Obtaining Benefits Sample Clauses

Obtaining Benefits. Unless otherwise specifically stated to the contrary, the services and supplies described in the Member Handbook and Supplemental Benefits brochures, if applicable, are Covered Benefits only if, and to the extent that they are: (a) Medically Necessary; (b) not specifically limited or excluded in the Member Handbook or Supplemental Benefits brochures; (c) provided by Plan Providers in the selected Plan Network (except for Emergency Services and Out-of-Area Urgent Care Services); (d) prescribed by a Plan Physician and, if required, Authorized in advance by the Member's PMG or Plan (except for Emergency Services and Out-of- Area Urgent Care Services); and (e) part of a treatment plan for Benefits or required to treat medical conditions that are direct and predictable complications or consequences of Benefits. If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary follow-up services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to “arrange coverage to ensure the delivery of medically necessary out-of-network services” includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the enrollee within geographic and timely access standards. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.
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Obtaining Benefits. Unless otherwise specifically stated to the contrary, the services described herein are Benefits only if, and to the extent, that they are authorized and directed by Plan and performed by an EAP Provider.
Obtaining Benefits. Unless otherwise specifically stated to the contrary, the services and supplies described in the Member Handbook and Supplemental Benefits brochures, if applicable, are Covered Benefits only if, and to the extent that they are: (a) Medically Necessary; (b) not specifically limited or excluded in the Member Handbook or Supplemental Benefits brochures; (c) provided by Plan Providers in the selected Plan Network (except for Emergency Services and Out-of-Area Urgent Care Services); (d) prescribed by a Plan Physician and, if required, Authorized in advance by the Member's PMG or Plan (except for Emergency Services and Out-of-Area Urgent Care Services); and (e) part of a treatment plan for Benefits or required to treat medical conditions that are direct and predictable complications or consequences of Benefits.
Obtaining Benefits. Unless otherwise specifically stated to the contrary, the services and supplies described in the Member Handbook and Supplemental Benefits brochures, if applicable, are Covered Benefits only if, and to the extent that they are: (a) Medically Necessary; (b) not specifically limited or excluded in the Member Handbook or Supplemental Benefits brochures; (c) provided by Plan Providers in the selected Plan Network (except for Emergency and Out of Area Urgent Care Services); (d) prescribed by a Plan Physician and Authorized in advance by the Member’s PCP or PMG, or the Plan, if required (except for Emergency and Out of Area Urgent Care Services); and (e) part of a treatment plan for covered services or required to treat medical conditions which are direct and predictable complications or consequences of Benefits.

Related to Obtaining Benefits

  • Health Benefits For the eighteen (18) month period following the Termination Date, provided that Executive is eligible for, and timely elects COBRA continuation coverage, the Company will pay on Executive’s behalf, the monthly cost of COBRA continuation coverage under the Company’s group health plan for Executive and, where applicable, her spouse and dependents, at the level in effect as of the Termination Date, adjusted for any increase in such level paid by the Company for active employees, less the employee portion of the applicable premiums that Executive would have paid had she remained employed during the such eighteen (18) month period (the COBRA continuation coverage period shall run concurrently with the eighteen (18) month period that COBRA premium payments are made on Executive’s behalf under this subsection 1(a)(ii)). The reimbursements described herein shall be paid in monthly installments, commencing on the sixtieth (60th) day following the Termination Date, provided that the first such installment payment shall include any unpaid reimbursements that would have been made during the first sixty (60) days following the Termination Date. Notwithstanding the foregoing, the Company’s payment of the monthly COBRA premiums in accordance with this subsection 1(a)(ii) shall cease immediately upon the earlier of: (A) the end of the eighteen (18) month period following the Termination Date, or (B) the date that Executive is eligible for comparable coverage with a subsequent employer. Executive agrees to notify the Company in writing immediately if subsequent employment is accepted prior to the end of the eighteen (18) month period following the Termination Date and Executive agrees to repay to the Company any COBRA premium amount paid on Executive’s behalf during such period for any period of employment during which group health coverage is available through a subsequent employer. Notwithstanding the foregoing, the Company reserves the right to restructure the foregoing COBRA premium payment arrangement in any manner necessary or appropriate to avoid fines, penalties or negative tax consequences to the Company or Executive (including, without limitation, to avoid any penalty imposed for violation of the nondiscrimination requirements under the Patient Protection and Affordable Care Act or the guidance issued thereunder), as determined by the Company in its sole and absolute discretion.

  • Severance Benefits In addition, if a Change in Control Severance Payment Event (as defined below) occurs, then the Company shall pay to Employee the Accrued Payments, and contingent upon Employee satisfying the Severance Conditions, the Company shall also provide Employee the following payments and other benefits (the “Change in Control Severance Package”): (i) Payment of an amount equal to 2.0 times the sum of (i) Employee’s annual rate of Base Salary as of the Termination Date or as of the date of the Change in Control, whichever is greater, plus (ii) Employee’s Target STI Payment, calculated based on Employee’s Base Salary as of the Termination Date or, if greater, as of the date of the Change in Control, payable to Employee on the 30th day following the Termination Date in a lump sum payment; plus (ii) Payment of a Pro-Rata Bonus for the calendar year of termination, payable as soon as administratively feasible following preparation of the Company’s audited financial statements for the applicable calendar year, but in no event later than March 31 (or earlier than January 1) of the calendar year following the calendar year to which such STI Payment relates; and (iii) The Company shall pay or reimburse on a monthly basis the premiums required to continue Employee’s group health care coverage for a period of eighteen (18) months following Employee’s Termination Date, under the applicable provisions of COBRA, provided that Employee or his dependents, as applicable, elect to continue and remain eligible for these benefits under COBRA. If necessary to avoid inclusion in taxable income by Employee of the value of in-kind benefits, such health care continuation premiums shall be provided in the form of taxable payments to Employee, which payments shall be made without regard to whether Employee elects to continue and remain eligible for such benefits under COBRA, and in which event Company shall pay to Employee, with each monthly reimbursement, an additional amount of cash equal to A/(1-R)-A, where A is the amount of the reimbursement for the month, and R is the sum of the maximum federal individual income tax rate then applicable to ordinary income and the maximum individual Colorado income tax rate then applicable to ordinary income; (iv) Provided, however, that the sum of (i) and (ii) above shall be reduced, but not below zero, by the sum of any actually benefits provided to Employee pursuant to Section 5(a)(i), (ii), or (iii) and any payments otherwise required pursuant to Section 5(a)(i), (ii), and (iii) shall not be made. Nothing in this Section 6 shall relieve the Company or any successor-in-interest thereof of its obligation to continue, following any Change in Control, to provide Employee with the compensation due pursuant to Section 3 of this Agreement or to otherwise comply with its obligations hereunder in the event Employee’s service continues pursuant to this Agreement following the occurrence of such Change in Control.

  • Relocation Benefits If the Executive moves his residence in order to pursue other business or employment opportunities during the Continuation Period and requests in writing that the Company provide relocation services, he will be reimbursed for any expenses incurred in that initial relocation (including taxes payable on the reimbursement) which are not reimbursed by another employer. Benefits under this provision will include assistance in selling the Executive's home and all other assistance and benefits which were customarily provided by the Company to transferred executives prior to the Change in Control.

  • Group Benefits To determine if a leave under the provisions of the Family and Medical Leave Act will be a paid or unpaid leave, contact the District’s Human Resources Department.

  • Pay and Benefits The Agency shall continue to pay salary and benefits which includes pension contribution, insurance and paid leave time consistent with what they earned before their appointment. Employees appointed as a Contract Specialist shall not be eligible for reimbursement for uniforms, boots or other ancillary items while serving as a Contract Specialist the specifics which will be noted in the employee’s Contract Specialist agreement.

  • Medical Benefits The Company shall reimburse the Employee for the cost of the Employee's group health, vision and dental plan coverage in effect until the end of the Termination Period. The Employee may use this payment, as well as any other payment made under this Section 6, for such continuation coverage or for any other purpose. To the extent the Employee pays the cost of such coverage, and the cost of such coverage is not deductible as a medical expense by the Employee, the Company shall "gross-up" the amount of such reimbursement for all taxes payable by the Employee on the amount of such reimbursement and the amount of such gross-up.

  • Life Insurance Benefits A. During the life of this Agreement, the basic life insurance benefit made available to Faculty members shall be calculated as 3 times base annual earnings, rounded to the next highest $1,000, but not more than $225,000. A separate additional benefit up to the amount of the life insurance will be paid for accidental death and dismemberment, or loss of sight. The amount of Life and Accidental Death and Dismemberment/Loss of Sight benefits will be reduced to 65% at age 65, and further reduced (from the original insurance amount) as follows: to 50% at age 70, and 35% at age 75. Basic life insurance and AD&D benefits will be provided with no employee contributions. B. Faculty members will be eligible to purchase the following supplemental coverage: 1. additional amounts of group term life insurance at a level of between one and three (3) times the Faculty member’s annual salary with a maximum of $600,000. The guaranteed issue level at initial enrollment will be determined by the life insurance carrier and any amounts over the guaranteed level will be subject to the underwriting requirements of the life insurance carrier. 2. group term life insurance for spouses and domestic partners at a level of between one (1) and three (3) times annual salary with a maximum of $600,000. The guaranteed issue level at initial enrollment will be determined by the life insurance carrier and any amounts over the guaranteed level will be subject to the underwriting requirements of the life insurance carrier. 3. group term life insurance for eligible dependent children at a level of $10,000.

  • Public Benefits ‌ 5.1 Developer to provide Public Benefits‌ The Developer must, at its cost and risk, provide the Public Benefits to the City in accordance with this document.

  • Insurance Benefits Borrower shall cooperate with Lender in obtaining for Lender the benefits of any Insurance Proceeds lawfully or equitably payable in connection with the Property, and Lender shall be reimbursed for any expenses incurred in connection therewith (including reasonable attorneys' fees and disbursements, and the payment by Borrower of the expense of an appraisal on behalf of Lender in case of a fire or other casualty affecting the Property or any part thereof) out of such Insurance Proceeds.

  • Retiree Health Benefits 1. There is currently in effect a retiree health benefit program for retired members of LACERS under LAAC Division 4, Chapter 11. All covered employees who are members of LACERS, regardless of retirement tier, shall contribute to LACERS four percent (4%) of their pre-tax compensation earnable toward vested retiree health benefits as provided by this program. The retiree health benefit available under this program is a vested benefit for all covered employees who make this contribution, including employees enrolled in LACERS Tier 3. 2. With regard to LACERS Tier 1, as provided by LAAC Section 4.1111, the monthly Maximum Medical Plan Premium Subsidy, which represents the Kaiser 2-party non-Medicare Part A and Part B premium, is vested for all members who made the additional contributions authorized by LAAC Section 4.1003(c). 3. Additionally, with regard to Tier 1 members who made the additional contribution authorized by LAAC Section 4.1003(c), the maximum amount of the annual increase authorized in LAAC Section 4.1111(b) is a vested benefit that shall be granted by the LACERS Board. 4. With regard to LACERS Tier 3, the Implementing Ordinance shall provide that all Tier 3 members shall contribute to LACERS four percent (4%) of their pre-tax compensation earnable toward vested retiree health benefits, and shall amend LAAC Division 4, Chapter 11 to provide the same vested benefits to all Tier 3 members as currently are provided to Tier 1 members who make the same four percent (4%) contribution to LACERS under the retiree health benefit program. 5. The entitlement to retiree health benefits under this provision shall be subject to the rules under LAAC Division 4, Chapter 11 in effect as of the effective date of this provision, and the rules that shall be placed into LAAC Division 4, Chapters 10 and 11, with regard to Tier 3, by the Implementing Ordinance. 6. As further provided herein, the amount of employee contributions is subject to bargaining in future MOU negotiations. 7. The vesting schedule for the Maximum Medical Plan Premium Subsidy for employees enrolled in LACERS Tier 1 and LACERS Tier 3 shall be the same. 8. Employees whose Health Service Credit, as defined in LAAC Division 4, Chapter 11, is based on periods of part-time and less than full-time employment, shall receive full, rather than prorated, Health Service Credit for periods of service. The monthly retiree medical subsidy amount to which these employees are entitled shall be prorated based on the extent to which their service credit is prorated due to their less than full time status.

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