Reso 2010-1529 - Laserfiche WebLink

Home Browse Search

') ) () . If the Health Professional and/or facility used is part of the PHCS Network, covered serviccs are payable at the middle Benefit Level specified in the Schedule of Benefits. The PHCS Network is not available within the AvMed Service Area. . If the Health Professional and/or facility used is an Out-of-Network Provider, benefits for services covered are payable at the low Benefit Level as specified in the Schedule of Benefits. An important feature of this Point of Service Plan is that the amount of your out-of-pocket expense is detelmined by your choice of provider at the time services are sought: . Members choosing AvMed Choice providers will be responsible for paying lower Co-payments and/or Co- insurance. . Members choosing Providers from the PHCS Network while outside the A vMed Service Area will be responsible for paying mid-level Co-payment and/or Deductible and Co-insurance amounts. . Members choosing Out-of-Network Providers will pay the highest Deductibles and Co-insurance amounts and will also be at risk for provider fees that are in excess of allowable amounts. In other words, a Member who chooses an Out-of-Network Provider may be responsible to pay the amount that exceeds the Maximum Allowable Payment for the particular medical service involved in addition to the applicable Deductible and Co-insurance amounts. Also, fees that are in excess of allowable amounts are not a covered benefit and therefore do not apply to your Deductible or annual out-of-pocket expense. It is the Member's responsibility when seeking benefits uuder this Contract to identifY himself as an AvMed Member and to verifY that the provider chosen is still a contracted provider of the selected network, if any. Any Member requiring medical, Hospital, or ambulance services for emergencies (as described in Subsections 2.20.01 and 2.20.02), either while outside the Service Area or within the Service Area but before they can reach a Participating Provider, may receive the emergency benefits as specified in Section 9.11. Only services and beuefits in conformity with Part II (Definitions), Part IX (Schedule of Basic Benefits), Part X (Limitations of Basic Benefits), Part XI (Exclusions from Basic Benefits) and the Schedule of Benefits, which by reference is incorporated herein, are covered by AvMed. Members must understand that services will not be covered if they are not, in AvMed's opinion, Medically Necessary. Any and all decisions made by AvMed in administering the provisious of this Contract, including without limitation, the provisions of Part IX (Schedule of Basic Benefits), Part X (Limitations of Basic Benefits), and Part XI (Exclusions from Basic Benefits), are made only to determine whether payment for auy benefits will be made by AvMed. Any and all decisions that pertain to the medical need for, or desirability of the provision or non-provision of Medical Services or benefits, including without limitation, the most appropriate level of such Medical Services or benefits, must be made solely by the Member and his physician, in accordance with the normal patient/physician relationship for purposes of determining what is in the best interest of the Member. AvMed does not have the right of control over the medical decisions made by the Member's physician or health care providers. The ordering of a service by a physician, whether participating or non-participating, does not in itself make such service Medically Necessary. Subscribing Group and Member acknowledge that it is possible that a Member and his physician may determine that such services or supplies are appropriate even though such services or supplies are not covered and will not be amU1ged or paid for by A vMed. Any covered service for which the member is seeking reimbursement, must be submitted to the Plan within one year from the date of service to be considered. Cost-Sharing Information Deductible. In some instances, you mllst satisfy the annual Deductible specified in the Schedule of Benefits before A vMed will begin paying expenses for services covered. The Deductible means the amount a Member must pay each calendar year for covered services before A vMed will make payment for eligible expenses. The 22 A V-CHOlCE-2009 MP-5320 (10/09)