Outside of California. The Blue Shield Trio HMO provides coverage for you and your family for your Urgent Service needs when you or your family are temporarily traveling outside of California. Urgent Services may be ob- tained from any provider; however, using the BlueCard® or Blue Shield Global Core programs can be more cost-effective and may eliminate the need for you to pay for the services when they are rendered and submit a claim for reimbursement. See the Inter-Plan Arrangements section of this EOC for more information on the BlueCard® and Blue Shield Global Core programs. Out-of-Area Follow-up Care is also covered and services may be received through the BlueCard® or Blue Shield Global Core programs. Authoriza- tion by Blue Shield is required for more than two Out-of-Area Follow-up Care outpatient visits. Blue Shield may direct the patient to receive the additional follow-up services from their Primary Care Physician.
Outside of California. The lower of: (a) the provider’s billed charge, or, (b) the amount, if any, established by the laws of the state to be paid for Emergency Services. Reconstructive Surgery — surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance to the extent possible; dental and orthodontic services that are an integral part of surgery for cleft palate procedures. Rehabilitation — inpatient or outpatient care furnished to an individual disabled by injury or illness, including Severe Mental Illness and Severe Emotional Disturbances of a Child, in order to restore an individual’s ability to function to the maximum extent practical. Rehabilitation services may consist of Physical Therapy, Occupational Therapy, and/or Respiratory Therapy. Resident of California - an individual who spends in the aggregate more than 180 days each year within the State of California and has not established a permanent residence in another state or country. Residential Care — Mental Health or Substance Abuse Services provided in a facility or a free-standing residential treatment center that provides overnight/extended-stay services for Members who do not require acute inpatient care. Respiratory Therapy — treatment, under the direction of a Doctor of Medicine and provided by a certified respiratory therapist, or other appropriately licensed or certified Health Care Provider to preserve or improve a patient’s pulmonary function.
Outside of California. The Blue Shield Access+ HMO provides coverage for you and your family for your Urgent Service needs when you or your family are temporarily traveling outside of California. You can receive urgent care services from any provider; however, using the BlueCard® Program, described herein, can be more cost-effective and eliminate the need for you to pay for the services when they are rendered and submit a claim for reimbursement. Note: Authorization by Blue Shield is required for care that involves a surgical or other procedure or inpatient stay. Out-of-Area Follow-up Care is covered and services may be received through the BlueCard® Program participating pro- vider network or from any provider. However, authorization by Blue Shield is required for more than two Out-of-Area Follow-up Care outpatient visits. Blue Shield may direct the patient to receive the additional follow-up services from the Personal Physician.
Outside of California. The lower of: (a) the provider’s billed charge, or, (b) the amount, if any, established by the laws of the state to be paid for Emergency Services. Rehabilitation — inpatient or outpatient care furnished to an individual disabled by injury or illness, including Severe Mental Illnesses and Severe Emotional Disturbances of a Child, in order to restore an individual’s ability to function to the maximum extent practical. Rehabilitation services may consist of Physical Therapy, Occupational Therapy, and/or Respiratory Therapy. Benefits for Speech Therapy are described in the section on Speech Therapy Benefits.
1) have one or more mental disorders in the most recent edition of the Diagnostic and Statistical manual of Mental Disorders (other than a primary substance use disorder or developmental disorder), that results in behavior inappropriate for the child’s age according to expected developmental norms; and
2) meet the criteria in paragraph (2) of subdivision (a) of Section 5600.3 of the Welfare and Institutions Code. This section states that members of this population shall meet one or more of the following criteria:
a) As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community: and either of the following has occurred: the child is at risk of removal from home or has already been removed from the home or the mental disorder and impairments have been present for more than 6 months or are likely to continue for more than one year without treatment;
b) The child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder. her Dependents has a 60-day Special Enrollment Period if any of the following occurs:
1) An individual or Dependent loses minimum essential coverage for a reason other than failure to pay premiums on a timely basis.
2) An individual or Dependent has lost or will lose coverage under an employer health benefit plan as a result of (a) termination of his or her employment; (b) termination of employment of the individual through whom he or she was covered as a Dependent; (c) change in his or her employment status or of the individual through whom he or she was covered as a Dependent, (d) termination of the other plan’s coverage, (e) exhaustion of COBRA or Cal-COBRA continuation coverage, (f) cessation of an employer’s contribution toward his or her cover...
Outside of California. The lower of: (a) the provider’s billed charge, or, (b) the amount, if any, established by the laws of the state to be paid for Emergency Services. Rehabilitation — inpatient or outpatient care furnished to an individual disabled by injury or illness, including Severe Mental Illnesses and Severe Emotional Disturbances of a Child, in order to restore an individual’s ability to function to the maximum extent practical. Rehabilitation services may consist of Physical Therapy, Occupational Therapy, and/or Respiratory Therapy. Benefits for Speech Therapy are described in the section on Speech Therapy Benefits. established a permanent residence in another state or country.
1) have one or more mental disorders in the most recent edition of the Diagnostic and Statistical manual of Mental Disorders (other than a primary substance use disorder or developmental disorder), that results in behavior inappropriate for the child’s age according to expected developmental norms; and
2) meet the criteria in paragraph (2) of subdivision (a) of Section 5600.3 of the Welfare and Institutions Code. This section states that members of this population shall meet one or more of the following criteria:
a) As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community: and either of the following has occurred: the child is at risk of removal from home or has already been removed from the home or the mental disorder and impairments have been present for more than 6 months or are likely to continue for more than one year without treatment;
b) The child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder.
1) An individual or Dependent loses minimum essential coverage for a reason other than failure to pay premiums on a timely basis.
2) An individual or Dependent has lost or will lose coverage under an employer health benefit plan as a result of (a) termination of his or her employment; (b) termination of employment of the individual through whom he or she was covered as a Dependent; (c) change in his or her employment status or of the individual through whom he or she was covered as a Dependent, (d) termination of the other plan’s coverage, (e) exhaustion of COBRA or Cal-COBRA continuation coverage, (f) cessation of an employer’s contribution toward his or her coverage,
Outside of California. The lower of: (a) the provider’s billed charge, or, (b) the amount, if any, established by the laws of the state to be paid for Emergency Services. congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance to the extent possible, including dental and orthodontic services that are an integral part of surgery for cleft palate proce- dures.
1) has one or more mental disorders in the most recent edition of the Diagnostic and Statistical manual of Mental Disorders (other than a pri- xxxx substance use disorder or developmental disorder), that results in behavior inappropriate for the child’s age according to expected de- velopmental norms; and
2) meets the criteria in paragraph (2) of subdivi- sion (a) of Section 5600.3 of the Welfare and Institutions Code. This section states that members of this population shall meet one or more of the following criteria:
a. As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, Family relationships, or abil- ity to function in the community: and either of the following has occurred: the child is at risk of removal from home or has al- ready been removed from the home or the mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment;
b. The child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder.
Outside of California. The Blue Shield Access+ HMO provides coverage for you and your family for your Urgent Service needs when you or your family are temporarily traveling outside of California. Urgent Services may be obtained from any provider; however, us- ing the BlueCard® or Blue Shield Global Core pro- grams can be more cost-effective and may elimi- additional follow-up services from their Primary Care Physician.
Outside of California. The lower of: (a) the provider’s billed charge, or, (b) the amount, if any, established by the laws of the state to be paid for Emergency Services. an integral part of surgery for cleft palate proce- dures.
1) has one or more mental disorders in the most recent edition of the Diagnostic and Statistical manual of Mental Disorders (other than a pri- xxxx substance use disorder or developmental disorder), that results in behavior inappropriate for the child’s age according to expected de- velopmental norms; and
2) meets the criteria in paragraph (2) of subdivi- sion (a) of Section 5600.3 of the Welfare and Institutions Code. This section states that members of this population shall meet one or more of the following criteria:
a. As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, Family relationships, or abil- ity to function in the community: and either of the following has occurred: the child is at risk of removal from home or has al- ready been removed from the home or the mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment;
b. The child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder.
1) The eligible Employee or Dependent meets all of the following requirements:
a. The Employee or Dependent was covered under another employer health benefit plan or had other health insurance coverage at the time he was offered enrollment under this plan;
b. The Employee or Dependent certified, at the time of the initial enrollment, that cov- erage under another employer health plan or other health insurance was the reason for declining enrollment provided that, if he was covered under another employer health plan or had other health insurance coverage, he was given the opportunity to make the certification required as was no- tified that failure to do so could result in later treatment as a Late Enrollee;
c. The Employee or Dependent has lost or will lose coverage under another employer health benefit plan as a result of termina- tion of his employment or of an individual through whom he was covered as a Depen- dent, change in his employment status or of an individual through whom he was cov- ered as a Dependent, termination of the other plan’s coverage, exhaustion of CO- BRA continuation coverage, cessation of an employer’s contribu...
Outside of California. The lower of: (a) the provider’s billed charge, or (b) the amount, if any, established by the laws of the state to be paid for Emergency Services.
1) have one or more mental disorders in the most recent edition of the Diagnostic and Statistical manual of Mental Disorders (other than a pri- xxxx substance use disorder or developmental disorder), that results in behavior inappropriate for the child’s age according to expected de- velopmental norms; and
2) meet the criteria in paragraph (2) of subdivi- sion (a) of Section 5600.3 of the Welfare and Institutions Code. This section states that Members of this population shall meet one or more of the following criteria:
Outside of California. The lower of: (a) the provider’s billed charge, or (b) the amount, if any, established by the laws of the state to be paid for Emergency Services.
1) have one or more mental disorders in the most recent edition of the Diagnostic and Statistical manual of Mental Disorders (other than a pri- xxxx substance use disorder or developmental disorder), that results in behavior inappropriate for the child’s age according to expected de- velopmental norms; and
2) meet the criteria in paragraph (2) of subdivi- sion (a) of Section 5600.3 of the Welfare and Institutions Code. This section states that Members of this population shall meet one or more of the following criteria:
a. As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community: and either of the following has occurred: the child is at risk of removal from home or has already been removed from the home or the mental disorder and impairments have been present for more than 6 months or are likely to continue for more than one year without treatment;
b. The child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder. Skilled Nursing — services performed by a li- censed nurse (either a registered nurse or a li- censed vocational nurse). in, this Health Plan outside of the initial and annual Open Enrollment Periods. An eligible Employee or an Employee’s Dependent has a 30-day Special Enrollment Period, except as otherwise stated, if any of the following occurs:
1) The eligible Employee or Dependent meets all of the following requirements:
