Common use of Prohibition on Enrollee Charges for Covered Services Clause in Contracts

Prohibition on Enrollee Charges for Covered Services. The Contractor must ensure Enrollees are not held liable for any of the following: 11.11.1. Costs due to receiving services from an out-of-network provider. 11.11.2. Covered behavioral health services provided by insolvent community psychiatric hospitals with which the Contractor has directly contracted. 11.11.3. Covered behavioral health services, including those purchased on behalf of the Enrollee. 11.11.4. Covered behavioral health services for which Great Rivers does not pay the Contractor. 11.11.5. Covered services provided to the Enrollee, for which the State or the Contractor does not pay the behavioral health medical provider, MHCP, CDP/CDPT, or BHA that furnishes the services under a contractual, referral, or other arrangement. 11.11.6. 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. 11.11.7. Covered behavioral health services provided by insolvent federally funded PIHPs 11.11.8. Debts of the Contractor if the Contractor becomes financially insolvent.