Common use of Networks Clause in Contracts

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor and management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence to perform highly specialized, high cost procedures such as transplants. The JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement to non-network providers shall be at a level no greater than the usual, customary, and reasonable fee/allowed amount which has been established by the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rate. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("co-insurance") for services will be at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's established selection criteria, or in violation of the vendor's established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor and management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence to perform highly specialized, high cost procedures such as transplants. The JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-network providers shall be at a level no greater than the usual, customary, and reasonable fee/allowed amount which has been established by the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rate. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("“co-insurance"”) for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative administration subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor Labor and management Management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence (XXX) to perform highly specialized, high cost procedures such as transplants. The JHCC or the Director, in consultation with the JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of after consultation with the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-non- network providers shall be at a level no greater than 60% of the usualcontracted allowable amount. Also, customary, member can be balance billed for the difference between what is charged and reasonable fee/allowed amount which has been established by what the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rateallows. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("“co-insurance"”) for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative administration subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor Labor and management Management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence (XXX) to perform highly specialized, high cost procedures such as transplants. The JHCC or the Director, in consultation with the JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of after consultation with the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-network providers shall be at a level no greater than 60% of the usualcontracted allowable amount. Also, customary, member can be balance billed for the difference between what is charged and reasonable fee/allowed amount which has been established by what the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rateallows. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("co-co- insurance") for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative administration subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor Labor and management Management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence (XXX) to perform highly specialized, high cost procedures such as transplants. The JHCC or the Director, in consultation with the JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of after consultation with the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-network providers shall be at a level no greater than 60% of the usualcontracted allowable amount. Also, customary, member can be balance billed for the difference between what is charged and reasonable fee/allowed amount which has been established by what the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rateallows. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("co-insurance") for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor and management co-co- chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence to perform highly specialized, high cost procedures such as transplants. The JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, Rreimbursement to non-non- network providers shall be at a level no greater than the usual, customary, and reasonable fee/allowed amount which has been established by the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rate. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("co-insurance") for services will be at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's established selection criteria, or in violation of the vendor's established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure ensure that no more than a reasonable percent of network providers have closed practices, practices and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative administration subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor Labor and management Management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence (XXX) to perform highly specialized, high cost procedures such as transplants. The JHCC or the Director, in consultation with the JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of after consultation with the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays copays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-network providers shall be at a level no greater than 60% of the usualcontracted allowable amount. Also, customary, a member can be balance billed for the difference between what is charged and reasonable fee/allowed amount which has been established by what the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rateallows. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("co-insurance") Telehealth services with a reduced copay for physician services offered via teleconferencing technology will be at least seventy percent (70%half of the office copays outlined in Article 20.03(C) by in the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximumPPO plan. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring ensuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor and management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence to perform highly specialized, high cost procedures such as transplants. The JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-co- pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-network providers shall be at a level no greater than the usual, customary, and reasonable fee/allowed amount which has been established by the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rate. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("“co-insurance"”) for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's vendor‟s established selection criteria, or in violation of the vendor's vendor‟s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative administration subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor Labor and management Management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence to perform highly specialized, high cost procedures such as transplants. The JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-network providers shall be at a level no greater than the usual, customary, and reasonable fee/allowed amount which has been established by the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rate. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("co-insurance") for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor and management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence to perform highly specialized, high cost procedures such as transplants. The JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-co- pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-network providers shall be at a level no greater than the usual, customary, and reasonable fee/allowed amount which has been established by the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rate. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("“co-insurance"”) for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative administration subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor Labor and management Management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence (XXX) to perform highly specialized, high cost procedures such as transplants. The JHCC or the Director, in consultation with the JHCC, may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of after consultation with the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-network providers shall be at a level no greater than 60% of the usualcontracted allowable amount. Also, customary, member can be balance billed for the difference between what is charged and reasonable fee/allowed amount which has been established by what the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rateallows. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("co-insurance") for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-of- pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.. ***

Networks. 1. Health plan provider networks must have a full range of primary care and specialist physicians with reasonable numbers of each in relationship to eligible State employees. 2. Health plans newly offered to State employees shall insure that no more than a reasonable percent of network providers have closed practices, and shall attempt to facilitate inclusion in their network primary care physicians already serving State employees in their service area. 3. A designated percentage of primary care physicians and specialist physicians shall be board certified. 4. Health plans shall adhere to reasonable standards of access for every employee to primary care physicians and to hospitals in urban and rural areas in time and distance as recommended by the administrative administration subcommittee of JHCC. 5. Health plans shall agree to refrain from dropping any hospital or health care facility from the network during a benefit period, unless the health plan has notified the Employer, and to the satisfaction of the labor Labor and management Management co-chairs, attempted to develop a method of delivering continuity of care for those persons who may be adversely affected by the change in the network. 6. Health plans shall include centers of excellence to perform highly specialized, high cost procedures such as transplants. The JHCC may modify this provision to best accommodate health plans while assuring quality services for participants. Furthermore, upon the recommendation of the JHCC, the Director of DAS may provide financial or other incentives (including but not limited to reduced co-pays or co-insurance) to participants to utilize quality providers. 7. Reimbursement For any plan that offers out-of-network coverage, reimbursement to non-non- network providers shall be at a level no greater than 60% of the usualcontracted allowable amount. Also, customary, member can be balance billed for the difference between what is charged and reasonable fee/allowed amount which has been established by what the plan administrator for that service or supply. HMO plans do not cover services by providers not in their network, except for emergencies. Ohio Med covers services by non-network providers, but at a reduced reimbursement rateallows. 8. For those employees assigned to work outside of Ohio who are enrolled in an indemnity plan, which does not offer the option of network providers and/or facilities, co-payments ("“co-insurance"”) for services will be paid at a rate which is at least seventy percent (70%) by the plan and no greater than thirty percent (30%) by the participant, after the deductible and up to the out-of-pocket maximum. 9. No hospital, doctor, laboratory, or other health care provider can be added to a plan network in violation of the vendor's ’s established selection criteria, or in violation of the vendor's ’s established standards governing the number of hospitals and other providers which will be part of the plan network in any given geographic area. 10. Medical Necessity and Preventive Services Health plans pay only for those covered services, supplies, and hospital admissions which are medically necessary or are classified as preventive services covered under the plan. Network providers and facilities are responsible for insuring that services, supplies, and admissions are medically necessary or preventive as defined by a plan. In plans with out-of-network benefits, the fact that a non-network provider may prescribe, order, recommend, guarantee, or approve a service, supply, or admission does not guarantee medical necessity or make such charges an allowable expense, even though they are not specifically listed as exclusions.