Reso 2010-1529 - Laserfiche WebLink

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) following the date the Subscriber enrolls. lIthe Subscriber fails to enroll within 60 days after the loss of such coverage or the determination of such eligibility, the Subscriber and the Subscriber's eligible Dependents must wait nntil the next open enrollment period to apply for coverage. ) VI. MONTHLY PAYMENTS AND CO-PAYMENTS 6.01 On or before the first day of each month for which coverage is sought, Subscribing Group or its designated agent shall remit to AvMed, on behalf of each Subscriber and his Dependents, the monthly premium based on the rate letter and Master Application. Only Members for whom the stipulated payment is actually received by AvMed shall be entitled to the heaIth services covered under this Contract and then only for the period for which such payment is applicable. Failure of the Subscribing Group to pay the premium due by the first of the month and not later than the end of the grace period (as provided in Section 6.02) shall result in retroactive termination of the Subscribing Group, effective at 12:00 a.m. (midnight) on the last day of the month for which the premium was paid, unless the payment of premiums has otherwise been contractually adjusted and specified by the parties in a fully executed addendnm to this Contract. An additional charge will apply to all late premium payments. See Section 16.17. . ) 6.02 Grace period. This Contract has a ten-day grace period. This provision means that if any required premium is not paid on or before the date it is due, it must be paid during the following grace period. During the grace period, the Contract will stay in force. However, if payment is not received by the last day of the grace period, termination of this Contract for nonpayment of the premium will be retroactive to 12:00 a.m. (midnight) on the last day of the month for which the premium was paid. Note: Certain provisions in Section 6.01 may apply if the parties have executed an addendum affecting premium payments. 6.03 Annual out-of-pocket maximum expense limit (as describcd in your Schedule of Benefits). Co-insurance and Co-payments you pay for benefits received during any calendar year are accumulated toward your annual out-of-pocket maximum expense limit. Once you meet your individual or family annual out-of- pocket maximum expense limit in any calendar year, AvMed will pay 100% of the contracted rate or Maximum Allowable Payment, as applicable, for all covered services for the remainder of that calcndar year. 6.03.01 Expenses that do not count toward the annual out-of-pocket maximum expense limit arc expenses related to charges for services not covered including amounts requested for covered services exceeding the Maximum Allowable Payment, additional amounts incurred for failure to pre-authorize a service requiring prior authorization, expenses that relate to services that exceed any specific treatment Limitations noted in the Schedule of Benefits, and expenses used to satisfY the individual or family deductible. 6.04 Member shall pay premiums, applicable supplemental amounts requested, Co-payments, deductibles or Co-insurance as provided in this Contract and applicable Schedule of Benefits. If the Member fails to pay the applicable premiums, upon 10 days written notice from AvMed to the Member, the Member's rights hereunder shall be terminated. Consideration for reinstatement with the Plan shall require a new application, and any re-enrollment shall be at the sole discretion of AvMed and shall not be retroactive. 6.05 Refund of premiums paid to AvMed by the Snbscribing Group for any Member after the date on which that Member's eligibility ceased or the Member was terminated shall bc limited to the total excess preminm amounts paid up to a maximum of 60 days from the date of such ineligibility or tennination, provided there are no Claims incurred subsequent to the effective date of termination. No retroactive terminations of Members will be made beyond 60 days from notification of the terminating event. ) 13 A V-CHOICE-2009 MP-5320 (10/09)