Maine Plan Participation Agreement between Blue Cross Blue Shield Assoc. and Blue Cross Blue Shield of MO regarding healthcare benefit provisions

• Category: Corporations - Public - Participation
• State: Multi-State
• Control #: US-EG-9383
• Format: Word; Rich Text

Description

Plan Participation Agreement between Blue Cross and Blue Shield Association and Blue Cross and Blue Shield of Missouri regarding health care benefit provisions (Federal Employee Program) dated January 1, 1995. 13 pages. The Maine Plan Participation Agreement is a contractual agreement between Blue Cross Blue Shield Association (BC BSA) and Blue Cross Blue Shield of Missouri (BCBS) that outlines the provisions and benefits related to healthcare coverage in the state of Maine. This agreement aims to ensure that Maine residents have access to quality healthcare services while maintaining the standard guidelines set by both BC BSA and BCBS. The Maine Plan Participation Agreement covers various healthcare benefit provisions, including but not limited to: 1. In-network and out-of-network coverage: The agreement defines the network of healthcare providers and facilities that participate in the Maine Plan. It outlines the benefits available when receiving care from in-network providers versus out-of-network providers. 2. Medical services coverage: The agreement details the specific medical services covered by the Maine Plan, such as physician visits, hospitalizations, surgeries, diagnostic tests, mental health services, preventive care, and prescription drugs. It also specifies any limitations or exclusions for certain procedures or treatments. 3. Cost-sharing arrangements: The agreement specifies the cost-sharing provisions, including deductibles, co-payments, and coinsurance, that members will be responsible for when receiving healthcare services. It also describes any maximum limits or annual out-of-pocket expenses. 4. Prior authorization requirements: The agreement outlines the process and criteria for obtaining prior authorization for certain medical services or procedures. It may include guidelines for medical necessity reviews and the documentation required for approval. 5. Emergency care coverage: The agreement clarifies the coverage provided for emergency medical services, including emergency room visits, ambulance transportation, and urgent care services. It may include guidelines for reimbursement when seeking emergency care out-of-network. 6. Provider reimbursement rates: The agreement specifies the reimbursement rates that BCBS will pay healthcare providers within the Maine Plan's network for covered services. It may outline any fee schedules or negotiated rates. It's important to note that there might be different types of Maine Plan Participation Agreements offered by BC BSA and BCBS, each tailored to meet the unique needs of different individuals or employer groups. These variations may include plans like: 1. Maine Plan Individual Agreement: This agreement is designed for individuals and families seeking healthcare coverage in Maine. It outlines the benefit provisions and cost-sharing requirements specifically applicable to individual policyholders. 2. Maine Plan Small Group Agreement: This agreement caters to small businesses with a limited number of employees in Maine. It specifies the healthcare benefits and coverage options available to employees within the small group plan. 3. Maine Plan Large Group Agreement: This agreement targets larger businesses or organizations employing a significant number of individuals. It provides comprehensive healthcare coverage options and benefits for employees within the large group plan. Overall, the Maine Plan Participation Agreement establishes a framework for the delivery of healthcare services and benefit provision within Maine, ensuring that individuals and groups covered by BCBS have access to necessary medical care while maintaining reasonable costs and quality standards.

The Maine Plan Participation Agreement is a contractual agreement between Blue Cross Blue Shield Association (BC BSA) and Blue Cross Blue Shield of Missouri (BCBS) that outlines the provisions and benefits related to healthcare coverage in the state of Maine. This agreement aims to ensure that Maine residents have access to quality healthcare services while maintaining the standard guidelines set by both BC BSA and BCBS. The Maine Plan Participation Agreement covers various healthcare benefit provisions, including but not limited to: 1. In-network and out-of-network coverage: The agreement defines the network of healthcare providers and facilities that participate in the Maine Plan. It outlines the benefits available when receiving care from in-network providers versus out-of-network providers. 2. Medical services coverage: The agreement details the specific medical services covered by the Maine Plan, such as physician visits, hospitalizations, surgeries, diagnostic tests, mental health services, preventive care, and prescription drugs. It also specifies any limitations or exclusions for certain procedures or treatments. 3. Cost-sharing arrangements: The agreement specifies the cost-sharing provisions, including deductibles, co-payments, and coinsurance, that members will be responsible for when receiving healthcare services. It also describes any maximum limits or annual out-of-pocket expenses. 4. Prior authorization requirements: The agreement outlines the process and criteria for obtaining prior authorization for certain medical services or procedures. It may include guidelines for medical necessity reviews and the documentation required for approval. 5. Emergency care coverage: The agreement clarifies the coverage provided for emergency medical services, including emergency room visits, ambulance transportation, and urgent care services. It may include guidelines for reimbursement when seeking emergency care out-of-network. 6. Provider reimbursement rates: The agreement specifies the reimbursement rates that BCBS will pay healthcare providers within the Maine Plan's network for covered services. It may outline any fee schedules or negotiated rates. It's important to note that there might be different types of Maine Plan Participation Agreements offered by BC BSA and BCBS, each tailored to meet the unique needs of different individuals or employer groups. These variations may include plans like: 1. Maine Plan Individual Agreement: This agreement is designed for individuals and families seeking healthcare coverage in Maine. It outlines the benefit provisions and cost-sharing requirements specifically applicable to individual policyholders. 2. Maine Plan Small Group Agreement: This agreement caters to small businesses with a limited number of employees in Maine. It specifies the healthcare benefits and coverage options available to employees within the small group plan. 3. Maine Plan Large Group Agreement: This agreement targets larger businesses or organizations employing a significant number of individuals. It provides comprehensive healthcare coverage options and benefits for employees within the large group plan. Overall, the Maine Plan Participation Agreement establishes a framework for the delivery of healthcare services and benefit provision within Maine, ensuring that individuals and groups covered by BCBS have access to necessary medical care while maintaining reasonable costs and quality standards.