Reso 2010-1529 - Laserfiche WebLink

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f) Amendment AvMED HEALTH PLANS Large Group. Deductible and Co-insurance These provisions of the policy are amended as follows: "a,tlll. DEFINITIONS, has been amended to add the following definitions: n . "Calendar Year" means the twelve-month period beginning January I and ending December 31. . IICo-insurance" means the amount a covered Member must pay, once the Deductible has been met, and is expressed as a percentage of tile allowed amount for the covered benefit. . "Deductible" means the first payments up to a specified dollar amount, excluding Co-payments, that a Member must make in the applicable Calendar Year for covered benefits. The Deductible applies to each Member, subject to any family Deductible listed on the Schedule of Benefits. Fo, purposes of the Deductible, "family" means the Subscriber and Covered Dependents. The Deductible must be satisfied once each Calendar Year, except for: o the Common Accident Provision: if the Deductible applies to accident expenses and if 2 or more Members of any family receive covered benefits because of disabilities resulting from injuries sustained in anyone accident, the Deductible will be applied only once with respect to all covered benefits received as a result of the accident. o the Deductible Credit Provision: any expense incurred by a Member while covered under the group's prior carrier will be credited toward satisfaction of the Deductible under this Plan if: o the expenses were incurred during the 90-day period before the effective date of the Group Plan; o the expenses were applied toward satisfaction of the Deductible under the prior coverage during the 90-day period before the effective date of this Group Plan; and o the expenses would be considered eligible expenses under this Group Plan. However, in order to receive credit, you must supply evidence of satisfaction of the Deductible under the prior coverage by providing A vMed Health Plans written proof of what has been paid by prior carrier. o the Carryover Provision: if any part or all of the Deductible has been satisfied during the last 3 months of the preceding Calendar Yea" the Deductible for the next Calendar year will be reduced by the amount satisfied. Under Pa,t VII. MONTHLY PAYMENTS AND CO-PAYMENTS, has been amended as follows: ) 7.03 Annual Maximum Out-of-Pocket Limits (as described in your Schedule of Benefits). Co-insurance and Co-payments you pay for benefits received during any Calendar Year are accumulated toward your annual maximum out-of-pocket limit. Once you meet your individual or family annual maximum out-of-pocket limit in any Calendar Year, AvMed will pay 100% of the allowable charges for all covered services for the remainder of that Calendar Year. Expenses that do not count toward the annual maximum out-of-pocket limit are expenses used to satisfy the individual or family Deductible and any services provided under the Prescription Drug, Mental Health, Substance Abuse, Vision and other supplemental riders. 7.04 Member shall pay premiums, applicable supplemental charges, Deductibles, Co~payments and/or Co-insurance as provided in this Contract. If the Member fails to do so, upon ten (10) days written notice from AvMed to Member, the Member's rights hereunder shall be terminated. Consideration for reinstatement with AvMed shall require a new application, and any re-enrollment shall be at the sole discretion of A vMed and shall not be retroactive. 7.07 A Member will be entitled to covered benefits after the Member has satisfied the Deductible amount, if any, specified on the Schedule of Benefits. After satisfying the Deductible, the Member must pay any applicable Co-insurance for covered benefits. Covered benefits to which the Deductible applies are shown in the Schedule of Benefits. The Deductible does not apply to certain covered benefits. In those instances, the Member must pay any applicable Co- payments for covered benefits to which the Deductible does not apply. A V-Deductible/Co-insurance Amendment.09 Mp.)647 (10109)