Payments from Enrollees. Enrollees utilizing medical services which are not medically necessary or who obtain Covered Services from Outside Providers without prior authorization and referral by the Contractor shall be responsible for payment in full of all costs associated with such services. The Contractor shall not require any co-payments, deductibles or other cost sharing by Enrollees for Covered Services under this Contract, nor may the Contractor charge Enrollees for missed appointments. Neither shall Enrollees who are insured under private health plans be required to pay any portion of the medical fees for Covered Services under this contract, even during the deductible periods of these other health plans.
Payments from Enrollees. The MCO shall not require co-payments, deductibles, or other forms of cost sharing from Medicaid Enrollees for Medicaid services covered under this Contract, nor shall MCO charge Enrollees for missed appointments. Enrollees who obtain services from Out-of-Network Providers without MCO authorization, except those services specified in Sections 6.3 and 6.18, shall be responsible for payment of costs associated with such services. As specified in 42 CFR 438.114(e), the MCO shall limit charges to enrollees for post-stabilization care services to an amount no greater than what the organization would charge the enrollee if he or she had obtained the services through MCO. Enrollees shall not be held liable for payments to Providers in the event that MCO or its subcontractors become insolvent or DMA does not pay MCO.
Payments from Enrollees. Enrollees utilizing medical services which are not medically necessary or who obtain Covered Services from Outside Providers without prior authorization and referral by the Contractor shall be responsible for payment in full of all costs associated with such services. The Contractor shall not require any co-payments, deductibles or other cost sharing by Enrollees for Covered Services under this Contract, nor may the Contractor charge Enrollees for missed appointments. Neither shall Enrollees who are insured under private health plans be required to pay any portion of the medical fees for Covered Services under this contract, even during the deductible periods of these other health plans. The Enrollee may be responsible for non-covered item(s) and/or service(s), only if, the provider ensures that written documentation in compliance with the Advance Beneficiary Notification (ABN) is received from the Enrollee that an item(s) or service(s) rendered is a non-covered item and/or service(s) and that the Enrollee will be financially responsible for the item(s) and/or service(s).
Payments from Enrollees. The LME shall not require co-payments, deductibles, or other forms of cost sharing from Medicaid Enrollees for Medicaid services covered under this Contract, nor shall the LME charge Enrollees for missed appointments. Enrollees who obtain services from Out-of-Network Providers without LME authorization, except those services specified in Sections 6.3 and 6.18, shall be responsible for payment of costs associated with such services. As specified in 42 CFR 438.114(e), the LME shall limit charges to enrollees for post-stabilization care services to an amount no greater than what the organization would charge the enrollee if he or she had obtained the services through the LME. Enrollees shall not be held liable for payments to Providers in the event that the LME or its subcontractors become insolvent or DMA does not pay the LME.
