SOUTH CENTRAL OHIO INSURANCE CONSORTIUM HEALTH BENEFIT PLAN

Transcription

1 SOUTH CENTRAL OHIO INSURANCE CONSORTIUM HEALTH BENEFIT PLAN For Employees of LOGAN-HOCKING LOCAL SCHOOLS CERTIFIED/CLASSIFIED STAFF NOTICE: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Read all of the rules very carefully, including the Coordination of Benefits section, and compare them with the rules of any other plan that covers you or your family. Effective: October 1, 2008

2 INTRODUCTION This booklet is a Summary Plan Description (SPD). It is intended to explain the benefits provided by the South Central Ohio Insurance Consortium for LOGAN-HOCKING LOCAL SCHOOLS. It does not constitute the Plan. Rights and benefits of Covered Persons are determined in accordance with the provisions of the Plan, and coverage is effective only if a Covered Person is eligible for coverage and becomes and remains covered in accordance with the terms of this Plan. The benefits described in this booklet replace similar types of benefits described in all booklets, amendments, certificates, or riders previously issued to Covered Persons by LOGAN- HOCKING LOCAL SCHOOLS. To avoid dual references throughout this booklet, masculine pronouns such as he, him and his will include the feminine gender as well for purpose of benefits and provisions of the plan. Many of the provisions in this booklet are interrelated; therefore, reading just one or two sections may not give the Covered Person an accurate impression of his coverage. You are responsible for knowing the terms and conditions of this Plan. Capitalization of the first letter of a word or phrase not normally capitalized according to the rules of standard punctuation (e.g., Surgery), with the exception of some job titles, company or agency names, certain types of coverage and references to specific sections of this Summary Plan Description, indicates a word or phrase that is defined in the Definitions section, or that refers to an item in the Schedule of Benefits. Anyone who intentionally includes false or misleading information in any enrollment material, claims submission, or other written material pertaining to the Plan in an attempt to defraud or deceive is guilty of insurance fraud. The Plan s Claims Administrator is: Employee Benefit Management Corp (EBMC) 4789 Rings Road Dublin, Ohio Toll-Free In Columbus, Ohio Website:

3 TABLE OF CONTENTS Page Managed Care Program...4 Schedule of Benefits...6 Eligibility and Effective Date of Coverage...12 Enrollment Requirements...14 Late Enrollment...14 Open Enrollment...14 Special Enrollment Periods...14 Pre-Existing Conditions Limitation...15 Employment Related Events Affecting Coverage...16 Individual Termination of Coverage...17 COBRA Continuation Coverage...18 Pre-Tax Election...21 COMPREHENSIVE MEDICAL BENEFITS...25 Maximum Lifetime Benefit...25 Calendar Year Deductible...25 Family Deductible...25 Deductible Carryover...25 Co-insurance...25 Per Visit Co-payment...26 Out-of-Pocket Maximum...26 Well Care Benefit...26 Hospital Benefit...28 Emergency Room Benefit...29 Urgent Care Facility Benefit...30 Ambulance Benefit...30 Skilled Nursing Facility Benefit...30 Hospice Care Benefit...30 Home Healthcare/Private-Duty Nursing Benefit...31 Physician Expense Benefit...32 Medical Supplies, Durable Medical Equipment, and Appliances...34 Therapy Services Expense Benefit...35 Radiation and Respiration Therapies, Chemotherapy. Kidney Dialysis and Cardiac Rehabilitation Benefit...36

4 TABLE OF CONTENTS (continued) Page Outpatient Mental Disorder Substance Abuse Treatment Benefit...36 TMJ (Temporomandibular Joint) Benefit...37 Independent Laboratory Benefit...37 Organ and/or Tissue Transplant Benefit...38 All Other Covered Medical Expenses...39 PRESCRIPTION DRUG PROGRAM...42 GENERAL PROVISIONS General Limitations...46 Coordination of Benefits with Group Plans and Medicare...50 Payment of Benefits...52 Recovery Rights...53 Amendment, Modification or Termination...54 Plan Information...54 Claim Procedures...55 HIPAA Privacy and Security Compliance...58 Definitions...61

5 MANAGED CARE PROGRAM NETWORK PPO (PREFERRED PROVIDER ORGANIZATION) The Plan has contracted with a Network of preferred provider Hospitals and Physicians to provide care at discounted rates. The Plan provides incentives for you to use in-network providers through benefit differential in the Calendar Year Deductible, Out-of-Pocket maximums and benefit percentages. The Network should be contacted to determine if a particular Hospital, Physician, or other health care provider participates in the Network. The In-network level of benefits may be payable for the following covered services: Covered lab services performed by a Non-Network independent lab facility, anesthesia services, and radiology interpretations. Emergency care at a Non-Network Hospital for an Accidental Injury or a Medical Emergency. A Medical Emergency is an Illness that manifests itself by such acute symptoms of sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: the patient s health, or in the case of a pregnancy, the health of the woman or her unborn child, would be placed in serious jeopardy; bodily function would be seriously impaired; or there would be serious dysfunction of a body organ or part. Examples of medical emergencies include heart attacks, loss of consciousness or respiration, and convulsions. For any Covered Person who cannot access Network Providers because he resides outside the Network service area, i.e. a student attending schools or a covered child living with a former spouse outside the Network service area. Persons residing outside the Network service area must be pre-approved and so designated by the Employer. PRE-CERTIFICATION AND UTILIZATION REVIEW The Plan uses the services of Alternative Care Management Systems, Inc. (ACMS) to provide the required pre-certification and utilization review services to the Plan. The Patient Services Center is the operations center of ACMS. It is staffed by nurses and other support personnel who work closely with Covered Persons and their Physicians in the delivery of healthcare services. The Covered Person, a friend, a relative or the Covered Person s Physician may contact the ACMS Patient Services Center. ACMS will also certify the length of the Hospital stay, as each day of confinement must be medically necessary. ACMS certification, however, is not a benefit determination and questions regarding benefit payment should be directed to the Claims Administrator. The pre-certification and utilization requirements of the Plan do not apply to Covered Persons whose primary coverage is Medicare. The following medical services require pre-certification or utilization review by ACMS: 4

6 NOTE: Hospital admissions (See the Benefit Section entitled Hospital Expense Benefits for special rules for maternity admissions and the time frames for precertification; Conversion of unused Inpatient Mental Health/Substance Abuse benefit days to Outpatient visits; Because additional discounts may be available, ACMS notification is encouraged prior to rental or purchase of any durable medical equipment exceeding $750. CASE MANAGEMENT ACMS also performs Case Management services for the Plan. Case Management applies if the nature of a patient s condition is, or is expected to become catastrophic or chronic, or when the cost of treatment is expected to be significant. Examples of conditions that might prompt case management intervention include organ transplants, amputations, multiple fractures, spinal cord injury, cerebral vascular accident, cancer, head trauma, AIDS, multiple sclerosis, severe burns, severe psychiatric disorder, or high risk pregnancy/high-risk infant. Additional information is available from ACMS. Payments for expenses not covered under the Plan that are recommended by a medical case management service shall be reimbursable with the approval of the Plan Sponsor. Office hours for ACMS are 8:00 a.m. to 5:00 p.m. (Eastern Time), Monday through Friday. An answering system will take messages during the hours when ACMS is closed. The toll-free telephone number for ACMS is: (In Columbus, Ohio) (Toll Free - Outside Columbus, Ohio) 5

7 SCHEDULE OF BENEFITS Effective October 1, 2008 COMPREHENSIVE MEDICAL BENEFITS (Eligible Employees and Dependents) All benefit considerations of the Plan are subject to the Usual, Customary, and Reasonable (UCR) Allowance and Necessary Medical Services provisions of the Plan. Before any benefits are payable from the Plan, the Calendar Year Deductible has to be satisfied for covered services unless it is specifically waived in this Schedule of Benefits. LIFETIME MAXIMUM BENEFIT... $5,000,000 Network and Non-Network benefits are combined Lifetime Maximum Benefit for Substance Abuse Treatment:...Two Inpatient or Outpatient Rehabilitation Programs NETWORK NON- NETWORK CALENDAR YEAR DEDUCTIBLE Per Covered Person... $250...$500 Per Covered Family... $ $1,000 Network and non-network deductibles do not accumulate toward each other. OUT OF POCKET LIMIT Per Covered Person... $1, $2,500 Per Covered Family... $2, $5,000 NOTE: The Out-of-Pocket Limit includes Deductibles and Co-insurance incurred by the Covered Person within the Calendar Year except for the following: Prescription Drug benefits Non-network Human Organ and Tissue Transplant services Co-Payments as required herein Network and non-network out-of-pocket-limits do not accumulate toward each other. NON- COVERED SERVICES NETWORK NETWORK PREVENTIVE CARE... Deductible and Co-...Deductible and Co- Insurance is based insurance is based on the setting where on the setting where service is performed service is performed 6

8 SCHEDULE OF BENEFITS (continued) NON- NETWORK NETWORK HOSPITAL BENEFIT Inpatient... 90%... 70% Calendar Year benefit maximums apply as follows: Mental Disorder or Network Only Substance Abuse Treatment (Combined) days days Non-Network Substance Abuse Treatment... $550 combined in- or out patient Biologically-Based Mental Illness (as defined herein) is covered the same as any other Illness Outpatient Surgical Facilities (includes alternative care facility)... 90%... 70% Diagnostic X-Ray and Lab (including their interpretations) %... 70% (Deductible Waived for In-Network services only) NOTE: Allergy testing, MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies and non-maternity related ultrasound services are covered under All OTHER COVERED MEDICAL SERVICES below EMERGENCY ROOM (deductible is waived)...$100 Co-Pay... Paid same Facility and Physician Charges per visit, then 100% as Network Co-payment is waived if admitted URGENT CARE CENTER...$15 Co-Pay...Paid same as Network AMBULANCE BENEFIT... 90%...Paid same as Network SKILLED NURSING FACILITY EXPENSE BENEFIT...90%...70% Maximum Confinement per Calendar Year (Combined) days days HOSPICE CARE BENEFIT... 90%... Paid same as Network HOME HEALTH CARE...90%... 70% Maximum visits per Calendar Year (Combined) Maximum Private Duty Nursing Care rendered in the home (combined) 1 : $50,000 per Calendar Year $100,000 per Lifetime PHYSICIAN EXPENSE BENEFIT Office or home Visits...$15 Co-Pay... 70% 7

9 SCHEDULE OF BENEFITS (continued) NETWORK NON- NETWORK Includes Primary Care Physician, Specialty Care Physician, or surgery performed in the office Related covered charges not billed by the Physician will be paid at the appropriate benefit percentage as indicated by the place of service. Allergy Injections... 90%... 70% The Allergy Injection coinsurance applies when the injection is billed by itself. The office visit co-payment/co-insurance applies if an office visit is billed with an allergy injection. Allergy testing, services are covered under All OTHER COVERED MEDICAL SERVICES as described herein: Mammogram (Routine or Diagnostic), Diabetes Self-Management training, or Network Only Medical Nutritional Therapy %... 70% Surgery and Assistant Surgeon... 90%... 70% Anesthesia... 90%...Paid Same As Network Hospital Inpatient Physician Visits... 90%... 70% Other In-patient or Outpatient Professional Services... 90%... 70% MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, APPLIANCES EXPENSE BENEFIT... 90%... 70% Maximum per Calendar Year: (Combined) 1 for all prosthetic devices received on an outpatient basis -$10,000 (not including surgical prosthetics) for all Durable Medical Equipment and orthotics - $10,000 NOTE: Because additional discounts may be available, ACMS notification is encouraged prior to rental or purchase of any durable medical equipment exceeding $750. THERAPY SERVICES... 90%... 70% Maximum Visits per Calendar Year (Combined) 1 for Physical Therapy for Occupational Therapy for Speech Therapy NOTES: The above limits apply when rendered as Physician Office visits or as outpatient services. When rendered in the home, Home Health Care limits apply for the above services; MANIPULATION THERAPY...$15 Co-pay... 70% Maximum Visits per Calendar Year (Combined) Manipulation Therapy is not covered in the home; 8

10 SCHEDULE OF BENEFITS (continued) NETWORK NON- NETWORK RADIATION, RESPIRATORY THERAPIES, CHEMOTHERAPY, KIDNEY DIALYSIS AND CARDIAC REHABILITATION EXPENSE BENEFIT... 90%... 70% OUTPATIENT MENTAL DISORDERS OR SUBSTANCE ABUSE TREATMENT Outpatient Services... 90%... 70% Physician Home/Office Service...$15 Co-Payment... 70% Maximum Visits Per Calendar Year Mental Disorders or Network only substance abuse Non-Network Substance Abuse Treatment...$550 combined in- or outpatient Biologically-Based Mental Illness (as defined herein) is covered the same as any other Illness TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJ)... 90%... 70% INDEPENDENT LAB EXPENSE BENEFIT (Calendar Year deductible is waived) (Including their Interpretation) %... Paid same as Network NOTE: MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies and nonmaternity related ultrasound services are covered under All OTHER COVERED MEDICAL SERVICES below ORGAN AND/OR TISSUE TRANSPLANTS (Calendar Year Deductible is waived) %... 50% ALL OTHER COVERED MEDICAL SERVICES...90%...70% 1 For purpose of benefits described in this Schedule, the term Combined means that Network and Non-Network charges are combined for one Maximum Benefit allowance. All expenses must be submitted within 12 months from the date such charges were incurred to be eligible for benefit payment under this Plan PRESCRIPTION DRUG PROGRAM (Eligible Employees and Dependents) CO-PAYMENT RETAIL RX PROGRAM (30-day supply) PER PRESCRIPTION OR REFILL Generic Prescription...$10 Preferred Brand-Name...$25 Non-Preferred Brand-Name...$45 9

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12 SCHEDULE OF BENEFITS (continued) MAIL-ORDER RX PROGRAM (90-day supply) Generic Prescription...$25 Preferred Brand-Name...$62 Non-Preferred Brand-Name...$112 SPECIALTY NETWORK DRUGS PROGRAM (30-day supply) Generic Prescription...$10 Preferred Brand-Name...$25 Non-Preferred Brand-Name...$45 If you obtain services from a non-network pharmacy, The Pharmacy Benefit Manager (PBM) will provide 50% reimbursement after a co-payment of $45. You must pay the full amount of the bill for the Prescription Drug at the time of purchase. Then you must file a standard claim form which can be obtained from the PBM, and payment will be made directly to you. You may be responsible for any amount in excess of the Prescription Drug Covered Charges. Prescription drug expenses under the Prescription Drug Program do not apply to the Calendar Year Deductible nor to the Out-of-Pocket Maximum under Comprehensive Medical Expense Benefits. 11

13 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE

14 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE ELIGIBLE EMPLOYEE Active, full-time Certified/Classified employees of the Employer who are regularly scheduled to work at least 20 hours per week or who were employed by the Logan Hocking Local Schools Board of Education before September 1, 1985, and elected Board of Education Members, are eligible to participate on the first day of the month following the date they become active employees or are elected. Substitute teachers who have been assigned to one specific position for a period of 60 days or more shall be eligible to participate in the Plan. Coverage may begin the first day of the month following the month in which the substitute teacher met the eligibility requirements. All Eligible Employees who are actively at work and enrolled on the Effective Date of the Plan will be covered on that date. New employees will be covered on the date they complete an Enrollment Form following completion of the Waiting Period and satisfaction of any other eligibility requirements, provided they are actively working on that date. An employee who is not actively at work on his Effective Date of coverage will not be covered until the date he returns to active employment. However, an employee who is not actively at work because of medical disability or other health conditions on his Effective Date of coverage will not be subject to the active-at-work requirements. ELIGIBLE DEPENDENT Eligible Dependents include the Eligible Employee s legal spouse as recognized by the state of residence (who is not also covered under the Plan as an employee), unless divorced or legally separated, and children to the end of the month in which they attain age 19 years of age provided the children have never been married and are dependent upon the Eligible Employee for support and maintenance. The term children includes: Natural children and legally adopted children Children for whom the Eligible Employee has retained the legal duty for total or partial support pending final adoption proceedings NOTE: The Pre-existing Conditions Limitation is waived for any child in the process of adoption. Stepchildren living with the Eligible Employee Children for whom the Eligible Employee has legal guardianship who are living with the Eligible Employee in a regular parent-child relationship Any child of an Eligible Employee covered under the Plan who is determined to be an Eligible Dependent under a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Notice (NMSN), as defined. 12

15 In addition to the above, children will be considered as Eligible Dependents from age 19 through the end of the month in which they reach age 25 if they are Full-Time Students at an accredited college, university or institution offering high school or post-high school education. They must never have been married and be dependent upon the Eligible Employee for support and maintenance. Full-Time Student status will be determined based on the standards of the institution attended. A full time student is absent from school no more than one term per Calendar Year. Summer is considered a school term. If a student does not return to school at the onset of the term following a school break, coverage under this Plan will terminate retroactive to the end of the last term attended. Eligibility will cease at the end of the month in which the dependent graduates or is no longer a Full-Time Student. If a child covered as an eligible dependent is between age 24 up through age 25, has gross income over the exemption amount set forth in Internal Revenue Code Section 151(d) or does not receive over one-half of his support for the year from the eligible employee, contributions attributable to this child s coverage will be included in the employee s gross income. Newborn children are eligible for coverage under the Plan from birth if enrolled within 31 days after birth. A child who is physically or mentally incapable of self-support upon attaining the age limit may be considered as an Eligible Dependent while remaining incapacitated and continuously covered as a dependent under this Plan or a previous employer-sponsored plan, and having never been married. This incapacity must have started before the age limit was reached and must be medically certified by a Physician. To continue a child under this provision, proof of incapacity must be submitted to the Claims Administrator at least 31 days prior to the child s attainment of the age limit. If approved, proof of continuing incapacity may be required from time to time thereafter. The Plan will recognize a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Notice (NMSN), as defined, for purposes of providing coverage to dependent children. The order must be sent to the Plan Administrator, who will notify the Eligible Employee named in the order and each Alternate Recipient (a child of an Eligible Employee who is recognized in the QMCSO or NMSN as having the right to enroll in the Plan) that a Medical Child Support Order (MCSO) has been received. The Plan Administrator must also advise the Eligible Employee of the Plan procedures for determining if it is a qualified MCSO. In addition, the Plan Administrator must notify each person specified in the MCSO as to his eligibility for coverage and must allow the Alternate Recipient to designate a representative to receive Plan communications. The term Eligible Dependent does not include anyone who is covered as an Eligible Employee or any dependent child who has ever been married. If the Company employs both parents, children will be covered only as dependents of one parent. 13

16 EFFECTIVE DATE OF COVERAGE FOR DEPENDENTS An Eligible Dependent who is enrolled after the Effective Date of this Plan will become covered on the same date as the Eligible Employee or the date such dependent is acquired, whichever is later. ENROLLMENT REQUIREMENTS Coverage does not become effective for an employee and/or his dependents who become eligible for coverage on or after the Effective Date of this Plan until the employee completes an Enrollment Form agreeing to any required contributions. If the Eligible Employee enrolls himself and his Eligible Dependents within 31 days after first becoming eligible, coverage for any additional dependents acquired later (e.g., a newborn or adopted child or a new spouse) will become effective on the date they qualify as Eligible Dependents. However, the employee must notify the Employer of any new dependents and complete a new Enrollment Form. Additional information verifying eligibility may be required. If the contribution level is affected, the employee must complete the Enrollment Form within 31 days. If the employee authorizes required contributions for himself and/or his Eligible Dependents more than 31 days after first becoming eligible, the enrollment is considered a late enrollment. LATE ENROLLMENT If the employee initially declines coverage for himself and/or his Eligible Dependents during the 31- day eligibility period following his date of hire, he will be considered a late enrollee. Late Enrollees may enroll only during the open enrollment period. OPEN ENROLLMENT In September of each year, an open enrollment period will allow all covered employees who failed to enroll in the Plan during their initial eligibility period to elect coverage under the Plan. The Effective Date of new coverage will be October 1, assuming the Enrollment Forms are submitted on a timely basis. No enrollment will be allowed at any other time during the year, except as provided under Special Enrollment Periods below. SPECIAL ENROLLMENT PERIODS An Eligible Employee who declined this coverage for himself or his dependents during the initial 31-day eligibility period may enroll for coverage later if the following conditions are met: 1) The Eligible Employee (and/or dependent) loses coverage under another Group Health Plan or other health insurance coverage, which was in force at the time this coverage was initially declined and was the reason for the declination. 2) The loss of coverage is due to one of the following events: 14

17 a) Loss of eligibility for coverage is due to cessation of employer contributions, legal separation, divorce, or due to a spouse s death, termination of employment or reduction in the number of hours employed. Loss of eligibility does not include any loss due to failure of the individual to pay premiums on a timely basis or termination for cause; or b) COBRA Continuation Coverage has been exhausted. A Special Enrollment Period is also offered to any Eligible Employee who previously declined coverage for any reason and later acquires an Eligible Dependent (or additional Eligible Dependent) due to: Marriage Birth of a child Adoption or placement for adoption In the case of enrollment during a Special Enrollment Period, the employee must request coverage as outlined in this section within 31 days of the date a) COBRA Continuation Coverage is exhausted; b) The other coverage is terminated due to loss of eligibility; or c) Of acquiring an Eligible Dependent. The Effective Date of coverage obtained under a Special Enrollment Period will be the date the completed request for enrollment is received by the Plan Administrator. However, in the case of marriage, birth, adoption or placement for adoption, the Effective Date will be the date of the event causing the Special Enrollment opportunity. PRE-EXISTING CONDITIONS LIMITATION Covered Persons will not be entitled to benefits for expenses incurred as the result of any Injury or Illness for which the Covered Person has consulted with a Physician, taken medication or received any medical care services during the three-month period immediately prior to becoming covered under the Plan, until the expiration of: 1) A period of 12 consecutive months from the Covered Person s Enrollment Date in the Plan; or 2) A period of 12 consecutive months from the Covered Person s Enrollment Date in the Plan, if enrollment is more than 31 days after the individual was first eligible as described under Enrollment Requirements. This provision does not apply to a newborn child enrolled within 31 days of his birth, or to an adopted child under age 18 who is enrolled within 31 days of his adoption or placement for adoption, or to expenses due to pregnancy which would otherwise have been eligible for benefits under the Plan. 15

18 Any period of time during which Creditable Coverage, as defined, was in effect will carry over to offset or reduce the Pre-Existing Conditions Limitation as long as no break in coverage of 63 days or more has occurred. Any Waiting Period for coverage is not considered a break in coverage. Certification of Creditable Coverage must be supplied indicating the exact time period such coverage was in effect. This certification is supplied by the employer, insurance company or other organization that provided the Creditable Coverage (see Definitions section, Creditable Coverage ). The Pre-Existing Conditions Limitation is reduced by one day for each day of prior Creditable Coverage certified. The newly enrolled individual will be notified in writing of the number of days remaining, if any, in the Pre-Existing Conditions Limitation after prior Creditable Coverage has been deducted. Eligible individuals have the right to appeal the decision relative to the application of Creditable Coverage and supply additional evidence of such prior coverage. EMPLOYMENT RELATED EVENTS AFFECTING COVERAGE PAID ABSENCE If the covered employee is absent from active work but continues to received regular payroll checks under a paid vacation, short term sick leave, bereavement, jury duty or other paid absence policy of the Employer, coverage under this Plan will continue for the duration of the approved, paid absence. MILITARY LEAVE If a covered employee is on a military leave of absence, coverage will continue for a maximum of 31 days from the date leave began, subject to payment of required employee contributions. Additionally, under the Uniformed Services Employment and Re-employment Rights Act of 1994 (USERRA), as amended by the Veterans Benefit Improvement Act of 2004 (VBIA), an eligible employee may elect to continue coverage for himself and his enrolled dependents for a period up to a maximum of 24 months. During this extended leave, the covered employee may be required to pay up to 102% of the cost of the coverage. Coverage will be reinstated effective on the date the employee returns to work. The section entitled COBRA Continuation Coverage outlines alternative continuation coverage. DEATH OF EMPLOYEE Coverage for enrolled dependents may be continued in full to the end of the month in which death of the covered employee occurs, subject to the payment of any required contributions. The section entitled COBRA Continuation Coverage outlines continued coverage provisions. 16

19 FMLA LEAVE OF ABSENCE Notwithstanding the policies stated above, the Plan shall at all times comply with the Family and Medical Leave Act of 1993 ( FMLA ), as amended, and as promulgated in regulations issued by the Department of Labor. During any leave taken under the FMLA (the FMLA Leave ), coverage under the Plan shall be maintained on the same conditions as coverage would have been provided if the covered Employee had been continuously employed during the FMLA Leave. If coverage under the Plan terminates during the FMLA Leave, coverage shall be reinstated for the Employee and his covered dependents if the Employee returns to work in accordance with the terms of the FMLA Leave. Coverage shall be reinstated only if the Employee and any covered dependents had coverage under the Plan when the FMLA Leave started, and shall be reinstated to the same extent that it was in force when that coverage terminated. NON-FMLA LEAVE OF ABSENCE During an approved non-fmla leave of absence, coverage under this Plan may be continued in accordance with the appropriate bargaining agreement or School Board policy. The section entitled COBRA Continuation Coverage outlines additional continued coverage provisions. INDIVIDUAL TERMINATION OF COVERAGE The coverage of any Covered Person under the Plan will terminate on the earliest of the following dates: The date of termination of the Plan or the date certain benefits terminate. The date a Covered Person becomes a full-time member of the armed forces of any country, except as specifically outlined for Military Leave in the previous section, Employment- Related Events Affecting Coverage. The beginning of a period of coverage for which the Covered Person fails to make any required contribution. The date an active covered employee or his eligible covered dependent spouse elects Medicare as the primary plan of benefits. The date a covered employee s employment terminates or the date he no longer meets eligibility requirements, except as provided in the previous section, Employment Related Events Affecting Coverage and as outlined in the following section, COBRA Continuation Coverage. With respect to a covered dependent, the date coverage terminates for the covered employee or the date the dependent no longer meets the qualifications of an Eligible Dependent, except as outlined in the following section, COBRA Continuation Coverage. 17

20 COBRA CONTINUATION COVERAGE (Consolidated Omnibus Budget Reconciliation Act) EMPLOYEE QUALIFYING EVENTS A covered employee and/or any covered dependent may elect COBRA Continuation Coverage under the Plan at his own expense for up to 18 months if coverage is lost due to one of the following qualifying events: 1) Voluntary or involuntary termination of employment of the covered employee (other than for gross misconduct) 2) A reduction in work hours for the covered employee DEPENDENT QUALIFYING EVENTS A covered dependent may elect COBRA Continuation Coverage under the Plan at his own expense for up to a maximum of 36 months if coverage is lost due to one of the following qualifying events: 1) The death of the covered employee 2) Loss of eligibility as a covered dependent as defined in the Plan 3) Divorce or legal separation of the covered employee 4) The covered employee becoming entitled to primary Medicare benefits 5) A filing for reorganization under Chapter 11 of the Bankruptcy Code by the Company in the case of a surviving spouse and/or dependent child(ren) of a deceased retired employee The covered employee or dependent is responsible for notifying the Company within 60 days of the events outlined in items 2) and 3) above. The notification must be in writing and include the name and address of the person affected as well as the date of the event. Failure to do so will result in the loss of the covered dependent s right to elect COBRA Continuation Coverage. MEDICARE S EFFECT ON COBRA If the employee is enrolled for Medicare benefits at the time coverage terminates due to an Employee Qualifying Event listed above, the period of continuation for covered dependents will be the longer of: a. 18 months from the date coverage terminates due to the Qualifying Event; or b. 36 months from the date the Employee became enrolled for Medicare benefits. MULTIPLE QUALIFYING EVENTS Subsequent Qualifying Events occurring while the COBRA continuation is in effect may entitle Qualified Beneficiaries to additional periods of coverage, but the total period of COBRA continuation coverage for all Qualifying Events will not exceed 36 months from the date of the original Qualifying Event. 18

21 COBRA RIGHTS AND OBLIGATIONS COBRA Continuation Coverage must be elected within 60 days from the later of the date coverage terminates or the date written notice of the right to elect COBRA Continuation Coverage is sent. Failure to elect within this time frame will result in the loss of the Covered Person s right of COBRA Continuation Coverage. Payment for the cost of COBRA Continuation Coverage is due by the first of the month for each month of coverage, and coverage will cease if the monthly payment is not received within 30 days of the date it was due. Payment for the full cost of COBRA Continuation Coverage for the period from when coverage was lost through the date of election must be made within 45 days after the election. A Qualified Beneficiary may waive COBRA continuation coverage during the 60-day election period. This waiver of coverage may be revoked by the Covered Person at any time before the end of the election period. In this case, coverage will be effective on the date of the waiver revocation notice is received by the COBRA Administrator. Coverage will not be provided retroactively. COBRA Continuation Coverage will be provided for each month as long as payment for that coverage period is made before the end of the grace period for that payment. However, if a monthly payment is paid later than the first day of the month, but before the end of the grace period for the coverage period, coverage under the Plan may be suspended and then retroactively reinstated (going back to the first day of the month) when the monthly payment is received. This means that any claims submitted while coverage is suspended may be denied and may have to be resubmitted once coverage is reinstated. If the Company makes revisions in coverage after a Covered Person has elected COBRA, any revisions to active employees will also apply to COBRA-qualified beneficiaries. Special rules apply to a loss of retiree health coverage resulting from a Company s Chapter 11 bankruptcy proceedings that commence within one year before or after the date the proceedings begin. A child who is born to or placed for adoption with the covered employee during a period of COBRA Continuation Coverage will be eligible to become covered as a dependent. In accordance with the terms of the Plan and federal law requirements, these new dependents may be added to COBRA Continuation Coverage upon proper notification to the Company of the birth or adoption. TRADE ACT OF 2002 Special COBRA rights apply to employees who have been terminated or experience a reduction of hours as a result of import competition or shifts of production to other countries. These employees may qualify for a trade readjustment allowance or alternative trade adjustment assistance under a federal law called the Trade Act of These employees are entitled to a second opportunity to elect COBRA Continuation Coverage for themselves and certain family members (if they did not elect COBRA Continuation Coverage), but only within a limited period of 60 days (or less) and only during the six months immediately after their Group Health Plan coverage ended. The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance. Under the new tax provisions, eligible individuals can either take a tax credit 19

22 or receive advanced payment of 65% of premiums paid for qualified health insurance, including COBRA Continuation Coverage. Employees who qualify, or may qualify, for assistance under the Trade Act of 2002, should contact their COBRA Administrator for additional information. They must contact their COBRA Administrator promptly after qualifying for assistance under the Trade Act of 2002 or they will lose their special COBRA rights. Any questions about the Trade Act of 2002 may be directed to the Health Care Tax Credit Customer Contact Center toll-free at , or the website can be accessed at COBRA DISABILITY CONTINUATION Covered employees and dependents entitled to elect COBRA Continuation Coverage due to an employee s termination of employment or reduction in hours may extend their coverage from 18 to 29 months. The covered employee or dependent must be disabled (as defined under Title II or Title XVI of the Social Security Act) at the time of termination or reduction in hours or within the first 60 days of COBRA Continuation Coverage. The covered employee or dependent must notify the Company (in writing) within 60 days of the Social Security disability determination (or, if later, within the first 60 days of COBRA Continuation Coverage) and before the end of the normal 18- month coverage period. Failure to provide notice within this time frame will result in the loss of the 11-month extension of COBRA Continuation Coverage. Beginning with the 19th month, the cost of the COBRA Continuation Coverage may increase up to 50%. The covered employee or dependent is also responsible for notifying the Company within 30 days after a final determination has been made by Social Security that the Covered Person is no longer disabled. COBRA Continuation Coverage may be terminated on the first day of the month that is more than 30 days after the final determination that the Covered Person is no longer disabled or on the date the individual becomes entitled to Medicare benefits, if sooner. TERMINATION OF COBRA COVERAGE Any COBRA Continuation Coverage made available above will cease if: The Company no longer provides group health coverage to any of its employees. After payment has begun, a covered employee or dependent fails to make the full payment when due or within the 30-day grace period allowed by law. The covered employee or dependent becomes entitled to Medicare after COBRA Continuation Coverage has been elected. The covered employee or dependent becomes covered (as an employee or otherwise) under another Group Health Plan after COBRA Continuation Coverage has been elected, unless that plan contains any exclusion or limitation in regard to a Pre-Existing Condition that is not waived by reason of prior Creditable Coverage. COBRA Continuation Coverage may also be terminated for any reason the Plan would terminate coverage of a Participant or beneficiary not receiving COBRA Continuation Coverage (such as fraud). 20

23 PLAN CONTACT INFORMATION Contact the Company for additional details concerning COBRA Continuation Coverage. In order to protect a family s rights, the covered person should keep the Company informed of any changes in the addresses of family members and/or any new dependents, and should retain a copy of any notices sent to the Company. For more information about rights under COBRA, the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting Group Health Plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) or visit the EBSA website at (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) PRE-TAX ELECTION Unless they elect otherwise, all covered employees will have their share of the cost of coverage paid on a pre-tax basis. This means the employee s share of the cost will be deducted from his pay before his taxable wages are determined. Therefore, total wages remain the same, but the amount of wages that is taxed is a lower amount. The use of pre-tax dollars to pay for coverage will reduce federal and state income taxes and increase an employee s spendable income. No change in election is permitted prior to that time except in cases of significant cost or coverage changes to the employee, separation from service by the employee or certain changein-status events. Change-in-status events include: 1) Marriage, divorce, legal separation or annulment of the employee s marriage 2) Death of the employee s spouse or a child 3) Birth, adoption or placement for adoption of a child of the employee, including the commencement or termination of an adoption proceeding 4) Commencement or termination of employment by the employee, the employee s spouse or a dependent 5) A reduction or increase in hours by the employee, spouse or dependent, including a switch from full-time to part-time employment, a strike or lockout, or commencement or return from an unpaid leave of absence 6) Dependent satisfies (or ceases to satisfy) dependent eligibility requirements 7) A change in the place of residence or work of the employee, spouse or dependent that affects the employee s eligibility for coverage 8) Significant change in the health coverage of the employee or spouse attributable to the spouse s employment 9) A judgment, decree or order resulting from a divorce, legal separation, annulment or change in legal custody (including a Qualified Medical Child Support Order as defined by ERISA) 21

24 10) The entitlement or loss of entitlement by the employee, spouse or dependent to Medicare or Medicaid 11) Increase or decrease during the Plan year in the cost of the healthcare program. The Plan will automatically make a corresponding change in the salary reduction amount. If the cost of the healthcare Plan reduces significantly, the employee is allowed to begin participation in the Pre-Tax Election option. If the cost of the healthcare Plan increases significantly, the employee is allowed to revoke his pre-tax election. 12) Significant curtailment without loss of employee, spouse or dependent s coverage. Significant curtailment means a significant increase in the deductible, co-payments or out-of-pocket limit of the Group Health Plan. If there is a significant curtailment with loss of employee, spouse or dependent s coverage, the employee may revoke his election. If the Plan adds a new coverage option or if an existing benefit package option is significantly improved, the Plan may permit a covered employee to revoke his election and, instead, make a pre-tax election on a prospective basis to fund for coverage under the new or improved benefit package option. 13) An election change that is due to, and corresponds with, a change made under another employer s cafeteria plan. The other cafeteria plan must permit Participants to make an election change that would be permitted under special enrollment rights; change in status; judgment, decree or order; entitlement to Medicare or Medicaid; significant cost or coverage changes; or special requirements related to the Family and Medical Leave Act (FMLA). 14) Loss of coverage under any group health coverage sponsored by a government or educational institution AN ELECTION CHANGE DUE TO A CHANGE IN STATUS MUST BE MADE WITHIN 30 DAYS OF THE DATE OF THE CHANGE IN STATUS. ACCORDING TO RULES ESTABLISHED BY THE INTERNAL REVENUE SERVICE, THE ELECTION CHANGE MUST BE CONSISTENT WITH THE CHANGE IN STATUS. In the event of separation from service and subsequent re-employment during the same Pre-Tax Election Plan year, if the employee should be rehired within 30 days of his termination, he would be able to make a new election if the facts and circumstances justified the change. If the employee is rehired more than 30 days after termination, he may make a new election regardless of the circumstances. The regulations also permit an employee to increase his pre-tax contributions for coverage under his current employer s health plan if a qualifying event as defined under the Consolidated Omnibus Budget Reconciliation Act (COBRA) occurs with respect to the employee, the employee s spouse or a dependent. As a result, the employee could increase pre-tax contributions in mid-year to pay his cost of COBRA Continuation Coverage. The right to increase pre-tax contributions does not apply to COBRA coverage under another employer s plan. The regulations also confirm that an employee may change his pre-tax election for health coverage to the extent the election change corresponds and is consistent with the special 22

25 enrollment rights under the Health Insurance Portability and Accountability Act (HIPAA). If an employee has a right to enroll in an employer s Group Health Plan or to add coverage for a family member under HIPAA, the employee may make a confirming election under this Pre-Tax Election option. 23

26 COMPREHENSIVE MEDICAL BENEFITS

27 COMPREHENSIVE MEDICAL BENEFITS If a Covered Person incurs covered medical expenses for Necessary Medical Services due to a non-occupational Injury or Illness, the Plan will consider benefits up to the Usual, Customary, and Reasonable (UCR) Allowance and pay benefits after the Calendar Year Deductible is satisfied (unless specifically waived) and at the benefit percentages specified in the Schedule of Benefits for covered medical services received during any one Calendar Year. The benefits payable shall not exceed the Maximum Lifetime Benefit and are subject to all limitations and conditions of the Plan. MAXIMUM LIFETIME BENEFIT The Maximum Lifetime Benefit per Covered Person under this Plan is listed in the Schedule of Benefits. This maximum includes, but is not in addition to, any separate maximums shown for specific treatment. For purposes of determining benefits under this Plan, the term Lifetime means the period of a person s life during which he is continuously covered under this Plan. Changing to another Plan Option offered by the Employer shall not create a new Lifetime Maximum benefit allowance. CALENDAR YEAR DEDUCTIBLE Covered medical expenses are subject to the Calendar Year Deductible amount shown in the Schedule of Benefits, except when specifically waived in the Schedule of Benefits. Covered medical expenses used to satisfy this deductible are not reimbursable by the Plan. The Calendar Year Deductible is satisfied when the Covered Person or covered Family has incurred covered medical expenses within a Calendar Year as outlined in the Schedule of Benefits. Expenses applied to the In-Network Deductible shall not apply to the Out-of-Network Deductible and vice versa. Family Deductible If the total covered medical expenses applied to the individual deductibles of the family members exceed the family deductible amount shown in the Schedule of Benefits, no additional deductibles are required of the family members for the remainder of that Calendar Year. Deductible Carryover Covered medical expenses incurred during the last three months of any Calendar Year that are applied toward the individual and family Calendar Year Deductible for that year are also applied toward the individual and family Calendar Year Deductible for the next year. CO-INSURANCE The term co-insurance generally refers to the Covered Person s responsibility for payment of a medical service where the Plan pays less than 100% of the covered charge. The percentage that the Plan will pay for any specific type of medical services is shown on the Schedule of Benefits. The Covered Person is responsible for the remainder of the charge or the co-insurance. The co-insurance may be used to satisfy the Out-of-Pocket maximum unless the type of service is specifically excluded. 25

28 PER VISIT CO-PAYMENT The Plan may impose an initial per visit Co-payment each time a Covered Person incurs charges for certain types of medical services. The amount of this Co-payment is shown in the Schedule of Benefits when it is applicable. The per-visit-co-payment is not applied to the Calendar Year Deductible nor to the Out-of-Pocket limit. OUT-OF-POCKET MAXIMUM If the maximum out-of-pocket amount shown in the Schedule of Benefits is met during any one Calendar Year, the Plan will pay 100% of additional incurred covered expenses for the remainder of that Calendar Year. Deductibles and co-insurance can be used to satisfy the Outof-Pocket Maximum except as specified below. Network deductibles and co-insurance shall not apply to the Non-Network Out-of-Pocket Maximum amount and vice versa. The following will not apply to the Out-of-Pocket Maximum: Prescription Drug co-payments Non-network Human Organ and Tissue Transplant services Per-visit co-payments as required herein Any charges not covered by the Plan. WELL CARE EXPENSE BENEFIT If a Covered Person incurs charges for the following well care, the Plan will pay benefits for Inpatient or Outpatient services, and Physician home and office services at the benefit level and up to the maximums shown in the Schedule of Benefits. The covered services may vary based on the age, sex, and personal history of the individual, and as determined appropriate by the Plan s clinical coverage guidelines. Screenings and other services are generally covered as Well Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service. Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Well Care for that condition but instead benefits will be considered under the Diagnostic Service benefit. The following are examples of covered Well Care services: 1. Routine or periodic exams, including school enrollment physical exams. (Physical exams and immunizations required for travel, enrollment in any insurance program, as a condition of employment, for licensing, sports programs, or for other purposed are not covered services.) Exams include but are not limited to: Well-baby care and Well Child Care (as defined herein). Adult routine physical examinations. Pelvic examinations. Routine EKG, Chest x-ray, laboratory tests such as complete blood count, comprehensive metabolic panel, and urinalysis. Annual dilated eye examination for diabetic retinopathy. 26

29 2. Immunizations (including those required for school), following the current Childhood and Adolescent Immunization Schedule as approved by the Advisory Committee on Immunization Practice (ACIP), the American Academy of Pediatrics (AAP), and the American Academy for Family Physicians (AAPP). For Adults, the Plan follows the Adult Immunization Schedule by age and medical condition as approved by the Advisory Committee on Immunization Practice (ACIP) and accepted by the American College of Gynecologists (ACOG) and the American Academy of Family Physician. These include but are not limited to Hepatitis A Vaccine. Hepatitis B Vaccine. Hemophilus influenza b vaccine (Hib). Influenza virus vaccine. Rabies vaccine. Diphtheria, Tetanus, Pertussis vaccine. Mumps virus vaccine. Measles virus vaccine. Rubella virus vaccine. Poliovirus vaccine. 3. Screening examinations: Routine vision screening for disease or abnormalities, including but not limited to diseased such as glaucoma, strabismus, amblyopic, cataracts. Routine hearing screening. Routine cytologic screening for the presence of cervical cancer and Chlamydia screening including pap test). Routine bone density testing for women. Routine prostate specific antigen testing Routine colorectal cancer examination and related laboratory tests. No benefits are payable for: physical examinations required for enrollment in any insurance program, as a condition of employment, for licensing, or for other purposes; self-help training and other forms of non-medical self-care except as otherwise provided herein; examinations relating to research screenings. 27

30 INPATIENT HOSPITAL EXPENSES HOSPITAL BENEFIT All Inpatient Hospital admissions for Covered Persons require ACMS Patient Services Center notification according to the following timetables. Elective Admission...Seven days advance notice Emergency Admission...Within 48 hours following admission Maternity Management...Notification is encouraged as soon as possible after pregnancy is confirmed. No reduction in Hospital benefits will be made for Hospital stays of up to 48 hours after a vaginal delivery or 96 hours after a cesarean delivery. If a Covered Person is in her second or third trimester of pregnancy on her effective date of coverage, both in-patient and outpatient obstetrical care may be continued.with the current provider through the end of the pregnancy and the immediate post-partum period upon ACMS approval and benefits will be provided at the Network level based on the place where service is rendered. The toll-free telephone number for ACMS is: ACMS office hours are 8:00 a.m. to 5:00 p.m. (Eastern Time), Monday through Friday. An answering system will take messages when ACMS is closed. When hospitalization of a Covered Person is authorized and recommended by a Physician for the necessary treatment of a non-occupational Injury or Illness, the Plan will consider medically necessary Hospital charges and pay benefits after the Calendar Year Deductible is met (if applicable) and at the percentage and terms shown in the Schedule of Benefits. Covered charges include charges for daily room and board, including routine nursery care of healthy newborns, and miscellaneous expenses. Miscellaneous expenses means necessary services, medicines and supplies for diagnosis and treatment, including anesthesia materials, radiology and pathology, but excluding charges of a private-duty nurse or Physician. Biologically-Based Mental Illness is paid the same as any other Illness. Benefits for treatment of mental disorders, (as defined herein), or substance abuse is limited to the maximums shown in the Schedule of Benefits per Covered Person per Calendar Year. ACMS may recommend either a Day Treatment Program, Partial Hospitalization, or an Intensive Outpatient Treatment Program, as defined, instead of an Inpatient confinement for treatment of mental health (including Biologically-Based Mental Illness) or substance abuse. In that case, benefits will be payable at the same benefit percentage as Inpatient confinement for this alternative Outpatient care. Each two days used for a Day Treatment Program, Partial Hospitalization, or an Intensive Outpatient Treatment Program will apply as one Inpatient Hospital day toward the maximum confinement period shown in the Schedule of Benefits. 28

31 If a Covered Person is treated at a Hospital for dental care for accidental Injury to sound natural teeth, either Inpatient or Outpatient Hospital benefits may be payable as outlined herein. An Inpatient admission for dental care must be certified as medically necessary. The Plan will recognize a birthing center as a covered facility for covered services of the Plan. Newborns and Mothers Health Protection Act of 1996 The Plan will not restrict benefits or require authorization for any Hospital stay in connection with childbirth of 48 hours or less following a normal vaginal delivery, or of 96 hours or less following a cesarean section. This applies to Hospital Inpatient expenses for both the mother and the newborn child. The mother may leave the Hospital sooner than these periods if she and her attending Physician agree to an earlier release. For Maternity Management purposes, the Plan encourages all Participants to notify ACMS of their pregnancy as soon as possible after a pregnancy is confirmed or as soon as coverage becomes effective if a new Participant is pregnant on her Effective Date. This notification to ACMS will not affect reimbursement levels for the minimum length of Hospital stay. OUTPATIENT HOSPITAL EXPENSES The Plan will pay benefits at the benefit percentages shown in the Schedule of Benefits for Outpatient Hospital services in connection with: 1) Use of facilities and supplies when surgery is performed in the Outpatient department of a Hospital, or at a Free-Standing Surgical or Emergency Care Facility 2) The Calendar Year Deductible is waived for diagnostic x-ray and laboratory services when received from an in-network provider, including their interpretations. Medical tests such as MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies, and nonmaternity related ultra-sound services are subject to the provisions of ALL OTHER COVERED MEDICAL SERVICES as described herein. EMERGENCY ROOM EXPENSE BENEFIT (Calendar Year Deductible is waived) When a Covered Person uses the services of a Hospital emergency room for treatment of an Illness or Injury, facility and Physician charges will be paid after a co-payment per visit and at the benefit percentage as shown in the Schedule of Benefits.. The co-payment will not apply to the Calendar Year Deductible nor to the Out-of-Pocket Maximum. The co-payment requirement will be waived if admission as n In-patient occurs within 48 hours of the emergency treatment. 29

32 URGENT CARE FACILITY EXPENSE BENEFIT When a Covered Person uses the services of an Urgent Care Facility for treatment of an Illness or Injury, facility and Physician charges will be paid as shown in the Schedule of Benefits. AMBULANCE BENEFIT If a Covered Person incurs expenses for medically necessary professional ambulance (whether ground or air) service due to accidental Injury or Illness, the Plan will pay benefits at the benefit percentages specified in the Schedule of Benefits for transportation to the nearest Hospital qualified to provide care, as well as to a Skilled Nursing Facility from a Hospital when recommended by the attending Physician. No benefits are payable hereunder for: Ambulette or wheelchair accessible van; Ambulance usage for the convenience of family or Physician; Trips to a physician s office or clinic; Trip to a morgue or funeral home. SKILLED NURSING FACILITY BENEFIT If a Covered Person is transferred to a Skilled Nursing Facility from a Hospital following a confinement and/or the attending Physician makes documented certification of medical necessity, the Plan will pay benefits for daily room and board and covered miscellaneous expenses. Benefits are payable at the benefit percentages up to the maximum confinement per Calendar Year shown in the Schedule of Benefits. Benefits are subject to the following conditions: a. The confinement must be certified by the attending physician as Medically Necessary for recuperation from the same Injury or Illness that caused the prior Hospital confinement. b. The attending Physician must continue to render treatment for that Injury or Illness throughout the confinement. No benefits are payable under this Section of the Plan: Once a patient can no longer significantly improve from treatment for the current conditions unless it is deemed Medically Necessary; For Custodial Care, rest care or care which is only for someone s convenience; or For the treatment of mental illness, drug abuse or alcoholism. HOSPICE CARE BENEFIT If a Covered Person incurs charges made by a Hospice Care program either as an Inpatient or Outpatient, the Plan will pay benefits at the benefit percentages and up to the maximum benefit 30

33 shown in the Schedule of Benefits. Hospice treatment must be recommended by the attending Physician and is normally rendered within six months of the terminally ill Covered Person s entry or re-entry (after a remission period) into the Hospice Care program. Hospice services consist of: Inpatient charges at a Hospice if medically necessary Periodic respite care Services of Physicians Part-time nursing care and home health aide services Necessary medical supplies, drugs and medicines Laboratory services, radiotherapy, oxygen and oxygen equipment Emotional support services and bereavement counseling furnished within six months after the patient s death Physical, occupational, speech, respiratory and chemical therapy No Hospice benefits are payable for: Services or supplies rendered during any period in which the Covered Person is not under the regular care of a Physician Services or supplies which might be considered as a covered expense under other sections of the Plan Charges incurred during a remission period when the Covered Person is discharged from the Hospice Care program Charges for services provided by the Covered Person, spouse, child, brother, sister or parent of the Covered Person or spouse Pre-death counseling and bereavement counseling not provided by or through the Hospice HOME HEALTHCARE/PRIVATE-DUTY NURSING BENEFIT If a Covered Person incurs charges for services rendered by a Home Healthcare Agency or for private-duty nursing care for treatment due to an Injury or Illness, the Plan will pay benefits at the benefit percentages and for the maximum benefit amount as shown in the Schedule of Benefits. Home healthcare and private-duty nursing services must be established and approved in writing by the attending Physician and must be rendered following a Hospital confinement and/or after documented certification of medical necessity is made by the attending Physician. A visit occurs each time an employee of a Home Healthcare Agency visits the patient. Each four hours or less of home healthcare services will be considered one home healthcare visit. Home healthcare/private-duty nursing services consist of: Care by or under the supervision of a registered nurse (R.N.) or licensed practical nurse (L.P.N.) 31

34 Part-time or intermittent home health aide services primarily for the care of the Covered Person as long as the Covered Person is receiving either skilled nursing care or physical, speech, respiratory or occupational therapy by the Home Health Care Agency Physical, speech, respiratory or occupational therapy provided in the Covered Person s home (Manipulation therapy is not covered when provided in the home). Medical supplies, drugs and medicines prescribed by a Physician, and laboratory services No home healthcare/private-duty nursing benefits are payable for: Services performed by a member of the Covered Person s family or a person residing in the Covered Person s home Transportation services Services or supplies rendered during any period in which the Covered Person is not under the regular care of a Physician Food, housing, homemaker services and home delivered meals. Upon ACMS approval, home infusion therapy may be covered. Benefits for home infusion therapy include a combination of nursing care, durable medical equipment and pharmaceutical services which are delivered and administered intravenously in the home. Home IV therapy includes but is not limited to: o injections,(intra-muscular, subcutaneous, continuous subcutaneous, o Total Parenteral Nutrition (TPN); o Enteral nutrition therapy; o Antibiotic therapy; o pain management; o chemotherapy. PHYSICIAN EXPENSE BENEFIT If a Covered Person incurs eligible expenses as the result of a non-occupational Injury or Illness for the medical services listed below, the Plan will pay benefits as shown in the Schedule of Benefits for the Physician s charges, not to exceed the Usual, Customary and Reasonable Charge for such services. Certain In-Network services are subject to a per-visit co-payment (see the Schedule of Benefits for the specific amount). Office or Home Visits Physician expense benefits are payable for office/home visits, including any surgery, x-ray and laboratory tests performed in connection with the office visit and billed by the doctor s office, as well as clinic facility charges related to the office visit. In-Network Physician charges are payable after the per-visit office co-payment shown in the Schedule of Benefits. Urgent Care/After-Hours Clinic Urgent care or after-hours clinic benefits are payable as shown in the Schedule of Benefits. In- Network care is payable after the per-visit co-payment shown in the Schedule of Benefits. 32

35 Mammograms, Diabetes Self-Management Training, Routine and Diagnostic mammograms and diabetes self management training are covered as shown in the Schedule of Benefits. Diabetes Self Management Training is available for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition when: Medically Necessary; Ordered in writing by a physician or a podiatrist; and Provided by a Health Care Professional who is licensed, registered, or certified under state law. For purposes of this provision, a Health Care Professional: means the Physician or podiatrist ordering the training or a Provider who has obtained certification in diabetes education by the American Diabetes Association. Surgery Surgical benefits are payable as shown in the Schedule of Benefits and include operative and cutting procedures when performed by a Physician acting within the scope of his license who is not an employee of the Hospital where the surgery is performed. Vasectomy and tubal ligation but not reversals of sterilization and certain oral surgical procedures will also be covered, including: Surgical removal of full bony impacted teeth Repair of Injury to teeth within 12 months from the Injury, or as reasonably soon thereafter as possible and includes all examinations and treatment to complete the repair. For a child requiring facial reconstruction due to dental related injury, there may be several years between the accident and the final repair. Excision of tumors and cysts of the mouth and oral cavity Note: ACMS may recommend a Second Surgical Opinion during the pre-admission review process. Obtaining a Second Surgical Opinion is entirely voluntary on the part of the Covered Person. With regard to services of an assistant surgeon, charges will be covered if provided by a Physician who is not a Hospital intern, resident or employee and they are certified by the operating surgeon as medically necessary. Women s Health and Cancer Rights Act of 1998 Medical and surgical services for mastectomy, as well as subsequent reconstruction in connection with a mastectomy, will be covered under the Plan as follows: Reconstruction of the breast on which the mastectomy has been performed Surgery and reconstruction of the other breast to produce symmetrical appearance 33

36 Coverage for prostheses and physical complications of all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending Physician and the patient Anesthesia Anesthesia benefits are payable as shown in the Schedule of Benefits, including charges for administration of general anesthesia in connection with a covered surgical procedure. Anesthesia services must be ordered by the Physician or surgeon and administered by a Physician or surgeon who is not the operating surgeon, his surgical assistant or the Physician performing an obstetrical delivery. A qualified registered nurse who is not an employee of the Hospital may also administer anesthesia. This registered nurse must be under the direction and immediate presence of a Physician or surgeon. Physician Hospital Visits Physician Hospital visits limited to one visit per day by any one physician, consultations which are a personal bedside examination by another Physician when requested by the attending Physician, and intensive medical care when medically necessary are payable as shown in the Schedule of Benefits and include the Physician s charges for each day the Covered Person is hospitalized. These services must be rendered by a Physician other than the operating surgeon or his assistant and, in the case of a surgical admission, must be for a non-related medical condition. Pathology and Radiology Interpretation Pathology and radiology interpretation benefits are payable as shown in the Schedule of Benefits and include such Necessary Medical Services performed by a Physician who is not an employee of the Hospital. MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND APPLIANCES Note: Because additional discounts may be available, ACMS notification is encouraged prior to rental or purchase of any durable medical equipment exceeding $750. If the Covered Person incurs expenses for medical supplies, rental of durable medical equipment (not to exceed purchase price or purchase at the Plan s option), or prosthetics, the Plan will pay benefits as outlined herein at the benefit percentage and up to the maximum amounts shown in the Schedule of Benefits, subject to the following: Medical and surgical supplies Supplies and equipment for the management of Illness or Injury are covered. Covered items include but are not limited to: syringes, needles, oxygen, surgical dressings, splints and other similar items which serve only a medical purpose. Items for which no benefits are payable include but are not limited to: items usually stocked in the home for general use such as adhesive tape, band aids, vitamin, arch supports, and which can be purchased without a prescription. 34

37 Durable Medical Equipment Rental, or at the Plan s option, purchase, of durable medical equipment prescribed by a Physician is covered. Examples of covered durable medical equipment include but are not limited to: wheelchairs, crutches, hospital beds. and oxygen equipment. Rental price may not exceed the purchase price. Items for which no benefits are payable include, but are not limited to: translift chairs, air conditioning, exercise equipment, and tub chairs for use in the shower. Prosthetic Devices Prosthetic appliances such as artificial limbs and eyes, including repairs, replacements and adjustments when medically necessary. The Plan will also pay for the first wig following cancer treatment, limited to one per Calendar Year. Items for which no benefits are payable include but are not limited to: dental appliances artificial heart implants, non-rigid appliance such as support hose, and wigs except as specifically stated herein. Orthotic devices: Covered orthotic devices may include but are not limited to: cervical collars, special surgical corsets, splints slings and wristlets. Non-covered items may include but are not limited to: orthopedic shoes, foot supports or elastic stockings. THERAPY SERVICES EXPENSE BENEFIT If a Covered Person incurs charges for physical, occupational, speech, or manipulation therapies which are medically necessary and recommended by the attending Physician due to Illness or Injury, the Plan will pay benefits as shown in the Schedule of Benefits. If different types of Therapy Services are performed during one Physician Office Service, or Outpatient Service, then each different type therapy Service performed will be considered a separate Therapy visit. Each Therapy visit will count against the applicable maximum visits listed in the Schedule of Benefits. For example, if both a Physical Therapy service and a manipulation therapy service are performed during one Office service or Outpatient service, they will count as both one Physical Therapy Visit and one Manipulation Visit. Physical or Occupational Therapy Physical or occupational therapy rendered by a licensed Physician, physical therapist (L.P.T.), occupational therapist (O.T.), registered physical therapist (R.P.T.) will be considered as shown in the Schedule of Benefits. Physical therapy must result in improvement of a bodily function. Physical or occupational therapy are subject to periodic evaluation for continued medical necessity and should proceed according to a written referral or treatment plan submitted by the attending Physician and/or therapist indicating the projected number of treatments and the length of the treatment program. Speech Therapy Speech therapy rendered by a licensed, certified speech therapist (C.S.T.) will be considered as shown in the Schedule of Benefits. Restorative or rehabilitative speech therapy must be for 35

38 speech loss or impairment due to an Illness or Injury or due to surgery performed as the result of an Illness or Injury. Speech therapy services provided due to developmental delays are not covered by the Plan; however, such services may be available through state programs. This Plan will not duplicate speech therapy services. Because not all speech therapy is covered, it is recommended that after the first visit, a treatment plan be submitted to ACMS for review. Manipulation Therapy If a Covered Person incurs charges for the treatment of neuromusculoskeletal conditions by the use of spinal-adjustment techniques, manipulative therapy and/or any other treatment modalities, the Plan will pay benefits after the Covered Person s Co-payment and up to the maximum benefit per Calendar Year shown in the Schedule of Benefits. This also includes diagnostic X- rays, laboratory tests and office visits performed in conjunction with these services. Neuromusculoskeletal services are subject to periodic evaluation for continued medical necessity and should proceed according to a treatment plan submitted by the Physician outlining the projected number of treatments and the length of the treatment program. RADIATION AND RESPIRATION THERAPIES, CHEMOTHERAPY, KIDNEY DIALYSIS, AND CARDIAC REHABILITATION BENEFIT Radiation therapy, chemotherapy, Inhalation Therapy, and pulmonary rehabilitation therapy benefits are payable as shown in the Schedule of Benefits. They include the Physician s charges for treatment using roentgen rays, radium rays or the rays of other radioactive substance. Kidney dialysis benefits are payable as shown in the Schedule of Benefits and include necessary kidney dialysis services performed by a Physician who is not an employee of the Hospital. Cardiac Rehabilitation Cardiac rehabilitation (Level I and II only) will be covered in connection with a myocardial infarction, coronary bypass or coronary occlusion when such services begin within 12 weeks after other treatment of the condition ends and are rendered in a medical care facility under the supervision of a Physician. Home programs, on-going conditioning, and maintenance are not covered. OUTPATIENT MENTAL DISORDERS OR SUBSTANCE ABUSE TREATMENT BENEFIT If a Covered Person incurs charges by a Physician for Outpatient treatment of mental health or substance abuse, including services at a Community Mental Health Center, Hospital or freestanding mental health agency, the Plan will pay benefits at the benefit percentages and up to the Calendar Year maximum number of visits shown in the Schedule of Benefits for: All professional services performed by an employee of, and billed by, the facility; also, psychological testing when administered by a licensed psychologist 36

39 Prescription drugs dispensed and administered by the facility in connection with the condition being treated Drugs, biological treatments and solutions dispensed and administered in the facility Electroshock therapy, including anesthesia when administered by a Physician X-ray and lab charges ACMS may recommend substitution of a Day Treatment Program, Partial Hospitalization, or an Intensive Outpatient Treatment Program instead of Inpatient confinement. This alternative care would be payable at the same benefit percentage as Inpatient confinement. The Calendar Year Deductible applies to both In-Network and Out-of-Network Outpatient care of mental health or substance abuse treatment. No benefits are payable under this section of the Plan for: Services of the attending Physician or other medical services, except as specified Mental healthcare services beyond the period necessary for evaluation and diagnosis of mental deficiency or retardation Marriage counseling Benefits for Biologically Based Mental Illness are provided at the same level and are subject to the same benefit provisions as any other Illness. Depending on where the covered services are provided, benefits will be the same as those stated under each covered medical service. TMJ (TEMPOROMANDIBULAR JOINT) EXPENSE BENEFIT Medical and surgical services necessary for the treatment of TMJ (temporomandibular joint) dysfunction will be covered under the medical plan at the benefit percentage and up to the maximum benefit shown in the Schedule of benefits, but no orthodontic treatment will be covered under the medical plan. Depending on where the covered services are provided, benefits will be the same as those stated under each covered medical service. INDEPENDENT LABORATORY BENEFIT (Calendar Year Deductible is waived) If a Covered Person incurs charges from an independent laboratory for tests performed to diagnose a non-occupational Injury or Illness (including their interpretation), the Plan will pay benefits at the benefit percentages shown in the Schedule of Benefits. No benefits are payable under this section of the Plan for: Dental X-rays, except as the result of an Injury or surgical removal of impacted teeth Any examination which is payable under the Hospital Benefit section of the Plan. 37

40 ORGAN AND/OR TISSUE TRANSPLANT BENEFIT (Calendar Year Deductible is waived) The Plan will pay benefits after satisfaction of the Calendar Year Deductible at the benefit percentages shown in the Schedule of Benefits for charges for services and supplies provided in connection with organ and/or tissue transplant procedures, including bone marrow/stem cell transplants as outlined below: ACMS Out-of-Network care will be considered at the In-Network level if ACMS has coordinated the treatment. Compatibility Tests for Potential Donors All such diagnostic tests are payable on the same basis as the surgery outlined under Donor Costs below. Donor Costs 1) When the donor is a Covered Person and the recipient is not a Covered Person, benefits are payable for donor costs only to the extent that such expenses are not paid by the recipient s plan. In the event the recipient s plan has a similar provision to 2) below, benefits are then payable for donor costs. 2) When the donor is not a Covered Person, and the recipient is a Covered Person, only those expenses of the donor not paid by the donor s plan will be recognized as eligible expenses. Benefits will be payable only to the extent that benefits remain available under the individual Lifetime maximum outlined below. Recipient Costs When the recipient is a Covered Person, benefits are payable for recipient costs whether or not the donor is a Covered Person. Organ and/or Tissue Acquisition Benefits will be payable for Hospital standard acquisition costs (live donor or cadaver). Maximum Lifetime Benefit All combined benefits (recipient and donor) paid directly or indirectly as the result of any and all transplant procedures, including prescription drugs and all follow-up care, are subject to a Maximum Lifetime Benefit per Covered Person as shown in the Schedule of Benefits. Travel and Lodging Expenses The covered patient and one other individual (two individuals permitted for a minor child) are eligible for travel and lodging (excluding food or beverages) expenses to receive care at a Hospital in connection with the transplant procedure, subject to the following: 1) Total travel and lodging benefits will not exceed $10,000 per transplant. 2) The Hospital must be located at least 100 miles away (one way) from the patient s home. 3) ACMS must pre-approve all travel and lodging expenses. 4) Such expenses will be covered for a pre-transplant evaluation even if certification for the transplant is not deemed medically appropriate by ACMS. 38

41 Limitations If the donor is not a Covered Person, benefits for donor costs are limited to those directly related to the transplant procedure itself, including complications, and do not include any medical care costs related to other treatment of the donor. No benefits are payable for: 1) Donor transportation costs whether or not the donor is a Covered Person 2) Artificial organs 3) Any expenses in connection with any transplant procedure which is not in accordance with generally accepted professional medical standards, or for an Experimental or Investigative procedure which has not been proven successful and effective 4) Any transplant procedure (recipient or donor) performed under a study, grant or research program ALL OTHER COVERED MEDICAL EXPENSES The Plan will pay benefits for All Other Covered Medical Expenses at the benefit percentages shown in the Schedule of Benefits for the Usual, Customary and Reasonable Charges incurred for the following types of medically necessary services, supplies and treatment not considered under any other section of this Plan, if applicable: 1. Blood. Blood transfusions, blood and blood plasma, and blood derivatives; 2. Dental Services. Care and treatment to or on the teeth and gums, limited to treatment rendered within 12 months following an Injury to sound natural teeth. Damage resulting from chewing or biting is not considered an Accident Injury. For a child requiring facial reconstruction due to dental-related injury, there may be several years between the accident and the final repair; 3. Diagnostic Tests. Allergy testing, MRA, MRI, PET scan, nuclear cardiology imaging studies, and non-maternity related ultrasound services are covered under this section of the Plan without consideration of where the service is performed; 4. Midwife. Charges incurred by a licensed Midwife, or a Midwife in an approved facility licensed by the appropriate state health department; 5. Nutritional Counseling. Nutritional Counseling with a registered dietitian or other health care professional specifically trained in nutrition, limited as follows: a. Three visits per lifetime for the Covered Person newly diagnosed with Diabetes. b. One visit per lifetime as determined by ACMS for the Covered Person newly diagnosed with a specific qualifying health condition; 6. Oxygen. Oxygen and rental or purchase at the Plan s option of equipment for its administration; 39

42 7. Physician Charges. Charges made by Physicians for diagnosis and treatment which are not specifically outlined in another section of this Plan; 8. Prescriptions. Prescription drugs not available through the Prescription Drug Program, specialty drugs, or drugs administered in the Physician s office. 40

43 PRESCRIPTION DRUG PROGRAM

44 PRESCRIPTION DRUG PROGRAM The Prescription Drug Expense Benefit section of the Plan provides benefits for covered expenses incurred by a Covered Person for prescription drugs as shown in the Schedule of Benefits. The Plan provides three options for the payment of prescription drugs. COVERED DRUGS Covered drugs include: 1. Legend drugs except those which are specifically excluded. Legend drugs are those which federal law requires to bear the legend, Caution: Federal law prohibits dispensing without a prescription; 2. compounded medications when at least one ingredient is a legend drug; 3. injectable insulin, insulin needles and syringes, and diabetic supplies when prescribed by the attending Physician; 4. Prenatal vitamins and oral contraceptive medication. Any questions regarding the Network pharmacy program can be answered by calling the telephone number shown on the Covered Person s health plan identification card. If you obtain services from a non-network pharmacy, the Pharmacy Benefit Manager (PBM) will provide 50% reimbursement after a co-payment of $45. You must pay the full amount of the bill for the Prescription Drug at the time of purchase. Then you must file a standard claim form which can be obtained from the PBM, and payment will be made directly to you. You may be responsible for any amount in excess of the Prescription Drug Covered Charges. Option 1 Pharmacy Program Prescriptions for up to a 30-day supply may be filled at any pharmacy that accepts the health plan identification card. The Plan will pay the full cost after the Covered Person pays the applicable copayment shown in the Schedule of Benefits. The co-payment must be made at the time of purchase. A list of pharmacies that accept the health plan identification care is available in the Principal s or Supervisor s office. Option 2 Mail-Order Maintenance Program The mail-order program is designed for maintenance drugs taken on a continuing basis. This program fills prescriptions for a 90-day supply of medication, and provides for automatic substitution of FDA-approved generic drugs unless otherwise specified by the attending Physician. The Plan will pay the full cost after the Covered Person pays the applicable copayment shown in the Schedule of Benefits. Covered Persons currently using prescribed maintenance drugs should contact their Physician for a new prescription. They should explain to the Physician that the prescription will be submitted to a different mail-order pharmacy than they had been using. When a prescription is mailed to the mail-order pharmacy for the first time, the Covered Person must include the co-payment in the form of a check or credit card information along with a Mail Service Enrollment Form and the prescription. Mailing envelopes and order forms are available from the Principal s or Supervisor s office. 42

45 Each order will include a Refill Request Slip for submission when a 14-day supply of medication remains. The Refill Request Slip and a check or credit card information for the co-payment should be submitted in a mailing envelope. Refills may also be requested by phone using the 24- hour toll-free number on the refill slip or via the pharmacy program website listed on the refill slip. Option 3 - SPECIALTY NETWORK DRUGS PROGRAM (30-day supply) Drugs for certain illnesses or diseases (usually injectable drugs) are very specialized and expensive. These injectable drugs are now covered under the Prescription Drug Program, subject to the co-payment and terms outlined in the Schedule of Benefits. The Plan uses the services of the Specialty Pharmacy of the Pharmacy Benefit Manager to help manage the cost of these drugs. Additional information is available by contacting the Pharmacy Benefit Manager at the Phone number on the Covered Person s Medical ID card. PRE-AUTHORIZATION Many prescription drugs can be prescribed for both medical and non-medical purposes. For example, Retin-A is approved for the treatment of acne but also has the side effect of reducing wrinkles. To assure that the Plan pays benefits for these drugs only when prescribed to treat a medical conditions, pre-authorization is required. Those drugs that require pre-authorization include Attention Deficit Disorder Drugs for Covered Person age 20 or older Cosmetic Indications (i.e. Retin-A) for Covered Person age 25 or older Injectable Growth Hormone Anabolic Steroids If a Physician prescribes one of these substances, the Covered Person should obtain a letter from him certifying that the drug is Medically Necessary for the treatment of a medical condition, what that medical condition is, and how long the drug will need to be taken. The Plan Administrator will review the letter and, if approved, will authorize the purchase of the drug for a period of up to one year. If the drug is required for longer than one year, a new letter must be submitted each year. STEP THERAPY PROGRAM So that certain drugs will be used in a sequential therapy program, the plan utilizes a Step Therapy Program. This means that, for a given medical condition, the more cost-effective drug (step-one) will be dispensed first, rather than the more costly drug (step-two). Drugs that qualify for this step-therapy are often costly and highly advertised. Drug classifications included in the Step Therapy Program are Proton Pump Inhibitor (PPI), Cox-2 Inhibitor, and Singulair. More information about the program is available from the Pharmacy Benefit Manager whose phone number is listed on the Covered Person s Medical ID card. PRESCRIPTION DRUG PROGRAM LIMITATIONS Benefits paid under the Prescription Drug Program will apply to the Maximum Lifetime Benefit Per Covered Person shown in the Schedule of Benefits under Comprehensive Medical Benefits. The copayment, however, will not apply to Comprehensive Medical Benefits. 43

46 No prescription benefits will be payable for: 1) Administration. Charges for administration or injection of any drug; 2) Apparatus. Medical apparatus, equipment, therapeutic devices or appliances such as support garments or other non-medical substances, regardless of the intended us; 3) Compounded prescriptions. Compounded prescriptions unless at least one ingredient is in prescription strength; 4) Cosmetic. Drugs prescribed for cosmetic purposes, except as specifically provided; 5) Experimental. Experimental or Investigational drugs or drugs intended for nonmedical use; 6) Government. Prescriptions which a Covered Person is entitled to receive without charge from any governmental program; 7) Injectables. Immunization agents, biological sera, blood or blood plasma; 8) Miscellaneous. Fertility drugs; Rogaine, nutritional supplements; 9) Not Medically Necessary. Prescriptions that are not necessary for the treatment of an Illness or Injury unless specifically outlined herein; 10) Over the Counter (OTC). Items that can be purchased legally without a prescription except as specifically provided for herein; 11) Work Related. Prescriptions which the Covered Person is entitled to received under any worker s compensation or similar program. 44

47 GENERAL PROVISIONS

48 GENERAL LIMITATIONS No benefits shall be payable under the Plan for medical charges in connection with: 1) Alternative Medicine. For services or supplies related to alternative or complementary medicine. Services in this category include, but are not limited to, acupuncture, holistic medicine, homeopathy, hypnosis, aroma therapy, massage therapy, reike therapy, herbal, vitamin or dietary products or therapies, naturopathy, thermograph, orthomolecular therapy, contact reflex analysis, bioenergial synchronization techniques (BEST) and iridology-study of the iris; 2) Artificial Impregnation. For artificial impregnation, including artificial insemination or in vitro fertilization and the hiring or services of a surrogate mother; 3) Bariatric Surgery. For bariatric surgery, regardless of the purpose for which it is proposed or performed. Complications directly related to bariatric surgery that result in an Inpatient stay or an extended Inpatient stay for the bariatric surgery are not covered. Not included in this limitation is myocardial infarction, excessive nausea/vomiting; pneumonia and exacerbation of co-morbid medical conditions during the procedure or in the immediate post-operative time frame; 4) Billing. For unbundled charges. To the extent multiple fees are billed which should have been included in a global fee or surgical suite rate. For fees which are up-coded or exploded, to the extent higher payment is requested than the procedures performed justify. For other billing activity outside the standard of medical or traditional billing practice; 5) Cosmetic Surgery. For Cosmetic Surgery, except: a) As the result of an accidental Injury provided treatment begins as soon as medically possible following the date of the Accident; b) Due to surgical removal of tissue as a result of a cyst, tumor or other carcinoma and as outlined under Women s Health and Cancer Rights Act of 1998; c) Repair of congenital abnormalities of covered dependent children which results in improved physical function provided treatment begins as soon as medically possible after the date of the child s birth; 6) Court Ordered Care. For court-ordered care or voluntarily negotiated care to avoid incarceration or fines, except individual therapy which is medically necessary; 7) Custodial Care. For custodial, rest care, or for personal comfort items; 8) Dental Care. For dental care services except as specifically outlined herein. Examples of dental treatment limited herein preventive care, diagnosis, treatment of or related to the teeth, jawbone (except TMJ) or gums, extraction, restoration and replacement of teeth, medical, surgical treatment of dental conditions, dental implants or braces; 9) Education. In connection with any treatment, therapy, teaching technique or program for remedial education or habilitative training; 46

49 10) Excess Therapy. Charges incurred for therapy services and musculoskeletal manipulations/adjustments and related modalities in excess of those number of visits shown in the Schedule of Benefits; 11) Exercise programs. For exercise programs (including orthoptic training) for treatment of any condition except for Physician supervised cardiac rehabilitation (Level I and II only), or occupational and physical therapy specified as covered in this Plan; 12) Experimental. For, or in connection with, Experimental, Investigational or Unproven drugs, procedures or treatment as defined, including complications directly related to such procedure. Directly related means that the service or treatment would not have occurred or taken place in the absence of the Experimental/Investigational/Unproven procedure; 13) Eye and Hearing Care. For refractions, eyeglasses and contact lenses (except for the first pair of surgically implanted intra-ocular lenses after cataract surgery, or soft contact lenses due to a medical condition), radial keratotomy or similar refractive surgery intended to correct refractive errors, hearing aids or examinations for the prescription or fitting thereof; 14) Family Member. For professional services by a person who ordinarily resides in the Covered Person s household or who is an immediate family member of the Covered Person; 15) Foot Care. Charges incurred for foot care only to improve comfort or appearance, such as care for flat feet, subluxation, bunions, (except capsular or bone surgery), corns, calluses and toenails, unless at least part of the nail root is removed or when needed because the patient has a metabolic or peripheral-vascular disease; 16) Government Benefits. For any service or supply for care or treatment provided or furnished by the United States government, or any service or supply for care or treatment provided or furnished by any state or local government when, without this coverage, the employee would not be required to make payment, except: a) Treatment rendered United States veterans for non-service-related Injury or Illness in Veterans Administration Hospitals; or b) Inpatient Hospital charges for treatment rendered to military retirees and their Eligible Dependents while confined in a military Hospital; 17) Human Growth Hormones. Human growth hormones for children born small for gestational age; 18) Illegal Activity. For Injury or Illness resulting from or sustained as a result of being engaged in an illegal occupation and commission of or attempted commission of an assault or felonious act (unless due to a medical condition or domestic violence); 19) Infertility. Charges incurred for or in connection with:` a. Diagnostic testing b. Procedures or drugs intended solely to increase or enhance fertility c. Fertility drug therapy, artificial insemination, in-vitro fertilization, gamete-intrafallopian transfer (GIFT), or any similar or related procedures 47

50 d. The freezing or storage of sperm, eggs, or embryos; 20) Marital Counseling; 21) Medicare. Charges incurred to the extent they exceed the Medicare limiting charge, for Covered Persons for whom this Plan pays its Benefits secondary to Medicare; 22) Miscellaneous. Stand-by Physician or stand-by Anesthesia Services; vitamins, minerals, food supplements or food substitutes; 23) No Coverage. Charges incurred at a time when no coverage is in force for the person incurring charges; charges incurred for a person who does not meet the eligibility requirements s for coverage under this Plan; charge for which no benefits are provided under this plan; 24) No Legal Obligation. For services or supplies for which the Covered Person has no legal obligation to pay and/or for which no charge would ordinarily be made in the absence of coverage under this Plan; 25) Not Medically Necessary. For services or supplies not deemed medically necessary for the active treatment of an Illness or Injury, for equipment and supplies available without a Physician s prescription and not limited in use to medical purposes, for other care and treatment which are not Medically Necessary for the treatment of an Illness or Injury, including those which are not consistent with the diagnoses Illness or Injury. However, coverage is provided for the following: a. Wellness care as specifically provided herein b. Circumcision of a covered newborn child c. Voluntary sterilizations, but not the reversal of any sterilization d. Routine hospital nursery care and routine pediatric exams of a covered newborn child; 26) Not Prescribed. For services or supplies which are not prescribed or recommended by a Physician or Dentist acting within the scope of his license; 27) Nutritional Therapy. Nutritional supplements and therapies are not covered except for enteral and parenteral nutrition therapies when medically necessary. Medical necessity is determined on a case by case basis and the treatment plan and a detailed explanation of the medical necessity must be submitted to the ACMS for review and approval. Not covered are: a) Enteral tube feedings for individuals who are capable of adequate oral intake. b) Food supplements, specialized infant formula, vitamins and/or minerals taken orally c) Parenteral nutrition for individuals with a functioning gastrointestinal tract whose need for parenteral nutrition is only due to: Swallowing disorder Temporary defect in gastric emptying Psychological disorder Hemodialysis Disorders inducing anorexia such as cancer 48

51 Peritoneal dialysis [intraperitoneal amino acid (IPPA) supplementation for individuals on peritoneal dialysis may be considered if certain criteria are met]; 28) Outside the Country. Charges incurred outside the United States if the Covered Person traveled outside the U.S. for the purpose of obtaining medical care, treatment, services or supplies; 29) Private Duty Nursing Care. Private Duty Nursing care rendered in a Hospital or Skilled Nursing Facility. Private Duty Nursing care is covered only when provided through a Home Health Care Agency and limited as stated in the Schedule of Benefits. 30) Riot or Civil Insurrection. For Injury caused by participation in civil insurrection or a riot (unless due to a medical condition or domestic violence); 31) Self-Inflicted. For intentionally self-inflicted Injury and any attempts to commit suicide or complications arising out of the attempt(s) (unless due to a medical condition or domestic violence); 32) Sexual Dysfunction. For services or supplies in connection with transgender surgery (and/or reversal thereof), male or female sexual or erectile dysfunction or inadequacies, regardless of origin or cause. This exclusion includes sexual therapy and counseling, penile prostheses or implants, vascular or artificial reconstruction, prescription drugs, and all other procedures and equipment developed for or used in the treatment of impotency and all related Diagnostic Testing; 33) Travel. For mileage, lodging and meal costs and other travel expenses except as specifically provided for herein; 34) UCR. In excess of Usual, Customary, and Reasonable Allowance as defined; 35) War. For Injury or Illness resulting from duty as a member of the armed forces of any state or country, war or act of war, declared or undeclared; 36) Weight Loss. For any weight loss by diet control, medication or any other method of weight loss including any weight loss programs for medical reasons; 37) Work Related. For Illness or Injury that would entitle the Covered Person to any benefits under a Workers Compensation Act or similar legislation, or related to any work for wage or profit if Workers Compensation coverage was available but not purchased; 38) Workplace Clinic. For services or supplies provided through a medical department, clinic or other facility provided by or maintained by the employer, or a medical clinic or similar facility for which services or supplies are or should be available without charge to the Covered Person. 49

52 COORDINATION OF BENEFITS WITH GROUP PLANS AND MEDICARE The Plan has been designed to help meet the cost of Illness or Injury. Since it is not intended that greater benefits be received than the actual medical expenses incurred, the amount of benefits payable under the Plan will take into account any coverage under other plans and be coordinated with the benefits of the other plans. The Plan will always pay either its regular benefits in full if it is determined to be the Primary Plan (plan primarily responsible for payment) or, if the Plan is determined to be the Secondary Plan, a reduced amount which, when added to the benefits payable by the Primary Plan, will not exceed 100% of Allowable Expenses. In no event, however, will payment exceed the maximum benefits payable under this Plan. PRIMARY PLAN "Coordination of benefits" is the procedure used to pay health care expenses when a person is covered by more than one plan. The Plan follows rules established by Ohio law to decide which plan pays first and how much the other plan must pay. The objective is to make sure the combined payments of all plans are no more than your actual bills. When you or your family members are covered by another group plan in addition to this one, this Plan will follow Ohio coordination of benefits rules to determine which plan is the Primary Plan and which plan is the Secondary Plan. You must submit all bills first to the Primary Plan. The Primary Plan must pay its full benefits as if you had no other coverage. If the Primary Plan denies the claim or does not pay the full bill, you may then submit the balance to the Secondary Plan. The Plan pays for health care only when you follow the Plan's rules and procedures. If the Plan's rules conflict with those of another plan, it may be impossible to receive benefits from both plans, and you will be forced to choose which plan to use. Plans That Do Not Coordinate The Plan will pay benefits without regard to benefits paid by the following kinds of coverage: Individual (not group) policies or contracts; Medicaid; Group hospital indemnity plans which pay less than $100 per day; School accident coverage; Some supplemental sickness and accident policies; How This Plan Pays As Primary Plan When this Plan is the Primary Plan, it will pay the full benefit allowed under the terms of the Plan as if you had no other coverage. How This Plan Pays As Secondary Plan When this Plan is the Secondary Plan, payments from this Plan will be based on the balance left after the Primary Plan has paid. This Plan will pay no more than that balance. In no event will this Plan pay more than it would have paid had it been the Primary Plan. 50

53 This Plan will pay only for health care expenses that are covered by the Plan. This Plan will only pay if you have followed all of its procedural requirements. This Plan will pay no more than the Allowable Expenses for the health care involved. If this Plan's Allowable Expenses is lower than the Primary Plan's, this Plan will use the Primary Plan's Allowable Expenses. That may be less than the actual bill. Which Plan Is Primary? To determine which plan is the Primary Plan, the Plan must consider both the coordination provisions of the other plan and which member of your family is involved in a claim. The Primary Plan will be determined by the first of the following which applies: 1. Non-coordinating Plan. If you have another group plan which does not coordinate benefits, it will always be the Primary Plan. 2. Employee. The plan which covers you as an employee (neither laid off nor retired) is always the Primary Plan. 3. Children (Parents Divorced or Separated). If the court decree makes one parent responsible for health care expenses, that parent's plan is the Primary Plan. If the court decree gives joint custody and does not mention health care, the Plan follows the "birthday rule." If neither of those rules applies, the order will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits. 4. Children and the Birthday Rule. When your children's health care expenses are involved, the Plan follows the "birthday rule." The plan of the parent with the first birthday in a calendar year is always primary for the children. If your birthday is in January and your spouse's birthday is in March, your plan will be the Primary Plan for all of your children. 5. Other Situations. For all other situations not described above, the order of benefits will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits. COORDINATION DISPUTES If you believe that the Plan has not paid a claim properly in accordance with these coordination of benefits rules, you should first attempt to resolve the problem by contacting the Plan in accordance with the claims procedures described in this booklet. If you are still not satisfied, you may call the Ohio Department of Insurance for instructions on filing a consumer complaint. Call (614) or ALLOWABLE EXPENSES Allowable Expenses means any necessary Usual, Customary and Reasonable expenses incurred while eligible for benefits under the Plan, part or all of which would be covered under any of the plans, but not including any expenses contained in the list of General Limitations. With regard to any Covered Person eligible to elect Medicare except those described in the next paragraph, Medicare benefits will be considered as having been paid whether or not the Covered Person has applied for Medicare coverage or submitted a claim for Medicare benefits. It is the 51

54 Covered Person s responsibility to apply for and maintain both Part A and Part B Medicare coverage. With regard to an actively-at-work Eligible Employee age 65 or older, or an eligible covered dependent spouse of an active Eligible Employee also over age 65, either of whom has elected in writing to be covered under this Plan, the benefits of this Plan will be primary. This Plan will also be primary for military retirees and their Eligible Dependents for Inpatient Hospital charges in military medical Hospitals as required by law and in accordance with this Plan. The Claims Administrator has the right to request and release any information which is necessary in order to determine the Primary Plan. The Plan pays secondary to any and all PIP (Personal Injury Protection), Med-Pay (medical payments coverage) or No-Fault coverage. The Plan has no duty or obligation to pay any claims until PIP, Med-Pay or No-Fault coverage is exhausted. In the event the Plan pays claims under this provision that should have been paid by PIP, Med-Pay or No-Fault coverage, then the Plan has a right of recovery from the PIP, Med-Pay or No-Fault carrier. PAYMENT OF BENEFITS If in the opinion of the Claims Administrator, a valid release cannot be rendered for the payment of any benefit payable under this plan, the Claims Administrator may, at his option, make such payment to the individual or individuals as are, in the Claims Administrator s opinion, equitably entitled thereto. In the event pf the death of the Covered Person prior to such time as all benefit payments due him have been made, the Claims Administrator may, at his sole discretion and option, honor benefit assignments, if any, made prior to the death of such Covered Person. Benefits payable under the Plan may be assigned to the provider of service. The Claims Administrator will endeavor to pay assigned benefits directly to the assignee, but to the extent any such benefits are paid directly to the Covered Person, the Plan and the Claims Administrator shall be deemed to have fulfilled their obligations with respect to the payment. To avoid the payment of assigned benefits directly to the assignee, the Claims Administrator must receive a written request signed by both the Covered Person and the assignee no later than the time the claim for benefits is filed. 52

55 RECOVERY RIGHTS INTRODUCTION The Plan has the right to recover in full the medical benefits (and disability benefits if provided by the Plan) paid for injuries caused by the act or omission of any party. The Plan s right of recovery, as explained below, may be from the Covered Person, the third party, any liability or other insurance covering the third party, the Covered Person s own uninsured motorist benefits, underinsured motorist benefits or any medical pay or no-fault benefits which are paid or payable to the Covered Person from any source whatsoever. The Plan s right to any monies recovered (through either reimbursement or subrogation) takes priority over any other party s right (including that of the Covered Person) to monies recovered, regardless of whether the amount recovered constitutes a partial or full recovery of the benefits paid by the Plan. RIGHT OF REIMBURSEMENT To the extent of the payment of benefits by the Plan, the Covered Person shall reimburse the Plan from money recovered by or on behalf of the Covered Person from any source, including, but not limited to, any third party, any liability or other insurance covering the third party, the Covered Person s own uninsured motorist benefits, underinsured motorist benefits or any medical pay or no-fault automobile benefits. The Covered Person s obligation to make restitution to the Plan applies whether the Covered Person has received partial or complete recovery and whether or not the Covered Person is made whole. Accordingly, the Plan hereby expressly disclaims the makewhole doctrine. Out of the first payment(s) or recovery of compensation or benefits by a third party, the full amount of compensation benefits paid by the Plan must be repaid to the Plan, regardless of the ultimate amount of any recovery, up to and including the amount that such payment(s) or recovery equals the amounts paid by the Plan. The Plan s right of reimbursement is a firstpriority right to monies recovered by the Covered Person by way of any settlement of the Covered Person s claim, a judgment in any court proceeding or otherwise. The Plan s recovery rights shall apply to any funds, regardless of how these funds were categorized. Any amounts recovered by the Covered Person shall be held in trust for the exclusive benefit of the Plan, until the Plan s rights, as set forth in this section, have been fully resolved. The Plan will not pay or share in any attorneys fees, expenses or costs associated with any claim or lawsuit brought by or on behalf of any Covered Person. Specifically, the Plan does not permit a deduction in any amount to which it is subrogated or to which it is entitled to reimbursement for attorneys fees, costs or expenses expended by or on behalf of a Covered Person to obtain a settlement, payment, judgment or other recovery. SUBROGATION Whether or not the Covered Person pursues recovery from the liable third party or the Covered Person s individual policies, the Plan is subrogated to the rights of the Covered Person and may pursue the claim on its own. The Plan s right to subrogation applies regardless of whether the Covered Person has received partial or complete recovery and regardless of whether or not the Covered Person has been made whole. The Covered Person agrees to cooperate with the Plan s representative who is pursuing the subrogation recovery. The Plan may, but is not obligated to, take legal action against the third party, any liability insurer covering the third party or the Covered Person s own insurer to recover the benefits the Plan has paid. 53

56 The Covered Person s failure to comply with the requirements of this section may, at the Plan Administrator s discretion, result in a forfeiture of benefits under the Plan. IN GENERAL The Covered Person further agrees that he will not release any third party or his insurer without prior written approval from the Plan and will take no action that prejudices the Plan s recovery right. The Covered Person agrees to include the Plan s name as a co-payee on any settlement check. The Covered Person agrees to refrain from characterizing any settlement in any manner so as to avoid repayment of the Plan s recovery lien. Payment of any claims to or on behalf of the Covered Person may be delayed, withheld or denied unless the Covered Person cooperates fully and enters into any requested reimbursement/subrogation agreement. The Covered Person is obligated to inform his attorney of the right of reimbursement/ subrogation lien and to make no distributions from any settlement or judgment which will in any way result in the Plan receiving less than the full amount of its lien without the written approval of the Plan. AMENDMENT, MODIFICATION OR TERMINATION The Plan Sponsor of this Plan reserves the right to amend, modify or terminate any or all of the provisions of this Plan (including retroactively if necessary or appropriate to meet statutory requirements) at any time. Amendment, modification or termination, however, shall not adversely affect the right of a Covered Person to receive reimbursement for medical expenses incurred prior to the date of such amendment, modification or termination. PLAN INFORMATION NAME OF THE PLAN South Central Ohio Insurance Consortium Health Plan END OF THE PLAN YEAR June 30 PLAN SPONSOR South Central Ohio Insurance Consortium c/o Liberty Union School District 621 Washington Street Baltimore, Ohio EMPLOYER IDENTIFICATION NUMBER

57 PLAN ADMINISTRATOR/AGENT FOR SERVICE OF LEGAL PROCESS South Central Ohio Insurance Consortium c/o Liberty Union School District 621 Washington Street Baltimore, Ohio TYPE OF PLAN AND ADMINISTRATION This is a benefit plan providing reimbursement for certain healthcare expenses including medical and prescription drugs. This Plan is administered through a Trust set up by the Plan Sponsor. Benefits are not provided by insurance. METHOD OF PROVIDING BENEFITS AND FUNDING MEDIUM The Plan is self-funded by the South Central Ohio Insurance Consortium, with contributions from Member Employers. Each Member Employer establishes if and the extent to which their individual Plan participants are required to make contributions toward the cost of coverage. Contributions are deposited directly into the SCOIC Fund account to be used to provide benefits and pay for administrative expenses of the Plan. CLAIM PROCEDURES The administration of the Plan and interpretation of all Plan provisions is the responsibility of the Plan Administrator, South Central Ohio Insurance Consortium. The Plan Administrator has contracted with an independent third-party Claims administrator to perform many of the administrative duties connected with the Plan. However, the Plan Administrator is the final authority on any question that involves discretionary interpretation of Plan provisions. How to File a Claim You, the claimant, or the medical provider must file claims for benefits under this Plan with the Claims Administrator. Filed means that the claim has been received by the Claims Administrator. The Employer will provide you with the necessary forms and information to file your claims. The Claims Administrator is: EMPLOYEE BENEFIT MANAGEMENT CORP RINGS ROAD COLUMBUS, OH Toll Free In Columbus, Ohio Website: 55

58 Proof of Loss Proof of Loss means a claim for payment along with enough documentation for the Claims Administrator to accept or reject the claim and to determine the benefits payable under the Plan. Ordinarily, this consists of a completed claim form available from the Employer, but the provider s claim form or computerized billing is acceptable if it contains essentially the same information. The Claims Administrator will consult the Plan Administrator on any claim requiring discretionary interpretation or application of Plan provisions. Decisions of the Plan Administrator will be final and binding. Keep separate records of expenses for yourself and each covered Dependent. Submitted bills must show the following information: 1. Name of patient. 2. Period of time covered by the charges. 3. Date and charge for each service or supply. 4. Diagnosis and type of care rendered or supply received. 5. Physician s name. 6. Name and professional status of nurse, therapist, or other provider of service. Original bills must be submitted with the claim form. Canceled checks, balance due statements, photocopies, payment receipts and cash register receipts cannot be accepted as Proof of Loss. Notice of Proof of Loss Written proof of loss must be furnished to the Benefit Representative within 90 days after the day on which the loss was incurred. Failure to furnish written proof of loss within that time will not invalidate or reduce any claim if: It was not reasonably possible to furnish written proof of loss within that time; and Written proof of loss was furnished as soon as was reasonably possible. In any case, the proof of loss required must be submitted no later than 12 months after the date the loss was incurred, unless the claimant was legally incapacitated. Payment of Benefits When written proof of loss is received, the Claims Administrator will promptly issue payment of all Benefits provided under the Plan. Benefits for charges of Network Providers are payable directly to the provider. Benefits for charges of other providers are payable to either the provider or you, the Employee, at the Plan s discretion, except that under a Qualified Medical Child Support Order, Benefits will be payable to the child s custodial parent or legal guardian. (Exception: See the provision entitled PAYMENT OF BENEFITS ) Assignment of Benefits No Covered Person has any right to assign the Benefits, rights and privileges to which he is or may become entitled under this Plan. Any purported assignment is void. Right of Recovery If, at any time, payments made under this Plan exceed Benefits that should have been paid under the terms of the Plan, the Plan has the right to recover the excess payments from any person to or for whom payments were made or from any organization or plan from which similar Benefits remain payable. At the Plan Administrator s option, it may recover excess payments by reducing future payments due under the Plan, or by any other method it 56

59 finds appropriate. Each Covered Person is deemed, through participation in the Plan, to authorize such recovery of overpayments. Notice of Claim Denial The Claims Administrator will let you know if a claim, or any part of a claim, is denied. It will send you a written notice within 90 days after the claim was filed. Under special circumstances, the Benefit Representative is allowed an additional 90 days (180 days in total) within which to let you know its decision. If this extension is required, you will receive written notice showing the reason for the delay and the date you may expect a final decision. This notice of denial shall include: The specific reason or reasons for denial and the Plan provisions on which the denial is based; I. A description of any additional material or information necessary to complete the claim and an explanation of why that material or information is necessary; and II. The steps to take if you or your beneficiary wish to have the decision reviewed. If the Benefit Representative does not respond to the claim within the time limits stated you should assume that the claim has been denied. You should begin the appeal process at that time. Claims Appeal and Review Procedure You, the claimant, or your authorized representative may appeal a denied claim within 60 days after you receive the Benefit Representative s notice of denial. You have the right to: Submit to the Plan Administrator a written request for review; Review pertinent documents; and Submit issues and comments in writing to the Plan Administrator. Your appeal should include the following: 1. The name of the Employee. 2. The Employee s social security number. 3. The name of the patient. 4. The group name or identification number. 5. The reason or reasons for disagreement with the handling of the claim. All facts and theories supporting the claim for Benefits. Failure to include any theories or facts in the written appeal will result in their being deemed waived. In other words, you will lose the right to raise factual arguments and theories which support your claim if you fail to include them in the written appeal. The Plan Administrator will make full and fair review of the claim. It may require additional documents to make such a review. 57

60 The final decision will be furnished in writing within 60 days from the date the Plan Administrator receives the request for review. This final decision will include the reasons for the decision and the Plan provisions on which it is based. If special circumstances require an extension of time for processing, the Plan Administrator will tell you the reasons for the extension. In this case, a decision will be made not later than 120 days following the date the Plan Administrator receives the request for review. The Plan Administrator s decision on review will be final, binding and conclusive and will be afforded the maximum deference permitted by law. It shall be your responsibility to submit proof that the claim for Benefits is covered and payable under the provisions of the Plan. Physical Exam The Plan Administrator will have the right and opportunity to have any claimant examined by a Physician of its choice, at the Plan s expense, when and as often as it may reasonably require while the claim is pending, and to have an autopsy performed in case of death, where it is not forbidden by law. Legal Action All claim review procedures provided for in the Plan must be exhausted before any legal action is brought. No action at law or in equity may be brought regarding claims for Benefits or a fiduciary s breach of any duty under this Plan: 1. Earlier than 60 days after proof of loss has been filed; or 2. Later than three years after the date proof of loss is required. HIPAA PRIVACY AND SECURITY COMPLIANCE The requirements of (f) of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations, 45 Code of Federal Regulations (C.F.R.) Parts 160 through 164, established the extent to which the Plan Sponsor will receive, use and/or disclose Protected Health Information (PHI). PLAN SPONSOR S CERTIFICATION OF COMPLIANCE Neither the Plan nor any health insurance issuer or Business Associate servicing the Plan will disclose Plan Participants PHI to the Plan Sponsor unless the Plan Sponsor certifies that the Plan Documents have been amended to incorporate this section and agrees to abide by it. PURPOSE OF DISCLOSURE TO PLAN SPONSOR 1) The Plan and any health insurance issuer or Business Associate servicing the Plan will disclose Plan Participants PHI to the Plan Sponsor only to permit the Plan Sponsor to carry out Plan administration functions for the Plan not inconsistent with the requirements of the Health Insurance Portability and Accountability Act of 1996 and its implementing Regulations (45 C.F.R. Parts ). Any disclosure to and use by 58

61 the Plan Sponsor of Plan Participants PHI will be subject to and consistent with the provisions of this section. 2) Neither the Plan nor any health insurance issuer or Business Associate servicing the Plan will disclose Plan Participants PHI to the Plan Sponsor unless the disclosures are explained in the Notice of Privacy Practices distributed to the Plan Participants. 3) Neither the Plan nor any health insurance issuer or Business Associate servicing the Plan will disclose Plan Participants PHI to the Plan Sponsor for the purpose of employmentrelated actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor. RESTRICTIONS ON PLAN SPONSOR S USE AND DISCLOSURE OF PHI 1) The Plan Sponsor will neither use nor further disclose Plan Participants PHI, except as permitted or required by the Plan Document, as amended, or required by law. 2) The Plan Sponsor will ensure that any agent, including any subcontractor, to whom it provides Plan Participants PHI agrees to the restrictions and conditions of the Plan Document, including this section, with respect to Plan Participants PHI. 3) The Plan Sponsor will neither use nor disclose Plan Participants PHI for employmentrelated actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor. 4) The Plan Sponsor will report to the Plan any use or disclosure of Plan Participants PHI that is inconsistent with the uses and disclosures allowed under this section promptly upon learning of such inconsistent use or disclosure. 5) The Plan Sponsor will make PHI available to the Plan Participant who is the subject of the information in accordance with 45 C.F.R ) The Plan Sponsor will make Plan Participants PHI available for amendment, and will on notice amend Plan Participants PHI, in accordance with 45 C.F.R ) The Plan Sponsor will track disclosures it may make of Plan Participants PHI so that it can make available the information required for the Plan to provide an accounting of disclosures in accordance with 45 C.F.R ) The Plan Sponsor will make its internal practices, books and records, relating to its use and disclosure of Plan Participants PHI, available to the Plan and to the U.S. Department of Health and Human Services (HHS) to determine compliance with 45 C.F.R. Parts ) The Plan Sponsor will, if feasible, return or destroy all Plan Participants PHI, in whatever form or medium (including in any electronic medium under the Plan Sponsor s custody or control), received from the Plan, including all copies of and any data or compilations derived from and allowing identification of any Participant who is the subject of the PHI, when the Plan Participants PHI is no longer needed for the Plan administration functions for which the disclosure was made. If it is not feasible to return or destroy all Plan Participants PHI, the Plan Sponsor will limit the use or disclosure of any Plan Participant s PHI it cannot feasibly return or destroy to those purposes that make the return or destruction of the information infeasible. 59

62 ADEQUATE SEPARATION BETWEEN THE PLAN SPONSOR AND THE PLAN 1) The employees, classes of employees or other workforce members designated by the Privacy Officer may be given access to Plan Participants PHI received from the Plan or a health insurance issuer or Business Associate servicing the Plan. 2) The employees, classes of employees or other workforce members designated by the Privacy Officer may receive Plan Participants PHI relating to payment under, healthcare operations of or other matters pertaining to the Plan in the ordinary course of business. 3) The employees, classes of employees or other workforce members designated by the Privacy Officer will have access to Plan Participants PHI only to perform the Plan administration functions that the Plan Sponsor provides for the Plan. 4) The employees, classes of employees or other workforce members designated by the Privacy Officer will be subject to disciplinary action and sanctions, including, but not limited to, termination of employment or affiliation with the Plan Sponsor, for use or disclosure of Plan Participants PHI in breach or violation of or non-compliance with the provisions of this section to the Plan Document. The Plan Sponsor will promptly report such breach, violation or non-compliance to the Plan, as required by this section, and will cooperate with the Plan to correct the breach, violation or non-compliance, to impose appropriate disciplinary action or sanctions on each employee or other workforce member causing the breach, violation or non-compliance, and to mitigate any deleterious effect of the breach, violation or non-compliance on any Participant, the privacy of whose PHI may have been compromised by the breach, violation or non-compliance. HIPAA SECURITY STANDARDS Where Electronic Protected Health Information will be created, received, maintained or transmitted to or by the Plan Sponsor on behalf of the Plan, the Plan Sponsor shall reasonably safeguard the Electronic Protected Health Information as follows: 1) The Plan Sponsor shall implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the Electronic Protected Health Information that the Plan Sponsor creates, receives, maintains or transmits on behalf of the Plan. 2) The Plan Sponsor shall ensure that the adequate separation that is required by 45 C.F.R (f)(2)(iii) of the HIPAA Privacy Rule is supported by reasonable and appropriate security measures. 3) The Plan Sponsor shall ensure that any agent, including a subcontractor, to whom it provides Electronic Protected Health Information, agrees to implement reasonable and appropriate security measures to protect such information. 4) The Plan Sponsor shall report to the Plan any Security Incidents of which it becomes aware as described below: a) The Plan Sponsor shall report to the Plan within a reasonable time after the Plan Sponsor becomes aware, any Security Incident that results in unauthorized access, use, disclosure, modification or destruction of the Plan s Electronic Protected Health Information; and b) The Plan Sponsor shall report to the Plan any other Security Incident upon the Plan s request. 60

63 DEFINITIONS ADVERSE BENEFIT DETERMINATION An Adverse Benefit Determination is any denial or failure to make payment, in whole or in part, in response to a claim properly submitted to the Claims Administrator. This can include determination of a person s eligibility to participate in the Plan, any failure to provide or make payment due to utilization review and a denial of an item or service that is determined to be Experimental, Investigational or not medically necessary. ALCOHOLISM TREATMENT FACILITY An Alcoholism Treatment Facility is a facility that: Is approved by the Joint Commission on Accreditation of Healthcare Organizations or is certified by the Department of Health Has in effect plans for utilization and peer review Has in effect a program for detoxification or rehabilitation Residential Alcoholism Treatment Facility is herein defined as a facility that operates 24 hours a day and seven days a week. Outpatient Alcoholism Treatment Facility is herein defined as a facility that provides services to ambulatory patients during designated hours and/or specified days. ALTERNATE RECIPIENT An Alternate Recipient is any child of an Eligible Employee or other Participant under the Plan who is recognized under a Medical Child Support Order (MCSO) as having a right to enrollment under the Plan with respect to that Eligible Employee or Participant. ALTERNATIVE CARE MANAGEMENT SYSTEMS, INC. (ACMS) ACMS is a healthcare management company that provides its clients a comprehensive range of programs designed to monitor the delivery of health care. ACMS endorses freedom of choice in the selection of a Physician, while at the same time working closely with local Physicians in determining guidelines for patient care in accordance with acceptable medical and professional standards. AMBULATORY CARE CENTER An Ambulatory Care Center is any public or private establishment with an organized medical staff of Physicians. It must have permanent facilities that are equipped and operated primarily to perform surgical procedures, with continuous Physician services and registered professional nursing services whenever a patient is in the facility, and which does not provide services or other accommodations for patients to stay overnight. ASSIGNMENT OF BENEFITS Assignment of Benefits is written authorization by the Covered Person for the Claims Administrator to pay benefits directly to the provider of service. 61

64 BIOLOGICALLY BASED MENTAL ILLNESS A Biologically-Based mental Illness means Schizophrenia, schizoaffective disorder, major depressive disorder, obsessive-compulsive disorder and panic disorder, as these terms are defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American Psychiatric Association. BIRTHING CENTER A birthing center is a facility which: Is used solely for the performance of childbirth and related obstetrical procedures Is licensed by the state in which the facility is located Is approved by the State Commission on Hospitals or Health Care or similar agency Is operated under the supervision of a doctor of obstetrics Maintains a written agreement with at least one hospital in the area for immediate acceptance of patients who develop complications or require post-natal confinement Maintains an adequate medical record for each patient BUSINESS ASSOCIATE A Business Associate is a person or organization that performs a function or activity on behalf of a Covered Entity, but is not part of the Covered Entity s workforce. A Business Associate can also be a Covered Entity in its own right. CALENDAR YEAR A Calendar Year is a period of 12 consecutive months beginning with January 1 and ending December 31. CLAIMS ADMINISTRATOR A Claims Administrator is an entity that recommends or determines whether to pay claims to enrollees, Physicians, Hospitals or others on behalf of the group benefit plan. Employee Benefit Management Corp administers the claims as the Claims Administrator. Such claims information is available on EBMC s website at COBRA CONTINUATION COVERAGE COBRA refers to the Consolidated Omnibus Budget Reconciliation Act of 1985 and has the meaning set forth in Pub. L. No , as amended. It generally provides the right to temporary continuation of health coverage for certain former employees, retirees, spouses, former spouses and dependent children at their own expense, but at group rates, if they lose coverage because of a loss of employment, reduction in hours, divorce, death of the supporting spouse or other designated events. COMMUNITY MENTAL HEALTH CENTER A Community Mental Health Center is a facility that: Is approved by the Joint Commission on Accreditation of Healthcare Organizations or certified by the applicable state Department of Mental Health and Mental Retardation Is approved by a regional health planning agency or is providing services under the applicable state statute 62

65 Has in effect a plan for utilization review and for peer review COMPANY Company refers to South Central Ohio Insurance Consortium and any governmental subdivision that has elected to participate in the Plan. CO-INSURANCE The term co-insurance generally refers to the Covered Person s responsibility for payment of a medical service where the Plan pays less than 100% of the covered charge. The percentage that the Plan will pay for any specific type of medical services is shown on the Schedule of Benefits. The Covered Person is responsible for the remainder of the charge or the co-insurance. CO-PAYMENT The term Co-payment means a per-visit dollar amount that must be paid for a specific service at the time the service is received. (e.g., office visit). Generally, the Physician will collect this amount at the time the service is rendered. COSMETIC SURGERY Cosmetic Surgery is surgical alteration for the improvement of the Covered Person s appearance, rather than improvement or restoration of bodily functions, including treatment of complications directly related to cosmetic services. COVERED ENTITY A Covered Entity is a health plan, healthcare clearinghouse or healthcare provider that transmits any health information in electronic form in connection with a HIPAA transaction, as defined in 45 C.F.R COVERED PERSON A Covered Person is an Eligible Employee who completes an Enrollment Form and agrees to any required contributions, his Eligible Dependents if the Eligible Employee elects family coverage and former covered employees or dependents who have elected COBRA Continuation Coverage. CREDITABLE COVERAGE Creditable Coverage means those periods of coverage required to be included as such under Section 701(c) of ERISA and shall exclude those periods of coverage permitted to be excluded under Section 701(c) of ERISA, the purpose of which is to give credit for prior healthcare coverage under: A Group Health Plan A governmental or church health plan An individual health insurance plan Medicare Part A and B Medicaid A military-sponsored healthcare plan A program of the Indian Health Service or of a tribal organization A state health benefits risk pool 63

66 The Federal Employees Health Benefits Program A public health plan as defined in regulations Any plan created by the Peace Corps Act CUSTODIAL CARE Custodial Care is any type of service including room and board and other institutional services designed essentially to assist the Covered Person, whether disabled or not, in the activities of daily living. Such services include assistance in walking or getting in and out of bed, bathing, dressing, feeding, preparation of special diets or supervision over medication that can normally be self-administered. DAY TREATMENT PROGRAM/PARTIAL HOSPITALIZATION A Day Treatment Program/Partial Hospitalization is an interdisciplinary program for mentally ill/chemically dependent clients. It must be licensed by the state where the treatment is rendered and supervised by a D.O., M.D. or Ph.D. Treatment is a minimum of four hours per day, four to five days per week. It may consist of individual therapy, group therapy, educational groups, team meetings, occupational therapy and recreational therapies. Program Participants may choose to stay at the facility overnight; however, the Plan does not pay for room-and-board charges. EFFECTIVE DATE The Effective Date of the Plan is October 1, ELECTIVE ADMISSION An Elective Admission is a Hospital Inpatient admission for a healthcare condition that is not life-threatening and for which there is flexibility in making Hospital arrangements. The ACMS Patient Services Center should be notified at least seven days prior to an Elective Admission. ELECTIVE SURGERY Elective Surgery is any non-emergency surgical procedure that may be scheduled at the convenience of the patient without jeopardizing the patient s life or causing serious impairment to the patient s bodily functions. ELECTRONIC PROTECTED HEALTH INFORMATION Electronic Protected Health Information has the meaning set forth in 45 C.F.R , as amended from time to time, and generally means Protected Health Information that is transmitted or maintained in any electronic media. EMERGENCY ADMISSION An Emergency Admission is an Inpatient admission that occurs because of an immediate lifethreatening situation. The ACMS Patient Services Center should be notified within [48] hours following an Emergency Admission. ENROLLMENT DATE Enrollment Date has the meaning as set forth in ERISA 701(b)(3)(B), as amended, and means the first day on which an Eligible Employee is able to receive benefits (coverage begins) under a Group Health Plan or, if earlier, the first day of the Waiting Period for such enrollment. 64

67 EXPERIMENTAL, INVESTIGATIONAL OR UNPROVEN Experimental, Investigational or Unproven means any drug, medical device or procedure that: 1) Is not approved for use by the U.S. Food and Drug Administration (FDA); 2) Is not approved for the treatment of the specific condition 3) Is the subject of an ongoing Phase I, II, III or IV clinical trial as defined by the National Institutes of Health (NIH) 4) Has documentation from peer-reviewed literature which states that further research or trails are necessary to determine the safety or efficacy of the treatment; or 5) One that lacks scientific evidence in the peer-reviewed literature demonstrating efficacy for the intended physical or mental condition. Benefits may be payable for an Experimental and Investigational medication, device or procedure if the following criteria are met: 1) The drug, device or procedure is approved by the FDA for some Illness or Injury, AND 2) The drug, device or procedure has sufficient documentation in the peer-reviewed literature which demonstrates efficacy and safety for the condition being treated, AND 3) The drug, device or procedure is currently being used within the medical community as a treatment for the proposed condition, AND 4) Other more conventional methods of treatment have been exhausted, AND 5) There is not clearly superior, non-investigational treatment alternative and there is a reasonable expectation that the treatment will be more effective than the noninvestigational alternative, AND 6) The drug, device or procedure is not the subject of a Phase I or II clinical trial as defined by NIH, AND 7) There exists an evidence-based support within the medical literature for the proposed treatment as outlined by the Agency for Healthcare Research and Quality (AHRQ) or the Cochrane reviews. For the treatment of cancer, there exists evidence-based support present as published on the National Comprehensive Cancer Network (NCCN) or by the Association of Community Cancer Centers (ACCC), AND 8) No documentation exists in the peer-reviewed literature that questions the safety or effectiveness of the use of the treatment for the condition being treated, AND 9) No documentation exists in the peer-reviewed literature which suggests that further research or clinical trials are needed to establish safety or efficacy, AND 10) The drug, device or procedure is not otherwise excluded under the Plan. FAMILY Family is a covered employee and his eligible, enrolled dependents. FREE-STANDING SURGICAL OR EMERGENCY CARE FACILITY A Free-Standing Surgical or Emergency Care Facility is a facility that is constituted, licensed and operated in accordance with the laws of legally authorized agencies responsible for medical institutions and that: Has emergency facilities and/or permanent operating rooms and at least one recovery room and all necessary equipment for use before, during and after surgery Is supervised by an organized medical staff, including registered nurses (R.N.) available for care in an operating or recovery room 65

68 Has a contract with at least one nearby Hospital for immediate acceptance of patients who require Hospital care following care in the Free-Standing Surgical or Emergency Care Facility Is other than a private office or clinic of one or more doctors FULL-TIME STUDENT A Full-Time Student is a student in an accredited high school, college or university who fulfills the requirements for being full time as defined by that institution and who is absent from school no more than one quarter (or semester) per Calendar Year. Summer is considered a school quarter (or semester). GROUP HEALTH PLAN A Group Health Plan is an employee welfare benefit plan as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974 (ERISA) to the extent that the Plan provides medical care. This includes items and services paid for as medical care to employees or their dependents, as defined under the terms of the Plan, directly or through insurance, reimbursement or otherwise. HIPAA HIPAA refers to the Health Insurance Portability and Accountability Act of 1996 and has the meaning set forth in Pub. L. No , as amended. It generally has two sections: Title I which allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationship, and Title II which mandates the adoption of standards for protecting the privacy and security of individually identifiable health information. HOME HEALTHCARE AGENCY A Home Healthcare Agency is a public or private agency or organization, or a subdivision thereof, that: Is primarily engaged in providing skilled nursing and other therapeutic services Has policies established by professional personnel, including one or more Physicians and one or more registered nurses (R.N.), to govern the services provided under the supervision of such Physician or nurse Maintains clinical records on all patients In cases where the applicable state or local law provides for the licensing of agencies or organizations of this nature, the latter are licensed or approved by the state or local laws as meeting the standards established for such licensing The term Home Healthcare Agency does not include any agency or organization that is engaged primarily in the care and treatment of mental health or provides primarily Custodial Care. HOME HEALTHCARE AIDE A Home Healthcare Aide is an individual who provides medical or therapeutic care and who reports to and is under the direct supervision of a Home Healthcare Agency. 66

69 HOME HEALTHCARE PLAN A Home Healthcare Plan is a plan for home care and treatment established and approved in writing by a Physician who certifies that the individual would require confinement in place of the care and treatment specified in the plan. HOSPICE A Hospice is a facility that is engaged primarily in providing Hospice services to terminally ill persons and which meets all the requirements set forth below: 1) It has obtained any required state or government certificate of need approval. 2) It is under the supervision of a duly qualified Physician. 3) It provides 24-hour-a-day, seven-day-a-week service. 4) It has a full-time administrator. 5) It has a nurse coordinator who is a registered nurse (R.N.) with four years of full-time clinical experience, at least two of which involved caring for terminally ill patients. 6) It has a social-service coordinator licensed in the jurisdiction where located. 7) It maintains written records of services on all patients. 8) It is established and operated in accordance with the applicable laws in the jurisdiction where located, and is licensed and approved by the regulatory authority having responsibility for licensing under the law. 9) Its employees are bonded and it provides malpractice and malplacement insurance. HOSPICE CARE Hospice Care is a plan for Inpatient or Outpatient treatment of a terminally ill patient with a life expectancy of six months or less as certified by a legally qualified Physician. HOSPICE CARE, PERIOD OF A Period of Hospice Care is a period of time during which a Covered Person is in a Hospice Care program. Successive Periods of Hospice Care will be considered related and to have occurred in one period of care unless separated by at least three consecutive months. HOSPITAL A Hospital is an institution that is engaged primarily in providing medical care and treatment of sick and injured persons on an Inpatient basis at the patient s expense and which meets all the requirements set forth below: 1) It maintains permanent and full-time facilities for bed care of resident patients. 2) It maintains, on the premises, diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of duly qualified Physicians. 3) It continuously provides, on the premises, 24-hour-a-day nursing service by or under the supervision of graduate registered nurses. 4) It is operated continuously with organized facilities for operative surgery on the premises and is operating lawfully as a Hospital in the jurisdiction where located. 67

70 However, the requirements of facilities for surgery shall not apply to a qualified psychiatric institution or to an acute rehabilitation Hospital. The term Hospital may also include a Free-Standing Surgical or Emergency Care Facility, but does not include a hotel, rest home, nursing home, convalescent home or facility for Custodial Care of the mentally ill or of the aged. ILLNESS Illness means a bodily disorder, disease or physical sickness. Illness includes Pregnancy, childbirth, miscarriage or complications of Pregnancy and shall also include Biologically Based Mental Illness, as defined herein. INJURY An Injury is a non-occupational accident that causes trauma to the body through unexpected external means. INPATIENT An Inpatient is a patient in a Hospital or other licensed facility whose length of stay is 24 hours or longer. INTENSIVE OUTPATIENT TREATMENT PROGRAM (IOP) IOP is an Outpatient interdisciplinary program for the mentally ill or chemically dependent. It must be licensed by the state where the treatment is rendered, and supervised by a D.O., M.D. or Ph.D. Treatment is a minimum of three times per week, three hours per session. It consists of individual therapy, group therapy, educational groups, team meetings, occupational therapy and recreational therapies. Program Participants may choose to stay at the facility overnight; however, the Plan does not pay for room-and-board charges. LIFETIME Lifetime means, with regard to the Maximum Lifetime Benefit, the period of time during which a person is continuously covered under this Plan. Changing to another Option offered under the Plan or by the Employer will not create a new Lifetime Maximum Benefit. MATERNITY MANAGEMENT Maternity Management includes counseling regarding prenatal care, risk assessment and recommendations for lifestyle modifications. ACMS Patient Services Center notification is encouraged as soon as possible after pregnancy has been confirmed to begin Maternity Management. MEDICAL CHILD SUPPORT ORDER A Medical Child Support Order (MCSO) is any court order, judgment, decree or order (including a court s approval of a domestic relations settlement agreement) that: 1) Provides for child support related to health benefits with respect to the child of a Group Health Plan Participant, or requires health benefit coverage of such child in such plan, and is ordered under state domestic relations law; or 2) Enforces a state medical child support law enacted under Section 1908 of the Social Security Act with respect to a Group Health Plan. 68

71 MENTAL DISORDER Mental Disorder means any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of International Classification of Diseases, published by the U.S. Department of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. This excludes Biologically Based Mental Illness as defined herein. MENTAL HEALTH PROVIDER Mental Health Provider means a Physician, psychologist, professional clinical counselor, professional counselor, independent social worker or clinical nurse specialist whose nursing specialty is mental health. MIDWIFE According to the International Confederation of Midwives, World Health Organization and Federation of International Gynecologists and Obstetricians, a Midwife is a person who, having been regularly admitted to a midwifery educational program, is fully recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. NATIONAL MEDICAL SUPPORT NOTICE A National Medical Support Notice (NMSN) is a notice completed under an order issued by a court or by a state child support agency. The NMSN can be a Qualified Domestic Relations Order (QDRO), and is acceptable under ERISA in place of a Qualified Medical Child Support Order (QMCSO) for adding a child under the Plan for medical and/or other coverage and which contains one or more of the following: The name of the issuing agency; The name and mailing address of an employee who is a Participant in the Plan or eligible for participation under the Plan, who is a non-custodial parent obligated by a state court or administrative order to provide medical child support for one or more children named in the notice; The name and mailing address of one or more Alternate Recipient(s); and The family group healthcare coverage required by the order is identified and available. The Company must transfer Part B of the notice to the Plan Administrator within 20 business days, and the Plan Administrator must complete and return the notice to the issuing agency within 20 business days of receipt of the NMSN. Notification will be sent to the custodial and/or non-custodial parent whose coverage is the basis of the NMSN and from whom any necessary employee contributions will be withheld as determined under Part A of the notice. NECESSARY MEDICAL SERVICES Necessary Medical Services, procedures or levels of care are those health services, supplies or drug therapies that are determined by the Plan to be medically necessary to meet the health needs of a Covered Person according to the benefits available in this Summary Plan Description. 69

72 Determination of Necessary Medical Services is made on a case-by-case basis and considers several factors including, but not limited to, the standards of the medical community. The fact that a Physician has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment of a particular Injury or Illness, does not mean that it is medically necessary. In addition, the service must be, in the Plan s judgment: Consistent with the diagnosis of and prescribed course of treatment for the Covered Person s Injury or Illness Necessary to treat the Covered Person s Injury or Illness Required for reasons other than the convenience of the Covered Person or his Physician, or not required for custodial, comfort or maintenance reasons Rendered at the frequency which is accepted by the medical community and in accordance with the Plan s guidelines NETWORK (Preferred Provider Organization PPO) A Network consists of Hospitals, Physicians and/or other healthcare providers who have contracted with the Plan Sponsor to provide medical care at negotiated rates. In-Network Provider: A provider of service who has contracted with the PPO that is affiliated with the Plan. This provider has agreed to discounts through the PPO. The patient is not responsible for the difference between the undiscounted and discounted charges. Out-of-Network Provider: A provider of service who has not contracted with the PPO that is affiliated with the Plan. The provider is subject to the Usual, Customary and Reasonable (UCR) Allowance and the patient would be responsible for any charges in excess of the UCR Charge. NO-FAULT AUTO INSURANCE No-fault auto insurance is the basic reparation provision of a law providing for payments without determining fault in connection with an automobile accident. NOTICE OF PRIVACY PRACTICES Notice of Privacy Practices has the meaning as set forth in 45 C.F.R , as amended, and is a document that outlines how a Covered Entity will use and disclose Protected Health Information and certain privacy and security rights under HIPAA. OUTPATIENT An Outpatient is a patient who receives healthcare services without being admitted to a Hospital or other facility for an overnight stay, his confinement is not an Inpatient, and the duration of his stay at the facility is less than 24 hours. PARTICIPANT Participant means an employee or former employee of the Company, or a member or former member of the Company, who is or may become eligible to receive a benefit of any type from an employee benefit plan that covers employees or members of such Company, or whose beneficiaries may be eligible to receive any such benefit. 70

73 PHYSICIAN A Physician is a person duly licensed under the governing authority to perform the services rendered for benefits covered under the Plan. Should such person be other than a Medical Doctor (M.D.), Doctor of Osteopathy (D.O.) or Doctor of Dental Surgery (D.D.S.), and the licensing requirements of the applicable jurisdiction require that such person be recognized as a provider to the extent that he is performing services within the scope of his license, such services will be recognized under the Plan. PLAN Plan refers to the benefits and provisions for payment of benefits as set forth in the South Central Ohio Insurance Consortium Health Plan adopted by the Plan Sponsor. PLAN DOCUMENT Plan Document refers to the Group Health Plan s governing documents and instruments (i.e., the documents under which the Group Health Plan was established and is maintained). PLAN SPONSOR Plan Sponsor means South Central Ohio Insurance Consortium. POST-SERVICE CLAIM A Post-Service Claim is any claim that is not a Pre-Service Claim. A Post-Service Claim includes a claim that contains re-priced claims amounts, if applicable. PRE-SERVICE CLAIM A Pre-Service Claim is any claim that relates to treatment that must be pre-certified or pre-approved under the terms of the Plan. PRIVACY OFFICER A Privacy Officer is the person responsible for developing and implementing the Company s policies and procedures under HIPAA s privacy and security rules. PROTECTED HEALTH INFORMATION (PHI) Protected Health Information (PHI) is individually identifiable health information transmitted or maintained in any form or medium, which is held by a Covered Entity or its Business Associate. QUALIFIED MEDICAL CHILD SUPPORT ORDER A Qualified Medical Child Support Order (QMCSO) is a Medical Child Support Order (MCSO) which creates or recognizes the existence of an Alternate Recipient s right to, or assigns to an Alternate Recipient the right to, receive benefits for which an Eligible Employee or other Participant is eligible under a Group Health Plan, and specifies: The name and last known mailing address of the Eligible Employee to whom the MCSO relates The name and address of each child of the Eligible Employee ( Alternate Recipient ) covered by the MCSO A reasonable description of the type of coverage to be provided to each such Alternate Recipient or the manner in which such type of coverage is to be determined 71

74 The MCSO is qualified only if it does not require the Group Health Plan to provide any type or form of benefit, or any option, not otherwise provided under the Group Health Plan, except to the extent necessary to meet the requirements of the law as stated in 42 U.S.C et seq. QUALIFIED MEDICAL EMERGENCY A Qualified Medical Emergency is the sudden and unexpected onset of a serious medical condition. This condition must include symptoms so severe as to cause the person to seek immediate medical care and when failure to obtain immediate medical care would cause serious harm to the person s health or jeopardize his life and is so certified by the attending Physician. Such conditions can include heart attacks, strokes, poisonings, respiratory distress, suffocation, convulsions, hemorrhage, high fever, unconsciousness and diabetic shock. Other examples might include a spontaneous lung collapse, acute appendicitis or heat prostration. RESIDENTIAL TREATMENT Mental health or substance abuse treatment in a facility or part of a facility operated for the primary purpose of providing residential mental health/chemical dependency care. The facility must be licensed by the state and JCAHO-approved for the treatment of a specific population. The treatment is 24 hours a day, seven days a week. It is direct, sub-acute mental health or chemical dependency treatment provided by licensed professionals in a multidisciplinary team. The providers of care are available 24 hours a day and are directly supervised by a licensed Physician. SECOND SURGICAL OPINION A Second Surgical Opinion is an opinion of a board-certified surgical specialist based on his examination of a patient regarding the advisability of an elective surgical procedure, after another licensed surgeon has recommended surgery, but prior to the actual performance of the procedure. SECURITY INCIDENT Security Incident has the meaning set forth in 45 C.F.R , as amended from time to time, and generally means the attempted or successful unauthorized access, use, disclosure, modification or destruction of information or interference with systems operations in an information system. SKILLED NURSING FACILITY A Skilled Nursing Facility is an institution or distinct part of an institution that: Is licensed pursuant to the law or approved by the appropriate authority Provides 24-hour nursing care for sick and injured patients on an Inpatient basis Has nursing care and service policies developed with the advice of and subject to review by professional personnel Has a Physician, registered nurse or other medical staff responsible for the execution of such policies Requires every patient to be under the care of a Physician and makes a Physician available to furnish medical care in case of emergency Maintains clinical records on all patients, has appropriate methods for dispensing drugs and medicines and has at least one registered nurse employed on a full-time basis 72

75 Provides for a group of Physicians to periodically review medical necessity for admissions, continuation of confinements, duration of stay and adequacy of care The term Skilled Nursing Facility does not include an institution that is primarily for Custodial Care. TOTALLY DISABLED Totally Disabled means the Covered Person is under the regular care of a Physician and is unable to perform any and every duty of his occupation and is not employed for wage or profit. If the Covered Person is not employed, Totally Disabled shall mean that he is unable to perform any of the normal activities of a person of like age and sex in good health. URGENT CARE CLAIM An Urgent Care Claim is any claim for treatment that, if delayed, could seriously jeopardize the life or health of the patient, would limit the ability of the claimant to regain maximum function or would subject the patient to severe pain that could not be adequately managed without the treatment that is the subject of the claim. USUAL, CUSTOMARY AND REASONABLE (UCR) ALLOWANCE The Usual, Customary, and Reasonable (UCR) Allowance is the prevailing fee or fees most frequently accepted by providers of the same services with similar training and experience for comparable services, or services of comparable gravity, severity and magnitude, in the locality where the services were performed. The UCR allowance is established using historical data within a specific geographical area, supplemented by data provided by independent research firms that specialize in collecting this data. Updates are provided periodically. For Network charges, the "Usual, Customary and Reasonable" (UCR) Allowance is the fee set forth in the negotiated fee schedule. All charges shall be deemed to be incurred as of the date of the treatment that gives rise to the charge or as of the date of purchase of the supply or service covered by the charge. The Claims Administrator will follow the prevailing and most commonly applied reimbursement rules and guidelines. WAITING PERIOD With respect to a Group Health Plan and an individual who is a potential Participant under the Plan, a Waiting Period is the period that must pass for an individual before he is eligible to enroll for coverage under the terms of the Plan. For a late enrollee or a special enrollee, however, any period before such late or special enrollment is not a Waiting Period. WELL-CHILD CARE Well-Child Care is a periodic review of a child s physical and emotional status performed by a Physician or by a healthcare professional under the supervision of a Physician. A periodic review is a review performed in accordance with the recommendations of the American Academy of Pediatrics and includes a history, complete physical examination, development assessment, anticipatory guidance, appropriate immunizations and laboratory tests. 73

76 EMPLOYEE BENEFIT MANAGEMENT CORP CLAIMS ADMINISTRATORS / CONSULTANTS COLUMBUS, OHIO E112408sFF