Scott & White Benefits Book - Austin Community College

52 Pages·2011·1.23 MB·English

LARGE EMPLOYER
HEALTH CARE
EVIDENCE OF COVERAGE
THIS HEALTH CARE EVIDENCE OF COVERAGE IS NOTAPOLICYOF WORKERS'
COMPENSATION INSURANCE. YOU SHOULD CONSULTYOUR EMPLOYER
TO DETERMINE WHETHERYOUR EMPLOYER ISASUBSCRIBER TO THE
WORKERS' COMPENSATION SYSTEM.
CorporateOffice
2401South31st Street
Temple,Texas 76508
[phone]
[phone]
ERS9/2011
CERTIFICATE OF COVERAGE
In consideration of the completed and accepted EnrollmentApplication and timelypayment of the required payments, Scott
and White Health Plan agrees to provide or arrange to provide the benefits specified in thisAgreement, in accordance with
andsubjecttothetermsstatedhereinandallapplicablelocal,stateandfederallaws. ThisAgreement,application,formsand
anyattachmentstothemformtheentirecontract.
In consideration of the Health Plan's Agreement to provide those Health Care Services specified in this Agreement and
subjectto the termsstated herein,Youand the ContractHolder promise to payallrequired payments whendue, abidebyall
ofthetermsofthisAgreementandcomplywithallapplicablelocal,stateandfederallaws.
ImportantNotices:
1. The initialratesagreed uponbyGroup and ScottandWhite HealthPlanareeffective duringthe initial year
from and after the effective date of this Agreement. Thereafter, Health Plan reserves the right to change
ratesupon60daysnoticepriortorenewal.
2. The coverage provided under thisAgreement is health maintenance organization (HMO) coverage and not
indemnity insurance. As an HMO, the Health Plan contracts with only certain providers; therefore, with
certain exceptions as explained herein, You and Your Covered Dependents are required to use those
providersinordertoreceivethecoveragedescribed. Thoseprovidersshalldeterminethemethodsusedand
the form of Treatment to be provided. The Health Plan does not intend that all alternative forms and
methods of Treatment will be eligible for coverage. If You or Your Covered Dependents elect to receive
Treatment from a non-Health Plan provider, or receive a form of Treatment not authorized by the Health
Plan,Youmayberequiredtopayfortheservicesprovidedoutofyourownpocket.
3. ScottandWhite HealthPlan isa named fiduciaryto review claims under thisAgreement. Group delegates
to Health Plan the discretion to determine whether You and Your Covered Dependents are entitled to the
benefitsofthisAgreement. In makingthese determinations, HealthPlan hasthe authorityto reviewclaims
inaccordwiththeprocedurescontainedhereinandtoconstruethisAgreementtodetermineifYouandYour
Covered Dependents are entitled to its benefits. If Group is subject to the Employee Retirement Income
SecurityAct,afederallaw,thisAgreementmaybegovernedbytheprovisionsofthatlaw.
In witness whereof Scott and White Health Plan has caused this Health CareAgreement to be executed as of the Effective
Date.
______________________________
PresidentandCEO
ScottandWhiteHealthPlan
2401South31stStreet
Temple,Texas76508
1
Summary of HMO Benefits for Plan Year 20121
Member’s Copayment
Benefit Description PY 2012
Planyearout-of-pocketcoinsurancemaximum(perperson) $2,000
Planyearout-of-pocketcopaymentmaximum(perperson) None
Lifetimemaximum None
Physiciansand LabServices
*PhysicianOfficeVisitPrimaryCarePhysician(ifapplicable) $25
SpecialistOfficeVisit $40
*Routinephysicals-Oneperplanyearforadults;periodicforchildren,oras $25
directedbytheprimarycarephysician
*Diagnosticx-rays,mammography,andlabtests 20%
HighTechRadiology(CTscans,MRI,andnuclearmedicine)–Outpatienttesting $100copaymentplus20%
only
*Immunizations-ForChildren0to6yearsofage Nocharge
(zerocostsharingforpreventivehealthservicesundertheAffordableCareAct)
*Immunizations-ForChildren7yearsandolder,andadults Nocharge
(zerocostsharingforpreventivehealthservicesundertheAffordableCareAct)
*Wellwomanexam-Oneperplanyear Nocharge
*Vision,speech,andhearingscreenings-ForallenrolledParticipants 20%withoutofficevisit,
$40plus20%withofficevisit
*ColorectalCancerScreening–subjecttolanguagein13.4.13.2ofthe Nocharge
DescriptionofBenefits(zerocostsharingforcertainpreventiveservicesunder
theAffordableCareAct)
*ExamforDetectionandPreventionofOsteoporosis–subjecttolanguagein Nocharge
13.4.13.3oftheDescriptionofBenefits(zerocostsharingforcertainpreventive
servicesundertheAffordableCareAct)
*CervicalCancerScreening–subjecttolanguagein13.4.13.5oftheDescription Nocharge
ofBenefits(zerocostsharingforcertainpreventiveservicesundertheAffordable
CareAct)
Speechandhearingtesting-ForallenrolledParticipants 20%withoutofficevisit,
$40plus20%withofficevisit
Speechtherapyandrehabilitativetherapy,includingphysicalandoccupational 20%withoutofficevisit,
therapy-Coveredasanyotherillnessandnotsubjecttoanymaximum $40plus20%withofficevisit
Allergytesting 20%
Allergyserum 20%
Allergyserumadministration-Whenallergyshotisadministeredwithoutan 20%
officevisit
*Routineeyeexam-Oneperplanyear2 $40
Officesurgeryandprocedures(allofficesurgeries,excludingvasectomiesand 20%
tuballigations)
Maternitycare-Physicianservices,includingdiagnosisofpregnancy,pre-& $40forfirstofficevisit
post-natalcare,anddelivery(includingdeliverybyC-section)–see“Hospital
Services”forInpatientcharges
Familyplanning $40
Vasectomyandtuballigation 20%
Infertilitybenefits3 50%
*UndertheAffordableCareAct,certainpreventivehealthservicesarepaidat100%(i.e.,atnocostto
themember)dependentuponphysicianbillinganddiagnosis,includingcolorectalcancerscreening,
examfordetectionandpreventionofosteoporosis,andcervicalcancerscreening. Insomecases,you
willberesponsibleforpaymentofsomeservices.
ERSSB9/2011
Member’s Copayment
Benefit Description PY 2012
HospitalServices10
Inpatienthospital-Semi-privateroomandboardorintensivecareunits $150perdaycopaymentper
admission,5daymax.
$2,250max.perpersonper
yearplus20%
Outpatientdaysurgery $100copaymentplus20%
Otherinpatientcharges,includingmedicallynecessarysurgicalprocedures. $150perdaycopaymentper
Includesorthognathicsurgery. Guesttrays,cots,telephone,maternitykits, admission,5daymax.
paternitykits,andotherpersonalitemsnotcovered $2,250max.perpersonper
yearplus20%
Bloodandbloodproducts-Inpatientandoutpatient 20%
PrivateDutyNursing(basedonmedicalnecessity) 20%
Outpatientfacilities,includingpre-admissiontestingand/ortreatmentroom 20%
Emergencycare-In-areaandout-of-areacoveredatlistedcopayment. If $150copaymentplus20%
hospitalized,copaymentisappliedtohospitalconfinement.
Urgentcare-Includesphysician'safter-hourscareoratanurgentcarefacility $50copaymentplus20%
ExtendedCareServices(Basedonmedicalnecessity)
SkilledNursingfacility(basedonmedicalnecessity)-Coveredupto60daysper 20%
planyear
HospiceCare-Inpatientandoutpatient(basedonmedicalnecessity) 20%
Homehealth 20%
Privatedutynursing 20%
Other Medical Services
Hearingaids(Repairsnotcovered) Planpays$500perear
every3years
Hearingaidbatteries-Notsubjecttoanymaximumamounts 20%
Dental4-Restorationandcorrectionofdamagecausedbyexternalviolent 20%
accidentalinjurytohealthy,naturalteeth,occurringwhilecoveredundertheplan
forservicesprovidedwithin24monthsofthedateoftheaccident. Certainoral
surgeriesarecovered
DurableMedicalEquipment5,6-Includesmedicallynecessarypurchaseand/or 20%
rental. Benefitsforrentalarelimitedto,andwillnotexceed,thepurchasepriceof
theequipment. (Repairsarecoveredifnotduetoneglectorabuse.)
Thisbenefitalsoincludesdiabeticsuppliesotherthaninsulin,diabeticoral
agent(s),andsyringesasspecifiedin Section1358.051(2),Tex.Ins.Code
Prostheses-Artificialdevices,surgicalornon-surgical,whichreplacebodyparts, 20%
includingarms,legs,eyesandcochlearimplantsarecovered. Replacements
andrepairsarecoveredasrequiredbymedicalnecessity.Prostheticdevices,
orthoticdevices,andprofessionalservicesrelatedtothefittinganduseofthese
devicesareincluded,ifservicesarepre-authorizedandprovidedbyacontracted
provider.
OrganTransplants-Coveredasanyotherillnessforkidney,cornea,liver,heart, $150perdaycopaymentper
heart-lung,lung,pancreatic-kidney,bonemarrow,andotherorgantransplants admission,5daymax.
thattheHMOdeterminestobenotexperimentaland/ornotinvestigational $2250max.perpersonper
accordingtocurrentmedicalplanguidelines. Donorexpensesarecovered. yearplus20%
Artificialorgans(e.g.heart)notcovered
Ambulance-Professionallocalgroundorairambulancetransportationservices 20%
tothenearesthospital,appropriatelyequippedandstaffedforthetreatmentof
theParticipant'scondition
Member’sCopayment
Benefit Description PY 2012
BehavioralHealthCareBenefits
Inpatientmentalhealth $150perdaycopaymentper
admission,5daymax.
$2250max.perpersonper
yearplus20%
Inpatientseriousmentalillness-Coveredasanyotherillness8 $150perdaycopaymentper
admission,5daymax.
$2250max.perpersonper
yearplus20%
Inpatientchemicaldependency-Coveredasanyotherillness(basedonmedical $150perdaycopaymentper
necessity) admission,5daymax.
$2250max.perpersonper
yearplus20%
Outpatientmentalhealth $40
Outpatientseriousmentalillness-Coveredasanyotherillness8 $40
Outpatientchemicaldependency-Sameasanyotherillnessandnotsubjectto $40
anymaximums
Member’sCopayment
Benefit Description PY 2012
Prescription Drugs9 Plan Year Deductible $50
IfaBrandNamemedicationisdispensedwhenaGenericisavailable,member
shallberesponsiblefortheGenericCopaymentplusthecostdifferencebetween
theGenericandtheBrandNamemedication
ParticipatingRetailPharmacy-Tier1,Tier2&Tier3
Uptoa30-daysupplyperprescriptionorrefillofNon-Maintenancemedication $15/$35/$60
Uptoa30-daysupplyperprescriptionorrefillofMaintenancemedication $20/$45/$75
Infertilitydrugs 50%
Uptoa30-daysupplyofinsulinforonecopayment $15/$35/$60
Uptoa30-daysupplyofeachdiabeticoralagentforonecopayment $15/$35/$60
Thesupplyofnecessarydisposablesyringesfortheinsulinsupplyforone $35
copayment
Diabeticsuppliesotherthaninsulin,diabeticoralagent(s),andsyringesas 20%
specifiedinSection1358.051(2),Tex.Ins.Codeforuptoa30-daysupply
MailOrderPharmacy-Tier1,Tier2&Tier3
Uptoa90-daysupplyperprescriptionorrefillforonemailorder $45/$105/$180
copayment
Oralcontraceptivesuptoa90-daysupplyforonemailordercopayment $45/$105/$180
Infertilitydrugs 50%
Uptoa90-daysupplyofinsulinforonemailordercopayment $45/$105/$180
Uptoa90-daysupplyofeachdiabeticoralagent foronemailorder $45/$105/$180
copayment
Thesupplyofnecessarydisposablesyringesfortheinsulinsupplyforone $105
mailordercopayment
Diabeticsuppliesotherthaninsulin,diabeticoralagent(s),andsyringesas 20%
specifiedinSection1358.051(2),Tex.Ins.Codeforuptoa90-daysupply
Pre-existing conditions are covered as of 12:01 a.m. September 1, 2011 and lifetime benefit
maximumsareunlimited.
Footnotes:
1. This Summary of HMO Benefits reflects the current benefit plan structure and is subject to
change as required by state and federal laws, rules and regulations or if ERS deems it to be
in the best interests of ERS, GBP, its Participants, or the state of Texas. All state mandated
services shall be provided for in the HMO’s Evidence of Coverage whether included in or
omittedfrom thisSummaryofBenefits. TheSummaryofHMOBenefitsitemizestheservices
required by Chapter 1551, TIC, generally, by the TIC and by the rules of the TDI. The
Summary of HMO Benefits is not intended to identify all services required by the TIC and
TDI;however,thefollowingbenefitsshouldbelisted:
a. Well-childcarefrombirthperTICsection1271.154;
b. ScreeningtestforhearinglossfornewbornsperTICsection1367.103;
c. TestsfordetectionofprostatecancerperTICsection1362.003;
d. TestsfordetectionofcolorectalcancerperTICsection1363.003;
e. Coverage for hospital stays following performance of a mastectomy and certain related
proceduresperTICsection1357.054;
f. CoverageforreconstructivesurgeryaftermastectomyperTICsection1357.004;
g. BenefitsfordetectionandpreventionofosteoporosisperTICsection1361.003;
h. CoverageforcraniofacialabnormalitiesperTICsection1367.151-153;
i. TelemedicineperTICsection1455.004;
j. AnesthesiafordentalproceduresinahospitalsettingperTICChapter1360;
k. CoverageforcertainbenefitsrelatedtobraininjuryperTICChapter1352;
l. Coverage for prescription contraceptive drugs and devices and related services per TIC
section1369.104;
m. CoverageforinpatientstayfollowingchildbirthperTICsection1366.055;
n. Coverage for special dietaryformulas for individuals with Phenylketonuria (PKU) or other
heritablediseasesperTICsection1359.003;
o. Coverageforcertainaminoacid-basedelementalformulasperTICsection1377.051;
p. Coverageforoff-labeldruguseperTICChapter1369;
q. CoverageforfibrocysticbreastconditionsperTICsection544.201-204;
r. EligibilityforbenefitsforAlzheimer’sdiseaseperTICChapter1354;
s. CoverageforcervicalcancerperTICChapter1370;
t. Coverage for certain tests for early detection of cardiovascular disease per TIC section
1376.003;
u. Coverage for routine patient care costs for enrollees participating in certain clinical trials
perTICsection1379.051;and
v. Coverage for autism spectrum disorder from date of diagnosis until the enrollee
completesnineyearsofageperTICsection1355.015.
2. Routine eye exam means an eye exam by a Doctor of Ophthalmology or a Doctor of
Optometrywhich,whenwithinthescopeoftheirlicense,includessuchservicesas:
 Externalexaminationoftheeyeanditsstructure;
 Determinationofrefractivestatus;and
 Glaucomascreeningtest.
It does not include a contact lens exam, prescriptions or fittings of contact lenses or
eyeglasses,andthecostofthecontactlensesoreyeglasses.
3. Infertility Benefits do not include sterilization reversal, transsexual surgery, gender
reassignment, intra-fallopian transfer and related services, artificial insemination, or in-vitro
fertilization. Also excluded from coverage are any services or supplies used in any
procedures performed in preparation for or immediately after any of the above-referenced
excludedprocedures. Pharmaceuticalsarecoveredat50%copayment.
4. Certainoralsurgeriesmeanmaxillofacialsurgicalprocedureslimitedto:
 Excision of neoplasm,includingbenign,malignantand premalignant lesions,tumors,and
nonodontogeniccysts.
 Incisionanddrainageofcellulitis.
 Surgicalproceduresinvolvingaccessorysinuses,salivaryglandsandducts.
 Coverage for temporomandibular joint (“TMJ”) shall be in compliance with Chapter 1360,
TIC. Excludes oral appliances and devices used to treat TMJ pain disorders or
dysfunctionofthejointandrelatedstructures,suchasthejaw,jawmuscles,andnerves.
5. The diabetes benefit is as listed in Section 1358.051 of the TIC and includes benefits for
diabetic equipment, diabetes supplies, and diabetes self-management training programs as
follows:
Diabeticequipment:(20%copayment)
a. Bloodglucosemonitors,includingmonitorsdesignedtobeusedbyblindindividuals.
b. Insulinpumpsandassociatedappurtenances.
c. Insulininfusiondevices.
d. Podiatricappliancesforthepreventionofcomplicationsassociatedwithdiabetes.
Diabeticsupplies:
a. Insulinandinsulinanalogs(coveredunderpharmacybenefit).
b. Syringes(coveredunderpharmacybenefitattheTier2copayment).
c. Prescriptive and nonprescriptive oral agents for controlling blood sugar levels (covered
underpharmacybenefit).
d. Glucagonemergencykits(coveredunderpharmacybenefit).
e. Teststripsforbloodglucosemonitors(20%copayment).
f. Visualreadingandurineteststrips(20%copayment).
g. Lancetsandlancetdevices(20%copayment).
h. Injectionaids(20%copayment).
i. Alcoholwipes(20%copayment).
Diabeticself-managementtrainingprograms:(sameasofficevisitcopayment)
a. Training provided after the initial diagnosis of diabetes in the care and management of
that condition, including nutritional counseling and proper use of diabetes equipment and
supplies.
b. Additional training is provided after a diagnosed significant change in the member’s
symptomsorconditionthatrequireschangesintheself-managementregime.
c. The Food and Drug Administration approves periodic or episodic continuing education
training as warranted by the development of new techniques and treatments for the
treatmentofdiabetes.
6. ERS defines orthotics as pertaining to the feet; therefore, services or supplies for routine foot
care, insoles, or shoe inserts of any type are not covered, except when prescribed for a
diagnosis of or related to the treatment of diabetes or circulatory disorders of the lower
extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous
insufficiency. Orthotic devices, and the professional services relating to the fitting and use of
those devices, are covered if the services are pre-authorized and provided by a contracted
provider.
7. Restrictions on mental health benefits are not applicable to expenses incurred for the
treatment of “serious mental illness” as defined in Section 1355.001, TIC. At a minimum,
coverage for autism spectrum disorder must be provided from the date of diagnosis until the
enrolleecompletesnineyearsofageasdescribedinSection1355.015,TIC.
8. PharmacyBenefits:ERSallowstheuseofaformularyprovideditoffersabroadspectrumof
highqualitydrugtherapies. Vitaminsarenotcoveredexceptthosethatrequireaprescription
bylawandhavenonon-prescriptionequivalent.
9. Weight reduction programs, services, supplies, surgeries, or gym memberships are not
covered, even if the Participant has medical conditions that might be helped by weight loss,
orevenifprescribedbyaphysician.
10. All ApplicableCopaymentandDeductibleResets
10.a. Break in Coverage: The prescription drug deductible and the inpatient out-of-pocket
maximum per person per plan year should be reset for a Participant designated as a new
hire. This would include an employee who left state or higher education employment and
experienced a break in health insurance coverage. This Participant would be considered a
new employee and the prescription deductible and the inpatient out-of-pocket maximum
shouldbecalculatedthesameasforanewemployee.
10.b. COBRA/Dependent Coverage: Participants under COBRA and dependents who were
previously covered but are now directly insured under the GBP shall not be requested to
satisfy a new prescription deductible and inpatient out-of-pocket maximums as soon as their
coveragebecomeseffectiveasadirectlyinsuredGBPParticipant.
IMPORTANTNOTICE AVISOIMPORTANTE
Toobtaininformationormakeacomplaint: Para obtener informacion o para someter una
queja:
You may call Scott and White Health Plan's Usted puede llamar al numeros de telefono gratis
toll-free telephone numbers for information or de la Scott and White Health Plan's para
tomakeacomplaintat informacionoparasometerunaquejaal
LOCAL/LONGDISTANCENUMBERS NUMEROSLOCALES/DELARGADISTANCIA
Temple Bryan/CollegeStation Temple Bryan/CollegeStation
[phone] [phone] [phone] [phone]
[phone] [phone] [phone] [phone]
Georgetown Waco Georgetown Waco
[phone] [phone] [phone] [phone]
[phone] [phone] [phone] [phone]
SanAngelo SanAngelo
[phone] [phone]
[phone] [phone]
You may also write to Scott and White Health UstedtambienpuedeescribiralaScottandWhite
Planat: HealthPlan
2401South31stStreet 2401South31stStreet
Temple,TX 76508 Temple,TX 76508
You may contact the Texas Department of Puede communicarse con el Departmento de
Insurancetoobtaininformationoncompanies, segurosdeTexaspara obtenerinformacionacerca
coverage,rightsorcomplaintsat: decompanias,coberturas,derechosoquejasal:
1-800-252-3439 1-800-252-3439
You may write the Texas Department of Puede escribir al Departamento de Seguros de
Insurance: Texas:
P.O.Box149104 P.O.Box149104
Austin,TX 78714-9104 Austin,TX78714-9104
FAX:[phone] FAX#[phone]
Email: [email protected] Email:[email protected]
Internet: www.tdi.tx.state.us Internet: www.tdi.tx.state.us
PREMIUM OR CLAIM DISPUTES: Should DISPUTASSOBREPRIMASORECLAMOS: Si
you have a dispute concerning your premium tiene una disputa concerniente a su prima o a un
or about a claim you should contact the Scott reclamo,debecomunicarseconelScottandWhite
and White Health Plan first. If the dispute is HealthPlanprimero. Sinose resuelve la disputa,
not resolved, you may contact the Texas puede entonces communicarse con el
DepartmentofInsurance. departamento(TDI).
ATTACHTHISNOTICETOYOURPOLICY: UNAESTEAVISOASU POLIZA: Este aviso es
Thisnoticeisforinformationonlyanddoes solo para proposito de informacion y no se
notbecomeapartorconditionoftheattached convierte en parte o condicion del documento
document. adjunto.
SPECIALTOLL-FREEBEHAVIORAL AVISO DE NUMERO TELFONICO GRATIS
HEALTHCOMPLAINTNUMBER: ESPECIALMENTE PARA QUEJAS DE SALUD
MENTAL:
To make a complaint about a prívate Para someter una queja acerca de un hospital
psychiatric Hospital, chemical dependency psyquiatrico privado, de centro, tratamiento para
treatment center, or psychiatric or chemical la dependencia química, de servicios phiquiatrico
dependencyservicesatageneralHospital,call: o de dependencia química en un hospital general,
[phone] llamea: [phone]
Yourcomplaintwillbereferredtothestate
Suquejaseráreferidaalaagenciaestatalque
agencythatregulatesHospitalorchemical
regulalahospitalocentrodetratamientoparala
dependencytreatmentcenters.
dependenciaquímica.
2
TABLE OF CONTENTS
Health Care Evidence of Coverage
Page
CERTIFICATEOFCOVERAGE....................................................................................................................................1
IMPORTANTNOTICE.....................................................................................................................................................2
1. DEFINITIONS.............................................................................................................................................................5
2. ELIGIBILITYPROVISIONS
2.1 GeneralEligibilityProvisions.......................................................................................................................11
2.2 AdditionalProvisions....................................................................................................................................11
3. PROVIDERSOTHERTHANHEALTHPLANPROVIDERS
3.1 HealthPlanNotLiableforExpensesofProvidersOtherThanHealthPlanProviders................................12
3.2 ContractStatusofProviders..........................................................................................................................12
4. TERMINATIONOFCOVERAGE
4.1 TerminationofCoverageforMembers.........................................................................................................12
4.2 TerminationorNon-RenewalofCoverageforGroup..................................................................................12
4.3 Liability.........................................................................................................................................................12
5. CONTINUATIONOFCOVERAGEOPTION
5.1 LossofEligibility..........................................................................................................................................12
5.2 COBRAContinuationofCoverage...............................................................................................................13
5.3 AdditionalContinuationProvisions..............................................................................................................13
5.4 TexasHighRiskPoolCoverageNotification...............................................................................................13
6. REQUIREDPAYMENTS
6.1 CopaymentsandDeductibles........................................................................................................................14
6.2 SubrogationandCoordinationofBenefitsPayments....................................................................................14
7. HEALTHCARESERVICES
7.1 HealthCareServicesWithintheServiceArea..............................................................................................14
7.2 HealthCareServicesOutsideoftheServiceArea........................................................................................14
7.3 LimitationsandExclusions...........................................................................................................................14
7.4 HealthCareServicesthatarenotMedicallyNecessary................................................................................14
7.5 NatureofCoverageProvidedandHealthPlan'sRighttoContract...............................................................14
7.6 RefusaltoAcceptTreatment.........................................................................................................................15
7.7 CoordinationofHealthCareServices...........................................................................................................15
7.8 ContinuityofTreatment................................................................................................................................16
7.9 HealthCareServicesNotAvailableFromContractingProviders................................................................16
8. CLAIMPROCEDURE
8.1 NecessityofFilingClaims............................................................................................................................16
8.2 EffectofFailuretoFileClaimWithin60Days............................................................................................16
8.3 AcknowledgementofClaim..........................................................................................................................16
8.4 AcceptanceorRejectionofClaim.................................................................................................................17
8.5 PaymentofClaims........................................................................................................................................17
8.6 PaymenttoPhysicianorProvider.................................................................................................................17
8.7 LimitationsonActions..................................................................................................................................17
9. EFFECTOFMEDICARE,SUBROGATIONANDCOORDINATIONOFBENEFITS
9.1 EffectofMedicare.........................................................................................................................................17
9.2 Subrogation...................................................................................................................................................17
9.3 CoordinationofBenefits...............................................................................................................................18
9.4 FacilityofPayment.......................................................................................................................................19
9.5 RighttoReleaseandReceiveNeededConfidentialInformation..................................................................20
10. RECORDS
10.1 RecordsMaintainedbyHealthPlan..............................................................................................................20
10.2 NecessityofRequestedInformation.............................................................................................................20
10.3 NotificationofChangesinStatus..................................................................................................................20
11. COMPLAINTANDAPPEALPROCEDURE
11.1 Purpose..........................................................................................................................................................21
11.2 Complaints....................................................................................................................................................21
11.3 Appeals..........................................................................................................................................................21
11.4 AppealofAdverseDeterminations...............................................................................................................22
11.5 IndependentReviewofAdverseDeterminations..........................................................................................22
3
12. MISCELLANEOUSPROVISIONS
12.1 Confidentiality..............................................................................................................................................23
12.2 IndependentAgents.......................................................................................................................................23
12.3 EntireAgreement..........................................................................................................................................23
12.4 Severability...................................................................................................................................................23
12.5 ModificationofTerms..................................................................................................................................23
12.6 NotaWaiver.................................................................................................................................................23
12.7 Recovery.......................................................................................................................................................23
12.8 Notice............................................................................................................................................................24
12.9 Incontestability..............................................................................................................................................24
12.10 ProofofCoverage.........................................................................................................................................24
12.11 IdentificationCard........................................................................................................................................24
13. DESCRIPTIONOFBENEFITS
13. What'sCovered.............................................................................................................................................25
13.1 CopaymentsandDeductibles........................................................................................................................25
13.2 Out-of-PocketMaximum..............................................................................................................................25
13.3 BenefitLimitations........................................................................................................................................25
13.4 Benefits.........................................................................................................................................................25
13.4.1 MedicalServices...........................................................................................................................................25
13.4.2 PreventiveCareServices...............................................................................................................................25
13.4.3 HospitalServices...........................................................................................................................................26
13.4.4. EmergencyCareServices..............................................................................................................................26
13.4.5. MentalHealthCare.......................................................................................................................................27
13.4.6. TreatmentforChemicalDependency............................................................................................................28
13.4.7 RehabilitativeTherapy..................................................................................................................................28
13.4.8 HomeHealthServices...................................................................................................................................29
13.4.9 HospiceServices...........................................................................................................................................29
13.4.10 MaternityServices........................................................................................................................................29
13.4.11 FamilyPlanningandInfertilityServices......................................................................................................29
13.4.12 DurableMedicalEquipment/ConsumableSupplies/Orthotics/ProstheticDevices.......................................30
13.4.13 Immunizations...............................................................................................................................................30
13.4.14 BenefitsforScreeningExams.......................................................................................................................31
13.4.15 BreastReconstructionBenefits.....................................................................................................................31
13.4.16 MinimumInpatientStayFollowingMastectomyorRelatedProcedure.......................................................31
13.4.17 BenefitsforTreatmentandDiagnosisofConditionsAffectingTemporomandibularJoint..........................31
13.4.18 TreatmentforCraniofacialAbnormalitiesofaChild...................................................................................32
13.4.19 DiabeticSupplies,EquipmentandSelf-ManagementTraining....................................................................32
13.4.20 TransplantServices.......................................................................................................................................32
13.4.21 AcquiredBrainInjury...................................................................................................................................32
13.4.22 Telemedicine.................................................................................................................................................33
13.4.23 DentalBenefitsandCertainOralSurgery.....................................................................................................33
13.4.24 AutismSpectrumDisorderServices.............................................................................................................33
13.4.25 AminoAcid-BasedElementalFormulas.......................................................................................................34
13.4.26 CardiovascularDiseaseScreeningforHighRiskIndividuals.......................................................................34
13.4.27 RoutinePatientCareCostsforClinicalTrials..............................................................................................35
13.5 Out-of-NetworkReferrals.............................................................................................................................35
14. EXCLUSIONSANDLIMITATIONS.....................................................................................................................35
4