Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group Health’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16, Group Health recommends each Member choose a personal physician. This decision is important since the designated personal physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician who participates in one of the Group Health networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physician, and for a list of the participating personal physicians, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health or from any other person (including a personal physician) to access obstetrical or gynecological care from a health care professional in the Group Health network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000- 0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: All stages of reconstruction of the breast on which the mastectomy has been performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health will provide the information regarding the types of plans offered by Group Health to Members on request. Please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000. I. Introduction 6 II. How Covered Services Work 6 III. Financial Responsibilities 9 IV. Benefits Details 10 V. General Exclusions 41 VI. Eligibility, Enrollment and Termination 43 VII. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 XI. Subrogation and Reimbursement Rights 53 XII. Definitions 55
Appears in 1 contract
Samples: Group Medical Coverage Agreement
Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group Health’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16CA-1888a17, Group Health recommends each Member choose a personal physicianNetwork Personal Physician. This decision is important since the designated personal physician Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician Network Personal Physician who participates in one of the Group Health networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physicianNetwork Personal Physician, and for a list of the participating personal physiciansNetwork Personal Physicians, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health or from any other person (including a personal physicianNetwork Personal Physician) to access obstetrical or gynecological care from a health care professional in the Group Health network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000- 000-0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: All stages of reconstruction of the breast on which the mastectomy has been performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health will provide the information regarding the types of plans offered by Group Health to Members on request. Please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000.
I. Introduction 6 II. How Covered Services Work 6 III6
C. Confidentiality 8 D. Modification of the Benefits Booklet. 8 E. Nondiscrimination 8 F. Preauthorization 8 G. Recommended Treatment. 8 H. Second Opinions 8 I. Unusual Circumstances 9 J. Utilization Management. 9 A. Premium 9 B. Financial Responsibilities 9
IVfor Covered Services. 9 C. Financial Responsibilities for Non-Covered Services 10 Annual Deductible 11 Coinsurance 11 Lifetime Maximum 11 Out-of-pocket Limit 11 Pre-existing Condition Waiting Period 11 Acupuncture 12 Allergy Services 12 Ambulance 12 Cancer Screening and Diagnostic Services 12 Chemical Dependency 13 Circumcision 14 Clinical Trials 14 Dental Services and Dental Anesthesia 15 Devices, Equipment and Supplies (for home use) 15 Diabetic Education, Equipment and Pharmacy Supplies 16 Dialysis (Home and Outpatient) 16 Drugs - Outpatient Prescription 17 Emergency Services 19 Hearing Examinations and Hearing Aids 20 Home Health Care 20 Hospice 21 Hospital - Inpatient and Outpatient 22 Infertility (including sterility) 22 Infusion Therapy 23 Laboratory and Radiology 23 Manipulative Therapy 23 Maternity and Pregnancy 24 Mental Health 24 Naturopathy 25 Newborn Services 26 Nutritional Counseling 26 Nutritional Therapy 26 Obesity Related Services 27 On the Job Injuries or Illnesses 27 Oncology 27 Optical (vision) 28 Oral Surgery 29 Outpatient Services 30 Plastic and Reconstructive Surgery 30 Podiatry 30 Preventive Services 30 Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy 32 Sexual Dysfunction 32 Skilled Nursing Facility 33 Sterilization 33 Telemedicine 33 Temporomandibular Joint (TMJ) 34 Tobacco Cessation 34 Transgender Services 34 Transplants 35 Urgent Care 35 Virtual Care 35 A. Eligibility 37 B. Application for Enrollment. 38 C. When Coverage Begins 39 D. Eligibility for Medicare. 40 E. Termination of Coverage. 40 F. Continuation of Inpatient Services. 40 G. Continuation of Coverage Options 41 Definitions 45 Order of Benefit Determination Rules. 46 Effect on the Benefits Details 10 V. General Exclusions 41 VIof this Plan 48 Right to Receive and Release Needed Information 48 Facility of Payment. Eligibility, Enrollment and Termination 43 VII48 Right of Recovery 48 Effect of Medicare. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 XI. Subrogation and Reimbursement Rights 53
XII. Definitions 5548
Appears in 1 contract
Samples: Group Medical Coverage Agreement
Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health KFHPWA may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group HealthKFHPWA’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16Xxxxxx Foundation Health Plan of Washington CA-1888a18, Group Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a personal physicianNetwork Personal Physician. This decision is important since the designated personal physician Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician Network Personal Physician who participates in one of the Group Health KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physicianNetwork Personal Physician, and for a list of the participating personal physiciansNetwork Personal Physicians, please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000888-000901-00004636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health KFHPWA or from any other person (including a personal physicianNetwork Personal Physician) to access obstetrical or gynecological care from a health care professional in the Group Health KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000- 000-0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health KFHPWA will provide the information regarding the types of plans offered by Group Health KFHPWA to Members on request. Please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 11- 888-000901-000-00004636.
I. Introduction 6 II. How Covered Services Work 6 III6
C. Confidentiality 8 D. Modification of the Benefits Booklet. 8 E. Nondiscrimination 8 F. Preauthorization 8 G. Recommended Treatment. 9 H. Second Opinions 9 I. Unusual Circumstances 9 J. Utilization Management. 9 A. Premium 10 B. Financial Responsibilities 9
IVfor Covered Services. 10 C. Financial Responsibilities for Non-Covered Services 10 Annual Deductible 11 Coinsurance 11 Lifetime Maximum 11 Out-of-pocket Limit 11 Pre-existing Condition Waiting Period 11 Acupuncture 12 Allergy Services 12 Ambulance 12 Cancer Screening and Diagnostic Services 12 Chemical Dependency 13 Circumcision 14 Clinical Trials 14 Dental Services and Dental Anesthesia 15 Devices, Equipment and Supplies (for home use) 15 Diabetic Education, Equipment and Pharmacy Supplies 16 Dialysis (Home and Outpatient) 16 Drugs - Outpatient Prescription 17 Emergency Services 19 Hearing Examinations and Hearing Aids 20 Home Health Care 20 Hospice 21 Hospital - Inpatient and Outpatient 22 Infertility (including sterility) 23 Infusion Therapy 23 Laboratory and Radiology 23 Manipulative Therapy 23 Maternity and Pregnancy 24 Mental Health 24 Naturopathy 26 Newborn Services 26 Nutritional Counseling 26 Nutritional Therapy 27 Obesity Related Services 27 On the Job Injuries or Illnesses 27 Oncology 28 Optical (vision) 28 Oral Surgery 30 Outpatient Services 30 Plastic and Reconstructive Surgery 30 Podiatry 31 Preventive Services 31 Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy 32 Sexual Dysfunction 33 Skilled Nursing Facility 33 Sterilization 33 Telemedicine 34 Temporomandibular Joint (TMJ) 34 Tobacco Cessation 34 Transgender Services 35 Transplants 35 Urgent Care 35 Virtual Care 36 A. Eligibility 38 B. Application for Enrollment. 38 C. When Coverage Begins 40 D. Eligibility for Medicare. 40 E. Termination of Coverage. 40 F. Continuation of Inpatient Services. 41 G. Continuation of Coverage Options 41 Definitions 45 Order of Benefit Determination Rules. 47 Effect on the Benefits Details 10 V. General Exclusions 41 VIof this Plan 48 Right to Receive and Release Needed Information 48 Facility of Payment. Eligibility, Enrollment and Termination 43 VII48 Right of Recovery 48 Effect of Medicare. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 XI. Subrogation and Reimbursement Rights 53
XII. Definitions 5549
Appears in 1 contract
Samples: Group Medical Coverage Agreement
Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health KFHPWA may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group HealthKFHPWA’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16Xxxxxx Foundation Health Plan of Washington CA-1888a17r, Group Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a personal physicianNetwork Personal Physician. This decision is important since the designated personal physician Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician Network Personal Physician who participates in one of the Group Health KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physicianNetwork Personal Physician, and for a list of the participating personal physiciansNetwork Personal Physicians, please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000888-000901-00004636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health KFHPWA or from any other person (including a personal physicianNetwork Personal Physician) to access obstetrical or gynecological care from a health care professional in the Group Health KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000- 000-0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: All stages of reconstruction of the breast on which the mastectomy has been performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health KFHPWA will provide the information regarding the types of plans offered by Group Health KFHPWA to Members on request. Please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 11- 888-000901-000-00004636.
I. Introduction 6 II. How Covered Services Work 6 III6
C. Confidentiality 8 D. Modification of the Benefits Booklet. 8 E. Nondiscrimination 8 F. Preauthorization 8 G. Recommended Treatment. 8 H. Second Opinions 8 I. Unusual Circumstances 9 J. Utilization Management. 9 A. Premium 9 B. Financial Responsibilities 9
IVfor Covered Services. 9 C. Financial Responsibilities for Non-Covered Services 10 Annual Deductible 11 Coinsurance 11 Lifetime Maximum 11 Out-of-pocket Limit 11 Pre-existing Condition Waiting Period 11 Acupuncture 12 Allergy Services 12 Ambulance 12 Cancer Screening and Diagnostic Services 12 Chemical Dependency 13 Circumcision 14 Clinical Trials 14 Dental Services and Dental Anesthesia 15 Devices, Equipment and Supplies (for home use) 15 Diabetic Education, Equipment and Pharmacy Supplies 16 Dialysis (Home and Outpatient) 17 Drugs - Outpatient Prescription 17 Emergency Services 20 Hearing Examinations and Hearing Aids 20 Home Health Care 21 Hospice 21 Hospital - Inpatient and Outpatient 22 Infertility (including sterility) 23 Infusion Therapy 23 Laboratory and Radiology 23 Manipulative Therapy 24 Maternity and Pregnancy 24 Mental Health 25 Naturopathy 26 Newborn Services 26 Nutritional Counseling 27 Nutritional Therapy 27 Obesity Related Services 27 On the Job Injuries or Illnesses 28 Oncology 28 Optical (vision) 28 Oral Surgery 29 Outpatient Services 29 Plastic and Reconstructive Surgery 30 Podiatry 30 Preventive Services 30 Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy 31 Sexual Dysfunction 32 Skilled Nursing Facility 32 Sterilization 33 Telemedicine 33 Temporomandibular Joint (TMJ) 34 Tobacco Cessation 34 Transgender Services 34 Transplants 35 Urgent Care 35 Virtual Care 36 A. Eligibility 37 B. Application for Enrollment. 38 C. When Coverage Begins 39 D. Eligibility for Medicare. 40 E. Termination of Coverage. 40 F. Continuation of Inpatient Services. 41 G. Continuation of Coverage Options 41 Definitions. 45 Order of Benefit Determination Rules. 46 Effect on the Benefits Details 10 V. General Exclusions 41 VIof this Plan 48 Right to Receive and Release Needed Information 48 Facility of Payment. Eligibility, Enrollment and Termination 43 VII48 Right of Recovery 48 Effect of Medicare. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 XI. Subrogation and Reimbursement Rights 53
XII. Definitions 5548
Appears in 1 contract
Samples: Group Medical Coverage Agreement
Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health KFHPWA may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group HealthKFHPWA’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16, Group Xxxxxx Foundation Health Plan of Washington 1258EID2017c Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a personal physicianNetwork Personal Physician. This decision is important since the designated personal physician Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician Network Personal Physician who participates in one of the Group Health KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physicianNetwork Personal Physician, and for a list of the participating personal physiciansNetwork Personal Physicians, please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000888-000901-00004636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health KFHPWA or from any other person (including a personal physicianNetwork Personal Physician) to access obstetrical or gynecological care from a health care professional in the Group Health KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000- 000-0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: All stages of reconstruction of the breast on which the mastectomy has been performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health KFHPWA will provide the information regarding the types of plans offered by Group Health KFHPWA to Members on request. Please call the Group Health Customer Service Center Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 11- 888-000901-000-00004636.
I. Introduction 6 II. How Covered Services Work 6 III6
C. Confidentiality 8 D. Modification of the Benefits Booklet. 8 E. Nondiscrimination 8 F. Preauthorization 8 G. Recommended Treatment. 8 H. Second Opinions 8 I. Unusual Circumstances 9 J. Utilization Management. 9 A. Premium 9 B. Financial Responsibilities 9for Covered Services. 9 C. Financial Responsibilities for Non-Covered Services 10 Annual Deductible 11 Coinsurance 11 Lifetime Maximum 11 Out-of-pocket Limit 11 Pre-existing Condition Waiting Period 11 Acupuncture 12 Allergy Services 12 Ambulance 12 Cancer Screening and Diagnostic Services 12 Chemical Dependency 12 Circumcision 14 Clinical Trials 14 Dental Services and Dental Anesthesia 14 Devices, Equipment and Supplies (for home use) 15 Diabetic Education, Equipment and Pharmacy Supplies 16 Dialysis (Home and Outpatient) 16 Drugs - Outpatient Prescription 17 Emergency Services 19 Hearing Examinations and Hearing Aids 20 Home Health Care 20 Hospice 21 Hospital - Inpatient and Outpatient 22 Infertility (including sterility) 23 Infusion Therapy 23 Laboratory and Radiology 23 Manipulative Therapy 24 Maternity and Pregnancy 24 Mental Health 24 Naturopathy 26 Newborn Services 26 Nutritional Counseling 26 Nutritional Therapy 26 Obesity Related Services 27 On the Job Injuries or Illnesses 27 Oncology 28 Optical (vision) 28 Oral Surgery 29 Outpatient Services 30 Plastic and Reconstructive Surgery 30 Podiatry 30 Preventive Services 31 Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy 32 Sexual Dysfunction 33 Skilled Nursing Facility 33 Sterilization 33 Telemedicine 34 Temporomandibular Joint (TMJ) 34 Tobacco Cessation 34 Transgender Services 34 Transplants 35 Urgent Care 35 Virtual Care 36 A. Eligibility 37 B. Application for Enrollment. 38 C. When Coverage Begins 39 D. Eligibility for Medicare. 40 E. Termination of Coverage. 40 F. Continuation of Inpatient Services. 41 G. Continuation of Coverage Options 41
IV. Benefits Details 10 V. General Exclusions 41 VI. Eligibility, Enrollment and Termination 43 VII. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 44 XI. Subrogation and Reimbursement Rights 53
XII. Definitions 5549
Appears in 1 contract
Samples: Group Medical Coverage Agreement
Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group Health’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16CA-1888a16, Group Health recommends each Member choose a personal physicianNetwork Personal Physician. This decision is important since the designated personal physician Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician Network Personal Physician who participates in one of the Group Health networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physicianNetwork Personal Physician, and for a list of the participating personal physiciansNetwork Personal Physicians, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health or from any other person (including a personal physicianNetwork Personal Physician) to access obstetrical or gynecological care from a health care professional in the Group Health network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000- 000-0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: All stages of reconstruction of the breast on which the mastectomy has been performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health will provide the information regarding the types of plans offered by Group Health to Members on request. Please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000.
I. Introduction 6 II. How Covered Services Work 6 III6
C. Confidentiality 8 D. Modification of the Benefits Booklet. 8 E. Nondiscrimination 8 F. Preauthorization 8 G. Recommended Treatment. 8 H. Second Opinions 8 I. Unusual Circumstances 9 J. Utilization Management. 9 A. Premium 9 B. Financial Responsibilities 9for Covered Services. 9 C. Financial Responsibilities for Non-Covered Services 10 Annual Deductible 11 Coinsurance 11 Lifetime Maximum 11 Out-of-pocket Limit 11 Pre-existing Condition Waiting Period 11 Acupuncture 12 Allergy Services 12 Ambulance 12 Cancer Screening and Diagnostic Services 12 Chemical Dependency 13 Circumcision 14 Clinical Trials 14 Dental Services and Dental Anesthesia 14 Devices, Equipment and Supplies (for home use) 15 Diabetic Education, Equipment and Pharmacy Supplies 16 Dialysis (Home and Outpatient) 16 Drugs - Outpatient Prescription 17 Emergency Services 19 Hearing Examinations and Hearing Aids 20 Home Health Care 20 Hospice 21 Hospital - Inpatient and Outpatient 22 Infertility (including sterility) 23 Infusion Therapy 23 Laboratory and Radiology 23 Manipulative Therapy 23 Maternity and Pregnancy 24 Mental Health 24 Naturopathy 26 Newborn Services 26 Nutritional Counseling 26 Nutritional Therapy 27 Obesity Related Services 27 On the Job Injuries or Illnesses 27 Oncology 28 Optical (vision) 28 Oral Surgery 29 Outpatient Services 29 Plastic and Reconstructive Surgery 29 Podiatry 30 Preventive Services 30 Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy 31 Sexual Dysfunction 32 Skilled Nursing Facility 32 Sterilization 32 Telehealth 33 Temporomandibular Joint (TMJ) 33 Tobacco Cessation 34 Transgender Services 34 Transplants 34 Urgent Care 35 A. Eligibility 37 B. Application for Enrollment. 38 C. When Coverage Begins 39 D. Eligibility for Medicare. 39 E. Termination of Coverage. 40 F. Continuation of Inpatient Services. 40 G. Continuation of Coverage Options 40
IV. Benefits Details 10 V. General Exclusions 41 VI. Eligibility, Enrollment and Termination 43 VII. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 44 XI. Subrogation and Reimbursement Rights 53
48 XII. Definitions 5549
Appears in 1 contract
Samples: Group Medical Coverage Agreement
Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group Health’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16CA-2563a17, C427626512200 Group Health recommends each Member choose a personal physicianNetwork Personal Physician. This decision is important since the designated personal physician Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician Network Personal Physician who participates in one of the Group Health networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physicianNetwork Personal Physician, and for a list of the participating personal physiciansNetwork Personal Physicians, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health or from any other person (including a personal physicianNetwork Personal Physician) to access obstetrical or gynecological care from a health care professional in the Group Health network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000- 000-0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health will provide the information regarding the types of plans offered by Group Health to Members on request. Please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000.
I. Introduction 6 II. How Covered Services Work 6 III6
C. Confidentiality 8 D. Modification of the Benefits Booklet. 8 E. Nondiscrimination 8 F. Preauthorization 9 G. Recommended Treatment. 9 H. Second Opinions 9 I. Unusual Circumstances 9 J. Utilization Management. 9 A. Premium 10 B. Financial Responsibilities 9for Covered Services. 10 C. Financial Responsibilities for Non-Covered Services 10 Annual Deductible 11 Coinsurance 11 Lifetime Maximum 11 Out-of-pocket Limit 11 Pre-existing Condition Waiting Period 11 Acupuncture 12 Allergy Services 12 Ambulance 12 Cancer Screening and Diagnostic Services 12 Chemical Dependency 13 Circumcision 14 Clinical Trials 14 Dental Services and Dental Anesthesia 15 Devices, Equipment and Supplies (for home use) 15 Diabetic Education, Equipment and Pharmacy Supplies 16 Dialysis (Home and Outpatient) 17 Drugs - Outpatient Prescription 18 Emergency Services 20 Hearing Examinations and Hearing Aids 21 Home Health Care 21 Hospice 22 Hospital - Inpatient and Outpatient 23 Infertility (including sterility) 24 Infusion Therapy 24 Laboratory and Radiology 24 Manipulative Therapy 25 Maternity and Pregnancy 25 Mental Health 26 Naturopathy 27 Newborn Services 27 Nutritional Counseling 27 Nutritional Therapy 28 Obesity Related Services 28 On the Job Injuries or Illnesses 28 Oncology 29 Optical (vision) 29 Oral Surgery 30 Outpatient Services 30 Plastic and Reconstructive Surgery 31 Podiatry 31 Preventive Services 31 Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy 32 Sexual Dysfunction 33 Skilled Nursing Facility 33 Sterilization 34 Telemedicine 34 Temporomandibular Joint (TMJ) 35 Tobacco Cessation 35 Transgender Services 35 Transplants 36 Urgent Care 36 Virtual Care 37 A. Eligibility 39 B. Application for Enrollment. 39 C. When Coverage Begins 41 D. Eligibility for Medicare. 41 E. Termination of Coverage. 41 F. Continuation of Inpatient Services. 42 G. Continuation of Coverage Options 42 Definitions 46 Order of Benefit Determination Rules. 47 Effect on the Benefits of this Plan 49 Right to Receive and Release Needed Information 49 Facility of Payment. 49 Right of Recovery 49 Effect of Medicare. 50
IVI. Introduction This Benefits Booklet is a statement of benefits, exclusions and other provisions as set forth in the Group medical coverage agreement between Group Health Options, Inc. (“Group Health”) and the Group. The benefits were approved by the Group who contracts with Group Health for health care coverage. This Benefits Details 10 V. General Exclusions 41 VIBooklet is not the Group medical coverage agreement itself. EligibilityIn the event of a conflict between the Group medical coverage agreement and the benefits booklet, Enrollment the benefits booklet language will govern. The provisions of the Benefits Booklet must be considered together to fully understand the benefits available under the Benefits Booklet. Words with special meaning are capitalized and Termination 43 VII. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 XI. Subrogation and Reimbursement Rights 53
are defined in Section XII. Definitions 55Contact Group Health Customer Service at 000-000-0000 or toll-free 0-000-000-0000 for benefits questions.
II. How Covered Services Work
Appears in 1 contract
Samples: Group Medical Coverage Agreement
Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group Health’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16CA-1888a17, Group Health recommends each Member choose a personal physicianNetwork Personal Physician. This decision is important since the designated personal physician Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician Network Personal Physician who participates in one of the Group Health networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physicianNetwork Personal Physician, and for a list of the participating personal physiciansNetwork Personal Physicians, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health or from any other person (including a personal physicianNetwork Personal Physician) to access obstetrical or gynecological care from a health care professional in the Group Health network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000- 000-0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health will provide the information regarding the types of plans offered by Group Health to Members on request. Please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000.
I. Introduction 6 II. How Covered Services Work 6 III6
C. Confidentiality 8 D. Modification of the Benefits Booklet. 8 E. Nondiscrimination 8 F. Preauthorization 8 G. Recommended Treatment. 8 H. Second Opinions 8 I. Unusual Circumstances 9 J. Utilization Management. 9 A. Premium 9 B. Financial Responsibilities 9
IVfor Covered Services. 9 C. Financial Responsibilities for Non-Covered Services 10 Annual Deductible 11 Coinsurance 11 Lifetime Maximum 11 Out-of-pocket Limit 11 Pre-existing Condition Waiting Period 11 Acupuncture 12 Allergy Services 12 Ambulance 12 Cancer Screening and Diagnostic Services 12 Chemical Dependency 13 Circumcision 14 Clinical Trials 14 Dental Services and Dental Anesthesia 15 Devices, Equipment and Supplies (for home use) 15 Diabetic Education, Equipment and Pharmacy Supplies 16 Dialysis (Home and Outpatient) 17 Drugs - Outpatient Prescription 17 Emergency Services 20 Hearing Examinations and Hearing Aids 20 Home Health Care 21 Hospice 21 Hospital - Inpatient and Outpatient 22 Infertility (including sterility) 23 Infusion Therapy 23 Laboratory and Radiology 23 Manipulative Therapy 24 Maternity and Pregnancy 24 Mental Health 25 Naturopathy 26 Newborn Services 26 Nutritional Counseling 27 Nutritional Therapy 27 Obesity Related Services 27 On the Job Injuries or Illnesses 28 Oncology 28 Optical (vision) 28 Oral Surgery 30 Outpatient Services 30 Plastic and Reconstructive Surgery 31 Podiatry 31 Preventive Services 31 Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy 32 Sexual Dysfunction 33 Skilled Nursing Facility 33 Sterilization 34 Telemedicine 34 Temporomandibular Joint (TMJ) 35 Tobacco Cessation 35 Transgender Services 35 Transplants 36 Urgent Care 36 Virtual Care 37 A. Eligibility 38 B. Application for Enrollment. 39 C. When Coverage Begins 40 D. Eligibility for Medicare. 41 E. Termination of Coverage. 41 F. Continuation of Inpatient Services. 42 G. Continuation of Coverage Options 42 Definitions 46 Order of Benefit Determination Rules. 47 Effect on the Benefits Details 10 V. General Exclusions 41 VIof this Plan 49 Right to Receive and Release Needed Information 49 Facility of Payment. Eligibility, Enrollment and Termination 43 VII49 Right of Recovery 49 Effect of Medicare. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 XI. Subrogation and Reimbursement Rights 53
XII. Definitions 5549
Appears in 1 contract
Samples: Group Medical Coverage Agreement
Limitation on Enrollment. The Agreement will be open for applications for enrollment as described in the group master application. Subject to prior approval by the Washington State Office of the Insurance Commissioner, Group Health may limit enrollment, establish quotas or set priorities for acceptance of new applications if it determines that Group Health’s capacity, in relation to its total enrollment, is not adequate to provide services to additional persons. CA-3962a16CA-2563a17, C427636512300 Group Health recommends each Member choose a personal physicianNetwork Personal Physician. This decision is important since the designated personal physician Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any personal physician Network Personal Physician who participates in one of the Group Health networks and who is available to accept the Member or the Member’s family members. For information on how to select a personal physicianNetwork Personal Physician, and for a list of the participating personal physiciansNetwork Personal Physicians, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from Group Health or from any other person (including a personal physicianNetwork Personal Physician) to access obstetrical or gynecological care from a health care professional in the Group Health network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000- 000-0000. If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: All stages of reconstruction of the breast on which the mastectomy has been performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Benefits Booklet. Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. Group Health will provide the information regarding the types of plans offered by Group Health to Members on request. Please call the Group Health Customer Service Center at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000.
I. Introduction 6 II. How Covered Services Work 6 III6
C. Confidentiality 8 D. Modification of the Benefits Booklet. 8 E. Nondiscrimination 8 F. Preauthorization 9 G. Recommended Treatment. 9 H. Second Opinions 9 I. Unusual Circumstances 9 J. Utilization Management. 9 A. Premium 10 B. Financial Responsibilities 9for Covered Services. 10 C. Financial Responsibilities for Non-Covered Services 10 Annual Deductible 11 Coinsurance 11 Lifetime Maximum 11 Out-of-pocket Limit 11 Pre-existing Condition Waiting Period 11 Acupuncture 12 Allergy Services 12 Ambulance 12 Cancer Screening and Diagnostic Services 12 Chemical Dependency 13 Circumcision 14 Clinical Trials 14 Dental Services and Dental Anesthesia 15 Devices, Equipment and Supplies (for home use) 15 Diabetic Education, Equipment and Pharmacy Supplies 16 Dialysis (Home and Outpatient) 17 Drugs - Outpatient Prescription 18 Emergency Services 20 Hearing Examinations and Hearing Aids 21 Home Health Care 21 Hospice 22 Hospital - Inpatient and Outpatient 23 Infertility (including sterility) 24 Infusion Therapy 24 Laboratory and Radiology 24 Manipulative Therapy 25 Maternity and Pregnancy 25 Mental Health 26 Naturopathy 27 Newborn Services 27 Nutritional Counseling 27 Nutritional Therapy 28 Obesity Related Services 28 On the Job Injuries or Illnesses 28 Oncology 29 Optical (vision) 29 Oral Surgery 30 Outpatient Services 30 Plastic and Reconstructive Surgery 31 Podiatry 31 Preventive Services 31 Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy 32 Sexual Dysfunction 33 Skilled Nursing Facility 33 Sterilization 34 Telemedicine 34 Temporomandibular Joint (TMJ) 35 Tobacco Cessation 35 Transgender Services 35 Transplants 36 Urgent Care 36 Virtual Care 37 A. Eligibility 39 B. Application for Enrollment. 39 C. When Coverage Begins 41 D. Eligibility for Medicare. 41 E. Termination of Coverage. 41 F. Continuation of Inpatient Services. 42 G. Continuation of Coverage Options 42 Definitions 46 Order of Benefit Determination Rules. 47 Effect on the Benefits of this Plan 49 Right to Receive and Release Needed Information 49 Facility of Payment. 49 Right of Recovery 49 Effect of Medicare. 50
IVI. Introduction This Benefits Booklet is a statement of benefits, exclusions and other provisions as set forth in the Group medical coverage agreement between Group Health Options, Inc. (“Group Health”) and the Group. The benefits were approved by the Group who contracts with Group Health for health care coverage. This Benefits Details 10 V. General Exclusions 41 VIBooklet is not the Group medical coverage agreement itself. EligibilityIn the event of a conflict between the Group medical coverage agreement and the benefits booklet, Enrollment the benefits booklet language will govern. The provisions of the Benefits Booklet must be considered together to fully understand the benefits available under the Benefits Booklet. Words with special meaning are capitalized and Termination 43 VII. Grievances 47 VIII. Appeals 48 IX. Claims 49 X. Coordination of Benefits 49 XI. Subrogation and Reimbursement Rights 53
are defined in Section XII. Definitions 55Contact Group Health Customer Service at 206-901-4636 or toll-free 1-000-000-0000 for benefits questions.
II. How Covered Services Work
Appears in 1 contract
Samples: Group Medical Coverage Agreement
