deductible, Coinsurance and/or CopaymentCopayments) at the time you receive Covered Services. We will reimburse the R fer to Practitioner/Provider the balance for Covered Se vices Services based upon Total Allowable Charges (some services may not require a Cost Sharing Deductible, Coinsurance and/or Copayment). Refer to your Summary ofof Benefits and Coverage to find Covered Services subject to Cost Sharing amounts. To receive care under our plan, you must select an In-network Primary Care Physician to Impo tant Information manage your he lth care needs. Your Primary Care Physician will be able to meet most of these needs. A list of Practitioners/Providers who serve as In-network Primary Care r Physicians may be found in the Provider Directory. Primary Care Physicians include, but are not limited to, General Practitioners, Family Practice Physicians, Internists, Pediatricians, and Obstetricians/Gynecologists (if applicable). As a Member of the health plan, you may choose as your Primary Care Physician any doctor or Nurse Practitioner on that list. If you do not designate a Primary Care Physician on your enrollment form, we suggest one for you. Provider Directory will CS C Call P 505‐923‐5678 You will find our Primary Care Physicians close to where you live and work across the State. The Provider Directory is available on our website at xxx.xxx.xxx/xxxxxxxxx or by calling ur Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 o p. 1‐800‐356‐2219 m. at (000) 000-0000 or t ll-free at 0-000-000-0000. Hearing impaired users may call the TTY line at 711 or toll-free 0-000-000-0000. The Provider Directory is subject to change and you should always verify the Practitioner/Provider’s network status by visiting our website at xxxxx://xxx.xxx.xxx/doctors- services/Pages/find-a-doctor.aspx. Obtaining Health Care How to Obtain Primary Care Services To receive care under this plan, you and all Covered Members of your family must select an In-network Primary Care Physician (PCP) to manage your health care needs. Primary Care Physicians include, but are not limited to, General Practitioners, Family Practice Physicians, Internists, Pediatricians and Obstetricians/Gynecologists (if applicable).
Appears in 1 contract
Samples: Presbyterian Health Plan
How the Plan Works. This Section explains how your Health Benefit Plan works, how to access your Primary Care Practitioner to get Health Care Services, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. This plan is an “HMO” (Health Maintenance Organization). People who receive Health Care Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive to work closely with Subscribers, their Covered Dependents, and their health care Practitioners/Providers to prevent illness and provide quality, cost-effective health care. Because of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health plan. This pl n is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHP. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Some preventive benefits are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PHP and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxx://xxx.xxxxxxx.xxx/offices/public-affairs/hsa. We require that: You must physically live in the State of New Mexico (our Service Area) unless you are a Dependent and meet all of the terms and conditions for such Coverage as outlined in the Refer to Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. You and/or your Dependents cannot be eligible for Medicare due to age, illness or disability. Refer to All of your healthcare services are provided by In-Network Contract Practitioner/Providers, except for Urgent and Emergency Health Care Services situations. Please refer to the Benefits Section Accidental Injury / Urgent Care / Emergency Health Care Services / Observation / Trauma Services. You select a Primary Care Physician (PCP) from the Provider Directory to coordinate all of your care. Refer to You pay your pre-determined Cost Sharing (Deductible, Coinsurance and/or Copayment) at the time you receive Covered Services. We will reimburse the Practitioner/Provider the balance for Covered Se vices based upon Total Allowable Charges (some services may not require a Cost Sharing Deductible, Coinsurance and/or Copayment). Refer to your Summary ofCoverage
Appears in 1 contract
Samples: Presbyterian Health Plan
How the Plan Works. This Section explains how your Health Benefit Plan worksto find Practitioners/Providers who are in our network (In- network), how to access your Primary Care Practitioner to get Health Care ServicesHealthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. This plan is an “HMO” a Preferred Provider Organization (Health Maintenance Organization)PPO) Healthcare Plan. People who Each time you need Healthcare Services, you can choose your Practitioners and Providers and the level of Covered Benefits that will apply to their charges. You will receive Health Care the highest level of Covered Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive and the lowest cost to work closely with Subscribers, their Covered Dependents, and their health care you when you obtain services from our In-network Practitioners/Providers Providers. You still have the flexibility provided by the Out-of-network benefits to prevent illness and provide quality, cost-effective health care. Because see any Practitioner/Provider you choose for many of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health planyour Healthcare Services. This pl n plan is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHPPIC. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Some preventive benefits Preventive benefits, as defined by the Affordable Care Act (ACA) are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PHP PIC and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxx://xxx.xxxxxxx.xxx/offices/public-affairs/hsaxxxxx://xxxx.xxxxxxxx.xxx/. Under the Market Stabilization rule finalized on April 13, 2017, to the extent permitted by State law, Presbyterian Insurance Company Inc. may attribute to any past-due premium amounts owed to it the initial premium payment made in accordance with the terms of the health insurance policy to effectuate coverage, for coverage in the 12-month period preceding the effective date. We require that: You This is done in an effort to prohibit abuse of the grace period. Be aware that failure to pay premiums in a preceding 12-month period may result in the group or individual’s inability to effectuate new coverage until past-due premium payments and initial premium payments are satisfied. PIC accepts premium and cost-sharing payments from the following third-party entities from plan enrollees (in the case of a downstream entity, to the extent the entity routinely collects premiums or cost-sharing): a Xxxx Xxxxx HIV/AIDS Program under title XXVI of the Public Health Service Act, an Indian tribe, tribal organization, or urban Indian organization, and a local, State, of Federal government program, including a grantee directed by a government program to make payments on its behalf. In-network Benefits In order to be eligible to enroll and participate in this Plan you must physically live work for an employer Group that is headquartered in the State of New Mexico (our Service Area) unless you are a Dependent and ). Your Dependents may be eligible to enroll if they meet all of the terms and conditions for such Coverage as outlined described in the Refer to Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. You and/or When you or your Covered Dependents cannot be eligible for Medicare due to age, illness or disability. Refer to All of your healthcare services are provided by receive care from Practitioners and Providers in our network (In-Network Contract network Practitioners/Providers), the In-network benefit level will apply to the cost of the Healthcare Services. You will be responsible for your Cost Sharing amounts (Copayments, Deductibles or Coinsurance) at the time of service. As shown in your Summary of Benefits and Coverage, your benefit levels are highest and your Out-of- pocket Cost Sharing amounts are lowest when you use our In-network Practitioner/Providers. Your In-network Practitioner/Provider will bill us directly for the cost of services. You will generally not have claims to file or papers to fill out in order to be reimbursed for medical services obtained from In-network Practitioners and Providers. In-network Practitioners and Providers cannot bill you for any additional costs over and above your Cost Sharing amounts. Hospital Inpatient Admission and some other Healthcare Services require our review and Prior Authorization before the services are provided. If you seek care from an In-network Practitioner/Provider, except for Urgent your In-network Practitioner/Provider will notify us and Emergency Health Care Services situationshandle all aspects of your care. Please refer to the Benefits Prior Authorization Section Accidental Injury / Urgent Care / Emergency Health Care Services / Observation / Trauma Servicesfor complete details on Prior Authorization. You select a Primary Care Physician (PCP) from the Provider Directory You will find our In-network Practitioners/Providers close to coordinate all where you live and work across the State. Our Provider Directory lists the In-network Practitioners, as well as In-network Hospitals, pharmacies, outpatient facilities and other healthcare Providers. The Provider Directory is available on our website at xxxxx://xxx.xxx.xxx/Pages/find-a- doctor.aspx. If you need additional information about a Provider, you may call our Presbyterian Customer Service Center Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. The Provider Directory is subject to change and you should always verify the Practitioner/Provider’s network status by visiting our website at xxxxx://xxx.xxx.xxx/Pages/find-a-doctor.aspx. Updates are made to the provider directory on a daily basis, so the online version is always the most current list. However, if you require a printed copy of the directory, you may request it by calling the Presbyterian Customer Service Center at the number above. Out-of-network Benefits When you obtain care from a Practitioner/Provider who is not in our network (Out- of-network Practitioner/Provider), the Out-of-network Covered Benefits will apply. As shown in the Summary of Benefits and Coverage, the benefit levels are lower and your care. Refer to You pay your pre-determined Cost Sharing (DeductibleCopayments, Coinsurance and/or CopaymentDeductibles and Coinsurance) amounts are higher. Additionally, when you receive care from Out-of-network Practitioners/Providers, our payments to them for Covered Services will be limited to Medicare Allowable. You will be responsible for any amount due above the Medicare Allowable Charges, in addition to any applicable Cost Sharing amount. Medicare Allowable is defined in the Glossary of Terms Section. If you pay a non-participating provider more than the in-network cost-sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating provider must refund to you within 45 calendar days of receipt of payment from Presbyterian any amount paid in excess of the in-network cost-sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59A, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. Please refer to your Summary of Benefits and Coverage, the Benefit Section and the Exclusions Section for a complete listing of Covered and Excluded services. For Hospital admissions and other services from Out-of-network Practitioners/Providers that require Prior Authorization, you receive Covered Servicesare responsible for ensuring that proper Prior Authorization has been obtained before being admitted to the Hospital or before receiving those services that require Prior Authorization from Out-of-network Practitioners/Providers. We will reimburse the If you are referred to an Out-of-network Practitioner/Provider, services from that Out-of-network Practitioner/Provider are subject to the balance for Covered Se vices based upon Total Allowable Charges Out-of-network benefit levels shown in the Summary of Benefits and Coverage. National PPO Providers As an additional benefit PHP contracts with National Network Provider/ Healthcare Services (some services may not MultiPlan/PHCS), a national preferred Provider organization with over 3,500 acute care Hospitals and 400,000 practitioners. If you live or are traveling outside the State of New Mexico, and require a Cost Sharing Deductiblemedical attention, Coinsurance and/or Copayment). Refer we encourage you to your Summary ofsee MultiPlan/PHCS practitioners and
Appears in 1 contract
Samples: Group Subscriber Agreement
How the Plan Works. This Section explains how your Health Benefit Plan worksto find Practitioners/Providers who are in our network (In- network), how to access your Primary Care Practitioner to get Health Care ServicesHealthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. This plan is an “HMO” a Preferred Provider Organization (Health Maintenance Organization)PPO) Healthcare Plan. People who Each time you need Healthcare Services, you can choose your Practitioners and Providers and the level of Covered Benefits that will apply to their charges. You will receive Health Care the highest level of Covered Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive and the lowest cost to work closely with Subscribers, their Covered Dependents, and their health care you when you obtain services from our In-network Practitioners/Providers Providers. You still have the flexibility provided by the Out-of-network benefits to prevent illness and provide quality, cost-effective health care. Because see any Practitioner/Provider you choose for many of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health planyour Healthcare Services. This pl n plan is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHPPIC. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Some preventive benefits Preventive benefits, as defined by the Affordable Care Act (ACA) are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PHP PIC and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxx://xxx.xxxxxxx.xxx/offices/public-affairs/hsaxxxxx://xxxx.xxxxxxxx.xxx/. Under the Market Stabilization rule finalized on April 13, 2017, to the extent permitted by State law, Presbyterian Insurance Company Inc. may attribute to any past-due premium amounts owed to it the initial premium payment made in accordance with the terms of the health insurance policy to effectuate coverage, for coverage in the 12-month period preceding the effective date. We require that: You This is done in an effort to prohibit abuse of the grace period. Be aware that failure to pay premiums in a preceding 12-month period may result in the group or individual’s inability to effectuate new coverage until past-due premium payments and initial premium payments are satisfied. PIC accepts premium and cost-sharing payments from the following third-party entities from plan enrollees (in the case of a downstream entity, to the extent the entity routinely collects premiums or cost-sharing): a Xxxx Xxxxx HIV/AIDS Program under title XXVI of the Public Health Service Act, an Indian tribe, tribal organization, or urban Indian organization, and a local, State, of Federal government program, including a grantee directed by a government program to make payments on its behalf. In-network Benefits In order to be eligible to enroll and participate in this Plan you must physically live work for an employer Group that is headquartered in the State of New Mexico (our Service Area) unless you are a Dependent and ). Your Dependents may be eligible to enroll if they meet all of the terms and conditions for such Coverage as outlined described in the Refer to Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. You and/or When you or your Covered Dependents cannot be eligible for Medicare due to age, illness or disability. Refer to All of your healthcare services are provided by receive care from Practitioners and Providers in our network (In-Network Contract network Practitioners/Providers), the In-network benefit level will apply to the cost of the Healthcare Services. You will be responsible for your Cost Sharing amounts (Copayments, Deductibles or Coinsurance) at the time of service. As shown in your Summary of Benefits and Coverage, your benefit levels are highest and your Out-of- pocket Cost Sharing amounts are lowest when you use our In-network Practitioner/Providers. Your In-network Practitioner/Provider will bill us directly for the cost of services. You will generally not have claims to file or papers to fill out in order to be reimbursed for medical services obtained from In-network Practitioners and Providers. In-network Practitioners and Providers cannot bill you for any additional costs over and above your Cost Sharing amounts. Hospital Inpatient Admission and some other Healthcare Services require our review and Prior Authorization before the services are provided. If you seek care from an In-network Practitioner/Provider, except for Urgent your In-network Practitioner/Provider will notify us and Emergency Health Care Services situationshandle all aspects of your care. Please refer to the Benefits Prior Authorization Section Accidental Injury / Urgent Care / Emergency Health Care Services / Observation / Trauma Servicesfor complete details on Prior Authorization. You select a Primary Care Physician (PCP) from the Provider Directory You will find our In-network Practitioners/Providers close to coordinate all where you live and work across the State. Our Provider Directory lists the In-network Practitioners, as well as In-network Hospitals, pharmacies, outpatient facilities and other healthcare Providers. The Provider Directory is available on our website at xxxxx://xxx.xxx.xxx/Pages/find-a- doctor.aspx. If you need additional information about a Provider, you may call our Presbyterian Customer Service Center Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. The Provider Directory is subject to change and you should always verify the Practitioner/Provider’s network status by visiting our website at xxxxx://xxx.xxx.xxx/Pages/find-a-doctor.aspx. Updates are made to the provider directory on a daily basis, so the online version is always the most current list. However, if you require a printed copy of the directory, you may request it by calling the Presbyterian Customer Service Center at the number above. Out-of-network Benefits When you obtain care from a Practitioner/Provider who is not in our network (Out- of-network Practitioner/Provider), the Out-of-network Covered Benefits will apply. As shown in the Summary of Benefits and Coverage, the benefit levels are lower and your care. Refer to You pay your pre-determined Cost Sharing (DeductibleCopayments, Coinsurance and/or CopaymentDeductibles and Coinsurance) amounts are higher. Additionally, when you receive care from Out-of-network Practitioners/Providers, our payments to them for Covered Services will be limited to Medicare Allowable. You will be responsible for any amount due above the Medicare Allowable Charges, in addition to any applicable Cost Sharing amount. Medicare Allowable is defined in the Glossary of Terms Section. If you pay a non-participating provider more than the in-network cost-sharing amount for services provided under circumstances giving rise to a surprise bill, the non-participating provider must refund to you within 45 calendar days of receipt of payment from Presbyterian any amount paid in excess of the in-network cost-sharing amount. In accordance with the hearing procedures established pursuant to the Patient Protection Act [chapter 59A, Article 57 NMSA 1978], you may appeal Presbyterian’s determination made regarding a surprise bill. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. Please refer to your Summary of Benefits and Coverage, the Benefit Section and the Exclusions Section for a complete listing of Covered and Excluded services. For Hospital admissions and other services from Out-of-network Practitioners/Providers that require Prior Authorization, you receive Covered Servicesare responsible for ensuring that proper Prior Authorization has been obtained before being admitted to the Hospital or before receiving those services that require Prior Authorization from Out-of-network Practitioners/Providers. We will reimburse the If you are referred to an Out-of-network Practitioner/Provider, services from that Out-of-network Practitioner/Provider are subject to the balance for Covered Se vices based upon Total Allowable Charges Out-of-network benefit levels shown in the Summary of Benefits and Coverage. National PPO Providers As an additional benefit PHP contracts with National Network Provider/ Healthcare Services (some services may not MultiPlan/PHCS), a national preferred Provider organization with over 3,500 acute care Hospitals and 400,000 practitioners. If you live or are traveling outside the State of New Mexico, and require a Cost Sharing Deductiblemedical attention, Coinsurance and/or Copayment). Refer we encourage you to your Summary ofsee MultiPlan/PHCS practitioners and
Appears in 1 contract
Samples: Group Subscriber Agreement
How the Plan Works. This Section explains how your Health Benefit Plan works, how to access your Primary Care Practitioner PCP to get Health Care Healthcare Services, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. This plan is an “HMO” (Health Maintenance Organization). People who receive Health Care Healthcare Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive to work closely with Subscribers, their Covered Dependents, and their health care healthcare Practitioners/Providers to prevent illness and provide quality, cost-effective health carehealthcare. Because of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health plan. This pl n plan is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHP. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Some preventive benefits Preventive benefits, as defined by the Affordable Care Act (ACA) are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PHP and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxx://xxx.xxxxxxx.xxx/offices/public-affairs/hsaxxxxx://xxxx.xxxxxxxx.xxx/. PHP accepts premium and cost-sharing payments from the following third-party entities from plan enrollees (in the case of a downstream entity, to the extent the entity routinely collects premiums or cost-sharing): a Xxxx Xxxxx HIV/AIDS Program under title XXVI of the Public Health Service Act, an Indian tribe, tribal organization, or urban Indian organization, and a local, State, of Federal government program, including a grantee directed by a government program to make payments on its behalf. We require that: • You must physically live or work (commuting daily) in the State of New Mexico (our Service Area) unless you are a Dependent and meet all of the terms and conditions for such Coverage as outlined in the Refer to Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. You and/or your Dependents cannot be eligible for Medicare due to age, illness or disability. Refer to • All of your healthcare services Healthcare Services are provided by provided by In-Network Contract Practitioner/ProvidersProviders in our Service Area, except for Urgent and Emergency Health Care Healthcare Services situations. Please refer to the Benefits Section Accidental Injury / Urgent Care / Emergency Health Care Healthcare Services / Observation / Trauma Services. • You select a Primary Care Physician (PCP) PCP from the Provider Directory to coordinate all of your care. Refer to • You pay your pre-determined Cost Sharing (Deductible, Coinsurance and/or CopaymentCopayments) at the time you receive Covered Services. We will reimburse the Practitioner/Provider the balance for Covered Se vices Services based upon Total Allowable Charges (some services may not require a Cost Cost-Sharing Deductible, Coinsurance and/or Copayment). Refer to your Summary ofof Benefits and Coverage to find Covered Services subject to Cost-Sharing amounts. • Under the Market Stabilization rule finalized on April 13, 2017, to the extent permitted by State law, Presbyterian Health Plan may attribute to any past-due premium amounts owed to it the initial premium payment made in accordance with the terms of the health insurance policy to effectuate coverage, for coverage in the 12-month period preceding the effective date. This is done in an effort to prohibit abuse of the grace period. Be aware that failure to pay premiums in a preceding 12-month period may result in the group or individual’s inability to effectuate new coverage until past-due premium payments and initial premium payments are satisfied. To receive care under our plan, you must select an In-network PCP to manage your healthcare needs. Your PCP will be able to meet most of these needs. A list of Practitioners/Providers who serve as In-network PCPs may be found in the Provider Directory. PCPs include, but are not limited to, general practitioners, family practice physicians, internists, pediatricians, and Obstetricians/Gynecologists (if applicable). As a Member of the health plan, you may choose as your PCP any provider, doctor, or Nurse Practitioner on that list. If you do not designate a Primary Care Physician on your enrollment form, we will suggest one for you. Provider Directory
Appears in 1 contract
Samples: Presbyterian Health
How the Plan Works. This Section explains how your Health Benefit Plan works, how to access your Primary Care Practitioner to get Health Care Services, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. This plan is an “HMO” (Health Maintenance Organization). People who receive Health Care Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive to work closely with Subscribers, their Covered Dependents, and their health care Practitioners/Providers to prevent illness and provide quality, cost-effective health care. Because of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health plan. This pl n plan is a fully qualified High Deductible Health Plan (HDHP) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHP. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Some preventive benefits Preventive benefits, as defined by the Affordable Care Act (ACA) are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PHP and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxx://xxx.xxxxxxx.xxx/offices/public-affairs/hsa. We require that: ➢ You must physically live or work (commuting daily) in the State of New Mexico (our Service Area) unless you are a Dependent and meet all of the terms and conditions for such Coverage as outlined in the Refer to Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. You and/or your Dependents cannot be eligible for Medicare due to age, illness or disability. Refer to ➢ All of your healthcare services Health Care Services are provided by In-Network Contract Practitioner/ProvidersProviders in our Service Area, except for Urgent and Emergency Health Care Services situations. Please refer to the Benefits Section Accidental Injury / Urgent Care / Emergency Health Care Services / Observation / Trauma Services. ➢ You select a Primary Care Physician (PCP) from the Provider Directory to coordinate all of your care. Refer to ➢ You pay your pre-determined Cost Sharing (Deductible, Coinsurance and/or CopaymentCopayments) at the time you receive Covered Services. We will reimburse the Practitioner/Provider the balance for Covered Se vices Services based upon Total Allowable Charges (some services may not require a Cost Sharing Deductible, Coinsurance and/or Copayment). Refer to your Summary ofof Benefits and Coverage to find Covered Services subject to Cost Sharing amounts. ➢ Under the Market Stabilization rule finalized on April 13, 2017, to the extent permitted by State law, Presbyterian Health Plan may attribute to any past-due premium amounts owed to it the initial premium payment made in accordance with the terms of the health insurance policy to effectuate coverage, for coverage in the 12-month period preceding the effective date. This is done in an effort to prohibit abuse of the grace period. Be aware that failure to pay premiums in a preceding 12-month period may result in the group or individual’s inability to effectuate new coverage until past-due premium payments and initial premium payments are satisfied. To receive care under our plan, you must select an In-network Primary Care Physician to manage your health care needs. Your Primary Care Physician will be able to meet most of these needs. A list of Practitioners/Providers who serve as In-network Primary Care Physicians may be found in the Provider Directory. Primary Care Physicians include, but are not limited to, General Practitioners, Family Practice Physicians, Internists, Pediatricians, and Obstetricians/Gynecologists (if applicable). As a Member of the health plan, you may choose as your Primary Care Physician any doctor or Nurse Practitioner on that list. CSC Call P 000-000-0000 0-000-000-0000 If you do not designate a Primary Care Physician on your enrollment form, we will suggest one for you. Provider Directory T o p You will find our Primary Care Physicians close to where you live and work across the State. he Provider Directory is available on our website at xxx.xxx.xxx/xxxxxxxxx or by calling ur Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 .m. at (000) 000-0000 or toll-free at 0-000-000-0000. Hearing impaired users may call the TTY line at 711. The Provider Directory is subject to change and you should always verify the Practitioner/Provider’s network status by visiting our website at xxxxx://xxx.xxx.xxx/doctors- services/Pages/find-a-doctor.aspx.
Appears in 1 contract
Samples: Presbyterian Health Plan
How the Plan Works. This Section explains how your Health Benefit Plan works, how to access your Primary Care Practitioner to get Health Care Services, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. This plan is an “HMO” (Health Maintenance Organization). People who receive Health Care Benefits through an HMO are sometimes called “Enrollees” or “Subscribers. We strive to work closely with Subscribers, their Covered Dependents, and their health care Practitioners/Providers to prevent illness and provide quality, cost-effective health care. Because of this close working relationship, we consider our Enrollees and Subscribers to be Members of our health plan. This pl n is a fully qualified High Deductible Health Plan Preventive benefits, as defined by the Affordable Care Act (HDHPACA) which means that you must meet an individual or family Deductible before any benefits (including pharmacy benefits) are paid out by PHP. Once the Deductible is met, you will be required to pay a Coinsurance (in most cases) or portion of the cost of the Covered services that are provided. This is explained in greater detail in the General Information Section. Some preventive benefits are not subject to the Deductible. This means you can access this benefit and the plan will pay even if you have not met the individual or family Deductible. Please see the “Clinical Preventive Services” benefit on your Summary of Benefits and Coverage for further information. Prescription Drugs are not part of the Clinical Preventive Services benefit and thus, are subject to the Deductible and Coinsurance listed in the Summary of Benefits and Coverage. This Plan is qualified for use in conjunction with a Health Savings Account (HSA). Please see the “HSA Note(s)” posted throughout this document. Please remember, though, that this booklet describes only the medical/surgical benefits available to you. HSAs are not administered by PHP and are regulated by the United States Department of the Treasury (United States Treasury). For more information, please see the United States Treasury’s website at: xxxx://xxx.xxxxxxx.xxx/offices/public-affairs/hsa. We require that: Refer to You must physically live or work (commuting daily) in the State of New Mexico (our Service Area) unless you are a Dependent and meet all of the terms and conditions for such Coverage as outlined in the Refer to Eligibility, Enrollment and Effective Dates, Termination and Continuation of Coverage Section. You and/or your Dependents cannot be eligible for Medicare due to age, illness or disability. Refer to All of your healthcare services Health Care Services are provided by In-Network Contract Practitioner/ProvidersProviders in our Service Area, except for Urgent and Emergency Health Care Services situations. Please refer to the Benefits Section Accidental Injury / Urgent Care / Emergency Health Care Services / Observation / Trauma Services. You select a Primary Care Physician (PCP) from the Provider Directory to coordinate all of your care. Refer to You pay your pre-determined Cost Sharing (Deductible, Coinsurance and/or CopaymentCopayments) at the time you receive Covered Services. We will reimburse the Practitioner/Provider the balance for Covered Se vices Services based upon Total Allowable Charges (some services may not require a Cost Sharing Deductible, Coinsurance and/or Copayment). Refer to your Summary ofof Benefits and Coverage to find Covered Services subject to Cost Sharing amounts. Important
Appears in 1 contract
Samples: Presbyterian Health Plan
