Health Care Services Agreement - Free Download | Page 3
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ABC HEALTH PROVIDERs
Family Planning One 3
Emergency Medical Services or Emergency Care. "Emergency Medical Services" or "Emergency
Care" shall mean health care services required to be provided to Enrollees as a result of a medical or
behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health
could reasonably expect the absence of immediate attention to result in: (i) placing the health of the person
afflicted with such condition or another individual in serious jeopardy; (ii) serious impairment of such person's
bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; or (iv) disfigurement.
Enrollee. "Enrollee" shall mean an Eligible Person who has elected, or for whom an authorized
representative has elected on his or her behalf, to receive care and services under the terms and conditions
of the MEDICAID Agreement and who has an effective Membership Handbook with ABCHP.
Excluded Services. "Excluded Services" shall mean those medical and other health care services to
which Enrollees are not entitled under the terms of the applicable Member Handbook and which are not
covered under the New York State Medicaid Plan.
Fee-for-Service Rates. "Fee-for-Service Rates" shall mean the amount of total reimbursement, as
set forth on Exhibit A, payable to HC for Authorized Specialty Services provided to Enrollees.
Family Health Plus Enrollee or FHP Enrollee. “Family Health Plus Enrollee” or “FHP Enrollee”
shall mean an Enrollee who receives services under ABCHP’s Family Health Plus program, in
accordance with the FHP Agreement and applicable Benefit Plan.
FHP Agreement. The “FHP Agreement” is the contract entered into by ABCHP with the DOH, and
all exhibits, attachments, amendments and addenda thereto, to administer the Family Health Plus
Program. The FHP Agreement is hereby incorporated by reference as if specifically set forth herein.
Government Contracts. The “Government Contracts” shall mean any or all of the Medicaid
Agreement, FHP Agreement, and CHP Agreement.
HHS. "HHS" shall mean the United States Department of Health and Human Services.
HIPAA. “HIPAA” is the Health Insurance Portability and Accountability Act of 1996, including any