GROUP HEALTH INCORPORATED

Transcription

1 GROUP HEALTH INCORPORATED (hereinafter referred to as "GHI") 441 Ninth Avenue, New York NY HEALTH INSURANCE FOR YOU AND YOUR DEPENDENTS GHI-THE CITY UNIVERSITY OF NEW YORK EXCEPT AS SPECIFICALLY PROVIDED OTHERWISE, YOU MUST RECEIVE COVERED SERVICES FROM A GHI PARTICIPATING PROVIDER IN ORDER TO BE ELIGIBLE FOR BENEFITS UNDER THIS PROGRAM GROUP HEALTH INCORPORATED PLH-5144B 8/05

2 The insurance evidenced by this Certificate meets the minimum standards for basic hospital and basic medical insurance as defined by the New York State Insurance Department. It does NOT meet the minimum standards for major medical insurance as defined by the New York State Insurance Department.

3 TABLE OF CONTENTS Section One Introduction/Who Is Covered [1] Section Two Definitions [6] HOSPITAL BENEFITS Section Three Covered Inpatient Hospital Care [8] Section Four Covered Outpatient Hospital Care [11] Section Five Covered Home Care Services [14] Section Six Covered Out-Patient Treatment of Alcoholism and Substance Abuse [15] Section Seven Hospice Care [16] MEDICAL BENEFITS Section Eight Use of Participating Providers for Paid-In-Full Benefits [17] Section Nine Covered Medical Services [17] Section Ten Durable Medical Equipment [24] ADDITIONAL BENEFITS & PROGRAMS Section Eleven Pre-Hospital Emergency Medical Services [25] Section Twelve Centers of Specialized Care [25] Section Thirteen Coordinated Care Program [26] GENERAL PROVISIONS Section Fourteen Principal Limitations and Exclusions [27] Section Fifteen Coordination of Benefits [32] Section Sixteen Filing of Claims [33] Section Seventeen Termination of Coverage [38] Section Eighteen Continuation of Coverage [39] Section Nineteen Coverage for Those Eligible for Medicare [39] Section Twenty Miscellaneous Provisions [39]

4 SECTION ONE. - INTRODUCTION/WHO IS COVERED: 1. Your Coverage Under GHI/HSP/CBP. Your University has entered into a Group Contract with Group Health Incorporated (GHI) to provide you with health insurance benefits. Under this Group Contract, GHI will provide the benefits described in this booklet to covered persons. Your coverage will be referred to in this booklet as GHI CUNY Program or as this Program. This booklet is your Certificate of Insurance. It is evidence of your coverage under the Group Contract. It is not a contract between you and GHI. You should keep this booklet with your other important papers so that it is available for your future reference. This Program protects you with benefits for covered health services rendered by GHI Participating Providers. The full extent of your coverage is detailed in the Sections that follow. EXCEPT AS SPECIFICALLY PROVIDED OTHERWISE IN THIS CERTIFICATE, GHI WILL NOT COVER SERVICES RENDERED BY A NON-PARTICIPATING PROVIDER. 2. Who is Covered. You are eligible for coverage if you are a matriculated student at the City University of New York carrying more than six (6) credit hours of class per semester. Student status shall be determined by CUNY. Eligibility may continue for a period not to exceed six (6) months for all graduating students. 3. Coverage of Spouse and Dependent Children. If you have family coverage, benefits are available for your covered spouse and covered, unmarried dependents under the age of 19. Unmarried dependent children are covered until the end of the year in which they attain age 19. Your newborn child is covered from the moment of birth for injury or sickness. You must add the newborn child to your coverage within 30 days of the child s birth. If you have individual coverage, you may elect to cover your newborn child from the moment of birth for injury and sickness. You must add the newborn child to your coverage within 30 days of the child s birth. This will change your individual coverage to family coverage. An ex-spouse is never covered under this Program regardless of the terms of any settlement agreement. The submission of a claim by or for an ex-spouse of a covered student is an insurance fraud. A dependent who is not your spouse or natural child may be eligible for coverage. A dependent who is an adoptive child or stepchild is eligible for coverage. The child must be chiefly dependent upon you for support. A dependent adoptive child will be covered on the same basis as a natural child during any waiting period prior to finalization of the adoption. A dependent child or stepchild is covered at the earliest of the dates set forth below. A court of Law accepts consent to adopt and you enter into an agreement to support the child. A court of Law makes you legally responsible for the support and maintenance of the child. An adopted newborn is covered from the moment of birth for injury and sickness if you add the adopted newborn to this Policy within thirty (30) days of birth. You must take physical custody of the newborn upon the newborn s release from the hospital. You must also file a petition for adoption or apply for temporary guardianship within thirty (30) days after the child s birth. Benefits for the adopted newborn s initial hospital stay are not available if a natural parent has insurance coverage available to cover the newborn. An unmarried child over age 19 may also be eligible for benefits. In order to be eligible, he or she must meet all of the conditions set forth below. (a) He or she must be incapable of self-sustaining employment due to mental illness, developmental disability, mental retardation as defined in the New York State Mental Hygiene Law, or physical handicap. (b) He or she must have been so incapable before the age at which dependent coverage would otherwise terminate. (c) He or she must have been eligible for benefits before the age at which dependent coverage would otherwise terminate. (d) The child s condition must be certified by a physician. 1

5 (e) Proof of the condition is submitted to GHI within 31 days of the date the dependent reaches the age at which dependent coverage would otherwise terminate. GHI may ask you to prove that the child is and continues to qualify as a dependent incapable of self-sustaining employment. 4. Domestic Partners. Benefits are available for your covered domestic partner and his or her eligible dependents. Your domestic partner and any eligible dependents will be covered following a one-semester waiting period. The domestic partnership must consist of two people who are 18 years of age or older and who live together and have been living together on a continuous basis for at least six (6) months. The domestic partnership must involve a close and committed personal relationship. Neither you nor your domestic partner may be married or related by blood in a manner that would bar marriage in New York State. Your domestic partner must be chiefly dependent upon you for support and maintenance. In order to be eligible for coverage, you must show that you and your domestic partner are economically interdependent by meeting the criteria set forth below. (a) The domestic partnership must be registered under the Domestic Partnership Registration Program of the City of New York Office of the Mayor as well as with the City Clerk. (In the case of students living outside of the City of New York, an alternate affidavit of domestic partnership recognized by the City University of New York may be presented in lieu of registration.) (b) You must supply proof of cohabitation. This may be shown by means of drivers licenses, tax returns or other proof recognized by the City University of New York. (c) You must present evidence of at least two of the indications of economic interdependency set forth below. A joint bank account. A joint credit or charge card. A joint obligation on a loan. Status as an authorized signatory on your domestic partner s bank account, credit card or charge card. Joint ownership or holding of investments. Joint ownership of a residence. Joint ownership of real estate other than a residence. Listing of both you and your domestic partner as tenants on the lease of a shared residence. Shared rental payments for a residence. Listing of you and your domestic partner as tenants on a lease or shared rental payments for property other than a residence. A common household and shared household expenses, such as grocery bills, utility bills and telephone bills. Shared household budget for purposes of receiving government benefits. Status of one as representative payee for the other s government benefits. Joint ownership of major items of personal property, such as appliances and furniture. Joint ownership of a motor vehicle. Joint responsibility for child care. This may be shown be means of school documents, guardianship papers or similar documents. Shared child care expenses, such as baby sitting, day care and school bills. Execution of wills naming each other as executor and/or beneficiary. 2

6 Designation of one as beneficiary under the other s life insurance policy. Designation of one as beneficiary under the other s retirement benefits account. Mutual grant of power of attorney. Mutual grant of authority to make health care decisions, such as a health care power of attorney. Affidavit by a creditor or other individual able to testify to your partner s financial interdependence. Other items of proof acceptable to the City University of New York showing economic interdependency. 5. Medicare. If you are eligible for Medicare due to age, you are not eligible for coverage under this Program. Refer to the section entitled Coverage for Those Eligible for Medicare for more information. 6. Criteria for Coverage. In order to request benefits, you must file a claim with GHI. You, your authorized representative or your provider may file a claim for benefits with GHI on your behalf. For information about how to file a claim, please see the section of this Certificate entitled Filing of Claims, Grievances and Appeals. GHI will provide benefits only for the services that are listed as covered in this Certificate. GHI will cover these services only if they are medically necessary and not otherwise excluded from coverage. The services must also be rendered by an eligible Provider. Medically necessary services are health care services that are rendered by a Hospital or a licensed Provider and are determined by GHI to meet all of the criteria listed below. They are provided for the diagnosis, or direct care or treatment of the condition, illness, disease, injury or ailment. They are consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment. They are in accordance with accepted standards of good medical practice in the community. They are furnished in a setting commensurate with the patient s medical needs and condition. They cannot be omitted under the standards referenced above. They are not in excess of the care indicated by generally accepted standards of good medical practice in the community. They are not furnished primarily for the convenience of the patient, the patient s family or the Provider. In the case of a hospitalization, the services cannot be rendered safely or adequately on an outpatient basis and, therefore, require that the patient receive acute care as a bed patient. 7. Utilization Review Decisions. Utilization review is the process by which GHI decides whether or not an item or service for which you request benefits is medically necessary and/or experimental or investigational in nature. Utilization review is performed under the supervision of GHI s Medical Director. A clinical peer reviewer will confirm each finding by GHI that an item or service is not medically necessary or that an item or service is experimental or investigational and, therefore, not covered. GHI will notify you of utilization review decisions as set forth below. If you disagree with GHI s decision that an item or service(s) is not medically necessary or is experimental or investigational in nature and therefore, not covered, you may file an appeal. Please see the section of this Certificate entitled Filing of Claims, Grievances and Appeals for instructions on how to file an appeal. (a) Pre-Service Claims. A pre-service claim is a claim for a service that you must pre-certify with GHI under the terms of this Certificate. GHI will notify you and your Provider of its decision on a pre-service claim within the earlier of three (3) business days or five (5) calendar days after GHI s receipt of the claim. GHI will notify you in writing and by telephone. 3

7 If GHI requires more information to decide your claim, GHI will request such information within fifteen (15) days after its receipt of the claim. GHI will give you at least forty-five (45) days to supply the information. If you supply all of the requested information to GHI within the time that GHI gives you to supply it, then GHI will notify you of its decision within three (3) business days, but not later than five (5) calendar days after its receipt of the information. Otherwise, GHI will notify you of its decision within fifteen (15) days of its receipt of partial information or within fifteen (15) days of the end of the time period GHI gives you to supply it. If you fail to pre-certify a service when it is required by this Certificate, GHI will inform you of the proper precertification procedure within five (5) days (or within twenty-four (24) hours in the case of a pre-service urgent care claim) of receipt of the claim by a GHI person or unit customarily responsible for handling benefit matters. (b) Post-Service Claims. A post service claim refers to any claim for benefits relating to a service that has already been provided to you. GHI will notify you, and if appropriate your provider, of its decision on a post-service claim within thirty (30) days after its receipt of the claim. GHI will notify you in writing. If GHI requires more information to decide your claim, GHI will request such information within thirty (30) days after its receipt of the claim. GHI will give you at least forty-five (45) days to supply the information. If GHI requests more information, GHI will notify you of its decision on your claim within fifteen (15) days after GHI s receipt of all or part of the information or within fifteen (15) days after the end of the time period GHI gives you to supply the information. (c) Urgent Care Claims. An urgent care claim refers to a claim that, if subjected to the other time periods set forth in this section, could seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function, or subject the patient to severe pain that cannot be managed adequately. GHI may reasonably require you or your provider to explain the medical reasons that give rise to a need for urgent care. If care has not yet been initiated, GHI will notify you and your provider of its decision on your urgent care claim within seventy-two (72) hours from receipt of the claim. GHI will notify you in writing and by telephone. If GHI requires more information to make a decision, GHI will notify you of the required information within twenty-four (24) hours after GHI s receipt of the claim. GHI will give you at least forty-eight (48) hours to supply the information. GHI will notify you of its decision on your claim within forty-eight (48) hours of its receipt of the information or within forty-eight (48) hours of the end of the time period GHI gives you to supply the information. If care has already been initiated and you are seeking an extension of urgent care, the time in which GHI will decide your urgent care claim will vary. It will depend upon when GHI receives your claim. If GHI receives your claim at least twenty-four (24) hours before the end of the previously approved treatment plan, then GHI will notify you and your provider of its decision on your urgent care claim within twenty-four (24) hours after GHI s receipt of the claim. If GHI receives your claim less than twenty-four (24) hours before the end of the previously approved treatment plan, then GHI will notify you and your provider of its decision within the earlier of one (1) business day of its receipt of all necessary information or seventy-two (72) hours of its receipt of the claim. GHI will notify you in writing and by telephone. (d) Concurrent Care Decisions. A concurrent care decision refers to a claim decision by GHI that affects an ongoing course of treatment taking place over a period of time or a number of treatments. If you or your provider request a non-urgent continuation, extension or addition to a previously approved plan of care, GHI will notify you and if appropriate, your provider of its decision within one (1) business day of GHI s receipt of all necessary information, but not more than fifteen (15) days after GHI s receipt of the claim. If GHI reduces or terminates a previously approved course of treatment (for reasons other than amendment or termination of the Group Contract or your GHI coverage), GHI will notify you and if appropriate, your provider of its decision sufficiently in advance so that you that you can appeal the decision. GHI will notify you in writing and by telephone. 4

8 8. Other Claim Decisions. Your claim may not involve any issues relating to medical necessity. When this is the case, GHI will review your claim by confirming your eligibility for benefits, verifying that the service you received or will receive is a covered service under this Program and, if appropriate, determining the proper amount of payment. If your claim does not involve a determination by GHI regarding the medical necessity or experimental or investigational nature of the requested service(s), GHI will notify you of its decision on your claim as set forth below. (a) Pre-Service Claims. A pre-service claim is a claim for a service that you must pre-certify with GHI under the terms of this Certificate. GHI will notify you and your Provider of its decision on a pre-service claim within fifteen (15) days after GHI s receipt of the claim. GHI will notify you in writing. If GHI requires more information to decide your claim, GHI will request such information within fifteen (15) days after its receipt of the claim. GHI will give you at least forty-five (45) days to supply the information. If GHI requests more information, GHI will notify you of its decision on your claim within fifteen (15) days after its receipt of all or part of the information or within fifteen (15) days after the end of the time period GHI gives you to supply it. If you fail to pre-certify services when it is required by this Certificate, GHI will inform you of the proper precertification procedures within five (5) days (or within twenty-four (24) hours in the case of a pre-service urgent care claim) of receipt of the claim by a GHI person or unit customarily responsible for handling benefit matters. (b) Post-Service Claims. A post service claim refers to any claim for benefits that is not a pre-service claim. GHI will notify you of its decision on a post-service claim within thirty (30) days of its receipt of the claim. GHI will give such notice in writing. If GHI requires more information to decide your claim, GHI will request such information within thirty (30) days after its receipt of the claim. GHI will give you at least forty-five (45) days to supply the information. If GHI requests more information, GHI will notify you of its decision on your claim within fifteen (15) days after the earlier of GHI s receipt of all or part of the information or the end of the time period GHI gives you to supply it. GHI may combine its request for more information with a notice of denial. If GHI does not receive any information, then this denial will apply. In such a case, you will not receive a notice from GHI at the end of the time period GHI gives you to supply information. If you receive services from a GHI participating provider, and your only liability for the service(s) is a Co-pay Charge, then the time periods above do not apply. (c) Urgent Care Claims. An urgent care claim refers to a claim that, if subjected to the other time periods set forth in this section, could seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function, or subject the patient to severe pain that cannot be managed adequately. GHI may reasonably require you or your provider to explain the medical reasons that give rise to a need for urgent care. If care has not yet been initiated, GHI will notify you of its decision on your urgent care claim within seventy-two (72) hours of its receipt of the claim. If care has already been initiated and you are seeking an extension of urgent care, the time in which GHI will decide your urgent care claim will vary. It will depend upon when GHI receives your claim. If GHI receives your claim at least twenty-four (24) hours before the end of the previously approved treatment plan, then GHI will notify you of its decision on your urgent care claim within twenty-four (24) hours after GHI s receipt of the claim. If GHI receives your claim less than twenty-four (24) hours before the end of the previously approved treatment plan, then GHI will notify you and your provider of its decision within seventy-two (72) hours of its receipt of the claim. GHI will provide such notice in writing. If GHI requires more information to make a decision on your urgent care claim, GHI will notify you of the required information within twenty-four (24) hours after GHI s receipt of the claim. If GHI requests more information, GHI will give you at least fortyeight (48) hours to supply the information. GHI will notify you of its decision on your claim within forty-eight (48) hours of the earlier of its receipt of the information or the end of the time period GHI gives you to supply the information. 5

9 (d) Concurrent Care Decisions. A concurrent care decision refers to a claim decision by GHI that affects an ongoing course of treatment taking place over a period of time or a number of treatments. If you or your provider request a non-urgent continuation, extension or addition to a previously approved plan of care, GHI will notify you of its decision within fifteen (15) days from GHI s receipt of the claim. If GHI reduces or terminates a previously approved course of treatment (for reasons other than amendment or termination of the Group Contract or your GHI coverage), GHI will notify you of its decision sufficiently in advance so that you that you can appeal the decision. GHI will give such notice in writing. The following definitions apply to your benefits. SECTION TWO. - DEFINITIONS: 1. You. The word you refers to you, the subscriber. It also refers to any members of your family who are covered under this Program. 2. Group Contract. The Group Contract is the agreement GHI has with your group, the City University of New York. 3. Certificate of Insurance. This document and any riders or amendments thereto is your Certificate of Insurance. It is evidence of your coverage under the Group Contract. 4. Certificate. The word Certificate in the text refers to the Certificate of Insurance. 5. Hospital. Hospital is a general hospital that has medical and surgical facilities for the care and treatment of the sick. It must be a short-term acute care general hospital. A short-term acute care general hospital is an institution engaged primarily in providing inpatient diagnostic and therapeutic facilities for surgical and medical diagnosis, treatment and care of injured and sick persons. The hospital must provide 24-hour nursing service by registered graduate nurses who are present and on duty. The hospital must be supervised by a staff of physicians. A hospital is not one of the following. (a) An old age, rest, or nursing home. (b) A convalescent home or similar institution. (c) A sanitarium. (d) A camp, school, college, or university infirmary. (e) A facility for the treatment of mental problems, tuberculosis, drug abuse, or alcoholism. (f) A weight loss or fitness center. (g) A skilled nursing center or facility. (h) An institution utilized primarily for custodial care or as a domicile. (I) Health resorts or spas. (j) Places for hospice care treatment. (k) Rehabilitation facilities. 6. Schedule of Allowances. The Schedule of Allowances ( Schedule ) is GHI s listing of the payments for covered medical services rendered by most Participating Providers. The Schedule is on file with the New York State Insurance Department. It is available for inspection at the offices of the New York State Insurance Department and at GHI s offices. Payment is made under the Schedule directly to a Participating Provider. 7. Provider. A Provider is a medical practitioner or covered facility recognized by GHI for reimbursement purposes. A Provider may be any of the following subject to the conditions listed in this paragraph: 6

10 (a) A doctor of medicine. (b) A doctor of osteopathy. (c) A dentist. (d) A chiropractor. (e) A doctor of podiatric medicine. (f) A physical therapist. (g) A nurse midwife. (h) A certified and registered psychologist. (I) A certified and qualified social worker. (j) An optometrist. (k) A nurse anesthetist. (l) A speech therapist. (m) An audiologist. (n) A clinical laboratory. (o) A screening center. (p) A general hospital. (q) Any other type of practitioner or facility specifically listed in this Certificate as a practitioner or facility recognized by GHI for reimbursement purposes. A Provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider s license or certification. Please note that not all services rendered by a specific class of Providers listed above are covered services. In order for you to be covered, the service rendered to you must be covered. In addition, the practitioner or facility rendering the service must be listed in this Certificate as a Provider who is recognized by GHI to render the covered service. Please refer to the benefit description to find out if a service is covered. 8. Participating Provider. A Participating Provider is any doctor, hospital or other Provider who has agreed with GHI to accept GHI s Schedule or negotiated rate as payment in full for covered services, subject to the applicable Co-pay Charge(s), and who is a member of the GHI network that applies to this Program. Consult your Directory of Physicians and other Providers for the names of Participating Providers. You may also call or write to GHI or visit GHI s website at for this information. 9. Co-pay Charge. A Co-pay Charge is a fixed dollar amount you must pay to a Provider for certain services. Copay Charges may apply to home and office visits, out-of-hospital consultations, certain diagnostic services and other services as noted in this Certificate. 10. Allowed Charge. The Allowed Charge is the amount that GHI will reimburse for a covered hospital inpatient or outpatient services rendered by a non-participating Provider. Allowed Charges are determined differently depending upon the type of service you receive. If you are a registered bed patient in a non-participating Hospital or you receive outpatient services from a nonparticipating Hospital, the Allowed Charge will be the lesser of the following: the negotiated rate between GHI and the Hospital the negotiated rate between the Hospital and any network arrangements with which GHI has an agreement; the Hospital s published rate for the service; 7

11 for out of area Hospitals and facilities, the Hospital or facility s published rate for the service, not to exceed the average charge of GHI Participating Hospitals for the same or similar services; charges. There may be occasions where GHI does not have an Allowed Charge for a particular hospital service. When this is the case, GHI will make payment based upon either Medicare guidelines and/or the Relative Value Scale to determine comparability between procedures. The Relative Value Scale is a standard of rating generally accepted in the health insurance field. HOSPITAL BENEFITS SECTION THREE. - COVERED INPATIENT HOSPITAL CARE: GHI will cover for the services listed below when you are an inpatient in the Hospitals described below. 1. Services Provided in a GHI Participating Hospital. After you pay a $150 Co-pay Charge per single hospital confinement, GHI will provide benefits for covered inpatient services rendered in a GHI Participating Hospital. A GHI Participating Hospital is any Hospital that has an agreement with GHI to provide services to persons covered under GHI Hospital Service contracts. If you are a registered bed patient in a Hospital, GHI will pay for most of the services provided by the Hospital. GHI will pay only for services covered by this Certificate. GHI will provide coverage in full for the benefits described herein. GHI will not pay for any service unless the conditions set forth below are met. (i) The service is given to you by an employee of the Hospital. (ii) The Hospital submits a bill for the service. (iii) The Hospital retains the money paid for the service. Your benefits include all patient care services customarily provided by the Hospital. These services vary from Hospital to Hospital. They do not include services charged for by a private practitioner. Typically, covered services consist of the items set forth below. (a) Bed and board. This includes special diet and nutritional therapy. It also includes routine nursery care during the mother s covered Hospital stay. (Family coverage only). (b) General, special, and critical care nursing service other than private-duty nursing service. (c) Facilities, services, supplies and equipment related to surgical operations, recovery facilities, cystoscopic rooms and equipment, anesthesia and facilities for intensive or special care. (d) Oxygen and other inhalation therapeutic services and supplies. (e) Drugs and medications which are listed and approved for such use in the U.S. Pharmacopoeia, the National Formulary, the U.S. Homeopathic Pharmacopoeia, or in New Drugs or Accepted Dental Remedies. (f) Sera, biologicals, vaccines, intravenous preparations and visualizing dyes for care in the Hospital, and administration thereof, dressings, casts, and materials for diagnostic studies. Visualizing dyes that are not commercially available for purchase and readily obtainable by the Hospital are not covered. (g) Services, supplies and equipment related to the administration of blood, blood products, and blood derivatives. You are also covered for blood if it is not replaced and if it is charged for by the Hospital. (h) Facilities, services, supplies and equipment related to physiotherapy and occupational therapy and rehabilitation. (i) Facilities, services, supplies and equipment related to diagnostic studies. This includes, but is not limited to, laboratory, pathology, X-ray examinations, radiation therapy, cardiographic, endoscopic, and electroencephalographic studies and examinations and electrocardiographs. (j) Social, psychological, and pastoral services. 8

12 (k) Facilities, services, supplies and equipment related to radiation, nuclear therapy, and chemotherapy. (l) Facilities, services, supplies and equipment related to emergency medical care. (m) Any additional medical, surgical, or related services, supplies and equipment which are customarily furnished by Hospitals with agreements with GHI, except to the extent that such are excluded by this Certificate. GHI will never pay benefits for care rendered on any day when, by its determination, acute hospital care was not necessary. GHI will pay only for a semi-private room or Hospital ward. A semi-private room is a room which the Hospital considers to be semi-private. If you occupy a private room in a Hospital, GHI will only pay the Hospital s most common semi-private room charge. You will have to pay the difference between that charge and the charge for the private room. The Hospital portion of this Certificate does not cover the following services. (a) Private-duty nursing services. (b) Special braces, appliances or equipment which only you can use. (c) Non-medical items, such as television rental. (d) Medications, supplies and equipment which you take home from the Hospital. (e) Doctor s charges, unless the doctor is employed by the Hospital. (These may be covered under other sections of this Certificate). (f) Emergency Ambulance. (Please refer to the Pre-Hospital Emergency Medical Services section for information regarding ambulance coverage.) 2. Services Provided in a Non-Participating Hospital. (a) A non-participating Hospital is a short-term acute care general Hospital that does not have an agreement with GHI. A short-term acute care general Hospital is a licensed institution primarily engaged in providing inpatient diagnostic and therapeutic facilities for surgical and medical diagnosis. It also provides treatment and care of injured and sick persons by or under the supervision of physicians. It also provides twenty-four hour nursing service by or under the supervision of registered nurses. (b) If you are a registered bed patient in a non-participating Hospital, GHI will pay up to 80% of the Allowed Charge for a semi-private room. GHI will also pay up to 80% of the Allowed Charge for the other services that would be covered in a GHI Participating Hospital. 3. Number of Days of Care Covered. Except as specifically provided otherwise in this section, GHI will cover the first 365 days of care in each single hospital confinement. A single hospital confinement begins when you enter a Hospital that meets the requirements set forth above. Successive stays in one or more Hospitals count as a single hospital confinement unless 90 days or more elapse between the day of discharge and the next admission. Different limitations apply for admissions for physical therapy, physical medicine and physical rehabilitation. Any hospital stay that is the result of an accidental injury counts as a separate hospital confinement. This is true so long as there was not a hospital stay for the same or related injury in the previous 90 days. If there was, then the new stay is part of a continuing single hospital confinement for the accidental injury. Hospital stays for accidental injuries do not count as part of a single hospital confinement for any other unrelated injury or illness. A hospital stay which is the result of an accidental injury is not counted as part of any other single hospital confinement if the stay is not related to any other injury or illness. You are always entitled to 365 days of hospital care for each single hospital confinement related to the same accidental injury. The day you are admitted to a Hospital will be counted as one day. The day you are discharged will not be counted. If you are admitted and discharged on the same day, one day will be counted. 9

13 GHI will pay for consecutive days of care from the date of your admission to the Hospital. You cannot choose which days of care in a Hospital you want GHI to pay for. Each day of care as an inpatient in a Hospital counts as one day of care toward the 365-day single hospital confinement limit. 4. Benefits for Inpatient Maternity Care. GHI will cover the services set forth below in connection with maternity care, other than perinatal complications. GHI will cover inpatient Hospital services for a covered mother and her newborn for forty-eight (48) hours immediately after any delivery other than a cesarean section. GHI will cover inpatient Hospital services for a covered mother and her newborn for ninety-six (96) hours immediately after delivery by cesarean section. The mother has the option to be discharged from the Hospital earlier than the time periods set forth above. In such case, GHI will cover one (1) home health care visit for a covered mother and her newborn. This visit is in addition to the other home health care visits covered under this Policy. The mother must request this visit during the time period after delivery in which she would otherwise be covered for inpatient Hospital services under this provision. The visit is not subject to any deductible or coinsurance. Coverage includes parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal and newborn child assessments provided and billed for by the Hospital or home health care provider during the covered Hospital stay or home care visit. 5. Coverage for Mastectomy Services. GHI will cover the number of inpatient days that your attending physician determines to be medically appropriate following the procedures listed below for the treatment of breast cancer. Lymph Node Dissection. Lumpectomy. Mastectomy; whether full/radical or partial. Your coverage includes prostheses and physical complications for all stages of mastectomy, including lymphedemas. 6. Infertility Services. GHI will cover the inpatient hospital services for the diagnosis and treatment of correctable medical conditions that result in infertility. Infertility refers to the inability to conceive after one (1) year of unprotected intercourse. The diagnosis and treatment must also be consistent with the guidelines for infertility coverage set forth by the New York State Department of Insurance. GHI will cover the types of services set forth below. Surgical or medical procedures that correct malformation, disease or dysfunction resulting in infertility. Diagnostic tests and procedures that are necessary to determine infertility or that are necessary in connection with any surgical or medical treatments or prescription drug regimens. A physician must prescribe the diagnosis and treatment as part of his/her overall plan of care. Covered services include: Hysterosalpingogram. Hysteroscopy. Endometrial biopsy. Laparoscopy. Sono-hysterogram. Post coital tests. Testis biopsy. Semen analysis. 10

14 Blood tests. Ultrasound. GHI will NOT cover the items or services set forth below. GHI also will not cover any items or services provided to you in connection with the items or services set forth below. Prescription drugs for use in the diagnosis and treatment of infertility as set forth above. (However, if you have prescription drug insurance through GHI, then GHI will cover prescription drugs for use in the diagnosis and treatment of infertility according to the terms that apply to your GHI prescription drug insurance.) In vitro fertilization (IVF). Gamete intrafallopian tube transfers. Zygote intrafallopian tube transfers. Reversal of elective sterilization. Sex change procedures. Cloning. Medical or surgical services or procedures that are deemed experimental pursuant to guidelines for infertility coverage set forth by the New York State Department of Insurance. 7. How To Obtain Hospital Benefits. Your GHI Hospital Service Identification Card must be shown upon admission to a Hospital. The Hospital will contact GHI to check eligibility and coverage. In most instances, the Hospital will bill GHI directly. If you are billed, you should submit your bill to GHI in order for GHI to determine your eligibility and process the claim. 8. Criteria for In-Hospital Coverage. In addition to other criteria set forth in this Certificate, you must meet all of the following conditions set forth below in order to qualify for benefits. (a) Be a registered bed patient in a Hospital. (b) Need to stay in the Hospital for the proper care and treatment of the illness or injury. (c) Be under the care of a physician. SECTION FOUR. - COVERED OUTPATIENT HOSPITAL CARE: A. General Outpatient Care. You are covered for the outpatient services set forth below. In order to be covered under this section, the service must be provided and billed by a Hospital. Except as specifically provided otherwise, GHI covers the same services to the same extent that it would if you were an inpatient when you receive services in the outpatient department of a Participating Hospital or a non-participating Hospital in connection with the services below. 1. Emergency Care. GHI will cover emergency care rendered in the emergency room of a Hospital. This applies whether you receive services from a GHI Participating Provider or a non-participating Hospital. You are subject to a $50 Co-pay Charge for outpatient emergency care. If you are admitted to the Hospital immediately from the emergency room, GHI will waive the Co-pay Charge for the emergency room visit. You should call GHI within two (2) business days after your admission or as soon thereafter as you are medically able to do so. This applies whether you are hospitalized in a Participating or a non-participating Hospital. GHI will determine whether you require emergency care based upon the definition of emergency care below and data received from the Provider. Emergency care is defined as care for a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing 11

15 an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy, or serious impairment to such person s bodily functions; serious dysfunction of any bodily organ or part of such person; or serious disfigurement of such person. If you receive a medical service that is listed as covered in Section Nine from a physician or other Provider that is not an employee of the Hospital during your emergency room visit, GHI will cover the service. If the Provider is a GHI Participating Provider, then GHI will provide benefits according to the terms set forth in Sections Eight and Nine. If the Provider is a non-participating Provider, then GHI will reimburse you for the service at the GHI CBP Schedule of Allowances. 2. Surgery. Surgery includes closed reduction of fractures, dislocations of bones, endoscopies requiring use of the surgical facilities of the Hospital and any incision or puncture of the skin or other tissue except for inoculation, vaccination, collection of blood, and drug administration or injection. 3. Referred Ambulatory Care. You are covered for referred ambulatory care in Hospital outpatient facilities. There is a $25 Co-pay Charge for each referred ambulatory procedure. You are covered for the services as set forth below. (a) Laboratory Tests. You are covered for laboratory tests only if they are required for the treatment or diagnosis of your illness or injury. The tests must be ordered by a doctor. Coverage is not provided for charges billed by a physician for interpretation of laboratory tests. (b) Diagnostic X-Rays and Radiation Therapy. GHI will pay for diagnostic X-rays only if they are required for the treatment or diagnosis of your illness or injury and they are ordered by a doctor. Radiation therapy, including the use of isotopes, for therapeutic or diagnostic purposes is also covered. Coverage is not provided for charges billed by a physician for interpretation of X-rays. (c) Chemotherapy Care. You are covered for care and drugs used for non-experimental cancer chemotherapy and cancer hormone therapy. 4. Pre-admission Testing. You are covered for tests ordered by a doctor that are given to you as a planned preliminary to your admission to the Hospital as a registered bed patient for surgery. The tests must meet the conditions set forth below. (a) They must be necessary for and consistent with the diagnosis and treatment of the condition for which surgery is to be performed. (b) You must have a reservation for the hospital bed and for the operating room before the tests are given. (c) You must be physically present at the Hospital when the tests are given. (d) Surgery must actually take place within seven (7) days after the tests are performed. If surgery is canceled due to these pre-surgical test findings, GHI will still cover the cost of these tests. 5. Mammography Screening. You are covered for mammography screening as set forth below. A mammography screening is a breast X-ray examination that is done using dedicated mammography equipment. (a) A mammography at any time if recommended by a physician. (b) A single baseline mammography if you are thirty-five through thirty-nine years of age. (c) An annual mammography if you are forty years of age or older. 12

16 6. Cervical Cytology Screening. You are covered for an annual cervical cytology screening. This test is used to detect cervical cancer. Your coverage includes an annual pelvic examination. It also includes the collection and preparation of a Pap smear. It also includes the laboratory and diagnostic services needed to examine and evaluate the Pap smear. 7. Infertility Services. GHI will cover the inpatient hospital services for the diagnosis and treatment of correctable medical conditions that result in infertility. Infertility refers to the inability to conceive after one (1) year of unprotected intercourse. The diagnosis and treatment must also be consistent with the guidelines for infertility coverage set forth by the New York State Department of Insurance. GHI will cover the types of services set forth below. Surgical or medical procedures that correct malformation, disease or dysfunction resulting in infertility. Diagnostic tests and procedures that are necessary to determine infertility or that are necessary in connection with any surgical or medical treatments or prescription drug regimens. A physician must prescribe the diagnosis and treatment as part of his/her overall plan of care. Covered services include: Hysterosalpingogram. Hysteroscopy. Endometrial biopsy. Laparoscopy. Sono-hysterogram. Post coital tests. Testis biopsy. Semen analysis. Blood tests. Ultrasound. GHI will NOT cover the items or services set forth below. GHI also will not cover any items or services provided to you in connection with the items or services set forth below. Prescription drugs for use in the diagnosis and treatment of infertility as set forth above. (However, if you have prescription drug insurance through GHI, then GHI will cover prescription drugs for use in the diagnosis and treatment of infertility according to the terms that apply to your GHI prescription drug insurance.) In vitro fertilization (IVF). Gamete intrafallopian tube transfers. Zygote intrafallopian tube transfers. Reversal of elective sterilization. Sex change procedures. Cloning. Medical or surgical services or procedures that are deemed experimental pursuant to guidelines for infertility coverage set forth by the New York State Department of Insurance. 13

17 B. Outpatient Benefits for Dialysis. If you have chronic kidney failure and need hemodialysis or peritoneal dialysis, GHI will cover dialysis on an ambulatory basis as set forth below. 1. GHI will cover dialysis treatment in a hospital-based or free-standing facility, dialysis treatment on a walk-in basis. The dialysis program must be approved by the appropriate governmental authorities. 2. For facility-based benefits to be covered, the treatments must be provided, supervised, or arranged by a physician. You must also be a registered patient of an approved kidney disease treatment center. 3. Benefits for ambulatory dialysis are not subject to a time limit. The benefits continue while enrollment is in good standing or until you become eligible for coverage by Medicare. (Please see the section entitled Coverage for Those Eligible for Medicare. ) C. Freestanding Ambulatory Surgery Center Care. You are covered for ambulatory surgical care rendered only in a participating freestanding ambulatory surgery center. The ambulatory surgery center must be certified under the Public Health Law of the State of New York. If the facility is located outside New York State, it must be approved as a freestanding ambulatory surgery center by a comparable state authority. A GHI Participating Facility is a facility that has an agreement with GHI. This agreement is to provide ambulatory surgery services to GHI hospital insurance subscribers. GHI will reimburse the facility directly. You will not have to make any payments to the facility for covered services. SECTION FIVE. - COVERED HOME CARE SERVICES: 1. Type of Home Care Agency Covered. GHI will pay for home care visits made by a Hospital or a home care agency that is certified or licensed by the appropriate state authority(s) to provide home care services. 2. Conditions for Home Care Coverage. GHI will pay for home care visits only if the conditions set forth below are met. (a) If you had not received home care visits, you would have had to have been hospitalized or cared for in a skilled nursing facility. The home care visits must be a substitution for Hospital care or care in a skilled nursing facility. (b) A plan for your home care must have been established and approved in writing by a physician. 3. Home Care Services Covered. You are covered in full for the home care services listed below. (a) Part-time or intermittent home nursing care by or under the supervision of a registered professional nurse (R.N.). (b) Part-time or intermittent home health aide services which consist primarily of caring for the patient. (c) Physical, occupational, or speech therapy if the home care agency or Hospital provides these services. (d) Medical supplies, drugs, and medications prescribed by a doctor, but only if GHI would have paid for these items if you were in a Hospital or skilled nursing facility. (e) Laboratory services provided by or on behalf of the home care agency or Hospital. 4. Number of Home Care Visits. GHI will pay for home care visits and for the other services listed above only for as long as you would otherwise have had to be confined in a Hospital or in a skilled nursing facility. However, GHI will not pay for more than 40 visits in each calendar year. Each visit by a member of a home care team is counted as one home care visit. Up to four hours of home health aide service are counted as one home care visit. 5. Payments. GHI will only cover services rendered by a GHI Participating Provider. Participating Providers. You are covered in full for services rendered by a Participating Provider. GHI will pay the Provider directly. You will not have to make any payments. Non-participating Providers. GHI will NOT cover services rendered by a non-participating Provider. 14

18 SECTION SIX. - COVERED OUTPATIENT TREATMENT OF ALCOHOLISM AND SUBSTANCE ABUSE: 1. Covered Outpatient Visits. You are covered for outpatient visits in a GHI Participating facility described below for the diagnosis and treatment of alcoholism or substance abuse. In order to be covered, each visit must consist of at least one of the services listed below. (a) Individual or group alcoholism or substance abuse counseling. (b) Activity therapy. (c) Diagnostic evaluations by a doctor or other licensed medical professional to determine the nature and extent of your illness or disability. GHI will not pay for visits that consist primarily of participation in programs of a social, recreational, or companionship nature. An employee of the facility must provide all of the services. GHI will not make any payments to an individual who provides any of the covered services, nor will payment be made if the facility turns the payments over to the individual who provided the service. 2. Treatment Plan. The facility where you receive treatment must submit a treatment plan to GHI for its approval within 10 days after you begin treatment. If a treatment plan is not submitted within 10 days, or if we do not approve the treatment plan, GHI will not pay for any visit that takes place more than 10 days after you begin treatment. 3. Number of Visits Covered. You are covered for up to a total of 60 outpatient visits for alcoholism and/or substance abuse services in each calendar year for each person covered under this Program. The visits must take place at the type of facilities described below. GHI will only pay for one visit per day. However, GHI will pay for a family therapy visit that takes place on the same day that the person with the alcohol or substance abuse problem has a visit separate from the family visit. If you have family coverage, up to 20 of the 60 visits available to the person with the alcohol or substance abuse problem may be used for family therapy. The 20 family therapy visits are covered even if the person with the alcohol or substance abuse problem is not receiving treatment. The family therapy visits may only be used by members of the family who are covered under this Program. Regardless of the number of covered family members, only 20 family therapy visits are available for the treatment of the family member with the alcohol or substance abuse problem. Family therapy consists of visits for members of a family. The purpose of these visits is to aid in the understanding of the illness. These visits also help family members play a meaningful role in the recovery. Payment for a family therapy session will be the same amount, regardless of the number of family members who attend the family-therapy session. 4. Covered Facilities for Treatment. You are covered for treatment of alcoholism in New York State only if the facility where the outpatient visit takes place is certified by the New York State Division of Alcoholism and Alcohol Abuse to provide an alcohol treatment program. Coverage for substance abuse will be limited to facilities that are certified to provide medically supervised ambulatory substance abuse programs by the Division of Substance Abuse Services in New York State. If you receive treatment outside of New York State, the facility must be accredited to provide an alcohol or substance abuse treatment program by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A person whose primary diagnosis is substance abuse or substance dependence may be treated only in a facility approved by the Division of Substance Abuse Services. A person whose primary diagnosis is alcoholism or alcohol abuse may be treated only in a facility certified by the Division of Alcoholism and Alcohol Abuse. 5. Payments. GHI will only cover services rendered by a GHI Participating Provider. Participating Providers. You are covered in full for services rendered by a Participating facility. GHI will pay the facility directly. You will not have to make any payments. Non-participating Providers. GHI will NOT cover services rendered by a non-participating facility. 15

19 SECTION SEVEN. - HOSPICE CARE: You are covered for hospice benefits when you have been accepted as a hospice patient at a GHI Participating hospice organization. 1. Eligibility for Benefits. To obtain hospice benefits you must meet all of the conditions set forth below. (a) You must experience an illness for which the attending physician s prognosis for life expectancy is estimated to be 6 months or less. (b) Palliative care, rather than curative care, is considered most appropriate. Palliative care is pain control and symptom relief services. (c) The attending physician must refer you to the hospice organization s program and must be in agreement with the plan for care of your condition. (d) You must be formally admitted to the hospice program. 2. Hospice Organizations. GHI will cover hospice care provided by a GHI Participating hospice organization. GHI will NOT cover hospice care that you receive from a non-participating Provider. 3. Hospice Benefits. GHI will cover up to 210 days of hospice care per lifetime. Five visits are available for bereavement counseling services for the family at any time. GHI covers only those services provided by the Participating hospice organization, including drugs and medical supplies, in the patient s home, a hospice center, or a Hospital. GHI will cover home care and outpatient services that are provided and billed by the Participating hospice. The services may include the items below. (a) Intermittent nursing care by an R.N., L.P.N. or Home Health Aide. (b) Physical therapy. (c) Speech therapy. (d) Occupational therapy. (e) Respiratory therapy. (f) Social services. (g) Nutritional services. (h) Laboratory examinations, X-rays, chemotherapy and radiation therapy when required for control of symptoms. (i) Medical supplies. (j) Drugs and medications prescribed by a physician and which are considered approved under the Untied States Pharmacopoeia and/or National Formulary. This Program will not pay when the drug or medication is of an experimental nature. (k) Medical care provided by the hospice physician. (l) Durable medical equipment (rental only). (m) Transportation between home and Hospital or hospice organization when medically necessary. All services must be medically necessary and appropriate for the care of the patient. All services must be provided and billed for by the hospice organization. 4. Payments. GHI will only cover services rendered by a GHI Participating hospice organization. Participating Providers. You are covered in full for hospice services rendered by a Participating hospice organization. GHI will pay the organization directly. You will not have to make any payments. Non-participating Providers. GHI will NOT cover services rendered by a non-participating Provider. 16

20 MEDICAL BENEFITS SECTION EIGHT. - USE OF PARTICIPATING PROVIDERS FOR PAID-IN-FULL BENEFITS: 1. Benefits Available. Benefits listed under this section of this Certificate are available only through Participating Providers. Certain services are subject to annual limits or pre-authorization. Except as specifically provided otherwise, GHI WILL NOT COVER MEDICAL SERVICES THAT YOU RECEIVE FROM A NON- PARTICIPATING PROVIDER. 2. Participating Providers. GHI Participating Providers accept GHI s Schedule of Allowances or negotiated rate as payment in full for covered services. There is no deductible or co-insurance when you use a Participating Provider to receive covered medical services. However, there is a $27 Co-pay Charge for each home or office visit and a $20 Co-pay Charge for out-of-hospital specialist consultations. There is also a $20 Co-pay Charge for each diagnostic X-ray and laboratory test. However, a maximum of one Co-pay Charge will apply per date of service, per Provider, for diagnostic X-rays and lab tests. This means that if one Participating Provider performs two tests on the same day, you will be subject to one $20 Co-pay Charge only for the diagnostic tests. If, however, two or more different Participating Providers perform one or more lab or diagnostic services on the same day, you will be subject to one Co-pay Charge for each Provider. Consult your Directory of Participating Providers or phone GHI to obtain the names of Participating Providers in your area. You may also visit GHI s website at for this information. You must advise a Participating Provider of your GHI/CBP coverage before you receive services. You must verify that the Provider is a Participating Provider. You should not pay the Participating Provider directly for any covered services, except for the Co-pay Charge, if applicable. 3. As with all covered services, the medical service you receive must be medically necessary. GHI may require a Provider s statement to be furnished detailing the medical necessity of any service. The statement must be acceptable to GHI. In some cases, GHI may request that a treatment plan and statement be filed at the commencement of your treatment. SECTION NINE. - COVERED MEDICAL SERVICES: GHI will provide benefits for the covered medical services listed below only when you receive them from a GHI Participating Provider. 1. General Medical Care. You are covered for home and office visits. Payments are made for the types of services listed below. (a) Treatment or diagnosis of illness or injury. (b) Allergy desensitization. (c) Physio-Therapy, Occupational Therapy and Osteopathic Manipulations, subject to an annual maximum of ten (10) visits per person. (d) Speech Therapy, subject to an annual maximum of eight (8) visits per person. (e) Emergency first aid service. Office visits for immunizations. The cost of the immunizing agent is covered. (g) Chiropractic care. (h) Routine podiatric care, subject to a maximum of four (4) visits per person per calendar year. 17

21 2. Surgical Services. You are covered for surgical procedures. These consist of operating and cutting procedures for the treatment of illness or injury. They also consist of endoscopic procedures. Payment includes the customary preand post-operative visits. In order to receive benefits, the surgeon rendering services to you may not be an employee of the Hospital. GHI will cover breast reconstructive surgery following a mastectomy. This includes all stages of reconstruction of the breast on which the mastectomy has been performed. GHI will cover surgery and reconstruction of the other breast to produce a symmetrical appearance. GHI will also cover reconstructive surgery when such surgery is incidental to or follows surgery resulting from trauma, infection or other diseases of the part of the body involved. GHI will also cover reconstructive surgery performed due to congenital disease or anomaly of a covered child that results in a functional defect. Multiple surgical procedures, when performed through different incisions, will be paid at 100% of the higher surgical allowance, plus one-half the other surgical allowance. If performed through the same incision, GHI will pay the rate for the procedure with the highest allowance. You are covered for the services of assistant surgeons. Payment for the first assistant surgeon is at 20% of the Surgical Allowance. Payment for a second assistant is at 10% of the Surgical Allowance. 3. Dental/Dental-Related Benefits. The benefits set forth below are the only dental/dental-related benefits covered under this Program. A physician or dentist must perform them. GHI will cover treatment rendered within twelve (12) months of the date of an accident for the repair of sound natural teeth due to injury sustained accidentally. GHI will also cover dental care or treatment necessary due to congenital disease or anomaly. GHI will also cover the services listed below. Excision of impacted teeth. Reduction of fractures of the jaw or facial bones. Treatment of salivary gland disorders. Cutting surgery on tissue of the mouth other than the gums and alveolar bone. The surgery cannot be rendered in connection with the extraction, repair, or replacement of the teeth. Implants and implant surgery, including preparation of the alveolar process for the insertion of dental implants, are not covered. Removal of cysts of dental origin is not covered. Visits for the purpose of diagnosis or treatment of temporo-mandibular joint dysfunction (TMJ) syndrome. However, dental examinations and/or dental X-Rays, even if taken in conjunction with a TMJ syndrome diagnosis, are not covered. Treatment of TMJ syndrome by occlusional adjustment is not covered. You are not covered for intra-oral appliances and/or intra-oral orthopedic appliances and their maintenance. 4. Administration of Anesthesia. You are covered for the administration of anesthesia. In order for you to receive benefits, the Participating Provider may not be your surgeon, an assistant surgeon, or a hospital employee. The anesthesia must be rendered in connection with a covered surgical or obstetrical service. Payments for anesthesia include the administration of blood and all other fluids. 5. Maternity Care. GHI will cover childbirth and for conditions related to pregnancy. This includes operations for extra-uterine pregnancies and the treatment of miscarriages. GHI will also cover terminations of pregnancy. GHI s payment includes the usual care given before and after the delivery or termination. GHI will pay maternity benefits in three installments. Two payments shall be made for pre-natal care and one payment for delivery and post-partum care. Payments shall be made only for services rendered. A claim for the services must be filed with GHI for each installment. GHI will pay 15% of the Scheduled amount as the first installment. GHI will pay 25% of the Scheduled amount as the second installment. GHI will pay 60% of the Scheduled amount as the third installment. In no event shall GHI pay more than the Scheduled amount in its total payments. 18

22 Claims for services rendered may only be filed after the installment date. Please note, you may still file your entire claim after delivery. The following is GHI s schedule of installment dates. (a) First Installment: Three months after conception. (b) Second Installment: Six months after conception. (c) Third Installment: After delivery. Maternity care must be rendered by a physician or certified nurse midwife. The nurse midwife must be permitted to perform the service under the Laws of the State where the services are rendered. Complications of pregnancy are covered as part of your maternity benefit. Benefits are available for maternity upon enrollment. The delivery must take place while you are insured under this Program in order to be covered. Deliveries occurring after your coverage terminates are not covered under this Program, except as provided in the Section entitled Termination of Coverage. 6. In-Hospital Medical Care. You are covered for medical care. The care must be rendered in the Hospital. The doctor s service must be unrelated to surgery. In-hospital medical care consists of the following. (a) Routine Medical Care. This includes care of premature infants and treatment of illness of newborns. This benefit consists of physician services rendered to a person who is a bed patient in a Hospital for treatment of sickness or injury. The sickness or injury must be unrelated to surgical or pregnancy care. (b) In-Hospital Well-Baby Care. You are covered for in-hospital well-baby care. 7. Radiation Therapy. You are covered for the administration of radiation therapy. The cost of radium or other radioactive materials is not covered under the medical portion of the Certificate. 8. Specialist Consultations. Your doctor may want you to see a Specialist. The Specialist may or may not be a Participating Provider. If you wish to use a Specialist who is Participating Provider, you may call GHI for a list of Participating Specialists in your area. You are covered for one out-of-hospital consultation in each specialty per calendar year, for each condition being treated. You are not covered for consultations in the fields of pathology, roentgenology, or anesthesiology. However, a consultation with an anesthesiologist regarding pain control unrelated to the administration of anesthesia is covered. Consultations are covered only upon the referral of your attending physician. In order for the service to be covered, the consultant must submit a written report to the attending physician. GHI will also cover second surgical opinion consultations. 9. Diagnostic Procedures, X-Ray Examinations and Laboratory Tests. You are covered for diagnostic procedures. They consist of diagnostic laboratory and X-ray procedures performed on an outpatient basis by a doctor or an independent laboratory, or the outpatient department of the Hospital. Screening exams are covered. In-hospital services are covered only if billed by independent physicians, who are not hospital employees. You are covered for the separate interpretation of X-rays and laboratory tests. A radiologist or pathologist must give you a separate bill for this service. 10. Shock Therapy. You are covered for shock therapy. It may be given in or out of the Hospital. There is no annual maximum number of treatments for this benefit. 19

23 11. Preventive Care. You are covered for the following preventive care services. (a) One annual eye examination per person per calendar year. (b) Office visits for immunizations. The cost of the immunizing agent is covered. (c) One annual cervical cytology screening. Your screening includes the services listed below. (i) An annual pelvic examination. (ii) The collection and preparation of a Pap smear. (iii) The laboratory and diagnostic services needed to examine and evaluate the Pap smear. (d) Mammography Screening. GHI will cover mammography screening as set forth below. A mammography screening is a breast X-ray examination that is done using dedicated mammography equipment. (i) Anual mammography if you are forty years of age or older. (e) Prostate Cancer Screening. 12. Chemotherapy. You are covered for chemotherapy. 13. Intermittent Skilled Nursing Service in Your Home. (Visiting Nurse Service). Visits by registered nurses from accredited Participating nurse service agencies or from GHI Participating nurses are covered. The services must be for the treatment of a condition covered by this Certificate. The care must be rendered under the orders of and supervision of a doctor. Payment in full will be made by GHI directly to the agency or the nurse. This benefit covers only part-time or intermittent visits. Generally, these visits are for less than 2 hours per day. This service may be rendered by a Licensed Practical Nurse (L.P.N.) only if a Registered Nurse (R.N.) is not available. A statement to that effect must be filed with GHI. This service is never covered when it is or could be rendered by home health aides, homemakers, housekeepers, home attendants, or similar practitioners. GHI will not cover custodial care. Custodial care is care that is provided primarily for personal needs. It usually can be provided by aides who have no professional skills or training. Help in walking or getting in or out of bed are examples of custodial care. Assistance in bathing, dressing, eating or orally taking medicine is also considered custodial. Custodial care is never covered, even if rendered by an R.N. or L.P.N. In determining what is custodial care, GHI is also guided by the standards established by Medicare. 14. Hemodialysis Services. You are covered for hemodialysis services. 15. Child Preventive and Primary Care Services for Dependent Children. GHI will cover preventive and primary care services for your covered dependent child from birth until age nineteen (19). GHI will cover an initial in hospital pediatric visit and well-child visits according to the prevailing clinical standards of the American Academy of Pediatrics ( AAP ). The prevailing clinical standards of the AAP may change from time to time. The services must be provided or supervised by a Provider set forth below. A physician. A registered nurse (R.N.). A licensed practical nurse (L.P.N.) The services must be performed in the Provider s office or in a hospital as defined in Section 2801 of the Public Health Law. You must receive these services from a GHI Participating Provider. However, the services are not subject to a Co-pay Charge. They are paid in full. 20

24 (a) Initial In-Hospital Pediatric Visit. GHI will cover one (1) initial in-hospital well-baby visit for your newborn. (b) Well Child Visits. GHI will cover well child visits scheduled in accordance with the prevailing clinical standards of the American Academy of Pediatrics (AAP). Each visit must include services in accordance with these prevailing clinical standards including: Medical history. Complete physical examination. Developmental assessment. Anticipatory guidance. Appropriate immunizations and laboratory tests. These must be ordered at the time of the visit. They must be performed in the Provider s office or in a clinical laboratory. (c) Necessary immunizations. GHI will cover necessary immunizations as determined by the New York State Superintendent of Insurance in consultation with the New York State Commissioner of Health. These consist of at least adequate dosages of vaccine against the diseases set forth below. The dosages of vaccine must meet standards approved by the United States Public Health Service for such biological products. Diphtheria. Pertussis. Tetanus. Polio. Haemophilus influenza type b. Measles. Mumps. Rubella. Hepatitis b. Other immunizations according to the prevailing clinical standards of the AAP. 16. Diabetes Management. GHI will cover equipment and supplies for the treatment of diabetes. In order to be covered, a Provider must recommend or prescribe the equipment and supplies. The Provider must be legally authorized to write a prescription. (a) You are covered for the items set forth below. Blood glucose monitors. This includes blood glucose monitors for the visually impaired. Data management systems. Test strips for glucose monitors and visual reading and urine testing strips. Injection aids. Cartridges for the visually impaired. Insulin pumps. This includes appurtenances to insulin pumps. It also includes batteries for insulin pumps. Insulin infusion devices. Lancets and automatic lancing devices. Alcohol swabs. Any additional items listed by the Commissioner of the Department of Health to be medically necessary for the treatment of diabetes. 21

25 The items listed above are covered in full when you obtain them from a GHI Durable Medical Equipment (DME) Preferred Provider. They are not subject to the DME deductible or maxima set forth in the Durable Medical Equipment section. For names of GHI DME Preferred Providers, please call: (212) 501-4GHI or GHI (b) You are also covered for the following items. Insulin. Glucagon. Syringes. Oral agents for controlling blood sugar. You are subject to a $5 Co-pay Charge for these items. They are not available from Participating Providers. You must pay the full cost for these items. You must obtain a receipt for your purchase. You must submit a claim form. GHI will reimburse you directly. You will be paid in full, less the $5 Co-pay Charge. Coverage of these items is not subject to a deductible or maximum. (c) You are also covered for diabetes self-management education. This includes education relating to proper diet. Diabetes self-management education ensures that persons with diabetes are informed as to the proper selfmanagement and treatment of their diabetic condition. It is covered only if it is conducted by a Provider. The Provider must be legally authorized to write a prescription. It may also be provided by a member of the Provider s staff. It must be part of an office visit for diabetes diagnosis or treatment. It is covered only in the instances set forth below. Upon the diagnosis of diabetes. Upon a physician s diagnosis of a significant change in symptoms or conditions which require changes in self management. Where re-education or refresher education is necessary. Diabetes self-management education may also be conducted by one of the following. A certified diabetes nurse educator. A certified nutritionist. A certified or registered dietician. In order to be covered, you must be referred by a Provider. The Provider must be authorized to write a prescription. The education must be provided in a group setting if practicable. A home visit is covered only if medically necessary. 17. Infertility Services. GHI will cover the diagnosis and treatment of correctable medical conditions that result in infertility. Infertility refers to the inability to conceive after one (1) year of unprotected intercourse. The diagnosis and treatment must also be consistent with the guidelines for infertility coverage set forth by the New York State Department of Insurance. GHI will cover the types of services set forth below. Surgical or medical procedures that correct malformation, disease or dysfunction resulting in infertility. Diagnostic tests and procedures that are necessary to determine infertility or that are necessary in connection with any surgical or medical treatments or prescription drug regimens. A physician must prescribe the diagnosis and treatment as part of his/her overall plan of care. Covered services include: Hysterosalpingogram. Hysteroscopy. Endometrial biopsy. Laparoscopy. 22

26 Sono-hysterogram. Post coital tests. Testis biopsy. Semen analysis. Blood tests. Ultrasound. GHI will NOT cover the items or services set forth below. GHI also will not cover any items or services provided to you in connection with the items or services set forth below. Prescription drugs for use in the diagnosis and treatment of infertility as set forth above. (However, if you have prescription drug insurance through GHI, then GHI will cover prescription drugs for use in the diagnosis and treatment of infertility according to the terms that apply to your GHI prescription drug insurance.) In vitro fertilization (IVF). Gamete intrafallopian tube transfers. Zygote intrafallopian tube transfers. Reversal of elective sterilization. Sex change procedures. Cloning. Medical or surgical services or procedures that are deemed experimental pursuant to guidelines for infertility coverage set forth by the New York State Department of Insurance. 18. Osteoporosis Screening. GHI will cover bone mineral density measurements or tests, including but not limited to dual-energy x-ray absorptiometry, in accordance with standards that include the criteria established by Medicare and the National Institutes of Health (NIH) for the detection of osteoporosis. In order to qualify for benefits, you must meet the criteria of Medicare or NIH, and to the extent consistent with such criteria, meet one or more of the conditions set forth below. You must be previously diagnosed as having osteoporosis or having a family history of osteoporosis. You must have symptoms or conditions indicative of the presence, or the significant risk of osteoporosis. You must be on a prescribed drug regiment posing a significant risk of osteoporosis. You must have lifestyle factors to such a degree as posing a significant risk of osteoporosis. You must have age, gender and/or other physiological characteristics that pose a significant risk of osteoporosis. GHI will NOT cover bone mineral density prescription drugs, drugs and devices. However, if you have prescription drug insurance through GHI, then GHI will cover bone mineral density prescription drugs and devices approved by the Federal Food and Drug Administration (FDA) or generic equivalents as approved substitutes, subject to the terms that apply to your GHI prescription drug insurance. 19. Second Medical Opinion for Cancer Diagnosis and Treatment. GHI will cover a second medical opinion by an appropriate specialist in any of the events set forth below. A positive diagnosis of cancer. A negative diagnosis of cancer. A recurrence of cancer. 23

27 A recommendation of a course of treatment for cancer. If your attending physician provides you with a written referral to a specialist for a second opinion in any of the above events, you are covered in full for the second opinion after you pay the applicable Co-pay Charge. This applies even if the written referral is made to a non-participating Provider. SECTION TEN. - DURABLE MEDICAL EQUIPMENT COVERAGE: GHI will cover durable medical equipment (DME) as set forth in this section. GHI will cover DME only if you receive it from a GHI Participating DME Provider. 1. Prior Authorization. Your GHI Participating Provider must pre-authorize DME in some cases. Preauthorization is required when the charge for DME equals or exceeds $2,000. It is also required for all prosthetic devices, orthotic devices and infusion therapy. The DME Participating Provider must telephone GHI s Coordinated Care Department for pre-authorization. The number(s) to call for pre-authorization is or (212) Durable Medical Equipment. GHI will cover the rental, purchase, repair and maintenance (when not covered by a manufacturer s warranty or purchase agreement) of durable medical equipment (DME) from GHI Participating DME Providers. DME refers to items that: can withstand repeated use; could be rented and used to serve a medical purpose; are necessary for illness or injury and usually used in the home; and are generally not useful in patients in the absence of illness or injury. GHI will cover the DME items set forth below when medically necessary. GHI will use Medicare guidelines to determine what is payable. (a) Hospital Beds. (b) Crutches. (c) Walkers. (d) Wheelchairs. (e) Belts and trusses. (f) Lamps and diathermy equipment. (g) Artificial eyes, limbs and other prosthetic appliances, which replace internal body organs. (h) Orthopedic and incontinence appliances. (i) Oxygen and oxygen equipment. (j) Durable Syringes. (k) Other medically necessary durable medical equipment and appliances. The items listed below are examples of items that GHI will NOT cover under this section.. (a) Splints. (b) Casts. (c) Orthopedic or orthotic devices for the feet. (d) Air conditioning devices. (e) De-humidifiers or other climate control devices. (f) Elevator stairs. (g) Wigs, hairplugs or other hairpieces. (h) Intra-oral appliances and intra-oral orthopedic devices and their maintenance. 24

28 (i) Adjustable beds or other beds which are not strictly hospital beds. (j) Over the counter items, such as antiseptics, alcohol, cotton balls, gels, ointments and other similar items. (k) Medical alarm or alert services, systems or devices. (l) Air purifiers and humidifiers. (m) Whirlpools, saunas and related apparatus. (n) Exercise bicycles and other types of exercise equipment. (o) Bath or shower benches. 3. Payments. In order to be eligible for benefits, you must receive DME from a GHI Participating DME Provider. You are covered in full for DME after you meet a $100 deductible per person per calendar year. GHI will not pay more than $10,000 per person per year for DME. For the names of GHI Participating DME Providers, please call: (212) 501-4GHI or GHI ADDITIONAL BENEFITS & PROGRAMS SECTION ELEVEN. PRE-HOSPITAL EMERGENCY MEDICAL SERVICES 1. Pre-hospital Emergency Medical Services (Emergency Ambulance Services). GHI will cover prehospital emergency medical services rendered by a certified ambulance service. Pre-hospital emergency medical services refer to the prompt evaluation and treatment of an emergency condition and non-airborne transportation of the patient to the Hospital. These services are not available through GHI Participating Providers. GHI will reimburse you directly for up to the usual and customary charge, as determined by GHI, for covered services. In order to be eligible for pre-hospital emergency medical service coverage, you must have required treatment for an emergency condition. An emergency condition means a condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy, or serious impairment to such person s bodily functions; serious dysfunction of any bodily organ or part of such person; or serious disfigurement of such person. SECTION TWELVE. - CENTERS OF SPECIALIZED CARE: You may be eligible for paid-in-full benefits for select cardiac procedures, and organ and bone marrow transplants under the GHI Centers of Specialized Care Program. 1. The Program. The GHI Centers of Specialized Care Program is a network of Hospitals designed to offer you paid-in-full hospital and medical benefits for select cardiac tests and surgeries, organ and bone marrow transplants. 2. Eligibility. This program is available to you only if you are: (a) a full-time student; (b) a covered dependent of a full-time student. GHI must be the patient s primary insurance carrier in order to be eligible to participate in the Program. 25

29 3. How the Program Works. (a) Paid-in-Full Benefits. Hospitals and physicians who participate in the GHI Centers of Specialized Care network have agreed to accept GHI s payment as payment in full for the procedures covered under the Program. When you choose a network Hospital, you incur no out-of-pocket expenses for these covered transplant and cardiac procedures. If you choose to receive services outside of the network, your care will be covered according to the other Sections of this Certificate. (b) Access to the Program. You must call GHI s Coordinated Care Program at or (212) in order to participate in the GHI Centers of Specialized Care Program. Only certain cardiac services and organ transplants are covered under this Program. As such, you should call GHI as soon as you learn that you need such care. For example: If cardiac surgery may be necessary, and you are referred to a cardiologist for tests, call GHI if you wish to have the tests provided through the network. If an organ transplant is necessary, and your physician refers you to a transplant coordinator, call GHI if you wish to have the surgery provided through the network. As with all planned Hospital admissions, you must precertify all admissions under the GHI Centers of Specialized Care Program with GHI s Coordinated Care Program. Call at least 10 days prior to your admission to maximize your benefits and avoid penalties. A GHI nurse consultant will answer your questions. He or she will also coordinate the arrangements for your care. (c) Limitations. The GHI Centers of Specialized Care Program covers only cardiac care and certain organ and bone marrow transplant procedures. Any non-cardiac care or care unrelated to the organ or bone marrow transplant provided to you during your hospital stay will be covered according to the other Sections of this Certificate. They will not be covered as part of the GHI Centers of Specialized Care Program. SECTION THIRTEEN. - COORDINATED CARE PROGRAM: GHI s Coordinated Care Program helps you receive health services at an appropriate level of medical care. In order for you to be eligible to receive full benefits under this Certificate, you must comply with all Coordinated Care Program requirements. Coordinated Care includes the programs set forth below. (a) Pre-certification of hospital admissions. (b) Complex Case Management Program. PRE-CERTIFICATION PROGRAM 1. Pre-certification Procedures. In all cases, you must notify GHI Coordinated Care of a planned hospital admission. GHI Coordinated Care can be reached at (212) in New York City or at outside the New York City area. (a) If your doctor recommends hospitalization, you must call GHI prior to the admission date. Call at least ten (10) days prior to the planned admission date, whenever possible. You must always call before a non-emergency admission. (b) If you are pregnant, you should call GHI during your second trimester of pregnancy to pre-certify your admission. In all cases, you must call before admission. (c) You are not required to pre-certify an emergency admission. However, if you are hospitalized as a result of a medical emergency, you should call GHI within two (2) business days of the admission or as soon as reasonably possible. 26

30 2. Penalties. If you fail to pre-certify your admission, your benefits will be reduced by $250. In no event, however, will the penalty exceed 50% of the benefits otherwise payable. COMPLEX CASE MANAGEMENT GHI s Complex Case Management Program concentrates on alternatives to improve the quality and cost effectiveness of care. It focuses on catastrophic and long-term illnesses. The process begins when GHI is notified that a subscriber or eligible dependent has experienced a specific illness or injury with potential long-term effects or changes in lifestyle. GHI s Case Managers assess individual needs and the full range of treatment and financial exposures from the onset of a condition or illness through recovery or stabilization. GHI s health care professionals collaborate with the health care team and family with the goal of helping the patient return to pre-illness/injury function, or to lessen the burden of chronic or terminal conditions. As a result, the subscriber is aided in receiving quality care delivered in the most direct, cost-effective manner and setting. The Case Manager provides the family with support and advice, ranging from referral to family counseling services to assistance in securing special grant programs. If it is determined that involvement of a Case Manager would be both careand cost-effective, GHI will obtain the necessary authorization from the patient. Throughout the process, GHI will maintain strict confidentiality. The Case Manager maintains ongoing communication with the attending physician and family. The final decision on all health care matters always rests with you and your physician. SECTION FOURTEEN. - PRINCIPAL LIMITATIONS AND EXCLUSIONS: In addition to the exclusions and limitations listed elsewhere in this booklet, benefits are not available for the items and services listed below. 1. Non-Participating Provider Services. Except as specifically provided otherwise in this Certificate, GHI will not cover services rendered by a non-participating Provider. 2. Prohibited Referrals. GHI will not cover clinical laboratory services, X-ray or imaging services, pharmacy services or other services provided pursuant to a referral prohibited by Section 238-a(1) of the New York State Public Health Law. 3. Cosmetic Surgery and Treatment. GHI will not cover services in connection with elective cosmetic surgery or treatment which is primarily intended to improve your appearance unless otherwise medically necessary. However, GHI will cover breast reconstructive surgery following a mastectomy. This includes all stages of reconstruction of the breast on which the mastectomy has been performed. GHI will cover surgery and reconstruction of the other breast to produce a symmetrical appearance. GHI will also cover services in connection with reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the part of the body involved. GHI will also cover reconstructive surgery performed due to congenital disease or anomaly of a covered child that has resulted in a functional defect. 4. Workers Compensation. GHI will not pay for care for any injury, condition, or disease if payment is available to you under the Workers Compensation Law or similar legislation. GHI will not make any payments even if you do not claim benefits you are entitled to receive under the Workers Compensation Law. Also, payment will not be made even if you bring a lawsuit against the person who caused the injury or condition. Payment will not be made even if you receive money from that lawsuit and you have repaid the Hospital or other Provider. 5. Eye and Hearing Care. GHI will not cover eyeglasses, hearing aids or contact lenses (except corrective postcataract lenses to replace the natural lens of the eye that may be covered as a durable medical equipment benefit). GHI 27

31 will not cover examinations for the prescription or fitting of eyeglasses, hearing aids or contact lenses. GHI will not cover routine eye examinations. 6. Services Covered by Government. Except for Medicaid, GHI will not cover services furnished, even in part, under the laws of the United States or any State or Municipality. However, GHI will cover care for non-service related injuries or illnesses rendered in a Veteran Affairs Hospital. 7. Services Rendered in Governmental Hospitals. You are not covered for care, unless otherwise specifically provided, in any Hospital or other institution which is owned, operated, or maintained by the Veterans Administration (except as noted below), the federal government, a state government, or any local government, unless the Hospital has an agreement with GHI to provide services to GHI subscribers. However, you are covered in such a Hospital if, because of serious injury or sudden illness, you are taken to one of these Hospitals for emergency care. You must be taken to this Hospital because it is close to the place where you were injured or became ill. In this type of emergency situation, GHI will continue to make payment only for as long as emergency care, in our sole judgment, is necessary and it is not possible for you to be transferred to another Hospital. GHI will make payments for outpatient visits for the treatment of alcoholism or substance abuse even if the facility is owned, operated, or maintained by a state government or any local government. However, the facility must be certified or accredited. GHI will make payments to such a certified or accredited facility only if the facility would have charged you if you did not have insurance. Payment will not be made for any service that is normally furnished without charge. Care for non-service related injuries or illnesses rendered in a Veterans Administration Hospital is always covered. 8. Hospital Stays for Diagnostic Studies. GHI will not cover any hospital stay, or any portion of a hospital stay, that is primarily for diagnostic purposes, unless otherwise medically necessary. This exclusion applies to a hospital stay or a portion of a hospital stay during which the services you receive are primarily for diagnostic X-rays, laboratory tests, or other types of diagnostic studies. 9. Air Ambulance. GHI will not cover air ambulance. 10. Non-Acute Hospital Care. You are not covered for a hospital stay or a portion of a hospital stay during which you receive non-acute care. This exclusion applies to a hospital stay or a portion of a hospital stay in connection with physical checkups, convalescent or custodial care, rest cures, or sanitarium type care. Care is considered custodial when it is primarily for the purpose of meeting personal needs and could be provided by persons without professional skills or training. For example, custodial care includes help in walking, getting in and out of bed, bathing, dressing, eating, and orally taking medicine. 11. War. Payment will not be made for services for care of illness or injury due to war, declared or undeclared. 12. Care Furnished without Charge. Payment will not be made for any care if the care is furnished or would normally be furnished to you without charge. You are not covered for services rendered for which no legally enforceable charge is incurred. 13. Medicare and Other Government Programs. Payment under this Program will be reduced by the amount you are eligible to receive for the same service under Medicare or any other federal, state, or local government program. However, GHI will pay for services covered under this Program even though you are eligible for Medicaid. 14. No-Fault Automobile Insurance. GHI will not make payment for any service for which mandatory automobile no-fault benefits are recovered or are recoverable. 15. Experimental Treatment. GHI will not cover expenses that GHI finds to be related to: (a) experimental treatment; or 28

32 (b) investigational treatment; or (c) clinical trials. Experimental treatment is a treatment that has not been tested in human beings; or that is being tested but has not yet been approved for general use; or that is subject to review or approval by an Institutional Review Board. Investigational treatment includes, but is not limited to services or supplies which are under study or in a clinical trial to evaluate their toxicity, safety and efficacy for a particular diagnosis or set of indications. Clinical trials include, but are not limited to controlled experiments having a clinical event as an outcome measurement involving persons having a specific disease or health condition; or involve the administration of different study treatments in a parallel treatment design done to evaluate the efficacy and safety of a test treatment. Clinical trials include Phase I, Phase II and Phase III Studies. Clinical trials also include randomized trials or studies. However, GHI will cover an experimental or investigational treatment approved by an external appeal agent certified by New York State. If the external appeal agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, GHI will only cover the costs of services required to provide treatment to you according to the design of the trial. GHI will not be responsible for the costs set forth below. Investigational drugs or devices. Costs of non-health care services. Costs of managing research. Costs that would not be covered under this Certificate for non-experimental or non-investigational treatments provided in such clinical trial. 16. Services through Your University. You are not covered for services rendered in a hospital, department, or clinic run by your University for which there is no charge. 17. Unnecessary Care. In general, GHI will not cover any health care service that GHI finds to be not medically necessary. But if an external appeal agent certified by New York State overturns GHI s denial, GHI will cover the procedure, treatment, service or item that GHI had denied. In such a case, GHI will provide coverage to the extent that such procedure, treatment, service or item would otherwise be covered under this Program. 18. Services Not Listed. Payment will not be made for services that are not listed as covered in this Certificate. 19. Convalescent or Custodial Care. GHI will not cover services related to bed rest, rest cures, convalescent care, or custodial care. You are not covered for sanitarium care. 20. Alcoholism and Substance Abuse. Except as specifically provided otherwise in this Certificate, GHI will not cover services for the treatment of alcoholism or substance abuse. 21. Prescription Drugs. Except as specifically provided otherwise in this Certificate, GHI will not cover prescription drugs. 22. Admissions Primarily for Physical Therapy, Physical Medicine or Physical Rehabilitation. GHI will not cover hospital stays (or portions of a hospital stay) the primary purpose of which is physical therapy, physical medicine or physical rehabilitation or a combination of these types of care unless otherwise medically necessary. 23. Psychiatric Care Services. Except as specifically provided otherwise in this Certificate, GHI will not cover the treatment of mental, nervous or emotional disorders. 29

33 24. Stand-by-Services. GHI will not cover stand-by services. Stand-by services are services that a Provider performs relating to being available to provide services on a contingent basis. Mere standing-by is not covered. Stand-by services may be deemed to be rendered by any Provider. Listed below are examples of two types of stand-by services. Example One. The administration of anesthesia is not a stand-by service. It is a covered service. The services listed below when rendered by an anesthesiologist are not covered. They are deemed stand-by services. (a) Preparing a contingency anesthesia plan. (b) Merely being in the operating area. (c) Merely being in the Hospital. (d) Being available for diagnosis or treatment on a contingent basis if needed. Example Two. Stand-by services may also be provided by a surgeon. Surgery or assisting at surgery are not standby services. They are covered services. The services listed below when performed by a surgeon are not covered. They are deemed stand-by services. (a) Preparing a contingency surgery plan. (b) Merely reviewing a patient s chart. (c) Merely being in the operating area. (d) Merely being in the hospital. (e) Being available for diagnosis, treatment or surgery on a contingent basis if needed. 25. Medical Summaries. GHI will not cover medical summaries and/or medical invoice preparations. 26. Duplicate Services. GHI will not cover duplicate services actually provided by both a certified nurse-midwife and a physician. 27. Services Rendered by Member of Immediate Family. GHI will not cover services rendered by the subscriber, the subscriber s spouse, or a child, brother, sister or parent of the subscriber or of the subscriber s spouse. 28. Assisted Reproductive Technologies. GHI will not cover in vitro fertilization, gamete intrafallopian tube transfers, zygote intrafallopian tube transfers, reversal of elective sterilization or cloning. 29. Educational or Vocational Services. GHI will not cover services that are either educational or vocational in nature. 30. Dental/Dental-Related Services. GHI will not cover dental/dental-related services except as specifically provided otherwise in this Certificate. 31. Nutritionists and Related Services. GHI will not cover the services of nutritionists or special dietary products, except as provided in this Certificate. GHI will not cover weight counseling. GHI will not cover weight control programs, such as commercial weight loss plans. However, GHI will cover medical and surgical services that are listed as covered when medically necessary or rendered for the treatment of morbid obesity. 32. Private Duty Professional Nursing Services. GHI will not cover private duty professional nursing services. 33. Routine Podiatric Care. Except as specifically provided otherwise, GHI will not cover the services set forth below rendered in connection with the routine care of the feet. (a) Orthopedic shoes and other supportive devices. (b) Services or supplies for the treatment of the following unless open surgery is necessary: (i) Weak feet. 30

34 (ii) Strained feet. (iii) Flat feet. (iv) Any instability or imbalance of the feet. (v) Metatarsalgia (pain in the sole of the foot in the region of the arch). (vi) Bunions. (c) Services or supplies for the treatment of any of the following services, except when the treatment is prescribed for a metabolic disease: (i) Corns. (ii) Calluses. (iii) Toenails. 34. Alternative Medicine. GHI will not pay for alternative medicine unless otherwise medically necessary. This may include homeopathy, naturopathy, aromatherapy and like services. 35. Acupuncture. GHI will not pay for acupuncture except when used as anesthesia for covered surgery and such form of anesthesia would otherwise be medically safe and appropriate. 36. Massage or Massage Therapy. GHI will not cover massage or massage therapy except as part of a covered physical therapy regimen or as provided in connection with or incident to chiropractic care. 37. Trans-Sexual Surgery. GHI will not pay for trans-sexual surgery and related charges unless otherwise medically necessary. 38. Contraceptives. Unless specifically provided otherwise, GHI will not pay for contraceptive drugs and devices. 39. Pre-Existing Conditions. Any illness, injury, or condition that starts after your first day of coverage is covered. However, coverage of a pre-existing illness, injury or condition may be limited. A pre-existing condition is any disease, symptom or condition that was present on the first day of coverage, and for which medical advice or treatment was recommended or received during the six (6) month period prior to the enrollment date. If a pre-existing condition applies to your coverage then a pre-existing condition is not covered during the first eleven (11) months this contract is in effect. For example, if you have asthma prior to your enrollment date under this Policy, you will be covered for treatment of asthma beginning on the first day of the twelfth month after the enrollment date. The limitation applies to all services related to a pre-existing condition, disease, or symptom. There are several exceptions to this rule. The enrollment date refers to your first day of coverage under this Certificate or if earlier, the first day of the waiting period that must pass before you are eligible to be covered for benefits. (a) Coverage Under a Prior Health Plan. If you were previously covered under a health insurance plan and the lapse in coverage between the termination of the prior plan and the your enrollment date under this Policy does not exceed sixty-three (63) days, GHI will credit the time you were covered under the prior plan toward the eleven (11) month pre-existing condition limitation that applies to this Policy. For purposes of this paragraph, a health insurance plan includes any of the following: a group health plan; health insurance coverage; Part A or B of Title XVIII of the Social Security Act(Medicare); Title XIX of the Social Security Act (Medicaid) (other than coverage consisting solely of benefits under Section 1928); Chapter 55 of Title 10 of the United States Code (CHAMPUS and TRICARE health programs for the uniformed military services); 31

35 a medical care program of the Indian Health Service or of a tribal organization; a state health benefits risk pool; a health plan offered under Chapter 89 of Title 5 of the United States Code (Federal Employees Health Benefits Program); a public health plan (as defined in regulations); a health benefit plan under Section 5(E) of the Peace Corp Act (22 U.S.C. 2504(e)). (b) Birth Defects. Treatments of birth defects (congenital anomalies) of a covered child are not subject to the preexisting condition limitation. (c) Pregnancy. Pregnancy existing on the enrollment date is considered to be a pre-existing condition, but the limitation period for pregnancy is only ten (10) months. (d) Newborns and Adopted Children. A newborn or a child who is adopted or placed for adoption before they are eighteen (18) years old, will not be subject to a pre-existing condition limitation. This will apply if the child is enrolled under creditable coverage within thirty (30) days after birth or adoption or placement for adoption. This provision will not apply if the child has a break in coverage exceeding sixty-three (63) days. (e) Federal Trade Adjustment Assistance Reform Act of An individual, and any dependent of such individual, who is eligible for a federal tax credit under the Federal Trade Adjustment Assistance Reform Act of 2002 and who has three (3) or more months of creditable coverage is not subject to the pre-existing condition limitation. SECTION FIFTEEN. - COORDINATION OF BENEFITS (COB): 1. General. You may be covered by two or more group health benefit plans. These programs may provide similar benefits. Should you have services covered by more than one plan, GHI will coordinate benefit payments with the other plan. In this case, one plan pays its full benefit as a primary benefit. The other plan pays secondary benefits. This prevents duplicate payments and overpayments. In no event shall payments exceed 100% of a charge. In order to determine which plan is primary, certain rules have been established. GHI follows these rules. These rules apply whether or not you make a claim under both plans. If GHI pays you more than you should have been paid under this provision, it has the right to recover the overpayment. GHI may recover the overpayment from you or any other person, insurance company, or other organization which gained from the overpayment. You must help GHI in recovering any overpayment. This help may mean filing claim forms with another company. It may mean endorsing checks over to GHI. GHI may, without the consent of or notice to any person, give or receive any information about coverage, expenses, and benefits which is needed to apply this provision. Please note that the above applies, except as required by Article 25 of the New York State General Business Law. 2. Plan. A plan is a form of group coverage other than Medicaid on which these rules of coordination of benefits are allowed. A plan includes: (a) Group insurance, group or group remittance subscriber contracts. (b) Uninsured group coverage. (c) Prepayment group coverage including HMOs, group practice and individual practice plans. (d) Blanket contracts, except blanket school accident coverages or such coverages issued to a substantially similar group, where the policyholder pays the premium. 32

36 (e) The medical benefits coverage in group and individual mandatory automobile no-fault contracts. 3. Rules of Coordination. The rules for determining primary and secondary benefits are as follows: (a) The plan covering you as a full-time student is primary before a plan covering you as a dependent. (b) The plan of a parent whose birthday occurs first in the year is primary for dependent children covered under plans maintained by both parents. Birthday refers only to the month and day on which the parent is born and not the year. If both parents have the same birthday, the plan covering you for the longer time is primary. If the other plan does not have the rule discussed above but has a rule based upon the gender of the parent, that plan s rule determines order of benefits. (c) If no other criteria apply, the plan covering you the longest is primary. 4. Special Rules for Dependents of Separated or Divorced Parents. (a) If there is a court decree that imposes financial responsibility for the health care expenses of the dependent child on one parent, that parent s plan is primary. That plan must have actual knowledge of the decree. GHI has the right to request a copy of the portion of the decree pertaining to the health care expenses of the dependent child. (b) If there is no court decree, the plan covering the parent with custody of a dependent child is primary. (c) If the parent with custody of a dependent child remarries, that parent s plan is primary. The step-parent s plan is secondary. The plan covering the parent without custody is tertiary. 5. Payment of Benefits. (a) When GHI is the primary plan, GHI will pay its full benefits. The other plan will pay secondary benefits. (b) When GHI is deemed secondary, GHI will reduce its benefits so that the combined payment or benefit from all plans is not more than the actual charge for the covered service. Please note that GHI will never pay more than its full benefits as a secondary plan, even if the benefits or payments of the combined plans are less than 100% of charges. 6. Plans with Different COB Rules. Group plans are written in many States. Not all States or groups follow the same rules. Some plans have language that states that the plan is an excess plan or is always secondary. In that event, GHI will coordinate as follows: (a) If GHI would be primary under the rules listed above, it will pay primary benefits. (b) If GHI would be secondary under the rules listed above, it will pay its benefits first. However, the amount of benefits paid will be determined as if GHI was the secondary plan. Such payments will be the limit of GHI s liability. (c) In order to determine benefits under (b), GHI may need information from the other plan. If that plan does not provide the information necessary for GHI to determine benefits within thirty (30) days of a request to do so, GHI will assume the benefits of the other plan are identical to GHI s. Benefits will then be paid accordingly. Adjustments will be made if information becomes available as to the benefits of the other plan. SECTION SIXTEEN. - FILING OF CLAIMS: 1. How to File a Claim. Claims will usually be filed directly with GHI by Hospitals and Participating Providers that are members of the network applicable to this Certificate. All claims must be filed within the time limits set forth below. In order to expedite processing, claims should be submitted on a standardized hospital claims form or an appropriate GHI claim form. 33

37 Participating Providers will have a supply of claim forms. You should complete the Subscriber portion of the form at the time the services are rendered. The Provider should complete the Provider s portion of the form and mail the form to GHI. If the Provider s charges have been paid or if the Provider is not a Participating Provider, GHI will forward its payment directly to you. 2. When To File a Claim for Services If You are Billed Directly. In order to receive benefits, you must promptly complete and file your claim form. You must file your claim form with GHI within eighteen (18) months of the date upon which a service has been rendered. If you fail to file your claim in a timely manner, GHI may still pay the claim if it was not reasonably possible for you to have filed your claim on time. You must file your claim when it becomes reasonably possible to do so. Please mail hospital claim forms to the address below: Group Health Incorporated - Hospital Claims P.O. Box 2833 New York, New York Mail medical/physician claim forms to the following address: Group Health Incorporated - Medical Claims P.O. Box 3000 New York, New York Telephone and Written Inquiries. For information on specific claims, enrollment and general information, please call: (212) or GHI Customer Service or GHI s Coordinated Care Department For general correspondence, please write to: Group Health Incorporated P.O. Box 1701 New York, New York Mail written inquiries to the address below: Group Health Incorporated - Hospital Claims P.O. Box 2833 New York, New York Mail written inquiries to the address below: Group Health Incorporated - Medical Claims P.O. Box 3000 New York, New York Grievances. If you do not agree with a decision made by GHI (other than a decision regarding the medical necessity or experimental or investigational nature of a requested service), you may file a grievance with GHI. You may also file a grievance with GHI if you are not satisfied with one or more aspects of this GHI insurance program. You may authorize a representative to file a grievance on your behalf. You must file the grievance within one hundred and eighty (180) days from the date that you received notice of GHI s decision. Your grievance must include your GHI identification number and claim number(s). It must also describe your complaint. It should also include any other information that you wish GHI to consider. 34

38 Please send your grievance(s) to: GHI - Grievance Unit P.O. Box 4007 New York, New York GHI will reply to your grievance in writing. GHI will reply to your grievance within the time period(s) set forth below. Urgent Care Claims: seventy-two (72) hours after GHI s receipt of the grievance Pre-Service Claims: thirty (30) days after GHI s receipt of the grievance. Post Service Claims and Other Grievances: sixty (60) days after GHI s receipt of the grievance. 5. Your Provider s Right to Reconsideration. If GHI denies a covered service on the basis that it is not medically necessary or it is experimental or investigational in nature, and GHI does not first try to discuss the decision with your Provider, your Provider has the right to request a reconsideration by GHI. If you have not yet received the service, GHI will reconsider the decision within one (1) business day of GHI s receipt of the request. 6. Internal Appeals. (a) Standard Appeals. If GHI denies a claim for a covered service on the basis that the service is not medically necessary or is experimental or investigational in nature, you may file an appeal with GHI. You may also authorize a representative to file an appeal on your behalf. You may file the appeal by telephone or in writing. You must file the appeal within one hundred and eighty (180) days from the date that you receive notice of GHI s denial. The appeal must include your GHI identification number and claim number(s). It should also include any medical data and comments in support of your appeal. You must file a verbal appeal by calling GHI toll free at: You must direct written appeals to: GHI - Utilization Review Appeals P.O. Box 2887 New York, New York GHI will acknowledge receipt of your appeal within fifteen (15) days of GHI s receipt of your appeal. If GHI needs more information to decide your appeal, GHI will also notify you and your Provider of the needed information within fifteen (15) days of GHI s receipt of the appeal. The time within which GHI must respond to your appeal will vary depending upon the type of claim that you are appealing. If GHI fails to decide your appeal within these time periods, the service will be deemed approved. Pre-Service Claim Appeals: thirty (30) days from GHI s receipt of the appeal. Post-Service Claim Appeals: thirty (30) business days of GHI s receipt of all necessary information, but not more than sixty (60) days from GHI s receipt of the appeal. Urgent Care Claim Appeals: the earlier or two (2) business days of GHI s receipt of all necessary information or seventy-two (72) hours after GHI s receipt of the appeal. Concurrent Care Appeals. If you are appealing GHI s denial of a non-urgent continuation, extension or addition to the care plan, GHI will decide your appeal within the earlier of two (2) business days of GHI s receipt of all necessary information or thirty (30) days after GHI s receipt of the appeal. If you are appealing GHI s reduction or termination of a previously approved care plan, GHI will decide your appeal within seventy-two (72) hours of GHI s receipt of the appeal. 35

39 (b) Expedited Appeals. GHI offers an expedited appeal process in certain cases. An expedited appeal may be filed only in the cases below. Cases that involve continued or extended health care services, procedures or treatments. Cases that involve requests for additional services for a person undergoing a course of continued treatment. Cases where the Provider believes an immediate appeal is warranted due to imminent or serious threat to the health of the person. If GHI needs more information to decide your appeal, GHI will notify you and your Provider of the needed information within twenty-four (24) hours. GHI will make a decision on your appeal within two (2) business days of GHI s receipt of the information needed for GHI to conduct a full and fair review, but not more than seventy-two (72) hours from GHI s receipt of the appeal. If GHI fails to decide your appeal within these time periods, the service will be deemed approved. To file an expedited appeal, please call GHI toll free at External Appeals. YOUR RIGHT TO AN EXTERNAL APPEAL Under certain circumstances, you have a right to an external appeal of a denial of coverage. Specifically, if GHI has denied coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you or your representative may appeal that decision to an external appeal agent, an independent entity certified by the State to conduct such appeals. YOUR RIGHT TO APPEAL A DETERMINATION THAT A SERVICE IS NOT MEDICALLY NECESSARY If GHI has denied coverage on the basis that the service is not medically necessary, your may appeal to an external appeal agent if you satisfy the following two (2) criteria: The service, procedure or treatment must otherwise be a covered service under this Certificate; and You must have received a final adverse determination through the GHI s internal appeal process and GHI must have upheld the denial or you and GHI must agree in writing to waive any internal appeal. YOUR RIGHT TO APPEAL A DETERMINATION THAT A SERVICE IS EXPERIMENTAL OR INVESTIGA- TIONAL If you have been denied coverage on the basis that the service is an experimental or investigational treatment, you must satisfy the following two (2) criteria: The service must otherwise be a covered service under this Certificate; and You must have received a final adverse determination through GHI s internal appeal process and GHI must have upheld the denial or you and GHI must agree in writing to waive any internal appeal. In addition, your attending physician must certify that you have a life threatening or disabling condition or disease. A life-threatening condition or disease is one which, according to the current diagnosis of your attending physician, has a high probability of death. A disabling condition or disease is any medically determinable physical or mental impairment that can be expected to result in death, or that has lasted or can be expected to last for a continuous period of not less than twelve (12) months, which renders you unable to engage in any substantial gainful activities. In the case of a child under the age of eighteen, a disabling condition or disease is any medically determinable physical or mental impairment of comparable severity. Your attending physician must also certify that your life-threatening or disabling condition or disease is one for which standard health services are ineffective or medically inappropriate or one for which there does not exist a more beneficial 36

40 standard service or procedure covered by GHI or one for which there exists a clinical trail (as defined by law). In addition, your attending physician must have recommended one of the following: A service, procedure or treatment that two (2) documents from available medical and scientific evidence indicate is likely to be more beneficial to you than any standard covered service (only certain documents will be considered in support of this recommendation your attending physician should contact the State of New York in order to obtain current information as to what documents will be considered acceptable): or A clinical trial for which you are eligible (only certain clinical trials can be considered). For the purposes of this section, your attending physician must be a licensed, board-certified or board eligible physician qualified to practice in the area appropriate to treat your life-threatening or disabling condition or disease. THE EXTERNAL APPEAL PROCESS If, through GHI s internal appeal process, you have received a final adverse determination upholding a denial of coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you have forty-five (45) days from receipt of such notice to file a written request for an external appeal. If you and GHI have agreed in writing to waive any internal appeal, you have forty-five (45) days from receipt of such waiver to file a written request for an external appeal. GHI will provide an external appeal application with the final adverse determination issued through GHI s internal appeal process or its written waiver of an internal appeal. You may also request an external appeal application from New York State. Submit the completed application to State Department of Insurance at the address indicated on the application. If you satisfy the criteria for an external appeal, the State will forward the request to a certified external appeal agent. You will have an opportunity to submit additional documentation with your request. If the external appeal agent determines that the information you submit represents a material change from the information on which GHI based its denial, the external appeal agent will share this information with GHI in order for it to exercise its right to reconsider its decision. If GHI chooses to exercise this right, GHI will have three (3) business days to amend or confirm its decision. Please note that in the case of an expedited appeal (described below), GHI does not have a right to reconsider its decision. In general, the external appeal agent must make a decision within thirty (30) days of receipt of your completed application. The external appeal agent may request additional information from you, your physician or GHI. If the external appeal agent requested additional information, it will have five (5) additional business days to make its decision. The external appeal agent must notify you in writing of its decision within two (2) business days. If your attending physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to your health, you may request an expedited external appeal. In that case, the external appeal agent must make a decision within three (3) days of receipt of your completed application. Immediately after reaching a decision, the external appeal agent must try to notify you and GHI by telephone or facsimile of that decision. The external appeal agent must also notify you in writing of its decision. If the external appeal agent overturns GHI s decision that a service is not medically necessary or approves coverage of an experimental or investigational treatment, GHI will provide coverage subject to the other terms and conditions of this Certificate. Please note that if the external appeal agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, GHI will only cover the costs of services required to provide treatment to you according to the design of the trial. GHI shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing research, or costs which would not be covered under this Certificate for non-experimental or non-investigational treatments provided in such clinical trial. The external appeal agent s decision is binding on both you and GHI. The external appeal agent s decision is admissible in any court proceeding. 37

41 GHI will charge you a fee of fifty dollars ($50) for an external appeal. The external appeal application will instruct you on the manner in which you must submit the fee. GHI will also waive the fee if GHI determines that paying the fee would pose a hardship to you. If the external appeal agent overturns the denial of coverage, the fee shall be refunded to you. YOUR RESPONSIBILITES It is your responsibility to initiate the external appeal process. You may initiate the external appeal process by filing a completed application with the New York State Department of Insurance. If the requested service has already been provided to you, your physician may file an external appeal application on your behalf, but only if you have consented to this in writing. Under New York State law, your completed request for appeal must be filed within forty-five (45) days of either the date upon which you receive written notification from GHI that it has upheld a denial of coverage or the date upon which you receive a written waiver of any internal appeal. GHI has no authority to grant an extension of this deadline. SECTION SEVENTEEN. - TERMINATION OF COVERAGE: 1. Termination. Your coverage under this Certificate will terminate upon the events below. (a) You are no longer eligible for benefits. Examples of loss of eligibility would include: loss of full-time student status. (See Paragraph 3 of this Section for an exception). divorce. death of a member. a dependent reaching the age limitation. becoming eligible for Medicare due to age. (b) The Group Contract between CUNY and GHI terminates. (c) By operation of law. You will be notified as required by law. (d) Failure to pay premium within the grace period. Premiums are due and billed quarterly. The premium is due in advance. However, GHI grants a ten (10) day grace period. Except for the initial premium (which is payable with your application) the premium payment must be made before the end of the grace period. (e) GHI finds a fraud on your part. The fraud may be related either to your application or a claim for benefits. 2. Benefits After Termination. If your coverage terminates, you may be entitled to certain benefits after termination as set forth in this paragraph 2. (a) GHI will provide maternity care coverage for a pregnancy that commenced while the mother was covered as a member under this Policy, even after all other coverage under this Policy is terminated. (b) If you are totally disabled due to injury, sickness or pregnancy at the time of termination, then you may be eligible to continue to receive limited benefits under this Policy. You must be totally disabled as determined by GHI. In no event shall GHI extend benefits beyond the duration of total disability. This extension of benefits only covers services rendered with respect to the injury, sickness or pregnancy causing the total disability. In no event shall benefits extended after termination exceeds the coverage provided under the Policy prior to its termination. The level of extended benefits depends on the reason coverage under this Policy is terminated. If coverage under this Policy terminates by reason of termination of active student status, then GHI will extend benefits with respect to the injury, sickness or pregnancy causing the total disability for a period not to exceed twelve (12) months. This extension will not be effective if coverage is provided for total disability under another group plan. 38

42 If coverage under this Policy terminates due to termination of eligibility or termination of the Group Contract, then benefits will be extended for hospital confinements commencing or surgery performed within thirty-one (31) days of the termination. In such a case, benefits will only be extended with respect to the injury, sickness or pregnancy causing the total disability. SECTION EIGHTEEN. - CONTINUATION OF COVERAGE: 1. Job Transition Program. When you graduate from any division of CUNY, you will be eligible to continue your coverage under this program for up to six (6) months following your date of graduation, provided you continue to pay the required premium on a timely basis. SECTION NINETEEN. - COVERAGE FOR THOSE ELIGIBLE FOR MEDICARE: 1. Medicare Eligible Persons. Active Members. If you are eligible for Medicare due to age, you are not entitled to coverage under this Program. If you are not eligible for Medicare, this Section does not affect your benefits. 2. Special Provisions for Those with End-Stage Renal Disease. (Chronic Kidney Failure). If you are disabled due to end-stage renal disease, your benefits for covered services will be paid as set forth below. (a) During the first thirty months during which you incur covered services, your benefits will be paid as follows. (i) This Program will be the Primary Payor, subject to the Coordination of Benefits provisions of this Contract. (ii) Medicare will be a Secondary Payor. (b) After the first thirty months during which you incurred covered services, your benefits will be paid as follows: (i) Medicare will be the Primary Payor of benefits and will pay the benefits available under Medicare. (ii) This Program will be a Secondary Payor. Benefits will be paid only to the extent that benefits are not paid under Medicare. SECTION TWENTY. - MISCELLANEOUS PROVISIONS: 1. No Assignment. You cannot, without GHI s consent, assign any benefits or monies due from GHI to any person, corporation, Hospital, or other organization. Any assignment by you will be void. Assignment means the transfer to another person or organization of your right to the services provided or your right to collect from GHI for those services. 2. Your Hospital and Medical Records. In order to process your claims, it may be necessary for GHI to obtain your hospital and medical records and data from Hospitals, skilled nursing facilities, doctors, pharmacists, or other practitioners who treated you. When you become covered you give GHI permission to obtain and use these records. The information will be kept confidential. 3. Recovery of Overpayments. If GHI pays benefits for services incurred on your account and it is found that GHI paid more benefits than should have been paid because you were: (a) not covered; (b) the services were not covered; (c) payment was in an amount greater than that to which you are entitled under this Policy; or (d) payment was in an amount greater than that to which you are entitled because you were repaid for all or some of those expenses by another source; then GHI will have the right to a refund from you. You must return the amount of the overpayment within sixty (60) days of GHI s request. 4. Right to Develop Guidelines. GHI reserves the right to develop or adopt standards and criteria which set forth in more detail the circumstances under which it will make payment. 39

43 5. Lawsuits. A lawsuit against GHI regarding this Certificate must be started within two years from the date you received the medical or hospital service for which you want GHI to pay. 6. Suits Against GHI for Actions of Others. You cannot sue GHI for the actions of any person, hospital, or other organization which renders covered medical or hospital services to you. 7. New York Law. This Certificate is in all respects governed by the Laws of New York State. This Certificate and the benefits and premium rates may be changed only in accordance with the laws and regulations of New York State. GHI reserves the right to so change or modify this Contract. 8. Who Receives Payment Under This Program. Payments for covered services rendered by a Participating Provider will be made directly to that Provider. If you receive services from a non-participating Provider and that services are covered under this Certificate when received from a non-participating Provider, GHI reserves the right to pay you or the Provider. 9. Patient s Relationship with the Provider. Nothing in this Certificate shall force a Provider to accept you as a patient. This Certificate is not meant to change the normal relationship between the provider and patient. At all times, the Provider s usual rules will govern the service provided to the patient. GHI cannot guarantee admission to any Hospital or receipt of any particular service or accommodation. 10. Changing Your GHI Health Insurance Benefit Plan. If you wish to change your GHI Health Insurance Benefit Program, you may do so only on your annual Contract anniversary date. 11. Authorization for Medicare Carriers to Submit Medical Information to GHI for Payment of Supplemental and Complementary Benefits. When you become covered, you authorize the parties listed below to provide medical information to GHI or its designee. (a) Health Care Financing Administration. (b). Medicare intermediaries. (c). Medicare carriers. (d) Providers. GHI must receive this information in order to: (a) Process claims; and (b) Provide benefits. These terms remain in effect until all claims incurred by you are processed. 12. Subrogation and Reimbursement. This paragraph applies when another party (including any insurance carrier) is, or is alleged to be, liable for your injury, illness or other condition and GHI has provided benefits in connection with that injury, sickness or condition. GHI is subrogated to all of your rights against any such party (including any insurance carrier) to the extent of the reasonable value of the benefits provided to you under this Policy. This means that GHI has the right independently of you, or as a plaintiff-intervenor in any action you may have commenced, to proceed against the party responsible for your injury, illness, or condition to recover the benefits that have been provided under the GHI Policy. You must cooperate with GHI in proceeding against the party responsible for your injury, illness or condition to recover the benefits GHI has provided. In addition, in GHI s sole discretion, if you (or your legal representative, estate or heirs) make recovery from any liable party (including any insurance carrier), you will promptly reimburse GHI for any benefits provided by GHI in connection with the injury, illness or condition from any settlement, verdict or insurance proceeds received to the extent that such settlement, verdict or other amounts received is specifically identified as being for medical expenses paid out. 40

44 13. Non-Vesting. Under no circumstances do you acquire a vested interest in continued receipt of a particular benefit or level of benefits. Benefits shall be determined according to the Group Contract terms in effect when an expense is incurred. Benefits may be amended at any time in accordance with applicable provisions of the Group Contract. 41