Office Visit Copay Visits to a physician, physician assistant (PA), or nurse practitioner (NP) at a participating physician group (PPG) or contracting physician's office and specialist consultations are covered on all Health Net plans. Office Visit Copays are required when seen in a physician's office or participating provider group by a physician, physician assistant or nurse practitioner

Durable Medical Equipment (DME) Copay Durable medical equipment serves a medical purpose, (its reason for existing is to fulfill a medical need, and it is not useful to anyone in the absence of illness or injury,) withstands repeated use, and fulfills basic medical needs, as opposed to satisfying personal preferences regarding style and range of capabilities. Examples of DME include canes, walkers, braces, etc.

Emergency Room Copay Emergency Care is any otherwise covered service that a reasonable person with an average knowledge of health and medicine would seek if he or she was having serious symptoms, and believed that without immediate treatment, any of the following would occur: His or her health would be put in serious danger (and in the case of a pregnant woman, would put the health of her unborn child in serious danger). His or her bodily functions, organs or parts would become seriously damaged or malfunction. Emergency Care also includes treatment of severe pain or active labor. Emergency Care also includes additional screening, examination and evaluation by a Physician or other qualified health care provider to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate such condition is within the capability of the facility. The emergency room copayment specified in the Member's Evidence of Coverage or Certificate of Insurance applies for all emergency room visits except when the patient is admitted from the emergency room to the inpatient hospital. In this case, the emergency room copayment is waived.

Urgent Care Center Copay Urgent Care is medically necessary services that are required to prevent serious deterioration of an individual's health from an unexpected illness or injury. Urgent Care requires professional care within several hours or 24 hours, but is not life threatening. Urgent Care is different from Emergency Care in that emergency care requires immediate attention to prevent death or serious impairment of health. An Urgent Care Center is a licensed facility, except a hospital, which provides urgent care. It is a medical facility where ambulatory patients can be treated on a walk-in basis, without an appointment, and receive immediate, non-emergency care. The Urgent Care Center Copayment may differ from the Emergency Room Copayment as specified in the Member's Evidence of Coverage or Certificate of Insurance

Specialist Copay A doctor of medicine, physician assistant or nurse practitioner who has specialized training. Specialists generally are not PCP's (general practice, family practitioner).

Rehabilitation Therapy Copay Treatment aimed at enabling a person to live an independent life following injury or illness. Rehabilitation therapy generally includes speech therapy, physical therapy, and occupational therapy. The copayment amount is specified in the Member's Evidence of Coverage or Certificate of Insurance

Allergy Copay An immune response to a foreign antigen that results in inflammation and organ dysfunction. Generally includes allergy testing, allergy immunotherapy, and allergy injection services. The copayment amount is specified in the Member's Evidence of Coverage or Certificate of Insurance

Mental Health Copay A Mental Disorder is a nervous or mental condition that meets all of the following conditions: It is a clinically significant behavioral or psychological syndrome or pattern; It is associated with a painful symptom, such as distress; It impairs a patient's ability to function in one or more major life activities; or It is a condition listed as an Axis I Disorder (excluding V Codes) in the most recent edition of the DSM by the American Psychiatric Association. A copayment may be collected from the member at the time services are rendered for some covered mental health and substance abuse services.�The copayment amount is specified in the Member's Evidence of Coverage or Certificate of Insurance. Any required copayment should be collected by the Managed Health Network (MHN) provider or facility rendering the services.

Outpatient Services Copay Outpatient services and supplies within the participating physician group (PPG) service area are covered with no charge to the member. Copayments are required on some plans. See the Schedule of Benefits for services received in the outpatient department of a hospital, emergency room, urgent care center, ambulatory care center, or alternative birth centers (ABC).

Hospital Inpatient Services Copay Inpatient services in a hospital are covered, subject to the scheduled copayments. Some plans, however, charge a flat dollar amount or percentage of the inpatient admission copayment. Benefits for hospital care are limited to the hospital�s most common charge for a semiprivate (two-bed) room. If the member elects to have a private room, the member is responsible for any amount over the semiprivate room rate, plus the copayment called for by the plan. If the Participating Provider Group (PPG) or qualified physician has authorized a private room as medically necessary, the member has no financial responsibility beyond the required copayment.

Maximum Individual Deductible An amount specified in the Member's Evidence of Coverage or Certificate of Insurance which an individual Member is required to pay before benefit payment beings each calendar year. Once the Member meets the Maximum Copayment Liability, the Member's services will be covered at 100% of the benefit.

Maximum Family Deductible The Maximum Family Deductible limits the amount a family must pay in total before benefit payments begin. If three members of an enrolled family each meet their separate Maximum Individual Deductible during any calendar year, no further deductible will be required for any other family members for the remainder of that calendar year. The Maximum Family Deductible amount is specified in the Member's Evidence of Coverage or Certificate of Insurance

Individual Out Of Pocket Maximum The maximum dollar amount generally includes Coinsurance / Deductibles and Copayment for which the Member is reponsible in a calendar year. Once satisfied, no additional copayments, coinsurance or deductibles will be required for the individual member for the remainder of the calendar year.

Family Out Of Pocket Maximum The maximum dollar amount generally includes Coinsurance / Deductibles and Copayment for which the family is reponsible in a calendar year. Once satisfied, no additional copayments, coinsurance or deductibles will be required for any family member for the remainder of the calendar year.