Missed Appointment Fee. If you cannot keep a scheduled medical appointment, please notify your health care professional’s office at least one day prior to the appointment. If you fail to cancel your appointment, you may be responsible for the payment of an administrative fee for the missed appointment. The fee for a missed appointment at a Plan Medical Center is shown in the Appendix - Summary of Services and Cost Shares section of this EOC. The fee will not count toward your Deductible or Out of Pocket Maximum. Using Your Identification Card Each Member has a Health Plan ID card with a Medical Record Number on it to use when you call for advice, make an appointment, or go to a Plan Provider for care. The Medical Record Number is used to identify your medical records and membership information. You should always have the same Medical Record Number. If you need to replace your card, or if we ever inadvertently issue you more than one Medical Record Number, please let us know by calling our Member Services Department in the Washington, D.C., Metropolitan area at (000) 000-0000, or in the Baltimore, Maryland Metropolitan Area at 0-000-000-0000. Our TTY is (000) 000-0000. Your ID card is for identification only. You will be issued a Health Plan ID card that will serve as evidence of your membership status. In addition to your Health Plan ID card, you may be asked to show a valid photo ID at your medical appointments. Allowing another person to use your card will result in forfeiture of your membership card and may result in termination of your membership. Visiting Other Xxxxxx Permanente Regions or Group Health Cooperative Service Areas If you visit a different Xxxxxx Permanente or Group Health Cooperative service area temporarily (not more than 90 days), you can receive visiting member care from designated providers in that area. The covered Services, Copayments, Coinsurance and Deductibles may differ from those in this Service Area, and are governed by the Xxxxxx Permanente program for visiting members. This program does not cover certain Services, such as transplant Services or infertility Services. Also, except for out-of-Plan Emergency Services, your right to receive covered Services in the visited service area ends after 90 days unless you receive prior written authorization from us to continue receiving covered Services in the visited service area. The 90-day limit on visiting member care does not apply to a Member who attends an accredited college or accredited vocational school. To receive more information about visiting member Services, including facility locations across the United States, you may call our Member Services Department at: Inside the Washington, D.C. Metropolitan Area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan Area 0-000-000-0000 Service areas and facilities where you may obtain visiting member care may change at any time. The following visiting member care is covered when it is provided or arranged by a Plan Physician in the visited service area. The benefits may not be the same as those you receive in your home service area. Hospital Inpatient Care: Physician Services Room and board Necessary Services and supplies Maternity Services Prescription drugs Outpatient Care: Office visits Outpatient surgery Physical, speech and occupational therapy (up to 20 visits for physical therapy per incident; up to two months for occupational and speech therapy) Allergy tests and allergy injections Dialysis care Laboratory and X-Ray: Covered in or out of the hospital Outpatient Prescription Drugs: Covered only if you have an outpatient prescription drug benefit (regular home Service Area Copayments, Coinsurance, Deductibles, exclusions and limitations apply) Mental Health Services Other than for Emergency or Urgent Care services: Outpatient visits and inpatient hospital days Substance Abuse Treatment Other than for Emergency or Urgent Care services: Inpatient and outpatient medical detoxification and other outpatient visits Skilled Nursing Facility Care: Up to 100 days per calendar year Home Health Care: Home health care Services inside the visited service area Hospice Care: Home-based hospice care inside the visited service area Pre-Authorization Required for Certain Services The following Services require preauthorization from your home Service Area while you are visiting another Xxxxxx Permanente or Group Health Cooperative service area: Inpatient physical rehabilitation Any other Service that would require pre- authorization in your home Service Area In addition, some Services require pre-authorization from the visited region or service area. Please contact Member Services in the other Xxxxxx Permanente region or Group Health Cooperative (GHC) service area, once you have obtained pre- authorization from your home region or GHC service area. Visiting Member Service Exclusions The following Services are not covered under your visiting member benefits. (“Services” include equipment and supplies.) However, some of these Services, such as Emergency Services, may be covered under your home Service Area benefits, and applicable Copayments, Coinsurance and/or Deductibles will apply. For coverage information, refer to the “Benefits” section of this EOC. Services that are not Medically Necessary Physical examinations and related Services for insurance, employment, or licensing Drugs for the treatment of sexual dysfunction disorders Dental care and dental X-rays Services to reverse voluntary infertility Infertility Services Services related to conception by artificial means, such as IVF and GIFT Experimental Services and all clinical trials Cosmetic surgery or other Services primarily to change appearance Custodial care and care provided in an intermediate care facility Services related to sexual reassignment Transplants and related care Complementary and alternative medicine Services, such as chiropractic Services Services received as a result of a written referral from a Plan provider in your home service area Emergency Services, including emergency ambulance Services Services that are excluded or limited in your home Service Area Moving to Another Xxxxxx Permanente or Group Health Cooperative Service Area If you move to another Xxxxxx Permanente or Group Health Cooperative service area, you may be able to transfer your Group membership if there is an arrangement with your Group in the new service area. However, eligibility requirements, benefits, Premium, Copayments, Coinsurance and Deductibles may not be the same in the other service area. You should contact your Group’s employee benefits coordinator before you move. Value Added Services Health Plan makes available a variety of value added services to its Members in order to aid Members in their quest for better health by providing access to additional services, which may not be covered under this plan. Examples may include discounted eyewear, non-covered health education classes and publications, discounted fitness club memberships, health promotion and wellness programs and rewards for participating in those programs. Some of these value added services are available to all Members and others may be available only to Members enrolled in certain groups and/or plans. To take advantage of these services, a Member need only identify himself/herself as a Health Plan Member by showing his/her ID card and paying the fee, if any, at the time of service. Because these value added services are not covered Services, any fees you pay will not accrue to any coverage calculations, such as deductibles and out-of-pocket maximum calculations. For information concerning these services, including which ones are available to you, you may contact our Member Services Department at: Inside the Washington, D.C., Metropolitan area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000 Our Member Services Representatives are available to assist you Monday through Friday from 7:30 a.m. until 9:00 p.m. These value added services are neither offered nor guaranteed under your Health Plan coverage. Some of these services may be provided by entities other than the Health Plan. We may change or discontinue some or all of these services at any time. These value added services are not offered as an inducement to purchase a health care plan from Health Plan. Although they are not covered Services, we may include their costs in the calculation of your Premium. Health Plan does not endorse or make any representations regarding the quality of such services or their medical efficacy, nor the financial integrity of the entities providing the value added services. The Health Plan expressly disclaims any liability for these services provided by these entities. If you have a dispute regarding these products or services, you must resolve it with the entity offering the product or service. Although we have no obligation to assist with such resolution, should a problem arise with any of these products or services, you may call the Member Services Call Center, and the Health Plan may try to assist in getting the issue resolved.
Appears in 2 contracts
Samples: Group Agreement, Your Group Agreement
Missed Appointment Fee. If you cannot keep a scheduled medical appointment, please notify your health care professional’s office at least one day prior to the appointment. If you fail to cancel your appointment, you may be responsible for the payment of an administrative fee for the missed appointment. The fee for a missed appointment at a Plan Medical Center is shown in the Appendix - Summary of Services and Cost Shares section of this EOCthe Appendix. The This fee will not count toward your Deductible or Out of Pocket MaximumCopayment if applicable. Using Your Identification Card Each Member has a Health Plan ID card with a Medical Record Number on it to use when you call for advice, make an appointment, or go to a Plan Provider for care. The Medical Record Number is used to identify your medical records and membership information. You should always have the same Medical Record Number. If you need to replace your card, or if we ever inadvertently issue you more than one Medical Record Number, please let us know by calling our Member Services Department in the Washington, D.C., Metropolitan area at (000) -000-0000, or in the Baltimore, Maryland Metropolitan Area at 0-000-000-0000. Our TTY TYY is (000) 000-0000000-0 380. Your ID card is for identification only. You will be issued a Health Plan ID Kaiser Membership card that will serve as evidence of your membership status. In addition to your Health Plan ID Membership card, you may be asked to show a valid photo ID at your medical appointments. Allowing another person to use your Membership card will result in forfeiture of your membership card and may result in termination of your membership. Visiting Other Xxxxxx Permanente Regions or Group Health Cooperative Service Areas If you visit a different Xxxxxx Permanente Region or Group Health Cooperative service area temporarily (not more than 90 days), you can receive visiting member care from designated providers in that area. The covered Services, Copayments, Coinsurance and Deductibles may differ from those in this Service Area, and are governed by the Xxxxxx Permanente program for visiting members. This program does not cover certain Services, such as transplant Services or infertility Services. Also, except for outOut-of-Plan Emergency Services, your right to receive covered Services in the visited service area ends after 90 days unless you receive prior written authorization from us to continue receiving covered Services in the visited service area. The 90-day limit on visiting member care does not apply to a Member Members who attends attend an accredited college or accredited vocational school. To receive more information about visiting member Services, including facility locations across the United States, you may call our Member Services Department atDepartment: Inside the Washington, D.C. Metropolitan Area (000) -000-0000 TTY (TYY 000) -000-0000 Outside the Washington, D.C. Metropolitan Area 0-000-000-0000 Service areas and facilities where you may obtain visiting member care may change at any time. The following visiting member care is covered when it is provided or arranged by a Plan Physician in the visited service area. The benefits may not be the same as those you receive in your home service area. Except for outpatient prescription drugs, these benefits are provided at no charge to you. Hospital Inpatient Care: • Physician Services • Room and board • Necessary Services and supplies • Maternity Services • Prescription drugs Outpatient Care: • Office visits • Outpatient surgery • Physical, speech and occupational therapy (up to 20 visits for physical therapy per incident; up to two months for occupational and speech therapy) • Allergy tests and allergy injections • Dialysis care Laboratory and X-Ray: • Covered in or out of the hospital Outpatient Prescription Drugs: • Covered only if you have an outpatient prescription drug benefit (regular home Service Area Copayments, Coinsurance, Deductibles, exclusions and limitations apply) Mental Health Services Other than for Emergency or Urgent Care servicesServices: • Outpatient visits and inpatient hospital days Substance Abuse Treatment Other than for Emergency or Urgent Care servicesServices: • Inpatient and outpatient medical detoxification and other outpatient visits Skilled Nursing Facility Care: • Up to 100 days per calendar year Home Health Care: • Home health care Services inside the visited service area Hospice Care: • Home-based hospice care inside the visited service area Pre-Authorization Required for Certain Services The following Services require preauthorization from your home Service Area while you are visiting another Xxxxxx Permanente Region or Group Health Cooperative service area: • Inpatient physical rehabilitation Any other Service that would require pre- authorization in your home Service Area In addition, some • Mental health hospital Services require pre-authorization from the visited region • Residential facility admissions for chemical dependency • Outpatient mental health or service area. Please contact Member Services in the other Xxxxxx Permanente region or Group Health Cooperative (GHC) service area, once you have obtained pre- authorization from your home region or GHC service area. chemical dependency benefits Visiting Member Service Exclusions The following Services are not covered under your visiting member benefits. (“Services” include equipment and supplies.) However, some of these Services, such as Emergency Services, may be covered under your home Service Area benefits, and applicable Copayments, Coinsurance and/or Deductibles will apply. For coverage information, refer to the “Benefits” section of this EOC. • Services that are not Medically Necessary • Physical examinations and related Services for insurance, employment, or licensing • Drugs for the treatment of sexual dysfunction disorders • Dental care and dental X-rays • Services to reverse voluntary infertility • Infertility Services • Services related to conception by artificial means, such as IVF and GIFT • Experimental Services and all clinical trials • Cosmetic surgery or other Services primarily to change appearance • Custodial care and care provided in an intermediate care facility • Services related to sexual reassignment • Transplants and related care • Complementary and alternative medicine Services, such as chiropractic Services • Services received as a result of a written referral from a Plan provider in your home service area • Emergency Services, including emergency ambulance Services • Services that are excluded or limited in your home Service Area Moving to Another Xxxxxx Permanente Region or Group Health Cooperative Service Area If you move to another Xxxxxx Permanente Region or Group Health Cooperative service area, you may be able to transfer your Group membership if there is an arrangement with your Group in the new service area. However, eligibility requirements, benefits, Premium, Copayments, Coinsurance and Deductibles may not be the same in the other service area. You should contact your Group’s employee benefits coordinator before you move. Value Added Services Health Plan makes available a variety of value added services to its Members in order to aid Members in their quest for better health by providing access to additional services, which may not be covered under this plan. Examples may include discounted eyewear, non-covered health education classes and publications, discounted fitness club memberships, health promotion and wellness programs and rewards for participating in those programs. Some of these value added services are available to all Members and others may be available only to Members enrolled in certain groups and/or plans. To take advantage of these services, a Member need only identify himself/herself as a Health Plan Member by showing his/her ID card and paying the fee, if any, at the time of service. Because these value added services are not covered Services, any fees you pay will not accrue to any coverage calculations, such as deductibles and out-of-pocket maximum calculations. For information concerning these services, including which ones are available to you, you may contact our Member Services Department at: Inside the Washington, D.C., Metropolitan area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000 Our Member Services Representatives are available to assist you Monday through Friday from 7:30 a.m. until 9:00 p.m. These value added services are neither offered nor guaranteed under your Health Plan coverage. Some of these services may be provided by entities other than the Health Plan. We may change or discontinue some or all of these services at any time. These value added services are not offered as an inducement to purchase a health care plan from Health Plan. Although they are not covered Services, we may include their costs in the calculation of your Premium. Health Plan does not endorse or make any representations regarding the quality of such services or their medical efficacy, nor the financial integrity of the entities providing the value added services. The Health Plan expressly disclaims any liability for these services provided by these entities. If you have a dispute regarding these products or services, you must resolve it with the entity offering the product or service. Although we have no obligation to assist with such resolution, should a problem arise with any of these products or services, you may call the Member Services Call Center, and the Health Plan may try to assist in getting the issue resolved.
Appears in 1 contract
Samples: Your Group Agreement
Missed Appointment Fee. If The amount you cannot may be required to pay if you fail to keep a scheduled medical appointment, please appointment and you do not notify your health care professional’s office us at least one $25 per missed appointment day prior to the appointment. If you fail to cancel your appointment, you may be responsible Outpatient Care Copayments and Coinsurance Covered Service You Pay Office visits (for the payment other than preventive health care Services) Primary care office visits For adults $20 per visit For children under 5 years of an administrative fee age No charge For children 5 years of age or older $20 per visit Specialty care office visits $30 per visit Consultations and immunizations for the missed appointment. The fee for a missed appointment at a Plan Medical Center is shown foreign travel $20 per visit Outpatient surgery $30 per visit Diagnostic testing (not preventive screening) as described under Outpatient Care in the Appendix - Summary of Services and Section 3 Applicable Cost Shares section will apply based on place and type of this EOC. The fee will not count toward your Deductible or Out of Pocket Maximum. Using Your Identification Card Each Member has Service Anesthesia No charge Chemotherapy and radiation therapy $30 per visit Respiratory therapy $30 per visit Medical social Services $20 per visit House calls No charge Hospital Inpatient Care All charges incurred during a Health Plan ID card with covered stay as an inpatient in a Medical Record Number on it to use when you call for advice, make an appointment, or go hospital $300 per admission Accidental Dental Injury Services Limited to a Plan Provider maximum benefit of $2,000 per contract year. Applicable Cost Shares will apply, based on type and place of Service Allergy Services Evaluations and treatment Injection visits and serum Applicable Cost Shares will apply, based on type and place of Service Applicable Cost Shares will apply, based on type and place of Service, not to exceed the cost of the serum plus administration Ambulance Services By a licensed ambulance Service, per encounter $50 per encounter Anesthesia for care. The Medical Record Number is used to identify your medical records Dental Services Anesthesia and membership information. You should always have the same Medical Record Number. If you need to replace your card, associated hospital or if we ever inadvertently issue you more than one Medical Record Number, please let us know by calling our Member ambulatory Services Department in the Washington, D.C., Metropolitan area at (000) 000-0000, or in the Baltimore, Maryland Metropolitan Area at 0-000-000-0000. Our TTY is (000) 000-0000. Your ID card is for identification certain individuals only. Applicable Cost Shares will apply, based on type and place of Service Blood, Blood Products and Their Administration No charge Covered Service You will be issued a Health Plan ID card that will serve as evidence of your membership status. In addition to your Health Plan ID card, you may be asked to show a valid photo ID at your medical appointments. Allowing another person to use your card will result in forfeiture of your membership card Pay Chemical Dependency and may result in termination of your membership. Visiting Other Xxxxxx Permanente Regions or Group Health Cooperative Service Areas If you visit a different Xxxxxx Permanente or Group Health Cooperative service area temporarily (not more than 90 days), you can receive visiting member care from designated providers in that area. The covered Services, Copayments, Coinsurance and Deductibles may differ from those in this Service Area, and are governed by the Xxxxxx Permanente program for visiting members. This program does not cover certain Services, such as transplant Services or infertility Services. Also, except for out-of-Plan Emergency Services, your right to receive covered Services in the visited service area ends after 90 days unless you receive prior written authorization from us to continue receiving covered Services in the visited service area. The 90-day limit on visiting member care does not apply to a Member who attends an accredited college or accredited vocational school. To receive more information about visiting member Services, including facility locations across the United States, you may call our Member Services Department at: Inside the Washington, D.C. Metropolitan Area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan Area 0-000-000-0000 Service areas and facilities where you may obtain visiting member care may change at any time. The following visiting member care is covered when it is provided or arranged by a Plan Physician in the visited service area. The benefits may not be the same as those you receive in your home service area. Hospital Inpatient Care: Physician Services Room and board Necessary Services and supplies Maternity Services Prescription drugs Outpatient Care: Office visits Outpatient surgery Physical, speech and occupational therapy (up to 20 visits for physical therapy per incident; up to two months for occupational and speech therapy) Allergy tests and allergy injections Dialysis care Laboratory and X-Ray: Covered in or out of the hospital Outpatient Prescription Drugs: Covered only if you have an outpatient prescription drug benefit (regular home Service Area Copayments, Coinsurance, Deductibles, exclusions and limitations apply) Mental Health Services Other than for Emergency or Urgent Care services: Outpatient visits Treatment of mental illness, emotional disorders, drug and inpatient hospital days Substance Abuse Treatment Other than for Emergency or Urgent Care services: Inpatient and outpatient medical detoxification and other outpatient visits Skilled Nursing Facility Care: Up to 100 days per calendar year Home Health Care: Home health care Services inside the visited service area Hospice Care: Home-based hospice care inside the visited service area Pre-Authorization Required for Certain Services The following Services require preauthorization from your home Service Area while you are visiting another Xxxxxx Permanente or Group Health Cooperative service area: Inpatient physical rehabilitation Any other Service that would require pre- authorization alcohol abuse described in your home Service Area In addition, some Services require pre-authorization from the visited region or service area. Please contact Member Services in the other Xxxxxx Permanente region or Group Health Cooperative (GHC) service area, once you have obtained pre- authorization from your home region or GHC service area. Visiting Member Service Exclusions The following Services are not covered under your visiting member benefits. (“Services” include equipment and supplies.) However, some of these Services, such as Emergency Services, may be covered under your home Service Area benefits, and applicable Copayments, Coinsurance and/or Deductibles will apply. For coverage information, refer to the “Benefits” section Inpatient psychiatric and substance abuse care, including detoxification Partial hospitalization Outpatient psychiatric and substance abuse care · Individual therapy · Group therapy Medication management visits Methadone treatment Psychiatric Residential Crisis Services Applicable inpatient Cost Shares will apply $20 per visit $20 per visit for individual therapy $10 per visit for group therapy $20 per visit $30 per week, but not to exceed 50% of the daily cost of the treatment $300 per visit Cleft Lip, Cleft Palate, or Both Applicable Cost Shares will apply, based on type and place of Service Clinical Trials Applicable Cost Shares will apply, based on type and place of Service Diabetic Equipment, Supplies and Self-Management Training Diabetic equipment and supplies Self-management training Dialysis Inpatient care Outpatient Care No charge Applicable Cost Shares will apply, based on place of Service Applicable inpatient care Cost Shares will apply $30 per visit Drugs, Supplies, and Supplements Administered by or under the supervision of a Plan Provider No charge Durable Medical Equipment Applicable inpatient hospital cost shares will apply to equipment provided while you are confined as an inpatient. Covered Service You Pay Basic Durable Medical Equipment No charge Supplemental Durable Medical Equipment · Oxygen and Equipment (Must be certified every 30 days) No charge for 1st 3 months; 50% of AC* each month thereafter · Positive Airway Pressure Equipment (Must be certified every 30 days) No charge for 1st 3 months; 50% of AC* each month thereafter · Apnea Monitors (under age 3, not to exceed a period of 6 months) No charge · Asthma Equipment No charge · Bilirubin Lights (under age 3, not to exceed a period of 6 months) No charge Emergency Services Emergency Room Visits · Inside the Service Area · Outside the Service Area Transfer to an observation bed or observation status does not qualify as an admission to a hospital and your emergency room visit Copayment will not be waived. Family Planning $100 per visit; Copayment waived if immediately admitted as an inpatient $100 per visit; Copayment waived if immediately admitted as an inpatient Office visits $30 per visit Tubal ligation, Vasectomy, Voluntary termination of pregnancy Applicable Cost Share will apply based on place of Service Habilitative Services For children under age 19 Note: applicable Inpatient Hospital Cost Shares will also apply for Services provided in a Hospital. $30 per visit Hearing Services Hearing tests (newborn hearing screening tests are covered under preventive health care Services) Hearing aids for children under age 18. · Hearing aid tests · Hearing aids (Limited to a maximum benefit of $1400 per hearing aid per ear, or to $2800 for a single hearing device that provides hearing aid to both ears, every 36 months.) Home Health Care See Section 3 for benefit limitations The visit maximum does not apply to home visits following mastectomy or testicle removal; and home visits following mastectomy or testicle removal do not count toward the maximum visits. Applicable office visit Cost Share will apply based on place of service Applicable office visit Cost Share will apply No charge up to Health Plan maximum payment. No charge Covered Service You Pay Hospice Care No charge Infertility Services Office visits Inpatient Hospital Care All other Services for treatment of infertility Note: Coverage for in vitro fertilization is limited to a maximum of three attempts per live birth, not to exceed a maximum lifetime benefit of $100,000. 50% of AC* 50% of AC* 50% of AC* Maternity Services Routine global maternity care (after confirmation of pregnancy) Non-routine obstetrical care Inpatient Services Postpartum home visits (as described in Section 3) No charge $30 per visit $300 per admission No Charge Medical Foods (including Amino Acid-based Elemental Formula) 25% of AC* Morbid Obesity Services Applicable Cost Shares will apply based on type and place of Service Oral Surgery Note: applicable inpatient Cost Shares will also apply for Services provided in a hospital or other inpatient facility. $30 per visit Preventive Health Care Services No charge Prosthetic Devices Internally implanted devices Replacements for legs, arms or eyes, and their components and repair Ostomy and urological supplies No charge No charge No charge Breast prosthetics Hair Prosthesis (Limited to a maximum of $350 per course of chemotherapy and/or radiation therapy) No charge No charge Reconstructive Surgery Applicable Cost Shares will apply based on place and type of Service. Skilled Nursing Facility Care Limited to a maximum benefit of 100 days per contract year $300 per admission Therapy and Rehabilitation Services (Refer to Section 3 for benefit maximums) Covered Service You Pay Inpatient Services Outpatient Services Note: All Services received in one day for multidisciplinary rehabilitation Services at a day treatment program will be considered one visit. Applicable inpatient Cost Shares will apply $30 per visit Transplants Applicable Cost Shares will apply based on place and type of Service Urgent Care Office visit during regular office hours Applicable office visit Cost Share will apply After-Hours Urgent Care or Urgent Care Center $30 per visit Vision Services Eye exams · by an Optometrist · by an Ophthalmologist Eyeglass lenses and frames $20 per visit $30 per visit You receive a 25% discount off retail price** for eyeglass lenses and for eyeglass frames once per contract year Contact lenses You receive a 15% discount off retail price** on initial pair of contact lenses X-ray, Laboratory and Special Procedures Diagnostic Imaging, interventional diagnostic and laboratory tests Inpatient Services Outpatient Services Specialty Imaging (including CT, MRI, PET Scans, Nuclear Medicine) and Special Procedures Inpatient Services Outpatient Services Sleep lab and sleep studies Applicable inpatient Cost Shares will apply No charge Applicable inpatient Cost Shares will apply $50 per test $50 per visit Copayment Maximum The Copayment Maximum is the limit to the total amount of Copayments and Coinsurance you must pay in a contract year for the Basic Health Services (listed below) covered under this EOC. Once you have met the Copayment Maximum, you will not be required to pay any additional Copayments or Coinsurance for these Basic Health Services. After two or more Members of a Family Unit combined have met the Family Copayment Maximum, the Copayment Maximum will be met for all Members of the Family Unit for the rest of the contract year. Basic Health Services. Except as excluded below, the following Services are considered “Basic Health Services” that apply toward the Copayment Maximum: · Inpatient and outpatient physician Services · Inpatient hospital Services · Outpatient medical Services · Preventive health care Services · Emergency Services · X-ray, laboratory and special procedures · Inpatient and outpatient chemical dependency and mental health Services Copayment Maximum Exclusions. The following Services, if covered, are not Medically Necessary Physical examinations considered “Basic Health Services” and related do not apply toward your Copayment Maximum. Your Cost Share for these Services for insurancewill continue to apply even after you have met your Copayment Maximum: · Outpatient drugs, employment, or licensing Drugs for the treatment of sexual dysfunction disorders Dental care supplies and dental X-rays Services to reverse voluntary infertility Infertility Services Services related to conception by artificial means, such as IVF and GIFT Experimental Services and all clinical trials Cosmetic surgery or other Services primarily to change appearance Custodial care and care provided in an intermediate care facility Services related to sexual reassignment Transplants and related care Complementary and alternative medicine Services, such as chiropractic Services Services received as a result of a written referral from a Plan provider in your home service area Emergency Servicessupplements, including emergency ambulance Services Services that are excluded or limited in your home Service Area Moving to Another Xxxxxx Permanente or Group Health Cooperative Service Area If you move to another Xxxxxx Permanente or Group Health Cooperative service areablood, you may be able to transfer your Group membership if there is an arrangement with your Group in the new service area. However, eligibility requirements, benefits, Premium, Copayments, Coinsurance and Deductibles may not be the same in the other service area. You should contact your Group’s employee benefits coordinator before you move. Value Added Services Health Plan makes available a variety of value added services to its Members in order to aid Members in their quest for better health by providing access to additional services, which may not be covered under this plan. Examples may include discounted eyewear, non-covered health education classes and publications, discounted fitness club memberships, health promotion and wellness programs and rewards for participating in those programs. Some of these value added services are available to all Members and others may be available only to Members enrolled in certain groups and/or plans. To take advantage of these services, a Member need only identify himself/herself as a Health Plan Member by showing his/her ID card and paying the fee, if any, at the time of service. Because these value added services are not covered Services, any fees you pay will not accrue to any coverage calculations, such as deductibles and out-of-pocket maximum calculations. For information concerning these services, including which ones are available to you, you may contact our Member Services Department at: Inside the Washington, D.C., Metropolitan area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000 Our Member Services Representatives are available to assist you Monday through Friday from 7:30 a.m. until 9:00 p.m. These value added services are neither offered nor guaranteed under your Health Plan coverage. Some of these services may be provided by entities other than the Health Plan. We may change or discontinue some or all of these services at any time. These value added services are not offered as an inducement to purchase a health care plan from Health Plan. Although they are not covered Services, we may include their costs in the calculation of your Premium. Health Plan does not endorse or make any representations regarding the quality of such services or their medical efficacy, nor the financial integrity of the entities providing the value added services. The Health Plan expressly disclaims any liability for these services provided by these entities. If you have a dispute regarding these products or services, you must resolve it with the entity offering the product or service. Although we have no obligation to assist with such resolution, should a problem arise with any of these products or services, you may call the Member Services Call Centerblood products, and the Health Plan may try to assist in getting the issue resolved.medical foods · Outpatient durable medical equipment and prosthetic and orthotic devices · Inpatient and outpatient infertility Services
Appears in 1 contract
Samples: Your Group Agreement
Missed Appointment Fee. If you cannot keep a scheduled medical appointment, please notify your health care professional’s office at least one day prior to the appointment. If you fail to cancel your appointment, you may be responsible for the payment of an administrative fee for the missed appointment. The fee for a missed appointment at a Plan Medical Center is shown in the Appendix - Summary of Services and Cost Shares section of this EOC. The fee will not count toward your Deductible or Out of Pocket Maximum. Using Your Identification Card Each Member has a Health Plan ID card with a Medical Record Number on it to use when you call for advice, make an appointment, or go to a Plan Provider for care. The Medical Record Number is used to identify your medical records and membership information. You should always have the same Medical Record Number. If you need to replace your card, or if we ever inadvertently issue you more than one Medical Record Number, please let us know by calling our Member Services Department in the Washington, D.C., Metropolitan area at (000) 000-0000, or in the Baltimore, Maryland Metropolitan Area at 0-000-000-0000. Our TTY is (000) 000-0000. Your ID card is for identification only. You will be issued a Health Plan ID card that will serve as evidence of your membership status. In addition to your Health Plan ID card, you may be asked to show a valid photo ID at your medical appointments. Allowing another person to use your card will result in forfeiture of your membership card and may result in termination of your membership. Visiting Other Xxxxxx Permanente Regions or Group Health Cooperative Service Areas If you visit a different Xxxxxx Permanente or Group Health Cooperative service area temporarily (not more than 90 days), you can receive visiting member care from designated providers in that area. The covered Services, Copayments, Coinsurance and Deductibles may differ from those in this Service Area, and are governed by the Xxxxxx Permanente program for visiting members. This program does not cover certain Services, such as transplant Services or infertility Services. Also, except for out-of-Plan Emergency Services, your right to receive covered Services in the visited service area ends after 90 days unless you receive prior written authorization from us to continue receiving covered Services in the visited service area. The 90-day limit on visiting member care does not apply to a Member who attends an accredited college or accredited vocational school. To receive more information about visiting member Services, including facility locations across the United States, you may call our Member Services Department at: Inside the Washington, D.C. Metropolitan Area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan Area 0-000-000-0000 Service areas and facilities where you may obtain visiting member care may change at any time. The following visiting member care is covered when it is provided or arranged by a Plan Physician in the visited service area. The benefits may not be the same as those you receive in your home service areaService Area. Hospital Inpatient Care: • Physician Services • Room and board • Necessary Services and supplies • Maternity Services • Prescription drugs Outpatient Care: • Office visits • Outpatient surgery • Physical, speech and occupational therapy (up to 20 visits for physical therapy per incident; up to two months for occupational and speech therapy) • Allergy tests and allergy injections • Dialysis care Laboratory and X-Ray: • Covered in or out of the hospital Outpatient Prescription Drugs: • Covered only if you have an outpatient prescription drug benefit (regular home Service Area Copayments, Coinsurance, Deductibles, exclusions and limitations apply) Mental Health Services Other than for Emergency or Urgent Care services: • Outpatient visits and inpatient hospital days Substance Abuse Treatment Treatm ent Other than for Emergency or Urgent Care services: • Inpatient and outpatient medical detoxification and other outpatient visits Skilled Nursing Facility Care: • Up to 100 days per calendar year Home Health Care: • Home health care Services inside the visited service area Hospice Care: • Home-based hospice care inside the visited service area Pre-Authorization Required for Certain Services The following Services require preauthorization from your home Service Area while you are visiting another Xxxxxx Permanente or Group Health Cooperative service area: • Inpatient physical rehabilitation Any other Service that would require pre- authorization • Mental health hospital services in your home Service Area In addition, some Services require pre-authorization from the visited region excess of 10 days • Residential facility admissions for chemical dependency • Outpatient mental health or service area. Please contact Member Services in the other Xxxxxx Permanente region or Group Health Cooperative (GHC) service area, once you have obtained pre- authorization from your home region or GHC service area. chemical dependency benefits Visiting Member Service Exclusions The following Services are not covered under your visiting member benefits. (“Services” include equipment and supplies.) However, some of these Services, such as Emergency Services, may be covered under your home Service Area benefits, and applicable Copayments, Coinsurance and/or Deductibles will apply. For coverage information, refer to the “Benefits” section of this EOC. • Services that are not Medically Necessary • Physical examinations and related Services for insurance, employment, or licensing • Drugs for the treatment of sexual dysfunction disorders • Dental care and dental X-rays • Services to reverse voluntary infertility • Infertility Services • Services related to conception by artificial means, such as IVF and GIFT • Experimental Services and all clinical trials • Cosmetic surgery or other Services primarily to change appearance • Custodial care and care provided in an intermediate care facility • Services related to sexual reassignment • Transplants and related care • Complementary and alternative medicine Services, such as chiropractic Services • Services received as a result of a written referral from a Plan provider in your home service area • Emergency Services, including emergency ambulance Services • Services that are excluded or limited in your home Service Area Moving to Another Xxxxxx Permanente or Group Health Cooperative Service Area If you move to another Xxxxxx Permanente or Group Health Cooperative service area, you may be able to transfer your Group membership if there is an arrangement with your Group in the new service area. However, eligibility requirements, benefits, Premium, Copayments, Coinsurance and Deductibles may not be the same in the other service area. You should contact your Group’s employee benefits coordinator before you move. Value Added Services Health Plan makes available a variety of value added services to its Members in order to aid Members in their quest for better health by providing access to additional services, which may not be covered under this plan. Examples may include discounted eyewear, non-covered health education classes and publications, discounted fitness club memberships, health promotion and wellness programs and rewards for participating in those programs. Some of these value added services are available to all Members and others may be available only to Members enrolled in certain groups and/or plans. To take advantage of these services, a Member need only identify himself/herself as a Health Plan Member by showing his/her ID card and paying the fee, if any, at the time of service. Because these value added services are not covered Services, any fees you pay will not accrue to any coverage calculations, such as deductibles and out-of-pocket maximum calculations. For information concerning these services, including which ones are available to you, you may contact our Member Services Department at: Inside the Washington, D.C., Metropolitan area (000) 000-0000 TTY (000) 000-0000 Outside the Washington, D.C. Metropolitan area 0-000-000-0000 Our Member Services Representatives are available to assist you Monday through Friday from 7:30 a.m. until 9:00 5:30 p.m. These value added services are neither offered nor guaranteed under your Health Plan coverage. Some of these services may be provided by entities other than the Health Plan. We may change or discontinue some or all of these services at any time. These value added services are not offered as an inducement to purchase a health care plan from Health Plan. Although they are not covered Services, we may include their costs in the calculation of your Premium. Health Plan does not endorse or make any representations regarding the quality of such services or their medical efficacy, nor the financial integrity of the entities providing the value added services. The Health Plan expressly disclaims any liability for these services provided by these entities. If you have a dispute regarding these products or services, you must resolve it with the entity offering the product or service. Although we have no obligation to assist with such resolution, should a problem arise with any of these products or services, you may call the Member Services Call Center, and the Health Plan may try to assist in getting the issue resolved.
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Samples: Your Group Agreement
