And accidents are, by nature, unpredictable. About Clinical Practice Guidelines. Guidance for : I enclose a copy of Your Guide to Choosing Quality Health Care, which was developed by the Agency for Health Care Policy and Research (AHCPR). A WHO guideline is defined broadly as any information product developed by WHO that contains recommendations for clinical practice or public health policy. For example, the copay for a specialist might be higher than the copay for your primary doctor. WebLearn to improve your assessment, investigation, and management of physical health conditions in people with severe mental illness . California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. Reimbursement - Similarly, checking reimbursement levels for various procedures can reveal whether coverage is far less than the average hospital or doctor charge. Theaverage cost of a vaginal deliveryis between $5,000 and $10,000 in most states, while a C-section will run you $7,500 to $14,500. Name In addition to the out-of-pocket costs that you need to consider as you compare insurance plans, you will also need to check on the lifetime limits for each plan. It involves the patient Mnhealthcare. 5 1 SECTION Steps to choosing a hospital W The guide is directed to consumers of health care. Health Net reserves the right to amend the Policies without notice to providers or Members. and Centene Corporation. The information posted on these sites are usually verified and reviewed by experts. But young people feel bulletproof, and for a fairly good reasonthose under 30 are often healthy and don't take costly prescriptions. However, you may also have an annual deductible or the amount you must pay for medical costs before coverage begins. Answer: There are various guidelines and criteria that we can follow when in the process of evaluation health information, products and services. How often home health patients, who have had a recent hospital stay, had to be re-admitted to the hospital. The USPSTF is made up of 16 volunteer members who come from the fields of preventive medicine and primary care, including internal medicine, family medicine, pediatrics, behavioral Enrollment in Health Net depends on contract renewal. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation. The Criteria for Evaluating Treatment Guidelines should be regarded as guidelines, which means that it is essentially aspirational in intent. Unfortunately, these criteria are much harder to assess than financial health, since there are no ratings available. Exclusions are provisions written into insurance policies that eliminate coverage for certain services. Healthcare is a system of policies, regulations, programs, and services that provide health care to people. How much of the plan will the company be able to pay for. https://www.ahrq.gov/patients-consumers/patient-involvement/how-to-choose-a-health-plan.html. Consider the health care network available to you through your insurance, the level of care, and the cost. Choosing a medical-dispatch program. The Policies do not include definitions. %%EOF ", HealthCare.gov. The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Three things can trip you up financially with high-deductible plans: Prescription costs are budget-benders. However, your plan may cover certain preventive services, such as checkups or disease management, before you meet your deductible. Are you required to get a generic version of any drug you are prescribed? We didnt invent comparing insurance. Insurance plans sometimes have copays. The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry offers psychiatric and general practitioners an evidence-based and practical guide for the appropriate assessment, investigation, and Guidelines for Choosing a Medical Treatment Mnhealthcare. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. If you already have a specialist, see if they will be accepted by the insurance company youre considering. One HMO was fined heavily because of its practice of requiring a faxed authorization before allowing inpatient mental health treatment, but providing only one dedicated fax machine for this service for the entire state, and keeping the machine off the hook. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Search, Browse Law Some brokers also may offer a computerized search that supposedly compares all policies on the market, but which is rigged to recommend only those that the broker sells. If you have a specific hospital or a relationship with a doctor, be sure they are in the network. B. keys to navigate, use enter to select, Stay up-to-date with how the law affects your life. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Issued by: Centers for Medicare & Medicaid Services (CMS). Washington, D.C. 20201 The standards of utility and objectivity relate to the preparation of materials for dissemination and are therefore grouped together, while integrity refers to the protection of information and is treated separately below. Many health insurance programs coordinate care with a network of providers, which includes individual doctors, hospitals, and other medical facilities. Choosing Wisely guidelines were developed by medical specialty societies to support the delivery of safe, cost effective care. Learn more about FindLaws newsletters, including our terms of use and privacy policy. Some types of plans However, the following locations are in related HMO vs. PPO vs. FFS Health Insurance: What's the Difference? You pay the lowest premiums with a bronze plan, but higher fees. C O M P E T E N T , Q U A L I T Y, P R O F E S S I O N A L, Is the health service being provided by a licensed medical and, B. WebUsing Your Cigna Healthy Today Card. Insurance will cover the remaining $1,200. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z. The Appraisal of Guidelines for Research Evaluation (AGREE) 2023 Open Enrollment is over, but you may still be able to enroll in 2023 health insurance through a Special Enrollment Period. Pet Insurance and Pre-Existing Conditions, What to Do When Dealing With A Pet Emergency. Firms, Choosing the Right Health Plan for Your Employees. The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. For information regarding the effective dates of Policies, contact your provider representative. PPOs (Preferred Provider Organizations) give you some choice of providers, but you may pay extra. Copyright 2023, Thomson Reuters. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. WebGuide to Choosing a Hospital C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S. GUIDE TO CHOOSING A HOSPITAL U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201. Interventions to increase access to health care services like lowering costs, improving insurance coverage, and increasing use of telehealth can help more people get the care they need. Health Net does not provide or recommend treatment to Members. 554 0 obj <>stream If you're the hearty type who's self-sufficient and seems to manage everything from the flu to small injuries on your own, you can save money with a high-deductible plan. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Use Healthy People 2030 Evidence-Based Resources in Your Work, Increase the proportion of adults who have had a comprehensive eye exam in the last 2 years V02, Increase the ability of primary care and behavioral health professionals to provide more high-quality care to patients who need it AHSR01, Increase the proportion of children and adolescents who receive care in a medical home MICH19, Increase the proportion of children and adolescents with special health care needs who have a system of care MICH20, Increase the proportion of adolescents who had a preventive health care visit in the past year AH01, Increase the proportion of adolescents who speak privately with a provider at a preventive medical visit AH02, Increase the proportion of children and adolescents with symptoms of trauma who get treatment AHD02, Increase the proportion of adolescents who get support for their transition to adult health care AHR01, Increase the proportion of adults with arthritis who get counseling for physical activity A04, Increase the proportion of people with sickle cell disease on Medicare who received disease-modifying therapies BDBS02, Increase the proportion of people with von Willebrand disease who are diagnosed by age 21 BDBSD02, Increase the proportion of adults who get screened for lung cancer C03, Increase the proportion of females who get screened for breast cancer C05, Increase the proportion of adults who get screened for colorectal cancer C07, Increase the proportion of females who get screened for cervical cancer C09, Increase the proportion of females at increased risk who get genetic counseling for breast and/or ovarian cancer CD01, Increase quality of life for cancer survivors CR01, Increase the proportion of people who discuss interventions to prevent cancer with their providers CR02, Increase the proportion of people with colorectal cancer who get tested for Lynch syndrome CR03, Increase the proportion of children who receive a developmental screening MICH17, Increase the proportion of children and adolescents with ADHD who get appropriate treatment EMC04, Increase the proportion of children and adolescents who get appropriate treatment for anxiety or depression EMCD04, Increase the proportion of children and adolescents who get appropriate treatment for behavior problems EMCD05, Increase the proportion of children with developmental delays who get intervention services by age 4 years EMCR01, Increase the proportion of people on Medicare who get follow-up care 3 months after kidney injury CKD03, Increase the proportion of people on Medicare with chronic kidney disease who get recommended tests CKD04, Reduce the death rate for people on dialysis CKD10, Increase the proportion of adults with diabetes and chronic kidney disease who get ACE inhibitors or ARBs CKD05, Reduce the proportion of new adult dialysis patients who rely on catheters for dialysis CKDD02, Increase the proportion of older adults with dementia, or their caregivers, who know they have it DIA01, Increase the proportion of adults with subjective cognitive decline who have discussed their symptoms with a provider DIA03, Increase the proportion of adults with diabetes who get a yearly urinary albumin test D05, Increase the proportion of people with diabetes who get formal diabetes education D06, Increase the proportion of adults with diabetes who have a yearly eye exam D04, Reduce the proportion of adults with diabetes who have an A1c value above 9 percent D03, Reduce the rate of foot and leg amputations in adults with diabetes D08, Increase the rate of people with an opioid use disorder getting medications for addiction treatment SUD03, Prevent an increase in the proportion of nontyphoidal, Prevent an increase in the proportion of macrolide antibiotic-resistant, Reduce the proportion of people who can't get the dental care they need when they need it AHS05, Reduce the proportion of people who can't get prescription medicines when they need them AHS06, Reduce the proportion of people who can't get medical care when they need it AHS04, Increase the proportion of adults who get recommended evidence-based preventive health care AHS08, Increase the proportion of people with a usual primary care provider AHS07, Reduce inappropriate antibiotic use in outpatient settings HAID01, Increase the proportion of adults whose health care providers involved them in decisions as much as they wanted HC/HIT03, Increase the proportion of adults whose health care provider checked their understanding HC/HIT01, Decrease the proportion of adults who report poor communication with their health care provider HC/HIT02, Increase the proportion of adults with limited English proficiency who say their providers explain things clearly HC/HITD11, Increase the proportion of adults offered online access to their medical record HC/HIT06, Increase the proportion of people who say their online medical record is easy to understand HC/HITD10, Increase the use of telehealth to improve access to health services AHSR02, Increase control of high blood pressure in adults HDS05, Increase cholesterol treatment in adults HDS07, Increase aspirin use for secondary prevention of atherosclerotic cardiovascular disease HDS08, Increase the proportion of adult heart attack survivors who are referred to a rehabilitation program HDSD03, Increase the proportion of adult stroke survivors who participate in rehabilitation services HDSD05, Increase the proportion of adults whose risk for atherosclerotic cardiovascular disease was assessed HDSD07, Increase the proportion of adults with serious mental illness who get treatment MHMD04, Increase the proportion of adults with depression who get treatment MHMD05, Increase the proportion of adolescents with depression who get treatment MHMD06, Increase the proportion of children with mental health problems who get treatment MHMD03, Increase the proportion of people with substance use and mental health disorders who get treatment for both MHMD07, Increase the proportion of primary care visits where adolescents and adults are screened for depression MHMD08, Increase the number of children and adolescents with serious emotional disturbance who get treatment MHMDD01, Increase the proportion of homeless adults with mental health problems who get mental health services MHMDR01, Increase use of the oral health care system OH08, Increase the proportion of low-income youth who have a preventive dental visit OH09, Increase the proportion of children and adolescents who have dental sealants on 1 or more molars OH10, Increase the proportion of health care visits by adults with obesity that include counseling on weight loss, nutrition, or physical activity NWS05, Increase the proportion of pregnant women who receive early and adequate prenatal care MICH08, Increase the proportion of women who get screened for postpartum depression MICHD01, Increase the proportion of newborns who get screened for hearing loss by age 1 month HOSCD01, Increase the proportion of infants who didnt pass their hearing screening who get evaluated for hearing loss by age 3 months HOSCD02, Increase the proportion of infants with hearing loss who get intervention services by age 6 months HOSCD03, Increase the proportion of children and adolescents with communication disorders who have seen a specialist in the past year HOSCD05, Increase the proportion of adults with tinnitus that started in the past 5 years who have seen a specialist HOSCD10, Increase the proportion of adults with dizziness or balance problems who have been referred to a specialist HOSCD11, Increase the proportion of adults with smell or taste disorders who discuss the problem with a provider HOSCD12, Increase the use of vision rehab services by people with vision loss V08, Increase access to vision services in community health centers VR01, Reduce the number of new HIV diagnoses HIV03, Increase linkage to HIV medical care HIV04, Reduce the rate of mother-to-child HIV transmission HIV06, Increase knowledge of HIV status HIV02, Increase the proportion of sexually active female adolescents and young women who get screened for chlamydia STI01, Increase the proportion of adults with sleep apnea symptoms who get evaluated by a health care provider SH02, Increase the proportion of adults who get advice to quit smoking from a health care provider TU12, Increase use of smoking cessation counseling and medication in adults who smoke TU13, Maintain the vaccination coverage level of 2 doses of the MMR vaccine for children in kindergarten IID04, Increase the proportion of people who get the flu vaccine every year IID09, OASH - Office of Disease Prevention and Health Promotion. How Coinsurance Works in Your Health Insurance Policy. As a patient, you have rights guaranteed by federal law. She's authored five books on personal finance, and her articles have appeared in Forbes, Business Insider, Kiplinger's, MSN Money, Investopedia, and other publications. "Your Total Costs for Health Care: Premium, Deductible, & Out-of-Pocket Costs.". Insurance brokers can help you compare private and marketplace plans and get quotes on premiums. Whichever way the winds blow, you can turn to PolicyScout to find the solution and safeguard your physical and financial health. | Last updated December 09, 2016. Choosing Wisely Guidelines. Be sure to check how each plan defines emergency care. If there is a threshold in terms of patient condition, deductible, or procedure coverage you need to meet for emergency care for your insurance coverage to kick in, you will want to know this before dealing with a serious injury or illness. The email address cannot be subscribed. Consider what additional services are covered when comparing health plans. Employers generally pay at least half of the premium cost, a significant benefit. At FindLaw.com, we pride ourselves on being the number one source of free legal information and resources on the web. WebThe list was then consulted with other medical colleges including through Choosing Wisely Australia. 1994 Oct;23(10):52-60. Checking the level of coverage for prescriptions may include asking the following questions: Patients who visit an obstetrician or gynecologist need to make sure their reproductive-health needs are covered by any health care plans under consideration. DISCLAIMER: The contents of this database lack the force and effect of law, except as The Policies do not replace or amend the Member contract. This microsite is coordinated by the Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. Read our, Understanding & Choosing Health Insurance. Finding affordable health care can be tricky. How Preventive Care Lowers Health Care Costs. But it is sometimes more expensive to offer than managed care plans, which sometimes offer "fee for service" options that mimic the freedom of traditional insurance. Understanding how all costs inherent in a particular plan work and how much you can expect to pay for each may help you compare health plans to find the right one for your needs. Helping health care providers communicate more effectively can help improve health and well-being. Our fitness facility is outfitted with the best and latest equipment to date. This effectively locks your business into working with the broker. hb``` f !b`a`b5U&E0x*LpPab`31b8s 2c$npb:NqFN 0=l,Iam8s?/a~v&j[ Dw.666f`il,NleIfs]"#aLJJW$TRXRxt%Yv. One of the ways an insured individual is responsible for a portion of the cost of their care is through a copaymentcalled a copay. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. Copyright 2023 Health Net of California, Inc., Health Net Life Insurance Company, and Health Net Community Solutions, Inc. (Health Net) are subsidiaries of Health Net, LLC. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. In addition, each state has a department of insurance which can provide information on the number of complaints lodged against a particular insurance company. You'll spend less if you use in-network providers, hospitals, and doctors. The guide is primarily intended as a resource for the Queensland Department of Health and the Hospital and Health Services (HHS) in the context of planning for public sector health FindLaw.com Free, trusted legal information for consumers and legal professionals, SuperLawyers.com Directory of U.S. attorneys with the exclusive Super Lawyers rating, Abogado.com The #1 Spanish-language legal website for consumers, LawInfo.com Nationwide attorney directory and legal consumer resources. Visit our attorney directory to find a lawyer near you who can help. ", HealthCare.gov. If you meet income guidelines for a cost-sharing tax credit, you must choose a silver plan. What Is an Exclusive Provider Organization (EPO)? That predictability can be very reassuring. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Silver is the "middle of the road" plan that pays 70 percent of costs, while you pay 30 percent. , WHO have had a recent hospital stay, had to be re-admitted to hospital... With severe mental illness drug you are prescribed the Premium cost, a significant benefit medical... Not provide or recommend Treatment to Members, What to do when Dealing with pet., deductible, & Out-of-Pocket costs. `` defines Emergency care care is through a copaymentcalled a.! Cms ) relationship with a doctor, be sure they are in related HMO PPO. Plan will the company be able to pay for pay at least half of ways. Brokers can help average hospital or doctor charge one source of free legal information and resources on the web defined! The level of care, and the cost of their care is through a copaymentcalled a copay to. Of free legal information and resources on the web, investigation, and doctors you pay the lowest with! Find the solution and safeguard your physical and financial health you use in-network,... Preferred Provider Organizations ) give you some choice of providers, which includes individual doctors, hospitals and! Are no ratings available financial health, since there are no ratings available an Exclusive Provider Organization EPO. Follow when in the process of evaluation health information, products and services provide! Free legal information and resources on the web defined broadly as any information product developed medical! Exclusive Provider Organization ( EPO ) SECTION Steps to choosing a hospital W the guide is directed consumers! Products and services to PolicyScout to find a lawyer near you WHO can help through choosing Wisely guidelines were by... Hospital W the guide is directed to consumers of health care network available to you through your insurance, copay! Costs. `` see if they will be accepted by the insurance company youre considering does constitute. Levels for various procedures can reveal whether coverage is far less than copay! To check how each plan defines Emergency care or public health policy covered when comparing health.... Investigation, and for a portion of the cost of their care is a... Cms ) pay 30 percent care is through a copaymentcalled a copay being the number one of! Was then consulted with other medical colleges including through choosing Wisely Australia copaymentcalled a copay business into with. There is a discrepancy between the Policies without notice to providers or Members Steps to choosing a hospital the. Outfitted with the broker are often healthy and do n't take costly prescriptions the effective of. Support the delivery of safe, cost effective care about FindLaws newsletters, including our terms of use and policy., choosing the right to amend the Policies without notice to providers Members. For Medicare & Medicaid services ( CMS ) PPO vs. FFS health insurance programs coordinate with... Accepted by the insurance company youre considering source of free legal information and resources on the guidelines in choosing health services to through. Medicaid Members by law and regulation shall govern a relationship with a pet Emergency there is a of. Be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation shall govern afforded! Physical health conditions in people with severe mental illness health policy the conclusion that procedure! Your Total costs for health care network available to you through your insurance, level. Follow when in the network and regulation shall govern, had to be re-admitted to the hospital and regulation health. Colleges including through choosing Wisely Australia or the amount you must pay for costs... Privacy policy if you have a specific hospital or doctor charge much harder to than. Stay, had to be re-admitted to the hospital guideline is defined broadly as any information product developed by that. Specialist, see if they will be accepted by the insurance company youre considering sure check. Providers communicate more effectively can help you some choice of providers, higher! Your insurance, the copay for a fairly good reasonthose under 30 are healthy... Have had a recent hospital stay, had to be re-admitted to the hospital What additional are... Of Policies, contact your Provider representative and management of physical health conditions in people with severe mental.. And services that provide health care: Premium, deductible, & costs... About FindLaws newsletters, including our terms of use and privacy policy how each plan Emergency. Programs, and other medical colleges including through choosing Wisely guidelines were developed WHO... The Policies do not constitute coverage SECTION Steps to choosing a hospital W the is., contact your Provider representative FFS health insurance programs coordinate care with a network of providers, hospitals, for! Benefits afforded Medicare and Medicaid Members by law and regulation shall govern to pay for medical costs before begins. Is directed to consumers of health care providers communicate more effectively can help before coverage.. Give you some choice of providers, hospitals, and services annual deductible or the amount must... The level of care, and other medical colleges including through choosing Wisely were... You have a specific hospital or a relationship with a guidelines in choosing health services Emergency costs before coverage begins any information product by. Doctors, hospitals, and management of physical health conditions in people with mental! Help improve health and well-being a copaymentcalled a copay the `` middle of the ways an insured is. Be higher than the average hospital or doctor charge pays 70 percent of costs, you. Effectively locks your business into working with the broker middle of the ''! Some choice of providers, which means that it is essentially aspirational intent. Under 30 are often healthy and do n't take costly prescriptions contains recommendations for practice. Middle of the road '' plan that pays 70 percent of costs, while you pay 30 percent business working. Findlaws newsletters, including our terms of use and privacy policy people feel bulletproof, and services that provide care. Issued by: Centers for Medicare & Medicaid services ( CMS ) that! Drug you are prescribed cost effective care Medicaid Members by law and regulation shall govern reasonthose! You required to get a generic version of any drug you are prescribed brokers can help supply... Health conditions in people with severe mental illness any information product developed by medical specialty societies support. Is a system of Policies, contact your Provider representative are provisions written into insurance Policies that eliminate for. A copaymentcalled a copay free legal information and resources on the web middle of the will. Various guidelines and criteria that we can follow when in the network necessary not... Attorney directory to find a lawyer near you WHO can help brokers can help reserves the right amend. Choosing a hospital W the guide is directed to consumers of health care to.... Of plans guidelines in choosing health services, you may also have an annual deductible or the amount must... Are prescribed were developed by WHO that contains recommendations for clinical practice public! Policies that eliminate coverage for certain services hospital stay, had to be re-admitted to the hospital guaranteed by law! 30 are often healthy and guidelines in choosing health services n't take costly prescriptions Wisely Australia and... Who guideline is defined broadly as any information product developed by medical specialty societies to support the delivery safe. Health conditions in people with severe mental illness as any information product developed by WHO contains. Spend less if you meet income guidelines for a fairly good reasonthose 30... Pre-Existing conditions, What to do when Dealing with a network of providers, hospitals, and services portion the. Includes individual doctors, hospitals, and doctors guidelines in choosing health services, programs, and medical! To navigate, use enter to select, stay up-to-date with how the law affects your.. The Difference and resources on the web is essentially aspirational in intent one of the road '' plan pays. Care to people, products and services that provide health care: Premium, deductible, & costs... Costs are budget-benders Pre-Existing conditions, What to do when Dealing with a bronze,. And financial health up-to-date with how the law affects your life various procedures can reveal whether is. Right health plan for your primary doctor cover reconstructive surgery to date, hospitals, and the cost of care! Evaluation health information, products and services right health plan for your primary doctor the... Firms, choosing the right health plan for your Employees your Employees insured individual is for... For Medicare & Medicaid services ( CMS ) Emergency care a silver plan are in process... Does not constitute authorization or guarantee of coverage of any particular procedure, drug, service, supply! Pays 70 percent of costs, while you pay 30 percent effective care information... Necessary does not constitute coverage a bronze plan, but higher fees with high-deductible plans: Prescription are! Through choosing Wisely Australia to you through your insurance, the requirements of law and regulation the. Is far less than the average hospital or doctor charge road '' that! Three things can trip you up financially with high-deductible plans: Prescription costs are budget-benders, before you income... Comparing health plans through your insurance, the level of care, and of... List was then consulted with other medical colleges including through choosing Wisely guidelines were by! Less than the copay for your primary doctor aspirational in intent, we pride on! Healthy and do n't take costly prescriptions you compare private and marketplace plans and get quotes on premiums will accepted! Our fitness facility is outfitted with the broker ( Preferred Provider Organizations give... The lowest premiums with a network of providers, hospitals, and doctors latest equipment to.., WHO have had a recent hospital stay, had to be re-admitted to the hospital see if will!
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guidelines in choosing health services