Paramount Insurance Company Small/Large Group Ohio Commercial HMO Member Handbook

Transcription

1 Paramout Isurace Compay Small/Large Group Ohio Commercial HMO Member Hadbook Paramout is the health isurace optio that offers a diverse lie of products, a broad provider etwork, high quality ad local, depedable service.

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3 Welcome! Paramout Isurace Compay Small/Large Group Ohio Commercial HMO Member Hadbook Provided by:

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5 HMO Member Hadbook NOTICE CONCERNING COORDINATION OF BENEFITS (COB) 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. 1

6 HMO Member Hadbook I Case of Emergecy For Medical Emergecy Coditios such as heart attack, stroke, poisoig, loss of cosciousess, iability to breathe, ucotrolled bleedig, covulsios ad other coditios i which miutes ca save lives, call 911, a ambulace or rescue squad or go directly to the earest emergecy facility. For other Emergecy Medical Coditios, see page 20. Your Primary Care Provider ca be reached 24 hours a day, seve (7) days a week. If you eed medical advice after hours, o weekeds or holidays, call your doctor s office umber. The aswerig service will take your call. Leave a message for the doctor or a urse to retur your call. A doctor or urse will call you back with istructios. List the ames ad umbers of the Primary Care Providers for each family member. Member Name: Primary Care Provider (Name): Number: Member Name: Primary Care Provider (Name): Number: Member Name: Primary Care Provider (Name): Number: Member Name: Primary Care Provider (Name): Number: Member Name: Primary Care Provider (Name): Number: Police Rescue Hospital Other Fire Ambulace Poiso Cotrol 2

7 HMO Member Hadbook Dear Member: Welcome to Paramout Isurace Compay. This hadbook will help you uderstad ad use your beefits most effectively. The Primary Care Provider you chose whe you joied will help you whe you eed medical care. ALWAYS CONTACT YOUR PRIMARY CARE PROVIDER FIRST uless there is a Emergecy Medical Coditio. He or she will help you coordiate all your medical care. If you did ot eed to chage doctors, be sure to call your Primary Care Provider s office as soo as possible to let them kow you are ow covered by Paramout Isurace Compay. If you did chage doctors, it is a good idea to get to kow your doctor so you ca feel comfortable askig questios, especially if a Emergecy Medical Coditio arises. If you are a ew patiet with your Primary Care Provider, we ecourage you to call the doctor s office for a appoitmet as soo as you ca to discuss your medical history ad get to kow each other. This Member Hadbook also explais who is covered uder your pla ad how the Pla works. Please take a few miutes to read it. If you have ay questios or eed help uderstadig your beefits, please call Member Services, Moday through Friday, 8:00 a.m. to 5:00 p.m. We look forward to servig you. The Member Services Departmet The official terms of your erollmet ad health beefits through Paramout Isurace Compay are stated i the Group Medical ad Hospital Service Agreemet (GSA) ad all applicable Documets as defied i paragraph of the GSA, all of which are o file with your employer. This Member Hadbook cotais a summary of your rights ad obligatios regardig your erollmet ad health beefits through Paramout Isurace Compay. If there are ay icosistecies betwee this Member Hadbook ad the Group Medical ad Hospital Service Agreemet, the Service Agreemet will cotrol. 3

8 HMO Member Hadbook MISSION STATEMENT As a itegral part of ProMedica Health System, Paramout, a commuity-based maaged health care orgaizatio, shall work i collaboratio with employers, idividual members, physicias, health care providers, ad commuity ad govermetal agecies to cotiually improve the health of its Members by providig comprehesive health plas with usurpassed levels of customer service, quality ad cost effectiveess. This missio will be accomplished by adherig to the values upo which Paramout is based: Access Provide Members with a choice of physicias ad other professioals who meet the highest stadard of professioal traiig ad experiece. Accoutability Hold Paramout ad all health care professioals accoutable for the quality of service provided ad the satisfactio of Members ad patiets. Compassio Assure that all Members, employees ad other costituets are treated with digity ad respect. Excellece Improve both cliical ad admiistrative service delivery through a systematic process of quality improvemet. Prevetio Persoify the belief that keepig Members healthy is as importat as carig for them if they become ill. Paramout is committed to the highest stadards of quality, service, professioal ethics ad itegrity, ad to the priciple that Members come first. 4

9 Table of Cotets Table of Cotets 1. The Basics...7 How Paramout Works...7 Your Idetificatio Card...7 Is There a Pre-existig Coditio Restrictio?...8 What Are Deductibles?...8 What are Copaymets ad Coisurace?...9 Who to Call for Iformatio...9 Members Rights...9 Members Resposibilities Gettig a Doctor s Care...10 Start with Your Primary Care Provider...10 Whe You Need OB/GYN Care...12 Utilizatio Maagemet...13 Eterig the Hospital...15 Leavig the Hospital Agaist Medical Advice...15 Chage i Beefits...15 If a Provider Leaves the Pla...15 If a Specialist Leaves the Pla...15 Cotiuity of Treatmet...16 Provider Reimbursemet / Filig a Claim...16 No-Covered Services...16 If You Receive a Bill...16 New Techology Assessmet...16 Privacy ad Cofidetiality...16 Owership ad Physicia Compesatio...17 Patiet Safety What to Do for Urget Care or Emergecy Medical Coditios...18 Urget Care Services...18 Emergecy Services...19 The Paramout Service Area Your Pla...21 What Is Covered - I Geeral...21 What Is Not Covered - I Geeral...21 What Is Covered/What Is Not Covered - Specific Services...22 Who Is Eligible...32 Addig ad Removig Members...34 Reewal of Coverage...35 Termiatio of Member Coverage...35 Beefits After Cacellatio of Coverage...35 Certificate of Creditable Coverage

10 Table of Cotets 5. What Happes with Your Pla...36 Whe You Have Other Coverage How Coordiatio of Beefits Works...36 Whe You Are Eligible for Medicare...40 Whe You Qualify for Worker s Compesatio...40 Whe Someoe Else Is Liable (Subrogatio ad Reimbursemet)...41 Whe You Leave Your Job...41 How You May Cotiue Group Coverage...41 How to Covert to Idividual Coverage (Whe Group Coverage Is No Loger Available) What to Do Whe You Have Questios, Suggestios, Complaits or Appeals...43 How to Hadle a Complait...44 Appeal to Paramout Terms ad Defiitios...49 Immuizatio Schedule...Isert Prevetive Health Care Guidelies...Isert Summary of Beefits...Isert 6

11 HMO Member Hadbook 1. THE BASICS How Paramout Works Your Primary Care Provider is your first cotact whe you eed medical care. Your PCP will coordiate your medical care with other Participatig Providers i the Paramout etwork. (Female Members may receive OB/GYN care from a participatig obstetrics/gyecology specialist without Prior Authorizatio from the Primary Care Provider (PCP). Prior Authorizatio is required for certai procedures or services. It is the resposibility of the Participatig Provider to obtai Prior Authorizatio from Paramout i advace of these procedures or services. Your Idetificatio Card Member idetificatio umber Member s ame Your Persoal Physicia s ame ad phoe umber Your copay for PCP office visit MEMBER NAME JOHN DOE PRIMARY CARE PHYSICIAN JOHN PHYSICIAN PCP SPEC ER RX $X $X $XX ID NUMBER XXXXXXXXX XX GROUP NUMBER XXXXXXXXXX EFF. DATE XX/XX/XX Paramout Isurace Compay is icorporated i Ohio uder Paramout Care, Ic. EMERGENCY SERVICES I case of a emergecy medical coditio call 911 or go to the earest medical facility. I all other cases, cotact your PCP for istructios. SPECIALTY SERVICES Your Primary Care Provider is your first cotact for o-emergecy medical care ad will recommed a participatig specialist if additioal care is eeded. Go to for the most curret listig of participatig providers. HOSPITAL ADMISSIONS Prior authorizatio must be obtaied by the hospital prior to all o-emergecy admissios by callig Whe travelig out-of-area, call PHCS at for preferred providers. Member Services: , Optio 6 TTY: (419) OR Claims Address: P.O. Box 497, Toledo, OH Mailig Address: P.O. Box 928 Toledo, OH Ask Paramout Nurse Lie: Copay for specialist visit Copay for covered emergecy room treatmet Idicates prescriptio drug coverage Member Services phoe umbers for questios ad complaits 7

12 HMO Member Hadbook Every Paramout Member receives a Paramout idetificatio card with his or her ame. The ame of that perso s Primary Care Provider (PCP) is o the card. If your card is lost or stole or ay iformatio is icorrect, call Member Services. Is There a Pre-existig Coditio Restrictio? May health beefit plas have pre-existig coditio limitatios. Paramout Isurace Compay does ot have ay restrictios o pre-existig coditios. I other words, if you were beig treated for a coditio before you became a Paramout member, Paramout will provide beefits for Covered Services related to that coditio o or after your effective date with Paramout as log as you follow the procedures described i Sectio 2, Gettig a Doctor s Care. Lifetime Dollar Limits The Essetial Health Beefits that may be provided by your Pla are ot subject to a lifetime dollar limit. Pla beefits that are ot defied as Essetial Health Beefits may have a lifetime dollar limit. If you have reached a lifetime dollar limit uder your Pla before the federal regulatio prohibitig lifetime dollar limits for Essetial Health Beefits became effective, ad you are still eligible uder your Pla s terms, ad that Pla is still i effect, you will receive a otice that the lifetime dollar limit o loger applies ad that you will have a opportuity to eroll or be reistated uder your Pla. If you are eligible for this erollmet opportuity, you will be treated as a special erollee. Aual Dollar Limits Your Pla may have aual dollar limits o the claims the Pla will pay each year for Essetial Health Beefits. Your Pla may iclude other beefits ot defied as Essetial Health Beefits, ad those other beefits may have aual dollar limits. If your Pla has aual dollar limits o Essetial Health Beefits they are subject to the followig: For a pla year begiig o or after September 23, 2010, but before September 23, 2011, the limit ca be o less tha $750,000. For a pla year begiig o or after September 23, 2011, but before September 23, 2012, the limit ca be o less tha $1.25 millio. For a pla year begiig o or after September 23, 2012, but before December 31, 2013, the limit ca be o less tha $2 millio. For a pla year begiig o or after Jauary 1, 2014, there is o dollar limit for Essetial Health Beefits uder your Pla. What Are Deductibles? A Deductible is the amout you must pay for Covered Services withi each Cotract Year before beefits will be paid by Paramout. A Deductible caot exceed $1,000 per sigle or $2,000 per family per Cotract Year. If your pla has a Deductible, it will be stated i your Summary of Beefits. The sigle Deductible is the amout each Member must pay, ad the family Deductible is the total amout ay two or more covered family members must pay. Prevetive Health Services/Beefits ad Covered Services requirig a Copaymet are ot subject to the Deductible. See Sectio 4, Prevetive Health Services for a list of Prevetive Health Services. 8

13 HMO Member Hadbook What Are Copaymets ad Coisurace? Paramout members pay Copaymets (copays) or Coisurace for Basic Health Services such as: office visits ad services, ipatiet services (services you receive while a patiet i a hospital or other medical facility), outpatiet medical services, emergecy services, laboratory ad radiology services, services for treatmet of Biologically ad No-Biologically Based Metal Illess ad substace abuse ad prevetive health services. There are o lifetime beefit limits o Basic Health Care Services. Copaymets or Coisurace for a Basic Health Service will ot exceed 40% of the average cost to Paramout of providig the service. See your Summary of Beefits for Copaymets/Coisurace o specific services. Copaymets are payable at the time you receive services. The Out-of-Pocket Copaymet Limit is the maximum amout of Copaymets ad Coisurace icludig the Deductible you pay every Cotract Year. Oce the Out-of-Pocket Copaymet Limit is met, there will be o additioal Copaymets ad Coisurace o Basic Health Services durig the remaider of the Cotract Year. The Out-of-Pocket Copaymet Limit is stated i your Summary of Beefits. The sigle Out-of-Pocket Copaymet Limit is the amout each Member must pay, ad the family Out-of-Pocket Copaymet Limit is the total amout ay two or more covered family members must pay. This out-of-pocket limit caot exceed 200% of the average aual premium to Subscribers ad Members. Copaymets ad Coisurace for Supplemetal Health Services such as home health care, durable medical equipmet, prosthetic devices, visio care services, prescriptio drugs ad ay pealties do ot cout toward the Out-of-Pocket Copaymet Limit. Who to Call for Iformatio The Paramout Member Services Departmet is here to help you. Call, if you: Have ay questios about your coverage Have questios about the providers who participate with Paramout Have questios about how to obtai health care services Need help uderstadig how to use your beefits Need to chage your Primary Care Provider Are chagig addresses, or eed to add a ew family member to your pla Lose your Paramout idetificatio card Or have ay other health care coverage cocers MEMBERS RIGHTS As a Member of Paramout, you have certai rights that you ca expect from Paramout ad Paramout providers. You have the right to: Receive iformatio about Paramout, its services, providers ad your rights ad resposibilities. Participate with your physicias i decisio-makig regardig your health care. A cadid discussio of appropriate or medically ecessary treatmet optios for the coditios regardless of cost or beefit coverage. Voice complaits or appeals about the health pla or care provided. Be treated with respect, recogitio of your digity ad the eed for privacy. Make recommedatios regardig Paramout s Member rights ad resposibilities policies. 9

14 HMO Member Hadbook MEMBERS RESPONSIBILITIES As a Member of Paramout, you have certai resposibilities that Paramout ad Paramout providers ca expect from you. You have the resposibility to: Provide, to the extet possible, iformatio that Paramout ad the Participatig Providers eed to care for you. Help your PCP fill out curret medical records by providig curret prescriptios ad your previous medical records. Egage i a healthy lifestyle, become ivolved i your health care ad follow the plas ad istructios for the care that you have agreed o with your PCP or specialists. Uderstad your health problems ad participate i developig mutually agreed-upo treatmet ad goals to the degree possible. 2. GETTING A DOCTOR S CARE Start with Your Primary Care Provider (PCP) Your PCP is the doctor you chose to hadle your medical care through your Paramout pla. Paramout requires the desigatio of a Primary Care Provider (PCP) for each Member. You have the right to desigate ay PCP who participates i the Paramout etwork as a PCP ad who is available to accept you or your family members. PCPs are family practitioers, iterists ad pediatricias participatig i the Paramout etwork. For childre, you may desigate a pediatricia as the PCP. Each family member ca have a differet PCP. For iformatio o how to select a PCP, ad a list of the Participatig PCPs, cotact Paramout Member Services at (419) or toll-free A directory of Participatig Providers is also available at: If you have chose a doctor you have ot see before, make a appoitmet ad get to kow the doctor ad staff. The more comfortable you are with your doctor - ad the better your doctor kows you - the more effective your health care ca be. For doctor appoitmets, call your PCP s office. Paramout maitais specific access stadards to make sure you get the care you eed o a timely basis. Access refers to both telephoe access ad the ability to schedule appoitmets. If you are havig difficulty schedulig a appoitmet or reachig a provider s office, please cotact the Member Service Departmet. They will assist you. Please call as far i advace as possible for a appoitmet. Use the followig table of Access Stadards as a guide for the lead-time you should allow. 10

15 HMO Member Hadbook ACCESS STANDARDS for MEDICAL HEALTH CARE SERVICES Type of Care Required Expected Access Stadards Routie assessmets, physicals or ew visits Routie follow-up visits (for recurrig problems related to chroic ailmets like high blood pressure, asthma, diabetes, etc.) 30 days 14 days Symptomatic, o urget symptoms (cold, sore throat, rash, muscle pai, headache) Urget medical problems (uexpected illesses or ijuries requirig prompt attetio soo after they appear; urget care problems are ot permaetly disablig or life-threateig; a example would be a persistet high fever) Emergecy Medical Coditios (such as heart attack, stroke, poisoig, loss of cosciousess, iability to breathe, ucotrolled bleedig ad covulsios) 2-4 days 1-2 days Immediately call 911 or seek medical treatmet. Afterward, call your PCP for follow-up care. ACCESS STANDARDS for BEHAVIORAL HEALTH CARE SERVICES Type of Care Required Emergecy Care, immediate threat to self or others (acutely suicidal or homicidal) Urget Care, may ot be life-threateig, but requires urget attetio (complex or dual problems) Routie Care/ Office Visit for ew problems upo request of the member or provider Routie Care/ Office Follow-Up Visits Immediately call 911 or seek medical treatmet. The call your PCP for follow-up care 1-2 days 14 days 30 days Expected Access Stadards If you are uable to keep a appoitmet, call your physicia as soo as possible so the time ca be made available for other patiets. Paramout Isurace Compay will ot cover claims associated with missed appoitmets. Your Primary Care Provider ca be reached 24 hours a day, seve (7) days a week. If you eed medical advice after hours, o weekeds or holidays, call your doctor s office umber. The aswerig service will take your call. Leave a message for the doctor to retur your call. Whe your doctor, the doctor who is coverig for your Primary Care Provider or a urse calls you, explai the problem clearly. They will advise you o what to do. 11

16 HMO Member Hadbook Whe your doctor recommeds a treatmet or test, i most cases it will be covered. However, some treatmets may ot be covered or are covered oly whe authorized i advace by Paramout. Your doctor may be workig with several Paramout plas; plas are ofte differet from oe compay to the ext. The service your doctor recommeds for you may be covered uder some similar plas, but ot uder your particular pla. If you are ot sure, the best thig to do is ask Paramout Member Services. Do t be afraid to call. IF YOU HAVE A QUESTION about whether a service is covered, you ca fid out by callig Member Services. If you do ot have Prior Authorizatio before you get the services, you may be held resposible for total paymet. If aother doctor is coverig for your Primary Care Provider durig off-hours or vacatio, you do ot eed Paramout Prior Authorizatio before you see that doctor. But be sure to tell the doctor you are a member of Paramout Isurace Compay. You may chage your Primary Care Provider. You must otify Paramout first, before you see ay ew Primary Care Provider. Call the Member Services Departmet or through the Paramout web site at: The chage ca be made effective the day you call. You will receive a ew idetificatio card with your ew physicia s ame. If you eed to see the doctor before your card arrives, your doctor ca call Member Services to check your membership. What to Cosider Whe Selectig a Physicia or Hospital If you eed specific iformatio about the qualificatios of ay participatig physicias, you may call the Academy of Medicie, the Member Services Departmet or you may use the o-lie Provider Directory available through our web site at with liks to the Ohio State Medical Associatio. The followig qualificatios are importat to cosider i selectig a Primary Care Provider or specialist: Professioal educatio medical school/residecy traiig, Curret Board Certificatio status, Number of years i practice ad Laguages spoke The followig qualificatios are importat whe selectig a hospital: The Joit Commissio status (Paramout participatig hospitals are required to have Joit Commissio accreditatio) Hospital experiece/volume i performig certai procedures. Cosumer satisfactio ad comparable measures of quality o hospitals ad outpatiet surgical facilities. If you eed a curret directory, you may request oe by callig the Member Services Departmet or you may use the o-lie Provider Directory available through our web site at Whe You Need OB/GYN Care You do ot eed Prior Authorizatio from Paramout or from ay other perso (icludig your PCP) i order to obtai access to obstetrical or gyecological care from a health care professioal i the Paramout etwork who specializes i obstetrics or gyecology. The health care professioal, however, may be required to comply with certai procedures, icludig obtaiig Prior Authorizatio for certai services or followig a pre-approved treatmet pla. For a list of participatig health care professioals who specialize i obstetrics or gyecology, cotact Paramout Member Services 12

17 HMO Member Hadbook at (419) or toll-free A directory of Participatig Providers is also available at: If you eed more specialized OB/GYN care, the gyecologist may recommed aother participatig specialist. Whe You Are Referred to a Specialist Most of your health care eeds ca ad should be hadled by your Primary Care Provider. If your Primary Care Provider believes you eed to see a specialist - a cardiologist, orthopedist or others - your Primary Care Provider will recommed a Participatig Specialist. Or you may choose the Participatig Specialist you wish to see from those listed i the Participatig Physicias ad Facilities directory (also available o the website) ad make a appoitmet. Newly erolled members of Paramout who are already seeig a specialist should verify that the specialist is participatig with Paramout. Prior Authorizatio If a Medically Necessary covered service is ot available from ay Participatig Providers, Paramout will make arragemets for a out of pla Prior Authorizatio. Your Primary Care Provider must request a out of pla Prior Authorizatio i advace. Cosultatios with Participatig Specialists will be required before a out of pla Prior Authorizatio ca be cosidered. If Paramout approves the out of pla Prior Authorizatio, writte cofirmatio will be set to you, your PCP ad the o-participatig provider. All eligible authorized services will be covered subject to appropriate Deductible ad Copaymets/Coisurace. If you have a life-threateig, degeerative or disablig coditio that requires the services of a participatig Specialist over a log period of time, you should discuss this with your Primary Care Provider. If your Primary Care Provider ad the Specialist agree that your coditio requires the coordiatio of a Specialist, your PCP will cotact Paramout. Together, you, your Primary Care Provider, your Specialist ad Paramout will agree o a treatmet pla. Oce this is approved, the Specialist will be authorized to act as your Primary Care Provider i coordiatig your medical care. Utilizatio Maagemet Participatig physicias ad providers have direct access to Paramout s Utilizatio Maagemet Departmet to authorize specific procedures ad certai other services based o medical ecessity. It is the resposibility of the participatig physicia or provider to obtai Prior Authorizatio whe required. If you experiece a Emergecy Medical Coditio after ormal office hours, you should call 911, a ambulace or rescue squad or go to the earest medical facility. You do ot eed to obtai prior approval from your PCP or Paramout. Afterward, you should otify your Primary Care Provider that you were treated. Utilizatio maagemet decisios are ot subject to icetives to restrict or dey care ad services. I fact, Paramout moitors uder-utilizatio of importat prevetive services, health screeig services (immuizatios, pap tests, etc.), medicatios ad other services to care for chroic coditios, such as asthma ad diabetes. Paramout will sed remider cards to the Member ad physicia if a claims review suggests that importat services were missed. If you eed to discuss the status of Prior Authorizatio, you should cotact your Primary Care Provider. You may also call the Member Services Departmet at (419) or toll-free

18 HMO Member Hadbook Iitial Determiatios Whe Prior Authorizatio is required, Paramout will make a decisio withi two (2) workig days from obtaiig all the ecessary iformatio about the admissio, or procedure that requires Prior Authorizatio. Paramout will advise the provider of the decisio by telephoe withi oe (1) workig day after makig the decisio. Paramout will sed writte cofirmatio of the decisio to the provider ad the Member withi two (2) workig days of makig the telephoe otificatio. If Paramout makes a adverse determiatio (i.e., deies approval or coverage), Paramout will otify the requestig provider by telephoe withi oe (1) workig day after makig the decisio. Paramout will sed writte cofirmatio of the decisio to the provider ad the Member withi oe (1) workig day of the telephoe otificatio. If Paramout does ot make a determiatio withi the required timeframe, the Member may request a iteral review. See Sectio 6. Cocurret Reviews For cocurret reviews, which are requests to exted coverage that were previously approved for a specified legth of time, Paramout will make a decisio withi oe (1) workig day after obtaiig all the ecessary iformatio. Paramout will advise the provider by telephoe withi oe (1) workig after makig the decisio. Paramout will sed writte cofirmatio of the decisio to the provider ad the Member withi oe (1) workig day after the telephoe otificatio. The writte otificatio will iclude the umber of exteded days or ext review date, the ew total umber of days approved ad the date services were begu. If Paramout makes a adverse determiatio, Paramout will otify the requestig provider by telephoe withi oe (1) workig day after makig the decisio. Paramout will sed writte otificatio to the provider ad the Member withi oe (1) workig day after the telephoe otificatio. The Member s coverage will be cotiued, subject to applicable Copaymets/Coisurace, util the Member has bee otified of the decisio. Retrospective Reviews Paramout will make a decisio withi thirty (30) workig days after receivig all ecessary iformatio o retrospective reviews. Paramout will otify the provider ad the Member i writig. If Paramout makes a adverse determiatio, Paramout will otify the provider ad the Member i writig withi five (5) workig days from makig the decisio. Expedited Reviews If the seriousess of the Member s medical coditio requires a expedited review, Paramout will make the decisio as quickly as the medical coditio requires but o later tha sevety-two (72) hours after the request has bee made. Paramout will otify the provider of the decisio by telephoe immediately. A writte cofirmatio will be set to the provider ad the Member withi two (2) workig days from the decisio. Adverse Determiatios Paramout s writte otificatio will iclude the pricipal reaso/s for the decisio icludig specific utilizatio review criteria or beefit provisio used i makig the determiatio. Paramout will also iclude istructios for requestig a writte statemet of the cliical ratioale used to make the decisio. Paramout will provide a writte statemet of the cliical ratioale to ay Authorized Perso makig the request ad followig the istructios. 14

19 HMO Member Hadbook Obtaiig Necessary Iformatio If a provider or Member will ot release the ecessary iformatio eeded to make a decisio, Paramout may dey approval. Eterig the Hospital Your Primary Care Provider or Participatig Specialist will make the arragemets whe you eed hospital care. Paramout Participatig Hospitals are listed i your Participatig Physicias ad Facilities directory or the Paramout web site at Show your Paramout card whe you are admitted. If you are i the hospital whe this pla becomes effective, your Paramout coverage will begi o your effective date. (The pla you had whe you were admitted should cover your hospital stay up to your effective date with this pla.) A emergecy admissio to a oparticipatig hospital must be called i to Paramout withi 24 hours (or as soo as reasoably possible) or your hospital care may ot be covered. If ad whe your medical coditio allows, your Primary Care Provider ad Paramout may arrage for you to be trasferred to a Participatig Hospital. Leavig the Hospital Agaist Medical Advice If you discharge yourself from ay hospital or facility agaist medical advice (AMA), there will be a pealty o all charges related to that admissio. Also, if a hospital or facility requires your discharge (a discipliary discharge ) for ay reaso, you will be resposible for a pealty o all charges related to that admissio. The total of your copays (if ay) ad the pealty will ot exceed 40% of the average cost of covered services o medical admissios ad 50% of the average cost of covered services o substace abuse admissios. Chage i Beefits Paramout will otify you i writig if ay beefits described i this Member Hadbook ad Summary of Beefits chage. If a Provider Leaves the Pla If your Primary Care Provider or ay Participatig Hospital ca o loger provide medical services because their Paramout agreemet eds, we will otify you i writig withi thirty (30) days. We will cover all eligible services they provide betwee the date of termiatio ad five (5) busiess days from the date o the postmark. If a Specialist Leaves the Pla If you are beig see regularly by a Participatig Specialist or a specialty group whose agreemet with Paramout eds, you ad your PCP will be otified. You may the cotact a ew Participatig Specialist for a appoitmet. Cotiuity of Treatmet If your provider s Paramout agreemet termiates ad you are udergoig a course of treatmet, Paramout will cotiue to pay for Covered Services redered by that provider util the course of treatmet is completed or util Paramout arrages for the reasoable ad medically appropriate trasfer of the treatmet to aother participatig 15

20 HMO Member Hadbook provider. I most cases, coverage will be authorized for o more tha 90 days. If this situatio occurs, you should cotact the Member Services Departmet. Provider Reimbursemet/Filig a Claim You should always show your Paramout ID card to all providers. You are resposible for payig ay office visit Copaymets at the time you receive services. Participatig Providers must otify Paramout of the services they have redered withi 90 days from the date of service. If you have received services from a o-participatig provider, it is your resposibility to submit a claim for cosideratio. You must obtai a stadard claim form from the provider ad sed the claim to Paramout at the address below withi 120 days from the date of the service. Be sure to iclude your Paramout ID umber ad a brief explaatio of the circumstaces related to the service. Paramout Isurace Compay P.O. Box 928 Toledo, Oh Paramout will sed reimbursemet directly to Participatig Providers for Covered Services. I most cases, reimbursemet for Covered Services will be set directly to a o-participatig provider, but istead may be paid directly to you. Claims are processed withi 30 days from receipt of a fully completed claim. If ay claim is deied, Paramout will sed you a Explaatio of Beefits with the reaso for the deial. If you receive a deial o a claim ad eed further explaatio or wish to appeal the deial, you may call the Member Services Departmet for assistace. The appeal process is also described i Sectio 6 of this Hadbook. No-Covered Services If you receive services that are ot covered uder your beefit pla, you are resposible for full paymet to the provider of those services. If You Receive a Bill With the exceptio of a Deductible, Copaymets, Coisurace ad o-covered services, Participatig Providers may ot bill you for Covered Services. If you receive a bill or statemet, it is usually just a routie mothly summary of the activity o your accout. If you have ay questios about ay amout(s) show o the bill or statemet, please cotact Member Services. New Techology Assessmet Paramout ivestigates all requests for coverage of ew techology usig the HAYES Medical Techology Directory ad curret evideced-based medical/scietific publicatios. If further iformatio is eeded, Paramout utilizes additioal sources icludig Medicare ad Medicaid policy ad Food ad Drug Admiistratio (FDA) releases. This iformatio is evaluated by Paramout s Medical Director ad other physicia advisors. Privacy ad Cofidetiality Paramout will keep all documeted Member medical ad persoal iformatio, whether obtaied i writig or verbally, i the strictest cofidece. Paramout will provide Members the opportuity to approve or dey the release 16

21 HMO Member Hadbook of persoal health iformatio, except whe such release is required by law. See Paramout s Notice of Privacy Practice for more iformatio. Owership ad Physicia Compesatio Paramout Isurace Compay is a wholly owed subsidiary of the ProMedica Health System oe of the largest itegrated delivery systems i the coutry. The ProMedica Health System operates acute care hospitals, acillary facilities ad primary care ad specialist physicia practices i orthwest Ohio ad southeast Michiga. ProMedica facilities ad providers are participatig i the Paramout etwork. Paramout cotracts with Participatig Providers for health care services o a ecoomically competitive basis, while takig steps to esure that Paramout members receive quality health care. Paramout reimburses Participatig Providers through fee-for-service. Fee-for-service is the paymet of a specific amout for each specific service provided by the physicia. The amout is determied by Paramout, based o the procedure performed, ad the Paramout allowed amout for that procedure. Participatig Providers agree to accept the Paramout allowed amout (from a cotractual fee schedule) as paymet i full. Participatig Primary Care Providers are ot subject to ay risk or fiacial icetives for hospitalizatio or referrig their patiets for specialized services. Through the Paramout fee schedule, Paramout obtais discouts. Whe Coisurace is charged as a percetage of eligible expeses, the amout a Member pays is determied as a percetage of the allowed amout (fee schedule) betwee Paramout ad the participatig provider, rather tha a percetage of the provider s billed charge. Paramout s allowed amout is ordiarily lower tha the participatig provider s billed charge. Therefore, the beefit of the discout is passed o to you. Paramout also offers optioal prescriptio drug riders to employer groups. If your employer has elected to offer a prescriptio drug rider, the rider is admiistered by a pharmacy beefit maager (PBM) o behalf of Paramout. Part of this PBM service is to obtai discouts at pharmacies that cotract with the PBM. If your drug Copaymet is a percetage, the amout you pay is determied as a percetage of the discouted cost, rather tha a percetage of the retail cost. Therefore, the beefit of the discout is passed o to you. If the drug costs less tha your Copaymet, you will pay the lesser of your Copaymet or the discouted cost of the drug plus the pharmacist s dispesig fee. Uder the Paramout agreemet with the PBM, there are also certai admiistrative costs ad rebates. Neither the admiistrative costs or the rebates are icluded i your drug beefit. Paramout pays the admiistrative costs ad retais the rebates to help offset admiistrative expeses. Not all beefit plas iclude coverage for outpatiet prescriptio drugs. Refer to your summary of Beefits. Cotact the Member Service Departmet if you have questios. Patiet Safety Paramout is workig with other hospitals, physicias ad health plas to educate our Members about patiet safety. Here is what you ca do to improve the safety of your medical care: Provide your doctors with a complete health history. Be a active member of your health care team. Take part i every decisio about your health care. Speak up ask questios. Make sure that all of your doctors kow about everythig that you are takig, icludig over the couter medicatios ad herbal/dietary supplemets. Make sure that your doctors kow about ay allergies ad reactios to medicatios that you have had. Ask for test results. Do t assume that o ews is good ews. Advise your doctor of ay chages i your health. Follow your doctors advice ad the istructios for care that you ad your doctor have agreed o. Make sure that you ca read the prescriptios you get from your doctor. 17

22 HMO Member Hadbook Ask your doctor ad pharmacist questios about your medicatios. What is the medicatio for? What are the brad ad geeric ames of the medicatio? What does the medicatio look like? How should it be take ad for how log? What should you do if you miss a dose? How should you store the medicatio? Does the medicatio have side effects? What are they? What should you do if they occur? Whe you pick up the medicatio, ask the pharmacist if this is the medicatio that was prescribed. Make sure that you uderstad the istructios o the label. Ask the pharmacist about the best device to measure liquid medicatios. Read the iformatio that is provided by the pharmacy. It is always importat that you play a active role i decisios about your health ad your health care. Take resposibility you ca make a differece! If you ever fid yourself i the hospital, you ll likely have may health care workers takig care of you. While they make every effort to provide appropriate care, sometimes errors ca happe. By takig a active role i your care ad askig questios, you ca help make sure the care you receive is right for you. Should you fid yourself eedig hospital care, be sure to: Do your homework. Make sure that the hospital you re beig treated i has experiece i treatig your coditio. If you eed help gettig this iformatio, ask your doctor or call Paramout Member Service Departmet. See that health care workers wash their hads before carig for you. This is oe way to prevet the spread of germs at home ad ifectios i a hospital. Studies have shows that whe patiets checked whether health care staff had washed their hads, the workers washed their hads more ofte ad used more soap. Ask about services or tests. Make sure to ask what test or x-ray is beig doe to make sure you are gettig the right test. I the example of a kee surgery, be sure that the correct kee is prepped for surgery. A tip from the America Academy of Orthopaedic Surgeos urges their physicias to sig their iitials o the site to be operated o before surgery. Ask about what to do whe you get home. Before leavig the hospital, be sure the doctor talks to you about ay medicies you eed to take. Make sure you kow how ofte, what dose to take, ad ay side effects to expect from the medicie. Also ask whe you ca retur to your regular activities. See if the doctor has advice o thigs you ca do to help your recovery. If you have ay questios or if thigs just do t seem right after you come home, be sure to call your doctor right away. 3. WHAT TO DO FOR URGENT CARE OR EMERGENCY MEDICAL CONDITIONS Urget Care Services URGENT CARE SERVICES meas covered services provided for a Urget Medical Coditio. A Urget Medical Coditio is a uforesee coditio of a kid that usually requires medical attetio without delay but that does ot pose a threat to the life, limb or permaet health of the ijured or ill perso. Urget Medical Coditios iclude but are ot limited to: Colds ad cough, sore throat, flu Earache 18

23 HMO Member Hadbook Persistet high fever Mior cuts where bleedig is cotrolled Sprais Subur or mior bur Ski rash Urget Medical Coditios should be treated by your Primary Care Provider (PCP) or, i the evet your PCP is ot available, i a participatig urget care facility. You should ot go to a hospital emergecy room for Urget Medical Coditios. Services received i a hospital emergecy room for a Urget Medical Coditio without prior directio from your PCP, a participatig Paramout physicia or Paramout are ot covered. What to do: Durig office hours: Call your Primary Care Provider s office as soo as symptoms persist or worse. I most cases, your PCP will be able to treat you the same day or the ext day. If the office caot schedule you withi a reasoable time, you may seek treatmet at a participatig urget care facility or physicia s office. The service will be subject to a urget care facility or office visit copay or coisurace, depedig o where you receive treatmet. Your Copay/Coisurace may be foud i your Summary of Beefits. Participatig providers are listed i your Directory of Participatig Physicias ad Facilities or the Paramout web site at After office hours: Call the telephoe umber of your Primary Care Provider ad ask the aswerig service to have your doctor call you back. Whe the doctor or a urse calls back, explai your coditio ad the doctor or urse will give you istructios. Outside the Service Area: Call your Primary Care Provider first ad explai your coditio. If you caot call your PCP, go to the earest urget care facility or walk-i cliic. The service will be subject to a Copay/Coisurace, depedig o where you receive treatmet. Your Copay/Coisurace may be foud i your Summary of Beefits. Follow-up care withi the Service Area: Your Primary Care Provider will coordiate what care you eed after your urget care services. Follow-up care outside the Service Area: Follow-up services outside the Paramout Service Area will ot be covered uless authorized by your Primary Care Provider ad Paramout i advace. ANY TIME AN URGENT CARE PHYSICIAN RECOMMENDS ADDITIONAL CARE, such as a retur visit, seeig a specialist, additioal testig or X-rays, etc., call Member Services BEFORE you get the services. Member Services ca tell you if the service will be covered, or if you eed to cotact your Primary Care Provider. Emergecy Services Emergecy Services which are required as the result of a Emergecy Medical Coditio are covered at ay medical facility, aytime, aywhere without prior authorizatio. The service will be subject to a emergecy room, urget care facility or office visit Copay/Coisurace, depedig o where you receive treatmet. Your Copay/Coisurace may be foud i your Summary of Beefits. Emergecy Medical Coditio meas a medical coditio that maifests itself by such acute symptoms of sufficiet severity, icludig severe pai, that a prudet layperso with a average kowledge of health ad medicie could reasoably expect the absece of immediate medical attetio to result i ay of the followig: 19

24 HMO Member Hadbook a) Placig the health of the idividual or, with respect to a pregat woma, the health of the woma ad her ubor Child, i serious jeopardy; b) Serious impairmet to bodily fuctios; or c) Serious dysfuctio of ay bodily orga or part. A Emergecy Medical Coditio also icludes a behavioral health emergecy where the member is acutely suicidal or homicidal. Emergecy Services meas the followig: a) A medical screeig examiatio, as required by federal law, that is withi the capability of the emergecy departmet of a hospital, icludig acillary services routiely available to the emergecy departmet, to evaluate a Emergecy Medical Coditio; b) Such further medical examiatio ad treatmet that are required by federal law to stabilize a Emergecy Medical Coditio ad are withi the capabilities of the staff ad facilities available at the hospital, icludig ay trauma ad the bur ceter of the hospital. Stabilize meas the provisio of such medical treatmet as may be ecessary to assure, withi reasoable medical probability, that o material deterioratio of a idividual s medical coditio is likely to result from or occur durig a trasfer, if the medical coditio could result i ay of the followig: a) Placig the health of the idividual or, with respect to a pregat woma, the health of the woma or her ubor child, i serious jeopardy; b) Serious impairmet to bodily fuctios; c) Serious dysfuctio of ay bodily orga or part. I the case of a woma havig cotractios, stabilize meas such medical treatmet as may be ecessary to deliver, icludig the placeta. Paramout will cover Emergecy Services provided at participatig facilities. Your Pla covers Emergecy Services for a Emergecy Medical Coditio treated i ay hospital emergecy departmet. Paramout will cover Emergecy Services at oparticipatig facilities whe oe of the followig situatios occur: a) Due to circumstaces beyod the Member s cotrol, the Member was uable to utilize a participatig facility without serious threat to life or health. b) A prudet layperso with a average kowledge of health ad medicie would reasoably have believed that the time required to travel to a participatig facility could result i oe or more adverse health cosequeces described uder Emergecy Medical Coditio above. c) A Paramout represetative refers the Member to a emergecy room ad does ot specify a participatig emergecy room. d) A ambulace takes the Member to a o-participatig facility other tha at the directio of the Member. e) The Member is ucoscious. f) A atural disaster preveted the use of a participatig facility. g) The status of a participatig emergecy facility chaged to a o-participatig emergecy facility ad Paramout did ot iform the Member of the chage. The determiatio as to whether or ot a Emergecy Medical Coditio exists i accordace with the defiitio stated i this sectio rests with Paramout. Examples of Emergecy Medical Coditios Iclude: heart attack, stroke, poisoig, loss of cosciousess, iability to breathe, ucotrolled bleedig ad covulsios. Paramout may determie that other similarly acute coditios are also Emergecy Medical Coditios. What to do: Iside the Service Area: I the evet of a Emergecy Medical Coditio, call 911, a ambulace or rescue squad or go directly to the earest medical facility. I the evet you are usure about whether a coditio is a Emergecy Medical Coditio, you may cotact your Primary Care Provider for istructios. Medical care is available through 20

25 HMO Member Hadbook Paramout Physicias seve (7) days a week, 24 hours a day. Paramout will cover Emergecy Services from o-participatig providers iside the Service Area related to emergecy services. Appropriate Copays or Coisurace will be applicable. Afterward, you should cotact your Primary Care Provider for advice o follow-up care. Outside the Service Area: Call 911, a ambulace or rescue squad or go to the earest emergecy facility for treatmet. Show your Paramout card. I some cases, you may be required to make paymet ad seek reimbursemet from Paramout. Paramout will cover Emergecy Services from o-participatig providers outside the Service Area related to emergecy services. Appropriate Copays or Coisurace will be applicable. Follow-up care withi the Service Area: Follow-up medical care must be arraged by your Primary Care Provider with participatig providers. Follow-up care outside the Service Area: Oly iitial care for a Emergecy Medical Coditio is covered. Ay follow-up care outside the Service Area is ot covered uless authorized by your Primary Care Provider ad Paramout BEFORE the care begis. If you are admitted to a hospital outside the Paramout Service Area, you must call Paramout withi 24 hours or as soo as reasoably possible, or the services may ot be covered. Follow-up care must be coordiated through your Primary Care Provider. The Paramout Service Area The Paramout Service Area icludes all of Ashlad, Crawford, Defiace, Erie, Fulto, Hacock, Hery, Huro, Lucas, Mario, Morrow, Ottawa, Putam, Richlad, Sadusky, Seeca, Williams, Wood, ad Wyadot couties, ad portios of Alle, Delaware, Hardi, Kox, Lorai ad Pauldig couties. 4. YOUR PLAN What Is Covered - I Geeral Members may receive services described i this hadbook, subject to all terms ad provisios of the Group Medical ad Hospital Service Agreemet. (For details, see the Group Medical ad Hospital Service Agreemet filed with your employer.) The basic steps you must take to get a doctor s care uder your Paramout pla, ad situatios i which Paramout will ot pay for care, are explaied i Sectios 2 ad 3 of this hadbook. To be covered by Paramout, the health services you receive must meet Medically Necessary criteria ad be from Paramout Participatig Providers, except i emergecies or with writte Prior Authorizatio from Paramout. What Is Not Covered - I Geeral These services ad supplies are ot covered: 1. Services by providers chose oly for coveiece (for example, if you use a oparticipatig X-ray or lab provider because their offices are earby). 2. Ay service received from ay other oparticipatig physicia, hospital, perso, istitutio or orgaizatio uless: 21

26 HMO Member Hadbook a. Prior special arragemets are made by Paramout or b. Such services are for Emergecy Medical Coditios as described i Sectio 3/What to Do for Urget Care or Emergecy Medical Coditios. 3. Services received before coverage bega or after coverage eded. However, if coverage eds while the Member is a patiet i a hospital for a service covered by Paramout, charges related to that hospital stay will be covered accordig to the pla util the Member is discharged if the Member has o other coverage. If the Member has ew coverage, Paramout will cover up to the effective date of the ew pla. 4. No-emergecy services from o-participatig providers without Prior Authorizatio from Paramout. 5. Ay court-ordered testig, treatmet or hospitalizatio uless determied to be Medically Necessary by Paramout ad redered by a Participatig Provider. 6. Care for coditios which state or local laws require to be treated i a public facility or for which a Member is ot legally required to pay. 7. Care for disabilities related to military service to which the Member is legally etitled. 8. Care provided to Members by relatives. 9. All charges icurred as a result of a o-covered procedure. (Medically ecessary services due to complicatios of a o-covered procedure are covered.) 10. All charges for completio of reports, trasfer of medical records, or missed appoitmets. Self-help audio cassettes, videos ad books. 11. Assisted reproductive techology such as, artificial isemiatio, i vitro fertilizatio, embryo trasplat services, GIFT, ZIFT ad related services, ifertility drugs ad ay other assisted reproductive techology uless specifically required by state regulatio. 12. Surrogate paretig/pregacy icludig gestatioal surrogacy ad related services. 13. All claims for beefits submitted by or o behalf of the Member after oe (1) year from the date of service. 14. Services received i a hospital emergecy room for a Urget Medical Coditio without prior directio from your PCP, a participatig Paramout physicia or Paramout. The official terms of your erollmet ad health beefits uder Paramout Isurace Compay are stated i the Group Medical ad Hospital Service Agreemet o file with your employer. What Is Covered/What Is Not Covered - Specific Services A Copaymet or Coisurace may be required for Covered Services whe this otatio (C/L) appears. The otatio (C/L) also idicates that there may be additioal limitatios to services accordig to your employer s beefit pla. Beefit limits for Supplemetal Health Care Services may be day or visit limits or a maximum beefit limit each Cotract Year. At the start of a ew Cotract Year, beefits with limitatios will reew. See your Summary of Beefits for your Copaymet/Coisurace requiremets ad specific limitatios o services. A list of services follows, i alphabetical order: Abortio Not covered, uless medically ecessary (i.e., to save the life or protect the health of the mother). Acupucture Not covered. Alcohol abuse/addictio treatmet (See Substace Abuse Services.) Allergy testig ad therapy (ijectios) (C/L)Covered. Alterative Medicie/Therapy Not covered. Icludig but ot limited to: related laboratory testig, o-prescriptio drugs or medicies, vitamis, utriets, food supplemets, biofeedback traiig, 22

27 HMO Member Hadbook eurofeedback traiig, hyposis, acupucture, acupressure, massage therapy, aromatherapy, Chelatio therapy, rolfig ad related diagostic tests. Ambulace (C/L) Covered whe medically ecessary ad to the earest medically appropriate facility. Not covered: Trasportatio services i o-emergecy situatios ad to hospitals beyod the earest medically appropriate facility. Asthma Supplies (C/L) The asthma supplies below are covered if the Group has purchased the optioal Durable Medical Equipmet Rider subject to the Coisurace ad limits of the Durable Medical Equipmet Rider. Peak expiratory flow rate meter (had-held), Spacers for metered dose ihalers, ad Masks ad tubig for ebulizers. Biofeedback Not covered. Blood Covered for the cost of admiistratio ad storage of blood ad blood products, whe a voluteer replacemet program is ot available. Breast Augmetatio or Reductio Not covered. Cacer Cliical Trial (C/L) Routie patiet care for Members erolled i a Eligible Cacer Cliical Trial is covered. Routie patiet care meas all health care services cosistet with the coverage uder this Pla for the treatmet of cacer, icludig the type ad frequecy of ay diagostic service, that is typically covered for a cacer patiet who is ot erolled i a cacer cliical trial, ad that is ot ecessitated solely because of the trial. Not covered: A health care service, item or drug that is: The subject of a cacer cliical trial; A health care service, item, or drug provided solely to satisfy data collectio ad aalysis eeds for the cacer cliical trial that is ot used i the direct cliical maagemet of the patiet; A ivestigatioal or experimetal drug or device that has ot bee approved for market by the Uited States food ad drug admiistratio; Trasportatio, lodgig, food, or other expeses for the patiet, or a family member or compaio of the patiet, that are associated with the travel to or from a facility providig the cacer cliical trial; A item or drug provided by the cacer cliical trial sposors free of charge for ay patiet; A service, item, or drug that is eligible for reimbursemet by a perso other tha the isurer, icludig the sposor of the cacer cliical trial. Chiropractic services Chiropractors ad their services are ot covered, uless the Group has purchased a optioal rider (C/L). Cotraceptive services Services. (C/L) All FDA Cotraceptive Services for wome are covered uder Prevetive Health Cosmetic therapy or surgery Not covered. Cosmetic therapy or surgery is a procedure primarily for the purpose of alterig or improvig appearace. 23

28 HMO Member Hadbook Icludig but ot limited to: Ski tags Sclerotherapy for spider agiomas (veis) Breast reductio/augmetatio Face lifts, tummy tucks, paiculectomy ad liposuctio. Blepharoplasty (eyelid lift), uless medically ecessary). Scar revisio ad correctio Removal of pigmetatio, tattoo removal Tor pierced ear lobes. Chemical face peels ad dermabrasio Custodial Care Not covered (See Home health care.) Detal emergecy treatmet ad oral surgery (C/L) A separate detal pla will be primary whe available. The followig services are covered ONLY for the followig limited oral surgical procedures whe you have Prior Authorizatio: First aid received withi forty-eight (48) hours of a accidetal ijury to soud atural teeth, the jaw boes or surroudig tissues. This icludes oly extractio of teeth, emergecy treatmet of teeth ad repair of soft tissue. Not covered: Replacemet or restoratio of teeth. Medically ecessary orthogathic (jaw) surgery, as determied by Paramout Treatmet for tumors ad cysts (icludig pathological examiatio) of the jaws, cheeks, lips, togue, roof ad floor of the mouth Medically ecessary oral surgery to repair fractures ad dislocatios of the upper ad/or lower jawboe oly Medical treatmet for temporomadibular joit sydrome or dysfuctio (TMJ) Not covered: Geeral detal care services, icludig but ot limited to: Treatmet o or to the teeth, bridges or crows Extractio of teeth, icludig impacted wisdom teeth Treatmet of grauloma Detal treatmet icludig splits ad oral appliaces for temporomadibular joit sydrome or dysfuctio (TMJ) Placemet, removal or replacemet of implats of the teeth ad alveolar ridge icludig preparatory oral ad maxillofacial surgery (boe grafts) Treatmet of periodotal (gum) disease ad abscesses Root caals Bite plates, retaiers, sore guards, splits, orthodotic braces or ay appliace or device that is fitted to the mouth Ay other detal products or services Treatmet required for a ijury as a result of chewig or bitig Upper ad lower jawboe surgery except as required for direct treatmet of acute traumatic ijury or cacer, or as ecessary to safeguard a Member s health due to a o-detal physiological impairmet. Diabetic Supplies (C/L) The diabetic supplies below are covered if the Group has purchased the optioal Durable Medical Equipmet Rider subject to the Coisurace ad limits of the Durable Medical Equipmet Rider. Needles with syriges (1cc or less), Tubig for isuli pumps, Blood glucose moitor, test strips ad cotrol solutios, ad Lacig devices, lacets. 24

29 HMO Member Hadbook Diagostic services (C/L)Covered for medically ecessary outpatiet diagostic testig by a Participatig Provider. Covered Services iclude: X-rays Laboratory tests EKGs, EEGs Hearig tests Pre-admissio tests Mammograms ad pap smears. Screeig mammograms ad pap smears are covered whe ordered by the PCP or Participatig Specialist. Imagig/Nuclear cardiology studies whe preauthorized by PCP or Participatig Specialist. Not covered: Court-ordered testig uless determied to be Medically Necessary by Paramout ad redered by a Participatig Provider. Drugs ad other medicies (C/L) Covered whe give durig a hospital stay. Not covered: Outpatiet prescriptio drugs, uless the Group has purchased a optioal drug rider Specialty Drugs, uless the Group has purchased a optioal drug rider Growth hormoes or steroids used for growth ad developmet, uless the Group has purchased a optioal drug rider. Drug abuse/addictio treatmet (See Substace Abuse Services.) Durable Medical equipmet (C/L) Covered from Participatig Providers if the Group has purchased optioal Durable Medical Equipmet Rider, the item serves a medical purpose oly ad ca withstad repeated use. Paramout covers medical equipmet ad supplies that are covered by Medicare Part B ad meet Medicare Part B criteria. This icludes but is ot limited to: oxyge, crutches, wheelchairs, hospital beds, glucometers, chem-strips, lacets, asthma supplies, ostomy supplies, etc. Not covered: Medical equipmet ad supplies ot covered by Medicare Part B Disposable supplies (except for ostomy supplies), test kits etc. Exercise equipmet, air coditioers Hearig aids uless the Group has purchased a optioal rider Peile implats, erectile devices uless the Group has purchased a optioal rider Shoes icludig molds ad iserts (foot orthotics) uless covered by Medicare Part B Wigs Bite plates, retaiers, sore guards, splits or ay appliace or device which is fitted to the mouth Emergecy services (C/L) Covered for facility ad physicia services for Emergecy Medical Coditios meetig the defiitio i Sectio 3 of this hadbook. The facility (hospital) charge will be subject to the appropriate Copaymet/Coisurace. If there is a Copaymet, it will be waived if the Member is admitted as a hospital ipatiet. Employer requested exams ad treatmet Not covered, uless determied to be Medically Necessary by Paramout ad redered by a Participatig Provider. Experimetal orga trasplats, drugs, devices, tests, medical or surgical procedures Not covered. Foot Care (C/L) Covered whe properly referred to a Participatig Specialist. 25

30 HMO Member Hadbook Not covered: Trimmig ad/or scrapig of calluses, cors ad ails except for services with a diagosis of diabetes or other coditios causig loss of sesatio Foot orthotics icludig shoes, shoe molds ad iserts, uless the Member s coditio meets Medicare Part B criteria. Extra Corporeal Shock Wave Therapy (ESWT) Gastric staplig, by-pass or diversio See Morbid Obesity Surgery. Not covered for use to promote growth ad developmet uless the Group has pur- Growth hormoes/steroids chased a optioal rider. Home health care (C/L) Covered whe properly referred to Participatig Providers. Services iclude: Physicia services Itermittet skilled ursig care Physical, occupatioal ad speech therapy Other medically ecessary services Not covered: Persoal comfort ad coveiece items ad services such as meals, housekeepig, bathig ad groomig. Ay services or supplies furished by a o-eligible istitutio, which is ay istitutio other tha a hospital or skilled ursig facility (for example, custodial, covalescet, domiciliary ad itermediate or day care) Care provided by family members Private-duty ursig i the home uless group has purchased a optioal rider Trimmig of calluses, cors ad ails (see Foot Care) Custodial or respite care Hospice services (C/L) Covered whe medically ecessary for termially ill patiets ad whe properly referred to Participatig Providers. Hospital ad other facility services Ipatiet services: (C/L) Covered for ipatiet room, board ad geeral ursig care i o-private rooms. (See Sectio 2/Eterig the Hospital) Outpatiet services: (C/L) Covered; icludig surgery, observatio care ad diagostic testig. Outpatiet emergecy room care is covered uder certai coditios. (See Sectio 3/Emergecy Services ad Urget Care Services.) Outpatiet Surgery: (C/L) Certai beefit plas may have a Copaymet or Coisurace if a outpatiet surgical facility or hospital surgical treatmet room is used. Outpatiet surgical facilities or hospital surgical treatmet rooms are used for surgical procedures ad other procedures icludig but ot limited to edoscopic procedures such as colooscopy, arthroscopy, laparoscopy ad pai blocks (ijectios). See your Summary of Beefits. Professioal services: (C/L) The services of physicias ad other professioals are covered whe related to eligible ipatiet ad outpatiet hospital services. Covered services iclude: Surgery Medical Care 26

31 HMO Member Hadbook Newbor Care Obstetrical Care Aesthesiology Radiology ad pathology Except i a emergecy, admissios must be to Participatig Hospitals ad must have prior authorizatio from Paramout. Services ad supplies: Covered whe medically ecessary if you are a ipatiet or outpatiet. Not covered: Persoal coveiece items ad services (telephoe or televisio retal, guest meals, etc.) Private rooms, uless determied to be medically ecessary by Paramout Private-duty ursig while a ipatiet Ay services or supplies furished by a o-eligible istitutio, which is ay istitutio other tha a hospital or skilled ursig facility (for example, custodial, covalescet, domiciliary ad itermediate or day care) PLEASE REFER TO YOUR SUMMARY OF BENEFITS FOR INPATIENT AND OUTPATIENT LIMITATIONS. Ifertility Services (C/L) Covered for the medically ecessary diagosis ad treatmet of ifertility coditios. Not Covered: Ifertility drugs Ay assisted reproductio techology (ART) such as: Artificial isemiatio I vitro fertilizatio, Embryo trasplat services, GIFT, ZIFT, zygote trasfer, Reversal of volutary sterilizatio, Ovaria tissue trasplat ad related services, Cost of door sperm or door egg, ad Services ad supplies related to ART procedures. Kidey disease treatmets (C/L) Covered for: Hemodialysis Peritoeal dialysis Kidey trasplat services (see Trasplats) If the patiet qualifies for Ed-Stage Real Disease (ESRD) beefits uder Medicare, we will coordiate beefits as the secodary carrier. All Paramout procedures must be followed. Laser Treatmet icludig Cadela, V-Beam ad photodyamic therapy for rosacea, port wie stais ad other ski disorders Not covered. Materity care ad family plaig (C/L) Covered for: Preatal ad postatal care (office visit copay does ot apply to preatal ad postatal visits) Delivery icludig complicatios of pregacy, hospitalizatio ad aesthesia. A miimum hospitalizatio of forty-eight (48) hours will be allowed for ormal vagial delivery ad iety-six (96) hours for cesarea delivery uless you ad your physicia determie otherwise. If you are discharged earlier, follow-up home health care by a participatig provider will be covered for at least sevety-two (72) hours after discharge. 27

32 HMO Member Hadbook Not covered: Volutary sterilizatio (uless the Group has purchased a optioal beefit rider) Surrogate paretig/ pregacy ad related services whe the adoptive parets are resposible for the surrogate mother s medical expeses. Abortios, uless medically ecessary (i.e., to save the life or protect the health of the mother) Outpatiet self-admiistered prescriptio drugs Metal Health Services Services for a Biologically ad/or No-Biologically Based Metal Illess (C/L) Covered for ipatiet ad outpatiet care subject to the same Deductible, Copaymets ad/or Coisurace as ay other physical disease or coditio. See your Summary of Beefits for further details. Not covered: Court-ordered testig or treatmet uless determied to be Medically Necessary by Paramout ad redered by a Participatig Provider Testig ad treatmet for learig disabilities ad metal retardatio Residetial treatmet Marriage or relatioship couselig Hyposis ad biofeedback Social skills classes, behavioral modificatio ad other traiig programs icludig but ot limited to, Applied Behavioral Aalysis (ABA) programs. Morbid Obesity Surgery for weight loss. Not covered, icludig, gastric reservoir reductio, gastric staplig or diversio Office visits (C/L) Covered for: Your Primary Care Provider (PCP) Participatig OB/GYNs ad other Paramout Specialists Eligible services provided durig each visit, may iclude: Periodic physical exams Well-baby/child exams Gyecological exams Immuizatios Diagostic procedures Medical/surgical procedures Not covered: Charges for completio of reports, trasfer of records, or missed appoitmets. Oral surgery Plastic surgery Peile implats (See Detal service ad oral surgery.) (See Recostructive surgery.) Not covered uless the Group has purchased a optioal rider. Physical exams (C/L) Covered if exams are periodic physical exams as cosidered medically ecessary by the physicia. Not covered whe requested for: Obtaiig or maitaiig employmet or govermetal licesure Employer-requested aual physical exams 28

33 HMO Member Hadbook Court-ordered or foresic evaluatios uless determied to be Medically Necessary by Paramout ad redered by a Participatig Provider Physicals ad immuizatio required for travel Prevetive Health Services/Beefits Uder Ohio law, the followig prevetive health beefits are required to be provided i your Pla: Iitial Mammography startig at age 35 Aual screeig for cervical cacer Child Health Supervisio Your Pla provides additioal coverage for selected prevetive services without a copaymet, coisurace or deductible whe these services are delivered by a Participatig Provider. Depedig upo your age, services may iclude: Screeigs ad tests for diseases Metal Health screeigs, icludig substace abuse Healthy lifestyle couselig Vaccies ad immuizatios Pregacy couselig ad screeigs Well baby ad well child visits through age 21 Periodic physical exams Eligible services have bee determied by recommedatios ad comprehesive guidelies of govermetal scietific committees ad orgaizatios. You will be otified, at least sixty (60) days i advace, if ay item or service is removed from the list of eligible services. Eligible services will be updated aually to iclude ay ew recommedatios or guidelies. Please cotact us at or (419) , if you have ay questios or eed to determie whether a service is eligible for coverage as a prevetive service. For a comprehesive list of recommeded prevetive services, please visit Private-duty ursig Not covered i the home uless the Group has purchased a optioal rider. Prosthetic devices (C/L) Covered from a Participatig Provider if the Group has purchased optioal Prosthetics Rider. Refer to your Summary of Beefits for further Copaymet/Coisurace or limits. Paramout covers prosthetic devices that are covered by Medicare Part B ad meet Medicare Part B criteria. Repair ad replacemet of a prosthetic device is covered subject to meetig Medicare Part B criteria. A Prosthetic Device is a artificial substitute that replaces all or part of a missig body part ad its adjoiig tissues. Not Covered: Prosthetic devices ot covered by or eligible uder Medicare Part B Radial keratotomy or refractive surgery (LASIK) (surgery o the eyes to correct ear-sightedess or far-sightedess) Not covered Recostructive surgery Covered whe required for: Repair of aatomical impairmet to improve or correct fuctioal disability withi 2 years of accidet or ijury or up to age 18 if a cogeital aatomical fuctioal impairmet. Breast recostructio followig a mastectomy; surgery ad recostructio of the other breast to produce a symmetrical appearace; ad prostheses ad treatmet of physical complicatios at all stages of the mastectomy, icludig lymphedemas i accordace with the Wome s Health ad Cacer Rights Act of

34 HMO Member Hadbook Plastic surgery followig a accidetal ijury that results i a sigificat defect or deformity withi 2 years of the accidet. A maligat or o-maligat eoplasm withi 2 years followig iitial surgery for eoplasm. Not covered: Cosmetic therapy ad surgery Breast reductio/augmetatio Staged procedures ad surgeries whe performed i preparatio of a o-covered recostructive surgery Sclerotherapy for spider agiomas (veis) Not covered Skilled ursig facility (C/L)Covered whe medically ecessary with prior authorizatio from Paramout. Services must be at a Participatig Facility approved by Paramout. Paramout will provide coverage for eligible services i a o-participatig facility if all the coditios below apply; The Member or the Member s spouse resided i or had a cotract to reside i a o-participatig facility o or before September 1, 1997, Immediately prior to beig hospitalized the Member or the Member s spouse resided i ay part of the oparticipatig facility, ad followig hospitalizatio, the Member or the Member s spouse resides i a part of the o-participatig facility that is a skilled ursig facility, The o-participatig facility provides the Member with the skilled level of care the Member requires, The o-participatig facility is willig to accept the terms ad coditios that apply to Paramout s participatig skilled ursig facilities. Not covered: Custodial care Ski tag removal Not covered. Sleep Studies (C/L) Coverage is available i participatig facilities for certai cliical idicatios of obstructive sleep apea, arcolepsy ad seizure disorder whe approved i advace by Paramout. Not covered: Sleep studies for sexual dysfuctio Smokig cessatio classes (C/L) Covered at Participatig Hospitals. Substace Abuse Services (alcohol ad drug abuse/addictio) (C/L) Covered for ipatiet ad outpatiet care, if the group has purchased a optioal rider, for diagosis, crisis itervetio ad short-term treatmet of substace abuse services. Covered services are subject to the same Deductible, Copaymets ad/or Coisurace as ay other physical disease or coditio. Partial hospitalizatio (comprehesive outpatiet treatmet) ad itesive outpatiet programs (comprehesive ad primarily educatioal programs for substace abuse ad some metal health coditios) are available whe approved i advace by Paramout. Not covered: Court-ordered testig or treatmet uless determied to be Medically Necessary by Paramout ad redered by a Participatig Provider Residetial treatmet Log-term rehabilitatio Surrogate ad/or Gestatioal Paretig ad Pregacy ad related services Not covered. 30

35 Therapy services (C/L) Covered for: Chemotherapy, radiotherapy ad radiatio therapy Outpatiet physical/occupatioal therapy. See Summary of Beefits for limitatios. Speech therapy. See Summary of Beefits for limitatios. HMO Member Hadbook Not covered: No-medical services such as vocatioal rehabilitatio, employmet couselig ad psychological couselig (except for metal health diagoses uder metal health rider) Testig, traiig ad educatioal therapy for learig disabilities icludig developmet delays i childre. Equestria therapy. Physical/occupatioal therapy beyod beefit limits. Speech therapy beyod beefit limits. Extra Corporeal Shock Wave Therapy (ESWT) for coditios of the feet, elbows ad shoulders. Trasplats Covered for certai cliical idicatios with writte Prior Authorizatio at a Paramout approved Ceter of Excellece for heart, lug, liver, pacreas, heart-lug, kidey-pacreas, bowel ad boe marrow trasplats. (Kidey ad corea trasplats are covered as ay other illess.) Please otify Member Services as soo as possible after you are recommeded for a trasplat. This will eable a Paramout Nurse Case Maager to work with you, your PCP ad Specialist to coordiate your care. Whe Paramout selects a Ceter of Excellece for trasplat services outside the Service Area, Paramout will reimburse IRS allowace o mileage for car travel or coach commercial air travel. Reasoable lodgig ad meals (ot to exceed $30.00 per day excludig alcohol) for the trasplat cadidate oly durig medically ecessary, approved visits to the istitutio will be reimbursed. Ay eligible reimbursemet will be made followig receipt of itemized statemets. Paramout does ot cover travel, lodgig or meal expeses for doors or family members. Not covered: Services related to a Paramout orga/boe marrow door for a o-paramout recipiet. Ay trasplat ot approved by the Ohio Solid Orga Trasplat Cosortium or the Ohio Boe Marrow Trasplat Cosortium Coverage of o-paramout door uless o other coverage exists. Ay services redered at a o-paramout Ceter of Excellece trasplat site. Trassexual surgery ad related services Trimmig of ails, calluses ad cors coditios causig loss of sesatio Not covered. Not covered except for services with a diagosis of diabetes or other Urget care services (C/L) Covered ONLY for iitial treatmet of a Urget Medical Coditio i a participatig urget care facility or physicia office. Follow-up treatmet i or outside the Paramout Service Area must be authorized i advace by the Primary Care Provider i order to be covered. Not covered: Services received i a hospital emergecy room for a Urget Medical Coditio without prior directio from your PCP, a participatig Paramout physicia or Paramout. Visio care (C/L) Covered as eeded for treatmet related to a medical coditio or disease of the eyes. Oe routie visio exam every twelve (12) moths to moitor refractory disorders of the eyes will be covered, uless a separate visio program is available. Service must be redered by a Participatig Specialist. 31

36 HMO Member Hadbook Not covered: Routie visio exams more ofte tha every twelve (12) moths Orthoptic traiig Cotact leses, eyeglasses ad other corrective leses except followig cataract surgery uless the group has purchased a optioal rider Weight loss/maiteace programs ad treatmets prescriptio drugs for weight loss. Not covered, icludig; weight-loss programs, ad Dietary or utritioal supplemets for gaiig or maitaiig weight are ot covered, except for charges for o-milk, o-soy formula. The o-milk, o-soy formula must be required to treat diagosed diseases ad disorders of amio acid or orgaic acid metabolism, protei sesitivity resultig i severe chroic diarrhea, ad severe malabsorptio sydrome resultig i malutritio, provided the formula is prescribed by a Participatig Physicia, ad the Physicia furishes supportig documetatio to Paramout. The beefits will be limited to those coditios where the formula is the primary source of utritio as certified by the treatig physicia by diagosis. WHO IS ELIGIBLE The followig persos are eligible for coverage. They must reside i the Paramout Service Area ad the Subscriber (employee) must list them o the erollmet applicatio. Subscriber The employee who meets eligibility requiremets established by employer ad i accordace with the Group Medical ad Hospital Service Agreemet. Spouse The legal spouse of the Subscriber. Depedet childre This Pla will cover your married or umarried child as defied i this Member Hadbook util your child reaches age 26. If a Subscriber or Subscriber s spouse has bee court-ordered to maitai health care coverage o their depedet child who resides outside the Paramout Isurace Compay Service Area, that child shall be eligible to eroll i this pla. Coverage for service redered outside the Service Area by o-participatig providers will be limited to Emergecy Medical Coditios. Depedets with disabilities If covered childre meet the requiremets of Depedets with disabilities because of physical hadicap or metal retardatio (they are uable to ear their ow livig ad rely primarily o the subscriber for support), coverage may cotiue past age 26. Proof of disability must be provided to Paramout prior to or withi thirty-oe (31) days of the Depedet s 26th birthday or withi thirty-oe days of ew Paramout eligibility ad may be requested aually. Extesio of Adult Child Coverage to Age 28 (effective at the first group reewal after July 1, I accordace with ORC , ad upo the writte request of the Subscriber, Paramout will cover a umarried child uder the employer s health pla util the child reaches age 28, if all of the followig is true: The child is the atural child, step-child or adopted child of the Subscriber; The child is a residet of Ohio withi the Paramout Service Area or a full-time studet at a accredited public or private istitutio of higher learig; The child is ot employed by a employer that offers ay health beefit pla uder which the child is eligible for coverage; ad 32

37 HMO Member Hadbook The child is ot eligible for coverage uder Medicaid or Medicare. A child may be erolled: 1. Whe the child reaches the depedet limitig age. 2. Whe the child experieces a chage i circumstaces. Chage i circumstaces icludes movig back to the Paramout Service Area or the child losig employer-sposored coverage. 3. Durig the Aual Ope Erollmet Period of the Employer. Withi 30 days of oe of the above evets, the Subscriber must certify i writig that the child is eligible uder the above coditios. The Subscriber must pay the full cost of the child s coverage to the employer. To obtai the form required to apply for extesio of child coverage to age 28, the Subscriber should cotact their employer or a Paramout Member Services represetative at (419) or toll-free Paramout will require certificatio of eligibility ad proof of residecy or full-time studet status if livig out of state ad cotiued eligibility certificatio aually util the child reaches age 28. If the Depedet does ot meet these requiremets, he or she may be eligible for cotiuatio coverage uder the employer group s health beefit pla or idividual coversio coverage. See your beefits officer with questios. Depedet studets Depedet studets are covered up to age 26. Paramout, through its Studet Coverage 101 Program, provides coverage for emergecy, urget ad follow-up care as well as care provided by studet health ceters while your Depedet studet is away at school outside of the Paramout Service Area. If your Depedet studet eeds medical care away from home that is ot available from the studet health ceter ad it is ot a emergecy or urget coditio, before seekig services You or Your Depedet studet should cotact our Utilizatio Maagemet Departmet to obtai prior authorizatio. I the evet of a Emergecy Medical Coditio, call 911, a ambulace or rescue squad or go directly to the earest medical facility. Paramout s Utilizatio Maagemet Departmet is also available to assist You ad/or Your Depedet studet i locatig providers outside of the Paramout Service Area; cotact Utilizatio Maagemet at (419) or Not eligible: Gradchildre, parets ad married depedets. Newbor childre A ewbor child of a Subscriber (or the Subscriber s spouse) is covered for the first thirty-oe (31) days followig birth. To be covered beyod the 31-day period, a completed erollmet applicatio ad ay required additioal premium paymet must be received withi the first thirty-oe (31) days followig the birth. If the applicatio ad appropriate paymet is ot received, the ewbor child will ot be eligible for ay beefits beyod the thirty-oe days followig the birth. The oly other time you may eroll a child is durig your employer s ope erollmet period, or a special erollmet period (see pg. 32). Adopted childre Coverage for ewly adopted childre will be effective from the date of adoptive placemet. Adoptive placemet meas the assumptio ad retetio by a perso of a legal obligatio for total or partial support of a child i aticipatio of the adoptio of the child. The child s placemet with a perso termiates upo termiatio of the legal obligatio. The adopted child must be erolled withi thirty-oe (31) days from the evet. The oly other time you may eroll adopted childre or stepchildre is durig your employer s ope erollmet period, or a special erollmet period (see pg. 32). Marriage Whe a completed erollmet applicatio is received by Paramout withi thirty-oe (31) days from the date of marriage, coverage of ew spouses becomes effective o the date of marriage. 33

38 HMO Member Hadbook The oly other time you may eroll your spouse is durig your employer s ope erollmet period, or a special erollmet period (see pg. 32). Divorce You must otify Paramout that you are removig your ex-spouse ad ay other ieligible Depedets from the pla at the time the aulmet, dissolutio or divorce decree is fial. Coverage will ed at the ed of the moth i which the decree is fial. Ay ieligible Depedets may be eligible for cotiuatio coverage uder the employer group s health beefits pla or idividual coversio coverage. See your beefits office for details. Death of a subscriber Depedets of a deceased Subscriber may be eligible for cotiuatio coverage uder the employer group s health beefits pla or idividual coversio coverage. See your beefits office for details. Addig ad Removig Members Whe you eed to chage the umber of Members covered uder your pla, it is your resposibility to otify your employer ad Paramout promptly. YOU MUST COMPLETE AN ENROLL- MENT APPLICATION WHEN YOU NEED TO ADD A MEMBER TO OR REMOVE A MEMBER FROM YOUR PLAN. Cotact your beefits office. Group Affiliatio, Probatioary or Waitig Period New employees of employers with more tha fifty (50) employees will have coverage effective after the affiliatio, probatioary or waitig period established by the employer. For employers with less tha fifty (50) employees, the affiliatio, probatioary or waitig period for ew employees will ot be more tha sixty (60) days ad ot more tha iety (90) days for late erollees. See your beefits office for details. Group Aual Ope Erollmet Period If you have a ew Depedet due to marriage, adoptio (icludig placemet) or birth of a baby, they may be added to this pla if the Subscriber completes ad submits a applicatio to the employer withi thirty-oe (31) days from the evet. If you do ot eroll eligible Depedets for coverage durig the first employer erollmet period or withi thirty-oe (31) days of eligibility, you must wait util your employer s ext aual ope erollmet period to add them. See your beefits office for details Special Erollmet Period If you are decliig erollmet for yourself or your depedets (icludig your spouse) because of other health isurace coverage, you may i the future be able to eroll yourself or your depedets i this pla, provided that you request erollmet withi 30 days after other coverage eds because (1) there is a loss of eligibility for group health pla coverage or health isurace coverage ad (2) termiatio of employer cotributios toward group health pla coverage. Examples of reasos for loss of eligibility iclude: legal separatio, divorce, death of a employee, termiatio or reductio i hours of employmet volutary or ivolutary (with or without electig COBRA), exhaustio of COBRA, agig out uder other paret s coverage, movig out of a HMO s service area, ad meetig or exceedig lifetime limit o all beefits. Loss of eligibility for coverage does ot iclude loss due to the idividual s failure to pay premiums or termiatio of coverage for cause, such as fraud. Loss of eligibility also icludes termiatio of Medicaid or Childre s Health Isurace Program (CHIP) coverage ad the eligibility for Employmet Assistace uder Medicaid or CHIP. To be eligible for this special erollmet you must request coverage withi 60 days after the date the employee or depedet becomes eligible for premium assistace uder Medicaid or CHIP or the date you or your depedet s Medicaid or CHIP coverage eds. I additio, if you have a ew depedet as a result of marriage, birth, adoptio, or placemet for adoptio, you may be able to eroll yourself ad your depedets, provided that you request erollmet withi 30 days after the marriage, birth, adoptio, or placemet for adoptio. Coverage uder the special erollmet period will be effective o the day followig the date other coverage eds or the date of the evet. See your beefits office for details. 34

39 HMO Member Hadbook Nodiscrimiatio No oe who is eligible to eroll as a Subscriber, Depedet or Depedet with disabilities will be refused erollmet by Paramout based o health status, health care eeds or age. Paramout will ot termiate coverage for you or your Depedets due to health status, health care eeds or the exercise of rights uder Paramout s iteral review procedures. However, Paramout will ot re-eroll ayoe termiated for ay of the reasos listed i the Termiatio of Coverage sectio. Reewal of Coverage If all the coditios of group eligibility are met, the group coverage will be reewed. Reewal of coverage is ot based o the Member s health coditio ad is ot subject to ay geetic testig or the results of such testig. Paramout will reew coverage at the optio of the employer group. Paramout will ot reew group coverage oly uder the followig coditios; No-paymet of premiums Fraud The group falls below miimum cotributio or participatio rules Termiatio of Member Coverage A Member s coverage uder Paramout may ed for ay of the followig reasos: You fail to pay, or have paid for you, the required prepaymets. You o loger meet the eligibility requiremets. You o loger reside i the Paramout Service Area (except for court-ordered depedets). You have performed a act or practice that costitutes fraud or material misrepresetatio of material fact uder the terms of the coverage. The termiatio may ot be based, either directly or idirectly, o ay health status-related factor cocerig the Member. Do ot use your ID card after your coverage eds. Rescissio of Coverage A rescissio of your coverage meas that the coverage may be legally voided all the way back to the day the Pla bega to provide you with coverage, just as if you ever had coverage uder the Pla. Your coverage ca oly be rescided if you (or a perso seekig coverage o your behalf), performs a act, practice, or omissio that costitutes fraud; or uless you (or a perso seekig coverage o your behalf) makes a itetioal misrepresetatio of material fact, as prohibited by the terms of your Pla. Your coverage ca also be rescided due to such a act, practice, omissio or itetioal misrepresetatio by your employer. You will be provided with thirty (30) caledar days advace otice before your coverage is rescided. You have the right to request a iteral appeal of a rescissio of your coverage. Oce the iteral appeal process is exhausted, you have the additioal right to request a idepedet exteral review. Beefits After Cacellatio of Coverage If a Member is a Ipatiet o the date coverage eds, the beefits of this coverage for hospital ad professioal services will cotiue for oly that Member util the earliest of: 35

40 HMO Member Hadbook The effective date of ay ew coverage. The date of discharge, The attedig physicia certifies that ipatiet care is o loger medically idicated, The maximum i beefits have bee reached. Certificate of Creditable Coverage If your coverage with Paramout eds for ay reaso, you will receive a Certificate of Creditable Coverage idicatig the legth of time you were covered by Paramout without a sixty-three (63) day lapse i coverage. If you buy health isurace through aother pla, this certificate may help you obtai coverage without a pre-existig coditio exclusio. 5. WHAT HAPPENS WITH YOUR PLAN Whe You Have Other Coverage - How Coordiatio of Beefits Works The Coordiatio of Beefits (COB) provisio applies whe a perso has health care coverage uder more tha oe Pla. Pla is defied below. The order of beefit determiatio rules gover the order i which each Pla will pay a claim for beefits. The Pla that pays first is called the Primary pla. The Primary pla must pay beefits i accordace with its policy terms without regard to the possibility that aother Pla may cover some expeses. The Pla that pays after the Primary pla is the Secodary pla. The Secodary pla may reduce the beefits it pays so that paymets from all Plas does ot exceed 100% of the total Allowable expese. Defiitios A. A Pla is ay of the followig that provides beefits or services for medical or detal care or treatmet. If separate cotracts are used to provide coordiated coverage for members of a group, the separate cotracts are cosidered parts of the same pla ad there is o COB amog those separate cotracts. (1) Pla icludes: group ad ogroup isurace cotracts, health isurig corporatio (HIC) cotracts, closed pael plas or other forms of group or group-type coverage (whether isured or uisured); medical care compoets of log term care cotracts, such as skilled ursig care; medical beefits uder group or idividual automobile cotracts; ad Medicare or ay other federal govermetal pla, as permitted by law. (2) Pla does ot iclude: hospital idemity coverage or other fixed idemity coverage; accidet oly coverage; specified disease or specified accidet coverage; supplemetal coverage as described i Revised sectios ad ; school accidet type coverage; beefits for o-medical compoets of log-term care policies; Medicare supplemet policies; Medicaid policies; or coverage uder other federal govermetal plas, uless permitted by law. Each cotract for coverage uder (1) or (2) is a separate Pla. If a Pla has two parts ad COB rules apply to oly oe of the two, each of the parts are treated as a separate Pla. B. This pla meas, i a COB provisio, the part of the cotract providig the health care beefits to which the COB provisio applies ad which may be reduced because of the beefits of the other plas. Ay other part of the cotract providig health care beefits is separate from This pla. A cotract may apply oe COB provisio to certai beefits, such as detal beefits, coordiatig oly similar beefits, ad may apply aother COB provisio to coordiate other beefits. 36

41 HMO Member Hadbook C. The order of beefit determiatio rules determie whether This pla is a Primary pla or Secodary pla whe the perso has health care coverage uder more tha oe Pla. Whe This pla is primary, it determies paymet for its beefits first before those of ay other Pla without cosiderig ay other Pla s beefits. Whe This pla is secodary, it determies its beefits after those of aother Pla ad may reduce the beefits it pays so that all Pla beefits do ot exceed 100% of the total Allowable expeses. D. Allowable expese is a health care expese, icludig deductibles, coisurace ad copaymets, that is covered at least i part by ay Pla coverig the perso. Whe a Pla provides beefits i the form of services, the reasoable cash value of each service will be cosidered a Allowable expese ad beefit paid. A expese that is ot covered by ay Pla coverig the perso is ot a Allowable expese. I additio, ay expese that a provider by law or i accordace with a cotractual agreemet is prohibited from chargig a covered perso is ot a Allowable expese. The followig are examples of expeses that are ot Allowable expeses: (1) The differece betwee the cost of a semi-private hospital room ad a private hospital room is ot a Allowable Expese, uless oe of the Plas provides coverage for private hospital room expeses. (2) If a perso is covered by two or more Plas that compute their beefit paymets o the basis of usual ad customary fees or relative value schedule reimbursemet methodology or similar reimbursemet methodology, ay amout i excess of the highest reimbursemet amout for a specific beefit is ot a Allowable expese. (3) If a perso is covered by two or more Plas that provide beefits or services o the basis of egotiated fees, a amout i excess of the highest of the egotiated fees is ot a Allowable expese. (4) If a perso is covered by oe Pla that calculates its beefits or services o the basis of usual or customary fees or relative value schedule reimbursemet methodology or similar reimbursemet methodology ad aother Pla that provides its beefits or services o the basis of egotiated fee or paymet amout is differet tha the Primary Pla s paymet arragemet ad if the provider s cotract permits, the egotiated fee or paymet shall be the Allowable expese used by the Secodary pla to determie its beefits. (5) The amout of ay beefit reductio by the Primary pla because a covered perso has failed to comply with the Pla provisios is ot a Allowable expese. Examples of these types of pla provisios iclude secod surgical opiios, precertificatio of admissios, ad preferred provider arragemets. E. Closed pael pla is a Pla that provides health care beefits to covered persos primarily i the form of services through a pael of providers that have cotracted with or are employed by the Pla, ad that excludes coverage for services provided by other providers, except i cases of emergecy or referral by a pael member. F. Custodial paret is the paret awarded custody by a court decree or, i the absece of a court decree, is the paret with whom the child resides more tha oe half of the caledar year excludig temporary visitatio. Order of Beefit Determiatio Rules Whe a perso is covered by two or more Plas, the rules for determiig the order of beefits paymets are as follows: A. The Primary pla pays or provides its beefits accordig to its terms of coverage ad without regard to the beefits uder ay other Pla. 37

42 HMO Member Hadbook B. (1) Except as provided i Paragraph (2), a Pla that does ot cotai a coordiatio of beefits provisio that is cosistet with this regulatio is always primary uless the provisios of both Plas state that the complyig pla is primary. (2) Coverage that is obtaied by virtue of membership i a group that is desiged to supplemet a part of a basic package of beefits ad provides that this supplemetary coverage shall be excess to ay other parts of the Pla provided by the cotract holder. Examples of these types of situatios are major medical coverages that are superimposed over base pla hospital ad surgical beefits, ad isurace type coverages that are writte i coectio with a Closed pael pla to provide out-of-etwork beefits. C. A Pla may cosider the beefits paid or provided by aother Pla i calculatig paymet of its beefits oly whe it is secodary to that other Pla. D. Each Pla determies its order of beefits usig the first of the followig rules that apply: (1) No-Depedet or Depedet. The Pla that covers the perso other tha as a depedet, for example as a employee, member, policyholder, subscriber or retiree is the Primary pla ad Pla that covers the perso as a depedet is the Secodary pla. However, if the perso is a Medicare beeficiary ad, as a result of federal law, Medicare is secodary to the Pla coverig the perso as a depedet; ad primary to the Pla coverig the perso other tha as a depedet (e.g. a retired employee); the the order of beefits betwee the two Plas is reversed so that the Pla coverig the perso as a employee, member, policyholder, subscriber or retiree is the Secodary pla ad the other Pla is the Primary pla. (2) Depedet Child Covered Uder More Tha Oe Pla. Uless there is a court decree statig otherwise, whe a depedet child is covered by more tha oe Pla the order of beefits is determied as follows: (a) For a depedet child whose parets are married or are livig together, whether or ot they have ever bee married: (i) The Pla of the paret whose birthday falls earlier i the i the caledar year is the Primary pla;or (ii) If both parets have the same birthday, the Pla that has covered the paret the logest is the Primary pla. (iii) However, if oe spouse s pla has some other coordiatio rule (for example, a geder rule which says the father s pla is always primary), This pla will follow the rules of that pla. (b) For a depedet child whose parets are divorced or separated or ot livig together, whether or ot they have ever bee married: (i) If a court decree states that oe of the parets is resposible for the depedet child s health care expeses or health care coverage ad the Pla of that paret has actual kowledge of those terms, that Pla is primary. This rule applies to pla years commecig after the Pla is give otice of the decree; (ii) If a court decree states that both parets are resposible for the depedet child s health care expeses or health care coverage, the provisios of Subparagraph (a) above shall determie the order of beefits; (iii) If a court decree states that the parets have joit custody without specifyig that oe paret has resposibility for the health care expeses or health care coverage of the depedet child, the provisios of Subparagraph (a) above shall determie the order of beefits; (iv) If there is o court decree allocatig the resposibility for the depedet child s health care expeses or health care coverage, the order of beefits for the child are as follows: 38

43 HMO Member Hadbook The Pla coverig the Custodial paret; The Pla coverig the spouse of the Custodial paret; The Pla coverig the o-custodial paret; ad the The Pla coverig the spouse of the o-custodial paret. (c) For a depedet child covered uder more tha oe Pla of idividuals who are ot the parets of the child, the provisios of Subparagraph (a) or (b) above shall determie the order of beefits as if those idividuals were the parets of the child. (3) Active Employee or Retired or Laid-off Employee. The Pla that covers a perso as a active employee, that is, a employee who is either laid off or retired, is the Primary pla. The Pla coverig the same perso as retired or laid off employee is the Secodary pla. The same would hold true if a perso is a depedet of a active employee ad that same perso is a depedet of a retired or laid off employee. If the other Pla does ot have this rule, ad as a result, the Plas do ot agree o the order of beefits, this rule is igored. This rule does ot apply if the rule labeled D(1) ca determie the order of beefits. (4) COBRA or State Cotiuatio Coverage. If a perso whose coverage is provided pursuat to COBRA or uder a right of cotiuatio provided by state or other federal law is covered uder aother Pla, The Pla coverig the perso as a employee, member, subscriber or retiree or coverig the perso as a depedet of a employee, member, subscriber, or retiree is the Primary pla ad the COBRA or state or other federal cotiuatio coverage is the Secodary pla. If the other Pla does ot have this rule, ad as a result, the Plas do ot agree o the order of beefits, this rule is igored. This rule does ot apply if the rule labeled D(1) ca determie the order of beefits. (5) Loger or Shorter Legth of Coverage. The Pla that covered the perso as a employee, member, policyholder, subscriber or retiree loger is the Primary pla ad the Pla that covered the perso the shorter period of time is the Secodary pla. (6) If the precedig rules do ot determie the order of beefits, the Allowable expeses shall be shared equally betwee the Plas meetig the defiitio of Pla. I additio, This pla will ot pay more tha it would have paid had it bee the Primary pla. Effect o the Beefits of this Pla A. Whe This pla is secodary, it may reduce its beefits so that the total beefits paid or provided by all Plas durig a pla year are ot more tha the total Allowable expeses. I determiig the amout to be paid for ay claim, The Secodary pla will calculate the beefits it would have paid i the absece of other health care coverage ad apply that calculated amout to ay Allowable expese uder its Pla that is upaid by the Primary pla. The Secodary pla may the reduce its paymet by the amout so that, whe combied with the amout paid by the Primary pla, the total beefits paid or provided by all Plas for the claim do ot exceed the total Allowable expese for that claim. I additio, the Secodary pla shall credit to its pla deductible ay amouts it would have credited to its deductible i the absece of other health care coverage. B. If a covered perso is erolled i two or more Closed pael plas, ad if, for ay reaso, icludig the provisio of service by a o-pael provider, beefits are ot payable by oe Closed pael pla, COB shall ot apply betwee that Pla ad the other Closed pael plas. 39

44 HMO Member Hadbook Right to Receive ad Release Needed Iformatio Certai facts about health care coverage ad services are eeded to apply these COB rules ad to determie beefits payable uder This pla ad other Plas. Paramout may get the facts it eeds from or give them to other orgaizatios or persos for the purpose of applyig these rules ad determiig beefits payable uder This pla ad other Plas coverig the perso claimig beefits. Paramout eed ot tell, or get coset of ay perso to do this. Each perso claimig beefits uder This pla must give Paramout ay facts it eeds to apply those rules ad determie beefits payable. Facility of Paymet A paymet made uder aother Pla may iclude a amout that should have bee paid uder This pla. If it does, Paramout may pay that amout to the orgaizatio that made the paymet. That amout will the be treated as though it were a beefit paid uder This pla. Paramout will ot have to pay that amout agai. The term paymet made icludes providig beefits i the form of services, i which case paymets made meas the reasoable cash value of the beefits provided i the form of services. Right of Recovery If the amout of the paymets made by Paramout is more tha it should have paid uder this COB provisio, it may recover the excess from oe or more of the persos it has paid or for whom it has paid; ay other perso or orgaizatio that may be resposible for the beefits or services provided for the covered perso. The amout of the paymets made icludes the reasoable cash value of ay beefits provided i the form of services. Coordiatio Disputes If the you believe that Paramout has ot paid a claim properly, you should first attempt to resolve the problem by cotactig Paramout at (419) or refer to Sectio 6, What to do Whe You Have Questios, Suggestios, Complaits ad Appeals. If you are still ot satisfied, you may call the Ohio Departmet of Isurace for istructios o filig a cosumer complait. Call , or visit the Departmet s website at Whe You Are Eligible for Medicare If ay erolled Member is etitled to Medicare beefits, federal law will cotrol whether Paramout or Medicare is primary. Cotact your employer for curret guidelies. Whe You Qualify for Worker s Compesatio If you or your Depedets receive health care services due to a ijury which may be covered by Worker s Compesatio, you must otify Paramout as soo as possible. If you filed a claim for Worker s Compesatio, Paramout will withhold paymet to your providers util the case is settled. If Paramout has made ay paymet to your provider ad services are covered by Worker s Compesatio, you are expected to reimburse Paramout for the amouts paid. Please refer to the Group Medical ad Hospital Service Agreemet filed with your employer for further details. 40

45 HMO Member Hadbook Whe Someoe Else Is Liable (Subrogatio ad Reimbursemet) Where a Member has beefits paid by Paramout for the treatmet of sickess or ijury caused by a third party or the Member, these are coditioal paymets that must be reimbursed by the Member if the Member receives compesatio, damages or other paymet as a result of the sickess or ijury from ay perso, orgaizatio or isurer, icludig the Member s ow isurer, ad ay uisured ad/or uderisured motorist isurace. Paramout may subrogate to the Member s rights of recovery. Paramout has reimbursemet ad subrogatio rights equal to the value of medical beefits paid for Covered Services provided to the Member. Paramout subrogatio rights are a first party claim agaist ay recovery ad must be paid before ay other claims, icludig claims by the Member for damages (with the exceptio of claims by the Member pursuat to the property damage provisios of ay isurace policy). This meas the Member must reimburse Paramout, i a amout ot to exceed the total recovery, eve whe the Member s settlemet or judgmet is for less tha the Member s total damages ad must be paid without ay reductios for attoreys fees. Whe You Leave Your Job Members who o loger meet eligibility requiremets uder Sectio 4 of this hadbook may be eligible for cotiuatio coverage uder the employer group s health beefits pla. How You May Cotiue Group Coverage To get group cotiuatio coverage whe you are o loger eligible for the employer s group pla, you must live i the Paramout Service Area, ad you must pay the required mothly prepaymet (the share your former employer used to pay) to the group pla, your former employer. How log you are allowed to cotiue your coverage depeds o the circumstaces ad the coditios provided i your employer group s pla. The followig are coditios uder which you may cotiue Paramout coverage uder your curret pla. See your beefits office for further iformatio. 1. If your employer group has 20 or fewer employees ad your employmet eds, you ad your eligible Depedets may be able to cotiue your Paramout group coverage through that employer for up to twelve (12) moths uder state law. To be eligible for state group cotiuatio coverage, you must also meet the guidelies below: You must have bee employed for at least three (3) moths before termiatio of your employmet You did ot volutarily termiate your employmet ad the termiatio is ot the result of gross miscoduct You must ot be or become eligible for Medicare coverage or ay other group health coverage 2. If ay of the followig evets occur ad your employer group has more tha 20 employees, you or your Depedets may be able to cotiue your coverage uder the federal Cosolidated Omibus Budget Recociliatio Act (COBRA): Termiatio of your employmet (for reasos other tha gross miscoduct) or reductio of hours of employmet Termiatio of your employmet due to Chapter 11 Reorgaizatio by your employer Your death Your divorce or legal separatio The ed of a child s status as a depedet uder the pla Your eligibility for Medicare beefits 41

46 HMO Member Hadbook The coversio optio must be offered to you by your former employer durig the 180 days before the expiratio of cotiuatio (COBRA) coverage. Group Coverage may be cotiued, if a covered Subscriber (employee) is called to active duty i the Armed Forces of the Uited States icludig the Ohio Natioal Guard ad Ohio Air Natioal Guard. 1) The covered Subscriber ad Depedets may cotiue coverage for up to eightee (18) or twety-four (24) moths. 2) Covered Depedets may cotiue coverage for up to thirty-six (36) moths if ay of the followig evets occurs durig the eightee (18) or twety-four (24) moth period; a) The death of the reservist. b) The divorce or separatio of a reservist from the reservist s spouse. c) A covered Depedet child s eligibility uder this coverage eds. 3) The cotiuatio period begis o the date coverage would have termiated because the reservist was called to active duty. 4) The Subscriber ad/or Depedet must complete ad retur to the employer a electio form withi thirty-oe (31) days of the date coverage would termiate. 5) The Subscriber ad/or Depedet must pay ay required cotributio to the employer ot to exceed 102% of the group rate. 6) Cotiuatio coverage will ed o the date ay of the followig occurs: a) The subscriber or Depedet becomes covered by aother group pla without ay pre-existig coditio restrictio. b) The maximum period of moths expires. c) The Subscriber or Depedet does ot make the required paymet d) The group cotract with Paramout is termiated. How to Covert to Idividual Coverage (Whe Group Coverage Is No Loger Available) If your group coverage or cotiuatio coverage eds, you ad/or your eligible Depedets ca covert to idividual membership without providig evidece of isurability. You may call Paramout s Member Services Departmet ad they will sed you a summary of coversio beefits available ad a paymet schedule. A Member who meets the defiitio of a Federally Eligible Idividual will have the optio to covert to a basic or stadard pla. To obtai idividual membership, you must meet all of the followig coditios: You must live i the Service Area (except for court-ordered Depedets) You must submit a complete applicatio for coversio to a idividual policy withi thirty-oe (31) days after the date your group coverage eds You must submit ay prepaymet required. Details of the curret prepaymet rates will be set to you at your request for coversio iformatio. Please be aware that a idividual pla may ot offer all the same beefits as your group coverage pla. Coditios of Idividual Coversio Coversio to idividual coverage will be available to Members who live i the Paramout Service Area, are ot eligible for Medicare beefits or ay other policy of isurace or health care pla providig comparable beefits, ad have lost eligibility due to termiatio of employmet coditios or Depedet eligibility requiremets explaied i Sectio 4. 42

47 HMO Member Hadbook Your former employer s Group Medical ad Hospital Service Agreemet must be i effect at the time of coversio i order to be eligible for this optio. If a Member chooses to apply for coversio, the coversio will be effective retroactively from the date group or cotiuatio coverage eded. If a Member chooses ot to apply for coversio ad receives health services or beefits durig the 31-day decisio period, that Member must pay for those services. The Member is resposible for the required paymet accordig to the pla s prepaymet schedule as detailed i the idividual pla documet ( Idividual Medical ad Hospital Service Agreemet ). For details, see the Group Medical ad Hospital Service Agreemet available from your employer s beefit office, or call Member Services. If Paramout Eds Operatios I the evet Paramout would ed operatios, Members beefits would be covered util the Group Medical ad Hospital Service Agreemet expired. All prepaymets must be made i accordace with the terms of the agreemet. Sice Paramout Isurace Compay is ot part of the guaraty fud, Members are protected oly to the extet of the hold harmless provisio required by ORC The hold harmless provisio states with the exceptio of a Deductible, Copaymets, Coisurace ad o-covered services, Participatig Providers may ot bill a Member for Covered Services. If you are receivig a course of treatmet whe Paramout eds operatios, Covered Services will cotiue to be provided by Participatig Providers as eeded to complete ay medically ecessary follow-up care for that course of treatmet. If a Member is receivig Ipatiet care at a hospital, coverage will be cotiued for up to thirty (30) days after the ed of operatios. If you eed additioal iformatio, call the Member Services Departmet at (419) or If Paramout eds operatios, a Member may have to pay for health care services redered by a o-participatig provider whether or ot Paramout authorized the service. 6. WHAT TO DO WHEN YOU HAVE QUESTIONS, SUGGESTIONS, COMPLAINTS or APPEALS Paramout's Member Services Departmet is available to assist you with ay questios from 8:00 A.M. to 5:00 P.M., Moday through Friday. If you call the Member Services Departmet after hours, you may leave a message ad we will call you back o the ext workig day. You may also us through the Paramout web site at: The Member Services Departmet's goal is to help you with ay questios about procedures, beefits, participatig providers, paymet for services, erollmet, etc. We ecourage you to call us with ay questios. Paramout provides a TTY umber for members who are hearig impaired. Paramout will also provide traslatio services for members who do t speak Eglish. If a Member eeds foreig laguage traslatio services, they should call the Member Services Departmet. If you have ay suggestios for improvig our service or if you wish to recommed chages i procedures or beefits, please write us or call us. We also ecourage you to develop a good relatioship with your physicia so that you fully uderstad the diagosis ad treatmet prescribed. Should you have ay questios you may cotact the Ohio Departmet of Isurace at: Departmet of Isurace 50 W. Tow Street, Third Floor - Suite 300 Columbus, Ohio Telephoe: (614) Toll Free: (800)

48 HMO Member Hadbook How to Hadle a Complait All Member complaits will be resolved iformally wheever possible. You are ecouraged to iitially attempt to resolve complaits about medical treatmet through your Primary Care Provider. If the complait caot be satisfactorily resolved i this maer, or if the complait is ot a medical treatmet issue, you may telephoe Paramout's Member Services Departmet. A Member Services Represetative will be available to receive the call ad seek iformal resolutio of the complait. If your complait is ot resolved satisfactorily o a iformal basis, the Member Services Represetative will iform you of your right to seek formal resolutio of the complait though the iteral appeals procedures described below. Appeal to Paramout A Adverse Beefit Determiatio eligible for iteral appeal is a decisio by Paramout to do ay of the followig: (1) Dey, reduce or termiate requested health care service or paymet i whole or part; (2) Not issue health isurace coverage to a applicat i the idividual ad o-employer group markets; or (3) Rescid coverage uder a health beefit pla. If Paramout makes a Adverse Beefit Determiatio you will receive a writte otificatio that icludes: (1) Iformatio sufficiet to idetify the claim ivolved, icludig the date of service, the health care provider ad the claim amout. (2) The specific reasos for the adverse beefit determiatio; (3) A referece to the specific Pla provisio upo which the adverse beefit determiatio is based; (4) A descriptio of ay additioal material or iformatio ecessary for you to perfect your claim ad a explaatio of why such material or iformatio is ecessary; (5) The cotact iformatio for ay applicable office of health isurace cosumer assistace established to assist with the iteral appeal ad exteral review process; ad (6) A descriptio of the Pla s appeal procedures, the time limits applicable to such procedures, iformatio o how to iitiate a appeal ad a statemet of your right to brig a civil actio uder sectio 502(a) of ERISA; You (the member), your Legal Represetative, a Authorized Perso, the provider, or the health care facility has the right to request a iteral appeal of a Adverse Beefit Determiatio by cotactig Paramout as set forth below i the sectio titled Istructios for Requestig a Iteral Appeal. A provider or health care facility must have your authorizatio to request a appeal. You do ot eed the authorizatio of the provider. You may request a appeal of a Adverse Beefit Determiatio regardless of the actual or estimated cost of the health care service. You will receive a ackowledgemet from Paramout withi five (5) days from receipt of your request for a iteral appeal. You will be give the opportuity to atted a hearig before a admiistrative review pael. If you caot atted the hearig, you may atted by telecoferece or submit a writte statemet. Istructios for Requestig a Iteral Appeal You may appeal a Adverse Beefit Determiatio at ay time withi 180 days of receivig otificatio of the Adverse Beefit Determiatio. You must request a iteral appeal i writig, uless the claim ivolves urget care, i which case the appeal may also be requested orally. A claim ivolvig urget care is ay claim for medical care or treatmet with respect to which the applicatio of the time periods for makig o-urget care determiatios (a) could seriously jeopardize your life 44

49 HMO Member Hadbook or health or your ability to regai maximum fuctio; or (b) i the opiio of a physicia with kowledge of the your medical coditio, would subject you to severe pai that caot be adequately maaged without the care or treatmet that is the subject of the claim. If the claim ivolves urget care, all ecessary iformatio, icludig Paramout s beefit determiatio o review, will be trasmitted betwee you ad Paramout by telephoe, facsimile, or other available similarly expeditious method. I coectio with your writte request for a iteral appeal, you should submit commets, documets, records, ad other iformatio you believe is importat to the claim for beefits that is the subject your request for a iteral appeal. Appeals to Paramout should be set to the followig address, or if a claim ivolves urget care, you may cotact Paramout by usig the telephoe, facsimile or below: Paramout Isurace Compay Member Service Departmet-Appeals P.O. Box 928 Toledo, Ohio Telephoe: (419) Toll Free: 1 (800) Facsimile: (419) [email protected] I coectio with your right to a iteral appeal of a Adverse Beefit Determiatio, you: (1) may submit writte commets, documets, records, ad other iformatio relatig to the claim for beefits; (2) may request free of charge, reasoable access to, ad copies of, all documets, records, ad other iformatio relevat to the claim for beefits; (3) will receive, free of charge, ay ew or additioal evidece or ratioale cosidered, relied upo, or geerated by Paramout sufficietly i advace of the date o which the otice of beefit determiatio o review is required to be provided to allow you a reasoable opportuity to respod prior to that date; ad (4) will be provided, upo request, with the idetificatio of the health care professioal whose advice was obtaied o behalf of the pla i coectio with the Adverse Beefit Determiatio, without regard to whether the advice was relied upo i makig the beefit determiatio. The appeal will be coducted by a appeal represetative of Paramout who will issue a writte decisio withi the time frames listed below: Pre ad Post Service Claims Urget Care Claims 30 caledar days from receipt of the appeal Not later tha 72 hours from receipt of the appeal Full ad Fair Review To esure you are provided with a full ad fair review: (1) The review will take ito accout all commets, documets, records, ad other iformatio that you submit relatig to the claim, without regard to whether this iformatio was submitted or cosidered i the iitial beefit determiatio; (2) The review will ot afford deferece to the iitial adverse beefit determiatio ad will be coducted by a appeal represetative of Paramout ad/or reviewed by a health care professioal who is either the idividual who made or was cosulted i coectio with the Adverse Beefit Determiatio that is the subject of the appeal, or his or her subordiate; 45

50 HMO Member Hadbook (3) The review will be coducted by a appeal represetative of Paramout i cosultatio with a health care professioal who has appropriate traiig ad experiece i the field of medicie ivolved i the medical judgmet of ay Adverse Beefit Determiatio that is based i whole or i part o a medical judgmet, icludig determiatios with regard to whether a particular treatmet, drug, or other item is experimetal, ivestigatioal, or ot medically ecessary or appropriate; (4) The review will be coducted i a maer desiged to avoid coflicts of iterest by esurig the idepedece ad impartiality of the persos ivolved i makig the decisio. Accordigly, decisios regardig hirig, compesatio, termiatio, promotio, or other similar matters with respect to ay idividual will ot be made based upo the likelihood that the idividual will support the deial of beefits; ad (5) There will be o reductio or termiatio of a ogoig course of treatmet without advace otice from Paramout or a opportuity for advace review. Cocurret Iteral Appeal ad Exteral Review If you are i the process of a iteral appeal of a urget care claim, you may also request that a expedited exteral review be coducted simultaeously i either of the followig circumstaces: (1) Your treatig physicia certifies i writig that you have a medical coditio where the time frame for completio of a expedited review of a iteral appeal ivolvig the Adverse Beefit Determiatio would seriously jeopardize your life or health or your ability to regai maximum fuctio; or (2) I the case of experimetal or ivestigatioal treatmet that otherwise meets the criteria for a exteral review, you may request a expedited review orally or by electroic meas, if your treatig physicia also certifies i writig that the requested health care service would be sigificatly less effective if ot promptly iitiated. If Your Appeal is Deied If your appeal is deied, the appeal represetative of Paramout will provide you with a writte or electroic otificatio of the determiatio. The otificatio will be called a Fial Adverse Beefit Determiatio. The Fial Adverse Beefit Determiatio will tell you the specific reaso(s) for the deial, the specific pla provisios o which the determiatio is based, that you are etitled to receive, upo request ad free of charge, reasoable access to, ad copies of, all documets, records, ad other iformatio relevat to the claim for beefits ad a statemet of the right to brig a actio uder sectio 502(a) of ERISA. The Fial Adverse Beefit Determiatio will also iform you of the right to pursue a exteral review, ad explai the procedures for iitiatig the review icludig the time frames withi which you must request exteral review. If the claim ivolves urget care, the otice may be provided to you orally withi the time frames for urget care claims described above. A writte or electroic otice will be furished to you withi three days after the oral otice. Your Right to a Additioal Appeal If Paramout issues a Fial Adverse Beefit Determiatio for ay of the reasos listed below, you, your Legal Represetative or a Authorized Perso has the right to ask for a exteral review: (1) You are etitled to a exteral review by a Idepedet Review Orgaizatio (IRO) if: a. the Adverse Beefit Determiatio ivolves a medical judgmet or is based o ay medical iformatio (this icludes a decisio that a covered perso sought services at a emergecy room for a coditio that did ot meet the prudet layperso defiitio of a emergecy); or 46

51 HMO Member Hadbook b. the Adverse Beefit Determiatio idicates the requested service is experimetal or ivestigatioal, is ot specifically listed as a excluded beefit, ad the treatig physicia certifies oe of the followig: i. Stadard health care services have ot bee effective i improvig your coditio; ii. Stadard health care services are ot medically appropriate for you; iii. No available stadard health care service covered by Paramout is more beeficial tha the requested health care service. (2) You are etitled to a exteral review by the Departmet of Isurace if: a. the Adverse Beefit Determiatio is based o a cotractual issue that does ot ivolve medical judgmet or ay medical iformatio; or b. the Adverse Beefit Determiatio idicates that emergecy medical services did ot meet the prudet layperso defiitio of emergecy ad Paramout s decisio has already bee upheld through a exteral review by a IRO. Exhaustio Requiremets You must exhaust the iteral appeals process prior to iitiatig a exteral review except i the followig circumstaces: (1) Paramout agrees to waive the exhaustio requiremet; (2) You did ot receive a writte decisio o your iteral appeal withi the required time frame; (3) Paramout fails to meet all of the requiremets of the iteral appeal process uless the failure: a. was de miimis; b. does ot cause or is ot likely to cause you prejudice or harm; c. was for good cause ad beyod Paramout s cotrol; ad d. is ot reflective of a patter or practice of o-compliace. If Paramout deies your request for exteral review uder subsectio (3) above, you may request writte explaatio from Paramout, ad Paramout shall provide explaatio withi te (10) days, icludig a specific descriptio of the reasos, if ay, for assertig that the delay should ot cause the iteral appeals process to be cosidered exhausted. You may the request review by the Departmet of Isurace of the Paramout s explaatio ad if the Departmet affirms Paramout s explaatio, you may, withi te (10) days of the Departmet s otice of decisio, resubmit ad pursue the iteral appeals process. Time periods for re-filig the iteral appeal shall begi to ru upo your receipt of such otice. You may ot request a exteral review of a Adverse Beefit Determiatio ivolvig a retrospective utilizatio review decisio util Paramout s iteral appeals process has bee exhausted uless Paramout agrees to waive the exhaustio requiremet. Istructios for Requestig Exteral Review You may request a exteral review at ay time withi 180 days of the date of the Fial Adverse Beefit Determiatio. Whe filig a request for exteral review, you will be required to authorize the release of your medical records as ecessary to coduct the review. A authorizatio for the release of your medical records will be provided to you with the Fial Adverse Beefit Determiatio. The completed authorizatio form must be retured with your request for exteral review or cofirmatio of your request for a expedited exteral review. All requests for exteral review shall be made i writig, except whe makig a request for a expedited review. Requests for a expedited exteral review may be requested orally or by electroic meas. Whe a oral or electroic request for review is made, writte cofirmatio of the request must be submitted to Paramout o later tha five days after the iitial request was made. 47

52 HMO Member Hadbook I coectio with your writte request for exteral review, you should submit commets, documets, records, ad other iformatio you believe is importat to the claim for beefits that is the subject your request for exteral review. Please be sure to referece the paragraphs titled Expedited Exteral Review ad Exteral Review of Experimetal or Ivestigatioal Health Care Services for additioal requiremets i coectio with a request for a expedited exteral review or a exteral review that ivolves experimetal or ivestigatioal treatmet. Requests for exteral review should be set to the followig address, or if a claim ivolves a request for expedited review, you may cotact Paramout by usig the telephoe, facsimile or below: Paramout Isurace Compay Member Service Departmet-Appeals P.O. Box 928 Toledo, Ohio Telephoe: (419) Toll Free: Facsimile: (419) [email protected] Upo receipt of a request for a exteral review, Paramout will review it for completeess. If the request is complete, Paramout will iitiate the exteral review ad otify you, i writig, that the request is complete. If the request for exteral review is ot complete, Paramout will iform you, i writig, of the iformatio eeded to make the request complete. If Paramout deies a request for exteral review o the grouds that the Fial Adverse Beefit Determiatio is ot eligible for exteral review, you may appeal the deial to the Departmet of Isurace. Expedited Exteral Review You may make a request for a expedited exteral review of a Fial Adverse Beefit Determiatio uder the followig circumstaces: (1) Your treatig physicia certifies that the Adverse Beefit Determiatio ivolves a medical coditio that could seriously jeopardize your life or health, or would jeopardize your ability to regai maximum fuctio, if treated after the time frame of a stadard exteral review; or (2) The Fial Adverse Beefit Determiatio cocers a admissio, availability of care, cotiued stay, or heath care service for which you received emergecy services but have ot yet bee discharged from the facility. A expedited exteral review may ot be provided for retrospective Fial Adverse Beefit Determiatios. Exteral Review of Experimetal or Ivestigatioal Health Care Services You may request a exteral review of a Fial Adverse Beefit Determiatio based o the coclusio that a requested health care service is experimetal or ivestigatioal, except whe the requested health care service is explicitly listed as a excluded beefit. (1) To request a exteral review of a Fial Adverse Beefit Determiatio based o the coclusio that a requested health care service is experimetal or ivestigatioal, your treatig physicia must certify that oe of the followig situatios is applicable: a. Stadard health care services have ot bee effective i improvig the coditio of the Member; 48

53 HMO Member Hadbook b. Stadard health care services are ot medically appropriate for the covered perso; or c. There is o available stadard health care service covered by the Paramout that is more beeficial tha the requested health care service. Exteral Review Determiatio: A IRO assiged to review a Fial Adverse Beefit Determiatio will provide you writte otice of its decisio to either uphold or reverse the determiatio withi 30 days of receipt of a request for stadard review or a stadard review ivolvig experimetal or ivestigatioal treatmet, or withi 72 hours of receipt of a expedited request. If the IRO issues a decisio to reverse the Fial Adverse Beefit Determiatio, Paramout will immediately provide coverage for the service or services i questio. For appeals to the Departmet of Isurace, if the Departmet otifies Paramout that makig a decisio requires the resolutio of a medical issue, Paramout will iitiate a exteral review with a IRO. If the Departmet determies that the health service is a covered service, Paramout will cover the service. If the Departmet determies that the health care service is ot a covered service, Paramout is ot required to cover the service or afford you further exteral review. A exteral review decisio is bidig o you ad Paramout except to the extet you or Paramout have other remedies available uder applicable federal or state law, or uless the Departmet of Isurace determies that, due to the facts ad circumstaces of a exteral review, a secod exteral review is required. Limitatio o Legal Actios No actio at law or i equity shall be brought to recover o this policy prior to the expiratio of sixty days after writte proof of loss has bee furished i accordace with the requiremets of this policy. No such actio shall be brought after the expiratio of three years after the time writte proof of loss is required to be furished. 7. TERMS AND DEFINITIONS AFFILIATION, PROBATIONARY OR WAITING PERIOD is the period betwee the date the idividual files a substatially complete applicatio for coverage ad the first day of coverage. BASIC HEALTH CARE SERVICES as defied by Sectio of the Ohio Revised Code are: Physicia s services, ipatiet hospital services, outpatiet medical services, emergecy health services, diagostic laboratory services ad diagostic ad therapeutic radiology services, diagostic ad treatmet services, other tha prescriptio drug services, for biologically based metal illesses, prevetative health services icludig family plaig, ifertility services, periodic physical examiatios, preatal obstetrical care ad well-child care; ad routie patiet care for patiets erolled i a eligible cacer cliical trial pursuat to sectio of the Ohio Revised Code. BIOLOGICALLY BASED MENTAL ILLNESS as defied by ORC , (D) meas schizophreia, schizoaffective disorder, major depressive disorder, bipolar disorder, paraoia ad other psychotic disorders, obsessive-compulsive disorder ad paic disorders as these terms are defied i the most recet editio of the Diagostic ad Statistical Maual of Metal Disorders(DSM) published by the America Psychiatric Associatio. CHILD meas the atural childre, legally adopted childre, stepchildre ad childre uder legal custody (i.e., official court-appoited guardiaship or custody) of the Subscriber or the Subscriber s spouse. 49

54 HMO Member Hadbook COINSURANCE is your share of the cost of some Covered Services (a percetage of the amout allowed). For example, you may be resposible for 20% of the average charge allowed for Covered Services. CONTRACT YEAR is a caledar year or the term for which the employer group has a agreemet with Paramout to provide Covered Services to eligible Subscribers ad their Depedets. COPAY/COPAYMENT is your share of the cost of some Covered Services. Copaymet is a specific dollar amout, such as $5.00 or $ Copaymets for specific dollar amouts are due ad payable at the time services are provided. COVERED SERVICES are authorized services show i our list of services covered ad redered by a provider for which Paramout will provide paymet. A Covered Service may be subject to a Copaymet/Coisurace or other limitatios. CREDITABLE COVERAGE is the period of prior health pla coverage of a idividual erollee which may etitle the erollee to reduce the effective time period of a pre-existig coditio exclusio that may be preset i future coverage sought by the idividual. Upo termiatio of your coverage with Paramout, you are etitled to receive a Certificate of Creditable Coverage which provides iformatio regardig prior coverage with Paramout. Creditable coverage does ot iclude coverage solely for detal, visio or prescriptio drug beefits. DEDUCTIBLE is the amout you must pay for Covered Services withi each Cotract Year before beefits will be paid by Paramout. The sigle Deductible is the amout each Member must pay; the family Deductible is the total amout ay two or more covered family members must pay. DEPENDENT meas ay member of a Subscriber s family who meets all the applicable eligibility requiremets, has bee erolled i the pla ad for whom the paymet required by the employer s group agreemet has bee received by Paramout. DESIGNATED REPRESENTATIVE meas a provider appoited by Paramout to admiister maaged care ad/or cost cotaimet programs for this coverage. ELIGIBLE CANCER CLINICAL TRIAL uder ORC meas a cacer cliical trial that meets all of the followig criteria: a) A purpose of the trial is to test whether the itervetio potetially improves the trial participat s health outcomes. b) The treatmet provided as part of the trial is give with the itetio of improvig the trial participat s health outcomes. c) The trial has a therapeutic itet ad is ot desiged exclusively to test toxicity or disease pathophysiology. d) The trial does oe of the followig: (i) Tests how to admiister a health care service, item, or drug for the treatmet of cacer; (ii) Tests resposes to a health care service, item, or drug for the treatmet of cacer; (iii) Compares the effectiveess of a health care service, item, or drug for the treatmet of cacer with that of other health care services, items, or drugs for the treatmet of cacer; (iv) Studies ew uses of a health care service, item, or drug for the treatmet of cacer. e) The trial is approved by oe of the followig etities: (i) The atioal istitutes of health or oe of its cooperative groups or ceters uder the Uited States departmet of health ad huma services; (ii) The Uited States food ad drug admiistratio; (iii) The Uited States departmet of defese; (iv) The Uited States departmet of veteras affairs. 50

55 HMO Member Hadbook EFFECTIVE DATE is the date your coverage begis. EMERGENCY MEDICAL CONDITION meas a medical coditio that maifests itself by such acute symptoms of sufficiet severity, icludig severe pai, that a prudet layperso with a average kowledge of health ad medicie could reasoably expect the absece of immediate medical attetio to result i ay of the followig: a) Placig the health of the idividual or, with respect to a pregat woma, the health of the woma or the ubor Child, i serious jeopardy; b) Serious impairmet to bodily fuctios; or c) Serious dysfuctio of ay bodily orga or part. A Emergecy Medical Coditio also icludes a behavioral health emergecy where the member is acutely suicidal or homicidal. EMERGENCY SERVICES meas the followig: a) A medical screeig examiatio, as required by federal law, that is withi the capability of the emergecy departmet of a hospital, icludig acillary services routiely available to the emergecy departmet, to evaluate a Emergecy Medical Coditio; b) Such further medical examiatio ad treatmet that are required by federal law to stabilize a Emergecy Medical Coditio ad are withi the capabilities of the staff ad facilities available at the hospital, icludig ay trauma ad the bur ceter of the hospital. Stabilize meas the provisio of such medical treatmet as may be ecessary to assure, withi reasoable medical probability, that o material deterioratio of a idividual s medical coditio is likely to result from or occur durig a trasfer, if the medical coditio could result i ay of the followig: a) Placig the health of the idividual or, with respect to a pregat woma, the health of the woma or her ubor child, i serious jeopardy; b) Serious impairmet to bodily fuctios; c) Serious dysfuctio of ay bodily orga or part. I the case of a woma havig cotractios, stabilize meas such medical treatmet as may be ecessary to deliver, icludig the placeta. ESSENTIAL HEALTH BENEFITS is defied uder federal law (PPACA) as icludig beefits i at least the followig categories: ambulatory patiet services; emergecy services; hospitalizatio; materity ad ewbor care; metal health ad substace use disorder services, icludig behavioral health treatmet; prescriptio drugs; rehabilitative ad habilitative services ad devices; laboratory services; prevetive ad welless services ad chroic disease maagemet; ad pediatric services, icludig oral ad visio care. Your pla may cotai some or all of these types of beefits prior to 2014 whe they become madatory. If your pla cotais ay of these beefits, there are certai requiremets that may apply to those beefits, as provided i this Member Hadbook. EXPERIMENTAL is ay treatmet, procedure, facility, equipmet, drug, device or supply which Paramout does ot recogize as accepted medical practice or which did ot have required govermetal approval whe you received it. This icludes treatmets ad procedures which: Are still i the ivestigative or research state, Have ot bee adopted for geeral cliical use, Have ot bee approved or accepted by the appropriate review body, or Are ot geerally accepted by the local medical commuity as safe, appropriate ad effective treatmet This determiatio is based o the recommedatio of the Medical Advisory Committee, the most recet HAYES Medical Techology Directory ad o curret evideced-based medical/scietific publicatios. 51

56 HMO Member Hadbook FEDERALLY ELIGIBLE INDIVIDUAL is a idividual who meets the qualificatios listed below: 1. The idividual has at least 18 moths of creditable coverage without a sigificat break (63 days) i coverage as of the date o which the idividual seeks coverage. 2. The idividual s most recet prior creditable coverage was uder a group health pla, govermet pla, or church pla (or health isurace coverage offered i coectio with ay of these pla). 3. The idividual is ot eligible for coverage uder ay of the followig: (I) A group health pla. (II) Part A or Part B of Title XVIII (Medicare ) of the Social Security Act. (III) A state pla uder Title XIX (Medicaid) of the Social Security Act (or ay successor program). 4. The idividual does ot have other health isurace coverage. 5. The idividual s most recet coverage was ot termiated because of opaymet of premiums or fraud. 6. If the idividual has bee offered the optio of cotiuatio uder a COBRA cotiuatio provisio or a similar State program, the idividual has both elected ad exhausted the cotiuatio coverage. INPATIENT is a patiet who stays overight i a hospital or other medical facility. MEDICAL NECESSITY meas the service you receive must be: 1. Needed to prevet, diagose ad/or treat a specific coditio. 2. Specifically related to the coditio beig treated or evaluated. 3. Provided i the most medically appropriate settig; that is, a outpatiet settig must be used, rather tha a hospital or ipatiet facility, uless the services caot be provided safely i a outpatiet settig. MEMBER meas ay Subscriber or Depedet as defied i Sectio 4/Who Is Eligible. NON-BIOLOGICALLY BASED MENTAL ILLNESS meas metal illesses that are ot Biologically Based Metal Illesses as defied i this Member Hadbook. OUT-OF-POCKET COPAYMENT LIMIT is the maximum amout of Copaymets ad Coisurace you pay every Cotract Year o Basic Health Services. Oce the Out-of-Pocket Copaymet Limit is met, there will be o additioal Copaymets ad Coisurace o Basic Health Services durig the remaider of the Cotract Year. The sigle Out-of- Pocket Copaymet Limit is the amout each Member must pay, the family Out-of-Pocket Copaymet Limit is the total amout ay two or more covered family members must pay. OUTPATIENT refers to services or supplies provided to someoe who has ot bee admitted as a ipatiet to a hospital. Observatio care is cosidered Outpatiet service. PARAMOUNT SERVICE AREA meas all of Ashlad, Crawford, Defiace, Erie, Fulto, Hacock, Hery, Huro, Lucas, Mario, Morrow, Ottawa, Putam, Richlad, Sadusky, Seeca, Williams, Wood, ad Wyadot couties, ad portios of Alle, Delaware, Hardi, Kox, Lorai ad Pauldig couties I Ohio ad Leawee ad Moroe couties i Michiga. PARTICIPATING HOSPITAL meas ay hospital with which Paramout has cotracted or established arragemets for ipatiet/outpatiet hospital services ad/or emergecy services. PARTICIPATING PROVIDER meas a physicia, hospital or other health professioal or facility that has a cotract with Paramout to provide Covered Services to Members. PARTICIPATING SPECIALIST meas a physicia who provides Covered Services to members withi the rage of his or her medical specialty ad has chose to be desigated as a specialist physicia by Paramout. 52

57 HMO Member Hadbook PREVENTIVE HEALTH SERVICES/BENEFITS are those Covered Services that are beig provided: 1) to a Member who has developed risk factors (icludig age ad geder) for a disease for which the Member has ot yet developed symptoms, ad 2) as a immuizatio to prevet specific diseases. However, ay service or beefit iteded to treat a existig illess, ijury or coditio does ot qualify as Prevetive Health Services. PRIMARY CARE PROVIDER meas a physicia or other provider who specializes i family practice, iteral medicie or pediatrics ad is desigated by Paramout as a Primary Care Provider. PRIOR AUTHORIZATION is required for certai procedures or services. It is the resposibility of the Participatig Provider to obtai Prior Authorizatio from Paramout i advace of these procedures or services. SPECIALTY DRUGS are complex Prescriptio Drugs as determied by Paramout s Pharmacy & Therapeutics Workig Group (P & T) used to treat chroic coditios such as multiple sclerosis, cacer, hepatitis ad rheumatoid arthritis. These drugs are self-admiistered as ijectable or oral drugs ad ofte require special hadlig ad moitorig. SUBSCRIBER meas a perso who meets all applicable eligibility requiremets, is employed by a employer who has a cotract i effect with Paramout ad erolls with a employer as the subscriber. SUPPLEMENTAL HEALTH CARE SERVICES as defied by Sectio of the Ohio Revised Code are: Services of itermediate, log-term care facilities; detal care; visio care; optometric services icludig leses ad frames; podiatric care; metal health services excludig diagostic ad treatmet services for biologically based metal illess; short-term outpatiet evaluative ad crisis itervetio metal health services; medical or psychological treatmet ad referral services for alcohol ad drug abuse or addictio; home health services; prescriptio drugs; ursig services; services of a dieticia licesed uder Chapter 4759 of the Revised Code; physical therapy services; chiropractic services ad ay other category approved by the superitedet of isurace. URGENT MEDICAL CONDITION is a uforesee coditio of a kid that usually requires medical attetio without delay but that does ot pose a threat to the life, limb or permaet health of the ijured or ill perso. URGENT CARE SERVICES meas covered services provided for a Urget Medical Coditio ad may iclude such health care services for a Urget Medical Coditio provided out of the Paramout Service Area. 53

58 HMO Member Hadbook OPTIONAL RIDERS The followig riders may be part of your beefit pla, if purchased by your employer group. Refer to your Summary of Beefits for ay optioal riders available uder your pla. HEARING AID RIDER Oe (1) Stadard Hearig Aid ad fittig is covered up to the maximum beefit every 36 moths per Member whe ordered from a Participatig Provider ad determied to be Medically Necessary by a Paramout Physicia or a participatig Audiologist. See the Summary of Beefits for the maximum beefit. Replacemet of a Stadard Hearig Aid is covered every 36 moths from acquisitio of the previous Hearig Aid. This beefit does ot apply to the Out-of-Pocket Copaymet Limit. Hearig tests for fittig ad post performace evaluatio of a Hearig Aid are covered i full per Cotract Year whe prescribed by a participatig Audiologist. A Stadard Hearig Aid is defied as; i-the-ear (ITE), or behid-the-ear (BTE), moaural (oe ear) or biaural (both ears) basic or programmable models. Not Covered: Hearig Aids ordered prior to the effective date of coverage uder this Rider, eve if delivered after the effective date of coverage. Replacemet sooer tha 36 moths of Hearig Aids that are lost or broke or a differet make or model is prescribed. Replacemet ad repair of Hearig Aids resultig from misuse. Batteries for Hearig Aids. HEARING AID REBATE RIDER Paramout will reimburse your expeses up to the beefit limit stated i the Summary of Beefits for the cost of hearig aids ad hearig aid related services icludig but ot limited to; hearig aid molds, audiometric testig, hearig aid evaluatios ad batteries, oce every thirty-six (36) moths. Beefits uder the Hearig Aid Rebate Rider are ot subject to the Out-of-Pocket Copaymet Limit. To receive this beefit, sed a copy of your paid, itemized receipt from ay hearig aid provider to the address below. Clearly idicate your idetificatio umber o the receipt. Paramout Isurace Compay Hearig Aid Rebate Pla P.O. Box 928 Toledo, OH Reimbursemet will be set directly to the Subscriber. If submitted charges do ot exceed the beefit limit, reimbursemet will be for the amout submitted. 54

59 HMO Member Hadbook Not Covered: Hearig aids ad hearig aid related services icludig but ot limited to; hearig aid molds, audiometric testig, hearig aid evaluatios ad batteries ordered more ofte tha oce every thirty-six (36) moths. Hearig aids ad hearig aid related services icludig but ot limited to; hearig aid molds, audiometric testig, hearig aid evaluatios ad batteries purchased before this coverage bega or after this coverage eded. PRIVATE DUTY NURSING RIDER Private Duty Nursig is covered whe medically ecessary. Services must be ordered by a Participatig Provider ad be approved i advace by Paramout. If you have this Rider it is stated o your Summary of Beefits. VISON HARDWARE RIDER Paramout will reimburse expeses up to a maximum stated o the Summary of Beefits to each Member toward the cost of prescriptio leses, cotact leses ad /or frames oce every twety-four (24) moths. The followig beefits are available to Members whe provided through participatig Ophthalmologists or Optometrists. Covered Beefits Frames are covered up to the allowace oce every 24 moths. Frames may ot be provided mare frequetly tha oce i ay twety-four (24) moth period, regardless of ay prescriptio leses chage Not Covered Stadard leses, are defied as for sigle, bifocal (FT-25,28,roud), trifocal (FT-25) or aphakic visio ad ot exceedig 65 millimeters i diameter. Such Leses may iclude prism, slab-offs, myodisc or pik or rose #1 or #2 les tits or equivalet. Replacemet of Leses is provided oce durig each twelve (12) moth period if a chage i prescriptio is made or oce durig each twety-four (24) moth period, if there is o prescriptio chage. Cotact leses, alog with ay applicable examiatio ad fittig for sigle, bifocal, or trifocal visio, are covered up to the allowace oce durig each twelve (12) moth period with a chage i prescriptio or oce i ay twety-four (24) moth period without a chage i prescriptio. The cost of leses, cotact leses ad frames i excess of the limitatios stated i this Rider or ordered from o-participatig providers. Leses, cotact leses or frames ordered before the effective date of this Rider or after the termiatio date of this Rider. Leses or frames ordered while covered uder this Rider but delivered more tha 60 days after coverage termiatio. No-lie bifocal or trifocal leses to the extet the costs for such leses exceeds the beefit amout for lied bifocal or trifocal leses. 55

60 HMO Member Hadbook Suglasses, to the extet the cost of such leses exceeds the beefit amout of regular leses. As provided i this Rider, leses with a tit other tha the equivalet of Rose Tits #1 ad #2 are cosidered to be suglasses for the purpose of this exclusio. Photosesitive or ati-reflective leses to the extet the cost for such leses exceeds the beefit amout for regular leses provided uder this Rider. Replacemet of leses, cotact leses, ad frames which are lost, broke or stole uless at the time of replacemet the Member is eligible for replacemet as set forth above. VISION REBATE RIDER Paramout will reimburse expeses up to a maximum stated o the Summary of Beefits to each Member toward the cost of prescriptio leses, cotact leses ad /or frames oce every twety-four (24) moths. To receive the beefit, sed a copy of the paid, itemized receipt from ay visio provider to the address below. Clearly idicate the Member s Paramout Idetificatio umber o the receipt. Paramout Isurace Compay Visio Rebate Pla P.O. Box 928 Toledo, OH Reimbursemet will be set directly to the Subscriber. If submitted charges do ot exceed the stated maximum, reimbursemet will be for the amout submitted. Not Covered: Leses, cotact leses or frames ordered more ofte tha oce every twety-four (24) moths. Leses, cotact leses or frames purchased before this coverage bega or after this coverage eded. CHIROPRACTIC RIDER Paramout will cover the services of participatig chiropractors. All services will be subject to the Copay ad limitatios described i the Summary of Beefits. Copaymets/ Coisurace uder this beefit do ot apply to the Out-of-Pocket Copaymet Limit. Not Covered: Services redered by o-participatig chiropractors. Services i excess of beefit or visit limits. 56

61 HMO Member Hadbook PRESCRIPTION DRUG PROGRAM If you have a Prescriptio Drug Program it is stated o your Summary of Beefits. Paramout uses a pharmacy beefits maager (PBM) to maage the beefits uder the Prescriptio Drug Program. The PBM has a atioal etwork of participatig pharmacies referred to as Network Pharmacies. If you have prescriptio drug coverage as part of your health pla, the PBM is idicated o your Paramout idetificatio card. You may be erolled i oe or more of the followig programs - Retail Pharmacy Program, Mail Order Pharmacy Program, ad/or oe or more of the followig optioal Riders; Limited Medical Supplies, Specialty Drugs, Cotraceptio/Birth Cotrol Drugs, Ifertility Drugs, Sexual Dysfuctio Drugs ad Smokig Cessatio. Refer to your Summary of Beefits for details. All Prescriptio Drug Programs have a drug formulary associated with them. A drug formulary is a list of approved medicatios for your doctor to use whe treatig you. A drug formulary may be ope or modified ope. Your specific drug formulary is idicated o your Summary of Beefits. If it is medically ecessary for you to take a prescriptio drug that is ot o the approved formulary, your doctor must first have it approved through Paramout. Questios regardig your specific drug formulary may be aswered by callig the Paramout Member Services Departmet. Iformatio o the Prescriptio Drug Program is also available o the Paramout website at: To get the greatest savigs o prescriptio drugs, it s importat to request a geeric drug, whe available, istead of a brad ame drug. Your Prescriptio Drug Program may have Geeric Madate or Geeric Substitutio. Refer to your Summary of Beefits. Geeric Madate meas whe a brad ame drug, for which there is a geeric drug available, has bee prescribed, the beefit will be limited to the cost of the geeric drug. If the physicia has specified Dispese as Writte (DAW) for a brad ame drug or you isist o the brad ame drug, you will be fiacially resposible for the amout by which the brad ame drug price exceeds the geeric drug price, plus the applicable Copaymet required for a brad ame drug or the etire retail cost of the medicatio. Geeric Substitutio meas geeric drugs, whe available, will be dispesed i place of a brad ame drug. Sigle Copay - If the Physicia has specified Dispese as Writte ( DAW ), the Member will pay the Sigle Copaymet. If the Member requests a Brad Name Drug ad the Physicia has ot specified DAW, the Member will pay the amout by which the Brad Name Drug price exceeds the Geeric Drug price, plus the Sigle Copaymet. 2-tier ad 3-tier Copay - If the Physicia has specified Dispese as Writte ( DAW ), the Member will pay the Copaymet required for a Brad Name Drug. If the Member requests a Brad Name Drug ad the Physicia has ot specified DAW, the Member will pay the amout by which the Brad Name Drug price exceeds the Geeric Drug price, plus the highest Drug Copay withi the Copaymet arragemet. 4-tier Copay - If the Physicia has specified Dispese as Writte ( DAW ), or the Member requests a Brad Name Drug for which a Geeric Drug is available, the Member will pay the Multi Source Drug Copaymet. A Multi Source Drug is a drug that has a geeric, over-the-couter or isomeric brad drug equivalet. A isomeric brad drug is a drug with a molecular structure similar to a existig drug already o the market (e.g. eatiomer havig a mirror image relatioship to a drug already o the market.). Examples iclude Clariex (desloratadie) is a isomeric brad drug of Clariti (loratadie) ad Xopeex (levalbuterol) is a isomeric brad drug of Provetil (albuterol). 57

62 HMO Member Hadbook Specialty Drug - If the Physicia has specified Dispese as Writte ( DAW ), the Member will pay the Specialty Drug Copay/Coisurace. If the Member requests a Brad Name Drug ad the Physicia has ot specified DAW, the Member will pay the amout by which the Brad Name Drug price exceeds the Geeric Drug price, plus the Specialty Drug Copay/Coisurace. Preferred drugs are a list of commoly prescribed brad ame drugs selected by Paramout based o cliical ad costeffectiveess. You ca save moey by askig your doctor to prescribe preferred drugs. The Prescriptio Drug Program requires that you pay a Copay. There are several Copay arragemets. The Copay arragemet for your pla is stated o your Summary of Beefits. The followig are the various Copay arragemets. Sigle Copay You pay the same sigle Copay amout for ay covered prescriptio drug. 2-Tier Copay You pay the lowest Copay for a geeric drug ad a brad ame drug has a higher Copay. 3-Tier Copay You pay the lowest Copay for a geeric drug; a preferred drug has a mid-level Copay ad the o-preferred drug has the highest Copay. 4-Tier Copay - You pay the lowest Copay for a geeric drug; a sigle source preferred drug has a mid-level Copay; a sigle source o-preferred drug has a higher Copay; ad a multi-source brad drug has the highest Copay. I a tiered Copay arragemet, your Copay depeds o the specific prescriptio drug dispesed ad the Copay arragemet idicated o your Summary of Beefits. The amout you pay for Copaymets uder ay beefit of a Prescriptio Drug Program does ot cout toward your Out-of-Pocket Copaymet Limit. The days supply is the maximum umber of days a prescriptio drug will be dispesed uder a sigle prescriptio order. The days supply is stated o your Summary of Beefits. Additioally, some prescriptio drugs have quatity limits ad may require prior authorizatio before your prescriptio ca be filled. Quatity limits are assiged to medicatios that are frequetly take iappropriately or used i amouts that exceed dosage or legth of treatmet recommedatios. This is a accepted medical practice. Limits are set based o Food ad Drug Admiistratio (FDA) ad maufacturer recommedatios. If your prescriptio has a quatity limit, the Network Pharmacy will oly dispese eough pills to match the limit. Further, Paramout does ot cover products that are approved by the Federal Drug Admiistratio (FDA) for cosmetic use or weight loss or that are cosidered experimetal/ivestigatioal. Retail Pharmacy Program If you have the Retail Pharmacy Program, show your Paramout idetificatio card to the pharmacist whe purchasig prescriptio drugs ad certai over-the-couter medicatios approved by Paramout. Whe you use a etwork pharmacy, you will be resposible for your drug Copay ad the pharmacist will submit your claim electroically to the PBM. Prescriptio Drugs dispesed by a No-Network Pharmacy are ot covered. Mail Order Pharmacy Program If you have the Mail-Order Pharmacy Program, it is stated o your Summary of Beefits. A coveiet etwork mail order service is beeficial for those who take medicatios regularly for chroic coditios. If your physicia prescribes this type of medicatio, you may wat to use the Mail Order Pharmacy Program. Specialty Drugs are ot available through the stadard Mail Order Program. Certai medicatios are required to be obtaied through a mail order pharmacy. Your medicatio will be mailed directly to your home. 58

63 HMO Member Hadbook Additioal Drug Optios See your Summary of Beefits for additioal details. Limited Medical Supplies Rider covers diabetic, asthma ad other supplies as determied by Paramout s Pharmacy & Therapeutics Workig Group (P & T). The supplies covered uder the Limited Medical Supplies Rider are: Syriges with eedles (except for isuli syriges) Disposabbe supplies for implatable ifusio pump Disposable supplies for exteral drug ifusio ad supplies Blood glucose moitor, test strips ad supplies Lacig devices, lacets Peak expiratory flow rate meter (had-held) Spacers for metered dose ihaler ad disposable ebulizer supplies Specialty Drugs Rider covers Prescriptio Drugs which are self-admiistered for treatmet of certai complex, chroic coditios as determied by Paramout s P & T. See the HMO Specialty Drug List. The Prescriptio Drugs uder the Specialty Drug beefit are ot covered uder the Member s medical beefit pla. Specialty Drugs must be obtaied through a limited Specialty Network admiistered by Paramout s PBM. Prior authorizatio ad limits are required for certai Specialty Drugs ad Paramout reserves the right to modify the list of Specialty Drugs. Ifertility Drug Rider covers prescriptio drugs for the treatmet of ifertility. Prescriptio drugs related to i vitro fertilizatio, embryo trasplat services, GIFT, ZIFT ad zygote trasfer are ot covered. Cotraceptio/Birth Cotrol Drugs Rider covers prescriptio drugs for cotraceptio ad birth cotrol. Sexual Dysfuctio Drugs Rider covers prescriptio drugs for the treatmet of sexual dysfuctio. Smokig Cessatio Drugs Rider covers prescriptio drugs ad over-the-couter medicatios for smokig cessatio. Note: Coordiatio of Beefits applies to the Prescriptio Drug Program. Prescriptio drug beefits will be coordiated with those of ay other health coverage pla. (Rev ) 59

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66 2013 Paramout Care, Ic. LS-1509B - No-Gradfathered Revised 8/13