Reimbursement Levels and Coinsurance Sample Clauses

Reimbursement Levels and Coinsurance. Network providers and hospitals shall be prohibited from balance billing, that is, from charging any participant any additional amount other than co-pays, coinsurance or deductibles for covered services. Network Providers shall submit bills and other required paperwork on behalf of the participant. With the exception of certain preventive services which are covered at one hundred percent (100%) and office visits which are covered in full after payment of an office visit co-pay or other specified service, the plan will pay eighty percent (80%) of those covered services performed by network providers. In those instances the participant pays twenty percent (20%) of the plans’ reimbursement rate up to the medical/behavioral health out-of- pocket maximum. Non-network providers may or may not accept the plan’s payment as payment in full. The plan will pay sixty percent (60%) of the contracted allowable amount for non-network providers for covered services. The participant pays forty percent (40%). The non-network provider may xxxx the participant the balance between what is charged and what the plan allows.
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Reimbursement Levels and Coinsurance. Network providers and hospitals shall be prohibited from balance billing, that is, from charging any participant any additional amount other than copays, coinsurance or deductibles for covered services. Network Providers shall submit bills and other required paperwork on behalf of the participant. With the exception of certain preventive services which are covered at one hundred percent (100%) and office visits which are covered in full after payment of an office visit copay or other specified service, the plan will pay eighty percent (80%) of those covered services performed by network providers. In those instances, the participant pays twenty percent (20%) of the plans’ reimbursement rate up to the medical/behavioral health out-of- pocket maximum. Except as provided for in Section 55.04 (A), employee co-insurance shall not exceed twenty percent (20%) of the paid charges for covered network services. In health plans which offer to employees the option of using a network or a non-network provider or facility, the plan will pay sixty percent (60%) of the contracted allowable amount for non-network providers for covered services. The participant pays forty percent (40%). The employee coinsurance when using a non-network provider or facility shall not exceed forty percent (40%) of the plan’s contracted allowable amount for non-network providers. Non- network providers may or may not accept the plan’s payment as payment in full. The non-network provider may bill the participant the balance between what is charged and what the plan allows.
Sample 1

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