PPO II - EmblemHealth

2013 Evidence of Coverage for PPO II) II
Chapter 3. 3: Using the plan’s coverage for your medical services
Chapter 3. Using the plan’s coverage for your medical services
SECTION 1 Things to know about getting your medical care
covered as a member of our plan ...................................................... 35
Section 1.1 What are “network providers” and “covered services”? ................................................35
Section 1.2 Basic rules for getting your medical care covered by the plan ......................................35
SECTION 2 Using network and out-of-network providers
to get your medical care ..................................................................... 36
Section 2.1 How to get care from specialists and other network providers ....................................36
Section 2.2 How to get care from out-of-network providers .........................................................36
SECTION 3 How to get covered services when you have
an emergency or urgent need for care ............................................. 37
Section 3.1 Getting care if you have a medical emergency ............................................................37
Section 3.2 Getting care when you have an urgent need for care ...................................................38
SECTION 4 What if you are billed directly for the full
cost of your covered services? ........................................................... 39
Section 4.1 You can ask us to pay our share of the cost of covered services ....................................39
Section 4.2 If services are not covered by our plan, you must pay the full cost ..............................39
SECTION 5 How are your medical services covered when you
are in a “clinical research study”? ...................................................... 39
Section 5.1 What is a “clinical research study”? .............................................................................39
Section 5.2 When you participate in a clinical research study, who pays for what? ........................40
SECTION 6 Rules for getting care covered in a “religious
non-medical health care institution” ..................................................41
Section 6.1 What is a religious non-medical health care institution? .............................................41
Section 6.2 What care from a religious non-medical health care institution is covered by
our plan? .................................................................................................................42
SECTION 7 Rules for ownership of durable medical equipment ....................... 43
Section 7.1 Will you own the durable medical equipment after making a certain number of
payments under our plan? .......................................................................................43
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