General Provisions Your Benefits

Transcription

1 The contract between you, the member, and Blue Care Network (BCN) of Michigan includes General Provisions, and Your Benefits. BCN is an independent corporation operating under a license from the Blue Cross Blue Shield Association, which is an association of independent Blue Cross Blue Shield Plans. This Association permits BCN to use the Blue Cross Blue Shield Service Mark in Michigan. When you enroll in BCN, you understand that: BCN is not contracting as the agent of the Association. You have not entered into the contract with BCN based on representations by any person other than BCN. No person, entity or organization other than BCN will be held accountable or liable to you for any of BCN s obligations created under the contract. There are no additional obligations on the part of BCN other than those obligations stated under the provisions of the contract with BCN. CB 3368 i GENPRO3

2 Blue Care Network General Provisions Blue Care Network (BCN) is a Health Maintenance Organizations (HMO) licensed by the state of Michigan and affiliated with Blue Cross Blue Shield of Michigan. Your Certificate (Your Benefits and General Provisions) is issued by your BCN health plan and is an agreement between you as an enrolled member and BCN. If your coverage is arranged through your employment, your eligibility and benefits will also be subject to the contract made between your employer and BCN. Eligible members are entitled to the HMO services and benefits described in your Certificate in exchange for the premium paid to BCN. By enrolling in this health plan and accepting this Certificate, you, the member, agree to abide by the rules as stated in this Certificate. You also recognize that, except for emergency health services, only those health care services provided by your Primary Care Physician or arranged or approved by BCN are a benefit under this Certificate. Definitions These definitions will help you understand the terms used in this Certificate. BCN is Blue Care Network, the Health Maintenance Organization in which you are enrolled. Certificate is the two sections we issue to you that describe your coverage, and any riders we issue that change your coverage: Your Benefits is a detailed description of your health care coverage, including exclusions and limitations. General Provisions describes the rules of your BCN health coverage plan. Dependent Child is an eligible individual less than the age of 26 who is the son or daughter in relation to the Subscriber or spouse by birth, legal adoption, or for whom the Subscriber or spouse has legal guardianship. Note: A Principally Supported Child is not a Dependent Child for purposes of this Certificate. See definition of Principally Supported Child below. Enrollment means submitting a completed enrollment form and paying the necessary premium to BCN. Family Dependent is an eligible family member who is enrolled for health care Coverage. A Family Dependent includes Dependent Children and a Dependent under a Qualified Medical Child Support Order, but does not include a Principally Supported Child. Family Dependents must meet the requirements stated in the eligibility section of General Provisions. Geographic Region is the counties covered by your BCN regional office. CB3368 ii GENPRO3

3 Group is the legal entity that contracted with BCN on behalf of its employees to receive the benefits described in the Certificate. Hospital is a state-licensed, acute-care facility that provides continuous, 24-hour inpatient medical, surgical or obstetrical care. It is not primarily a nursing care facility, rest home, home for the aged or a facility to treat substance abuse, psychiatric disorders or pulmonary tuberculosis. Member is the subscriber or an eligible dependent entitled to benefits under this Certificate. Non-Group Subscriber is one who enrolls for BCN coverage and pays the premiums for coverage directly rather than through a group. Open Enrollment Period is a period of time each year when eligible people may enroll or disenroll in BCN. Primary Care Physician is a licensed medical doctor (MD) or doctor of osteopathy (DO) affiliated with BCN as a Primary Care Physician and located in your geographic region. Premium is the amount prepaid monthly for coverage. For group coverage, this amount may include employee contributions. Principally Supported Child is an individual less than 26 years of age for whom principal financial support is provided by the Subscriber in accordance with Internal Revenue Service standards, and who has met the eligibility standards for at least six full months prior to applying for Coverage. A Principally Supported Child must meet the requirements in Section 1.5. Note: A Principally Supported Child is not the same as a Dependent Child. Rescission is the retroactive termination of a contract due to fraud or intentional misrepresentation of material fact. Referral Physician is a provider to whom a member is referred by a Primary Care Physician. Service Area is the geographic area through approval by state authorities that is served by BCN. Skilled Nursing Facility is a state-licensed, certified nursing home that is affiliated with BCN and that provides a high level of specialized care to members. It is an alternative to extended hospital stays. Subscriber is the eligible person who has enrolled for health care coverage with BCN. This person is the one responsible for payment of health care coverage premiums or whose employment is the basis for coverage eligibility. This person is also known as a member. Other members are those dependents of the subscriber who are eligible for coverage. CB3368 iii GENPRO3

4 Table of Contents Topic Page Definitions Part 1: Eligibility, Enrollment and Effective Date of Coverage Group Subscriber Non-Group Subscriber Family Dependent Dependent under a Qualified Medical Child Support Order Principally Supported Child Additional Eligibility Guidelines 5 Part 2: Other Party Liability Nonduplication Auto Policy and Workers Compensation Claims Coordination of Benefits 6 Coordination 7 Order of Benefits Determination 7 COB Exception 8 COB Administration Subrogation 8 Part 3: Member Rights and Responsibilities Confidentiality of Health Care Records Inspection of Medical Records Primary Care Physician Refusal to Accept Treatment Complaint and Grievance Procedure Member s Role in Policy-Making PCP Notification of Termination 12 Part 4: Forms, Identification Cards, Records and Claims Forms and Applications Identification Card Misuse of Identification Card Membership Records Authorization to Receive Information Member Reimbursement 15 Part 5: Termination of Coverage Termination of Group Coverage Termination for Nonpayment Termination of a Member s Coverage Extension of Benefits 17 CB3368 iv GENPRO3

5 Topic Page Part 6: Conversion and Continuation Coverage Loss Because of Eligibility Loss Because of Moving Loss of Coverage by Dependent COBRA Coverage 18 Part 7: General Provisions Notice Change of Address Headings Governing Law Execution of Contract of Coverage Assignment BCN Policies Arbitration and Litigation Your Contract Waiver by Agents Amendments Major Disasters Obtaining Additional Information 22 CB3368 v GENPRO3

6 Part 1: Eligibility, Enrollment and Effective Date of Coverage This section describes eligibility, enrollment and effective date of coverage for the five types of subscribers listed below. All BCN subscribers and members must meet eligibility requirements established by BCN. Certain requirements depend on whether the subscriber is: a group subscriber a non-group subscriber / group-conversion subscriber family dependent dependent under a qualified medical child support order principally supported child All members must live in the BCN service area to be eligible for coverage unless stated otherwise in this Certificate. 1.1 Group Subscriber Eligibility A group subscriber must do all of the following: live in the BCN service area at least nine months out of the year; be an active employee or eligible retiree of a group; and meet the group s eligibility requirements. Enrollment A new employee must enroll within 30 days of becoming eligible or during an open enrollment period. NOTE: If the employee declines enrollment because of having other coverage, and that coverage ends, he/she may enroll if: Any COBRA coverage is exhausted, and The other coverage was terminated as a result of loss of employer contributions or loss of eligibility. The employee must request enrollment within 30 days after the other coverage ends. Effective Date The effective date of coverage depends on the agreement between the group and BCN. 1.2 Non-Group Subscriber Eligibility A non-group subscriber must: live in the BCN service area at least nine months out of the year; not be eligible for enrolling in group coverage or group conversion coverage; CB GENPRO3

7 not be eligible for or enrolled in other health care coverage as a subscriber or dependent, including Medicare. Enrollment Enrollment takes place during an open enrollment period or when the member is converting from group coverage to non-group coverage. See Part 6. Effective Date The effective date of coverage is the date designated by BCN. 1.3 Family Dependent Eligibility A Family Dependent may be either: The legally married spouse of the Subscriber, A Dependent Child, or A Dependent under a Qualified Medical Child Support Order Dependent Children and a Dependent under a Qualified Medical Child Support Order are eligible for Coverage until they become 26 years old. The child s BCN membership terminates at the end of the calendar year in which he or she becomes 26 years old. Exception: An unmarried Dependent Child and a Dependent under a Qualified Medical Child Support Order who becomes 26 while enrolled and who is totally and permanently disabled may continue health care Coverage if: The child is incapable of self-sustaining employment because of mental retardation or physical handicap; The child relies primarily on the Subscriber for financial support; The child lives in the Service Area; and The disability began before their 26th birthday. Physician certification, verifying the child s disability and that it occurred prior to the child s 26 th birthday, must be submitted to BCN by the end of the calendar year in which the child turns age 26. If the disabled child is entitled to Medicare benefits, BCN must be notified of Medicare coverage in order to coordinate member benefits. NOTE: A Dependent Child whose only disability is a learning disability or substance abuse does not qualify for health care coverage under this exception. Enrollment Eligible Family Dependents may be added to the Subscriber s contract: During the annual Open Enrollment Period CB GENPRO3

8 When the Subscriber enrolls Within 30 days of a qualifying event that is birth, marriage, placement for adoption or qualified medical child support order. NOTE: See below for additional requirements for Dependents under a Qualified Medical Child Support Order. If the eligible Family Dependents were not enrolled because of other coverage, and they lose their coverage, the Subscriber may add them within 30 days of their loss of coverage with supporting documentation. NOTE: Other non-enrolled eligible Family Dependents may also be added at the same time as the newly qualified Family Dependent. Effective Date of Coverage Other than Dependent under a Qualified Medical Child Support Order Coverage is effective on the date of the qualifying event, if the Family Dependent is enrolled within 30 days of the event. If the Family Dependent is not enrolled within 30 days, Coverage will not begin until the next Open Enrollment Period s effective date. For a Family Dependent who lost coverage and notifies BCN within 30 days, Coverage will be effective when the previous coverage lapses. If you do not notify BCN within 30 days, Coverage will not begin until the next Open Enrollment Period s effective date. Adopted children are eligible for Coverage from the date of placement. NOTE: Placement means when the Subscriber becomes legally responsible for the child; therefore, the child s coverage may begin before the child lives in the Subscriber s home. 1.4 Dependent under a Qualified Medical Child Support Order Eligibility The child will be enrolled under a Qualified Medical Child Support Order if the Subscriber is under court or administrative order that makes the Subscriber legally responsible to provide Coverage. NOTE: A copy of the court order, court-approved settlement agreement, or divorce decree is required to enroll the child. If you have questions about whether an order is qualified for purposes of State law, call your group representative or Customer Service at the number listed on the back of your ID card, or see Section 7.13 Obtaining Additional Information. Enrollment The child may be enrolled at any time, preferably within 30 days of the court order. CB GENPRO3

9 In addition: If the Subscriber parent who is under a court or administrative order to provide Coverage does not apply, the other parent or the state Medicaid agency may apply for Coverage for the child. If the parent, who is under court or administrative order to provide Coverage for the child, is not already a Subscriber, that parent may enroll (if eligible) when the child is enrolled. Neither parent may disenroll the child from an active contract while the court or administrative order is in effect unless the child becomes covered under another plan. Effective Date of Coverage If BCN receives notice within 30 days of the court or administrative order, Coverage is effective as of the date of the order. If BCN receives notice longer than 30 days after the order is issued, Coverage is effective on the date BCN receives notice. 1.5 Principally Supported Child Eligibility A Principally Supported Child must: Not be the child of the Subscriber or spouse by birth, legal adoption or legal guardianship; Be less than 26 years of age; Be unmarried; Live full-time in the home with the Subscriber; Not be eligible for Medicare or other group Coverage; and Be dependent on the Subscriber for principal financial support in accordance with Internal Revenue Service standards, and have met these standards for at least six full months prior to applying for Coverage. Enrollment You may apply for Coverage for a Principally Supported Child after you have been the principal support for six (6) months; Coverage will begin three (3) months after the application is accepted by BCN. To apply, you must furnish the following: Evidence that the child was reported as a dependent on the Subscriber s most recently filed tax return; or Evidence and a sworn statement that the dependent qualifies for dependent tax status in the current year; and Proof of eligibility if requested by BCN CB GENPRO3

10 Effective Date of Coverage Coverage for a Principally Supported Child begins on the first day of the month three (3) months after application and proof of support is received and accepted by BCN. The Group must remit the premium to BCN prior to the effective date of coverage. 1.6 Additional Eligibility Guidelines The following guidelines apply to all members: Medicare: If a member becomes eligible to enroll in Medicare, the member is eligible to enroll in only the applicable BCN Medicare program except when Medicare is the secondary payer by law. Service Area Waiver: Under certain circumstances BCN may waive the service area requirement in writing for a subscriber and family dependents who live outside the service area. Change of Status: You agree to notify BCN within 30 days of any change in eligibility status of you or any family dependents. When a member is no longer eligible for coverage, he or she is responsible for payment for any services or benefits. Members admitted to a hospital or skilled nursing facility prior to the effective date of coverage will be covered for inpatient care on the effective date of the Certificate only if: The member has no continuing coverage under any other health benefits contract, program or insurance. CB GENPRO3

11 Part 2: Other Party Liability BCN does not pay claims or coordinate benefits for services that: Are not provided or pre-authorized by BCN and a Primary Care Physician; and Are not a benefit under this Certificate. 2.1 Nonduplication BCN provides each member with full health care services within the limits of this Certificate. BCN does not duplicate benefits or pay more for covered services than the actual fees. Coverage for your benefits will be reduced to the extent that the benefits are available or payable under any other certificate or policy covering the member, whether or not you make a claim for the benefits. 2.2 Auto Policy and Workers Compensation Claims This Certificate is a coordinated certificate of coverage. That is, services and treatment for any automobile-related injury that are paid or payable under any automobile or nofault automobile policy will not be paid by BCN. BCN will not allow double-dipping whereby you would recover payment for the same services from both BCN and the automobile or no-fault carrier. Services and treatment for any work-related injury that are paid or payable under any workers compensation program will not be paid by BCN. If any such services are provided by BCN, BCN has the right to seek reimbursement from the other program or insurer. 2.3 Coordination of Benefits (COB) NOTE: Certificate and Policy used here include a certificate, contract or policy issued by: a health or medical care corporation, a hospital service corporation, a health maintenance organization, a dental care corporation, an insurance company, a labor-management trustee plan, a union welfare plan, an employer organization plan, or an employer self-insurance plan in connection with a group disability benefit plan under which health, dental, hospital, medical, surgical or sick care benefits are provided to subscribers. CB GENPRO3

12 Determination of benefits means determining the amount that will be paid for covered services. Coordination of Benefits means determining which certificate or policy is responsible for paying benefits for covered services first (primary carrier) when a member has dual coverage. Then, benefits payments are coordinated between two carriers to provide 100% coverage whenever possible for services covered in whole or in part under either plan, but not to pay in excess of 100% of the total amounts to which providers or members are entitled. Coordination When a member has coverage under a certificate or policy that does not contain a coordination of benefits provision, that certificate or policy will pay first. This means benefits under the other coverage will be determined before the benefits of your BCN Certificate. After those benefits are determined, BCN s benefits and the benefits of the other plan will be coordinated to provide 100% coverage whenever possible for services covered partly or totally under either plan. In no case will payments be more than the amounts to which providers or members are entitled. BCN does not pay claims or coordinate benefits for services that: Are not provided or pre-authorized by BCN and a Primary Care Physician, and Are not a benefit under this Certificate. Order of Benefits Determination (which policy will pay first) When a member has coverage under another policy or certificate that does have a coordination of benefits provision, these rules apply: 1. The benefits of the policy that covers the person as a subscriber (policy-holder) will be determined first. The benefits that cover the person as a dependent will be determined second. 2. If two policies cover a person as a dependent, the policy of the person whose birthday falls earlier in the calendar year will be considered primary, i.e., those benefits will be determined first. 3. If two policies cover a person as a dependent and the birthdays of the two policy-holders are identical, the policy that has covered the patient longer will be primary. NOTE: If either policy or certificate is lawfully issued in another state, and does not have the coordination of benefits procedure regarding dependents based on birthday anniversaries, and each policy or certificate determines its payment of benefits after the other, the policy that does not have the COB procedure based on birthdays will determine who pays first. 4. If the claim is for a dependent minor child, payment of benefits will be determined as follows: a. If the parents of the minor child are divorced, and the divorce decree or court order places financial responsibility for medical, dental or other health care expenses on one specific parent, the policy of that parent will be primary. CB GENPRO3

13 b. If the parents of the child are legally separated or divorced, and the parent with custody has not remarried and a court order does not specify which parent is responsible for medical coverage, the policy that covers the child as a dependent of the custodial parent will be paid first. (Also see paragraph a.) c. If the parents are divorced and the custodial parent has remarried: The benefits of the custodial parent s policy will be paid before the benefits of the custodial step-parent. The policy that covers the minor child as a dependent of the custodial parent s spouse will be paid before the benefits that cover the minor child as a dependent of the non-custodial parent. 5. If paragraphs 1, 2, 3 or 4 do not establish the order in which benefits should be paid, the policy or certificate that has covered the child longer will pay first, subject to the following: a. The benefits of a policy of a person who is laid-off or retired will be secondary to any other policy covering the minor child. b. If either policy or certificate is lawfully issued in another state and does not have a provision regarding laid-off or retired employees, and each policy determines its benefits after the other, then paragraph a) does not apply. COB Exception Benefits under this Certificate will not be reduced or otherwise limited because of a non-group contract that is issued as a hospital indemnity, surgical indemnity, specified disease or other policy of disability insurance as defined in section 3400 of the insurance code of 1956, Act No. 218 of the Public Acts of 1956, being section of the Michigan Compiled Laws. COB Administration If BCN determines that benefits under this Certificate should have been reduced because of benefits available under another certificate or policy, BCN has the right to: recover any payments made to the member directly from the member or assess a reasonable charge for services provided by BCN in excess of BCN s liability If benefits that should have been paid by BCN have been provided under another certificate or policy, BCN may directly reimburse whoever provided the benefits payments. For COB purposes, BCN may release, claim or obtain any necessary information from any insurance company or other organization. Any member who claims benefits payment under this Certificate must furnish BCN with any necessary information or authorization to do this. 2.4 Subrogation Subrogation is the assertion by BCN of your right, or the rights of your dependents or representatives, to make a legal claim against or to receive money or other valuable consideration from another person, insurance company, or organization. CB GENPRO3

14 Reimbursement is the right of BCN to make a claim against you, your dependents, or representatives if you or they have received funds or other valuable consideration from another party responsible for benefits paid by BCN. DEFINITIONS: The following terms are used in this section and have the following meanings: Claim for Damages means a lawsuit or demand against another person or organization for compensation for an injury to a person when the injured party seeks recovery for the medical expenses. Collateral Source Rule is a legal doctrine that requires the judge in a personal injury lawsuit to reduce the amount of payment awarded to the plaintiff by the amount of benefits BCN paid on behalf of the injured person. Common Fund Doctrine is a legal doctrine that requires BCN to reduce the amount received through subrogation by a pro rata share of the plaintiff s court costs and attorney fees. First Priority Security Interest means the right to be paid before any other person from any money or other valuable consideration recovered by: Judgment or settlement of a legal action: Settlement not due to legal action; or Undisputed payment. Lien means a first priority security interest in any money or other valuable consideration recovered by judgment, settlement, or otherwise up to the amount of benefits, costs, and legal fees BCN paid as a result of the plaintiff s injuries. Made Whole Doctrine is a legal doctrine that requires a plaintiff in a lawsuit be fully compensated for his or her damages before any Subrogation Liens may be paid. Other Equitable Distribution Principles means any legal or equitable doctrines, rules, laws, or statues that may reduce or eliminate all or part of BCN s claim of Subrogation. Plaintiff means a person who brings the lawsuit or claim for damages. The plaintiff may be the injured party or representative of the injured party. YOUR RESPONSIBILITIES: In certain cases, BCN may have paid for health care services for you or other Members on the Contract who should have been paid by another person, insurance company, or organization. In these cases: You assign to us your right to recover what BCN paid for your medical expenses for the purpose of subrogation. You grant BCN a Lien or Right of Recovery. Reimbursement on any money or other valuable consideration you receive through a judgment, settlement, or otherwise regardless of 1) who holds the money or other valuable consideration or where it is held, 2) whether the money or other valuable considerations is designated as economic or non-economic damages, and 3) whether the recovery is partial or complete. CB GENPRO3

15 You agree to inform BCN when your medical expenses should have been paid by another party but were not due to some act of omission. You agree to inform BCN when you hire an attorney to represent you, and to inform your attorney of BCN rights and your obligations under this Certificate. You must do whatever is reasonably necessary to help BCN recover the money paid to treat the injury that caused you to claim damages for personal injury. You must not settle a personal injury claim without first obtaining written consent from BCN if the settlement relates to services paid by BCN. You agree to cooperate with BCN in our efforts to recover money we paid on your behalf. You acknowledge and agree that this Certificate supersedes any Made Whole Doctrine, Collateral Source Rule, Common Fund Doctrine, or other Equitable Distribution Principles. You acknowledge and agree that this Certificate is a contract between you and BCN and any failure by you, other Members on the Contract, or representatives to follow the terms of this Certificate will be a material breach of your contract with us. a) When you accept a BCN ID card for Coverage, you agree that, as a condition of receiving Benefits and services under this Certificate, you will make every effort to recover funds from the liable party. b) When you accept a BCN ID card for Coverage, it is understood that you acknowledge BCN s right of subrogation. If BCN requests, you will authorize this action through a subrogation agreement. If a law suit by you or by BCN results in a financial recovery greater than the services and Benefits provided by BCN, BCN has the right to recover its legal fees and costs out of the excess. c) When reasonable collection costs and legal expenses are incurred in recovering amounts that benefit both you and BCN, the costs and legal expenses will be divided equitably. d) You agree not to compromise or settle a claim or take any action that would prejudice the rights and interests of BCN without getting BCN s prior written consent. e) BCN will have the right to recover from you the amount to which BCN has a right to subrogation. If you refuse or do not cooperate with BCN regarding subrogation, it will be grounds for terminating membership in BCN upon 30 days written advance notice. You have the right to appeal our decision by contacting Customer Service at CB GENPRO3

16 Part 3: Member Rights and Responsibilities 3.1 Confidentiality of Health Care Records A consent to release of medical information is written on your BCN identification card. By using your identification card and as a condition of receiving benefits under this Certificate you consent to the release of information from your medical records and information received from your health care providers incident to the doctor-patient relationship to BCN and to your Primary Care Physician. Your health care records will be kept confidential by BCN and your Primary Care Physician. BCN will not disclose information from your medical records without your consent except in connection with the administration of this Certificate, when required by law, for use of nonidentifying data for statistical studies or in bona fide medical research or education. It is your responsibility to cooperate with BCN by providing health history information and helping to obtain prior medical records at BCN s request. 3.2 Inspection of Medical Records You have access to your own medical records or those of your minor children or wards at the Medical Office during regular office hours. However, access to records of a minor without the minor s consent may be limited by law or applicable BCN policy. 3.3 Primary Care Physician BCN requires you to choose a Primary Care Physician. You have the right to designate any Primary Care Physician who is a Participating Physician and who is available to accept you. If you do not choose a Primary Care Physician upon enrollment, BCN will choose a Primary Care Physician for you. For children under the age of 18 ( Minors ), you may designate a Participating pediatrician as the Primary Care Physician if the Participating pediatrician is available to accept the child as a patient. Alternatively, the parent or guardian of a Minor may select a Participating family practitioner or general practitioner as the Minor s Primary Care Physician, and may access a Participating pediatrician for general pediatric services for the Minor (hereinafter Pediatric Services ). No PCP referral is required for a Minor to receive pediatric services from the Participating pediatrician. You do not need prior authorization from BCN or from any other person, including your Primary Care Physician, in order to obtain access to obstetrical or gynecological care from a Participating Provider who specializes in obstetric and gynecologic care. The Participating specialist, however, may be required to comply with certain BCN procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. The female Member retains the right to receive the obstetrical and/or gynecological services directly from her Primary Care Physician. CB GENPRO3

17 For information on how to select a Primary Care Physician, and for a list of Participating Primary Care Physicians, Participating pediatricians and Participating health care professionals who specialize in obstetrics and gynecology contact Customer Service at or online at If after reasonable efforts, you and the Primary Care Physician are unable to establish and maintain a satisfactory physician-patient relationship, you may be transferred to another Primary Care Physician. If a satisfactory physician-patient relationship cannot be established and maintained, you may be asked to disenroll upon 30 days written advance notice; all Dependent Family Members will also be required to disenroll from Coverage. (See Section 5.3) 3.4 Refusal to Accept Treatment You have the right to refuse treatment or procedures recommended by BCN physicians for personal or religious reasons. However, your decision could adversely affect the relationship between you and your physician, and the ability of your physician to provide appropriate care for you. If you refuse the treatment recommended, and the BCN physician believes that no other medically acceptable treatment is appropriate, the physician will notify you. If you still refuse the treatment or request procedures or treatment that BCN regards as medically or professionally inappropriate, BCN is no longer financially or professionally responsible for treating the condition. 3.5 Complaint and Grievance Procedure If you have a complaint or grievance regarding any aspect of BCN s services, you must follow the procedure established by BCN. You receive a copy of this procedure when you become a member. You also may obtain a copy at any time by contacting BCN at If grievances are not settled through BCN s procedure, you may appeal to the Office of Financial and Insurance Regulation Division of Insurance, Health Plans Division 611 Ottawa, Third Floor PO Box Lansing, MI Member s Role in Policy-Making At least one third of the Board of Directors of BCN will consist of BCN members, elected by subscribers. BCN provides nomination and election procedures to subscribers each year. 3.7 PCP Notification of Termination Each member may receive notification of termination from his or her physician with 15 days of knowledge of the termination effective date. The physician can continue care with a terminally ill member, diagnosed as such prior to the physician s notification of termination from the plan. CB GENPRO3

18 Limitations and Exclusions: If the physician provides notification to the member, BCN will permit the member to continue an ongoing course of treatment as follows: 1. For 90 days from the date of notice to the member by the physician of the physician s termination. 2. Through post-partum care directly related to the pregnancy if the member is in her second or third trimester of pregnancy at the time of the physician s termination. 3. The member must have been diagnosed as terminally ill prior to receiving notification of physician s termination. Continuation of care only applies if the physician adheres to BCN s policies and procedures. CB GENPRO3

19 Part 4: Forms, Identification Cards, Records and Claims 4.1 Forms and Applications You must complete and submit any enrollment form, medical questionnaires or other forms that BCN requests. You warrant that any information you submit is true, correct and complete. The submission of false or misleading information in connection with Coverage is cause for Rescission of your Contract upon 30 days written advance notice. You have the right to appeal our decision to Rescind your Coverage by following the complaint and grievance procedure described in your Certificate, on our website at MiBCN.com or by contacting Customer Service at Identification Card BCN issues identification cards to members. You must present these cards whenever you receive or seek services from a provider. This card is the property of BCN. BCN may request that the card be returned at any time. To be entitled to benefits, the person using the card must be the member for whom all premiums have been paid. If a person is not entitled to receive services, the person must pay for the services received. If your card is lost or stolen, report it to BCN immediately. 4.3 Misuse of Identification Card If any BCN member does any of the following: misuses the identification card, repeatedly fails to present the card when receiving services from a provider, permits any other person to use the card, and/or attempts to or defrauds BCN, BCN may confiscate the card, and all rights of the member under this Certificate will terminate. 4.4 Membership Records BCN will keep membership records. BCN will not provide coverage unless information is submitted in a satisfactory format by a group or a member. Any incorrect information submitted to BCN may (and should) be corrected. However, you will be responsible for reimbursing BCN for any service paid by BCN based on incorrect information. 4.5 Authorization to Receive Information By accepting coverage under this Certificate, you agree that: CB GENPRO3

20 BCN may obtain any information from providers in connection with services to a member. BCN may disclose any of your medical information to your Primary Care Physician. BCN may copy records related to your care. 4.6 Member Reimbursement There is no reason for you to pay a provider for covered services under this Certificate (other than copays), but if circumstances require that you do, and you can prove that you have, BCN will reimburse you for those covered services. You must provide written proof of the payment within 12 months of the date of service. Claims submitted more than 12 months after the date of service will not be paid. CB GENPRO3

21 Part 5: Termination of Coverage 5.1 Termination of Group Coverage This Certificate and the contract between a group and BCN will continue in effect for the period established by BCN and the group. The agreement continues from year to year, subject to the following: The group or BCN may terminate the Certificate with 30 days written notice. Benefits for all members of the group will terminate on the date the Certificate terminates. If the group terminates this Certificate, all rights to benefits end on the date of termination. BCN will cooperate with the group to arrange for continuing care of members who are hospitalized on the termination date. This Certificate and the contract between a Group and BCN will continue in effect for the period established by BCN and the Group. The agreement continues from year to year, subject to the following: The Group or BCN may terminate the Certificate with 30 days written notice. Benefits for all Members of the Group will terminate on the date the Certificate terminates. If the Group terminates this Certificate, all rights to benefits end on the date of termination to the extent permitted by law. BCN will cooperate with the Group in attempting to make arrangements for continuing care of Members who are hospitalized on the termination date. 5.2 Termination for Nonpayment Nonpayment of Premium If a group or individual subscriber fails to pay the premium by the due date, the Group or individual is in default. BCN allows a 30 day grace period, however, if the default continues, the Group and its Members, or the individual Subscriber may be terminated. BCN will allow a 30 day grace period, however, if the Group or individual is terminated, any benefits incurred by a member and paid by BCN after the termination will be charged to the Group or, as permitted by law, to the individual Subscriber. Nonpayment History BCN may refuse to accept an application for enrollment or may decline renewal of any member s coverage if the applicant or any member on the contract has a history of delinquent payment of premiums or copayments. Nonpayment of Member Copay BCN may terminate coverage for any contract under the following conditions: Members fail to pay copayments or other fees within 90 days of their due date, or Members do not make and comply with acceptable payment arrangements with the Participating Provider to correct the situation. CB GENPRO3

22 The termination will be effective at the renewal date of the Certificate. BCN will give reasonable notice of such termination. 5.3 Termination of a Member s Coverage a) Termination: Coverage for any Member may also be terminated for any of the reasons listed below. Such termination is subject to legally required notice and grievance rights required by law: You no longer meet eligibility requirements. Coverage is cancelled for nonpayment. The Group s Coverage is cancelled. You do not cooperate with BCN in pursuing subrogation. You are unable to establish a satisfactory physician-patient relationship. You act in an abusive or threatening manner toward BCN or Participating Providers, their staff, or other patients. Misuse of the BCN ID card (Section 4.3) that is not fraud or intentional misrepresentation of a material fact Misuse of the BCN system that is not fraud or intentional misrepresentation of a material fact b) Rescission: If you commit fraud that in any way affects your Coverage or make an intentional misrepresentation of a material fact to obtain, maintain or that otherwise affects your Coverage BCN will consider you in breach of contract and, upon 30 days written advance notice, your membership may be Rescinded. In some circumstances, fraud or intentional misrepresentation of a material fact may include: Misuse of the BCN ID card (Section 4.3) Intentional misuse of the BCN system Knowingly providing inaccurate information regarding eligibility You have the right to appeal our decision to Rescind your Coverage by following the BCN complaint and grievance procedure. You can find this procedure in your Certificate, on our website at MiBCN.com or you can contact Customer Service at who will provide you with a copy. 5.4 Extension of Benefits All rights to BCN benefits end on the termination date except: Benefits will be extended for an authorized inpatient admission that began prior to the termination date. As permitted by law, this extension of benefits will continue only for the condition being treated on the termination date, and only until any one of the following occurs: The patient is discharged. The benefits exhausted prior to the end of the contract. CB GENPRO3

23 Part 6: Conversion and Continuation Coverage 6.1 Loss Because of Eligibility Change If you no longer meet eligibility requirements for group coverage, you may apply for conversion to non-group coverage. There will be no lapse in coverage if the following events occur within 30 days after you lose eligibility for group coverage: You apply in writing. You are approved by BCN. You pay the applicable premium charges. NOTE: Your non-group coverage may not be the same level of coverage as your prior group coverage. 6.2 Loss Because of Moving If you no longer meet eligibility requirements because you move, but you are still eligible for coverage according to your group s guidelines, you have two choices. You must choose one of the following within 30 days to avoid a lapse in coverage: You may apply in writing for a waiver of the residency requirement. The waiver must be approved by BCN. or You must transfer to your group s alternate carrier, if any. If your group does not have an alternate carrier, you may apply for conversion coverage through Blue Cross Blue Shield of Michigan. 6.3 Loss of Coverage by Dependent If a family dependent ceases to be eligible for coverage because of: the death of the subscriber, divorce from the subscriber, change of residence or loss of dependent status, the dependent may apply for conversion coverage as outlined in Section 6.1. A minor or totally disabled dependent that is 19 years or older, may convert only as a dependent on a parent s conversion contract. If a family dependent member is no longer eligible to continue membership because he or she is eligible to enroll in Medicare, BCN will notify the member and convert the member s coverage to the applicable BCN Medicare program. 6.4 COBRA Coverage COBRA is the continuation of group coverage, but at the member s expense, for members who lose eligibility. Most groups with over 20 employees are required by federal law to offer this CB GENPRO3

24 coverage. The group is the administrator of its COBRA plan. If you have questions, contact the group. NOTE: Groups with less than 20 employees, church-related groups and federal employee groups are exempt from COBRA. If your group is subject to this federal law, and you are eligible for continuation coverage under the law, points 1, 2 and 3 below apply to you. 1. You may apply and pay for group continuation coverage directly to your employer, but you must do so within the time limits allowed by law. You must also comply with other requirements of federal law. 2. This coverage may continue for up to 18, 29 or 36 months, depending on the reason for your initial eligibility. You are considered a group member for all purposes, including termination for cause; however, events that would otherwise result in loss of eligibility are waived to the extent that the federal law specifically allows continuation. Continuation coverage and all benefits cease automatically under any of the following: The period allowed by law expires. The group stops offering BCN coverage. You begin coverage under any other plan (with some exceptions). You become eligible for Medicare. You do not pay for your coverage fully and on time. 3. If you maintain uninterrupted coverage in good standing, you may change from continuation coverage to non-group conversion coverage at any time during the last six months of the period you were allowed for continuation coverage. If you apply in writing and pay the premium to BCN before the last day of the period you were allowed for continuation coverage, there will be no lapse in coverage. The non-group conversion coverage may not be the same level of coverage as your prior group coverage. A minor or totally disabled dependent that is 19 years or older, may convert only as a dependent on a parent s conversion contract. CB GENPRO3

25 Part 7: General Provisions 7.1 Notice Any notice that BCN is required to give its members will be In writing; Delivered personally or sent by U.S. Mail; and Addressed to the subscriber s last address of record 7.2 Change of Address You, the subscriber, must notify BCN immediately of any change of address for yourself or any dependent. If you do not notify BCN of a change of address outside the service area within a reasonable period of time, your contract may be cancelled. 7.3 Headings The titles and headings in your Certificate are not a part of the Certificate. They are intended to make your Certificate easier to read and understand. 7.4 Governing Law This Certificate of coverage is made and will be interpreted under the laws of the state of Michigan. 7.5 Execution of Contract of Coverage When you, the subscriber, sign the BCN application form, you are agreeing to all terms, conditions and provisions of this Certificate. 7.6 Assignment The benefits provided under this Certificate are for the personal benefit of the members. They cannot be transferred or assigned to another person. If any member tries to assign this Certificate to another person, all rights will be automatically terminated. BCN will not pay any provider except under the provisions of this Certificate. 7.7 BCN Policies BCN may adopt reasonable policies, procedures, rules and interpretations in order to administer this Certificate. 7.8 Arbitration and Litigation Legal Actions: No action at law or in equity shall be brought to recover on this Policy prior to the expiration of 60 days after written Proof of Loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of 3 years after the time written Proof of Loss is required to be furnished. CB GENPRO3

26 If you are enrolled through a group which is subject to regulation under the Employee Retiree Income Security Act (ERISA), you may not file a legal action unless you have first followed the BCN internal grievance process. 7.9 Your Contract Your contract with BCN consists of all of the following: Your Benefits and General Provisions sections (the Certificate ) The agreement between the group and BCN (for group coverage) Any applicable riders The application signed by the subscriber BCN identification card These documents supersede all other agreements between BCN and members as of the effective date of the documents Waiver by Agents No agent or any other person, except an executive officer of BCN, has the authority to do any of the following: Waive any conditions or restrictions of this Certificate Extend the time for making payment Bind BCN by making promises or representations or by giving or receiving any information Amendments This Certificate and the agreement between the group and BCN are subject to amendment, modification or termination. Such changes must be made in accordance with the terms of this Certificate or by mutual agreement between the group and BCN, with regulatory approval, if required Major Disasters In the event of major disaster, epidemic or other circumstances beyond the control of BCN, BCN will attempt to perform covered services insofar as it is practical, according to BCN s best judgment and within any limitations of facilities and personnel that exist. If facilities and personnel are not available, causing delay or lack of services, there is no liability or obligation to perform covered services under such circumstances. Such circumstances include: complete or partial disruption of facilities disability of a significant part of facility or BCN personnel, etc. war CB GENPRO3

27 riot civil insurrection labor disputes not within the control of BCN 7.13 Obtaining Additional Information The following information is available from BCN by writing to BCN at Civic Center Drive, Southfield, Michigan The current provider network in your service area The professional credentials of the health care providers who are participating providers with BCN, including participating providers who are board certified in the specialty of pain medicine and the evaluation and treatment of intractable pain The names of participating hospitals where individual participating physicians have privileges for treatment How to contact the appropriate Michigan agency to obtain information about complaints or disciplinary actions against a health care provider Information about the financial relationships between BCN and a participating provider CB GENPRO3