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Rods – General Provisions

Rods – General Provisions
A. HEALTH BENEFITS
(10GENERAL PROVISIONS
· Acceptance of Plan by providers78-028
 
Administration07-0075, CA-0130
· Bonus, health care,93-031
· Coordination of benefits/copayment78-060
     –copayment fro spouse with coverage from employer, 98-017 
· Cost containment88-02488-25311-0143 
     —formulary drug program with surcharge, 98-013 98-01402-002 CA-056CA-072
     –hospital admission precertification,84-19688-253
     –implementation of network pharmacy program, 88-32288-40388-411
     –maintenance drug mail order program, CA-066
     –second surgical opinion,88-253
· Excessive charges,78-254
· Health maintenance organization (HMO)81-41181-53388-30211-0143
· Hold harmless provision,88-60988-667
     –beneficiary signs contract of adhesion, 84-531
     –deductible-must meet for hold harmless, 93-105
     –excessive charges, 84-26084-26484-41284-48484-58388-07698-048CA-040
     –medical necessity, 84-28084-53188-04388-13488-33588-41288-44988-48588-48688-50788-50988-51388-520CA-038CA-04402-04607-000807-0023
     –promulgation of rules, 84-26484-48484-70288-07688-25388-45288-50588-50888-55888-667
     –reimbursement of beneficiary’s payment, 84-26484-48488-10588-335
     –services not provided under Plan, 84-46784-602
· Medicare10281-044
     –active employee over age 65, 78-020
     –beneficiary fails to enroll in Part A & B, Q&A H-1278-02081-04481-26084-10384-27184-44884-49184-49784-51684-54284-63784-67988-20588-46788-64488-65088-659CA-022CA-071
     –beneficiary receives SSDI benefits, 88-650CA-071
     –bonus, health care, 93-031
     –enrollment in Part D, 02-02902-03002-03102-033CA-076CA-077CA-078, CA-07907-0021
     –notification of obligation to enroll in Part A & B, 84-44884-49184-51684-679
     –spouse fails to enroll Medicare Part B, 84-63702-026
     –benefits only to the extent benefits are not provided for under Medicare, 11-0149
     –coverage of inpatient Medicare deductible, 11-0149
· Non-duplication78-07881-41181-46281-49684-12888-06388-141, 11-0149
     —copayment for spouse with coverage from employer98-017
     –-individual insurance policy,88-369
     –Medicare,CA-031
     –spouse’s employer offers coverage, 88-13288-496CA-074
· Notice of coverage termination,84-44084-60688-674CA-04716-0004 
· Preferred Provider List (PPL), 93-035CA-062 
· Promulgation of rules,81-15581-59384-04284-196
     –alcoholism and drug rehabilitation program, 88-847 
     –claims reimbursement procedures,78-13288-440
     –drug utilization,88-41188-41488-571
     –employment status questionnaire, 88-113CA-047
     –enrollment Medicare Part D, 02-02902-03002-031CA-076CA-077CA-078CA-07907-0021
     –formulary drug program with surcharge , 98-01398-01402-002 CA-056CA-072
     –generic vs. brand name drugs88-40393-079CA-072
     –hold harmless procedures, 84-26484-48488-076
     –mail order88-61393-029CA-06602-00102-003
     –prescription drug reimbursement procedures84-04288-32288-40388-41188-41488-57188-613
     –time limit on claims submission, 78-33781-69781-71088-64511-0027
· Subrogation,84-25284-56588-14188-369
–auto insurance, 93-10498-049
–cases covered by workers’ compensation laws, 88-05588-52588-678
· Substandard health coverage plan81-55681-64584-03084-03484-05884-12584-14784-20584-21584-23884-29084-32584-41284-54784-63288-27888-32688-62388-62588-83293-035