Reso 2010-1529 - Laserfiche WebLink

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) AvMed, Inc. d/b/a AvMed HEALTH PLANS ) GROUPMEDlCAL AND HOSPITAL SERVICE CONTRACT WITH POINT OF SERVICE RIDER IN CONSIDERATION of the payment of monthly prepayment subscription charges as provided herein and of mutual promises and benefits hereinafter described, AvMed, Inc., a Florida corporation, d/b/a AvMed Health Plans, (hereinafter referred to as 'AvMed'), and (hereinafter referred to as 'Subscribing Group') agree as follows: I. GENERAL The Subscribing Group engages AvMed to arrange for the provision of Medical Services or benefits which are Medically Necessary for the diagnosis and treatment of Members of the Subscribing Group through the AvMed Choice Plan. The AvMed Choice Plan provides the Member with several choices for the provision of health care services: the A vMed Choice Network, the Private Healthcare Systems Network (PHCS) or out-of-network coverage. The Member's choice of providers and where they receive services will detem1ine the level of benefits. Under this Plan, a Member may choose to receive services from the AvMed Choice Network (high Benefit Lcvel), the PHCS Network (medium Bcnefit Level) or any Out-of-Network Provider (low Benefit Level). With the AvMed Choice Plan, a Member is not required to select a Primary Care Physician nor are referrals to specialists required. However, prior authorization from AvMed is required for some services (See Section IX). AvMed, in arranging for the delivery of Medical Services or benefits, does not directly provide these Medical Services or benefits. AvMed arranges for the provision of said services in accordance with the covenants and conditions contained in this Contract. AvMed shall rely upon the statements of the Subscriber in his application in providing coverage and benefits hereunder. This Contract is not intended to and does not cover or provide any Medical Services or benefits that are not Medically Necessary for the diagnosis and treatment of the Member. The determination as to which services are Medically Necessary shall be made by AvMed subject to the terms and conditions of this Contract. AvMed reserves the right to make changes in coverage criteria for covered products and services. Coverage criteria are medical and pharmaceutical protocols used to detenninc payment of products and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medicaVpharmaceutical societies. The Medical and Hospital Services covered by this Contract shall be provided without regard to the race, color, religion, physical handicap, or national origin of the Member in the diagnosis and treatment of patients; in the use of equipment and other facilities; or in the assignment of personnel to provide services, pursuant to the provisions of Title VI of the Civil Rights Act of 1964, as amended, and the Americans with Disabilities Act of 1990. ,) ) A V-CHOICE-2009 MP-5320 (10/09)