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 coverage; –type A State plan under Medicaid.
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.
hmo_poscontract.docx