Cost-Shares definition

Cost-Shares. The amount that a Member has to pay when services or drugs are received. It includes any combination of the following three types of payments: (1) any Deductible amount a plan may impose before services or drugs are covered; (2) any fixed Copayment amount that a plan requires when a specific service or drug is received; or (3) any Coinsurance amount, a percentage of the total amount paid for a service or a drug, that a plan requires when a specific service or drug is received. Custodial Care: Care for personal needs rather than Medically Necessary needs. Custodial Care is care that can be provided by people who do not have professional skills or training. This care includes help with walking, dressing, bathing, eating, preparation of special diets, and taking medications. This plan does not cover Custodial Care unless it is provided as a part of daily skilled nursing care or skilled rehabilitation services you are receiving Effective Date: The date when your coverage under this plan begins. If you re-enroll in this plan after a lapse in coverage, the date that the coverage begins again will be your Effective Date. Emergency Care: Covered Services that are: 1) rendered by a Provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize a Member with a condition considered a Medical Emergency. Stabilize means to provide such medical treatment of the Medical Emergency as may be necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the Member from a Medical Facility. Experimental/Investigational Services: Experimental or Investigational services include a treatment, procedure, equipment, drug, drug usage, medical device or supply that meets one or more of the criteria described below, as determined by us. An Experimental/Investigative service is: Formulary: CHPW’s list of selected Prescription Drugs that are covered under this plan. CHPW established its Formulary and reviews and updates it routinely. Drugs are reviewed and selected for inclusion in CHPW’s Formulary by an outside committee of Providers, including physicians and pharmacists.
View Source
Cost-Shares. In-Network Services Subject to Copays: Copays: Medical Office Visit, $5; Preventive Care Office Visit, $0; Emergency Room, $0; and Per inpatient Admission, $0. Office Visit Maximum: Unlimited. Lifetime Maximum in-Network Benefit: Unlimited. Coinsurance: 80% of the first $4,000 Individual/$8,000 Family worth of Eligible Expenses up to an Annual Out- of-Pocket Expense of $1,000 individual/$2,000 Family. Lifetime Maximum Out-of-Network Benefit: $1,000,000. Pediatric Covered according to an age-based schedule with $0 copay. Covered according to an age-based schedule with $0 copay. Vision Hearing Gynecological Covered once every 2 years with $0 copay. Covered once every 2 years with $0 copay. Covered once every year with $0 copay.
View Source

Examples of Cost-Shares in a sentence

  • See the Schedule of Cost-Shares and Benefits for any applicable Deductible, Coinsurance, Copayment, and Benefit Limitation information.

  • Refer to your Schedule of Cost-Shares and Benefits for any Copayment, Coinsurance, and/or Deductible that applies when you obtain Prescription Drugs.

  • Diagnostic Laboratory and Pathology Services Diagnostic Imaging Services and Electronic Diagnostic Tests Advanced Imaging Services Emergency Care and Urgent Care Services See the Schedule of Cost-Shares and Benefits for any applicable Deductible, Coinsurance, Copayment, and Benefit Limitation information.

  • So, as with other health care services, the cost of a medication is a factor when we decide where medications will go in our “tiered system” of Cost-Shares.

  • Please refer to your Benefit Summary to see if your Plan is one of our HSA-compatible high deductible health plans (HDHPs) and to find out which Cost-Shares apply to your Plan after the Plan Deductible is met.

  • Cost-Shares can be Deductibles, Copayments and/or Coinsurance amounts.

  • When a Member is transferred from one Hospital or other facility to another Hospital or other facility on the same day, any Copayment per admission in the Schedule of Cost-Shares and Benefits is waived for the second admission.

  • Therapy Services See the Schedule of Cost-Shares and Benefits for any applicable Deductible, Coinsurance, Copayment, and Benefit Limitation information.

  • Mastectomy Notice Sterilization Telemedicine Services Temporomandibular Joint (TMJ) and Craniomandibular Joint Services See the Schedule of Cost-Shares and Benefits for any applicable Deductible, Coinsurance, Copayment, and Benefit Limitation information.

  • Effective for Plan renewals or new Plans on or after September 23, 2010, some Participating Provider preventive and wellness services, as defined by the United States Preventive Service Task Force and that are listed in your Benefit Summary, are exempt from all Member Cost-Shares (Deductible, Copayment and Coinsurance) under the Patient Protection and Affordable Care Act (PPACA).

Related to Cost-Shares

  • Cost Share means the member’s financial obligation for a covered service. Depending on the plan type, cost-share may include one or more of the following: deductible, copay, access fee, coinsurance, pharmacy deductible, and precertification charges.

  • Net Shares has the meaning provided in Section 2.12 hereof.

  • Adjustment Shares shall have the meaning set forth in Section 11(a)(ii) hereof.

  • Coop Shares Shares issued by a Cooperative Corporation.

  • Earnout Shares has the meaning set forth in Section 3.6(a).