AETNA HEALTH INC. (VIRGINIA) 980 Jolly Road Blue Bell, PA (800) CERTIFICATE OF COVERAGE

Transcription

1 Plan Name VA Aetna Gold HMO A VAN109a AETNA HEALTH INC. (VIRGINIA) 980 Jolly Road Blue Bell, PA (800) CERTIFICATE OF COVERAGE This Certificate of Coverage ("Certificate") is part of the Group Agreement ("Group Agreement") between Aetna Health Inc.., hereinafter referred to as HMO, and the Contract Holder. The Group Agreement determines the terms and conditions of coverage. The Certificate describes covered health care benefits. Provisions of this Certificate include the Schedule of Benefits, and any amendments, endorsements, inserts, or attachments. Amendments, endorsements, inserts, or attachments may be delivered with the Certificate or added thereafter. HMO agrees with the Contract Holder to provide coverage for benefits, in accordance with the conditions, rights, and privileges as set forth in this Certificate. Members covered under this Certificate are subject to all the conditions and provisions of the Group Agreement Coverage is not provided for any services received before coverage starts or after coverage ends, except as shown in the Continuation and Conversion section of this Certificate. Certain words have specific meanings when used in this Certificate. The defined terms appear in bold type with initial capital letters. The definitions of those terms are found in the Definitions section of this Certificate. This Certificate is not in lieu of insurance for Workers Compensation. This Certificate is governed by applicable federal law and the laws of the Commonwealth of Virginia. READ THIS ENTIRE CERTIFICATE CAREFULLY. IT DESCRIBES THE RIGHTS AND OBLIGATIONS OF MEMBERS AND HMO. IT IS THE CONTRACT HOLDER S AND THE MEMBER'S RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CERTIFICATE. IN SOME CIRCUMSTANCES, CERTAIN MEDICAL SERVICES ARE NOT COVERED OR MAY REQUIRE PRECERTIFICATION BY HMO. NO SERVICES ARE COVERED UNDER THIS CERTIFICATE IN THE ABSENCE OF PAYMENT OF CURRENT PREMIUMS SUBJECT TO THE GRACE PERIOD AND THE PREMIUMS SECTION OF THE GROUP AGREEMENT. THIS CERTIFICATE APPLIES TO COVERAGE ONLY AND DOES NOT RESTRICT A MEMBER S ABILITY TO RECEIVE HEALTH CARE SERVICES THAT ARE NOT, OR MIGHT NOT BE, COVERED BENEFITS UNDER THIS CERTIFICATE. PARTICIPATING PROVIDERS, NON-PARTICIPATING PROVIDERS, INSTITUTIONS, FACILITIES OR AGENCIES ARE NEITHER AGENTS NOR EMPLOYEES OF HMO. HI VA SG-2014-COC 01 1

2 IMPORTANT INFORMATION REGARDING MEMBER S INSURANCE IN THE EVENT THE MEMBER NEEDS TO CONTACT SOMEONE ABOUT THIS INSURANCE FOR ANY REASON PLEASE CONTACT MEMBER S AGENT. IF NO AGENT WAS INVOLVED IN THE SALE OF THIS INSURANCE, OR IF THE MEMBER HAS ADDITIONAL QUESTIONS THE MEMBER MAY CONTACT HMO AT THE FOLLOWING ADDRESS AND TELEPHONE NUMBER: AETNA HEALTH INC. 980 Jolly Road Blue Bell, PA (800) WE RECOMMEND THAT THE MEMBER FAMILIARIZE THEMSELF WITH OUR COMPLAINTS AND APPEALS PROCEDURE AND MAKE USE OF IT BEFORE TAKING ANY OTHER ACTION. IF THE MEMBER HAS BEEN UNABLE TO CONTACT OR OBTAIN SATISFACTION FROM HMO OR THE AGENT, THE MEMBER MAY CONTACT THE VIRGINIA STATE CORPORATION COMMISSION S BUREAU OF INSURANCE AT: P.O. BOX 1157 RICHMOND, VA WRITTEN CORRESPONDENCE IS PREFERABLE SO THAT A RECORD OF THE MEMBER S INQUIRY IS MAINTAINED. WHEN CONTACTING THE MEMBER S AGENT, HMO OR THE BUREAU OF INSURANCE, HAVE THE MEMBER S POLICY NUMBER AVAILABLE. NOTICE HMO IS SUBJECT TO REGULATION IN THE COMMONWEALTH OF VIRGINIA BY BOTH THE STATECORPORATION COMMISSION BUREAU OF INSURANCE PURSUANT TO TITLE 38.2 AND THE VIRGINIA DEPARTMENT OF HEALTH PURSUANT TO TITLE Important Unless otherwise specifically provided, no Member has the right to receive the benefits of this plan for health care services or supplies furnished following termination of coverage. Benefits of this plan are available only for services or supplies furnished during the term the coverage is in effect and while the individual claiming the benefits is actually covered by the Group Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of the Group Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or elimination of benefits) apply for services or supplies furnished on or after the effective date of the modification. There is no vested right to receive the benefits of the Group Agreement. HI VA SG-2014-COC 01 2

3 TABLE OF CONTENTS Section Page HMO Procedure 4 Method of Payment 5 Eligibility and Enrollment 6 Covered Benefits 11 Exclusions and Limitations 53 Termination of Coverage 70 Continuation and Conversion 73 Claim Procedures/Complaints and Appeals 78 /Dispute Resolution Coordination of Benefits 84 Responsibility of Members 89 General Provisions 90 Definitions 93 HI VA SG-2014-COC 01 3

4 Selecting a Participating Primary Care Physician HMO PROCEDURE At the time of enrollment, each Member should select a Participating Primary Care Physician (PCP) from HMO s Directory of Participating Providers to access Covered Benefits as described in this Certificate. The choice of a PCP is made solely by the Member. If a Member does not select a PCP at the time of enrollment, one will be selected for the Member. If the Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on the Member s behalf. The Primary Care Physician The PCP coordinates a Member's medical care, as appropriate, either by providing treatment or by issuing Referrals to direct the Member to another Participating Provider. The PCP can also order lab tests and x-rays, prescribe medicines or therapies, and arrange hospitalization. In certain situations where a Member requires ongoing care from a Specialist, the Member may receive a standing Referral to such Specialist. Please refer to the Covered Benefits section of this Certificate for details. A Member may also receive a standing Referral from their PCP if: the Member has an ongoing special condition, meaning a condition or disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time, and after consulting with their PCP, they select a Participating Specialist who is responsible for and capable of providing and coordinating their primary and specialty care. During the treatment period authorized by the Referral, such Participating Specialist shall be permitted to treat the Member without a further Referral from the Member s PCP and authorize such Referrals, procedures, tests and other medical services related to the special condition as the Member s PCP would otherwise be permitted to provide or authorize under this Certificate; or the Member has been diagnosed with cancer and has selected a Participating Specialist who is boardcertified in pain management or oncology and who is authorized to provide pain management services that are covered under this Certificate. Except for Emergency Services or for certain direct access Specialist benefits as described in this Certificate, only those services which are provided by or referred by a Member s PCP will be covered. Covered Benefits are described in the Covered Benefits section of this Certificate. It is a Member s responsibility to consult with the PCP in all matters regarding the Member s medical care. Certain PCP offices are affiliated with integrated delivery systems or other provider groups (i.e., Independent Practice Associations and Physician-Hospital Organizations), and Members who select these PCPs will generally be referred to Specialists and Hospitals within that system or group. However, if the group does not include a Provider qualified to meet the Member s medical needs, the Member may request to have services provided by nonaffiliated Providers. If the Member s PCP performs, suggests, or recommends a Member for a course of treatment that includes services that are not Covered Benefits, the entire cost of any such non-covered services will be the Member s responsibility. HI VA SG-2014-COC 01 4

5 Availability of Providers HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. Except when a Provider is terminated for cause, if a Provider s participation in the HMO s Participating Provider network terminates, HMO will cover services and supplies that are Covered Benefits provided by the Provider to the Member: 1. for a period of at least 90 days from the date of the notice of the Provider s termination if the Member was in an active course of treatment with the Provider prior to the notice of termination and the Member requested to continue to receive Covered Benefits from the Provider. 2. at the Member s option, through the provision of postpartum care directly related to the delivery if the Member had entered their second trimester of pregnancy at the time of the Provider s termination of participation. 3. at the Member s option, for the remainder of the Member s life for care directly related to the treatment of the terminal illness if the Member is determined to be Terminally Ill at the time of the Provider s termination of participation. If the PCP initially selected cannot accept additional patients, the Member will be notified and given an opportunity to make another PCP selection. The Member must then cooperate with HMO to select another PCP. Changing a PCP A Member may change their PCP at any time by calling Member Services at the toll-free telephone number listed on the back of the Member s identification card or by written or electronic submission of the HMO s change form. A Member may contact HMO to request a change form or for assistance in completing that form. The change will become effective upon HMO s receipt and approval of the request. Ongoing Reviews HMO conducts ongoing reviews of those services and supplies which are recommended or provided by Health Professionals to determine whether such services and supplies are Covered Benefits under this Certificate. If HMO determines that the recommended services and supplies are not Covered Benefits, the Member will be notified. If a Member wishes to appeal such determination, the Member may then contact HMO to seek a review of the determination. Please refer to the Claim Procedures/Complaints and Appeals/Dispute Resolution section of this Certificate. Pre-authorization. Certain services and supplies under this Certificate may require pre-authorization by HMO to determine if they are Covered Benefits under this Certificate. Method of Payment A Member will be entitled to Covered Benefits after the Member has satisfied the Deductible amount, if any, specified on the Schedule of Benefits. After satisfying the Deductible, the Member must pay any applicable Copayment for Covered Benefits. The Deductible may not apply to certain Covered Benefits. Covered Benefits to which the Deductible may not apply are shown in the Schedule of Benefits. The Member must pay any applicable Copayments for Covered Benefits to which the Deductible does not apply. The Copayments, for Covered Benefits to which the Deductible does not apply, do not count towards satisfying the Deductible. HI VA SG-2014-COC 01 5

6 The Deductible. The Deductible applies to each Member, subject to any family Deductible, if any, listed on the Schedule of Benefits. For purposes of the Deductible, family means the Subscriber and Covered dependents. The Deductible must be satisfied once each plan year. Covered Benefits applied toward satisfaction of the Deductible will be counted toward any applicable visit or day maximums for Covered Benefits under this Certificate. Maximum Out-of-Pocket Limit. If a Member s Copayments, Coinsurance, plus the Deductible, if any, reach the Maximum Out-of-Pocket Limit set forth on the HMO Schedule of Benefits, HMO will pay 100% of the contracted charges for Covered Benefits for the remainder of that plan year, up to the Maximum Benefit, if any, listed on the Schedule of Benefits. Covered Benefits must be rendered to the Member during that plan year. Benefit Limitations. HMO will provide coverage to Members up to the Maximum Benefit for all Services and Supplies, if any, set forth on the Schedule of Benefits. Calculations; Determination of Benefits. A Member s financial responsibility for the costs of services will be calculated on the basis of when the service or supply is provided, not when payment is made. Benefits will be prorated to account for treatment or portions of stays that occur in more than 1 plan year. It is solely within the discretion of HMO to determine when benefits are covered under this Certificate. If a Member wishes to appeal such determination, the Member may then contact HMO to seek a review of the determination. Please refer to the Claim Procedures/Complaints and Appeals/Dispute Resolution section of this Certificate. Eligibility Subscriber ELIGIBILITY AND ENROLLMENT To be eligible to enroll as a Subscriber, an individual must: Meet all applicable eligibility requirements agreed upon by the Contract Holder and HMO; and Live or work in the Service Area Determining if You Are in an Eligible Class You are in an eligible class if you are a regular full-time employee, as defined by your employer. Determining When You Become Eligible The Member becomes eligible for the plan on the Member s eligibility date, which is determined as follows. HI VA SG-2014-COC 01 6

7 On the Effective Date of the Plan If the Member is in an Eligible Class on the effective date of the Member s plan, the Member s Eligibility Date is the effective date of this Plan or, if later, the date the Member completes the period of continuous service required by the Member s employer. The Member s employer determines the criteria that is used to define the Eligible Class for coverage under this Certificate. Such criteria are based solely upon conditions related to the Member s employment. See your employer for details. After the Effective Date of the Plan If the Member is in an Eligible Class on the date of hire, the Member s Eligibility Date is the effective date of this Plan or, if later, the date the Member completes the period of continuous service required by the Member s employer. The Member s employer determines the criteria that is used to define the Eligible Class for coverage under this Certificate. Such criteria are based solely upon conditions related to the Member s employment. See your employer for details. Probationary Period Once the Member enters an eligible class, the Member will need to complete a probationary period as defined by Member s employer, but not to exceed 90 days, before the Member s coverage under this plan begins. Obtaining Coverage for Dependents To be eligible to enroll as a Covered Dependent, the Contract Holder must provide dependent coverage for Subscribers who are eligible and the dependent must be: The Subscriber s legal spouse; or The Subscriber s domestic partner who meets the rules set by the Member s employer; or The Subscriber or the Subscriber s covered spouse s or the Subscriber s covered domestic partner s children who are under 26 years of age. A child means an individual who is: 1. The natural child, foster child, stepchild, legally adopted child, or grandchild of the Subscriber, spouse or domestic partner; 2. A child placed with the Subscriber, spouse or domestic partner for legal adoption; 3. Under testamentary or court appointed guardianship, other than temporary guardianship of less than 12 months duration, of the Subscriber, spouse or domestic partner; and 4. Has not attained the age of 26 under the terms of the policy or contract. A Member who resides outside the Service Area is required to choose a PCP and return to the Service Area for Covered Benefits. The only services covered outside the Service Area are Emergency Services and Urgent Care. Coverage for a Domestic Partner To be eligible for coverage, the Subscriber and the Subscriber s domestic partner will need to complete and sign a Declaration of Domestic Partnership. How And When To Enroll Enrollment Unless otherwise noted, an eligible individual and any eligible dependents may enroll in HMO regardless of health status, age, or requirements for health services within 31 days from the eligibility date. HI VA SG-2014-COC 01 7

8 Newly Eligible Individuals and Eligible Dependents An eligible individual and any eligible dependents may enroll within 31 days of the eligibility date. Open Enrollment Period Eligible individuals or dependents who are eligible for enrollment but do not enroll as stated above, may be enrolled during any subsequent Open Enrollment Period upon submission of complete enrollment information and Premium payment to HMO. Enrollment of Newly Eligible Dependents Newborns of the Subscriber, covered spouse or covered domestic partner are automatically covered for the first 31 days of life. TO CONTINUE COVERAGE, THE NEWBORN MUST BE ENROLLED AS A COVERED DEPENDENT BY NOTIFYING HMO IN WRITING WITHIN 31 DAYS OF BIRTH. THE SUBSCRIBER WILL BE RESPONSIBLE FOR ANY ADDITIONAL PREMIUM CHARGES DUE EFFECTIVE FROM THE DATE OF BIRTH. A child being adopted by the Subscriber, covered spouse or covered domestic partner will have coverage for the first 31 days from the date on which the adoptive child's birth parent or appropriate legal authority signs a written document granting the Subscriber, covered spouse or covered domestic partner the right to control health care for the adoptive child, or absent this document, the date on which other evidence exists of this right. TO CONTINUE COVERAGE, THE ADOPTED CHILD MUST BE ENROLLED AS A FAMILY MEMBER BY NOTIFYING US IN WRITING WITHIN 31 DAYS OF THE DATE THE SUBSCRIBER'S, COVERED SPOUSE OR COVERED DOMESTIC PARTNER S AUTHORITY TO CONTROL THE CHILD'S HEALTH CARE IS GRANTED. THE SUBSCRIBER WILL BE RESPONSIBLE FOR ANY ADDITIONAL PREMIUM CHARGES DUE EFFECTIVE FROM THE DATE THE SUBSCRIBER S, COVERED SPOUSE S OR COVERED DOMESTIC PARTNER S AUTHORITY TO CONTROL THE CHILD'S HEALTH CARE IS GRANTED. Newborns who are the children of a Subscriber's covered dependent under this policy are not covered after the first 31 days under this policy unless the Subscriber or the Subscriber's covered spouse or covered domestic partner has obtained court ordered custody of the child. Coverage for handicapped dependent children may continue after Member s covered dependent child reaches the limiting age. See When Coverage Ends for more information. Special Rules Which Apply to Children Qualified Medical Child Support Order Coverage is available for a dependent child not residing with a Subscriber and who resides outside the Service Area, if there is a qualified medical child support order requiring the Subscriber to provide covered dependent health coverage for a non-resident child and is issued on or after the date the Subscriber s coverage becomes effective. The child must meet the definition of a Covered Dependent, and the Subscriber must make a written request for coverage within 31 days of the court order. The initial coverage will not be affected by any provision in this Certificate which: i. requires evidence of good health acceptable to HMO for coverage to become effective; ii. delays coverage due to a confinement; or iii. limits coverage as to a preexisting condition. HI VA SG-2014-COC 01 8

9 Handicapped Children Coverage is available for a child who is chiefly dependent upon the Subscriber for support and maintenance and who is 26 year of age or older but incapable of self-support due to intellectual or physical incapacity. The incapacity must have commenced prior to the age the dependent would have lost eligibility. In order to continue coverage for a handicapped child, the Subscriber must provide evidence of the child's incapacity and dependency to HMO within 31 days of the date the child's coverage would otherwise terminate. Proof of continued incapacity, including a medical examination, must be submitted to HMO as requested, but not more frequently than annually beginning after the 2 year period following the child's attainment of the limiting age. This eligibility provision will no longer apply on the date the dependent s incapacity ends. Notification of Change in Status It shall be a Member s responsibility to notify HMO of any changes which affect the Member s coverage under this Certificate, unless a different notification process is agreed to between HMO and Contract Holder. Such status changes include, but are not limited to, change of address, change of Covered Dependent status, and enrollment in Medicare or any other group health plan of any Member. Additionally, if requested, a Subscriber must provide to HMO, within 31 days of the date of the request, evidence satisfactory to HMO that a dependent meets the eligibility requirements described in this Certificate. Special Enrollment Period An eligible individual and eligible dependents may be enrolled during a Special Enrollment Periods. A Special Enrollment Period may apply when an eligible individual or eligible dependent loses other health coverage or when an eligible individual acquires a new eligible dependent through marriage, birth, adoption or placement for adoption. Special Enrollment Period for Certain Individuals Who Lose Other Health Coverage: An eligible individual or an eligible dependent may be enrolled during a Special Enrollment Period, if the following requirements, as applicable, are met: The eligible individual or the eligible dependent was covered under another group health plan or other health insurance coverage when initially eligible for coverage under HMO; The eligible individual or eligible dependent previously declined coverage in writing under HMO; The eligible individual or eligible dependent loses coverage under the other group health plan or other health insurance coverage for one of the following reasons: The other group health coverage is COBRA continuation coverage under another plan, and the COBRA continuation coverage under that other plan has since been exhausted; The other coverage is a group health plan or other health insurance coverage, and the other coverage has been terminated as a result of loss of eligibility for the coverage or employer contributions towards the other coverage have been terminated; or The other health insurance coverage is Medicaid or an S-Chip plan and the eligible individual or eligible dependent no longer qualifies for such coverage. Loss of eligibility includes the following: A loss of coverage as a result of legal separation, divorce or death; Termination of employment; Reduction in the number of hours of employment; Any loss of eligibility after a period that is measured by reference to any of the foregoing; Termination of HMO coverage due to Member action- movement outside of the HMO s service area; and also the termination of health coverage including Non-HMO, due to plan termination. Plan ceases to offer coverage to a group of similarly situated individuals; HI VA SG-2014-COC 01 9

10 Cessation of a dependent s status as an eligible dependent Termination of benefit package Loss of eligibility does not include a loss due to failure of the individual or the participant to pay Premiums on a timely basis or due to termination of coverage for cause as referenced in the Termination of Coverage section of this Certificate. To be enrolled in HMO during a Special Enrollment Period, the eligible individual or eligible dependent must enroll within: 31 days, beginning on the date of the eligible individual's or eligible dependent's loss of other group health plan or other health insurance coverage; or 60 days, beginning on the date the eligible individual or eligible dependent Becomes eligible for premium assistance in connection with coverage under HMO, or Is no longer qualified for coverage under Medicaid or S-Chip. The Effective Date of Coverage will be the first day of the first calendar month following the date the completed request for enrollment is received. Special Enrollment Period When a New Eligible Dependent is Acquired: When a new eligible dependent is acquired through marriage, birth, adoption or placement for adoption, the new eligible dependent (and, if not otherwise enrolled, the eligible individual and other eligible dependents) may be enrolled during a special enrollment period. The special enrollment period is a period of 31 days, beginning on the date of the marriage, birth, adoption or placement for adoption (as the case may be). If a completed request for enrollment is made during that period, the Effective Date of Coverage will be: In the case of marriage, the first day of the first calendar month following the date the completed request for enrollment is received. In the case of a dependent s birth, adoption or placement for adoption, the date of such birth, adoption or placement for adoption. The eligible individual or the eligible dependent enrolling during a special enrollment period will not be subject to late enrollment provisions, if any, described in this Certificate. Effective Date of Coverage Coverage shall take effect at 12:01 a.m. on the Member s effective date. Coverage shall continue in effect from month to month subject to payment of Premiums made by the Contract Holder and subject to the Termination section of the Group Agreement, and the Termination of Coverage section of this Certificate. Hospital Confinement on Effective Date of Coverage If a Member is an inpatient in a Hospital on the Effective Date of Coverage, the Member will be covered as of that date. Such services are not covered if the Member is covered by another health plan on that date and the other health plan is responsible for the cost of the services. HMO will not cover any service that is not a Covered Benefit under this Certificate. To be covered, the Member must utilize Participating Providers and is subject to all the terms and conditions of this Certificate. HI VA SG-2014-COC 01 10

11 COVERED BENEFITS A Member shall be entitled to the Covered Benefits as specified below, in accordance with the terms and conditions of this Certificate. Unless specifically stated otherwise, in order for benefits to be covered, they must be Medically Necessary. For the purpose of coverage, HMO may determine whether any benefit provided under the Certificate is Medically Necessary, and HMO has the option to only authorize coverage for a Covered Benefit performed by a particular Provider. Preventive care, as described below, will be considered Medically Necessary. Important Note: The Member should review the Member s Schedule of Benefits for the cost sharing that applies to the Covered Benefits in this section. This will help the Member become familiar with the Member s payment responsibilities. Some Covered Benefits may have visit limits and maximums that apply to the service or supply. The Member should always review the Member s their Certificate and Schedule of Benefits together. ALL SERVICES ARE SUBJECT TO THE EXCLUSIONS AND LIMITATIONS DESCRIBED IN THIS CERTIFICATE. To be Medically Necessary, the service or supply must: Be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; Be care or services related to diagnosis or treatment of an existing illness or injury, except for covered periodic health evaluations and preventive and well baby care, as determined by HMO; Be a diagnostic procedure, indicated by the health status of the Member and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the Member's overall health condition; Include only those services and supplies that cannot be safely and satisfactorily provided at home, in a Physician s or Dental Provider s office, on an outpatient basis, or in any facility other than a Hospital, when used in relation to inpatient Hospital services. In determining if a service or supply is Medically Necessary, HMO s Patient Management Medical Director or its Physician or Dentist designee will consider: Information provided on the Member's health status; Reports in peer reviewed medical literature; Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; Professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment; The opinion of Health Professionals in the generally recognized health specialty involved; The opinion of the attending Physicians or Dental Providers, which have credence but do not overrule contrary opinions; and Any other relevant information brought to HMO's attention. HI VA SG-2014-COC 01 11

12 All Covered Benefits will be covered in accordance with the guidelines determined by HMO. If a Member has questions regarding coverage under this Certificate, the Member may call the Member Services toll-free telephone number listed on the back of the Member s identification card. THE MEMBER IS RESPONSIBLE FOR PAYMENT OF THE APPLICABLE COPAYMENTS AND DEDUCTIBLES LISTED ON THE SCHEDULE OF BENEFITS. EXCEPT FOR DIRECT ACCESS SPECIALIST BENEFITS OR FOR EMERGENCY SERVICES OR URGENT CARE SITUATION AS DESCRIBED IN THIS CERTIFICATE, THE FOLLOWING BENEFITS MUST BE ACCESSED THROUGH THE PCP S OFFICE THAT IS SHOWN ON THE MEMBER S IDENTIFICATION CARD, OR ELSEWHERE UPON PRIOR REFERRAL ISSUED BY THE MEMBER S PCP. Preventive Care and Wellness Benefits Preventive Care 1. The recommendations and guidelines of the: Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; United States Preventive Services Task Force; and Health Resources and Services Administration; as referenced throughout this Preventive Care Benefit may be updated periodically. This Plan is subject to updated recommendations or guidelines that are issued by these organizations beginning on the first day of the plan year, one year after the recommendation or guideline is issued. 2. If any diagnostic x-rays, lab, or other tests or procedures are ordered, or given, in connection with any of the Preventive Care Benefits described below, those diagnostic x-rays, lab or other tests or procedures will not be covered as Preventive Care Benefits. Those that are Covered Benefits will be subject to the cost-sharing that applies to those specific services under this Plan. 3. Refer to the Schedule of Benefits for information about cost-sharing and maximums that apply to Preventive Care benefits. Routine Physical Exam Benefit Covered Benefits include office visits to a Member's Primary Care Physician (PCP) for routine physical exams, including routine vision and hearing screenings given as part of the routine physical exam. A routine exam is a medical exam given by a PCP for a reason other than to diagnose or treat a suspected or identified illness or injury, and also includes: Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force. Immunizations for routine use in children, adolescents and adults that have in effect a recommendations from the Advisory Committee on Immunizations Practices of the Centers for Disease Control and Prevention. HI VA SG-2014-COC 01 12

13 For infants, children, and adolescents, evidence-informed preventive care and screenings in the Recommendations for Preventive Pediatric Health by the American Academy of Pediatrics and the Recommended Uniform Screening Panels by the Secretary s Advisory Committee on Heritable Disorders in Newborns and Children. For females, screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to: Screening and counseling services, such as those on: Interpersonal and domestic violence; Sexually transmitted diseases; and Human Immune Deficiency Virus (HIV) infections. Screening for gestational diabetes. High risk Human Papillomavirus (HPV) DNA testing for women age 30 and older. X-rays, lab and other tests given in connection with the exam. For covered newborns, an initial Hospital check up. Benefits for the routine physical exam services above may be subject to visit maximums as shown in the Schedule of Benefits. For details on the frequency and age limits that apply to Routine Physical Exam Benefit, Members may contact their Physician or Member Services by logging onto the HMO Navigator website or calling the toll-free number on the back of the ID card. Benefit Limitations: Not covered under this Preventive Care benefit are: Services which are for diagnosis or treatment of a suspected or identified illness or injury; Exams given while the Member is confined in a Hospital or other facility for medical care; Services not given by a Physician or under his or her direction; and Psychiatric, psychological, personality or emotional testing or exams. Infant Hearing Screening Expenses Covered medical expenses include charges for infant hearing screenings and all necessary audiological examinations for newborn children that are provided pursuant to the Virginia Hearing Impairment Identification and Monitoring System and include the use of any technology approved by the United States Food and Drug Administration, and as recommended by the national Joint Committee on Infant Hearing in its most current position statement addressing early hearing detection and intervention programs. Coverage includes benefits for any follow-up audiological examinations as recommended by a physician or audiologist and performed by a licensed audiologist to confirm the existence or absence of hearing loss, for those infants whose hearing screenings indicated the need for a diagnostic audiological examination. Preventive Care Immunizations Benefit Covered Benefits include: Immunizations for infectious diseases; and The materials for administration of immunizations; that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. A recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedule of the Centers for Disease Control and Prevention. HI VA SG-2014-COC 01 13

14 Childhood Immunization Expenses Covered Benefits include charges incurred by a covered dependent child between the ages of birth and 36-months for all routine and necessary immunizations administered on an outpatient basis. Routine and necessary immunizations mean immunizations against diphtheria, pertussis, tetanus, polio, hepatitis B, measles, mumps, rubella, and other such immunizations as may be prescribed by the Virginia Commissioner of Health. Benefit Limitations: Not covered under this benefit are: Immunizations that are not considered preventive care such as those required due to a Member's employment or travel. Well Woman Preventive Visits Benefit Covered Benefits include a routine well woman preventive exam office visit, including Pap smears and testing using any FDA approved gynecologic cytology screening technologies, provided by a Member's PCP, Physician, obstetrician, or gynecologist in accordance with the recommendations by the Health Resources and Services Administration. A routine well woman preventive exam is a medical exam given by a Physician for a reason other than to diagnose or treat a suspected or identified illness or injury. The Member may go directly to a Participating gynecologist without a Referral for a routine well woman preventive exam. Benefits for the well woman preventive visit services above are subject to visit maximums as shown in the Schedule of Benefits. Benefit Limitations: Not covered under this Preventive Care benefit are: Services which are for diagnosis or treatment of a suspected or identified illness or injury; Exams given while the Member is confined in a Hospital or other facility for medical care; Services not given by a Physician or under his or her direction; and Psychiatric, psychological, personality or emotional testing or exams. Screening and Counseling Services Benefit Covered Benefits include the following services provided by a Member's PCP or Physician, as applicable, in an individual or group setting: Obesity Benefit Covered Benefits include screening and counseling services to aid in weight reduction due to obesity. Coverage includes: Preventive counseling visits and/or risk factor reduction intervention; Medical nutrition therapy; Nutritional counseling; and Healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease. Benefits for the screening and counseling services above are subject to the visit maximums as shown in the Schedule of Benefits. Misuse of Alcohol and/or Drugs Benefit Covered Benefits include screening and counseling services to aid in the prevention or reduction of the use of an alcohol agent or controlled substance. Coverage includes preventive counseling visits, risk factor reduction intervention and a structured assessment. HI VA SG-2014-COC 01 14

15 Benefits for the screening and counseling services above are subject to visit maximums as shown later in this amendment. Use of Tobacco Products Benefit Covered Benefits include screening and counseling services to aid in the cessation of the use of tobacco products. Coverage includes: Preventive counseling visits; Treatment visits; and Class visits; to aid in the cessation of the use of tobacco products. Tobacco product means a substance containing tobacco or nicotine including: Cigarettes; Cigars; Smoking tobacco; Snuff; Smokeless tobacco; and Candy-like products that contain tobacco. Benefits for the screening and counseling services above are subject to visit maximums as shown in the Schedule of Benefits. Routine Cancer Screenings Benefit Covered Benefits include, but are not limited to, the following routine cancer screenings: One screening mammogram to covered persons age 35 through 39, one screening mammogram every two years for covered persons age 40 through 49, and one screening mammogram per plan year for covered persons age 50 and over; For covered persons age 50 and over and persons age 40 and over who are at high risk for prostate cancer according to the most recent published guidelines of the American Cancer Society, and that occur in connection with an annual exam for screening for cancer of the prostate: Digital rectal examinations, all in accordance with American Cancer Society guidelines; and One prostate specific antigen (PSA) test. Coverage for colorectal cancer screening, specifically screening with an annual fecal occult blood test, flexible sigmoidoscopy or colonoscopy, or in appropriate circumstances radiological imaging, shall be provided in accordance with the most recently published recommendations established by the American College of Gastroenterology, in consultation with the American Cancer Society, for the ages, family histories, and frequencies referenced in such recommendations. These benefits will be subject to any age, family history and frequency guidelines that are: Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force; and Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. As to routine gynecological exams performed as part of a routine cancer screening, the Member may go directly to a Participating obstetrician (OB), gynecologist (GYN), obstetrician/gynecologist (OB/GYN) without a Referral from the PCP. See the Direct Access Specialist Benefits section of the Certificate, for a description of this provision. HI VA SG-2014-COC 01 15

16 Prenatal Care Benefit Prenatal care will be covered as Preventive Care for services received by a pregnant female in a PCP, Physician's, obstetrician's, or gynecologist's office but only to the extent described below. Coverage for prenatal care under this benefit is limited to pregnancy-related Physician office visits including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure and fetal heart rate check). Benefit Limitations: Not covered under this benefit are: Services for maternity care (other than prenatal care as described above). Important Note: Refer to the: Maternity Care and Related Newborn Care Benefits section of the Certificate; and Prenatal Care Services, Delivery Services and Postpartum Care Services cost-sharing in the Schedule of Benefits; for more information on coverage for services related to maternity care under this Plan. Comprehensive Lactation Support and Counseling Services Benefit Covered Benefits include comprehensive lactation support (assistance and training in breast feeding) and counseling services provided to females during pregnancy and in the post partum period by a trained provider. The "post partum period" means the period directly following the child's date of birth. Covered Benefits incurred during the post partum period also include the rental or purchase of breast feeding equipment as described below. Lactation support and lactation counseling services are Covered Benefits when provided in either a group or individual setting. Breast Feeding Durable Medical Equipment Covered Benefits includes the rental or purchase of breast feeding Durable Medical Equipment for the purpose of lactation support (pumping and storage of breast milk) as follows. Breast Pumps Covered Benefits include the following: The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a Hospital. The purchase of: An electric breast pump (non-hospital grade).; or A manual breast pump. Breast Pump Supplies Coverage is limited to only one purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar purpose, and the accessories and supplies needed to operate the item. A Member is responsible for the entire cost of any additional pieces of the same or similar equipment purchased or rented for personal convenience or mobility. HI VA SG-2014-COC 01 16

17 HMO reserves the right to limit Covered Benefits to the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of HMO. Important Note: If a breast pump service or supply that a Member needs is covered under this Plan but not available from a Participating Provider in the Member's Service Area, the Member's PCP or Physician, as applicable, may refer the Member to a Non-Participating Provider and this Plan will cover such benefits with approval by HMO. The Member will be reimbursed for the cost of the breast pump service or supply obtained from a Non- Participating Provider. The Member must submit proof of loss to HMO to receive a claim payment. Refer to the provision entitled "Proof of Loss and Claim Payments" later in this amendment. For more information contact Member Services by logging onto HMO Navigator website at or calling the toll-free number on the back of the ID card for assistance. Family Planning Services - Female Contraceptives Benefit For females with reproductive capacity, Covered Benefits include those services and supplies that are provided to a Member to prevent pregnancy. All contraceptive methods, services and supplies covered under this benefit must be approved by the U.S. Food and Drug Administration (FDA). Coverage includes counseling services on contraceptive methods provided by a PCP, Physician, obstetrician or gynecologist. Such counseling services are Covered Benefits when provided in either a group or individual setting. They are subject to the contraceptive counseling services visit maximum as shown later in this amendment. The following contraceptive methods are Covered Benefits under this benefit: Voluntary Sterilization Covered Benefits include charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies including, but not limited to, tubal ligation and sterilization implants. Covered Benefits under this benefit would not include a voluntary sterilization procedure to the extent that the procedure was not billed separately by the provider or because it was not the primary purpose of the confinement. Contraceptives Covered Benefits include the following services and supplies provided by a Physician or pharmacy for: Female contraceptives that are Generic Prescription Drugs; Female contraceptive devices that are generic devices and brand name devices including the related services and supplies needed to administer the device. When contraceptive methods are obtained at a pharmacy, prescriptions must be submitted to the pharmacist for processing. The Member will be reimbursed for the cost of the prescription drug or device obtained from a pharmacy. The Member must submit proof of loss to HMO to receive a claim payment. Refer to the provision entitled "Proof of Loss and Claim Payments" later in this Certificate. For more information, contact Member Services by logging onto the current Navigator website or calling the tollfree number on the back of the ID card. Important Reminder: Refer to the section The Member s Pharmacy Benefit later in this Certificate for additional coverage of female contraceptives. HI VA SG-2014-COC 01 17

18 Benefit Limitations: Not covered under this Preventive Care benefit are: Services and supplies incurred for an abortion; Services which are for the treatment of an identified illness or injury; Services that are not given by a Physician or under his or her direction; Psychiatric, psychological, personality or emotional testing or exams; Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA; Male contraceptive methods, sterilization procedures or devices; and The reversal of voluntary sterilization procedures, including any related follow-up care. Additional Covered Medical Expenses Family Planning Services - Other Covered expenses include charges for the following family planning services, even though not provided to treat an illness or injury: Voluntary termination of pregnancy; Voluntary sterilization for males. Limitations: Not covered under this benefit are charges incurred for: Male contraceptive methods or devices; Reversal of voluntary sterilization procedures, for males and females including related follow-up care; Charges incurred for family planning services while confined as an inpatient in a hospital or other facility. Important Notes: Refer to the Schedule of Benefits for details about cost sharing and benefit maximums that apply to Family Planning Services - Other. For more information, see the sections on Family Planning Services - Female Contraceptives, Pregnancy Expenses and Treatment of Infertility in this Certificate. Physician and Other Health Professional Care Primary Care Physician Benefit Office visits during office hours. Home visits. After-hours PCP services. PCPs are required to provide or arrange for on-call coverage 24 hours a day, 7 days a week. If a Member becomes sick or is injured after the PCP's regular office hours, the Member should: call the PCP's office; identify himself or herself as a Member; and follow the PCP's or covering Physician s instructions. If the Member's injury or illness is a Medical Emergency, the Member should follow the procedures outlined under the Emergency Care/Urgent Care Benefits section of this Certificate. Covered Expenses include: Injectable drugs. Immunizations for infectious disease, but not if solely for a Member s employment or travel. Allergy testing and allergy injections, including allergy serum for allergy injections; Charges made by the Physician for supplies, radiological services, x-rays, and tests provided by the Physician. HI VA SG-2014-COC 01 18

19 Surgery Covered expenses include charges made by a physician for: Performing Member s surgical procedure; Preoperative and post-operative visits; and Consultation with another physician to obtain a second opinion prior to the surgery. Anesthetics Covered expenses include charges for the administration of anesthetics and oxygen by a physician, other than the operating physician, or Certified Registered Nurse Anesthetist (C.R.N.A.) in connection with a covered procedure. Specialist Physician Benefits Covered Benefits include outpatient and inpatient services. If a Member requires ongoing care from a Specialist, the Member may receive a standing Referral to such Specialist. If PCP in consultation with a HMO Medical Director and an appropriate Specialist determines that a standing Referral is warranted, the PCP shall make the Referral to a Specialist. This standing Referral shall be pursuant to a treatment plan approved by the HMO Medical Director in consultation with the PCP, Specialist and Member. A Member may request a second opinion regarding a proposed surgery or course of treatment recommended by Member's PCP or a Specialist. Second opinions must be obtained from a Participating Provider and are subject to precertification. To request a second opinion, Member should contact their PCP for a Referral. Important Reminder: For a description of the preventive care benefits covered under this Certificate, refer to the Preventive Care Benefits section in this Certificate. Telemedicine Services Covered benefits include charges for the provision of health care services that are covered under this policy and are appropriately provided through telemedicine services also known as E-visits. Registration with an internet service vendor may be required. Information about Participating Providers who conduct telemedicine services/e-visits may be found in the provider Directory, online in on or by calling the number on the back of your Member identification card. Telemedicine Services, as it pertains to the delivery of health care services, means the use of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation, or treatment. Telemedicine services do not include any audio-only telephone, electronic mail message or facsimile transmission. Walk-In Clinic Visits Covered benefits include charges made by walk-in clinics for: Unscheduled, non-emergency illnesses and injuries; The administration of certain immunizations administered within the scope of the clinic s license; and Individual screening and counseling services to aid you: to stop the use of tobacco products; in weight reduction due to obesity; in stress management. The stress management counseling sessions will: help you to identify the life events which cause you stress (the physical and mental strain on your body.); and teach you techniques and changes in behavior to reduce the stress. HI VA SG-2014-COC 01 19