Reso 2010-1529 - Laserfiche WebLink

Home Browse Search

In-area emergency does not include elective or routine care, care of minor illness, or care that can reasonably be sought and obtained from the Member's Primary Care Physician. The determination as to whether or not an illness or injury constitutes an emergency shall be made by AvMed and rnay be made retrospectively based upon all information known at the time the patient was present for treatment. Out-of-area emergency does not include care for conditions for which a Member could reasonably have foreseen the need of such care before leaving the Service Area or care that could safely be delayed until prompt return to the Service Area The determination as to whether or not an illness or injury constitutes an emergency shall be made by AvMed and may be made retrospectively based upon all information known at the time the patient was present for treatment. Exclusion means any provision of this Contract whereby coverage for a specific hazard or condition is entirely eliminated. Full-Time Student or Part-Time Student rneans one who is attending a recognized and/or accredited college, university, vocational, or secondary school and is carrying sufficient credits to qualifY as a Full- Time or Part-Time student in accordance with the requirements of the school. See Subsection 4.02.02(e). f) ) 3.17.01 3.17.02 3.18 () 3.19 3.20 Group Health Insurance (for purposes of Part XIII) means that form of health insurance covering groups of persons under a master Group Health Insurance policy issued to anyone of the groups listed in Chapters 627.552 (employee groups), 627.553 (debtor groups), 627.554 (labor union and association groups), and 627.5565 (additional groups), Florida Statutes. 3.20.01 ) 3.20.02 The terms 'amount of insurance' and 'jnsurance' include the benefits provided under a plan of self-insurance. The term 'insurer' includes any person, entity, or governmental unit providing a plan of self- insurance. The terms 'policy', 'insurance policy', 'health insurance policy', and 'Group Health Insurance policy' include plans of self-insurance providing health insurance benefits. 3.21 Health Professionals means physicians, osteopaths, podiatrists, chiropractors, physician assistants, nurses, social workers, pharmacists, optometrists, clinical psychologists, nutritionists, occupational therapists, physical therapists, and other professionals engaged in the delivery of health care services who are licensed and practice under an institutional license, individual practice association, or other authority consistent with State law and who are Participating Providers of AvMed. 3.22 Home Health Care Services (Skilled Home Health Care) means services that are provided for a Member who does not require confinement in a Hospital or Other Health Care Facility. Such services include, but are not limited to, the services of professional visiting nurses or other health care personnel for services covered under this Contract. A visit is limited to a period of 2 hours or less. See Section 10.28 regarding physical and occupational therapy Limitations. 3.20.03 3.23 Hospice means a public agency or private organization that is duly licensed by the State to provide Hospice services and with whorn AvMed has a current provider agreement. Such licensed entity must be principally engaged in providing pain relief, symptom management, and supportive services to terminally ill Members. 3.24 Hospital means any general acute care facility which is licensed by the State and with which AvMed has contracted or established arrangernents for inpatient Hospital Services and/or Emergency Medical Services and Care, and shall at times be referred to as a 'Participating Hospital'. A V -0100-2009 MP-5319 (10/09) 4