MASTER
PLAN DOCUMENT
EMPLOYEE
BENEFIT PLAN
PLAN
EFFECTIVE DATE
AS
MODIFIED AND AMENDED HEREIN
ADOPTION
has caused this
Employee Benefit Plan (“Plan”) to take effect as of the ,
199 , at ,
. This is a revision
of the Plan previous adopted on
and subsequently revised on ,
199 . I have read the
document herein, and certify the document reflects the terms and conditions
of the Employee Welfare Benefit Plan as established by .
By:
Date:
Plan Administrator
TABLE
OF CONTENTS
SUMMARY PLAN DESCRIPTION
STATEMENT OF ERISA RIGHTS
PLAN HIGHLIGHTS
PLAN OPTIONS
SCHEDULE OF BENEFITS
MEDICAL BENEFITS
DENTAL BENEFITS/ALL PLANS
VISION BENEFITS/ALL PLANS
PLAN A BENEFIT SCHEDULE
PLAN C BENEFIT SCHEDULE
HEALTH CARE MANAGEMENT
PRE-AUTHORIZATION
PRE-AUTHORIZATION APPEAL PROCESS
CASE MANAGEMENT/ALTERNATE TREATMENT
ELIGIBILITY
EMPLOYEE ELIGIBILITY
DEPENDENT(S) ELIGIBILITY
ENROLLMENT
APPLICATION FOR ENROLLMENT
WAIVER OF COVERAGE
SPECIAL ENROLLMENT PERIOD (OTHER COVERAGE)
SPECIAL ENROLLMENT PERIOD (DEPENDENT ACQUISITION)
LATE ENROLLMENT
OPEN ENROLLMENT
FAMILY STATUS CHANGE
EFFECTIVE DATE OF COVERAGE
EMPLOYEE(S) EFFECTIVE DATE
DEPENDENT(S) EFFECTIVE DATE
PRE-EXISTING CONDITIONS
TERMINATION OF COVERAGE
EMPLOYEE(S) TERMINATION DATE
DEPENDENT(S) TERMINATION DATE
LEAVE OF ABSENCE
FAMILY MEDICAL LEAVE ACT
EMPLOYEE REINSTATEMENT
STATUS CHANGE
EXTENSION OF BENEFITS DURING TOTAL DISABILITY
PLAN TERMINATION
CONTINUATION OF COVERAGE
QUALIFYING EVENTS
NOTIFICATION REQUIREMENTS
COST OF COVERAGE
WHEN CONTINUATION COVERAGE BEGINS
FAMILY MEMBERS ACQUIRED DURING CONTINUATION
COBRA PROVISIONS WITHIN THE HEALTH PORT-ABILITY
ACT AND ACCOUNTABILITY ACT OF 1996
SUBSEQUENT QUALIFYING EVENTS
END OF CONTINUATION
PRE-EXISTING CONDITIONS
EXTENSION FOR DISABLED INDIVIDUALS
MILITARY MOBILIZATION
THIS PLAN AND MEDICARE
MEDICAL EXPENSE BENEFIT
CO-PAYMENT
DEDUCTIBLE
COINSURANCE
OUT-OF-POCKET EXPENSE LIMIT
MAXIMUM BENEFIT
HOSPITAL/AMBULATORY SURGICAL CENTER
PRE-ADMISSION TESTING
AMBULANCE
EMERGENCY SERVICES/EMERGENCY ROOM
SUPPLEMENTAL ACCIDENT
REHABILITATIVE SERVICES
PHYSICIAN/PRACTITIONER SERVICES
SECOND SURGICAL OPINION
TRANSPLANTS
PREGNANCY
BIRTHING CENTER
NEWBORN CARE
PREVENTIVE CARE
STERILIZATION
EXTENDED CARE FACILITY
HOME HEALTH CARE
HOSPICE CARE
DURABLE MEDICAL EQUIPMENT
PROSTHESES
TEMPOROMANDIBULAR JOINT DYSFUNCTION
DENTAL SERVICES
SPECIAL EQUIPMENT AND SERVICES
COSMETIC SURGERY
MENTAL AND NERVOUS DISORDERS/ CHEMICAL
DEPENDENCY
PRESCRIPTIONS
MEDICAL EXCLUSIONS
PRESCRIPTION DRUG PROGRAM
PRESCRIPTION DRUG PROGRAM COVERED EXPENSES/DRUGS
PRESCRIPTION DRUG PROGRAM EXCLUSIONS
DENTAL EXPENSE BENEFIT
DENTAL PROVISIONS
DENTAL LIMITATIONS
DENTAL EXCLUSIONS
DENTAL SERVICES
PREDETERMINATION OF DENTAL BENEFITS
ALTERNATIVE TREATMENT/DENTAL CARE
DEDUCTIBLE
VISION EXPENSE BENEFIT
DEDUCTIBLE
COVERED VISION EXPENSE
VISION EXCLUSIONS
PLAN EXCLUSIONS
CLAIM PROCEDURE AND PAYMENT OF BENEFITS
FILING A CLAIM
NOTICE OF CLAIM
PAYMENT OF BENEFITS
APPEALING A CLAIM
ARBITRATION
FOREIGN CLAIMS
INCAPACITY
RECOVERY OF OVERPAYMENT
PHYSICAL EXAMINATION REQUIRED BY THE PLAN
LEGAL ACTIONS
COORDINATION OF BENEFITS
DEFINITIONS APPLICABLE TO THIS PROVISION
EFFECT ON BENEFITS
ORDER OF BENEFIT DETERMINATION
LIMITATIONS ON PAYMENTS
COORDINATION WITH MEDICARE
RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION
FACILITY OF BENEFIT PAYMENT
SUBROGATION/ THIRD PARTY LIABILITY
GENERAL PROVISIONS
ADMINISTRATION OF THE PLAN
ASSIGNMENT
BENEFITS NOT TRANSFERABLE
CLERICAL ERROR
CONFORMITY WITH STATUTES
EFFECTIVE DATE OF THE PLAN
FALSE STATEMENTS
FREE CHOICE OF HOSPITALS AND PHYSICIAN
INCONTESTABILITY
LIMITS ON LIABILITY
MEDICAL NECESSITY (MEDICALLY NECESSARY)
MISREPRESENTATION
PLAN IS NOT A CONTRACT
PLAN MODIFICATION AND AMENDMENT
PLAN TERMINATION
PRONOUNS
PROTECTION OF COVERAGE
TERMS OF COVERAGE
TIME EFFECTIVE
WORKERS COMPENSATION NOT AFFECTED
DEFINITIONS
INDEX
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Name of Plan:
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Name and Address of Employer
and Plan Sponsor:
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Employer Identification Number:
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Plan Number:
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Type of Plan:
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Welfare Benefit Plan:
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Type of Administration:
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Contract Administration
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Plan Administrator and Agent
for Service of Legal Process:
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Named Fiduciary:
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Eligibility Requirements:
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For detailed information, refer to following sections entitled
Eligibility, Enrollment, Effective Date of Coverage
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Termination of Coverage:
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For detailed information, refer to the sections entitled Schedule
of Benefits, Effective Date of Coverage, Pre-existing Conditions,
Termination of Coverage, and Plan Exclusions
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Source of Plan Contributions:
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Funding Method:
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The Employer pays Plan benefits and administration expenses
from general assets as needed. Contributions received from Covered
Persons are partial reimbursement to the Plan Administrator for
Plan expenses previously paid.
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Procedures for Filing Claims:
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Refer to the section entitled: Claim Procedures and Payment
of Benefits
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Ending Date of Plan’s Fiscal
Period:
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Designated Claims Processor:
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Eldorado Claim Services, Inc.
5353 North 16th Street Suite 410
Phoenix, Arizona 85016
602.604.3131 or 1.800.539.2695
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As a participant in the Plan, you are entitled to certain rights and
protection under the Employee Retirement Income Security Act of 1974
(“ERISA”). ERISA provides that all participants shall be entitled to:
1.
Examine, without charge, at the Plan Administrator’s office and
at other locations (work sites, etc.), all Plan Documents, including
insurance contracts, and copies of all documents filed by the Plan with
the U. S. Department of Labor.
2.
Obtain copies of all Plan Documents and other Plan information
upon written request to the Plan Administrator. The Plan Administrator
may make reasonable charge for the copies.
In addition to creating rights for Plan participants, ERISA imposes
obligations upon the people who are responsible for the operation of
the Plan. The people who operate your Plan, called “fiduciaries” of
the Plan, have a duty to do so prudently and in the interest of all
Plan participants and beneficiaries.
No one, including your Employer, a union, or any other person, may
fire you or discriminate against you to prevent you from obtaining any
benefit under the Plan or exercising your rights under ERISA.
If your claim for benefits under the Plan is denied in whole or in
part, you must receive written explanation of the reason for the denial.
You have the right to have the Plan review and reconsider your claim.
Under ERISA, there are steps you can take to enforce your rights. For
instance, if you request material from the Plan and do not receive such
within thirty (30) days, you may file suit in a federal court. In such
case, the court may require the Plan Administrator to provide the material
and pay you up to $110 a day until you receive the material, unless
the material was not provided for reasons beyond the control of the
Plan Administrator.
If you have a claim for benefits that is denied or ignored, in
whole or in part, you may file suit in a state or federal court.
If it should happen that Plan fiduciaries misuse the Plan’s money,
or if you are discriminated against for asserting your rights, you may
seek assistance from the U. S. Department of Labor, or you may file
suit in a federal court. The court will decide who will pay the costs
and legal fees. If you lose, the court may order you to pay these costs
and fees: for example, if it finds your claim frivolous.
If participants have any questions about this statement or about the
rights under ERISA, participants should contact the nearest office of
the Pension and Welfare Benefits Administration, U. S. Department of
Labor, listed in the telephone directory or the Division of Technical
Assistance and Inquiries, Pension and Welfare Benefits Administration,
U. S. Department of Labor, 200 Constitution Avenue, N. W., Washington,
D. C. 20210. The nearest Area Office to the Employer/Plan Sponsor is
the Los Angeles Regional Office, 790 E. Colorado Boulevard, Suite 514,
Pasadena, California, 91101, Phone 1.818.583.7862.
Eligibility and Effective Date of Coverage:
Active, regular Full-time Employees working a minimum of hours
per workweek are eligible to enroll in the Plan. An eligible Employee’s
coverage will begin on the employee’s .
Certain family members are eligible for Dependent coverage under the
Plan; their coverage will begin at the same time as the Employee’s coverage.
Employees must apply for coverage within thirty-one (31) days from the
date of their eligibility (date of hire). Employees and Dependents who
do not choose to be covered as soon as they are eligible may be subject
to Pre-existing Conditions limitations, if they desire to obtain coverage
at a later date. Refer to the sections entitled Eligibility,
Enrollment, and Effective Date of Coverage.
Pre-existing Conditions:
“Pre-existing Condition” means a condition (whether physical or mental),
regardless of the cause of the condition, for which medical advice,
diagnosis, care, or treatment, including the use of prescription drugs
or medicines was recommended by or received from a licensed Physician
or licensed health Practitioner within the six (6) month period ending
on the Covered Person’s Enrollment Date. Benefits will be provided
for the Pre-existing Condition(s) after the earliest of the following:
1.
Twelve* (12) months (365 days) continuous coverage under the
Plan, if the Employee has no prior creditable coverage; or
2.
Eighteen (18) months (545 days) continuous coverage under the
Plan, if the Employee was a Late Enrollee.
* This twelve (12) month period may be reduced for periods the employee
was covered under other Creditable Coverage.
Pre-existing Conditions limitations shall not apply to a newly adopted
child, a newborn child, or to Pregnancy. Refer to the sections entitled
Eligibility, Enrollment, and Effective Date of Coverage.
Cost of Coverage:
The Employer shares the cost of coverage with Employees and, where
applicable, their Dependents. Employees are required to make a modest
contribution in an amount determined by the Employer. The Employer may
change the amount of the Employee contribution from time to time. The
Employer will notify Employees of the contribution amount when coverage
becomes effective, and will also notify the Employees of any subsequent
changes in that amount. Individuals who continue their coverage pursuant
to COBRA will be required to pay the entire cost of that coverage.
Refer to the section entitled Continuation of Coverage.
Benefits Provided:
The Plan provides medical and prescription drug benefits for Employees
and their Dependent(s). The Plan offers Employees and their Dependent(s)
an opportunity to choose between two separate benefit programs through
the Preferred Provider Organization (PPO) or through the utilization
of Non-preferred Providers. Refer to the section entitled Plan
Options for a detailed explanation. The Covered Person may choose
between a provider of service contracted with the PPO (a Preferred Provider),
or with any other provider of choice (Non-Preferred Provider). The
Plan will pay higher benefits for services rendered by a Preferred Provider.
Refer to the section entitled Schedule of Benefits
Each Plan option has a Calendar Year Deductible the Covered Person
must pay from his/her own pocket before Plan benefits apply. For certain
services, the Calendar Year Deductible is waived. Refer to the section
entitled Schedule of Benefits for more information.
Exclusions:
There are categories of expenses that are not covered by the Plan.
A general listing of services and items excluded from the Plan can be
found in the sections entitled Medical Plan Exclusions
and Plan Exclusions.
Coordination of Benefits:
This Plan is designed to help the Covered Person meet the cost of Illness
or Injury. It is not intended to provide benefits greater than actual
expenses. Therefore, the Plan will take into account and coordinate
with the benefits of any Other Plan providing medical benefits so the
combined benefits of the Plans do not exceed 100% of the Allowable Expenses
incurred during the Claim Determination Period. However, benefits paid
under This Plan will not exceed those that would be payable in the absence
of any Other Plan.
Pre-authorization:
In the event of Hospitalization or Outpatient surgery, the Health Care
Management Organization must be notified and provided certain information.
If the Hospitalization or Outpatient surgery is planned in advance,
the call must be made three (3) days prior to admission or surgery.
If it is an Emergency or maternity admission, the call must be made
within 48 hours of admission. If pre-authorization is not obtained,
Covered Expenses shall be subject to an additional Deductible per occurrence
and a reduced Coinsurance. Refer to the section entitled Health
Care Management.
HEALTH CARE MANAGEMENT ORGANIZATION
Filing Claims:
Generally, to make a claim for a benefit, the Health Care Provider
should mail its bill directly to the Claims Processor, Eldorado Claims
Services, Inc. To obtain reimbursement for Covered Expenses that have
already been paid, the Covered Person must submit an itemized bill and
receipt for payment to the Claims Processor. To receive prescription
drug benefits, the prescription must be submitted to a participating
pharmacy, and the prescription drug card issued by the Plan must be
presented to the pharmacist. Refer to the section entitled Claim
Procedure and Payment of Benefits.
THIRD PARTY ADMINISTRATOR
ELDORADO CLAIM SERVICES,
INC.
5353 NORTH 16TH
STREET, SUITE 410
PHOENIX, ARIZONA 85016
602-604-3131
800-539-2695
602-604-3103 FAX
Continuation of Coverage:
If coverage under the Plan ceases for certain reasons, coverage may
be continued, at the Covered Person’s expense, in accordance with the
Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”). Dependents
covered by the Plan are also entitled to COBRA continuation coverage
under certain circumstances. Refer to the section entitled Continuation
of Coverage.
Subrogation/Third Party Liability Reimbursement:
As a condition of receiving benefits under the Plan, the Covered Person
agrees to the Plan’s right to reimbursement of benefits paid on behalf
of the Covered Person for expenses incurred due to the actions of a
third party. Refer to the section entitled Subrogation/Third
Party Liability.
This Plan offers Employees and their Dependents an opportunity to choose
between two separate benefit programs through the Preferred Provider
Organization or Non-Preferred Provider Organization (all other providers).
A brief description is as follows:
PPO-PREFERRED PROVIDERS:
A Preferred Provider is a Physician, Hospital, or ancillary service
having an agreement in effect with the Preferred Provider Organization
(PPO) to accept a reduced rate, known as the Negotiated Rate. The Preferred
Provider cannot bill the Covered Person for any amount in excess of
the Negotiated Rate. Because the Covered Person and Plan save money
when services or supplies are obtained from providers participating
in the Preferred Provider Organization, benefits are usually greater
than those available when using the services of a Non-Preferred Provider.
To participate in the benefit amounts for services under the PPO, the
Covered Person must use a preferred Hospital, Preferred Provider Physician,
preferred specialist, and other preferred ancillary services.
NON-PPO/NON-PREFERRED PROVIDERS:
A Non-Preferred Provider is free to charge patients at any rate. This
Plan will allow only the Customary and Reasonable Charge as a Covered
Expense. The Plan will pay its percentage of the Customary and Reasonable
Charge for the Non-Preferred Provider services. The Covered Person
is responsible for the remaining percentage of the Customary and Reasonable
Charge, plus the balance of the fees assessed by the provider. This
results in greater expense to the Covered Person.
REFERRALS:
Referrals to a Non-Preferred Provider or Non-Exclusive Provider are
covered as Non-Preferred Provider services and supplies. It is the
responsibility of the Covered Person to assure services to be rendered
are performed by PPO or EPO Physicians and facilities in order to receive
the higher level of benefits.
If the Health Care Management Organization recommends Medically Necessary
services or supplies be obtained from a provider out-of-area, Covered
Expenses shall be paid at the PPO benefit level. If the Covered Person
travels out-of-area for the purpose of obtaining medical services and
supplies, without the recommendation of the Health Care Management Organization,
Covered Expenses shall be paid at the Non-PPO benefit level.
The following Schedule of Benefits is designed as a quick
reference. For complete provisions of the Plan’s benefits, refer to
the following sections: Health Care Management, Medical Expense
Benefit and Plan Exclusions. A complete listing of participating
providers can be obtained from the Human Resources Department. Limitations
are combined maximums for services and supplies rendered by Preferred
and Non-Preferred Providers.
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Maximum Benefit per Covered Person while covered by this Plan
for:
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Medical
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$ 1,000,000
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Chemical Dependency
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25,000
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Maximum Benefit per Covered Person per Calendar Year for:
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Mental and Nervous Disorders
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Inpatient/30 days per calendar
year
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Outpatient/25 visits per
calendar year
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Chemical Dependency Inpatient
&/or Outpatient Hospital
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Inpatient Services
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$ 10,000
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Chemical Dependency
Outpatient Services
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2,000
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(Included in the Inpatient
and/or Outpatient limit of $10,000)
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Extended Care Facility/Treatment
and Confinement
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30 days per calendar year
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Chiropractic Care
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$ 300
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Home Health Care
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100 visits per Calendar
Year
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Preventive Care
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$ 300
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Calendar Year Deductible:
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Individual Deductible
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Family Deductible (Aggregate)
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Coinsurance Expense Limit Per Calendar Year
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Individual
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Additional Deductibles
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Hospital Admission NOT Pre-Authorized
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Outpatient Surgery NOT Pre-Authorized *
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*Outpatient Surgeries where
the Surgeon’s charges are $401 or more require Pre-Authorization.
Refer to the section entitled Health Care Management for
more details.
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Limitation per Occurrence
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Hospital Inpatient/Outpatient
Surgery Covered Expenses NOT Pre-Authorized/
Network Provider
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80%
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80%
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Hospital Inpatient/Outpatient
Surgery Covered Expenses NOT Pre-Authorized/
Non-Network Provider
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60%
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0%
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The following are Covered Dental Services. Refer to the section entitled
Dental Provisions, Dental Benefits, for details regarding the
services covered, exclusions, limitations and other provisions of the
Dental Benefit.
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ALL PROVIDERS
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CLASS I
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80%
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Limitation: Subject to maximum annual benefit per person
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CLASS II
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80%
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Limitation: Subject to deductible and
maximum annual benefit per person.
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CLASS II
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80%
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Limitation: Subject to deductible and
maximum annual benefit per person.)
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CLASS IV
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50%
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Limitation: Subject to
deductible and maximum lifetime benefit per person.)
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ALL CLASSES
CLASSES I, II, III
CLASS IV
(To be effective July 1, 1998)
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ALL PROVIDERS
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Individual Calendar Year Deductible:
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$25
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Examination / Maximum Benefit:
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$40
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Limitation: One exam during any 18 consecutive
months.
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Conventional Lenses / Maximum Benefit:
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Single Vision
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$40
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Bi-focal
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$50
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Tri-focal
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$60
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Lenticular
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$120
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$200
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$100
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Limitation: One pair during any 18 consecutive
months.
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Frames / Maximum Benefit:
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$40
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Limitation: One pair during any 18 consecutive
months.
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Refer to the section entitled Vision Expense Benefit for
complete details.
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For the purpose of determining the Coinsurance and Out-of-Pocket Expense
Limit, Covered Expenses are divided into the following three categories:
CATEGORY 1:
This category applies to such Covered Expenses made by all Preferred
Providers. For Employees who reside or work outside the Preferred Provider
service area (50 Miles or more from the nearest Preferred Provider),
Covered Expenses for Non-Preferred Provider services and supplies shall
be Category 1 expenses.
CATEGORY 2:
This category applies to such Covered Expenses made by Providers that
are Non-Preferred Providers if:
1.
Such expenses are made by pathologists, radiologists, or anesthesiologists
in connection with a covered Inpatient Preferred Hospital Confinement
or a covered Outpatient procedure performed in a Preferred Hospital.
2.
Such expenses are necessitated by an Emergency condition (as
defined in the Plan), and then only to the following extent: (a) in
the case of Emergency Outpatient treatment, such expenses incurred within
twenty-four (24) hours of the accident; and (b) in the case of an Inpatient
Hospital Confinement, such expenses up to the day the Covered Person
can reasonably be expected to safely transfer to a Preferred Provider.
3.
Such expenses are for care, treatment, services, or supplies
that are not rendered by any Preferred Provider.
4.
Such expenses are incurred while traveling outside of the Preferred
Provider area (50 miles or more from the nearest Preferred Provider).
CATEGORY 3:
This category applies to such Covered Expenses made by all other Non-Preferred
Providers.
Note: If the Covered Person elects to use Category 3, the Coinsurance
payable by the Covered Person shall NOT apply to the Out-of-Pocket Expense
Limit.
Out-of-Pocket
Expense Limit Per Calendar Year:
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Individual
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$ 1,000
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Family (Aggregate)
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2,000
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Refer to the section entitled Medical Expense Benefit,
Out-of-Pocket Expense Limit for a listing of charges not
applicable to the Out-of-Pocket Expense Limit.
The Plan pays the percentage listed on the following pages for Covered
Expenses incurred by a Covered Person during a Calendar Year after the
Individual or Family Deductible has been satisfied and until the Individual
or Family Out-of-Pocket Expense Limit has been reached. Thereafter,
the Plan pays 100% of incurred Covered Expenses for the remainder of
the Calendar Year, or until the Maximum Benefit has been reached. Refer
to the section entitled Medical Expense Benefit, Out-of-Pocket
Expense Limit for a listing of charges not applicable to the
100% Coinsurance.
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PLAN A
Benefit Description
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PPO Provider Category
1
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(see Page 7) Category
2
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Non-PPO Provider Category
3
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INPATIENT HOSPITAL
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90%*
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80%
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70%**
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* Benefits for Inpatient
Hospital/Network/Not Pre-authorized will be subject to a
separate and additional
$300 Deductible and 80% Coinsurance payment per
unapproved admission.
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** Benefits for Inpatient
Hospital/ Non-Network/Not Pre-authorized will be subject to a
separate and additional
$300 Deductible and 60% Coinsurance payment per
unapproved admission.
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OUTPATIENT SURGERY
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90%*
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80%
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70%**
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* Benefits for Outpatient
Surgery/Network/Not Pre-authorized will be subject to a
separate and additional
$300 Deductible and 80% Coinsurance payment per
unapproved surgical
procedure.
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** Benefits for Outpatient
Surgery/Non-Network/Not Pre-authorized will be subject to a
separate and additional
$300 Deductible and 60% Coinsurance payment per
unapproved surgical
procedure.
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ER SERVICES
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100% after $100 Co-pay* Deductible
Waived
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100% after $100 Co-pay* Deductible
Waived
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100% after $100 Co-pay* Deductible
Waived
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*The $100 Co-payment is
waived if Covered Person is admitted to the Hospital; coverage
reverts to Hospital Inpatient as noted above.
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URGENT CARE
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90% Subject to Deductible*
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90% Subject to Deductible*
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90% Subject to Deductible*
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*No Co-payment required.
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SUPPLEMENTAL ACCIDENT
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100% Ded. Waived up to $500.*
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100% Ded. Waived up to $500.*
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100% Ded. Waived up to $500.*
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*Limitation: Maximum
Benefit is $500 per accident; coverage then reverts to Plan Benefits.
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PRE-ADMISSION TESTING
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90%
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80%
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70%
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PHYSICIANS’ SERVICES
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90%
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80%
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70%
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Assistant Surgeon’s Covered
Expenses not to exceed 20% of the primary Physician’s Covered
Expenses.
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SECOND SURGICAL OPINION
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100% Ded. Waived
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100% Ded. Waived
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70% Ded. Waived
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100% Ded. Waived
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100% Ded. Waived
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70% Ded. Waived
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OUTPATIENT DIAGNOSTIC
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90%
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80%
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70%
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90%
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80%
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70%
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Limitation: Up to 30
days for treatment and Confinement per Calendar Year.
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90%
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80%
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70%
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90%
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80%
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70%
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Limitation: Maximum Benefit
per family unit for family bereavement counseling is $200.
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90%
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80%
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70%
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Limitation: Maximum Benefit
per Calendar Year not to exceed 100 days rental; Maximum Benefit
per Calendar Year for rental of Apnea Monitor (except if used
for infants), T.E.N.S. Unit, or equipment designed to assist bones
to heal faster is limited to $200 each.
|
| |
|
|
|
|
|
100% to $300 Ded. Waived*
|
Denied
|
Denied
|
| |
*Limitation: Up to $300
per Calendar Year benefit.
|
| |
|
|
|
|
|
90%*
|
90%*
|
70%*
|
| |
*Inpatient services subject
to maximum 30 days per calendar year; Outpatient services subject
to maximum 25 visits per calendar year.
|
| |
|
|
|
|
|
|
|
|
|
|
90%*
|
90%*
|
70%*
|
| |
*Limitation: $10,000
per Covered Person, per Calendar Year for Inpatient and Outpatient
Hospital.
|
| |
|
|
|
|
|
50%*
|
50%*
|
50%*
|
| |
*Limitation: $2,000 per
Covered Person, per Calendar Year (included in the Inpatient and/or
Outpatient limit of $10,000).
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
|
|
|
|
|
N/A
|
100%*
|
N/A
|
| |
*Maximum Benefit: $25
per treatment; maximum of 26 treatments per Calendar Year.
|
| |
|
|
|
|
|
N/A
|
80%
|
N/A
|
| |
|
|
|
|
|
N/A
|
90% Ded. Waived
|
N/A
|
| |
|
|
|
|
|
90%
|
80%
|
70%
|
| |
|
|
|
|
|
N/A*
|
N/A*
|
N/A*
|
| |
*100% after Prescription
Drug Co-payment: $5 generic/$15 brand name. Generic will be dispensed
unless specified “Dispense as Written.” Maintenance drugs will
be dispensed through a mail order program.
|
| |
|
|
|
|
|
|
|
|
For the Purpose of determining the Coinsurance and Out-of-Pocket Expense
Limit, Covered Expenses are divided into the following three (3) categories:
CATEGORY 1:
This category applies to such Covered Expenses made by all EPO Hospitals.
For Employees who reside or work outside the EPO service area (50 miles
or more from the nearest Preferred Provider), Covered Expenses for Non-Preferred
Provider services and supplies shall be Category 1 expenses.
CATEGORY 2:
This category applies to such Covered Expenses made by all other Exclusive
Providers and such Covered Expenses made by Providers that are not Exclusive
Providers if:
1.
Such expenses are made by pathologists, radiologists, or anesthesiologists
in connection with a covered Inpatient Exclusive Provider Hospital Confinement
or a covered Outpatient procedure performed in an Exclusive Provider
Hospital.
2.
Such Expenses are necessitated by an Emergency condition (as
defined in the Plan), and then only to the following extent: (a) in
the case of Emergency Outpatient treatment, such expenses are incurred
within twenty-four (24) hours of the accident; and (b) in the case of
an Inpatient Hospital Confinement, such expenses up to the day the Covered
Person can reasonably be expected to safely transfer to an Exclusive
Provider.
3.
Such expenses are for care, treatment, services, or supplies
that are not rendered by any Exclusive Provider.
4.
Such expenses are incurred while traveling outside of the Preferred
Provider area (50 miles or more from the nearest Preferred Provider).
CATEGORY 3:
This category applies to such Covered Expenses made by all other Non-EPO
Providers.
If the Covered Person elects to use a Non-Exclusive Provider, the
Coinsurance payable by the Covered Person shall not
apply to the Out-of-Pocket Expense Limit.
Out-of-Pocket
Expense Limit per Calendar Year:
| |
Individual
|
$ 1,500
|
| |
Family (Aggregate)
|
3,000
|
Refer to the section entitled Medical Expense Benefit,
Out-of-Pocket Expense Limit for a listing of charges not
applicable to the Out-of-Pocket Expense Limit.
The Plan pays the percentage listed on the following pages for Covered
Expenses incurred by a Covered Person during a Calendar Year after the
Individual or Family Deductible has been satisfied and until the Individual
or Family Out-of-Pocket Expense Limit has been reached. Thereafter,
the Plan pays 100% of incurred Covered Expenses for the remainder of
the Calendar Year or until the Maximum Benefit has been reached. Refer
to the section entitled Medical Expense Benefit, Out-of-Pocket
Expense Limit for a listing of charges not applicable to the
100% Coinsurance.
PLAN C
Benefit Description
|
EPO Provider Category
1
|
(see Page 7) Category
2
|
Non-EPO Provider Category
3
|
|
INPATIENT HOSPITAL*
|
100% Ded. Waived*
|
80%
|
Network only**
|
| |
* Benefits for Inpatient
Hospital Expenses will be subject to a separate and additional
$300 Deductible
and 80% Coinsurance per unapproved admission.
|
| |
** Emergency admissions
to Non-Network providers will be covered at the EPO Benefit
level provided Covered
Person is transferred to a Network provider as early as
possible. See Plan
Document for details.
|
| |
|
|
|
|
OUTPATIENT SURGERY*
|
100%*
|
80%
|
NETWORK ONLY
|
| |
* Benefits for Outpatient
Surgery expenses will be subject to a separate and additional
$300 Deductible
and 80-20% Coinsurance payment per unapproved surgical
procedure.
|
| |
|
|
|
|
ER SERVICES *
|
100% after $100 Co-pay
|
100% after $100 Co-pay
|
100% after $100 Co-Pay
|
| |
* The $100 Co-payment
is waived if Covered Person is admitted to the Hospital;
coverage reverts
to Hospital Inpatient as noted above.
|
| |
|
|
|
|
URGENT CARE
|
100% subj. to $15 Co-pay
|
80% subj. to $15 Co-pay
|
60% subj. to $15 Co-pay
|
| |
|
|
|
|
SUPPLEMENTAL ACCIDENT
|
100% Ded. Waived up to $500.*
|
100% Ded. Waived up to $500.*
|
100% Ded. Waived up to $500.**
|
| |
* Limitation: Maximum
Benefit $500 per accident; coverage then reverts to Plan
Benefits.
|
| |
|
|
|
|
PRE-ADMISSION TESTING
|
100%
|
80%
|
60%
|
| |
|
|
|
|
PHYSICIANS’ SERVICES
|
|
|
|
|
|
N/A
|
100% after $15 co-pay
|
60%
|
| |
|
|
|
|
|
80%
|
80%
|
80%
|
| |
Assistant Surgeon’s Covered
Expenses not to exceed 20% of the primary Physician’s Covered
Expenses.
|
| |
|
|
|
|
SECOND SURGICAL OPINION
|
|
|
|
|
|
N/A
|
100% Ded. Waived
|
60%
|
| |
|
|
|
|
|
N/A
|
100% Ded. Waived
|
60%
|
| |
|
|
|
|
OUTPATIENT DIAGNOSTIC
X-RAY AND LABORATORY*
|
100%*
|
100%*
|
60%*
|
| |
*Services ordered by an
EPO Physician and rendered as part of the EPO Physician office
visit shall be considered part of the EPO Physician office visit
Co-payment, whether or not the services are performed on the same
day as the office visit. Excluded from this provision is lab
work ordered for review and maintenance of a medical condition,
such as monthly visits to a lab for blood work. See “All Other
Outpatient Diagnostic X-rays and Laboratory” for benefit.
|
| |
|
|
|
|
ALL OTHER OUTPATIENT DIAGNOSTIC
X-RAYS AND LABORATORY
|
80%
|
80%
|
60%
|
| |
|
|
|
|
EXTENDED CARE FACILITY
|
N/A
|
80%
|
60%
|
| |
Limitation: Up to 30
days for treatment and Confinement per Calendar Year.
|
| |
|
|
|
|
HOME HEALTH CARE
|
N/A
|
80%
|
60%
|
| |
|
|
|
|
HOSPICE CARE
|
N/A
|
80%
|
60%
|
| |
Limitation: Maximum Benefit
per family unit for bereavement counseling is $200.
|
| |
|
|
|
|
DURABLE MEDICAL EQUIPMENT
|
N/A
|
80%
|
60%
|
| |
Limitation: Maximum Benefit
per Calendar Year not to exceed 100 days rental; Maximum Benefit
per Calendar Year for rental of Apnea Monitor (except if used
for infants), T.E.N.S. Unit or equipment designed to assist bones
to knit faster is limited to $200 each.
|
| |
|
|
|
|
PREVENTIVE CARE
|
N/A
|
100% to $300* Co-Pay and Ded.
Waived
|
Denied
|
| |
*Limitation: Up to $300
per Calendar Year benefit.
|
| |
|
|
|
|
MENTAL AND
NERVOUS DISORDERS*
|
100%*
|
80%*
|
60%*
|
| |
*Subject to a maximum
of 30 days per calendar year Inpatient services.
*Outpatient services subject
to $15 co-pay and maximum 25 visits per calendar year.
|
| |
|
|
|
|
CHEMICAL DEPENDENCY
|
|
|
|
|
Inpatient Services
|
100%*
|
80%*
|
60%*
|
| |
*Limitation: $10,000
per Covered Person per Calendar Year for Inpatient and Outpatient
Hospital
|
| |
|
|
|
|
Outpatient Services
|
N/A
|
50%*
|
50%*
|
| |
*Limitation: $2,000 per
Covered Person per Calendar Year (included in the Inpatient and/or
Outpatient limit of $10,000).
|
| |
|
|
|
|
PHYSICAL THERAPY
|
N/A
|
80%
|
60%
|
| |
|
|
|
|
SPEECH THERAPY
|
N/A
|
80%
|
60%
|
| |
|
|
|
|
CHIROPRACTIC CARE
|
N/A
|
100%*
|
N/A
|
| |
*Maximum Benefit: $25
per treatment; Maximum of 26 treatments per Calendar Year.
|
| |
|
|
|
|
AMBULANCE
|
N/A
|
80%
|
N/A
|
| |
|
|
|
|
BIRTHING CENTER
|
N/A
|
100%
|
N/A
|
| |
|
|
|
|
ALL OTHER COVERED EXPENSES
|
N/A
|
80%
|
80%
|
| |
|
|
|
|
PRESCRIPTION DRUGS
|
N/A*
|
N/A*
|
N/A*
|
| |
100% after Prescription
Drug Co-pay; $5 generic/$15 brand name. Generic will be dispensed
unless specified “Dispense as Written.” Maintenance drugs will
be dispensed through a mail order program.
|
|
|
|
|
|
Health Care Management is a means of monitoring services for Medical
Necessity to help ensure cost-effective care. Health Care Management
can eliminate unnecessary services, Hospitalizations, and shorten
Confinements, while improving quality of care and reducing costs to
the covered Person and the Plan. Certification of Medical Necessity
by the Health Care Management Organization does NOT establish eligibility
under the Plan nor guarantee benefits.
Hospital:
All hospital admissions must be certified in advance (Pre-authorization) by
the Health Care Management Organization, except for emergencies. The
Covered Person or their representative should call the Health Care Management
Organization at least three (3) days prior to admission.
Emergency Hospital admissions must
be reported to the Health Care Management Organization within forty-eight
(48) hours following admission, or on the next business day after admission.
After admission to the Hospital, the Health Care Management Organization
will continue to evaluate the Covered Person’s progress through Concurrent
Review to monitor the length of Confinement. If the Health Care Management
Organization disagrees with the length of Confinement recommended by
the Physician, the Covered Person and the Physician will be advised.
If the Health Care Management Organization determines that continued
Confinement is no longer necessary, additional days will not be certified.
Coinsurance for additional days not certified by the Health Care
Management Organization shall be denied.
Outpatient Surgery:
All Outpatient Surgical procedures must be certified in
advance (Pre-Authorization) by the Health Care Management
Organization, except for surgical procedures for which the surgeon’s
charges are $400 or less, or surgical procedures performed on an Outpatient
basis within forty-eight (48) hours of an Injury. The Covered Person,
or their representative, should call the Health Care Management Organization
at least three (3) days prior to surgery.
Second Surgical Opinion:
When an Inpatient or Outpatient Surgical procedure is recommended by
a Physician, the Covered Person should call the Health Care Management
Organization prior to surgery to obtain approval for the recommended
procedure. When an Outpatient Surgical procedure is recommended by
a Physician, and the Health Care Management Organization does not agree,
the Covered Person must obtain a Second Surgical Opinion. The two concurring
opinions will determine the certification of Medical Necessity. The
Covered Person may elect to obtain a Second Surgical Opinion prior to
any recommended surgery, and the Plan shall pay benefits as though required
by the Health Care Management Organization. Refer to the section entitled
Medical Expense Benefit, Second Surgical Opinion for complete
details.
Penalty:
Benefits payable for charges arising out of an unapproved Inpatient
Admission or Outpatient Surgical procedure will be subject to a separate
and additional $300 Deductible and 80% Coinsurance per each unapproved
Inpatient Admission or Outpatient Surgical procedure. This additional
Deductible and Coinsurance penalty is waived if the Covered Person is
traveling outside the United States or resides outside the United States.
After the Covered Person has satisfied this “per occurrence” penalty
deductible, the Calendar Year Deductible shall apply, then the Plan’s
Coinsurance shall apply. Refer to the section entitled Schedule
of Benefits for complete details.
In the event authorization for Medical Necessity is denied by the Health
Care Management Organization, the Covered Person may appeal the decision.
The Covered Person may call the Health Care Management Organization
for more information concerning the appeal process.
In cases where the Covered Person’s condition is expected to be, or
is, of a serious nature, the Employer may arrange for review and/or
case management services from a professional qualified to perform such
services. The Employer shall have the right to alter or waive the normal
provisions of this Plan when it is reasonable to expect a cost effective
result without a sacrifice to the quality of care. The use of case
management or alternate treatment is a voluntary program to the Covered
Person; however, the Plan will generally provide a greater benefit
to the Covered Person who chooses to participate in the program.
Benefits provided under this section are subject to all other Plan
provisions. Alternative care will be determined on the merits of each
individual case, and any care or treatment provided will not be considered
as setting any precedent or creating any future liability with respect
to that Covered Person or any other Covered Person.
This section identifies the Plan’s requirements for a person to be
eligible to enroll. Refer to the sections entitled Enrollment
and Effective Date of Coverage for more information.
All Active, Full-time Employees who are regularly scheduled to work
at least thirty-five (35) hours per work week shall be eligible to enroll
for coverage.. This average will be calculated at the end of the preceding
ninety (90) day period. Employee eligibility does not include temporary
or seasonal Employees.
The following describes Dependent eligibility requirements. At its
discretion, the Employer may require proof of Dependent status.
1.
The term “spouse” means the spouse of the Employee under a legally
valid existing marriage, unless court ordered separation exists.
2.
The term “child(ren)” means the Employee’s natural child(ren),
stepchild(ren), and legally adopted child(ren), and a child(ren) for
whom the Employee or covered spouse has been appointed legal guardian,
provided:
a.
The child(ren) is less than nineteen (19) years of age; and
b.
The child(ren) lives with the Employee in a parent-child relationship;
and
c.
The child(ren) is unmarried; and
d.
The child(ren) is principally dependent upon the Employee for
support and maintenance; and
3.
An eligible child shall also include any other child of an Employee
or his/her spouse who is recognized in a Qualified Medical Child Support
Order (QMCSO) that has been issued by any court judgment, decree, or
order as being entitled to enrollment for coverage under this Plan,
even if the child(ren) is not residing in the Employee’s household.
Such child shall be referred to as an Alternate Recipient. Alternate
Recipients are eligible for coverage regardless of whether or not the
Employee elects coverage for himself/herself. An application for enrollment
must be submitted to the Employer for coverage under this Plan. The
Employer shall establish written procedures for determining whether
a Medical Child Support Order is a QMCSO, and for administering the
provision of benefits under the Plan pursuant to a valid QMCSO. The
Employer reserves the right, waivable at its discretion, to seek clarification
with respect to the order from the court or administrative agency that
issued the order, up to and including the right to seek a hearing before
the court or agency.
4.
An adopted child(ren) who is less than 18 years of age
at the time of adoption shall be considered eligible from the moment
the child(ren) is Placed for Adoption. “Placed for Adoption” means
the date the Employee assumes legal obligation for the total or partial
support of the child(ren) during the adoption process.
5.
The child(ren) born unto the Dependent child(ren) of the Employee
shall be eligible to be enrolled as a Dependent(s) of the Employee provided:
a. The Dependent child(ren) of the Employee is unmarried.
b.
The Dependent child(ren) of the Employee and the child(ren)
born unto the Employee’s Dependent(s) live with the Employee and are
principally dependent upon the Employee for support and maintenance.
6.
Upon written notice to the Employer, an unmarried child(ren)
who has reached his/her nineteenth (19th ) birthday and is
principally dependent upon the Employee for support and maintenance,
may also be included herein as an eligible Dependent(s) until the child(ren)’s
twenty-third (23rd) birthday, provided such child(ren)is
unmarried, and is a full-time student in a secondary school, accredited
college, university or institution of higher learning. It is the Employee’s
responsibility to provide the Claims Processor with proof of Full-time
Student Status for each semester. Such proof must be obtained from
the school’s registrar. The Employee must notify the employer when
the Dependent(s) is no longer a Full-time Student.
7.
An unmarried child(ren), incapable of self-sustaining employment
and dependent upon the Employee for support due to a mental and/or
physical disability, and who was covered under the Plan prior to reaching
the maximum age limit or other loss of Dependent’s eligibility, will
remain eligible for coverage under this Plan beyond the date coverage
would otherwise be lost. Proof of incapacitation must be provided
within thirty (30) days of the child(ren)’s loss of eligibility and
thereafter as requested by the Employer or Claims Processor, but not
more than once every two (2) years. Eligibility may not be continued
beyond the earliest of the following:
a.
Cessation of the physical handicap; or
b.
Failure to furnish any required proof of mental retardation and/or
physical handicap or to submit to any required examination.
Every eligible Employee may enroll eligible Dependents. However, if
both the husband and wife are Employees, they may choose to have one
covered as the Employee, and the spouse covered as the Dependent of
the Employee, or they may choose to have both covered as Employees.
An eligible child(ren) may be enrolled as a Dependent(s) of one spouse,
but not both. A Dependent child(ren) who also qualifies as an eligible
Employee may be enrolled as a Dependent(s) of another Employee, but
shall not be enrolled as a Dependent child(ren) and an Employee simultaneously.
An Employee must file a written application with the Employer for coverage
hereunder for him/herself and his/her eligible Dependent(s): 1) on,
before, or within thirty (30) days of becoming eligible for coverage;
and 2) on, before, or within thirty days of marriage or the acquiring
of a) or birth of a child(ren).
The Employee shall have the responsibility of timely forwarding to
the Employer all applications for enrollment hereunder. Failure to complete
the application for enrollment within thirty (30) days shall result
in the Late Enrollment provision applying to the individual and/or Dependents.
An Alternate Recipient can be enrolled in the Plan at any time and shall
not be subject to the Late Enrollment provision.
The Employer must be notified of any change in eligibility of Dependents,
including the birth of a child(ren) who is to be covered, and adding
or deleting any other Dependent(s). Forms are available from the Employer
for reporting changes in Dependents’ eligibility as required.
If the Employee elects to terminate Employee coverage, then chooses
to re-enroll at a later date, the Employee shall be subject to the Late
Enrollment provision below.
If the Employee elects to terminate Dependent(s) coverage, then chooses
to re-enroll the Dependent(s) at a later date, the Dependent(s) shall
be subject to the Late Enrollment provision below.
A Dependent child(ren) who ceased to qualify for Full-time Student
Status and whose coverage terminated, shall be eligible to re-enroll
for coverage under the Plan, provided application for enrollment is
submitted to the Employer within thirty (30) days of the return to Full-time
Student Status.
Employees who elect not to enroll themselves and/or their Dependent(s)
must complete the Waiver of Coverage portion of the enrollment form.
The Waiver of Coverage must be submitted to the Employer within thirty
(30) days of meeting the Plan’s eligibility requirements. If waiver
of coverage is due to the existence of other group health coverage upon
meeting the Plan’s eligibility requirements, it is the Employee’s responsibility
to notify the Employer in writing of the existence of the other coverage,
and this being the reason for waiving the coverage upon meeting the
eligibility requirements.
Applications for Employee or Dependent(s) coverage not filed with the
Employer within thirty (30) days of meeting the eligibility requirements
of the Plan because other coverage existed, shall be subject
to the Special Enrollment provision. An Employee or Dependent may request
a special enrollment period if he/she is no longer eligible for the
other coverage, and if all of the following provisions are met:
1.
the employee or dependent was covered under another group or
individual health plan at the time coverage was initially offered; and
2.
the employee stated in writing at the time initial enrollment
was offered that other coverage was the reason for declining enrollment
in the Plan; and
3.
the employee or dependent lost the coverage as a result of a
specific event*, such as the loss of eligibility for coverage, expiration
of COBRA continuation coverage, termination of employment, or employer
contributions towards such coverage were terminated; and
4.
the employee requests such enrollment period, and effects the
enrollment, within thirty (30) days of loss of the other coverage.
The Effective Dates of Coverage as a result of a special enrollment
will be the first day of the first calendar month following the Employer’s
receipt of the completed enrollment form. Acceptance of enrollment
does not waive the Pre-existing Condition provision.
*However, loss of eligibility of other coverage does not include a
loss due to failure of the individual to pay premiums or contributions
on a timely basis, or termination of coverage for cause (such as making
a fraudulent claim, or an intentional misrepresentation of a material
fact in connection with the other coverage).
This Special Enrollment Period (Dependent Acquisition) allows
an eligible Employee to enroll Dependents when he/she marries or has
a new child(ren) (as a result of marriage, birth, adoption, or Placement
for Adoption). A spouse of an Employee can be enrolled separately at
the time of marriage, or when a child(ren) is born, adopted, or Placed
for Adoption. A spouse of an Employee can be enrolled together with
the Employee when they marry, or when a child(ren) is born, adopted,
or Placed for Adoption. A child(ren) who becomes a Dependent(s) of
an Employee as a result of marriage, birth, adoption, or Placed for
Adoption, may be enrolled when the child(ren) becomes an eligible Dependent(s).
The Employee must request the special enrollment within thirty (30)
days of the acquisition of the Dependent(s). The effective date of
coverage as a result of a special enrollment shall be:
1.
In the case of marriage, the first day of the first calendar
month following the Employer’s receipt of the completed enrollment form;
2.
In the case of a Dependent’s birth, the date of such birth;
3.
In the case of adoption or Placed for Adoption, the date of such
adoption or Placed for Adoption.
Applications for Employee or Dependent(s) coverage not filed with the
Employer within thirty (30) days of meeting the eligibility requirements
of the Plan, and do not fall under the provisions stated above in the
section entitled Special Enrollment, shall be subject
to the Late Enrollment provision.
Late enrollment applicants shall be eligible to enroll for coverage
only during the Plan’s annual Open Enrollment Period. The “Open Enrollment
Period” is at the discretion of the company and will be announced.
Coverage is effective the first of the month following an Open Enrollment
Period. Acceptance of enrollment does not waive the Pre-existing Condition
provision. This Late Enrollment provision does not apply to an Alternate
Recipient.
An Open Enrollment Period will be permitted once in each Calendar
Year. During this Open Enrollment Period, an eligible Employee and
his/her eligible Dependent(s) who were not previously covered by this
Plan may elect coverage under this Plan. This will be considered a Late
Enrollment. Acceptance of enrollment does not waive the Pre-existing
Condition provision.
Employees and enrolled Dependent(s) previously covered by this Plan
may elect to change Plan options (switch between Plan A and Plan C).
An election may not be changed by the Employee until the next Open Enrollment
Period. In subsequent years, an Employee is not required to complete
an new election form during the Open Enrollment Period, unless the Employee
elects to change his/her benefit program. The “Open Enrollment Period”
is at the discretion of the company and will be announced. Employees
and enrolled Dependents who are electing to change Plan options will
not be subject to any additional Pre-existing Conditions limitations.
When an Employee elects to change benefit programs (switch between Plan
A and Plan C), all previously incurred Covered Expenses, Coinsurance,
Deductibles, and Out-of-Pocket expenses will be transferred to the new
Plan benefit program and will apply to the Calendar Year Deductibles,
Calendar Year Maximum Benefits, Calendar Year Out-of-Pocket Expense
Limit, and Maximum Benefit.
Once enrolled in the Plan, it is the Employee’s responsibility to
notify the Human Resources Department of any change in eligibility of
a Dependent(s), including the birth of a child(ren) who is to be covered,
loss of Full-time Student Status of a Dependent child(ren) and/or adding
or deleting any other Dependent(s). Forms are available from the Human
Resources Department for reporting changes in family status as required.
If the Employee elects to terminate Dependent(s) coverage, then chooses
to re-enroll the Dependent(s), the Employee may re-enroll the Dependent(s),
subject to the Late Enrollment provisions.
A Dependent child(ren), who ceases to qualify for Full-time Student
Status and whose coverage was terminated, but who subsequently returns
to Full-time Student Status, may reapply for coverage without the application
of Special or Late Enrollment provisions, provided application for re-enrollment
is submitted to the Employer on, before, or within thirty (30) days
of eligibility.
Eligible Employees, as defined in the section entitled Eligibility,
are effective for coverage under the Plan from their date of hire,
provided they make application for coverage within thirty (30) days
from the date of hire.
If the Employee does not enroll for coverage on, before, or within
thirty (30) days of meeting the Plan’s eligibility requirements, the
Effective Date of Coverage will be delayed. Refer to the section entitled
Enrollment.
If an Employee transfers from any foreign country division of the Employer,
the Employee will be covered from their date of transfer, provided they
make application for coverage within thirty (30) days from the date
of transfer. Special and Late enrollment provisions will not apply to
the Employee transferring from any foreign country division, provided
application for coverage is made in a timely manner.
An eligible Dependent(s), as defined in the section entitled Eligibility,
will become covered under the Plan on the later of the following dates,
provided the Employee has enrolled the Dependent(s) in the Plan:
1.
The date the Employee’s coverage becomes effective;
2.
The date the Dependent(s) is acquired, provided:
a.
The Employee enrolls the Dependent(s) within thirty (30) days
following the date acquired; and
b.
The Employee makes any required contributions for Dependent coverage;
and
3.
Newborn child(ren) shall be covered from birth, regardless of
Confinement, provided the Employee has applied for Dependent(s) coverage
on, before, or within thirty (30) days of birth;
4.
Coverage for a newly adopted child shall be effective the date
the child is Placed for Adoption.
If the Employee does not enroll an eligible Dependent(s) on, before,
or within thirty (30) days of meeting the Plan’s eligibility requirements,
the Dependent(s)’s Effective Date of Coverage will be delayed. Refer
to the section entitled Enrollment.
“Pre-existing Condition” means a condition (whether physical or mental),
regardless of the cause of the condition, for which medical advice,
diagnosis, care, or treatment, including the use of prescription drugs
or medicines was recommended by, or received from, a licensed Physician
or a licensed health Practitioner during the six (6) month period
prior to the Covered Person’s Effective Date of Coverage. Benefits
will be provided for Pre-existing Conditions after the earliest of the
following:
1.
Twelve* (12) months (365 days) continuous coverage under the
Plan, if the Employee has no prior creditable coverage; or
2.
Eighteen (18) months (545 days) continuous coverage under the
Plan, if the Employee was a Late Enrollee.
* This 12 month period
may be reduced for periods the employee was covered under other Creditable
Coverage, provided there is not more than a sixty-three (63) day break
in coverage until the Enrollment Date of the Covered Person. The Covered
Person must submit certification of prior Credible Coverage to the Human
Resources Department in order to receive the credit for prior coverage.
This Pre-existing Condition limitation shall not apply to newborns
or newly adopted child(ren) who are enrolled in a timely manner (30
days). The Plan shall provide benefits for an adopted child(ren) the
same as a newborn child(ren).
This Pre-existing Condition limitation shall not apply to Pregnancy,
even when a Late Enrollee.
Pre-authorization from the Health Care Management Organization does
not constitute Plan liability for any Pre-existing Condition charges
during this waiting period.
Except as provided in the Plan’s sections entitled Continuation
of Coverage (COBRA) or Extension of Benefits provision,
coverage will terminate on the earliest of the following occurrences:
1.
The last day of the month the Employer terminates the Plan and
offers no other group health plan.
2.
The last day of the month the Employee ceases to meet the eligibility
requirements of the Plan.
3.
The last day of the month employment terminates.
4.
The last day of the month following the Employee’s written request
to terminate coverage under this Plan.
5.
The date the Employee becomes a Full-time, active member of the
armed forces of any country, other than scheduled drills or other training
not exceeding one month in any Calendar Year.
6.
The last day of the month for which contributions have been
made on the Employee’s behalf while on an approved Leave of Absence.
7.
The first day an Employee fails to return to work following an
approved Leave of Absence.
1.
The last day of the month the Employer terminates the Plan and
offers no other group health plan.
2.
The last day of the month the Employee’s coverage terminates.
However, if the Employee remains eligible for the Plan, but elects to
discontinue coverage, coverage may be extended for an Alternate Recipient(s).
3.
The last day of the month such person ceases to meet the eligibility
requirements of the Plan.
4.
The last day of the month following the Employee’s written request
to terminate Dependent(s) coverage under this Plan.
5.
Cessation of Full-time Student Status for a Dependent Child(ren)
age nineteen (19) or older shall terminate coverage on the earliest
of the following dates:
a.
The last day of the month in which the Dependent(s) ceases to
be a Full-time Student;
b.
The date the school reconvenes after school vacation, if the
Dependent(s) fails to meet the Full-time Student Status criteria;
c.
The last day of the month following graduation;
d.
The date the Dependent(s) reaches the maximum age limit as stated
in the section entitled Eligibility.
e.
If the Dependent(s)’s is Full-time Student Status ceases due
to disability, coverage may continue under this Plan, provided:
1.
The Physician submits a written statement to the Claims Processor;
and
2.
The Dependent(s) maintains an acceptable number of credit hours
of academic courses as approved by the Employer.
If approved, the coverage shall terminate on the first day of the school’s
next regular session following the date established by a Physician’s
written statement to the Claims Processor that the student is capable
of Full-time Student Status and full-time school attendance. It
is the Employee’s responsibility to notify the Employer of cessation
of Full-time Student Status.
6.
The last day of the month for which contributions have been
made on the Dependent(s)’s behalf.
7.
The date the Dependent(s) becomes a Full-time active member of
the armed forces of any country, other than scheduled drills or other
training not exceeding one month in any Calendar Year.
8.
The date Dependent(s) coverage is discontinued under the Plan.
Coverage may be continued for a limited time, contingent upon payment
of any required contributions for the Employee and/or Dependent(s),
when the Employee is on an authorized Leave of Absence from the Employer.
In no event will coverage continue for more than three (3) consecutive
months after the Employee’s active service ends. For further information,
refer to the Hypercom Corporation Human Resources Management Guide.
Eligible Leave:
If an Employee has worked for the Employer for at least twelve (12)
months and has performed at least 1250 hours of service for the Employer
during the previous twelve (12) month period, the Employee may remain
covered under the Plan on an approved Leave of Absence as defined in
the Family Medical Leave Act (FMLA). Coverage will be continued under
the same terms and conditions that would have applied had the Employee
continued in Active employment, provided the Employee continues to pay
his/her required contributions toward the cost of coverage.
Under the Family Medical Leave Act (FMLA), eligible, enrolled Employees
are entitled to a Leave of Absence up to twelve (12) work weeks during
any twelve (12) month period, provided the leave is:
1.
To care for a child(ren) of the Employee during the twelve (12)
months following the birth of the child(ren); or
2.
To care for a child(ren) placed with the Employee for adoption
or foster care during the twelve (12) months following the placement;
or
3.
To care for the Employee’s spouse, son, daughter, parent of the
Employee, or certain other people (as defined in the FMLA) having a
“serious health condition”; or
4.
Because the Employee has a “serious health condition” and is
unable to perform the functions of the Employee’s position.
“Serious health condition” is defined in FMLA, but generally means
an Illness, Injury, impairment, or physical or mental condition that
involves Inpatient care in a Hospital, Hospice, or residential medical
care facility, or continuing treatment by a health care provider. If
leave continues beyond the twelve (12) weeks, the Employee will be eligible
for Continuation of Coverage under COBRA.
Employee Notice:
If the leave is foreseeable, the Employee must give the Employer thirty
(30) days notice, or as much notice as practical.
Contributions:
During this leave, the Employer will continue to pay the same portion
of the Employer’s contribution for the Plan. The Employee shall be
responsible to continue payment for the Employee and his/her eligible
Dependent(s)’s coverage. If the covered Employee fails to make the required
contribution during an FMLA leave within thirty (30) days after the
date the contribution was due, the Employee’s coverage will terminate
effective on the date the contribution was due.
Reinstatement:
If coverage under the Plan was terminated during an approved Family
Medical Leave due to non-payment of the required contributions by the
Employee, and the Employee returns to Active employment immediately
upon completion of that leave, Plan coverage will be reinstated on the
date the Employee returns to Active employment without having to satisfy
any waiting period requirement or Pre-existing Condition limitation
provisions of the Plan, provided the Employee makes any necessary contributions
and re-enrolls for coverage within thirty (30) days of his/her return
to Active employment.
Repayment Requirement:
The Employer may require an Employee who fails to return from a leave
under FMLA to repay any contributions paid by the Employer on the Employee’s
behalf during such leave. This repayment will be required only if the
Employee’s failure to return from such leave is not related to a serious
health condition or events beyond the Employee’s control.
In the event the Employer experiences Employee layoffs, or an Employee
voluntarily terminates employment with the Employer, the Employees enrolled
in the Plan and their enrolled Dependent(s) are eligible for reinstatement
of coverage, provided:
1.
Rehire occurs within ninety (90) days of layoff or termination
of employment; and
2.
Coverage shall be from date of rehire. Prior accumulators, such
as Deductible, Maximum Benefit, and Pre-existing Condition waiting period,
shall be applied with no break in coverage.
An Employee of the Employer who voluntarily terminates employment with
the Employer and fails to return to Active, Full-time employment within
ninety (90) days following an approved Leave of Absence, layoff, or
separation of service, will be considered a new Employee for purposes
of eligibility under the Plan, and will be subject to all eligibility
requirements, including all requirements relating to the Enrollment
Date, and the Pre-existing Condition limitation.
If an Employee or Dependent(s) has a status change while covered under
this Plan (i.e., Dependent to Employee, COBRA to Active, etc.) and no
interruption in coverage has occurred, the Plan will allow continuance
of coverage with respect to any Pre-existing Condition limitation, Deductible(s),
Coinsurance and Maximum Benefit.
EXTENSION OF BENEFITS DURING
TOTAL DISABILITY:
If on the date coverage terminates, an Employee or Dependent(s) is
Totally Disabled, benefits will be extended only for the condition causing
such Total Disability and only during the uninterrupted continuance
of that disability without payment of Employee contributions for such
coverage. This extended benefit will terminate on the earlier of the
following:
1.
The date the Employee or Dependent(s) is no longer Totally Disabled;
2.
The date the person becomes eligible for Medicare;
3.
Upon eligibility for coverage in any other group health plan
that does not limit coverage for the disabling condition;
4.
The date the Maximum Benefits under this Plan have been paid
on the Employee’s or Dependent(s)’s behalf;
5.
Three (3) months following the date coverage terminated; or
6.
The date this Plan terminates.
The Employer expects this Plan to
continue, but reserves the right to terminate this Plan at any time.
Termination of this Plan shall completely end all obligation of the
Employer to provide benefits for incurred expenses after the date of
Plan termination. Refer to the section entitled General Provisions,
Plan Termination.
In order to comply with federal regulations, this document includes
a Continuation of Coverage option for certain individuals whose coverage
would otherwise terminate. The following is intended to comply with
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA),
as amended.
The coverage that may be continued under this provision consists of
health coverage. It does not include life insurance benefits, accidental
death and dismemberment benefits or income replacement benefits. Health
coverage includes medical and dental benefits as provided under the
Plan.
Under this provision, the following Covered Persons, whose coverage
would otherwise end, may continue coverage under the Plan:
1.
A Covered Dependent(s) of a covered Employee who dies;
2.
A covered Employee and his/her covered Dependent(s) upon the
Employee’s termination of employment (other than termination for gross
misconduct) or whose work hours have been reduced to less than the minimum
required for coverage under the Plan;
3.
A covered spouse (and any affected covered Dependent(s) ) upon
divorce or legal separation;
4.
A Covered Dependent(s) of a covered Employee whose termination
from the Plan is due to the covered Employee’s becoming eligible for
benefits under Medicare;
5.
A covered Dependent child(ren) who becomes married, attains the
maximum age at which a Dependent child(ren) may be covered under the
Plan, or otherwise becomes ineligible under the Plan’s terms because
of age or Dependent status;
6.
The last day of leave under the Family Medical Leave Act of 1993;
or
7.
Call up as a Reservist in the United States military or National
Guard.
1.
When eligibility for Continuation of Coverage results from a
spouse being divorced or legally separated from a covered Employee,
or a child(ren)’s marriage or attainment of the maximum age for coverage
under the Plan, the Employee or Dependent(s) must notify the Employer
of that event within sixty (60) days of the event. Failure to provide
such notice to the Employer will result in the person forfeiting his/her
rights to Continuation of Coverage under this provision
2.
Within forty-four days (44) of receiving notice, the Employer
will advise the Employee or Dependent(s) of his/her rights to continue
coverage.
3.
After receiving notice, the Employee or Dependent(s) has sixty
(60) days to decide whether to elect continued coverage. This sixty
(60) day period begins on the latter of the following:
a.
The date coverage under the Plan would otherwise terminate; or
b.
The date the person receives the notice from the Employer of
his/her rights to continuation of coverage.
If the Employee or Dependent(s) chooses to have continued coverage,
he/she must advise the Employer in writing of this choice. The Employer
must receive this written notice no later than the last day of the sixty
(60) day period. If the election is mailed, the election must be postmarked
on or before the last day of the sixty (60) day period.
4.
Within forty-five (45) days after the date the person notifies
the Employer that he/she has chosen to continue coverage, the person
must make the initial payment. The initial payment will be the amount
needed to provide coverage from the date continued health benefits begin
to the date the election was made. Thereafter, payments for the continued
coverage are to be made monthly, and are due in advance on the first
day each month.
5.
The Employee or Dependent(s) must make payments for the continued
coverage.
The Employer requires that Covered Persons pay the entire cost of
the continuation coverage, plus the legally permitted administration
fee. This must be remitted to the Employer, or the Employer’s designated
representative, on or before the first day of each month during the
continuation period. The payment must be remitted each month in order
to maintain the coverage in force.
For purposes of determining monthly costs for continued coverage, a
person originally covered as an Employee or as a spouse will pay the
rate applicable to an Employee if coverage is continued for him/herself
alone, or the rate applicable to an Employee with Dependent(s), if the
Employee and/or his/her spouse with one or more Dependent children,
continues coverage as a family unit. A child continuing coverage (except
a children continuing coverage as part of a family unit continuing coverage)
will pay the rate applicable to an Employee.
When continuation coverage is elected and the contributions paid, coverage
is reinstated back to the date of the loss of coverage, so no break
in coverage occurs. Coverage for a Dependent(s) acquired and properly
enrolled during the continuation period begins in accordance with the
enrollment provisions of the Plan.
A spouse or Dependent child(ren) newly acquired during continuation
coverage is eligible to be enrolled as a Dependent(s). The standard
enrollment provision of the Plan applies to enrollees during continuation
coverage. Any child(ren) born to, or adopted by, an Employee who is
on Continuation of Coverage under COBRA shall be deemed a “qualified
beneficiary.” Such child(ren) shall have all rights of a qualified
beneficiary including eligibility for extension of Continuation of Coverage
under COBRA due to a second qualifying event. A child born to, or Placed
for Adoption, with the former spouse of a covered Employee shall
not be eligible for the extension of continuation of coverage due to
a second qualifying event.
Once covered under continuation coverage, it is possible for a second
qualifying event to occur, including:
1.
Death of an Employee;
2.
Divorce or legal separation from an Employee;
3.
Employee’s entitlement to Medicare; or
4.
The child(ren)’s loss of Dependent status.
If one of these subsequent qualifying events occurs, a Dependent(s)
may be entitled to a second continuation period. This period will, in
no event, continue beyond thirty-six (36) months from the date of the
first qualifying event.
Except as provided in the section entitled Family Members Acquired
During Continuation, only a person covered prior to the original qualifying
event is eligible to continue coverage again as the result of a subsequent
qualifying event. A Dependent(s) acquired during continuation coverage
is not eligible to continue coverage as the result of a subsequent qualifying
event.
For example:
1.
Continuation may begin due to termination of employment. During
the continuation, if a child(ren) reaches the upper age limit of the
Plan, the child(ren) is eligible for a second continuation period.
This second continuation would end no later than thirty-six (36) months
from the date of the first qualifying event, i.e., the termination of
employment.
2.
An Employee terminates and elects continuation coverage for him/herself
and his/her spouse. They would be allowed continuation coverage for
up to eighteen (18) months. If, during the eighteen (18) months, the
Employee becomes entitled to Medicare, the spouse would be eligible
for additional continuation coverage up to a total of thirty-six (36)
months from the date of the first qualifying event.
Continuation will end on the earliest of the following dates:
1.
Eighteen (18) months from the date continuation began for an
Employee whose coverage ended because of a reduction of hours or termination
of employment; or
2.
Thirty-six (36) months from the date continuation began for a
Dependent(s) whose coverage ended because of the death of the Employee,
divorce or legal separation from the Employee, or the marriage or attainment
of the maximum age of eligibility by a Dependent(s); or
3.
The end of the period for which contributions are paid if the
Covered Person fails to make a payment on the date specified by the
Employer; or
4.
The date coverage under this Plan ends and the Employer offers
no other group health benefit plan; or
5.
The date the Covered Person becomes entitled to Medicare; or
6.
The date the Covered Person becomes covered under any other group
health plan, with the exception of the pre-existing provision below.
In the event a Covered Person becomes eligible for coverage under another
employer-sponsored group health plan, and that group health plan has
a pre-existing limitation or exclusion, the Covered Person may remain
covered under this Plan with Continuation of Coverage and elect coverage
under the other employer’s group health plan. Coordination of Benefits
may occur in certain situations when a benefit limitation, rather than
exclusion, applies to the Pre-existing Condition under the other employer’s
plan. This Plan will be secondary coverage to the other employer-sponsored
group health plan.
A person who is totally disabled may extend continuation coverage from
eighteen (18) months to twenty-nine (29) months, provided the Covered
Person receives a determination from the Social Security Administration
that the Covered Person was disabled at the time of the qualifying event,
or within sixty (60) days of the qualifying event. The disabled person
and the family members who were covered prior to the qualifying event
are eligible for up to twenty-nine (29) months of Continuation of Coverage.
The qualified beneficiary must submit proof of the determination of
disability by the Social Security Administration to the Employer within
the initial eighteen (18) month COBRA extension period and no later
than sixty (60) days after the Social Security Administrations determination
in order to be eligible for the additional eleven (11) month extension.
Employees going into, or returning from, military service will have
Plan rights as mandated by the Uniformed Services Employment and Reemployment
Rights Act (USERRA). These rights include up to eighteen (18) months
of extended health care coverage upon payment of the entire cost of
coverage, plus a legally permitted administration fee; and immediate
coverage with no Pre-Existing Conditions limitations applied in the
Plan upon return from service. These rights apply only to Employees
and their Dependent(s) covered under the Plan before leaving for military
service. Coverage will be immediately reinstated upon return to Active
employment meeting the eligibility requirements under this Plan. Restoration
of benefits will be at the same level that the Employee would have had
if the Employee remained continuously covered.
Plan exclusions may be imposed for any Illness or Injury determined
by the Secretary of Veterans Affairs to have been incurred in, or aggravated
during, military service.
Additionally, the Civilian Health and Medical Program for Uniformed
Services (CHAMPUS) is not considered “other group coverage” for the
purposes of termination of COBRA coverage.
Individuals who have earned the required number of quarters for Social
Security benefits within the specified time frame are eligible for Medicare
Part A at no cost. Ineligible individuals age sixty-five (65) and over
may purchase Medicare Part A by making application to the Social Security
Administration and paying the full cost. Participation in Medicare
Part B is available to all individuals who make application and pay
the full cost of the coverage.
1.
When an Employee becomes entitled to Medicare coverage and is
still Actively at Work, the Employee may continue health coverage under
this Plan at the same level of benefits and contribution rate that applied
before reaching Medicare entitlement.
2.
When a Dependent becomes entitled to Medicare coverage and the
Employee is still Actively at Work, the Dependent may continue health
coverage under this Plan at the same level of benefits and contribution
rate that applied before reaching Medicare entitlement.
3.
If the Employee and/or Dependent is also enrolled in Medicare,
this Plan shall pay as the primary plan; Medicare will pay as the secondary
plan.
4.
If the Employee and/or Dependent elect to discontinue health
coverage under this Plan, and enroll in Medicare, no benefits will be
paid under this Plan. Medicare will be the only payer.
This section is subject to the terms of the Medicare laws and regulations.
Any changes in these related laws and regulations will apply to the
provisions of this section.
Covered Expenses means the expenses actually incurred by, or on behalf
of, a Covered Person for the expenses listed in this section, provided
the expenses are incurred while such person is covered under this Plan.
The Covered Expenses for services or supplies provided must be recommended
by a Physician and be Medically Necessary care and treatment for the
Illness or Injury suffered by the Covered Person. Specified preventive
care expenses shall be Covered Expenses under this Plan. The extent
of benefits paid by the Plan for Covered Expenses is subject to any
applicable Deductible, Co-payment, Coinsurance, and Maximum Benefit
as shown in the section entitled Schedule of Benefits.
The Co-payment is the amount payable by the Covered Person for certain
medical treatment or services rendered by an EPO Provider. These services
and applicable Co-payments are shown in the section entitled Schedule
of Benefits. The Covered Person elects an EPO provider and
pays the provider the Co-payment. The Plan pays the remaining Covered
Expenses at the exclusive EPO rate. The Co-payment must be paid each
time the treatment or service is rendered. The Co-payment will not
be applied toward the following:
1.
the Calendar Year Deductible; or
2.
the maximum Out-of-Pocket Expense limit; or
3.
the common accident Deductible.
Penalty Deductible:
If the Covered Person fails to obtain Pre-authorization as specified
in the section entitled Health Care Management,
the Covered Person is responsible for an additional Deductible as specified
in the section entitled Schedule of Benefits. The penalty
Deductible shall be applied to Covered Expenses first, then any applicable
Calendar Year Deductible shall be applied. Thereafter, the Plan’s Coinsurance
shall apply. This penalty is waived if the Covered Person is traveling
or resides outside the United States.
Individual Deductible:
The Individual Deductible is the amount of Covered Expense the Covered
Person must incur and pay during each Calendar Year before any Plan
benefits are payable. Covered Expenses incurred during the last three
(3) months of the Calendar Year, and that are applied to the Individual
Deductible of any Covered Person will also be applied to the Individual
Deductible for the following Calendar Year. Deductible carry-over does
not apply to Family Deductibles.
Only one Deductible will be applied toward the Covered Expenses incurred
by a covered newborn Dependent(s)’s mother for a covered Pregnancy and
the Covered Expenses for such newborn Dependent(s)’s routine preventive
well-baby care incurred while such newborn Dependent(s) is less than
five (5) days old and is confined in the birth Hospital or alternative
Birthing Center.
Family Deductible:
The Family Deductible is satisfied after any number of Covered Persons
within a family unit combined satisfy the equivalent of two (2) individual
Deductibles within a Calendar Year. Thereafter, all other family members
will be deemed to have met their Deductible for that Calendar Year.
Common Accident:
If, as a result of the same accident, two (2) or more Covered Persons
within the same family unit sustain Injuries and incur medical charges
resulting from such Injuries, the Calendar Year Deductible requirements
will be applied among them for Covered Expenses related to that accident.
This Deductible feature is applied to Covered Persons for the Calendar
Year.
Deductible Exclusions:
The following items do not apply toward the satisfaction of the Deductible:
1.
Expenses for services or supplies not covered by this Plan;
2.
Expenses in excess of the Customary and Reasonable Charge;
3.
The Covered Person’s Coinsurance share of expenses partially
covered by the Plan;
4.
The penalty for failure to obtain Pre-authorization; and
5.
Co-payments.
The Coinsurance, otherwise referred to as the benefit percentage, is
the percentage of the Customary and Reasonable Charge the Plan will
pay for Non-Preferred Providers, or the percentage of the Negotiated
Rate for Preferred Providers, or the percentage of the exclusive rate
for Exclusive Providers. Once the Deductible or the Co-payment is satisfied,
the Plan shall pay benefits for incurred Covered Expenses during the
remainder of the Calendar Year at the applicable Coinsurance as specified
in the section entitled Schedule of Benefits. The Covered
Person is responsible for paying the remaining percentage. The Covered
Person’s portion of the Coinsurance represents his/her Out-of-Pocket
Expense limit.
The Non-Preferred Provider of service may charge more than the Customary
and Reasonable Charge. The portion of the Non-Preferred Provider’s
charges in excess of the Customary and Reasonable Charge are not Covered
Expenses under this Plan and are the responsibility of the Covered Person.
After the Covered Person has paid an amount equal to the Out-of-Pocket
Expense Limit shown in the section entitled Schedule of Benefits
for incurred Covered Expenses, the Plan will pay 100% of Covered Expenses
for the remainder of the Calendar Year for Category 1 and Category 2
Covered Expenses. Refer to the section entitled Schedule of Benefits
for an explanation of Category 1 and Category 2 Covered Expenses.
The Out-of-Pocket Expense Limit per covered family will be deemed to
be met when the combined total for all covered family members has been
satisfied. The Plan will pay 100% of Covered Expenses for the remainder
of the Calendar Year for all covered family members for Category 1 and
Category 2 Covered Expenses.
Out-of-Pocket Exclusions:
The following items do not apply toward satisfaction of the Out-of-Pocket
Expense Limit:
1.
Expenses for supplies not covered by this Plan;
2.
Co-payments;
3.
Deductibles;
4.
Expenses for Mental and Nervous Disorders or Chemical Dependency,
nor will the Plan pay 100% benefit;
5.
Expenses incurred as a result of failure to obtain Pre-authorization,
nor will the Plan pay 100% benefit; and
6.
Expenses for Non-Preferred Provider services and supplies, nor
will the Plan pay 100% benefit.
The Maximum Benefit payable on behalf of a Covered Person is stated
in the section entitled Schedule of Benefits. This Maximum
Benefit applies to the entire time he/she is covered under the Plan,
either as an Employee or Dependent. If the Covered Person’s coverage
under the Plan terminates and he/she subsequently returns to coverage
under the Plan, the Maximum Benefit will be calculated on the sum of
benefits paid by the Plan during each period of coverage.
The section entitled Schedule of Benefits contains separate
Maximum Benefits limitations for specified conditions. The above provision
will also apply to those maximums. Any separate Maximum Benefit is part
of, and not in addition to, the medical Maximum Benefit.
In the event the Covered Person changes coverage between any of the
Plan options (Plan A or Plan C), the benefits paid on
behalf of the Covered Person shall apply to the Maximum Benefit limitations
of all Plan options. Such accumulation of benefits apply to each Covered
Person for the duration the Covered Person is covered by any Plan option.
Restoration:
After a Covered Person reaches the $1,000,000 Medical Maximum Benefit,
the Plan may grant restoration of the Maximum Benefit while covered
by this Plan, if the Covered Person provides Physician certification
that the condition(s) no longer exists. The expense of such evidence
shall be the Covered Person’s responsibility. The benefit shall be
restored on the first day of the month coinciding with or next following
approval of such evidence in writing.
All Hospital admissions and Outpatient Surgeries, except surgeon’s
charges not exceeding $400 or procedures performed on an Outpatient
basis within forty-eight (48) hours of the Injury, are subject to Pre-authorization.
Failure to obtain Pre-authorization will result in a reduction of benefits.
Refer to the section entitled Health Care Management.
Covered Expenses shall include:
1.
Room and board for treatment in a Hospital, including Intensive
Care Units, Cardiac Care Units, and similarly necessary accommodations.
Covered Expenses for Room and Board shall be the Hospital’s average
semi-private rate. Covered Expenses for Intensive Care or Cardiac Care
Units shall be the Negotiated Rate for Preferred Providers and the Customary
and Reasonable Charge for Non-preferred Providers. A full private room
rate is covered if the private room is necessary for isolation purposes
and is not for the convenience of the Covered Person.
2.
Miscellaneous Hospital services, supplies, and treatments including,
but not limited to:
a.
Admission fees, and other fees assessed by the Hospital for rendering
Medically Necessary services, supplies, and treatments;
b.
Use of operating, treatment, or delivery rooms;
c.
Anesthesia, anesthesia supplies and its administration by an
employee of the Hospital;
d.
Medical and surgical dressings and supplies, casts and splints;
e.
Blood transfusions, including the cost of whole blood the administration
of blood, blood processing, and blood derivatives (to the extent blood
or blood derivatives are not donated or otherwise replaced);
f.
Drugs and medicines (except drugs not used or consumed in the
Hospital);
g.
X-ray and diagnostic laboratory procedures and services;
h.
Oxygen and other gas therapy and the administration thereof;
i.
Therapy services.
3.
Services, supplies and treatments described above and furnished
by an Ambulatory Surgical Center, including follow-up care provided
within seventy-two (72) hours of a procedure.
Pre-admission Testing enables the Covered Person to have necessary
tests done as an Outpatient prior to a scheduled admission or Outpatient
Surgery. Pre-admission Testing for Medically Necessary tests will be
covered provided all of the following conditions are met:
1.
The tests are ordered by a Physician;
2.
The tests are performed on an Outpatient basis;
3.
The tests are performed within seven (7) days prior to a Hospital
Confinement or Outpatient Surgery; and
4.
All tests must be related to the admitted diagnosis.
1.
Professional ambulance service for air or ground transportation
to the nearest Hospital or Ambulatory Surgical Center able to provide
the necessary services are considered Covered Expenses.
2.
In the event a condition requires specialized Emergency treatment
not available at a local Hospital, Medically Necessary transportation
for such treatment is covered when ordered by a Physician. The transportation
must be within the United States of America and Canada only, and be
by a regularly scheduled airline, railroad, or by licensed air or ground
ambulance. Covered transportation is only from the initial Hospital
to the nearest Hospital qualified to render the special treatment.
3.
Emergency services actually provided by an advance life support
unit, even though the unit does not provide transportation.
Coverage for Emergency Room treatment and Emergency Services rendered
shall be paid in accordance with the section entitled Schedule
of Benefits.
The supplemental accident benefit is designed to supplement the Medical
Expense Benefit and, therefore, is not subject to any Deductible or
Co-payment. Plan benefits will be payable subject to the Maximum Benefit
as specified in the section entitled Schedule of Benefits.
The injuries must be sustained subsequent to the Covered Person’s Effective
Date of Coverage under the Plan. Services and supplies must be furnished
within the ninety (90) day period beginning with the date the Covered
Person sustained the injuries.
Inpatient:
Inpatient rehabilitative services are subject to Pre-authorization.
Failure to obtain Pre-authorization shall result in reduction of benefits.
Inpatient rehabilitative services shall include Room and Board, including
regular daily services and supplies furnished by the facility, Physician
charges, physical therapy, speech therapy, and occupational therapy.
Outpatient:
Outpatient rehabilitative services shall include physical therapy,
occupational therapy, and speech therapy to aid restoration of normal
function that was previously normal but lost due to Illness or Injury.
Covered Expenses are:
1.
Diagnostic laboratory, examinations and x-ray services for a
specific condition; laboratory and x-ray services in connection with
covered preventive services;
2.
Charges of a Physician or Practitioner for medical and/or surgical
treatment;
3.
Surgical assistance provided by a Physician or Practitioner;
4.
Charges of Physician or professional anesthetist for furnishing
and administering anesthetics;
5.
Consultation charges requested by the attending Physician during
a Hospital Confinement;
6.
Radiologist or pathologist services for interpretation of x-rays
and laboratory tests necessary for diagnosis and treatment;
7.
Charges of a radiologist or laboratory for diagnosis or treatment,
including radiation therapy and chemotherapy;
8.
Charges for Chiropractic Care up to the Maximum Benefit specified
in the section entitled Schedule of Benefits;
9.
Charges for surgical treatment for sexual dysfunction; and
10.
Charges for surgical treatment for loss of hearing.
The Second Surgical Opinion benefit is designed to supplement the Medical
Expense Benefit and, therefore, is not subject to any Deductible.
1.
Benefits for a Second Surgical Opinion for an elective surgery
(non-emergency surgery) will be payable according to the section entitled
Schedule of Benefits when recommended by the Health Care
Management Organization or as required by the Plan, or the Covered Person
elects to obtain a Second Surgical Opinion.
2.
The Physician rendering the Second Surgical Opinion regarding
the Medical Necessity of such surgery must be qualified to render such
a service and must not be affiliated in any way with the Physician who
will be performing the actual surgery.
3.
In the event of conflicting opinions, a request for a third opinion
may be obtained. The Plan will consider payment for the third opinion
as a Second Surgical Opinion.
4.
The Second Surgical Opinion benefit includes Physician services
and any diagnostic services as may be required, if the Plan or Health
Care Management Organization requires a Second Surgical Opinion as specified
in the section entitled Schedule of Benefits.
5.
If the Covered Person should elect to obtain a Second Surgical
Opinion without the recommendation of the Health Care Management
Organization, the Second Surgical Opinion benefit includes Physician
services only. Any diagnostic services will be payable under the diagnostic
benefit as specified in the section entitled Schedule of Benefits.
Transplant procedures are subject to Pre-authorization. Failure to
obtain Pre-authorization will result in a reduction of benefits. Services
and supplies in connection with organ transplant procedures are subject
to the following conditions:
1.
If the recipient is covered under this Plan, eligible medical
expenses incurred by the recipient will be considered for benefits.
2.
If the donor is covered under this Plan, eligible medical expenses
incurred by the donor will be considered for benefits, provided the
recipient is also covered under this Plan (eligible medical expenses
incurred by each person will be treated separately for each person).
3.
Expenses incurred by the donor, who is not ordinarily covered
under this Plan according to eligibility requirements, will be Covered
Expenses to the extent that such expenses are not payable by any other
form of health coverage, including any government plan, and the recipient
is covered under this Plan. The donor’s expense shall be applied to
the recipient’s Maximum Benefits. In no event will benefits be payable
in excess of the Maximum Benefits still available to the recipient.
4.
The charges for securing an organ from a cadaver or tissue bank,
including the surgeon’s charges for removal of the organ, and a Hospital’s
charges for storage or transportation of the organ, will be Covered
Expenses.
Expenses incurred for medical care and treatment rendered to a Covered
Person’s Pregnancy shall be considered for benefits under this Plan,
subject to all of the Plan’s terms and conditions applicable to medical
care and treatment of an Illness.
The Plan shall cover services and supplies for Medically Necessary
abortions, when the physical health of the mother would be endangered
by continuation of the Pregnancy, or when the fetus has a known condition
incompatible with life.
No benefits shall be payable:
1.
As to Pregnancy-related care or procedures that are not certified
by a Physician as being Medically Necessary; or
2.
For an elective abortion outside the provision above.
Services and supplies rendered at a Birthing Center, including legal
midwife services or a registered midwife acting within the scope of
his/her license, will be a Covered Expense.
Covered Expenses for newborn well-baby care shall include Physician
and Hospital charges for Routine Nursery Care, while the mother is confined
for delivery, up to a Maximum Benefit of five (5) days. Routine care
includes charges related to circumcision.
Services rendered for immunizations, vaccinations, routine physical
examinations and diagnostic services not related to the treatment of
a specific diagnosis shall be a Covered Expense if rendered by a PPO
or EPO Provider. Preventive care shall be limited as specified in the
section entitled Schedule of Benefits.
Covered Expenses shall include elective sterilization procedures for
the covered Employee and covered spouse.
Charges made by an Extended Care Facility are eligible under the Plan
provided:
1.
The Covered Person was first confined in a Hospital for at least
three (3) consecutive days;
2.
The attending Physician recommends extended care Confinement
for convalescence from a condition that caused that Hospital confinement,
or a related condition;
3.
The extended care Confinement begins within fourteen (14) days
after discharge from that Hospital Confinement, or within fourteen (14)
days after a related extended care Confinement; and
4.
The Covered Person is under a Physician’s continuous care who
certifies the Covered Person must have twenty-four (24) hours-per-day
nursing care.
If the Covered Person is discharged from the Extended Care Facility
and again becomes an Inpatient in such facility within fourteen (14)
days of the original discharge, it is considered one period of Confinement.
Covered Expenses are:
1.
Room and Board, including regular daily services and supplies
furnished by the Extended Care Facility, limited to the facility’s average
semi-private room rate; and
2.
Other services and supplies, except for Professional Services,
ordered by a Physician and furnished by the Extended Care Facility for
Inpatient medical care.
Extended Care Facility benefits are limited to the number of days shown
in the section entitled Schedule of Benefits for all confinements
due to the same or related Illness or Injury, and are subject to all
the Plan’s limitations and exclusions.
Home Health Care enables the Covered Person to receive treatment in
his/her home for an Illness or Injury, instead of being confined in
a Hospital or Extended Care Facility. All of the following must
be satisfied to be covered under this benefit:
1.
The Covered Person’s Physician must establish and review a written
plan of care that specifically describes the Home Health services and
supplies to be provided; and
2.
The Covered Person must be homebound, meaning that leaving the
home could be harmful to the Covered Person, involves a considerable
and taxing effort, and the Covered Person is unable to use transportation
without assistance; and
3.
The Covered Person’s condition must be serious enough to require
Confinement in a Hospital or Extended Care Facility in the absence of
Home Health Care.
Home Health Care services include:
1.
Physician services;
2.
Nursing care by a registered nurse or licensed practical nurse;
3.
Physical, respiratory, occupational or speech therapy, medical
social work, and Home Health Aide Services;
4.
Medical appliances and equipment, laboratory services and special
meals, if such services and supplies would have been covered by the
Plan if the Covered Person had been in a Hospital; and
5.
Nutritional guidance by a registered dietitian, and nutritional
supplements such as diet substitutes administered intravenously or through
hyperalimentation as determined Medically Necessary.
The Plan will not pay for services or supplies excluded under the Plan’s
limitations and exclusions.
Hospice Benefits will be covered only if the Covered Person’s attending
Physician certifies:
1.
The Covered Person is terminally ill; and
2.
The Physician has certified the life expectancy is less than
six (6) months.
Covered Expenses are:
1.
Confinement in a Hospice Facility or at home;
2.
Ancillary charges furnished by the Hospice while the Covered
Person is confined;
3.
Medical supplies, drugs and medicines prescribed by the attending
Physician, but only to the extent such items are necessary for pain
control and management of the terminal condition;
4.
Physician services and/or nursing care by a registered nurse,
a licensed practical nurse, or a licensed vocational nurse;
5.
Home Health Aide Services and Home Health Care by an aide who
is employed by the Hospice, in the case of Hospice benefits, or by the
Home Health Care Agency, in the case of Home Health benefits, and is
provided part-time or as intermittent care under the supervision of
a registered nurse, physical therapist, occupational therapist, or speech
therapist. Such care includes ambulation and exercise, assistance with
self-administered medications, reporting changes in the Covered Person’s
conditions and needs, completing appropriate records, and personal care
or household services that are needed to achieve the medically desired
results;
6.
Nutrition services to include nutritional advice by a registered
dietitian, and nutritional supplements, such as diet substitutes administered
intravenously or through hyperalimentation, and special meals;
7.
Counseling services by a licensed social worker or a licensed
pastoral counselor as provided through the Hospice;
8.
Respite care for a minimum of four (4) or more hours per day
(provides care of the Covered Person to allow temporary relief to the
family members or friends from the duties of caring for the Covered
Person); and
9.
Bereavement counseling as a supportive service to Covered Persons
in the terminally ill Covered Person’s immediate family. Benefits will
be payable up to the bereavement care maximum shown in the section entitled
Schedule of Benefits, provided:
a.
On the date immediately before death, the terminally ill person
was covered under the Plan and received Hospice care benefits; and
b.
Charges for such services are incurred by the Covered Person
within six (6) months of the terminally ill person’s death.
No benefits are payable for Hospice care or services excluded under
the Plan’s limitations and exclusions. Any Covered Expense paid under
Hospice benefits will not be considered a Covered Expense under any
other provision of this Plan.
Rental or purchase, whichever is less costly, of necessary Durable
Medical Equipment for therapeutic use by the Covered Person is a Covered
Expense. Equipment ordered prior to the Covered Person’s Effective
Date of Coverage is not covered, even if delivered after the Effective
Date of Coverage. Repair or replacement of Medically Necessary Durable
Medical Equipment, due to the normal use or growth of a child(ren) will
be provided. Durable Medical Equipment is limited as specified in the
section entitled Schedule of Benefits.
Purchase of a prosthesis provided for functional reasons when replacing
a missing body part shall be considered a Covered Expense. No benefits
will be provided for cosmetic prostheses except for the Covered Person’s
external breast prosthesis once every three (3) Calendar Years, and
the first permanent internal breast prosthesis necessary because of
a mastectomy. A prosthesis ordered prior to the Covered Person’s Effective
Date of Coverage is not covered, even if delivered after the Effective
Date of Coverage. Repair or replacement of a Medically Necessary prosthesis,
due to normal use or growth of a child(ren), will be a Covered Expense.
Surgical and non-surgical treatment of Temporomandibular Joint (TMJ)
or myofacial pain syndrome shall be a Covered Expense, but shall not
include orthodontia.
Charges in connection with dental work, dental x-rays, dental examination,
or oral surgery, including Hospital Room and Board, necessary services
supplies, and charges of a Physician or repair of sound natural teeth
or other body tissue, shall be a Covered Expense, provided:
1.
It is the result of an Injury occurring while the Covered Person
is covered under this Plan; and
2.
Treatment begins within ninety (90) days of the date of such
Injury.
Charges directly related to the removal of impacted wisdom teeth are
Covered Expenses, if Dental coverage is not provided by this Plan.
Covered Expenses shall include Medically Necessary special equipment
and supplies to include, but not be limited to: casts, splints, braces,
trusses, surgical and orthopedic appliances, colostomy bags and supplies
required for their use, catheters, syringes and needles for diabetes
or allergies, test strips for diabetes, surgical dressings, crutches,
oxygen, the initial pair of glasses or contacts needed due to cataract
surgery, purchase or rental of orthopedic shoes and shoe inserts, blood,
blood plasma or blood derivatives and the administration thereof. Donated
blood or replaced blood is not a Covered Expense.
Charges for Cosmetic Surgery shall be a Covered Expense, provided:
1.
A Covered Person receives an Injury as a result of an accident
while covered for benefits hereunder and, as a result, suffers bodily
damage requiring surgery (cosmetic Surgery and treatment must be to
restore the Covered Person to his/her normal function immediately prior
to the accident);
2.
It is required to correct a congenital anomaly, i.e. a birth
defect for a child(ren) born while covered under this Plan or prior
plan of the Employer;
3.
It is for reconstructive breast surgery because of a mastectomy
that occurred while covered under this Plan;
4.
It is for reconstructive breast reduction on the non-diseased
breast to make it equal in size with the diseased breast following reconstructive
surgery on the diseased breast, provided the mastectomy occurred while
covered under this Plan.
Inpatient or Partial Confinement:
Subject to the Pre-authorization provisions of the Plan, the Plan will
pay the applicable Coinsurance as defined in the section entitled Schedule
of Benefits, for Confinement in a Hospital or Treatment Center
for services and supplies related to the treatment of Mental and Nervous
Disorders and/or Chemical Dependency. Two (2) days of Partial Confinement
will be considered as one day of Inpatient Confinement. Partial Confinement
means treatment for at least three (3) hours, but no more than twelve
(12) hours, in any twenty-four (24) hour period.
Outpatient:
The Plan will pay the applicable Coinsurance as defined in the section
entitled Schedule of Benefits, for Outpatient services
and supplies related to the treatment of Mental and Nervous Disorders
and/or Chemical Dependency.
Charges for drugs and medicines requiring a written Prescription and
that are dispensed by a Pharmacist shall be Covered Expenses. However,
if benefits for prescription drugs are provided under the Prescription
Drug Service Program of the Plan, payment of medical charges for prescription
drugs under the medical benefits of the Plan are limited to such charges
made by the Hospital or medical treatment facility for prescription
drugs administered to a Covered Person.
In addition to Plan Exclusions, no benefit will be provided under this
Plan for expenses incurred by a Covered Person for the following:
1.
Charges for Pre-existing Conditions, except as specifically stated
herein;
2.
Elective abortions, or the expenses related to medical treatment
for complications due to an elective abortion;
3.
Sterilization reversal;
4.
Charges for services, supplies or treatment related to the diagnosis
or treatment of infertility and artificial reproductive procedures,
including, but not limited to: artificial insemination, in vitro fertilization,
surrogate mother, fertility drugs when used for treatment of infertility,
embryo implantation, or gamete intrafallopian transfer (“GIFT”).
5.
Birth control supplies or devices, except as specified herein;
6.
Charges for services, supplies or treatment for transsexualism,
gender dysphoria, or sexual reassignment or change, including medications,
implants, hormone therapy, surgery, medical or psychiatric treatment.
7.
Expenses for Hospital admission on Friday, Saturday, or Sunday,
unless the admission is an Emergency situation, or surgery is scheduled
within twenty-four (24) hours. If neither situation applies, Room and
Board charges will only be payable commencing the date of the actual
surgery;
8.
Inpatient Room and Board charges in connection with a Hospital
Confinement primarily for diagnostic tests that could have been performed
safely on an Outpatient basis;
9.
Charges for biofeedback or educational therapy;
10.
Charges for marital or family counseling, except as provided
under the section entitled Medical Expense Benefit, Mental and
Nervous/Chemical Dependency;
11.
Expenses for, or in connection with, treatment of teeth or periodontium,
except as specifically stated herein;
12.
Optometric services, dispensing optician’s services, orthoptics,
eyeglasses, contact lenses, routine eye examinations and eye refractions
for the fitting of glasses, except as specifically stated under the
section entitled Medical Expense Benefit, Special Equipment and
Supplies; any eye surgery solely for the purpose of correcting
refractive defects of the eye, such as near-sightedness (myopia) and
astigmatism, or contact lenses or glasses required as a result of this
surgery;
13.
Routine foot care, including treatment of weak, strained, flat,
unstable, or unbalanced feet, metatarsalgia, corns, calluses, fallen
arches, and trimming of toenails, except for the removal of nail roots;
14.
Charges for services or supplies constituting personal comfort
or beautification items; television or telephone use; education, training
and bed and board while confined to an institution for training; a
place of rest; a place for the aged; a nursing home or institution of
like character, nor for Custodial Care;
15.
Charges for telephone consultations;
16.
Expenses for non-prescription drugs and medicines, such as vitamins,
cosmetic dietary aids, nutritional supplements and Nicorette, even through
a prescription number has been assigned. Amphetamines will not be considered
a Covered Expense when prescribed as a dietary aid;
17.
Air purifiers, air conditioners, humidifiers, exercise equipment,
water purifiers, whirlpools, heating pads, hot water bottles, allergenic
pillows or mattresses, or waterbeds;
18.
Purchase or rental of escalators or elevators, saunas or swimming
pools, professional medical equipment, such as blood pressure kits,
or supplies or attachments for any of these items;
19.
Therapeutic devices or appliances, including support garments
and other non-medical substances, regardless of intended use;
20.
Expenses for a cosmetic procedure and all related services, except
as specifically stated in the section entitled Medical Expense
Benefit, Cosmetic Surgery;
21.
Services or supplies primarily for weight reduction or treatment
of obesity. This exclusion will not apply to surgical treatment of
obesity if:
a.
Surgical treatment of obesity is necessary to treat another life-threatening
condition involving obesity; and
b.
It has been documented that non-surgical treatments of the obesity
have failed.
22.
Replacement of casts, splints, or similar devices damaged as
a result of negligence;
23.
Any charge for treatment of smoking cessation;
24.
Examination in connection with a hearing aid or the purchase
of a hearing aid, except as specified herein;
25.
Any and all services related to acupuncture treatment;
26.
Charges for additional days of Inpatient Hospital Confinement
denied by the Health Care Management Organization;
27.
Charges for homeopathy and naturopathy;
28.
Charges for Preventive Care rendered by a Non-Preferred Provider;
The Prescription Drug Program is provided through a contractor who
has contracted pharmacies to participate in the Prescription Drug Program.
For purposes of this section only, the following shall
apply:
1.
All other provisions in this Plan pertaining to Deductible amounts
and requirements are not applicable to the Prescription Drug Program.
2.
All other provisions in this Plan pertaining to the notice of
claim, proof of loss, and payment of benefits do not apply to the processing
of prescription drug claims.
A prescription drug identification card will be issued to each Employee
covered under this Prescription Drug Program.
PARTICIPATING PHARMACIES:
If a Covered Person incurs charges by a pharmacist who is participating
in the Prescription Drug Program of this Plan for Covered Prescription
Drugs, such charges in excess of the applicable prescription drug Co-payment
will be payable at 100%. This 100% payment will be in the form of a
reimbursement to the participating pharmacist, who has agreed to accept
this amount as payment in full, in an amount equal to the lesser of:
1.
The pharmacist’s submitted price for the drug; or
2.
The average wholesale price of the drug.
When patronizing a participating pharmacy, the Covered Person will
present the identification card and the Physician’s prescription to
the pharmacist. At the time the pharmacist dispenses the medication,
the Covered Person will pay the applicable prescription drug Co-payment
to the pharmacist. The pharmacist will require the Covered Person to
sign a form (furnished by the pharmacist) as acknowledgment of receipt
of the prescription drug. The pharmacist will forward the claim form
to the prescription drug contractor and reimbursement for the Covered
Prescription Drugs will be made to the pharmacist by the prescription
drug contractor, as outlined above.
For Co-payment amounts under the Prescription Drug Program/Participating
Pharmacies, refer to the section entitled Schedule of Benefits.
NON-PARTICIPATING PHARMACIES:
If a Covered Person incurs charges by a pharmacist or pharmacy who
is not participating in the Prescription Drug Program of this Plan for
Covered Prescription Drugs, such charges in excess of the prescription
drug Co-payment will be reimbursed to the Covered Person in an amount
equal to the lesser of:
1.
The Pharmacist’s submitted price for the drug; or
2.
The average wholesale price of the drug that would have been
paid had the Covered Person utilized a participating pharmacy.
If a Covered Person patronizes a pharmacy not participating in the
Prescription Drug Program of this Plan, such person should request the
pharmacist complete a direct reimbursement claim form obtainable from
the Employer’s Human Resources/Benefits Administration office. At the
time the pharmacist dispenses the medication, the Covered Person will
pay the entire cost of the prescription drug. The direct reimbursement
claim form should then be mailed by the Covered Person to the Claims
Processor. Reimbursement for the Covered Prescription Drugs will be
made to the Covered Person by the prescription drug contractor.
Subject to the exclusions and limitations of the Plan, “Covered Prescription
Drugs” shall mean:
1.
Federal legend drugs: Any medical substance bearing the legend,
“Caution: Federal law prohibits dispensing without a prescription.”
2.
State restricted drugs: Any medicinal substance that may be
dispensed by prescription only, according to state law.
3.
Compounded medications: A compounded prescription is an extemporaneously
prepared dosage form containing at least one Federal legend drug in
a therapeutic amount.
4.
Insulin: By prescription only.
5.
Oral Contraceptives.
A generic drug will automatically be substituted for a brand name,
unless the Physician writes on the prescription “Dispense as Written.”
The Claims Processor, on behalf of the Employer, will be responsible
for the final determination of payment on all submitted claims.
MAIL ORDER PRESCRIPTIONS:
It is the intent of this Plan to provide coverage for Mail Order Prescriptions;
therefore, the Employer has contracted with a company to provide maintenance
prescription drugs at a discounted rate through a mail-order program.
If the Covered Person requires a maintenance-type drug, the Physician
may write the prescription for up to a ninety (90) day supply or 300
units. The Plan shall pay 100% of Covered Expenses after satisfaction
of the Co-payment. A generic drug will automatically be substituted
for a brand name, unless the Physician writes on the prescription “dispense
as written.”
No benefits will be payable under the Prescription Drug Program for
the following prescription or non-prescription drugs and/or items:
1.
Diaphragms, contraceptive jellies ointments, foams, or other
contraceptive devices;
2.
Therapeutic devices or appliances, support garments, and other
non-drug substances, including, but not limited to insulin needles and
insulin syringes;
3.
Over-the-counter products;
4.
Drugs labeled: “Caution: Limited by Federal law to investigational
use”; or experimental drugs, even when charge is made to the Covered
Person;
5.
Medication for treatment of allergies except such medication
prescribed by a Physician;
6.
Charges for “Covered Prescription Drugs” made by any Hospital
or medical treatment facility that are not members of the Prescription
Drug Program under the Plan, and that are administered to the Covered
Person (these charges will be paid as medical benefits if they otherwise
qualify as such);
7.
Charges that can be excluded from the definition of medical charges
by virtue of Medical Benefits - exclusions and limitations to the same
extent as if Medical Benefit - exclusions and limitations were specifically
applicable to Covered Prescription Drugs;
8.
Charges incurred for the treatment of Pre-existing Condition(s),
except as specifically allowed by the Plan;
9.
Growth hormones, fertility agents, vitamins and dietary supplements,
anti-smoking aids, drugs used to treat or cure baldness, Retin-A for
Covered Persons older than twenty-seven (27) years of age, anorectic
(drugs used for the purpose of weight control), immunization agents,
biological sera, blood, or blood plasma.
Furthermore, no benefits will be paid under the prescription drug benefits
for drugs (including insulin) if the quantity of any one prescription
or refill, according to directions, exceeds a thirty-four (34) day supply,
or one hundred (100) tablets or capsules, whichever is greater, except
as described in the section entitled Prescription Drug Program
Covered Expenses/Drugs, Mail Order Prescriptions.
Payment is made for Covered Dental Services a Covered Person incurs,
not to exceed the Reasonable and Customary charges. The Benefit Payable,
Deductible, and Maximum Amounts that apply are shown in the Schedule
of Benefits.
Charges are deemed to be incurred on the date the service is performed,
except:
1.
Charges for full or partial dentures or fixed bridge work are
deemed to be incurred when the last impression is taken;
2.
Charges for crowns are deemed to be incurred when the tooth is
prepared or filed for crowning;
3.
Charges for root canals are deemed to be incurred when canal
work on the tooth starts.
1.
Oral exams, bitewing x-rays and prophylaxis are limited to two
(2) per Calendar Year;
2.
A complete mouth x-ray is limited to one (1) each three (3) years;
3.
Topical application of fluoride is limited to one (1) per Calendar
Year; and
4.
Prosthodontic appliances, cast restorations, dentures, individual
crowns and jackets will be replaced only after five (5) years have passed
since the last such service was performed.
5.
Maximum Lifetime Orthodontia Benefit is 50% to a maximum of $2,000
per Covered Person, with a one year waiting period (from date of eligibility).
6.
Maximum Annual Benefit is $1,000 per Covered Person.
1.
Any service not listed in Dental Services;
2.
Any service performed for cosmetic reasons (except if due to
accidental injury or congenital disease as specified in the Summary
Plan Document);
3.
Occupational accidents or illness covered by Workers’ Compensation
or Occupational Disease Law;
4.
Installation of, or addition to, full or partial dentures or
fixed bridge work are excluded unless:
a.
The installation or addition is an initial one needed because
of extraction of one (1) or more injured or diseased natural teeth;
and
b.
The denture or bridge work includes replacement of the extracted
tooth;
c.
The extraction takes place for a Covered Person on or after the
Effective Date of this Plan; or
d.
If the extraction occurs before the Effective Date of this Plan,
the person must have been covered for this benefit for at least three
(3) consecutive years under the Dental Plan replaced by this Plan.
5.
Oral hygiene and dietary instructions;
6.
Plaque control programs;
7.
Hospital services;
8.
Myofunctional therapy;
9.
Treatment of the Temporomandibular Joint;
10.
Hypnosis;
11.
Any operations or service not performed by a physician or dentist,
or licensed dental oral hygienist under the supervision of a dentist;
12.
Surgery required to restore occlusion;
13.
Expenses payable under the Employer’s medical plan, HMO Plan,
or similar plan;
14.
Charges for appointments not kept;
15.
Experimental procedures;
16.
Expenses incurred prior to the Covered Person’s Effective Date
of Coverage or after termination of coverage hereunder, except as specified
in the section entitled Continuation of Coverage.
17.
Prosthetics to replace teeth missing or extracted prior to the
Covered Person’s Effective Date of Coverage and not previously replaced;
18. Dentures that have been lost, mislaid, or stolen.
Refer to the section entitled Schedule of Benefits, Dental Benefits,
for details regarding Deductibles, annual and lifetime Maximum Benefits,
and the Coinsurance applicable to the following Dental Services. Subject
to the Limitations, Exclusions, and other provisions of the Dental Benefit,
the following are Covered Dental Services:
CLASS I INCLUDES: (Benefit paid at 80%, subject to maximum annual
benefit per person.)
1.
Oral examinations with required x-rays and prophylaxis;
2.
Topical application of fluoride for a Dependent child(ren) under
age 19;
3.
Emergency oral examination for pain relief; and
4.
Space maintainers for missing primary teeth.
CLASS II - INCLUDES: (Benefit paid at 80%, subject to deductible
and maximum annual benefit per person.)
1.
Acrylic, amalgam, plastic, porcelain, silicate or stainless steel
restorations;
2.
Extractions (including post-operative);
3.
Oral surgery;
4.
Endodontics;
5.
Periodontics; and
6.
Anesthesia.
CLASS III - INCLUDES: (Benefit paid at 80%, subject to deductible
and maximum annual benefit per person.)
1.
Inlays and crowns;
2.
Gold fillings;
3.
Replacement cast restorations;
4.
Bridges;
5.
Initial dentures; and
6.
Replacement prosthodontic appliances.
CLASS IV - INCLUDES: (Benefit paid at 50%, subject to deductible
and lifetime Maximum Benefit per person.)
1.
Orthodontia.
It is recommended that any treatment estimated to be in excess of $300
be sent to the Claims Processor in writing by the dentist, for review
prior to treatment, except for emergency care.
When more than one treatment plan is available to achieve satisfactory
results, benefits will be provided for the least expensive treatment
plan.
The individual deductible is the dollar amount of Covered Expense each
Covered Person must incur and pay during each Calendar Year before the
Plan pays applicable benefits. The individual deductible amount is
shown on the Schedule of Benefits.
(COVERAGE TO BE
EFFECTIVE JULY 1, 1998)
Vision benefits will be paid for approved covered vision expenses for
the Covered Persons as shown on the Schedule of Benefits.
The benefits will apply when charges are incurred for vision care
by a legally licensed Physician or Optometrist.
The individual deductible is the dollar amount of Covered Expense each
Covered Person must incur and pay during each Calendar Year before the
Plan pays applicable benefits. The individual deductible amount is
shown on the Schedule of Benefits.
The Plan provides coverage for services, supplies and treatment, after
the Calendar Year Deductible has been satisfied, for the following:
1.
One examination and refraction in any eighteen (18) consecutive
months.
2.
One pair of lenses or contacts in any eighteen (18) consecutive
months.
3.
One pair of frames in any eighteen (18) consecutive months.
In addition to Plan Exclusions, no benefit will be provided
under this Plan for Vision Expenses incurred by a Covered Person for
the following:
1.
Services or supplies rendered as a condition of employment or
by any governmental body.
2.
Replacement of lenses or frames that have been lost, stolen,
or broken..
3.
Laminating, tinting, or coating of lenses, sunglasses (plain
or prescription), safety lenses,
or goggles.
4.
Medical or surgical care of the eye. (Refer to the section entitled
Medical Expense Benefit for applicable coverage.)
5.
Artificial eyes. (Refer to the section entitled Medical
Expense Benefit for applicable coverage.)
6.
Any lenses not prescribed by a legally licensed Physician or
optometrist.
7.
Any services performed, or supplies provided, for special procedures,
such as orthoptics, or any aids for sub-normal vision.
No benefit will be provided under this Plan for expenses incurred by
a Covered Person for the following:
1.
Charges for services or supplies from any Hospital owned or operated
by the United States government or any agency thereof, or charges for
services, treatment or supplies furnished by the United States government
or any agency thereof, unless payment is legally required;
2.
Charges for services or supplies received caused by or contributed
to war, or any act of war. “War” means declared or undeclared war,
whether civil or international, and any substantial armed conflict between
organized forces of a military nature.
3.
Any condition for which benefits of any nature are recovered,
or are found to be recoverable, either by adjudication or settlement,
under any Worker’s Compensation law, Employer’s liability law, or occupational
disease law, even though the Covered Person fails to claim rights to
such benefits;
4.
Charges in connection with any Illness or Injury arising out
of, or in the course of, any employment for wage or profit;
5.
Charges made for services and supplies not Medically Necessary
for the treatment of Illness or Injury, or not recommended and approved
by the attending Physician, except as specifically stated herein, or
to the extent that the charges exceed the Customary and Reasonable Charge
or exceed the Negotiated Rate;
6.
Charges resulting from, or occurring during, the commission of
a crime by the Covered Person, while engaged in an illegal occupation,
felonious act or aggravated assault;
7.
To the extent that payment under this Plan is prohibited by any
law of the jurisdiction in which the Covered Person resides at the time
the expenses are incurred;
8.
Charges for services rendered and/or supplies received prior
to the Effective Date of Coverage or after the termination date of a
Covered Person’s coverage;
9.
Charges covered under any other plan of benefits through the
Employer;
10.
Any services or supplies for which the Covered Person is not
legally required to pay or for which no charge is made to the Covered
Person in the absence of coverage;
11.
Experimental or investigational services, meaning any service
so classified by the Food and Drug Administration (FDA), Health Care
Finance Administration (HCFA), or any service not generally recognized
by the medical profession as tested and accepted medical practice;
12.
Charges incurred outside the United States if the Covered Person
traveled to such a location for the sole purpose of obtaining medical
services, drugs or supplies;
13.
Charges for services rendered by a Physician or Practitioner,
if such professional is a Close Relative of the Covered Person or resides
in the same household of the Covered Person;
14.
Services rendered by providers beyond the scope of their license;
15.
Charges for injuries suffered by a Covered Person due to the
negligent conduct of a third party, if the Covered Person fails to provide
information as specified in the section entitled Subrogation/Third
Party Liability;
16.
Claims not submitted within twelve (12) months of the Incurred
Date.
1.
A claim form is to be completed on each covered family member
upon the initial submission of a claim incurred during the Calendar
Year and for each subsequent claim involving an Injury. Appropriate
claim forms are available from the Employer in the Human Resources/Benefits
Administration office.
2.
All bills submitted for payment must contain the following information:
a.
Name of patient;
b.
Patient’s date of birth;
c.
Name of Employee;
d.
Address of Employee;
e.
Name of Employer;
f.
Name, address and tax ID number of provider;
g.
Employee’s Social Security Number;
h.
Date of Service;
i.
Diagnosis;
j.
Description of service and procedure number;
k.
Charge for service;
l.
The nature of the accident, Injury, or Illness being treated.
3.
Claims not submitted within twelve (12) months of the date of
incurred liability will be denied.
The Covered Person may ask the provider to submit the bill directly
to the Claims Processor, or the Covered Person may file the bill with
a claim form. If the services of a Preferred Provider are used, the
Preferred Provider should file the claim on the Covered Person’s behalf.
However, it is ultimately the Covered Person’s responsibility to make
sure the claim has been filed for benefits.
A claim for benefits must be submitted to the Claims Processor within
ninety (90) days after the occurrence or commencement of any services
covered by the Plan, or as soon thereafter as reasonably possible.
Failure to file a claim within the time provided shall not invalidate
or reduce any claim, if it shall be shown:
1.
It was not reasonably possible to file a claim within that time;
and
2.
Such claim was furnished as soon as possible, but no later than
one (1) year after the loss occurred or commenced, unless the claimant
was legally incapacitated.
Notice given by, or on behalf of, a covered Employee or his/her beneficiary,
if any, to the Plan Administrator or to any authorized agent of the
Plan with information sufficient to identify the Covered Person, shall
be deemed notice of claim.
To obtain benefits under this Plan, the Covered Person must submit
proof to the Claims Processor that the Covered Expenses applicable to
the Deductible have been incurred. Proof will include an itemized bill
on the Provider’s letterhead or statement and the diagnosis.
If additional information is needed for payment of the claim, the Claims
Processor will request the same. The Claims Processor will approve,
partially approve, or deny the claim within ninety (90) days after all
necessary information is received to determine the validity of the claim.
If the services of a Preferred Provider or Exclusive Provider are used,
the Plan benefits are payable directly to the provider of service.
If the services of a Non-Preferred Provider are used, benefits are payable
to the Employee whose Illness or Injury, or whose Dependent(s) Illness
or Injury, is the basis of claim under this Plan, unless the Employee
has made an assignment of benefits to the provider of service.
In the event a claim for benefits under the Plan is not paid in whole
or in part, the Employee will receive written notification stating the
required information including the review procedure, in the same fashion
as reimbursement for a claim, in a manner calculated to be understood
by the Employee. A claim worksheet will be provided by the Claims Processor
showing the calculation of the total amount payable, charges not payable,
and the reason for the partial or total denial of benefit.
Review Procedure:
A Covered Person, or the Covered Person’s representative, may request
a review of the claim denial by making written request to the Claims
Processor within sixty (60) days of receipt of the notice of denial.
Written notice for review should:
1.
State the reasons the Covered Person feels the claim should not
have been denied; and
2.
Include any additional information the Covered Person believes
supports the claim.
Upon receipt of the written request for review of a claim, the Claims
Processor will review the claim and furnish copies of all documents
and all reasons and facts relative to the decision. An Employee, or
his/her authorized representative, may examine all pertinent documents
the Claims Processor may have and submit an opinion in writing of the
issues and his/her comments.
Decision on Review:
Decision by the Employer will be made within sixty (60) days, unless
special circumstances require more time, then the decision shall be
rendered as soon as possible, but no later than one hundred twenty (120)
days after receipt of the Employee’s request for review. This decision
will also be delivered to the Employee in writing, setting forth specific
reasons for the decision and specific references to the pertinent Plan
provisions upon which the decision is based.
Most people do not want to become involved in lawsuits. Litigation
can entail lengthy delays, high costs, unwanted publicity and ill will.
Appeals might be filed, causing further delay after a decision is rendered.
Arbitration, on the other hand, is usually faster and less expensive.
It is also conclusive.
Under arbitration, instead of going to court, those involved agree
to submit their dispute to an impartial third party for a final and
binding decision. Arbitration is a substitute for taking a dispute
to court, and disputes submitted to arbitration cannot later be taken
to court.
Either the Employer or the Covered Person can request a dispute be
submitted to binding arbitration. Either party can do this before a
lawsuit (called a complaint) has been filed or within sixty (60) days
after a complaint, an answer, a counter claim, or an amendment to a
complaint has been served.
Arbitration will be governed by the provisions of the Federal Arbitration
Act and to the extent any provisions of that Act are inapplicable, unenforceable,
or invalid, the laws of the State where the Plan Administrator is domiciled
will govern. To find out how to initiate arbitration, simply call any
office of the American Arbitration Association (AAA).
The decision of the arbitrator(s) shall be binding and final on the
Employer and the Covered Person, with the costs of the arbitration to
be borne by the party or parties as determined by the arbitrator(s).
In the event a Covered Person incurs Covered Expenses in a foreign
country, the Covered Person shall be responsible for providing the following
to the Claims Processor before payment of any benefits due are payable:
1.
The claim form, provider invoice, and any other documentation
required to process the claim, submitted in the English language;
2.
The charges for services converted into dollars; and
3.
A current conversion chart validating the conversion from the
foreign country’s currency into dollars.
If, in the opinion of the Employer, a Covered Person for whom a claim
has been made is incapable of furnishing a valid receipt of payment
due him/her and, in the absence of written evidence to the Plan of any
qualification of a guardian or personal representative for his estate,
the Plan may, at its discretion, make any and all such payments to the
provider of medical services or other person providing for the care
and support of such Covered Person. Any payment so made will constitute
a complete discharge of the Plan’s obligation to the extent of such
payment, and the Employer will not be required to see to the application
of the money so paid.
Whenever payments have been made from the Plan in excess of the maximum
amount of payment necessary, the Employer will have the right to recover
these excess payments to whom such overpayment was made.
The Plan, at its own expense, shall have the right to require an examination
of a Covered Person under this Plan when and as often as it may reasonably
require during the pending period of a claim.
No action at law or in equity shall be brought to recover on the Plan
prior to the expiration of sixty (60) days after a claim has been filed
in accordance with the requirements of the Plan. No such action shall
be brought after the expiration of three (3) years after the time a
claim is required to be furnished.
The Coordination of Benefits provision is intended to prevent duplication
of benefits. It applies when the Covered Person is also covered by
any Other Plans(s). When more than one coverage exists, one plan normally
pays its benefits in full, referred to as the primary plan. The Other
Plan(s), referred to as a secondary plan(s), pays a reduced benefit.
When coordination of benefits occurs, the total benefit payable by
all plans will not exceed 100% of “Allowable Expenses.” Only the amount
paid by this Plan will be charged against the Maximum Benefit.
The Coordination of Benefits provision applies whether or not a claim
is filed under the Other Plan(s). If the Other Plan(s) provides benefits
in the form of services rather than cash, the reasonable value of the
service rendered shall be deemed the benefit paid.
“Allowable Expenses” means any reasonable, necessary and customary
expenses incurred while covered under this Plan, part or all of which
would be covered under any of the Other Plan(s). Allowable Expenses
do not include expenses contained in the section entitled Exclusions.
When this Plan is secondary, Allowable Expenses will include any Deductible
or Coinsurance amounts not paid by the Other Plan(s).
When this Plan is secondary, Allowable Expenses shall NOT include any
amount that is not payable under the primary plan as a result of a contract
between the primary plan and a provider of service in which such provider
agrees to accept a reduced payment and not to bill the Covered Person
for the difference between the provider’s regularly billed charges.
“Other Plan” means any plan, policy or coverage providing benefits
or services for, or by reason of, medical, dental, or vision care.
Such Other Plan(s) may include, without limitation:
1.
Group insurance or any other arrangement for coverage for Covered
Persons in a group, whether on an insured or uninsured basis, including,
but not limited to, Hospital indemnity benefits and Hospital reimbursement-type
plans;
2.
Hospital or medical service organizations on a group basis, group
practice, and other group prepayment plans, or on an individual basis,
having a provision similar in effect to this provision;
3.
A licensed Health Maintenance Organization;
4.
Any coverage for students sponsored by, or provided through,
a school or other educational institution;
5.
Any coverage under a government program and any coverage required
or provided by any statute;
6.
Group automobile insurance;
7.
Individual automobile insurance coverage on an automobile owned
or leased by the Employer;
8.
Individual automobile insurance coverage based upon the principles
of “No-fault” coverage;
9.
Any plans or policies funded, in whole or in part, by an employer,
or deductions made by an employer from a Covered Person’s compensation
or retirement benefits; or
10.
Labor/management trustee, union welfare, employer organization,
or Employee benefit organization plans.
“This Plan” shall mean that portion of the Employer’s Plan providing
benefits that are subject to this provision.
“Claim Determination Period” means a Calendar Year, or that portion
of a Calendar Year, during which the Covered Person for whom a claim
is made has been covered under the Plan.
This provision shall apply in determining the benefits for a Covered
Person for each Claim Determination Period for the Allowable Expenses.
If This Plan is secondary, the benefits paid under This Plan may be
reduced so the sum of benefits paid by all plans does not exceed 100%
of total Allowable Expenses.
If the rules set forth below would require This Plan to determine its
benefits before such Other Plan(s), then the benefits of such Other
Plan(s) will be ignored for the purposes of determining the benefits
under This Plan.
Each Plan will make its claim payment according to the following order
of benefit determination:
1.
No Coordination of Benefits Provision: If the Other Plan(s)
contains no provision for Coordination of Benefits, then its benefits
shall be paid before all Other Plan(s).
2.
Employee/Dependent: The Plan covering the claimant as
an Employee (or Named Insured) pays as though no Other Plan(s) exists.
Remaining recognized charges are paid under the Plan covering the claimant
as a Dependent.
3.
Dependent Children of Parents not Separated or Divorced:
The Plan covering the parent whose birthday (month and day) occurs earlier
in the year pays first. The Plan covering the parent whose birthday
falls later in the year pays second. If both parents have the same
birthday, the plan that covered a parent longer pays first. A parent’s
year of birth is not relevant in applying this rule.
4.
Dependent Children of Separated or Divorced Parents:
When parents are separated or divorced, the birthday rule does not apply.
Instead:
a.
If a court decree has given one parent financial responsibility
for the child’s health care, the Plan of that parent pays first. The
Plan of the stepparent, if any, married to that parent pays second.
The Plan of the other natural parent pays third. The Plan of the spouse
of the other natural parent pays fourth.
b.
In the absence of such a court decree, the Plan of the parent
with custody pays first. The Plan of the stepparent, if any, married
to the parent with custody pays second. The Plan of the parent without
custody pays third. The Plan of the spouse of the parent without custody
pays fourth.
5.
Active/Inactive: The Plan covering a person as an Active
(not laid off or retired) Employee, or as that person’s Dependent(s)
pays first. The Plan covering that person as a laid off or retired
Employee, or as that person’s Dependent(s) pays second.
6.
Longer/Shorter Length of Coverage: If none of the above
rules determines the order of benefits, the Plan covering a person longer
pays first. The Plan covering that person for a shorter time pays second.
7.
Limited Continuation of Coverage: If a person is covered
under another group health plan, but is also covered under This Plan
for continuation of coverage due to the Other Plan’s limitations for
Pre-existing Conditions, the Other Plan shall be primary for all Covered
Expenses not related to the Pre-existing Condition. This Plan shall
be primary for the Pre-existing Condition only.
In no event shall the Covered Person recover under This Plan and all
Other Plan(s) combined more than the total Allowable Expenses offered
by This Plan and the Other Plan(s). Nothing contained in this section
shall entitle the Covered Person to benefits in excess of the total
Maximum Benefits of This Plan during the Claim Determination Period.
The Covered Person shall refund to the Employer any excess This Plan
may have paid.
Notwithstanding all other provisions of This Plan, all Covered Persons
who are eligible for Medicare benefits will be entitled to benefits
under This Plan in addition to Medicare, in accordance with Medicare
rules. The benefits of This Plan will be coordinated with Medicare.
If any Covered Person eligible for Medicare fails to enroll, benefits
will be paid as though he/she had enrolled.
For the purposes of determining the applicability of and implementing
the terms of this provision, the Employer may, without the consent of
or notice to any person, release to or obtain from any insurance company
or any other organization or person, any information with respect to
any person. Any person claiming benefits under This Plan shall furnish
to the Employer such information as may be necessary to implement the
Coordination of Benefits provision.
Whenever payments that should have been made under This Plan, in accordance
with this provision, have been made under any Other Plan(s), the Employer
shall have the right, exercisable alone and in its sole discretion,
to pay over to any organization making such other payments, any amounts
it shall determine to be warranted in order to satisfy the intent of
this provision. Amounts so paid shall be deemed to be benefits paid
under This Plan and, to the extent of such payments, the Employer shall
be fully discharged from liability under This Plan.
It is not the intent of this Plan that any Covered Person should be
reimbursed for more than 100% of his/her Allowable Expenses (as defined
in the Coordination of Benefits provision). Therefore,
this Plan maintains the right to seek reimbursement on its own behalf,
i.e., the right of subrogation. This Plan also reserves the right to
reimbursement upon a Plan participant’s receipt of settlement, judgment,
or award, i.e. the right of third party liability reimbursement. This
Plan reserves the right of recovery, either by subrogation or third
party liability, for Covered Expenses payable by this Plan as a result
of Illness or Injury suffered from an accident due to the negligent
conduct of a third party. These expenses are payable, in part or in
whole, by such third party, another person, an insurance company, or
from a judgment or settlement.
As a condition of receiving benefits under this Plan, the Plan participant
agrees to this Plan’s right to recovery under third party liability
or subrogation rights against any third party negligence, up to the
amount of expenses incurred by this Plan. Payment of benefits will
be contingent upon the participant’s cooperation with the Claims Processor
by providing This Plan with all required information and assistance
in the recovery of such payment or overpayment, to the extent of such
payment by this Plan. The term “information” includes any instruments
and documents as the Plan Administrator may reasonably require to enforce
its rights.
The Plan Administrator has delegated to the Claims Processor the right
to perform ministerial functions required to assert this Plan’s rights;
however, the Plan Administrator shall retain discretionary authority
with regard to asserting third party liability reimbursement and subrogation
rights of this Plan.
The Plan is administered through the Human Resources Department of
the Employer. The Employer is the Plan Administrator. The Employer
has retained the services of an independent Claims Processor experienced
in claims review. The Plan is a legal entity. Legal notices may be
filed with, and legal process served, upon the Employer.
The Employer is the Named Fiduciary of the Plan. As fiduciary, the
Employer maintains discretionary authority to review all denied claims
for benefits under the Plan with respect to which it has been designated
Named Fiduciary, including, but not limited to, the denial of certification
of the Medical Necessity of Hospital or medical treatment, to interpret
the terms of the Plan and to determine eligibility for and entitlement
to Plan benefits in accordance with the terms of the Plan. Any interpretation
or determination made pursuant to such discretionary authority shall
be given full force and effect, unless it can be shown that the interpretation
or determination was arbitrary and capricious.
The Plan will pay benefits under this Plan to the Employee, unless
payment has been assigned to a Hospital, Physician, or other provider
of service furnishing the services for which benefits are provided herein.
No assignment, however, shall be binding on the Plan unless the Claims
Processor is notified in writing of such assignment prior to payment
hereunder.
Preferred Providers and Exclusive Providers normally bill the Plan
directly. If service has been received from a Preferred Provider or
Exclusive Provider, benefits are automatically paid to that provider.
Any balance due after the Plan payment will then be billed to the Covered
Person by the Preferred Provider.
No person other than an eligible Covered Person is entitled to receive
benefits under this Plan. Such right to benefits are not transferable.
No clerical error on the part of the Employer or Claims Processor shall
operate to defeat any of the rights, privileges, services, or benefits
of any Employee or any Dependent(s) hereunder, nor create or continue
coverage that would not otherwise validly become effective or continue
in force hereunder. An equitable adjustment of contributions and/or
benefits will be made when the error or delay is discovered.
Any provision of the Plan in conflict with statutes applicable to this
Plan is hereby amended to conform to the minimum requirements of said
statute(s).
The original Effective Date of this Plan was June 1, 1993. The
effective dates of the modifications contained herein are June 1,
1995, with amendments dated June 1, 1996, July 1, 1996, August 1,
1996, January 1, 1997, March 1, 1997, and October 1, 1997, and June
1, 1998.
If the Covered Person, or anyone acting on behalf of the Covered Person,
makes a false statement on the application or eligibility records, or
withholds information with intent to deceive or affect the acceptance
of the enrollment application or the risks assumed by the Employer,
or otherwise misleads the Employer, the Employer shall be entitled to
recover its damages, including legal fees, from the Covered Person,
or from any other person responsible for misleading the Employer, and
from the person for whom the benefits were provided.
Nothing contained in this Plan shall, in any way or manner, restrict
or interfere with the right of any Covered Person entitled to service
and care hereunder to select a Hospital or to make a free choice of
the attending Physician. However, benefits will be paid in accordance
with the provisions of this Plan and the Covered Person will be Out-of-Pocket
more if the Covered Person uses the services of a Non-Preferred Provider.
All statements made by the Employer or by the Employee covered under
the Plan shall be deemed representations and not warranties. Such statements
shall not void or reduce the benefits under the Plan, or be used in
defense to a claim unless they are contained in writing, signed by the
Employer or by the Covered Person, as the case may be. A statement made
shall not be used in any legal contest, unless a copy of the instrument
containing the statement is or has been furnished to the other party
to such a contest.
Liability hereunder is limited to the services and benefits specified,
and the Employer shall not be liable for any obligation of the Covered
Person incurred in excess thereof.
The Employer shall not be liable for the negligence, wrongful act,
or omission of any Physician, Provider, Practitioner, Hospital, or other
institution, or their employees, or any other person. The liability
of the Plan shall be limited to the reasonable cost of Covered Expenses
and shall not include any liability for pain and suffering or general
damages.
The benefits of this Plan are provided only for services that are Medically
Necessary. The services must be ordered by the attending Physician for
the direct care and treatment of a covered Illness or Injury, except
for routine care as specifically stated herein. They must be standard
medical practice where received for the Illness or Injury being treated,
and must be legal in the United States. When an Inpatient Confinement
is necessary, services are limited to those that could not have been
performed on an Outpatient basis.
Any material misrepresentation on the part of the Covered Person in
making application for coverage, or any application for reclassification
thereof, or for services thereunder, shall render the coverage null
and void.
The Plan shall not be deemed to constitute a contract between the Employer
and any Employee, or to be a consideration for, or an inducement or
condition of, the employment of any Employee. Nothing in the Plan shall
be deemed to give any Employee the right to be retained in the service
of the Employer or to interfere with the right of the Employer to terminate
the employment of any Employee at any time.
The Employer may modify or amend the Plan from time to time at its
sole discretion, and such amendments or modifications affecting the
participants will be communicated to the participants. Any such amendments
shall be in writing, setting forth the modified provision of the Plan,
the Effective Date of the modifications, and shall be signed by the
Employer’s designee.
The Employer reserves the right to terminate the Plan at any time.
Upon termination, the rights of the Covered Persons to benefits are
limited to claims incurred up to the date of termination. Any termination
of the Plan will be communicated to the participants.
Upon termination of this Plan, all claims incurred prior to termination,
but not submitted to either the Employer or the Claims Processor within
three (3) months of the Effective Date of termination of this Plan,
will be excluded from any benefit consideration.
All personal pronouns used in this Plan shall include either gender
unless the context clearly indicates to the contrary.
The Employer shall not have the right to cancel or terminate coverage
of any individual Employee hereunder while this Plan remains in effect
and while said Employee remains eligible.
In order for a person to be entitled to benefits under this Plan, both
the Plan and the person’s coverage under the Plan must be in effect
on the date the expense giving rise to a claim for benefits is incurred.
The benefits a Covered Person may be entitled to will depend on the
terms of coverage in effect on the date the expense giving rise to a
claim for benefits is incurred. An expense is incurred on the date
the Covered Person received the service or supply for which a charge
is made.
The effective time, with respect to any dates used in this Plan, shall
be 12:01 a.m. (midnight) Standard Time as may be legally in effect at
the address of the Plan Administrator, or the Employee, as appropriate.
This Plan is not in lieu of, and does not affect any requirement for,
coverage by Workers’ Compensation Insurance.
Certain words and terms used herein shall be defined as follows and
are shown in capital letters throughout the document.
ACTIVE OR ACTIVELY AT WORK:
The active expenditure of time and energy in the service of the Employer.
An Employee shall be deemed Actively at Work on each day of a regular
paid vacation, sick leave, or on a regular non-working day, provided
he/she was Actively at Work on the last preceding regular work day.
ALTERNATE RECIPIENT:
Any child(ren) of the Employee or the spouse of the Employee who is
recognized in a Qualified Medical Child Support Order (QMCSO) issued
by any court judgment, decree, or order, as being entitled to enroll
for coverage under this Plan.
AMBULATORY SURGICAL CENTER:
A facility, other than a medical or dental office, whose main function
is performing surgical procedures on an Outpatient basis. It must be
licensed as an Outpatient clinic according to state and local laws and
must meet all requirements of an Outpatient clinic providing surgical
services.
BIRTHING CENTER:
A facility that meets professionally recognized standard and all of
the tests that follow:
1.
It mainly provides an Outpatient setting for childbirth following
a normal, uncomplicated Pregnancy.
2.
It has:
a.
At least two (2) delivery rooms;
b.
All the medical equipment needed to support the services furnished
by the facility;
c.
Laboratory diagnostic facilities; and
d.
Emergency equipment, trays, and supplies for use in life threatening
events.
3.
It has a medical staff that:
a.
Is supervised full-time by a Physician; and
b.
Includes a registered nurse at all times when patients are in
the facility.
4.
If it is not part of a Hospital, it has a written agreement(s)
with a local Hospital(s) and a local ambulance company for the immediate
transfer of patients who require greater care than can be furnished
at the facility.
5.
It admits only patients who:
a.
Have undergone an educational program to prepare them for the
birth; and
b.
Have records of adequate prenatal care.
6.
It schedules Confinements of not more than twenty-four (24) hours
for a birth.
7.
It maintains a medical record for each patient.
8.
It complies with all licensing and other legal requirements that
apply.
9.
It is not the office or clinic of one or more Physicians or a
specialized facility other than a Birthing Center.
CALENDAR YEAR:
A twelve (12) month period starting each January 1st at
12:01 a.m. Standard Time as may be in effect at the address of the Employer.
CHEMICAL DEPENDENCY:
A physiological or psychological dependency, or both, on a controlled
substance and/or alcoholic beverages. It is further characterized by
a frequent or intense pattern of pathological use to the extent the
user: exhibits a loss of self-control over the amount and circumstances
of use; develops symptoms of tolerance or physiological and/or psychological
withdrawal if the
use of the controlled substance or alcoholic beverage is reduced or
discontinued; and the user’s health is substantially impaired or endangered
or his/her social or economic function is substantially disrupted.
Diagnosis of these conditions will be determined based on standard DSM-III-R
(diagnostic and statistical manual of mental disorders) criteria.
CHIROPRACTIC CARE:
Services provided by a licensed Chiropractor, M. D., or D. O., to include:
spinal manipulation, adjunctive therapy, vertebral alignment, subluxation,
spinal column adjustments, necessary x-rays, and other treatments of
the spinal column, neck, extremities, or other joints, other than for
fractures or surgery.
CLOSE RELATIVE:
The Employee’s spouse, children, brothers, sisters, or parents; or
the children, brothers, sisters, or parents of the Employee’s spouse.
COINSURANCE:
The benefit percentage of Covered Expenses payable by the Plan for
benefits that are provided under the Plan. The Coinsurance is applied
to Covered Expenses after the Deductible(s) have been met.
CONCURRENT REVIEW:
Concurrent Review occurs during the Covered Person’s Hospital Confinement
to determine if continued Inpatient care is Medically Necessary.
CONFINEMENT:
A continuous stay in a Hospital, Extended Care Facility, or at home,
due to an Illness or Injury diagnosed by a Physician. Later stays shall
be deemed part of the original confinement, unless there was either
a complete recovery during the interim from the Illness or Injury causing
the initial stay, or unless the later stay results from a cause or causes
unrelated to the Illness or Injury causing the initial stay.
CO-PAYMENT:
A cost sharing arrangement whereby a Covered Person
pays a set amount for a specific service at the time that service is
provided.
COSMETIC SURGERY:
The surgical alteration of hard and soft tissue for the improvement
of a person’s appearance, rather than the improvement or restoration
of bodily functions.
COVERED EXPENSES:
Medically Necessary services, supplies, or treatments that are recommended
or provided by a licensed Physician, Practitioner, or covered facility
for the treatment of an Illness or Injury and that are not specifically
excluded from coverage herein. Covered Expenses shall include specified
preventive care services.
COVERED PERSON:
A person who is eligible for coverage under this Plan, or becomes eligible
at a later date, and for whom the coverage provided by this Plan is
in effect.
CREDITABLE COVERAGE:
Coverage of an individual under any of the following:
1.
A group health plan, including governmental plans and church
plans.
2.
Health insurance, either group or individual insurance, including
COBRA Continuation of Coverage.
3.
Part A or B of Title XVIII of the Social Security Act (Medicare).
4.
Title XIX of the Social Security Act (Medicaid), other than coverage
consisting solely of benefits under Section 1928 of the Social Security
Act (the program for distribution of pediatric vaccines).
5.
Title 10 U.S.C. Chapter 55 (medical and dental care for members
and certain former members of the uniformed services, and for their
dependents; for purposes of Title 10 U.S.C. Chapter 55, “uniformed services”
means the armed forces and the Commissioned Corps of the National Oceanic
and Atmospheric Administration and of Public Health Service.
6.
A medical care program of the Indian Health Service or of a tribal
organization.
7.
A state health benefits risk pool.
8.
The Federal Employee Health Benefits Plan (FEHBP).
9.
A public health plan as defined in HCFA regulations.
10.
Any health benefit plan under Peace Corps Act d
5(e).
CUSTODIAL CARE:
Care that does not require the continuing services of skilled medical
or allied health professionals and that is designed primarily to assist
the Covered Person in activities of daily living, including institutional
care that is primarily to support self-care and provide Room and Board.
Custodial Care includes, but is not limited to, help in walking,
getting into and out of bed, bathing, dressing, feeding and preparation
of special diets, and supervision of medications that are ordinarily
self-administered.
Room and Board and skilled nursing services are not, however, considered
Custodial Care if:
1.
Provided during Confinement in an institution for which coverage
is available under this Plan; and
2.
Combined with other necessary therapeutic services, under accepted
medical standards, that can reasonably be expected to substantially
improve the person’s medical condition.
CUSTOMARY AND REASONABLE CHARGES:
1.
Customary is the fee that falls within the range of prevailing
fees charged by Physicians of similar training or experience for a procedure
in a given geographic region.
2.
Reasonable is the fee that meets the requirements of customary
and is justified considering the complexity or the severity of treatment
for a specific case.
DEDUCTIBLE:
The accumulated amount of Covered Expenses incurred throughout the
Calendar Year the Covered Person must pay before any Coinsurance applies.
DEPENDENTS:
For a complete definition of “Dependent,” refer to the section entitled
Eligibility, Dependent Eligibility.
DURABLE MEDICAL EQUIPMENT:
Medical equipment which:
1.
Can withstand repeated use;
2.
Is not disposable;
3.
Is primarily and customarily used to serve a medical purpose;
4.
Is generally not used in the absence of Illness or Injury; and
5.
Is appropriate for used in the home.
Such equipment includes, but is not limited to, wheelchairs, kidney
dialysis machines, and hospital beds.
EFFECTIVE DATE:
The date of this Plan, or the date on which the Covered Person’s coverage
commences, whichever occurs last.
ELECTIVE SURGICAL PROCEDURE:
A surgical procedure that need not be performed on an Emergency basis
because reasonable delay will not cause life endangering complications.
EMERGENCY:
The sudden onset of an Illness or Injury requiring immediate medical
attention.
EMERGENCY ADMISSION:
An Emergency Admission occurs when a Covered Person is admitted to
the Hospital as an Inpatient due to an Emergency, as defined.
EMPLOYEE:
For a complete definition of Employee, refer to the section entitled
Eligibility, Employee Eligibility.
EMPLOYER:
Employer shall mean Hypercom, Inc.
ENROLLMENT DATE:
The first day of coverage, or the first day of the waiting period,
if any.
EXCLUSIVE PROVIDER:
A Physician or Hospital who has an agreement in effect with the Exclusive
Provider Organization at the time services are rendered. Exclusive
Providers agree to accept an exclusive rate of payment.
EXCLUSIVE RATE:
The rate Exclusive Providers have contracted to accept as payment in
full for the Covered Expenses of the Plan.
EXPERIMENTAL/INVESTIGATIONAL PROCEDURES:
Experimental procedures are:
1.
Those that have not yet been used frequently enough to establish
a track record;
2.
Procedures that have not yet achieved a success rate high enough
to be considered safe or effective; or
3.
Procedures that have progressed to limited use on humans, but
that are not widely accepted as proven and effective by the Health Care
Financing Administration.
Services, supplies and treatment not constituting accepted medical
practice properly within the range of appropriate medical practice under
the standards of the case and by the standards of a reasonably substantial,
qualified, responsible, relevant segment of the medical community or
government oversight agencies at the time services were rendered.
The Plan Administrator must make an independent evaluation of the experimental/non-experimental
standings of specific technologies. The Plan Administrator will be
guided by a reasonable interpretation of Plan provisions. The decisions
will be made in good faith and rendered following a factual background
investigation of the claim and the proposed treatment. The Plan Administrator
will be guided by the following principles:
1.
If the drug or device cannot be lawfully marketed without approval
of the U. S. Food and Drug Administration, and approval for marketing
has not been given at the time the drug or device is furnished; or
2.
If the drug, device, medical treatment or procedure, or the Covered
Person’s informed consent document utilized with the drug, device, treatment
or procedure, was reviewed and approved by the treating facility’s institutional
review board or other body serving a similar function, or if federal
law requires such review or approval; or
3.
If “reliable evidence” shows the drug, device, medical treatment
or procedure is the subject of on-going Phase I or Phase II clinical
trials, is in the research, experimental, study, or investigational
arm of on-going Phase II clinical trials, or is otherwise under study
to determine its maximum tolerated dose, its toxicity, its safety, its
efficacy, or its efficacy as compared with a standard means of treatment
or diagnosis; or
4.
If “reliable evidence” shows prevailing opinion among experts
regarding the drug, device, medical treatment or procedure is that further
studies or clinical trails are necessary to determine its maximum tolerated
dose, its toxicity, its safety, its efficacy, or its efficacy as compared
with standard means of treatment or diagnosis.
“Reliable evidence” shall mean only publishes reports and articles
in the authoritative medical and scientific literature; the written
protocol or protocols used by the treating facility or the protocol(s)
of another facility studying substantially the same drug, device, medical
treatment or procedure; or the written informed consent used by the
treating facility or by another facility studying substantially the
same drug, device, medical treatment or procedure.
EXTENDED CARE FACILITY:
An institution, or distinct part thereof, operated pursuant to law
and one meeting all of the following conditions:
1.
It is licensed to provide, and is engaged in providing, on an
Inpatient basis for persons convalescing from Illness or Injury, professional
nursing services rendered by a graduate registered nurse or by a licensed
practical nurse under the direction of a graduate registered nurse,
and physical restoration services to assist patient to reach a degree
of body functioning to permit self-care in essential daily living activities.
2.
Its services are provided for compensation from its patients
while under the full-time supervision of a Physician or graduate registered
nurse.
3.
It provides twenty-four (24) hours per day nursing services by
a licensed nurse while under the direction of a full-time graduate registered
nurse.
4.
It maintains a complete medical record on each patient.
5.
It is not, other than incidentally, a place for rest, a place
for the aged, a place for drug addicts, a place for alcoholics, a place
for the mentally retarded, a place for custodial or educational care,
or a place for care of mental disorders.
6.
It is approved and licensed by Medical.
This term shall also apply to expenses incurred in an institution referring
to itself as a Skilled Nursing Facility, Convalescent Nursing Facility,
or any such other similar designations.
FAMILY DEDUCTIBLE:
The accumulated amount of Covered Expenses incurred throughout the
Calendar Year the family must pay before any Coinsurance applies.
FULL-TIME:
Employees regularly scheduled to work not less than thirty-five hours
per work week.
FULL-TIME STUDENT STATUS:
An Employee’s Dependent child(ren) who is enrolled in, and regularly
attends, high school, an accredited college, university, or institution
of higher learning for the minimum number of credit hours required by
that institution in order to maintain Full-time Student Status.
GENERIC DRUG:
A drug that is generally equivalent to a higher-priced brand name drug
and meets all FDA bioavailability standards.
HEALTH CARE MANAGEMENT ORGANIZATION:
The individual or organization designated by the Employer to authorize
Hospital admissions and surgeries and to determine the Medical Necessity
of treatment for which Plan benefits are claimed
HOME HEALTH AIDE SERVICES:
Those services provided by a person, other than a registered nurse,
that are Medically Necessary for the proper care and treatment of a
person.
HOME HEALTH CARE AGENCY:
An agency or organization meeting fully every one of the following
requirements:
1.
It is primarily engaged in, and duly licensed (if such licensing
is required by the appropriate licensing authority), providing skilled
nursing and other therapeutic services.
2.
It has a policy established by a professional group associated
with the agency or organization to govern the services provided. This
professional group must include at least one Physician and at least
one graduate registered nurse. It must provide for full-time supervision
of such services by a Physician or graduate registered nurse.
3.
It maintains a complete medical record on each patient.
4.
It has a full-time administrator.
5.
It qualifies as a reimbursable service under Medicare.
HOSPICE:
An agency that provides counseling and medical services, may provide
Room and Board to a terminally ill patient, and meets all of the following
requirements:
1.
It has obtained any required state governmental Certificate of
Need approval.
2.
It provides service twenty-four (24) hours per day, seven (7)
days a week
3.
It is under the direct supervision of a Physician.
4.
It has a nurse coordinator who is a registered nurse.
5.
It has a social service coordinator who is licensed.
6.
It is an agency that has as its primary purpose the provision
of Hospice services.
7.
It has a full-time administrator.
8.
It maintains written records of services provided to the patient.
9.
It is licensed, if licensing is required.
HOSPITAL:
An institution meeting the following conditions:
1.
It is considered licensed and operated in accordance with the
laws of jurisdiction in which it is located that pertain to Hospitals.
2.
It is engaged primarily in providing medical care and treatment
to ill and injured persons on an Inpatient basis, at the patient’s expense.
3.
It maintains on its premises all the facilities necessary to
provide for diagnosis and medical or surgical treatment of an Illness
or Injury, with such treatment being provided by, or under the supervision
of, a Physician, with continuous, twenty-four (24) hour nursing services
by graduate registered nurses.
4.
It qualifies as a Hospital, or psychiatric Hospital, and is accredited
by the Joint Commission on the Accreditation of Health Care Organizations.
5.
It is approved by Medicare.
Under no circumstances will a Hospital be, other than incidentally,
a place for rest, a place for the aged, a place for drug addicts, a
place for alcoholics, or a nursing home.
ILLNESS:
A bodily disorder, disease, physical sickness, or Pregnancy of a Covered
Person. A recurrent Illness will be considered one Illness. Concurrent
Illnesses will be considered one Illness, unless the concurrent Illnesses
are totally unrelated. All such disorders existing simultaneously,
due to the same or related causes, shall be considered one Illness.
INCURRED DATE:
With respect to a Covered Expense, the date the services or supplies
are provided.
INJURY:
A physical harm or disability that is the result of a specific, unexpected
incident caused by an external force. The physical harm or disability
must have occurred at an identifiable time and place. Injury does not
include Illness or infection of a cut or wound.
INPATIENT:
A Confinement in a Hospital, Hospice, or Extended Care Facility as
a registered bed patient for which charges are made for Room and Board
to the Covered Person as a result of admission.
INTENSIVE CARE:
A service reserved for critically and seriously ill patients requiring
constant audiovisual surveillance as prescribed by the attending Physician.
Additionally, Intensive Care provides Room and Board and care by a graduate
registered nurse or other highly trained Hospital personnel utilizing
special equipment and supplies immediately available on a standby basis.
Services are rendered at a location segregated from the rest of the
Hospital’s facilities. This term does not include care in a surgical
recovery room.
LATE ENROLLEE:
An Employee or Dependent who: 1) does not enroll for coverage under
the Plan when first eligible for coverage; or 2) terminated coverage
under the Plan and desires to re-enroll; and 3) does not meet the provisions
of the Special Enrollment. An Alternate Recipient is not a Late Enrollee.
LEAVE OF ABSENCE:
A period of time during which the Employee does not work, but is of
stated duration, after which time the Employee is expected to return
to Active Work.
MAXIMUM BENEFIT:
Any one of the following, or any combination of the following:
1.
The maximum amount paid by this Plan for any one Covered Person
during the entire time he/she is covered by this Plan; or
2.
The maximum amount paid by this Plan for any one Covered Person
for a particular Covered Expense. This maximum amount can be for:
a.
The entire time the Covered Person is covered under this Plan;
or
b.
A specified period of time, such as a Calendar Year.
3.
The “maximum number” the Plan acknowledges as a Covered Expense.
The maximum number relates to the number of:
a.
Treatments during a specified period of time; or
b.
Days of Confinement: or
c.
Visits by a Home Health Care agency.
MEDICALLY NECESSARY (MEDICAL NECESSITY):
Health care service, supply, or treatment that is appropriate and consistent
with the diagnosis and that, in accordance with generally accepted medical
standards, could not have been omitted without adversely affecting the
Covered Person’s condition or the quality of medical care rendered.
A service, supply, or treatment will not be considered Medically Necessary
if:
1.
It is provided only as a convenience to the Covered Person or
Provider; or
2.
It is part of a plan of treatment that is experimental, unproven,
or related to a research protocol.
The fact that any particular Physician may prescribe, order, recommend,
or approve a service or supply does not, in and of itself, make the
service or supply Medically Necessary.
MEDICARE:
The programs established by Title XVIII, known as the Health Insurance
for the Aged Act, including:
1.
Part A: Hospital Benefits for the Aged;
2.
Part B: Supplementary Medical Insurance Benefits for the Aged;
and
3.
Part C: miscellaneous provisions regarding both programs; and
also including any subsequent changes or additions to those programs.
MENTAL AND NERVOUS DISORDER:
An emotional or mental condition characterized by abnormal functioning
of the mind or emotions, and in which psychological, intellectual, emotional
or behavioral disturbances are the dominating factor. Diagnosis of these
conditions will be determined based on standard SM-III-R (diagnostic
and statistical manual of mental disorders).
MIDWIFE:
Any licensed professional (or a professional person deemed by state
law to be the same as a legally qualified Midwife) who assists in the
delivery of newborns.
NEGOTIATED RATE:
The rate Preferred Providers have contracted to accept as payment in
full for Covered Expenses of the Plan.
NEWBORN CARE:
The normal care rendered on behalf of a newborn child(ren) not relating
to an Illness or Injury, but to the care and general health maintenance
required during the mother’s Confinement for delivery including, but
not limited to, circumcision, pediatrician’s charges, and Routine Nursery
Care.
NON-PREFERRED PROVIDER:
A Physician, Hospital, or other health care facility not having an
agreement in effect with the Preferred Provider Organization at the
time services are rendered.
OUTPATIENT:
A Covered Person shall be considered to be an “Outpatient” if treated
at:
1.
A Hospital as other than a registered bed patient;
2.
A Physicians office; or
3.
An Ambulatory Surgical Center.
Confinement is less than eighteen (18) consecutive hours.
OUTPATIENT SURGERY:
Elective Surgical Procedures performed in a surgical facility other
than Confinement in a Hospital as a registered bed patient.
PARTIAL CONFINEMENT:
A period of less than twenty-four (24) hours of active treatment in
a facility licensed or certified by the state in which treatment is
received to provide one or more of the following:
1.
Alcoholism treatment;
2.
Chemical Dependency treatment;
3.
Psychiatric services;
4.
Treatment of mental disorders.
The treatment periods may include day, early evening, evening, night
care, or a combination of these four periods.
PART-TIME:
Employees regularly scheduled to work not less than an average of twenty
(20) hours per work week (1000 hours per year).
PHYSICIAN/PRACTITIONER:
1.
A Doctor of Medicine (M. D.) or a Doctor of Osteopathy (D.
O.) who is licensed to practice medicine or osteopathy where the care
is provided; or
2.
One of the following providers, but only when the provider is
licensed to practice where the care is provided, who is rendering a
service within the scope of that license, and is providing a service
for which benefits are specified in this Plan and to whom benefits
would be payable if the services were provided by a Physician, as defined
in (1) above:
- A Dentist (D. D. S. or D. M. D.);
- An Optometrist (O. D.);
- A dispensing optician;
- A podiatrist or chiropodist (D. P. M., D. S. P., or D. S. C.);
- A psychologist;
- A chiropractor (D. C.).
3.
A Physician or person acting within the scope of applicable state
licensing/certification requirements and holding the degree of Certified
Nurse Midwife (C. N. M.), Certified Registered Nurse Anesthetists (C.
R. N. A.), Registered Physical Therapist, Physician’s Assistant, Registered
or Certified Respiratory Therapist, Occupational Therapist, Registered
Speed Therapist, Registered Nurses (R. N.), Licensed Practical Nurse
(L. P. N.), Nurse Practitioner, or Accredited Registered Nurse Practitioner
(A. R. N. P.), pathologist, and lab technicians.
Licensed health service providers in psychology,
when acting within the scope of their license or state certification,
are included in this definition for services covered under this Plan.
The following are those providers who fall under this definition: Certified
Social Workers (M. S. W.), Certified Mental Health Counselors (M. A.,
M. E., M. C., L. C. S. W., or R. C. S.), and Licensed Clinical Psychologists
(PSY).
The Physician may not be a Close Relative of the Covered Person.
PHYSICIAN VISIT:
A personal interview between a Covered Person and a Physician, including
during Hospital Confinement, but not including telephone calls or interviews
in which the Physician does not see the Covered Person.
PLACED FOR ADOPTION:
The date the Employee assumes legal obligation for the total or partial
support of the child(ren).
PLAN:
“Plan” refers to the benefits and provisions for payment of same as
described herein.
PLAN ADMINISTRATOR:
The Plan Administrator is responsible for the day-to-day functions
and management of the Plan. The Plan Administrator may employ persons
or firms to process the claims and perform other Plan connected services.
PRE-ADMISSION TESTING:
Testing prescribed by a Physician in connection with a planned Hospital
Confinement or Outpatient Surgery. The testing must be:
1.
Performed in a covered facility; and
2.
Necessary to diagnose and treat the condition for which Confinement
is planned.
Confinement or surgery must actually start within seven (7) days after
the test is performed.
PRE-EXISTING CONDITION:
A condition (whether physical or mental), regardless of the cause of
the condition, for which medical advice, diagnosis, care, or treatment,
including the use of prescription drugs or medicines was recommended
by or received from a licensed physician or licensed health practitioner
during the six (6) month period prior to the Covered Person’s Effective
Date of Coverage.
PREFERRED PROVIDER:
A Physician, Hospital, or other health care facility who has an agreement
in effect with the Preferred Provider Organization at the time the
services are rendered. Preferred Providers agree to accept the Negotiated
Rate as payment in full.
PREFERRED PROVIDER ORGANIZATION (PPO):
An organization who selects and contracts with several Hospitals, Physicians,
and other health care providers to provide services and supplies at
a reduced rate to a Covered Person.
PREGNANCY:
The physical state resulting in childbirth or miscarriage and any medical
complication arising our of or resulting from such state.
PREGNANCY COMPLICATIONS:
1.
Conditions requiring Hospital Confinement (when Pregnancy is
not terminated) whose diagnoses are distinct from Pregnancy, but are
adversely affected by Pregnancy or are caused by Pregnancy. Examples
are acute nephritis, nephrosis, cardiac decompensation, missed abortion,
and similar medical and surgical conditions of comparable severity.
2.
Non-elective cesarean section;
3.
Spontaneous termination of Pregnancy occurring during a period
of gestation in which a viable birth is not possible;
4.
Ectopic Pregnancy that is terminated.
“Pregnancy Complications, “ as defined above, are covered under the
Plan to the same extent as any other Illness.
The following are not considered Pregnancy Complications: false labor;
occasional spotting; Physician-prescribed rest during the period of
Pregnancy; morning sickness; hyperemesis gravidarum; pre-eclampsia;
and similar conditions associated with the management of a difficult
Pregnancy not constituting a nosologically distinct complication of
Pregnancy.
PROFESSIONAL SERVICES:
Reasonable and necessary services that are consistent with the Physician’s
diagnosis, for treatment or improvement of a Covered Person’s Illness
or Injury. Professional Services include charges made by a Physician
for x-ray and laboratory examinations.
QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO):
The QMSCO creates or recognizes the right of a child(ren) who is recognized
under the order as having a right to be enrolled under the Plan, to
receive benefits for which the Employee is entitled under the Plan,
and includes:
1.
The name and last known address of the Employee and of each such
child(ren);
2.
A reasonable description of the type of coverage to be provided
by the Plan;
3.
The period for which coverage must be provided; and
4.
Each Plan to which the order applies.
NOTE: A QMCSO cannot require the Plan to provide any type or form
of benefit that is not already offered.
REHABILITATION FACILITY:
A facility designed exclusively for rehabilitative services where the
Covered Person receives treatment as a result of catastrophic Illness
or Injury.
RETROSPECTIVE REVIEW:
Retrospective Review occurs after the Covered Person’s discharge to
determine if, and to what extent, Inpatient Care was Medically Necessary.
ROOM AND BOARD:
The Hospital’s most common semi-private Room and Board charge for room
and linen service, dietary service, including meals, special diets and
nourishment, and general nursing service. Room and Board does not include
personal items.
ROUTINE NURSERY CARE:
Hospital charges for Room and Board and supplies, if applicable, for
a newborn child(ren) while the mother is Hospital-confined due to delivery.
SECOND SURGICAL OPINION:
A surgical consultation by a specialist who is not affiliated with
the surgeon to confirm the medical advisability of proposed elective
surgery.
SEMI-PRIVATE:
The daily Room and Board charge a health care institution applies to
the greatest number of beds in its semi-private rooms containing two
(2) or more beds. If the institution has no semi-private rooms, the
semi-private room rate will be the daily Room and Board rate most commonly
charged for semi-private rooms with two (2) or more beds by similar
institutions in the area. The term “area” means a city, a county, or
any greater area necessary to obtain a representative cross section
of similar institutions.
SKILLED NURSING FACILITY:
A facility licensed in accordance with state and local laws pertaining
to such institutions to provide continuous skilled nursing services,
and recognized as a Skilled Nursing Facility by the Secretary of Health
and Human Services of the United States for participation under the
Medicare Act.
THIRD PARTY ADMINISTRATOR:
The firm contracted by the Employer responsible for the processing
of claims and other services deemed necessary for the operation of the
Plan.
TOTAL DISABILITY (TOTALLY DISABLED):
Total Disability shall mean the Employee is prevented from engaging
in his regular, customary occupation, or for an occupation for which
he/she becomes qualified by training or experience, and is performing
no work of any kind for compensation or profit. Total Disability also
means a Dependent(s) who is prevented from engaging in all of the normal
activities of a person of like sex and age who is in good health.
TREATMENT CENTER:
An institution not qualifying as a Hospital, but provides a program
of effective medical and therapeutic treatment for Chemical Dependency,
and:
1.
Where coverage of such treatment is mandated by law, has been
licensed and approved by the regulatory authority having responsibility
for such licensing and approval under the law;
2.
Where coverage of such treatment is not mandated by law, meets
all of the following requirements:
a.
It is established and operated in accordance with the applicable
laws of the jurisdiction in which it is located.
b.
It provides a program of treatment approved by the Physician.
c.
It has or maintains, a written, specific, and detailed regimen
requiring full-time residence and full-time participation by the Covered
Person.
d.
It provides at least the following basic service:
1.
Room and Board;
2.
Evaluations and diagnoses;
3.
Counseling;
4.
Referral and orientation to specialized community resources.
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