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Atlantis Outpatient Centers


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Introduction

Definitions

Agreement´┐ŻThis is the Contract between Atlantis and the Employer/Group including any attachments.

Contract´┐ŻThis is the document which binds your Employer/Group and Atlantis to their respective obligations.

Contract Year´┐ŻThe 12-month period beginning on the Effective Date of the Group Contract or any anniversary date thereafter, during which the Contract is in effect. Be careful to review the Contract for provisions that are based on calendar year, which may or may not correspond to the Contract year.

Coordination of Benefits´┐ŻA coordination of benefits (COB) provision is one that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more group health insurance plans. See Section XVIII ´┐ŻTermination of Coverage´┐Ż and Section XVII ´┐ŻCoordination of Benefits´┐Ż for more information.

Co-payment´┐ŻA co-payment is a dollar amount that you are responsible for at the time a medical service is received. Co-payment levels vary based upon the actual service. See Section XIV ´┐ŻCo-payments, Coinsurance and Deductibles´┐Ż and the ´┐ŻSUMMARY OF BENEFITS´┐Ż for more information.

Covered Dependents´┐ŻCovered dependents are eligible Members of your family who are covered if you have a family coverage. For the purposes of determining eligibility for Dependent coverage, the term child or children includes:

1. Natural children, including newborn children;

2. Stepchildren by a legal marriage;

3. Children legally placed for adoption, and legally adopted children of the Member;

4. Children for whom legal guardianship has been awarded;

5. Children eligible to be claimed as Dependents on the Member´┐Żs tax return; and

6. A dependent child whom the Member or Member´┐Żs spouse has a legal obligation under a divorce decree or other court orders to provide for the health care expenses of the child

See Section IV ´┐ŻEligibility and Family Coverage´┐Ż for more information on this topic.

Covered Service(s)´┐ŻMedically necessary health services and benefits to which Member is entitled under the terms of this Certificate of Coverage.

Creditable Coverage´┐ŻPrior coverage of a Member under any of the following:

1. A group health plan, including church and government plans,

2. Health insurance coverage;

3. Part A or Part B of Title XVIII of the Social Security Act (Medicare);

4. Medicaid, other than coverage consisting solely of benefits under section 1928;

5. The health plan for active military personnel, including CHAMPUS;

6. The Indian Health Service or other tribal organization program;

7. A state health benefits risk pool;

8. The Federal Employees Health Benefits Program;

9. A public health plan as defined in federal regulations;

10. A health benefit plan under section 5(e) of the Peace Corps Act;

11. Any other plan which provides comprehensive hospital, medical, and surgical services.

Creditable Coverage does not include any of the following:

1. Accident only coverage, disability income insurance, or any combination thereof;

2. Supplemental coverage to liability insurance;

3. Liability insurance, including general liability insurance and automobile liability insurance;

4. Worker´┐Żs compensation or similar insurance;

5. Coverage Automobile medical payment insurance;

6. Credit-only insurance;

7. Coverage for on-site medical claims;

8. Benefits if offered separately:

(a) Limited scope dental and vision;

(b) Long-term care, nursing home care, home health care, community based care, or any combination thereof;

(c) Other similar, limited benefits.

9. Benefits if offered as independent, non-coordinated benefits:

(a) Specified disease or illness coverage; and

(b) Hospital indemnity or other fixed indemnity insurance;

10. Benefits if offered as a separate policy:

(a) Medicare Supplemental insurance;

(b) Supplemental coverage to the health plan for active military personnel, including CHAMPUS;

(c) Similar supplemental coverage provided to group health plan coverage.

Effective Date´┐ŻThe first day of coverage of a Member under this Contract, as shown on the identification card.

Enrollment Date´┐ŻThe first day of coverage of a Member under this Contract or, if earlier, the first day of the longest waiting period that must pass before the individual is eligible to be covered for benefits.

Experimental and Investigational Drugs or Treatments´┐ŻDrugs or Treatments which have not been approved by the FDA and/or NIH or have not been shown to be safe and effective through clinical trials or are not generally accepted as safe and effective by a majority of clinical providers with significant experience in the usage of the Drugs or Treatments. Nor, any drug that the FDA has determined to be contra-indicated for treatment of the specific type of cancer for which the drug has been prescribed.

Group´┐ŻThe employer or other party who has entered an Agreement with Atlantis to provide health insurance coverage for its Members.

HMO´┐ŻAn HMO is a Health Maintenance Organization licensed by the New York State Insurance and Health Departments. The basic purpose of an HMO is to provide preventive care to Members on a cost-effective basis, so that potential illness may be prevented or detected and treated early. Atlantis Health Plan is an HMO.

Large Group´┐ŻAn employer group with more than fifty eligible employees or members (exclusive of spouses and dependents) on the date of application for coverage or in subsequent years on the Contract Renewal Date.

Member´┐ŻEveryone enrolled in Atlantis Health Plan is considered a Member, both the Subscriber and his or her covered family Members. Each Member is required to choose a Primary Care Provider at the time of enrollment. See Section IX ´┐ŻYour Primary Care Provider´┐Ż.

 

Introduction

Definitions

Participating Provider´┐ŻA participating provider is a Physician, Hospital, Skilled Nursing Facility, Home Healthcare Agency, or other duly licensed or certified institution or health professional under contract with Atlantis Health Plan to provide services to our Members. Services with non-participating providers are generally not covered unless approval has been received in advance, except in emergencies. See Section VI ´┐ŻBenefits- Emergency Services´┐Ż and Section I. ´┐ŻIn-Plan Referrals- Access to Out-of-network Providers´┐Ż for more information regarding this provision.

Point of Service Plan´┐ŻA plan which provides HMO services for a nominal co-payment when you stay within a network of providers and rules and Indemnity Benefits with coinsurance and deductibles when you do not use in-Plan providers or rules.

Policyholder´┐ŻThe policyholder is the employer or group who pays premiums to Atlantis for the health insurance coverage of its´┐Ż Members. As the remitting agent, the policyholder is bound by the terms of the Group Contract.

Pre-existing Condition´┐ŻA condition, (mental or physical), which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6- month period ending on the Enrollment Date. Genetic information may not be used as a condition in the absence of a diagnosis. Pregnancy is not considered a Pre-existing Condition. See Section V ´┐ŻPre-Existing Condition Limitation´┐Ż.

Primary Care Provider´┐ŻA Primary Care Provider (PCP) is generally a Pediatrician, a General Practitioner, a Family Practitioner, or an Internist. The Primary Care Provider is responsible for the coordination of your health care and will provide referrals to participating specialists and hospitals when medically necessary. See Section IX ´┐ŻYour Primary Care Provider´┐Ż.

Renewal Date´┐ŻAgreements between Atlantis and the "Group" to provide health insurance coverage is in effect for a 12-month Contract Year. To continue coverage, the Group must re-contract with Atlantis on the Contract Renewal Date.

Service Area´┐ŻService area refers to the five boroughs of New York City where Atlantis is licensed to operate as an HMO: Brooklyn, Bronx, Manhattan, Queens and Staten Island.

Subscriber´┐ŻThe Subscriber is the person who, along with covered family Members (see also Section III ´┐ŻDefinitions- Member´┐Ż), is entitled to the benefits of this Certificate of Coverage. It is important for all family Members to familiarize them with this Certificate of Coverage.

SUMMARY OF BENEFITS´┐ŻThe SUMMARY OF BENEFITS is a description of health services provided in the Certificate of Coverage (see also Section VI ´┐ŻBenefits´┐Ż, Section XIV ´┐ŻCopayments, Coinsurance and Deductibles´┐Ż). Your benefits may vary from this Certificate of Coverage if your employer/group have purchased additional riders for supplementary services such as dental, optical, pharmacy, etc.

The Plan´┐ŻThe Plan refers to Atlantis Health Plan, the HMO which your Employer/Group are contracting with through this document.

Usual, Customary or Reasonable Charge´┐ŻIn some instances, payments are made to providers based on usual, customary or reasonable (UCR) rates. The UCR is the lowest of: (1) the actual Provider charge for a service or supply; (2) the usual charge by the Provider for the same or similar service or supply; or (3) the usual charge of most other Providers of similar training or experience in the same or similar geographic area for the same or similar service or supply. Atlantis uses a comparable fee schedule, called Medical Data Research (MDR) for payments to non-Network providers. The MDR schedule is periodically updated to accurately reflect geographic differences. The allowed amount for out-of-Plan benefits will be the lesser of the actual provider charge or the MDR fee schedule amount. The schedule amount (reimbursement) for a particular elective surgical procedure(s) or treatment(s) is available to Members.

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