Medically Necessary In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Contract.
Non-Medical, Personalized Services The Practice shall also provide Members with the following non-medical services:
Dependent Care Assistance Program The County offers the option of enrolling in a Dependent Care Assistance Program (DCAP) designed to qualify for tax savings under Section 129 of the Internal Revenue Code, but such savings are not guaranteed. The program allows employees to set aside up to five thousand dollars ($5,000) of annual salary (before taxes) per calendar year to pay for eligible dependent care (child and elder care) expenses. Any unused balance is forfeited and cannot be recovered by the employee.
Medical Plan Eligible employees and dependants shall be covered by the British Columbia Medical Services Plan or carrier approved by the British Columbia Medical Services Commission. The Employer shall pay one hundred percent (100%) of the premium. An eligible employee who wishes to have coverage for other than dependants may do so provided the Medical Plan is agreeable and the extra premium is paid by the employee through payroll deduction. Membership shall be a condition of employment for eligible employees who shall be enrolled for coverage following the completion of three (3) months’ employment or upon the initial date of employment for those employees with portable service as outlined in Article 14.12.
Other Fringe Benefits During the Employment Period, Executive shall be entitled to receive such of the Company’s other fringe benefits as are being provided to other Executives of the Company on the Senior Executive Team.
Programs to Keep You Healthy Many health problems can be prevented by making positive changes to your lifestyle, including exercising regularly, eating a healthy diet, and not smoking. As a member, you can take advantage of our wellness programs at no additional cost. We offer wellness programs to our members from time to time. These programs include, but are not limited to: • online and in-person educational programs; • health assessments; • coaching; • biometric screenings, such as cholesterol or body mass index; • discounts We may provide incentives for you to participate in these programs. These incentives may include credits toward premium, and a reduction or waiver of deductible and/or copayments for certain covered healthcare services, as permitted by applicable state and federal law. For the subscriber of the plan, wellness incentives may also include rewards, which may take the form of cash or cash equivalents such as gift cards, discounts, and others. These rewards may be taxable income. Additional information is available on our website. Your participation in a wellness program may make your employer eligible for a group wellness incentive award. Your participation in our wellness programs is voluntary. We reserve the right to end wellness programs at any time. From time to time, we may offer you coupons, discounts, or other incentives as part of our member incentives program. These coupons, discounts and incentives are not benefits and do not change or affect your benefits under this plan. You must be a member to be eligible for member incentives. Restrictions may apply to these incentives, and we reserve the right to change or stop providing member incentives at any time. Care coordination gives you access to dedicated BCBSRI healthcare professionals, including nurses, dietitians, behavioral health providers, and community resources specialists. These care coordinators can help you set and meet your health goals. You can receive support for many health issues, including, but not limited to: • making the most of your physician’s visits; • navigating through the healthcare system; • managing medications or addressing side effects; • better understanding new or pre-existing medical conditions; • completing preventive screenings; • losing weight. Care Coordination is a personalized service that is part of your existing healthcare coverage and is available at no additional cost to you. For more information, please call (000) 000-XXXX (2273) or visit our website. If you have a chronic condition such as asthma, coronary heart disease, diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, we’re here to help. Our tools and information can help you manage your condition and improve your health. You may also be eligible to receive help through our care coordination program. This voluntary program is available at no additional cost you. To learn more about disease management, please call (000) 000-0000 or 0-000-000-0000. Our entire contract with you consists of this agreement and our contract with your employer. Your ID card will identify you as a member when you receive the healthcare services covered under this agreement. By presenting your ID card to receive covered healthcare services, you are agreeing to abide by the rules and obligations of this agreement. Your eligibility for benefits is determined under the provisions of this agreement. Your right to appeal and take action is described in Appeals in Section 5. This agreement describes the benefits, exclusions, conditions and limitations provided under your plan. It shall be construed under and shall be governed by the applicable laws and regulations of the State of Rhode Island and federal law as amended from time to time. It replaces any agreement previously issued to you. If this agreement changes, an amendment or new agreement will be provided.
Orthodontics We Cover orthodontics used to help restore oral structures to health and function and to treat serious medical conditions such as: cleft palate and cleft lip; maxillary/mandibular micrognathia (underdeveloped upper or lower jaw); extreme mandibular prognathism; severe asymmetry (craniofacial anomalies); ankylosis of the temporomandibular joint; and other significant skeletal dysplasias.
Prosthodontics We Cover prosthodontic services as follows:
Leave Donation Program Employees may donate paid leave to a fellow employee who is otherwise eligible to accrue and use sick leave and is employed by the same Agency. The intent of the leave donation program is to allow employees to voluntarily provide assistance to their co-workers who are in critical need of leave due to the serious illness or injury of the employee or a member of the employee's immediate family. The definition of immediate family as provided in rule 123:1-47-01 of the Administrative Code shall apply for the leave donation program.
A. An employee may receive donated leave, up to the number of hours the employee is scheduled to work each pay period, if the employee who is to receive donated leave:
1. Or a member of the employee's immediate family has a serious illness or injury;
2. Has no accrued leave or has not been approved to receive other state-paid benefits; and
3. Has applied for any paid leave, workers' compensation, or benefits program for which the employee is eligible. Employees who have applied for these programs may use donated leave to satisfy the waiting period for such benefits where applicable, and donated leave may be used following a waiting period, if one exists, in an amount equal to the benefit provided by the program, i.e. fifty six hours (56) pay period may be utilized by an employee who has satisfied the disability waiting period and is pending approval, this is equal to the seventy percent (70%) benefit provided by disability.
B. Employees may donate leave if the donating employee:
1. Voluntarily elects to donate leave and does so with the understanding that donated leave will not be returned;
2. Donates a minimum of eight hours; and
3. Retains a combined leave balance of at least eighty hours. Leave shall be donated in the same manner in which it would otherwise be used except that compensatory time is not eligible for donation.
C. The leave donation program shall be administered on a pay period by pay period basis. Employees using donated leave shall be considered in active pay status and shall accrue leave and be entitled to any benefits to which they would otherwise be entitled. Leave accrued by an employee while using donated leave shall be used, if necessary, in the following pay period before additional donated leave may be received. Donated leave shall not count toward the probationary period of an employee who receives donated leave during his or her probationary period. Donated leave shall be considered sick leave, but shall never be converted into a cash benefit.
D. Employees who wish to donate leave shall certify:
1. The name of the employee for whom the donated leave is intended;
2. The type of leave and number of hours to be donated;
3. That the employee will have a minimum combined leave balance of at least eighty hours; and
4. That the leave is donated voluntarily and the employee understands that the donated leave will not be returned.
E. Appointing authorities shall ensure that no employees are forced to donate leave. Appointing authorities shall respect an employee's right to privacy, however appointing authorities may, with the permission of the employee who is in need of leave or a member of the employee's immediate family, inform employees of their co-worker's critical need for leave. Appointing authorities shall not directly solicit leave donations from employees. The donation of leave shall occur on a strictly voluntary basis.
Outpatient If you receive infusion therapy services in a hospital's outpatient unit, we cover the use of the treatment room, related supplies, and solutions. For prescription drug coverage, see Section 3.27
