Common use of Obtaining Benefits Clause in Contracts

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.

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 followup 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.