CLASS(ES) [All eligible employees] SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (using copayment for network services) [Note to carriers: Dollar amounts shown on the schedule pages are illustrative only. Refer to N.J.A.C. 11:21-3.1 for permissible ranges. Network benefits may be structured with tiers. For an example refer to the HMO contract form, Appendix Exhibit G.] THE SERVICES, SUPPLIES AND BENEFITS COVERED UNDER THIS CONTRACT ARE SUBJECT TO THE PAYMENT OF THE APPLICABLE COPAYMENTS, DEDUCTIBLE AND COINSURANCE. SERVICES [NETWORK] [NON-NETWORK] Hospital Inpatient (unlimited days) [$150] Copayment / day; maximum / admission [$750]; maximum / cal. year [$1500] Deductible/Coinsurance Outpatient Visit [$15] Copayment / visit Deductible/Coinsurance Practitioner services provided at a Hospital Inpatient Visit $0 Copayment / visit Deductible/Coinsurance Outpatient Visit [$15] Copayment / visit; waived if another Copayment applies Deductible/Coinsurance 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] Pre-natal care [$0] Copayment / visit Deductible/Coinsurance Practitioner Services [$15] Copayment / visit Deductible/Coinsurance [Telemedicine Visits [E-Visits [$15] Copayment / visit [$15] Copayment / visit N/A] N/A]
(h) HOME HEALTH CARE. The following Services are covered upon prior written referral from a [Member]'s Primary Care Provider. When home health care can take the place of Inpatient care, We cover such care furnished to a [Member] under a written home health care plan. We cover all Medically Necessary and Appropriate services or supplies, such as: Routine Nursing Care furnished by or under the supervision of a registered Nurse; physical therapy; occupational therapy; medical social work; nutrition services; speech therapy; home health aide services; medical appliances and equipment, drugs and medications, laboratory services and special meals to the extent such items and services would have been covered under this Contract if the [Member] had been in a Hospital; and any Diagnostic or therapeutic service, including surgical services performed in a Hospital Outpatient department, a Practitioner's office or any other licensed health care Facility, provided such service would have been covered under the Contract if performed as Inpatient Hospital services. Payment is subject to all of the terms of this Contract and to the following conditions: a. The [Member’s] Practitioner must certify that home health care is needed in place of Inpatient care in a recognized Facility. Home health care is covered only in situations where continuing hospitalization or confinement in a Skilled Nursing Facility or would otherwise have been required if home health care were not provided. b. The services and supplies must be: ordered by the [Member’s] Practitioner; included in the home health care plan: and furnished by, or coordinated by, a Home Health Agency according to the written home health care plan. The services and supplies must be furnished by recognized health care professionals on a part-time or intermittent basis, except when full-time or 24 hour service is needed on a short-term (no more than three-day) basis. c. The home health care plan must be set up in writing by the [Member’s] Practitioner within 14 days after home health care starts. And it must be reviewed by the [Member’s] Practitioner at least once every 60 days. e. We do not pay for: services furnished to family members, other than the patient; or services and supplies not included in the home health care plan. Any visit by a member of a home health care team on any day shall be considered as one home health care visit. Benefits for Home Health Care are provided for no more than 60 visits per [Calendar] [Plan] Year.
The [Member's] Practitioner must certify that home health care is needed in place of Inpatient care in a recognized Facility. . Home health care is covered only in situations where continuing hospitalization or confinement in a Skilled Nursing Facility or would otherwise have been required if Home Health Care were not provided. The services and supplies must be: ordered by the [Member's] Practitioner; included in the home health care plan: and furnished by, or coordinated by, a Home Health Agency according to the written home health care plan. The services and supplies must be furnished by recognized health care professionals on a part-time or intermittent basis, except when full-time or 24 hour service is needed on a short-term (no more than three-day) basis. The home health care plan must be set up in writing by the [Member's] Practitioner within 14 days after home health care starts. And it must be reviewed by the [Member's] Practitioner at least once every 60 days. We do not pay for: services furnished to family members, other than the patient; or services and supplies not included in the home health care plan. Any visit by a member of a home health care team on any day shall be considered as one home health care visit. Benefits for Home Health Care are provided for no more than 60 visits per [Calendar] [Plan] Year. ANY HOME HEALTH CARE SERVICES OR SUPPLIES A [MEMBER] RECEIVES AS A [NETWORK] SERVICE OR SUPPLY WILL REDUCE THE HOME HEALTH CARE BENEFIT AVAILABLE AS A [NON-NETWORK] COVERED CHARGE. We will reduce benefits by 50% with respect to charges for treatment, services and supplies for Home Health Care which are not Pre-Approved by Us provided that benefits would otherwise be payable under this Contract. Practitioner's Charges for Non-Surgical Care and Treatment We cover Practitioner's charges for the Medically Necessary and Appropriate care and treatment of an Illness or Injury. Practitioner's Charges for Surgery We cover Practitioner's charges for Medically Necessary and Appropriate Surgery. [Carrier] does not pay for Cosmetic Surgery unless it is required as a result of an Illness or Injury or to correct a functional defect resulting from a congenital abnormality or developmental anomaly.
duration; the anticipated outcomes stated as goals; and the frequency by which the treatment plan will be updated. We may request additional information if necessary to determine the coverage under the Contract. We may require the submission of an updated treatment plan once every six months unless We and the treating physician agree to more frequent updates. If a Member: is eligible for early intervention services through the New Jersey Early Intervention System; and has been diagnosed with autism or other developmental disability; and receives physical therapy, occupational therapy, speech therapy, applied behavior analysis or related structured behavior services the portion of the family cost share attributable to such services is a Covered Charge under this Contract. The deductible, coinsurance or copayment as applicable to a physician visit for treatment of an Illness or Injury will apply to the family cost share. The therapy services a Member receives through New Jersey Early Intervention do not reduce the therapy services otherwise available under this Diagnosis and Treatment of Autism and Other Disabilities provision. NOTE: ANY SERVICES AND SUPPLIES A [MEMBER] RECEIVES AS [NETWORK] SERVICES AND SUPPLIES WILL REDUCE THE BENEFITS AVAILABLE AS A [NON-NETWORK] COVERED CHARGE. Fertility Services Subject to Our Pre-Approval We cover charges for procedures and Prescription Drugs to enhance fertility, except where specifically excluded in this Contract. We cover charges for: artificial insemination; and standard dosages, lengths of treatment and cycles of therapy of Prescription Drugs used to stimulate ovulation for artificial insemination or for unassisted conception. The Prescription Drugs noted in this section are subject to the terms and conditions of the Prescription Drugs section of this Contract. We will reduce benefits by 50% with respect to charges for Fertility Services which are not Pre-Approved by Us provided that benefits would otherwise be payable under this Contract. Preventive Care We cover charges for routine physical examinations including related laboratory tests and x-rays. We also cover charges for immunizations and vaccines, well baby care, pap smears, mammography , screening tests, bone density testing and Nicotine Dependence Treatment. [But We limit what We pay each [Calendar] [Plan] Year to: $750 per [Member] for a Dependent child from birth until the end of the [Calendar] [Plan] Year in which the Dependent child attains age 1, and $500 per [Member] for all other [Member]s.]
When this [Contract] is coordinating benefits with a Plan that provides benefits only for dental care, vision care, prescription drugs or hearing aids, Allowable Expense is limited to like items of expense. [Carrier] will not consider the difference between the cost of a private hospital room and that of a semi-private hospital room as an Allowable Expense unless the stay in a private room is Medically Necessary and Appropriate. When this [Contract] is coordinating benefits with a Plan that restricts coordination of benefits to a specific coverage, We will only consider corresponding services, supplies or items of expense to which coordination of benefits applies as an Allowable Expense. Allowed Charge: An amount that is not more than the usual or customary charge for the service or supply as determined by Us, based on a standard which is most often charged for a given service by a Provider within the same geographic area . Claim Determination Period: A [Calendar] [Plan] Year, or portion of a [Calendar] [Plan] Year, during which a [Member] is covered by this [Contract] and at least one other Plan and incurs one or more Allowable Expense(s) under such plans. Plan: Coverage with which coordination of benefits is allowed. Plan includes: Group insurance and group subscriber contracts, including insurance continued pursuant to a Federal or State continuation law; Self-funded arrangements of group or group-type coverage, including insurance continued pursuant to a Federal or State continuation law; Group or group-type coverage through a health maintenance organization (HMO) or other prepayment, group practice and individual practice plans, including insurance continued pursuant to a Federal or State continuation law; Group hospital indemnity benefit amounts that exceed $150 per day; Medicare or other governmental benefits, except when, pursuant to law, the benefits must be treated as in excess of those of any private insurance plan or plan. Plan does not include: Individual or family insurance contracts or subscriber contracts; Individual or family coverage through a health maintenance organization or under any other prepayment, group practice and individual practice plans; Group or group-type coverage where the cost of coverage is paid solely by the [Member] except that coverage being continued pursuant to a Federal or State continuation law shall be considered a Plan; Group hospital indemnity benefit amounts of $150 per day or less; School accident –type coverage; A State plan under Medicaid.
ASSIGNMENT No assignment or transfer by the Contractholder or [Member] of any of the Contractholder's or [Member’s] interest, as appropriate, under this Contract is valid unless We consent thereto. CLERICAL ERROR - MISSTATEMENTS Except as stated below, neither clerical error nor programming or systems error by the Contractholder, nor Us in keeping any records pertaining to coverage under this Contract, nor delays in making entries thereon, will invalidate coverage which would otherwise be in force, or continue coverage which would otherwise be validly terminated. Upon discovery of such error or delay, an appropriate adjustment of premiums will be made, as permitted by law. Exception: If an Employee contributed toward the premium payment and coverage continued in force beyond the date it should have been validly terminated as a result of such error or delay, the continued coverage will remain in effect through the end of the period for which the Employee contributed toward the premium payment and no premium adjustment will be made. Premium adjustments involving return of unearned premium to the Contractholder for such errors or delays will be made only if the Employee did not contribute toward the premium payment. Except as stated in the Premium Refunds section of the Premium Amounts provision, such return of premium will be limited to the period of 12 months preceding the date of Our receipt of satisfactory evidence that such adjustments should be made. If the age or gender of an Employee is found to have been misstated, and the premiums are thereby affected, an equitable adjustment of premiums will be made. CONFORMITY WITH LAW Any provision of this Contract which, is in conflict with the laws of the State of , or with Federal law, shall be construed and applied as if it were in full compliance with the minimum requirements of such State law or Federal law. CONTINUING RIGHTS Our failure to apply terms or conditions does not mean that We waive or give up any future rights under this Contract. EMPLOYEE'S EVIDENCE OF COVERAGE We will give the Contractholder an individual evidence of coverage to give each covered Employee. It will describe the Employee's coverage under this Contract. It will include: to whom We provide services and supplies or pay benefits; any protection and rights when the coverage ends; and claim rights and requirements.