UnitedHealthcare Benefits Plan of California Core Individual Medical Subscriber Agreement and Combined Evidence of Coverage and Disclosure Form

Transcription

1 UnitedHealthcare Benefits Plan of California Core Individual Medical Subscriber Agreement and Combined Evidence of Coverage and Disclosure Form 185 Asylum Street Hartford, CT Agreement and Consideration We will pay Benefits as set forth in this Subscriber Agreement. This Subscriber Agreement is issued in exchange for and on the basis of the statements made on your application and payment of the first Premium. It takes effect on the effective date shown above. Coverage will remain in force until the first Premium due date, and for such further periods for which Premium payment is received by us when due, subject to the renewal provision below. Coverage will begin at 12:01 a.m. and end at 12:00 midnight in the time zone where you live. Guaranteed Renewable Subject to Listed Conditions You may keep coverage in force by timely payment of the required Premiums under this Subscriber Agreement or under any subsequent coverage you have with us. This Subscriber Agreement will renew on January 1 of each calendar year. However, we may refuse renewal if we refuse to renew all policies issued on this form, with the same type and level of Benefits, to residents of the state where you then live, or there is fraud or a material misrepresentation made by or with the knowledge of a Member in filing a claim for Benefits. On January 1 of each calendar year, we may change the rate table used for this Subscriber Agreement form. Each Premium will be based on the rate table in effect on that Premium's due date. Some of the factors used in determining your Premium rates are the plan, type and level of Benefits and place of residence on the Premium due date and age of Members as of the effective date or renewal date of coverage. Premium rates are expected to increase over time. At least 60 days' notice of any plan to take an action or make a change permitted by this clause will be mailed to you at your last address as shown in our records. IEXPOL.I.16.CA.PPO 1 Sample

2 10-Day Right to Examine and Return this Subscriber Agreement Please read this Subscriber Agreement. If you are not satisfied, you may notify us within 10 days after you received it. Any Premium paid will be refunded, less claims paid. This Subscriber Agreement will then be void from its start. This Subscriber Agreement is signed for us as of the effective date as shown above. IEXPOL.I.16.CA.PPO 2

3 This Subscriber Agreement This Subscriber Agreement is a legal document between UnitedHealthcare Benefits Plan of California and you to provide Benefits to Members, subject to the terms, conditions, exclusions and limitations of this Subscriber Agreement. We issue this Subscriber Agreement based on the Subscriber's application and payment of the required Premium. This Subscriber Agreement includes: The Schedule of Benefits. The Subscriber's application. Addendums, including the Outpatient Prescription Drug Addendum, the Pediatric Vision Care Services Addendum and the Pediatric Dental Addendum. Amendments. Changes to the Document We may from time to time modify this Subscriber Agreement by attaching legal documents called Addendums and/or Amendments that may change certain provisions of this Subscriber Agreement. When that happens we will send you a new Subscriber Agreement, Addendum or Amendment pages. We will give you prior notice of any proposed decrease in the benefits described in this Subscriber Agreement. No one can make any changes to this Subscriber Agreement unless those changes are in writing. Other Information You Should Have We have the right to change, interpret, modify, withdraw or add Benefits, or to terminate this Subscriber Agreement, as permitted by law. This Subscriber Agreement will remain in effect as long as the Premium is paid when due, subject to the renewal and termination provisions of this Subscriber Agreement. We are delivering this Subscriber Agreement in the State of California. This Subscriber Agreement is governed by the laws of the State of California. We are subject to the requirements of the California Knox-Keene Health Care Service Plan Act of 1975, and the regulations promulgated thereunder (collectively the "Knox-Keene Act"), and any provision required to be in this Subscriber Agreement by the Knox-Keene Act shall bind us whether or not provided in this Subscriber Agreement. IEXPOL.I.16.CA.PPO 3

4 Introduction to Your Subscriber Agreement We are pleased to provide you with this Subscriber Agreement. This Subscriber Agreement describes your Benefits, as well as your rights and responsibilities, under this Subscriber Agreement. How to Use this Document We encourage you to read your Subscriber Agreement and any attached Addendums and/or Amendments carefully. We especially encourage you to review the Benefit limitations of this Subscriber Agreement by reading the attached Schedule of Benefits along with Section 1: Covered Health Services and Section 2: Exclusions and Limitations. You should also carefully read Section 7: General Legal Provisions to better understand how this Subscriber Agreement and your Benefits work. You should call us if you have questions about the limits of the coverage available to you. Many of the sections of this Subscriber Agreement are related to other sections of the document. You may not have all of the information you need by reading just one section. We also encourage you to keep your Subscriber Agreement and Schedule of Benefits and any attachments in a safe place for your future reference. If there is a conflict between this Subscriber Agreement and any summaries provided to you, this Subscriber Agreement will control. Please be aware that your Physician is not responsible for knowing or communicating your Benefits. Information about Defined Terms Because this Subscriber Agreement is a legal document, we want to give you information about the document that will help you understand it. Certain capitalized words have special meanings. We have defined these words in Section 8: Defined Terms. You can refer to Section 8: Defined Terms as you read this document to have a clearer understanding of your Subscriber Agreement. When we use the words "we," "us," and "our" in this document, we are referring to UnitedHealthcare Benefits Plan of California. When we use the words "you" and "your," we are referring to people who are Members, as that term is defined in Section 8: Defined Terms. Don't Hesitate to Contact Us Throughout the document you will find statements that encourage you to contact us for further information. Whenever you have a question or concern regarding your Benefits, please call us using the telephone number for Customer Care listed on your identification (ID) card. It will be our pleasure to assist you. Choice of Physicians and Providers You have the right to choose a Network Provider or Non-Network provider. Choosing a Non-Network provider may impact your personal financial costs. Refer to the Schedule of Benefits to review your Copayment and Coinsurance differences between these types of providers since your responsibility is often significantly higher when you use a Non-Network Provider. Network Providers include Physicians, Specialists, other health care providers, Hospitals, and other facilities who contract with us to provide services to our Members. Referrals are not needed to visit a Network Specialist. If you require Covered Health Services from a non-primary care provider and you believe an appropriate Network provider is not available within 30 miles or 60 minutes or other time or distance which may be unreasonable from your primary workplace or residence, please contact Customer Care using the telephone number on your ID Card. A Network provider may contact Customer Care on your behalf. Customer Care will help you identify an appropriate Network provider or help you request access to a IEXPOL.I.16.CA.PPO 4

5 Non-Network provider. No forms are required to submit a request for access to a Non-Network provider. If we authorize you to receive Covered Health Services from a Non-Network provider, you will receive written communication from us identifying the provider name, address, and phone number. You will pay the Network copays or coinsurance and deductibles, if any, when we authorize Covered Health Services from a Non-Network provider. PLEASE READ THE FOLLOWING INFORMATION SO THAT YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS YOU MAY GET HEALTH CARE. IEXPOL.I.16.CA.PPO 5

6 Your Responsibilities Be Enrolled and Pay Required Premiums Benefits are available to you only if you are enrolled for coverage under this Subscriber Agreement. Your enrollment options, and the corresponding dates that coverage begins, are listed in Section 3: When Coverage Begins and Premiums. To be enrolled with us and receive Benefits, all of the following apply: Your enrollment must be in accordance with this Subscriber Agreement, including the eligibility requirements. You must qualify as a Subscriber or his or her Dependent as those terms are defined in Section 8: Defined Terms. You must pay Premium as required. Be Aware this Subscriber Agreement Does Not Pay for All Health Services Your right to Benefits is limited to Covered Health Services, subject to the conditions, limitations and exclusions of this Subscriber Agreement. The extent of this Subscriber Agreement's payments for Covered Health Services and any obligation that you may have to pay for a portion of the cost of those Covered Health Services is set forth in the Schedule of Benefits. Decide What Services You Should Receive Care decisions are between you and your Physicians. We do not make decisions about the kind of care you should or should not receive. Some Hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or any enrolled Member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments or abortion. You should obtain more information before you enroll. Call your prospective doctor or clinic, or call us at to ensure that you can obtain the health care services that you need. Choose Your Physician It is your responsibility to select the health care professionals who will deliver care to you. We arrange for Physicians and other health care professionals and facilities to participate in a Network. Our credentialing process confirms public information about the professionals' and facilities' licenses and other credentials, but does not assure the quality of their services. These professionals and facilities are independent practitioners and entities that are solely responsible for the care they deliver. Obtain Prior Authorization Some Covered Health Services require prior authorization. In general, Physicians and other health care professionals who participate in a Network are responsible for obtaining prior authorization. However, if you choose to receive Covered Health Services from a Non-Network Provider, you are responsible for obtaining prior authorization before you receive the certain services. For detailed information on the Covered Health Services that require prior authorization, please refer to the Schedule of Benefits, Pediatric Dental Services Addendum, Pediatric Vision Services Addendum, and Outpatient Prescription Drug Addendum. IEXPOL.I.16.CA.PPO 6

7 IF PRIOR AUTHORIZATION IS NOT OBTAINED FOR COVERED HEALTH SERVICES FROM A NON-NETWORK PROVIDER OR A NETWORK PROVIDER AS SPECIFIED IN THIS SUBSCRIBER AGREEMENT, YOU ARE RESPONSIBLE FOR THE FULL AMOUNT OF THE SERVICES RENDERED EXCEPT FOR EMERGENT AND URGENT CARE. Pay Your Share (Other Charges) You must meet any applicable deductible and pay a Copayment and/or Coinsurance for most Covered Health Services. These payments are due at the time of service or when billed by the Physician, provider or facility. Copayment and Coinsurance amounts are listed in the Schedule of Benefits. You must also pay any amount that exceeds Eligible Expenses for Non-Network services. Annual Deductible The Annual Deductible is the amount incurred for a Covered Health Service that you are responsible for paying each calendar year before benefits are payable under the Subscriber Agreement. The amounts applied towards the Annual Deductible are based upon UnitedHealthcare Benefits Plan of California's contracted rate. The Deductible is waived for certain covered services. Please refer to the Schedule of Benefits for detailed information on the Deductible amount and Covered Health Services subject to the Deductible. If your coverage includes a Deductible, we will not cover certain services until you meet the Deductible each year. The Annual Deductible is in addition to any Copayment responsibility. The Annual Deductible applies to the Out-of-Pocket Maximum. Individual/Family Deductible When the amount incurred for Covered Health Services for all Family Members accrue to the amount indicated on the Schedule of Benefits, no additional Deductible will apply to the other Family Members for the rest of that calendar year. For plans with an Embedded Individual/Family Deductible as indicated on the Schedule of Benefits, the individual deductible is embedded in the family deductible. When an individual member of a family unit satisfies the Individual Deductible for the calendar year, no further Deductible will be required for that individual member for the remainder of the calendar year. The remaining family members will continue to pay full member charges for services that are subject to the deductible until the member satisfies the Individual Deductible or until the family, as a whole, meets the Family Deductible. Out-of-Pocket Maximum For certain Covered Health Services, there is a limit placed on the total amount you pay for Copayments during a calendar year. This limit is called your Out-of-Pocket Maximum, and when you reach it, for the remainder of the calendar year, you will not pay any additional Copayments for these Covered Health Services. Copayments paid for certain Covered Health Services are not applicable to a Member s Out-of- Pocket Maximum; these services are specified in the Schedule of Benefits. Note: The Out-of-Pocket Maximum applies to Covered Health Services under the Agreement as indicated in this Schedule of Benefits, including Covered Health Services provided under the Outpatient Prescription Drug Addendum, the Pediatric Vision Care Services Addendum and the Pediatric Dental Services Addendum. If You Get a Bill (Reimbursement Provisions) If you are billed for a Covered Health Service provided or authorized by us or if you receive a bill for Emergency or Urgently Needed Services, you should do the following: IEXPOL.I.16.CA.PPO 7

8 1. Call the provider, then let them know you have received a bill in error and you will be forwarding the bill to UnitedHealthcare Benefits Plan of California. 2. Give the provider your Health Plan information, including your name and UnitedHealthcare Benefits Plan of California Member number. 3. Forward the bill to: UnitedHealthcare Benefits Plan of California Claims Department P.O. Box Salt Lake City, UT Include your name, your Health Plan ID number and a brief note that indicates you believe the bill is for a Covered Health Service. The note should also include the date of service, the nature of the service and the name of the provider who authorized your care. If you need additional assistance, call our Customer Care department. Please Note: Your provider will bill you for services that are not covered by UnitedHealthcare Benefits Plan of California or haven t been properly authorized. You may also receive a bill if you have exceeded UnitedHealthcare Benefits Plan of California's coverage limit for a benefit. Pay the Cost of Excluded Services You must pay the cost of all excluded services and items. Review Section 2: Exclusions and Limitations to become familiar with this Subscriber Agreement's exclusions. Show Your ID Card You should show your identification (ID) card every time you request health services. If you do not show your ID card, the provider may fail to bill the correct entity for the services delivered, and any resulting delay may mean that you will be unable to collect any Benefits otherwise owed to you. File Claims with Complete and Accurate Information When you receive Covered Health Services from a Non-Network Provider you are responsible for requesting payment from us. You must file the claim in a format that contains all of the information we require, as described in Section 5: How to File a Claim. Difference between Subscriber and an Enrolled Family Member While both are Members of UnitedHealthcare Benefits Plan of California there is a difference between a Subscriber and an enrolled family Member. A Subscriber is the Member who enrolls after meeting the eligibility requirements of UnitedHealthcare Benefits Plan of California. An enrolled family Member is someone such as a legal spouse, Domestic Partner or child whose Dependent status with the Subscriber allows him or her to be enrolled. Subscribers often have special responsibilities, including sharing benefit updates with any enrolled family members. Subscribers also have special responsibilities that are noted throughout this publication. If you are a Subscriber, please pay attention to any instructions given specifically for you. Use Your Prior Health Care Coverage If you have prior coverage that, as required by state law, extends benefits for a particular condition or a disability, we will not pay Benefits for health services for that condition or disability until the prior coverage ends. We will pay Benefits as of the day your coverage begins under this Subscriber Agreement for all other Covered Health Services that are not related to the condition or disability for which you have other coverage. IEXPOL.I.16.CA.PPO 8

9 IMPORTANT! IN SOME AREAS A 911 EMERGENCY RESPONSE SYSTEM HAS BEEN ESTABLISHED AND OPERATING. IF YOU BELIEVE YOU ARE EXPERIENCING AN EMERGENCY MEDICAL CONDITION, CALL 911 OR GO DIRECTLY TO THE NEAREST HOSPITAL EMERGENCY ROOM OR OTHER FACILITY FOR TREATMENT. AMBULANCE TRANSPORTATION TO THE HOSPITAL OR FACILITY AND EMERGENCY SERVICES ARE COVERED IF YOU REASONABLY BELIEVE EMERGENCY SERVICES ARE REQUIRED. PRIOR AUTHORIZATION IS NOT REQUIRED FOR AN EMERGENCY MEDICAL CONDITION. IEXPOL.I.16.CA.PPO 9

10 Our Responsibilities Determine Benefits We do not make decisions about the kind of care you should or should not receive. You and your providers must make those treatment decisions. We will determine the following: Interpret Benefits and the other terms, limitations and exclusions set out in this Subscriber Agreement, the Schedule of Benefits and any Addendums and/or Amendments. Make factual determinations relating to Benefits. We may delegate this authority to other persons or entities that may provide administrative services for this Subscriber Agreement, such as claims processing. The identity of the service providers and the nature of their services may be changed, from time to time, as we determine. In order to receive Benefits, you must cooperate with those service providers. Pay for Our Portion of the Cost of Covered Health Services We pay Benefits for Covered Health Services as described in Section 1: Covered Health Services and in the Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and Limitations. This means we only pay our portion of the cost of Covered Health Services. It also means that not all of the health care services you receive may be paid for (in full or in part) by this Subscriber Agreement. Pay Network Providers It is the responsibility of Network Physicians and facilities to file for payment from us. When you receive Covered Health Services from Network Providers, you do not have to submit a claim to us. Pay for Covered Health Services Provided by Non-Network Providers In accordance with any state prompt pay requirements, we will pay Benefits after we receive your request for payment that includes all required information. See Section 5: How to File a Claim. Non-Network Providers may not balance bill you for Emergency Services. For Emergency Services, you are only required to pay the copayment amount specified in your Schedule of Benefits. Review and Determine Benefits in Accordance with our Reimbursement Policies We develop our reimbursement Subscriber Agreement guidelines in accordance with one or more of the following methodologies: As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS). As reported by generally recognized professionals or publications. As used for Medicare. As determined by medical staff and outside medical consultants pursuant to other appropriate sources or determinations that we accept. Following evaluation and validation of certain provider billings (e.g., error, abuse and fraud reviews), our reimbursement policies are applied to provider billings. We share our reimbursement policies with Physicians and other providers in our Network through our provider website. Network Physicians and providers may not bill you for the difference between their contract rate (as may be modified by our reimbursement policies) and the billed charge. However, Non-Network Providers are not subject to this IEXPOL.I.16.CA.PPO 10

11 prohibition, and may bill you for any amounts we do not pay, including amounts that are denied because one of our reimbursement policies does not reimburse (in whole or in part) for the service billed. You may obtain copies of our reimbursement policies for yourself or to share with your Non-Network Physician or Non-Network Provider by calling Customer Care at the telephone number on your ID card. Offer Health Education Services to You From time to time, we may provide you with access to information about additional services that are available to you, such as disease management programs, health education and patient advocacy. It is solely your decision whether to participate in the programs, but we recommend that you discuss them with your Physician. IEXPOL.I.16.CA.PPO 11

12 Emergency and Urgently Needed Services Worldwide, wherever you are, UnitedHealthcare Benefits Plan of California provides coverage for Emergency Services and Urgently Needed Services. This section will explain how to obtain Emergency Services and Urgently Needed Services. It will also explain what you should do following receipt of these services. What are Emergency Medical Services? Emergency Services are Medically Necessary ambulance or ambulance transport services provided through the 911 emergency response system. It is also the medical screening, examination and evaluation by a Physician, or other personnel to the extent provided by law to determine if an Emergency Medical Condition or Psychiatric Emergency Medical Condition exists. If this condition exists, Emergency Services include the care, treatment and/or surgery by a Physician necessary to stabilize or eliminate the Emergency Medical Condition or Psychiatric Emergency Medical Condition within the capabilities of the facility which includes admission or transfer to a psychiatric unit within a general acute care hospital or an acute psychiatric hospital for the purpose of providing care and treatment necessary to relieve or eliminate a Psychiatric Emergency Medical Condition. What is an Emergency Medical Condition or a Psychiatric Emergency Medical Condition? The State of California defines an Emergency Medical Condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected by the Member, as a Prudent Layperson, to result in any of the following: Placing the Member s health in serious jeopardy; Serious impairment to his or her bodily functions; A serious dysfunction of any bodily organ or part; or Active labor, meaning labor at a time that either of the following would occur: There is inadequate time to effect a safe transfer to another Hospital prior to delivery; or A transfer poses a threat to the health and safety of the Member or unborn child, or If in the opinion of the treating provider, it would not result in material deterioration of the Member's condition. An Emergency Medical Condition also includes a Psychiatric Emergency Medical Condition which is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: An immediate danger to himself or herself or others; or Immediately unable to provide for, or utilize, food, shelter or clothing, due to the mental disorder. What to Do When You Require Emergency Services If you believe you are experiencing an Emergency Medical Condition, call 911 or go directly to the nearest Hospital emergency room or other facility for treatment. You do not need to obtain prior authorization if you reasonably believe Emergency Services are needed to seek treatment for an Emergency Medical Condition that could cause you harm. Ambulance transport services provided through the 911 emergency response system are covered if you reasonably believe that your medical condition requires emergency ambulance transport services. UnitedHealthcare Benefits Plan of California covers all Medically Necessary Emergency Services provided to Members in order to stabilize an Emergency Medical Condition. IEXPOL.I.16.CA.PPO 12

13 You, or someone else on your behalf, must notify UnitedHealthcare Benefits Plan of California within 24 hours, or as soon as reasonably possible, following your receipt of Emergency Services so that we can coordinate your care and schedule any necessary follow-up treatment. When you call, please be prepared to give the name and location of the facility and a description of the Emergency Services that you received. Post-Stabilization and Follow-up Care Following the stabilization of an Emergency Medical Condition, the treating health care provider may believe that you require additional Medically Necessary Hospital (health care) services prior to your being safely discharged. If the hospital is not part of the Network, the medical facility (Hospital) will contact UnitedHealthcare Benefits Plan of California in order to obtain the timely authorization for these poststabilization services. If UnitedHealthcare Benefits Plan of California determines that you may be safely transferred, and you refuse to consent to the transfer, the facility (Hospital) must provide you written notice that you will be financially responsible for 100 percent of the cost of services provided to you once your emergency condition is stable. Also, if the facility (Hospital) is unable to determine your name and contact information at UnitedHealthcare Benefits Plan of California in order to request prior authorization for services once you are stable, it may bill you for such services. IF YOU FEEL THAT YOU WERE IMPROPERLY BILLED FOR SERVICES THAT YOU RECEIVED FROM A NON-NETWORK PROVIDER, PLEASE CONTACT UNITEDHEALTHCARE BENEFITS PLAN OF CALIFORNIA AT YOU ARE ONLY OBLIGATED TO PAY THE COPAYMENT AMOUNT SPECIFIED IN YOUR SCHEDULE OF BENEFITS REGARDLES OF WHETHER THE PROVIDER IS A NETWORK OR NON-NETWORK. Following your discharge from the Hospital, any Medically Necessary follow-up medical or Hospital Services must be provided by UnitedHealthcare Benefits Plan of CA. Regardless of where you are in the world, if you require additional follow-up medical or Hospital Services, please call UnitedHealthcare Benefits Plan of California to request authorization during regular business hours (8 a.m. 8 p.m., Pacific Time) at What to Do When You Require Urgently Needed Services If you need Urgently Needed Services, you should seek services from a licensed medical professional. You may want to seek care from a Network Urgent Care Center, if possible. You, or someone else on your behalf, must notify UnitedHealthcare Benefits Plan of California within 24 hours, or as soon as reasonably possible, after the initial receipt of Urgently Needed Services. When you call, please be prepared to give a description of the Urgently Needed Services that you received. International Emergency and Urgently Needed Services If you are out of the country and require Urgently Needed Services, you should still, if possible, call us. Just follow the same instructions outlined above. If you are out of the country and experience an Emergency Medical Condition, either use the available emergency response system or go directly to the nearest Hospital emergency room. Following receipt of Emergency Services, please notify us or your Physician within 24 hours, or as soon as reasonably possible, after initially receiving these services. Note: Under certain circumstances, you may need to initially pay for your Emergency or Urgently Needed Services. If this is necessary, please pay for such services and then contact UnitedHealthcare Benefits Plan of California at the earliest opportunity. Be sure to keep all receipts and copies of relevant medical documentation. You will need these to be properly reimbursed. For more information on submitting claims to UnitedHealthcare Benefits Plan of California, please refer to Section 5: How to File a Claim. ALWAYS REMEMBER Emergency services: Following receipt of Emergency Services, you, or someone else on your behalf, must notify UnitedHealthcare Benefits Plan of California within 24 hours, or as soon as reasonably possible, after initially receiving these services. IEXPOL.I.16.CA.PPO 13

14 Urgently Needed Services: When you require Urgently Needed Services, you should, if possible, call (or have someone else call on your behalf) us and you receive medical or Hospital Services, you must notify UnitedHealthcare Benefits Plan of California within 24 hours, or as soon as reasonably possible of initially receiving these services. IEXPOL.I.16.CA.PPO 14

15 Table of Contents Section 1: Covered Health Services Section 2: Exclusions and Limitations Section 3: When Coverage Begins and Premiums Section 4: When Coverage Ends Section 5: How to File a Claim Section 6: Questions, Complaints and Appeals Section 7: General Legal Provisions Section 8: Defined Terms IEXPOL.I.16.CA.PPO 15

16 Section 1: Covered Health Services Benefits for Covered Health Services Benefits are available only if all of the following are true: The health care service, supply or Pharmaceutical Product is only a Covered Health Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Service in Section 8: Defined Terms.) The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a Sickness, Injury, mental illness, substance-related and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a Covered Health Service under this Subscriber Agreement. Covered Health Services are received while this Subscriber Agreement is in effect. Covered Health Services are received prior to the date that any of the individual termination conditions listed in Section 4: When Coverage Ends occurs. The person who receives Covered Health Services is a Member and meets all eligibility requirements. This section describes Covered Health Services for which Benefits are available. Please refer to the attached Schedule of Benefits for details about: The amount you must pay for these Covered Health Services (including any Annual Deductible, Copayment and/or Coinsurance). Any limit that applies to these Covered Health Services (including visit, day and dollar limits on services). Any limit that applies to the amount of Eligible Expenses you are required to pay in a year (Out-of- Pocket Maximum). Any responsibility you have for obtaining prior authorization or notifying us. Please note that in listing services or examples, when we say "this includes," it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list "is limited to." 1. Ambulance Services Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance) to the nearest Hospital where Emergency Medical Condition can be performed. Non-Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance, as we determine appropriate) between facilities when the transport is any of the following: From a Non-Network Hospital to a Network Hospital. To a Hospital that provides a higher level of care that was not available at the original Hospital. To a more cost-effective acute care facility. From an acute facility to a sub-acute setting. When a physician determines the Member's condition requires the use of service that only a licensed ambulance or psychiatric transport van can provide if other means would endanger the Member's health. IEXPOL.I.16.CA.PPO 16

17 2. Clinical Trials Routine patient care costs incurred during participation in an approved clinical trial for the treatment of: Cancer or other life-threatening disease or condition. For purposes of this benefit, a life-threatening disease or condition is one from which the likelihood of death is probable unless the course of the disease or condition is interrupted. Cardiovascular disease (cardiac/stroke) which is not life threatening, for which a clinical trial meets the approved clinical trial criteria stated below. Surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, for which a clinical trial meets the approved clinical trial criteria stated below. Other diseases or disorders, which are not life threatening, for which a clinical trial meets the approved clinical trial criteria stated below. A Member is considered a Qualified Individual if the Member is eligible to participate in the approved clinical trial according to the trial s protocol and either a Participating Treating Physician has concluded that the Member s participation in the trial would be appropriate because the Member meets the trial protocol; or the Member self-refers to the trial and has provided medical and scientific information to establish that participation in the trial is consistent with the trial protocol. Routine Patient Care Costs are costs associated with the provision of health care services, including drugs, items, devices and services that would otherwise be covered by UnitedHealthcare Benefits Plan of California if those drugs, items, devices and services were not provided in connection with an approved clinical trial program including: Health care services for which Benefits are typically provided absent a clinical trial. Health care services required solely for the provision of the Investigational Service(s) or item, drug, device or service. Health care services required for the clinically appropriate monitoring of the Investigational item or service. Health care services provided for the prevention of complications arising from the provision of the Investigational drug, item, device or service. Health Services needed for reasonable and necessary care including the diagnosis and treatment of complications arising from the provision of an Investigational Service(s) or item, drug, device or service. For purposes of this benefit, Routine Patient Care Costs do not include the costs associated with the provision of any of the following, which are not covered by UnitedHealthcare Benefits Plan of California: The Investigational Service(s), device(s) or item(s). The only exceptions to this are: Certain Category B devices. Certain promising interventions for patients with terminal illnesses. Certain promising interventions refer to treatment that is likely safe but where limited to and/or conflicting evidence exists regarding its effectiveness. Other items and services that meet specified criteria in accordance with our medical and drug policies. Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient. A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis. Items and services provided by the research sponsors free of charge for any person enrolled in the trial. IEXPOL.I.16.CA.PPO 17

18 With respect to cancer or other life-threatening diseases or conditions, an approved clinical trial is a Phase I, Phase II, Phase III, or Phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-threatening disease or condition and which meets any of the following criteria in the bulleted list below. With respect to cardiovascular disease or musculoskeletal disorders of the spine, hip and knees and other diseases or disorders which are not life-threatening, an approved clinical trial is a Phase I, Phase II, or Phase III clinical trial that is conducted in relation to the detection or treatment of such non-lifethreatening disease or disorder and which meets any of the following criteria in the bulleted list below. Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following: National Institutes of Health (NIH). (Includes National Cancer Institute (NCI).) Centers for Disease Control and Prevention (CDC). Agency for Healthcare Research and Quality (AHRQ). Centers for Medicare and Medicaid Services (CMS). A cooperative group or center of any of the entities described above or the Department of Defense (DOD) or the Veterans Administration (VA). A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants. The Department of Veterans Affairs, the Department of Defense or the Department of Energy as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health and Human Services to meet both of the following criteria: Comparable to the system of peer review of studies and investigations used by the National Institutes of Health. Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review. The study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration. The study or investigation is a drug trial that is exempt from having such an investigational new drug application. The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a Covered Health Service and is not otherwise excluded under this Subscriber Agreement. 3. Diabetes Services Diabetes Self-Management and Training/Diabetic Eye Examinations/Foot Care Outpatient self-management training for the treatment of diabetes, education and medical nutrition therapy services. Diabetes outpatient self-management training, education and medical nutrition therapy services must be ordered by a Physician and provided by appropriately licensed or registered healthcare professionals. Benefits under this section also include medical eye examinations (dilated retinal examinations) and preventive foot care for Members with diabetes. Diabetic Self-Management Items Insulin pumps and supplies for the management and treatment of diabetes, based upon the medical needs of the Member. An insulin pump is subject to all the conditions of coverage stated under Durable Medical Equipment. Benefits for blood glucose monitors, insulin syringes with needles, blood glucose, IEXPOL.I.16.CA.PPO 18

19 glucagon and other diabetic medications and urine test strips, ketone test strips and tablets and lancets and lancet devices are described under the Outpatient Prescription Drug Addendum. Diabetes Treatment Diabetes equipment and supplies are limited to blood glucose monitors and blood glucose testing strips, blood glucose monitors designed to assist the visually impaired, insulin pumps and all related necessary supplies; ketone urine testing strips, lancets and lancet puncture devices, pen delivery systems for the administration of insulin, podiatric devices to prevent or treat diabetes-related complications, insulin syringes, visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin. Benefits for diabetes prescription items (limited to insulin, medication for the treatment of diabetes, and glucagon) are described in the Outpatient Prescription Drug Addendum. 4. Durable Medical Equipment Durable Medical Equipment that meets each of the following criteria: Ordered or provided by a Physician for outpatient use primarily in a home setting. Used for medical purposes. Not consumable or disposable except as needed for the effective use of covered Durable Medical Equipment. Not of use to a person in the absence of a disease or disability. Benefits under this section include Durable Medical Equipment provided to you by a Physician. If more than one piece of Durable Medical Equipment can meet your functional needs, Benefits are available only for the equipment that meets the minimum specifications for your needs. Examples of Durable Medical Equipment include: Equipment to assist mobility, such as a standard wheelchair. A standard Hospital-type bed. Oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks). Delivery pumps for tube feedings (including tubing and connectors) including enteral pump and supplies. Negative pressure wound therapy pumps (wound vacuums). Braces, including necessary adjustments to shoes to accommodate braces. Braces that stabilize an injured body part and braces to treat curvature of the spine are considered Durable Medical Equipment and are a Covered Health Service. Mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters and personal comfort items are excluded from coverage). Burn garments, compression burn garments and lymphedema wraps and garments. Insulin pumps and all related necessary supplies as described under Diabetes Services. External cochlear devices and systems. Benefits for cochlear implantation are provided under the applicable medical/surgical Benefit categories in this Subscriber Agreement. Standard curved handle or quad cane and replacement supplies. Standard or forearm crutches and replacement supplies. Dry pressure pad for a mattress, IV pole. IEXPOL.I.16.CA.PPO 19

20 Bone stimulator. Cervical traction (over the door). Phototherapy blankets for treatment of jaundice in newborns, certain dialysis care equipment. Brassieres required to hold a breast prosthesis (up to three every 12 months). Tracheostomy tube and supplies. Diabetic shoes and inserts: off-the-shelf depth-inlay shoes; custom-molded shoes; custom-molded multiple density inserts; fitting, modification, and follow-up care for podiatric devices. Standard oxygen-delivery systems and equipment for the treatment of asthma (nebulizers, masks, tubing and peak flow meters, the equipment and supplies must be prescribed by and are limited to the amount requested by the Physician). Outpatient drugs, prescription medications and inhaler spacers for the treatment of asthma are available under the prescription drug benefit. Please refer to the Outpatient Prescription Drug Addendum for coverage. Dialysis equipment and supplies for home hemodialysis and peritoneal dialysis. Benefits under this section do not include any device, appliance, pump, machine, stimulator, or monitor that is fully implanted into the body. We will decide if the equipment should be purchased or rented. Benefits are available for repairs and replacement, except that: Benefits for repair and replacement do not apply to damage due to misuse, malicious breakage or gross neglect. Benefits are not available to replace lost or stolen items. For more information on covered benefits, please call the toll-free Customer Care number Emergency Medical Condition - Outpatient Services that are required to stabilize or initiate treatment in an Emergency. Emergency Medical Condition must be received on an outpatient basis at a Hospital or Alternate Facility. Benefits under this section include the facility charge, supplies and all professional services required to stabilize your medical or psychiatric condition and/or initiate treatment. This includes placement in an observation bed for the purpose of monitoring your medical or psychiatric condition (rather than being admitted to a Hospital for an Inpatient Stay). Benefits under this section are not available for services to treat a condition that does not meet the definition of an Emergency. Covered urgently needed medical conditions are described under Urgent Care Services. 6. Home Health Care Services received from a Home Health Agency that are both of the following: Ordered by a Physician. Provided in your home by a registered nurse, home health aide or licensed practical nurse and supervised by a registered nurse. Benefits are available only when the Home Health Agency services are provided on a part-time, Intermittent Care schedule and when skilled care is required. Skilled care is skilled nursing, skilled teaching and skilled rehabilitation and habilitation services when all of the following are true: IEXPOL.I.16.CA.PPO 20

21 It must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient. It is ordered by a Physician. It is not delivered for the purpose of assisting with activities of daily living, including dressing, feeding, bathing or transferring from a bed to a chair. It requires clinical training in order to be delivered safely and effectively. It is not Custodial Care. We will determine if Benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. A service will not be determined to be "skilled" simply because there is not an available caregiver. 7. Hospice Care Hospice care that is recommended by a Physician. Hospice care is an integrated program that provides comfort and support services for the terminally ill. Hospice care includes physical, psychological, social, spiritual and respite care for the terminally ill person and short-term grief counseling for immediate family members while the Member is receiving hospice care. Benefits are available when hospice care is received from a licensed hospice agency. Please contact us for more information regarding our guidelines for hospice care. You can contact us at the telephone number on your ID card. 8. Hospital - Inpatient Stay Services and supplies provided during an Inpatient Stay in a Hospital. Benefits are available for: Supplies and non-physician services received during the Inpatient Stay. Room and board in a Semi-private Room (a room with two or more beds). Physician services for radiologists, anesthesiologists, pathologists and Emergency room Physicians. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) 9. Lab, X-Ray and Diagnostics - Outpatient Services for Sickness and Injury-related diagnostic purposes, received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office include: Lab and radiology/x-ray. Mammography. Benefits under this section include: The facility charge and the charge for supplies and equipment. Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services. CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services are described under Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient. 10. Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient Services for CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office. IEXPOL.I.16.CA.PPO 21

22 Benefits under this section include: The facility charge and the charge for supplies and equipment. Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services.) 11. Mental Health Services Mental Health Services include those received on an inpatient basis in a Hospital or an Alternate Facility, and those received on an outpatient basis, in a provider's office, in a group or individual therapy session, or at an Alternate Facility. Inpatient hospitalizations cover room and board. Benefits include the following services provided on either an inpatient or outpatient basis: Diagnostic evaluations, assessments and psychological testing. Treatment planning. Treatment and/or procedures. Referral services. Medication management and monitoring of drug therapy. Psychiatric observation for an acute psychiatric crisis. Individual, family, therapeutic group and provider-based case management services. Crisis intervention. Partial Hospitalization/Day Treatment. Services at a Residential Treatment Facility. Intensive Outpatient Treatment. Benefits under this section also include the diagnosis and all Medically Necessary treatment of Severe Mental Illness of a Member of any age and Serious Emotional Disturbances of an Enrolled Dependent child under the same terms and conditions that apply to medical conditions as required by California law. This includes, but is not limited to, Copayments and any Deductibles. Covered Health Services provided for Severe Mental Illness of a Member of any age and Serious Emotional Disturbances of a Child must meet the definitions of Severe Mental Illness and Serious Emotional Disturbances of a Child as defined in Section 8: Defined Terms. If you disagree with a determination, you can request an appeal. The complaint and appeals process, including independent medical review, is described under Section 6: Questions, Complaints and Appeals. You may also call Customer Care at the telephone number on your ID card. The Mental Health/Substance-Related and Addictive Disorders Designee determines coverage for all levels of care. If an Inpatient Stay is required, it is covered on a Semi-private Room basis. We encourage you to contact the Mental Health/Substance-Related and Addictive Disorders Designee for referrals to providers and coordination of care. Special Mental Health Programs and Services Special programs and services that are contracted under the Mental Health/Substance-Related and Addictive Disorders Designee may become available to you as a part of your Mental Health Services Benefit. The Mental Health Services Benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of Benefit use. Special programs or services provide access to services that are beneficial for the treatment of your mental illness which may not otherwise be covered under this Subscriber Agreement. You must be referred to such programs through the Mental Health/Substance-Related and Addictive Disorders IEXPOL.I.16.CA.PPO 22