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Health Insurance Benefit Agreement
"I need a Health Insurance Benefit Agreement for a mid-sized tech company with 250 employees, including international coverage options and comprehensive mental health benefits, to be effective from January 1, 2025."
1. Parties: Identification of insurer and insured parties
2. Background: Context and purpose of the insurance agreement
3. Definitions: Key terms used throughout the agreement including relevant legislative definitions from ACA, HIPAA, and ERISA
4. Coverage Details: Specific benefits, coverage limits, and exclusions in compliance with ACA essential health benefits
5. Premium Payment Terms: Payment amounts, schedules, and methods
6. Claims Procedures: Process for submitting and handling claims, including appeals processes
7. Privacy and Data Protection: HIPAA compliance provisions and data protection measures
8. Termination Provisions: Conditions for ending coverage and COBRA continuation rights
1. Network Provisions: Details about in-network and out-of-network coverage, applicable for plans with provider networks
2. International Coverage: Terms for coverage outside the US, applicable for plans offering international coverage
3. Wellness Programs: Details of additional wellness benefits and incentives, included when offering wellness programs
4. Employer-Specific Provisions: ERISA compliance provisions, applicable for employer-sponsored plans
1. Schedule A - Benefits Schedule: Detailed listing of covered services, cost-sharing, and associated benefits
2. Schedule B - Network Directory: List of in-network providers and facilities
3. Schedule C - Premium Rate Schedule: Detailed premium calculations and rates
4. Schedule D - Drug Formulary: List of covered medications and their respective tiers
5. Schedule E - Required Disclosures: State and federal mandated disclosures and notices
Authors
Allowed Amount
Benefit Period
Claims Administrator
COBRA
Coinsurance
Copayment
Covered Benefits
Covered Person
Deductible
Dependent
Effective Date
Emergency Medical Condition
Emergency Services
Enrollment Date
Exclusions
Experimental or Investigational Treatment
Explanation of Benefits (EOB)
Group Health Plan
HIPAA
In-Network Provider
Medical Necessity
Member
Network
Out-of-Network Provider
Out-of-Pocket Maximum
Plan Year
Policy
Pre-Authorization
Pre-Existing Condition
Premium
Primary Care Provider
Prior Authorization
Provider
Qualified Medical Child Support Order
Schedule of Benefits
Specialist
Spouse
Summary Plan Description
Urgent Care
Usual, Customary and Reasonable (UCR) Charges
Waiting Period
Premium Payment
Eligibility
Enrollment
Network Access
Claims and Reimbursement
Coordination of Benefits
Termination
Continuation of Coverage
Prior Authorization
Appeals and Grievances
Medical Necessity
Exclusions and Limitations
Privacy and Confidentiality
Subrogation and Recovery
Amendment and Modification
Force Majeure
Governing Law
Dispute Resolution
Notices
Assignment
Severability
Entire Agreement
Waiver
Third Party Rights
Fraud Prevention
Administrative Services
Emergency Services
Prescription Drug Coverage
Preventive Care
Renewal Terms
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