Emergency Room [$50] Copayment / visit; credited toward Inpatient Copayment if admission occurs within 24 hours [$50]Copayment; waived if admission occurs within 24 hours; Deductible/Coinsurance [Urgent Care [$30] Copayment/visit Deductible/Coinsurance] Immunizations and lead screening for children No Copayment, Deductible or Coinsurance Coinsurance Preventive Care No Copayment, Deductible or Coinsurance [Deductible/ Coinsurance] Orally administered prescription drugs Refer to the Covered Services and Supplies and Covered Charges sections Refer to the Covered Services and Supplies and Covered Charges sections All other Prescription Drugs Deductible/Coinsurance Deductible/Coinsurance All other services and supplies Deductible/Coinsurance Deductible/Coinsurance Cash Deductible per [Calendar] [Plan] Year Network and Non-Network Per Member [amount not to exceed $2,000] [Per Covered Family [Dollar amount which is two times the individual Deductible.] ] Coinsurance Network [50% - 10%, in 5% increments] Non-Network [50% - 10%, in 5% increments] Network Maximum Out of Pocket Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Network and covered services and supplies in a [Calendar] [Plan] Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Network Maximum Out of Pocket. Once the Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Network or Non-Network covered services and supplies for the remainder of the [Calendar] [Plan] Year. The Network Maximum Out of Pocket for this Policy is as follows: Per Member per [Calendar] [Plan] Year [An amount not to exceed $[6,850 or amount permitted by 45 C.F.R. 156.130]] cancer
DIAGNOSTIC SERVICES. Procedures ordered by a Provider because of specific symptoms to diagnose a specific condition or disease. Some examples include, but are not limited to: radiology, ultrasound, and nuclear medicine; laboratory and pathology; and EKGs, EEGs, and other electronic diagnostic tests. With respect to [Non-Network] benefits, except as allowed under the Preventive Care Covered Charge, Diagnostic Services are not covered under the Contract if the procedures are ordered as part of a routine or periodic physical examination or screening examination. DISCRETION / DETERMINATION / DETERMINE. Our right to make a decision or determination. The decision will be applied in a reasonable and non-discriminatory manner. DURABLE MEDICAL EQUIPMENT. Equipment We Determine to be: designed and able to withstand repeated use; used primarily and customarily for a medical purpose; is generally not useful to a [Member] in the absence of an Illness or Injury; and suitable for use in the home. Durable Medical Equipment includes, but is not limited to, apnea monitors, breathing equipment, hospital-type beds, walkers, and wheelchairs as well as hearing aids which are covered through age 15. Items such as walkers, wheelchairs and hearing aids are examples durable medical equipment that are also habilitative devices. Among other things, Durable Medical Equipment does not include: adjustments made to vehicles, air conditioners, air purifiers, humidifiers, dehumidifiers, elevators, ramps, stair glides, Emergency Alert equipment, handrails, heat appliances, improvements made to a [Member's] home or place of business, waterbeds, whirlpool baths, exercise and massage equipment. EFFECTIVE DATE. The date on which coverage begins under the Contract for the Contractholder, or the date coverage begins under the Contract for a [Member], as the context in which the term is used suggests. EMERGENCY. A medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of Substance Use Disorder such that a prudent layperson, who possesses an average knowledge of health and medicine, could expect the absence of immediate medical attention to result in: placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. With respect to a pregnant woman who is having Contractions, an Emergency exists where: there
Intravenous conscious sedation/analgesia – 2 hour maximum time Nitrous oxide/analgesia Non-intravenous conscious sedation – to include oral medications Behavior management – for additional time required to provide services to a child with special needs that requires more time than generally required to provide a dental service. Request must indicate specific medical diagnosis and clinical appearance. One unit equals 15 minutes of additional time Utilization thresholds are based on place of service as follows. Prior authorization is required when thresholds are exceeded. Office or Clinic maximum – 2 units Inpatient/Outpatient hospital – 4 units Skilled Nursing/Long Term Care – 2 units Consultation by or non-primary care provider Professional visits House or facility visit – for a single visit to a facility regardless of the number of members seen on that day. Hospital or ambulatory surgical center call For cases that are treated in a facility. For cases taken to the operating room –dental services are provided for patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation – (during regular hours) no other service performed Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments – by report Application of desensitizing medicament – per visit Occlusal guard – for treatment of bruxism, clenching or grinding Athletic mouthguard covered once per year Occlusal adjustment Limited - (per visit) Complete (regardless of the number of visits), once in a lifetime Odontoplasty Internal bleaching ] Note to carriers: the above Dental benefits provision is variable and may be deleted if a stand-alone dental plan is bought. If the provision is deleted include the following heading such that the under age 6 provision would be part of the Dental Care and Treatment provision.
Anesthesia Local anesthesia NOT in conjunction with operative or surgical procedures. Regional block Trigeminal division block. Deep sedation/general anesthesia provided by a dentist regardless of where the dental services are provided for a medical condition covered by this Policy which requires hospitalization or general anesthesia. 2 hour maximum time Intravenous conscious sedation/analgesia – 2 hour maximum time Nitrous oxide/analgesia Non-intravenous conscious sedation – to include oral medications Behavior management – for additional time required to provide services to a child with special needs that requires more time than generally required to provide a dental service. Request must indicate specific medical diagnosis and clinical appearance. One unit equals 15 minutes of additional time Utilization thresholds are based on place of service as follows. Prior authorization is required when thresholds are exceeded. Office or Clinic maximum – 2 units Inpatient/Outpatient hospital – 4 units Skilled Nursing/Long Term Care – 2 units Consultation by specialist or non-primary care provider Professional visits House or facility visit – for a single visit to a facility regardless of the number of members seen on that day. Hospital or ambulatory surgical center call For cases that are treated in a facility. For cases taken to the operating room –dental services are provided for patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation – (during regular hours) no other service performed Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments – by report Application of desensitizing medicament – per visit Occlusal guard – for treatment of bruxism, clenching or grinding Athletic mouthguard covered once per year Occlusal adjustment
Subject to the American Cancer Society guidelines, and medical necessity as determined by the [Member’s] Practitioner in consultation with the [Member] regarding methods to use, We will cover charges for: Annual gFOBT (guaiac-based fecal occult blood test) with high test sensitivity for cancer; Annual FIT (immunochemical-based fecal occult blood test) with high test sensitivity for cancer; Stool DNA (sDNA) test with high sensitivity for cancer flexible sigmoidoscopy, colonoscopy; contrast barium enema; Computed Tomography (CT) Colonography any combination of the services listed in items a – g above; or any updated colorectal screening examinations and laboratory tests recommended in the American Cancer Society guidelines. We will cover the above methods at the frequency recommended by the most recent published guidelines of the American Cancer Society and as determined to be medically necessary by the [Member’s] practitioner in consultation with the [Member.] High risk for colorectal cancer means a [Member] has: A family history of: familial adenomatous polyposis, heriditary non-polyposis colon cancer; or breast, ovarian, endometrial or colon cancer or polyps; Chronic inflammatory bowel disease; or A background, ethnicity or lifestyle that the practitioner believes puts the person at elevated risk for colorectal cancer. Please note that colorectal cancer screening is included under the Preventive Care provision. Private Duty Nursing Care We only cover charges by a Nurse for Medically Necessary and Appropriate private duty nursing care if such care is authorized as part of a written home health care plan, coordinated by a Home Health Agency, and covered under the Home Health Care Charges section. Any other charges for private duty nursing care are not covered. Therapy Services Therapy Services mean the following services or supplies, ordered by a Practitioner and used to treat, or promote recovery from, an Injury or Illness: Subject to the stated limits, We cover the Therapy Services listed below. We cover other types of Therapy Services provided they are performed by a licensed Provider, are Medically Necessary and Appropriate and are not Experimental or Investigational.
A domestic partner, a civil union partner, and the child of an Employee’s domestic partner or civil union partner are never considered Qualified Continuees eligible to elect CCR. They may, however, be a Qualified Continuee eligible to elect under New Jersey Group Continuation Rights (NJGCR). Refer to the NJGCR section for more information. Exception: A child who is born to the covered Employee, or who is placed for adoption with the covered Employee during the continuation provided by this section is a Qualified Continuee. If An Employee's Group Health Benefits Ends If an Employee's group health benefits end due to his or her termination of employment or reduction of work hours, he or she may elect to continue such benefits for up to 18 months, unless he or she was terminated due to gross misconduct. A Qualified Continuee may elect to continue coverage under COBRA even if the Qualified Continuee: is covered under another group plan on or before the date of the COBRA election; or is entitled to Medicare on or before the date of the COBRA election. The continuation: may cover the Employee and any other Qualified Continuee; and is subject to the When Continuation Ends section. Extra Continuation for Disabled Qualified Continuees If a Qualified Continuee is determined to be disabled under Title II or Title XVI of the United States Social Security Act on the date his or her group health benefits would otherwise end due to the Employee's termination of employment or reduction of work hours or during the first 60 days of continuation coverage, he or she and any Qualified Continuee who is not disabled may elect to extend his or her 18 month continuation period above for up to an extra 11 months. To elect the extra 11 months of continuation, the Qualified Continuee or other person acting on his or her behalf must give the Employer written proof of Social Security's determination of his or her disability within 60 days measured from the latest of: the date on which the Social Security Administration issues the disability determination; the date the group health benefits would have otherwise ended; or the date the Qualified Continuee receives the notice of COBRA continuation rights. If, during this extra 11 month continuation period, the Qualified Continuee is determined to be no longer disabled under the Social Security Act, he or she must notify the Employer within 30 days of such determination, and continuation will end, as explained in the When Continuation Ends section. An additional 50% of the total premium charge also may be required from the Qualified Continuee by the Employer during this extra 11 month continuation period.