Prohibition on Enrollee Charges for Covered Services. The Contractor must ensure Enrollees are not held liable for any of the following:
Prohibition on Enrollee Charges for Covered Services. 10.4.1 Under no circumstances will the Contractor, or any providers used to deliver services under the terms of this Contract, including non-participating providers, charge Enrollees for covered services as described in the (SSA 1932(b)(6), SSA 1128B(d)(1)), 42 C.F.R. § 438.106(c), 438.6(1), 438.230, 438.204(a) and WAC 182-502-0160).
Prohibition on Enrollee Charges for Covered Services. The Contractor shall ensure Enrollees are not held liable for any of the following: • Costs due to receiving services from an out-of-network provider. • Covered mental health services provided by insolvent community psychiatric hospitals with which the Contractor has directly contracted. • Covered mental health services, including those purchased on behalf of the Enrollee. • Covered mental health services for which the State does not pay the Contractor. • Covered services provided to the Enrollee, for which the State or the Contractor does not pay the MHCP or BHA that furnishes the services under a contractual, referral, or other arrangement. • Payments for covered services furnished under a Contract, referral, or other arrangement, to the extent that those payments are in excess of the amount that the Enrollee would owe if the Contractor provided the services directly. • Covered mental health services provided by insolvent federally funded PIHPs. • Debts of the Contractor if the Contractor becomes financially insolvent.
Prohibition on Enrollee Charges for Covered Services. 10.4.8 Under no circumstances shall the Contractor, or any providers used to deliver services under the terms of this Contract, including non-participating providers, charge enrollees for covered services, except enrollee participation in cost of care, and spend down payments required for certain eligibility groups.
