Transcription
MotivHealth InsuranceCompanyUtahCertificate of Coveragefor Liberty Press*MotivHealth Insurance Company is domiciled in, and subject to the laws of UtahLrgGrp. Cert. UT SF Ver. 10/2021 Liberty Press1 Page
ContentsContract Provisions.8Contract Amendments.8No Assignability.8Availability of Contract for Review.8No Vested Rights.8Acceptance of this gibleServices.8Agency.9Provider Agency.9ManagedCare.9Benefits are Limited.9AdministrativeProvisions.10Compliance Responsibilities.10Changes in Member Contact Information.10Requests for Information.10Notices.11Qualified Beneficiary.11Who Can Be Covered under COBRA Employees.11Spouse of Employees.11Dependent Children.12Secondary Event.12Your Duties Under the Law.12Employers’ Duties Under the Law.13Election of Continuation Coverage.13COBRA Premium Payments.13How Long Coverage May Last.13Special Rules for Disability.14Special Rules for Retirees.14Continuation Coverage May Be Terminated.15Separate Election.15MotivHealth Insurance Company Employee Responses.15Your Duties under the Law.16PremiumPayments.16Notice of Women’s Health and Cancer Rights Act (WHCRA).16LrgGrp. Cert. UT SF Ver. 10/2021 Liberty Press2 Page
Accidental .17Accident,Ambulatory Surgical Facility.17Benefits Review .18Coordination of Benefits.18Procedure .18CosmeticCoverage.18CustodialCare.18Deductible .19Dependent.19Device.20Durable Medical Equipment.20ElectiveTreatment.21Eligible Benefit. .21EmergencyCare.21Employee .21Employer.21Enrollment.21ExceptedBenefits .21Exclusions.22Experimental, Investigational, or Unproven.22FDA Approved .23Formulary.23GlobalFee.23High Deductible Health e Family p. Cert. UT SF Ver. 10/2021 Liberty Press3 Page
Limitations.24Maximum Allowable Fee.25Medical Case Management .25MedicalRecords .25Medically Necessary/ Medical Necessity.25Member.25Mental Health BM.26Preauthorization.26Pre-Notification.26Primary Care bilitation/Habilitation Therapy.27Skilled Nursing n.28Subscriber.28Surgical Procedure or Surgery.28Totally Disabled.28Unbundling.29Urgent Condition.29VerbalPreauthorization.29Waiting Period .29Enrollment, Eligibility & Termination.29General.29Eligibility.30Enrollment period.30SpecialEnrollment .30Loss of Other Coverage.30Family Status Change.31LrgGrp. Cert. UT SF Ver. 10/2021 Liberty Press4 Page
LegalGuardianship.31Military Activation .31Termination of Coverage.31Liability for Services After Termination.32Coordination of Benefits with Other Carriers.32Order of Benefit Determination .33Coordination of Benefits Rules.33DualCoverage.33Correction of Payment in Error.34No Coordination of Benefits with Other Types of Plans.34Coordination of Benefits with Medicare.34Policy.35Authorization to Obtain/Retain/Share Information.35Excess Payment or Mistaken Payments.35MedicalCaseManagement .35Benefits .36CoveredProviders .36ContractedRural Health Care nefits.38InpatientHospitalization.38Outpatient Facility Benefits.39Emergency Room Services.39ChiropracticBenefits.39Urgent Care Facility.39Limitations Relating to All Inpatient and Outpatient Hospital/Facility and Emergency Room Services.39Benefits .40SurgicalSecond Opinion and Surgical Review.41Limitations ns Relating to Anesthesia.42MedicalVisitBenefits.42Limitations Relating to Medical Visits.42Diagnostic Testing, Lab and X-Ray Benefits.43LrgGrp. Cert. UT SF Ver. 10/2021 Liberty Press5 Page
Limitations Relating to Diagnostic Testing, Lab and X-Ray.43MentalHealthBenefits.43Facility and Hospital Services-Mental Health lHealthBenefits.44Benefits.44Limitations Relating to Ambulance Benefits.44Home Health and Hospice Care Benefits .45Limitations Relating to Home Health and Hospice Care Benefits.45Benefits .45AdoptionAutism Spectrum Disorder.46Limitations Relating to Autism Spectrum Disorder.46Prescription and Specialty Drug Benefits.46Covered Formulary Drugs.46Preauthorization for Prescription and Specialty Medications.47Quantity Levels andStep Therapy.47Pharmacy Coordination of Benefits with Other Carriers.47Out of Area Prescriptions or Other Cash ons Relating to Prescription Drug 50Limitations Relating to Durable Medical Equipment/Supply Benefits.50PreventiveServices.50Covered Preventive Services for Adults .51Covered Preventive Services for reatment. .54UrgentTreatment .54Emergency Treatment.54Inpatient Treatment for Mental Health .54Out of Area Hospital Admission.54Maximum Out-of-Pocket Benefits.55Subrogation and Contractual Reimbursement Contractual Grp. Cert. UT SF Ver. 10/2021 Liberty Press6 Page
ired Information for Claims Submission.
Enrollment period to enroll and Coverage will become effective on the Subscriber'sannual renewal date. Special Enrollment Eligible persons who do not enroll themselves or their eligible Dependents during the initial Enrollment period, may enroll in Coverage prior to the next annual Enrollment period if they
