Exhibit 10.36
UNITED STATES HEALTH CARE SYSTEMS OF PENNSYLVANIA, INC.,
dba THE HEALTH MAINTENANCE ORGANIZATION OF
PENNSYLVANIA, INC. dba
U.S. HEALTHCARE
GROUP MASTER CONTRACT
United States Health Care Systems of Pennsylvania, Inc., dba The Health
Maintenance Organization of Pennsylvania, Inc. dba US Healthcare (referred to in
this Contract as "HMO") operates a comprehensive prepaid program of health care
which provides health care services and benefits to Members in order to protect
and promote their health and preserve and enhance patient dignity.
HMO agrees with the Contract Holder, subject to all the conditions and
provisions of this Contract, to provide the services and benefits and other
rights and privileges which are set forth in this Contract, as may be revised or
amended from time to time.
This Contract and all attachments and endorsements incorporated herein by
reference are delivered by HMO in consideration of the Contract Holder's payment
of premiums and shall take effect on the Contract Effective Date.
Under the Contract, the Subscriber engages HMO to make arrangements through
which medical and hospital benefits may be accessed in accordance with the
covenants and conditions hereafter provided and in reliance upon the statements
of each Subscriber in his/her Enrollment Application.
The Contract is not in lieu of and does not affect any requirement for coverage
by Workmen's Compensation Insurance.
This Contract is governed by the laws of the state in which filed. The Contract
specifications and the conditions and provisions on this and the following
pages, including the cover sheet, any amendments, riders or endorsements
included at delivery or added thereafter, are part of the Contract.
NO SERVICES ARE DELIVERABLE UNDER THIS CONTRACT IN THE ABSENCE OF PAYMENT OF
CURRENT PREMIUMS SUBJECT TO THE 30-DAY GRACE PERIOD AND SECTION VIII.A OF THIS
GROUP MASTER CONTRACT.
SECTION I - DEFINITIONS
The following words and phrases when used in this Contract shall have, unless
the context clearly indicates otherwise, the meaning given to them below:
1. Contract. This Group Master Contract issued to the Contract Holder by HMO
and as subsequently amended by operation of law and as filed with and
approved by applicable public authority.
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2. Contract Holder. An employer or organization who agrees to remit the
premiums for coverage payable to HMO. The Contract Holder shall act only as
an agent of HMO Members in the Contract Holder's Group, and shall not be
the agent of HMO for any purpose.
3. Coordination of Benefits. A Coordination of Benefits (COB) provision is one
that is intended to avoid claims payment delays and duplication of benefits
when a person is covered by two or more Plans providing benefits or
services for medical, dental or other care or treatment. It avoids claims
payment delays by establishing an order in which Plans pay their claims and
providing the authority for the orderly transfer of information needed to
pay claims promptly. It avoids duplication of benefits by permitting a
reduction of the benefits of a Plan when, by the rules established by this
provision it does not have to pay its benefits first. This provision does
not apply to student accident or group hospital indemnity plans.
4. Copayment. An amount required to be paid by or on behalf of a Member in
connection with benefits set forth in Section 11 of this Contract.
5. Custodial or Domiciliary Care. Any type of care that does not meet the
requirements of post-hospital Skilled Nursing Facility Care as defined by
the Medicare Law and set forth in 42 CFR Part 409.30 et seq. Custodial care
includes but is not limited to any type of care where the primary purpose
of the total care provided is to attend to the Member's daily living
activities which do not entail or require the continuing attention of
trained medical or paramedical personnel (for example, assistance in
walking, getting in and out of bed, bathing, dressing, feeding, using the
toilet, changes of dressings of noninfected, post operative or chronic
conditions, preparation of special diets, supervision of medication which
can be self-administered by Members, general maintenance care of colostomy
or ileostomy, routine services to maintain other service which, in the sole
determination of HMO, based on medically accepted standards can be safely
and adequately self-administered or performed by the average non-medical
person without the direct supervision of trained medical or paramedical
personnel, regardless of who actually provides the service}.
6. Dependent. Any person in a Subscriber's family who meets all the
eligibility requirements of Section IV.B of this Contract, has enrolled in
HMO, and is subject to premium requirements set forth in Section X of this
Contract.
7. Detoxification. The process whereby an alcohol or drug intoxicated or
alcohol or drug dependent person is assisted, in a facility licensed by the
Department of Health, through the period of time necessary to eliminate, by
metabolic or other means, the intoxicating alcohol or drug, alcohol or drug
dependent factors or alcohol in combination with drugs as determined by a
licensed physician, while keeping the physiological risk to the patient at
a minimum.
8. Effective Date. The commencement date of coverage under this Contract as
shown on the records of HMO.
9. Emergency Service. Professional health services medically necessary
immediately to preserve life or stabilize health, available on an inpatient
or outpatient basis, 24 hours per day, seven days per week.
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10. Group. Those employees in the eligible class(es) as shown on the Cover
Sheet of this Contract who enroll in HMO and whose premiums are remitted to
HMO by the Contract Holder.
11. Health Professionals. Physicians and other professionals, including
certified nurse midwives, who are engaged in the delivery of health care
services and who are licensed if required by law.
12. Homebound Member. A Member who is confined to the home due to an illness or
injury which makes leaving the home medically contraindicated or which
restricts his ability to leave his place of residence except with the aid
of supportive devices, the use of special transportation, or the assistance
of another person.
13. Home Health Services. Those items and services defined as "home health
services" by the Medicare Law and set forth in 42 CFR Part 417.101 et seq.,
if approved and coordinated in advance by HMO and provided upon the prior
written or verbal referral and direction of the Member's Primary Care
Physician. These services include: (a) Skilled nursing services, provided
by or under the supervision of a registered professional nurse to a
Homebound Member; (b) Services of a home health aide, rendered to a
Homebound Member under the supervision of a registered professional nurse,
or if appropriate, a qualified speech or physical therapist, provided,
however, that the primary purpose of the total Home Health Services
rendered to the Member is skilled in nature; (c) Medical Social Services
rendered to a Homebound Member by or under the supervision of a qualified
medical or psychiatric social worker, in conjunction with other Home Health
Services, if the Primary Care Physician certifies that such services are
essential for the effective treatment of the Member's medical condition;
(d) short-term physical or speech therapy provided by or under the
supervision of a qualified speech pathologist or physical therapist as set
forth in Section II.H of the Group Master Contract and short-term
occupational therapy (except for vocational rehabilitation or employment
counseling) rendered by or under the supervision of a qualified
occupational therapist in connection with other Home Health Services,
provided the Member's Primary Care Physician certifies that such services
will result in significant practical improvement in Member's condition
within a sixty (60) day period.
14 Home Health Agency. Any organization certified as a home health agency
under the Medicare law or otherwise approved by HMO for the delivery of
non-physician patient care in the home of a Member.
15. Hospital. An institution rendering inpatient and outpatient services,
accredited as a Hospital by either the Joint Commission on Accreditation of
Health Care Facilities or the Bureau of Hospitals of the American
Osteopathic Association. A Hospital may be a general, acute care
institution or a specialty institution provided that, in either case, it is
appropriately accredited as aforesaid, and licensed by the proper state
authorities.
16. Hospital Services. Those services which are listed in Section II of this
Contract.
17. Medical Services. Those professional services of physicians, paramedical
personnel, certified nurse midwives and other health professionals
including medical, surgical, diagnostic, therapeutic, preventive care and
birthing facility services.
18. Medical Social Services. Services of a medical or psychiatric social worker
which are provided by Participating Providers, upon the prior written
referral of the Member's
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Primary Care Physician, to assess and assist the Member in resolving, if
possible, emotional, marital and environmental factors related to the
Member's illness, need for care, response to treatment and adjustment to
care. Medical Social Services shall also include counseling services
provided to the Member upon the prior written referral of the Member's
Primary Care Physician and the provision to the Member of information, if
available, relating to community health and social welfare agencies and
related family counseling services, of which the Member may avail himself
but which are not covered by HMO.
19. Medically Necessary or Medical Necessity. Appropriate and necessary
services as determined by HMO which are rendered to a Member for a
condition requiring, according to generally accepted principles of good
medical practice, the diagnosis or direct care and treatment of an illness
or injury and which are not provided only as a convenience.
20. Medicare Law. Title XVIII of the federal Social Security Act and all
amendments and successors thereto.
21. Member. A Subscriber or Dependent as defined in this Section.
22. Non-Hospital Facility. A facility, licensed by the Department of Health,
for the care or treatment of alcohol or drug dependent persons, except for
transitional living facilities.
23. Non-Hospital Residential Care. The provision of medical, nursing,
counseling or therapeutic services to patients suffering from alcohol or
drug abuse or dependency in a residential environment, according to
individualized treatment plans.
24. Open Enrollment Period. A period of not less than ten (10) consecutive
working days, each calendar year, when eligible employees of Contract
Holder may enroll in HMO without a waiting period or exclusion or
limitation based on health status or, if already enrolled in HMO, may
transfer to an alternative health plan offered by Contract Holder.
25. Outpatient Care. The provision of medical, nursing, counseling or
therapeutic services to a Member who does not require an overnight stay in
a hospital or non-hospital facility on a regular and predetermined
schedule, according to an individualized treatment plan.
26. Participating Gynecologist. A Specialist Gynecological Physician who has
contracted with HMO to provide annual gynecological examination services to
members. A referral from the Participating Primary Physician is not
required for this service when the Member chooses a Participating
Gynecologist that is shown on the Member's Identification Card.
27. Partial Hospitalization. The provision of medical, nursing, counseling or
therapeutic services on a planned and regularly scheduled basis in a
hospital or non-hospital facility licensed as an alcoholism or drug abuse
treatment program by the Department of Health, designed for a patient or
client who would benefit from more intensive services than are offered in
outpatient treatment but who does not require inpatient care.
28. Participating Home Health Agency. A Home Health Agency which has entered
into a contractual agreement with HMO to provide home health services as
described in
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Section II of this Contract, to Members on a per visit or otherwise agreed
upon basis.
29. Participating Hospital. A Hospital which has entered into a contractual
agreement with HMO to provide services as described in Section II of this
Contract, to Members on a per diem or otherwise agreed upon basis.
30. Participating Mental Health Provider. A licensed professional providing
diagnostic, therapeutic or psychological services who has entered into a
contractual agreement with HMO. HMO may contract with Participating Mental
Health Providers on a geographic and/or per capita basis.
31. Participating Physician. A Primary Care Physician, Specialist Physician, or
other Health Professional who has contracted with HMO to provide medical
care and services to Members.
32. Participating Provider. A Provider which or who has entered into a
contractual agreement with HMO for the provision of services to Members on
an agreed upon basis.
33. Participating Skilled Nursing Facility. A Skilled Nursing Facility which
has entered into a contractual agreement with HMO to provide skilled
nursing facility services, as described in Section II of this Contract, to
Members on a per diem or otherwise agreed upon basis.
34. Part-Time or Intermittent Services. Covered services provided to a Member
on an infrequent basis, for no more than three hours a day, three days a
week or, on occasion; for up to eight hours a day, seven days a week if
medically necessary, recommended by the Primary Care Physician for a
limited period of time, and approved in advance by HMO.
35. Physician. A duly licensed member of a medical profession, practicing
within the scope of such license.
36. Physical Therapy. Therapy using physical modalities to achieve its goals.
37. Plan/Another Plan/The Plan. Any of these which provides benefits or
services for, or because of, medical or dental care or treatment:
1. Group insurance or group-type coverage, whether insured or uninsured.
This includes prepayment, group practice or individual practice
coverage. Coverage other than school accident-type coverage and Group
hospital indemnity contracts of $100 per day or less are excluded.
2. Coverage under a governmental plan, or coverage required or provided
by law. This does not include a state plan under Medicaid (Title XIX,
Grants to States for Medical Assistance Programs, of the United States
Social Security Act, as amended from time to time). In addition, the
"Plan" shall not include a law or plan when, by law, its benefits are
excess to those of any private insurance plan or other non-government
plan.
38. Primary Care Physician. A Physician who supervises, coordinates and
provides initial care and basic medical services as a general or family
care practitioner, or in some
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cases, as an internist or a pediatrician to Members; initiates their
referral for specialist care and maintains continuity of patient care.
39. Provider. A Physician, Health Professional, Hospital, Skilled Nursing
Facility, Home Health Agency or other entity or person providing services
to Members under this Contract.
40. Skilled Nursing Facility. An institution or a distinct part of an
institution that is licensed or approved under state or local law, and
which is primarily engaged in providing skilled nursing care and related
services as a skilled nursing facility, extended care facility, or nursing
care facility approved by the Joint Commission on Accreditation of Health
Care Organizations or the Bureau of Hospitals of the American Osteopathic
Association, or as a certified skilled nursing facility under Medicare law,
or as otherwise determined by HMO to meet the reasonable standards applied
by any of the aforesaid authorities.
41. Specialist Physician. A Physician who provides medical care in any
generally accepted medical or surgical specialty or subspecialty.
42. Subscriber. A person who meets all applicable eligibility requirements of
Section IV.A of this Contract, has enrolled in HMO, and is subject to
premium requirements set forth in Section X of this Contract.
43. Substance Abuse. Any use of alcohol or drugs which produces a pattern of
pathological use causing impairment in social or occupational functioning
or which produces physiological dependency evidenced by physical tolerance
or withdrawal.
SECTION II - BENEFITS
A. Outpatient Benefits. Except in an emergency as described in Section II.G of
this Contract, the following services will be provided to Members when
medically necessary and only at or through the Primary Care Physician's
office that is shown on Member's Identification Card, or elsewhere upon
prior written referral by Member's Primary Care Physician:
1. Office visits during office hours, and during non-office hours when
medically necessary. Member is responsible for a copayment for each
such visit in the amount shown on the Copayment Schedule, as may be
amended from time to time upon filing with and approval by the
applicable public authority and agreed to by the Contract Holder,
(hereinafter the "current Copayment Schedule").
2. Home visits by Member's Primary Care Physician when medically
necessary. Member is responsible for a copayment for each home visit
in the amount shown on the current Copayment Schedule.
3. Periodic health evaluations to include:
a. Well child care from birth including immunizations and booster
doses of all immunizing agents used in child immunizations which,
as determined by the Pennsylvania Department of Health conform to
the standards of the (Advisory Committee on Immunization
Practices of the Center for disease Control), U.S. Department of
Health and
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Human Services Immunization benefits are exempt from deductible
and dollar limits;
b Routine physical examinations;
c. Pelvic examinations;
d. Routine ear and hearing examinations;
e. Routine allergy injections and immunizations (but not if solely
for the purpose of travel); and
f. Routine eye examinations;
g. For children through age 11, preventive dental care at HMO
Participating Dental Facilities, limited to:
1) Oral prophylaxis (cleaning) as necessary;
2) Topical application of fluorides and the prescription of
fluorides for systematic use when not available in the
community water supply; and
3) Oral examination and hygiene instruction.
Copayment: Member is responsible for a copayment in the amount
listed on the attached Schedule of Benefits for the Primary
Dentist Visit.
4. Diagnostic Services including laboratory and x-ray services,
laboratory specimen collection, EKGs and other diagnostic services.
a. Female members age 40 or older are entitled to one routine
mammography by a participating provider every contract year.
Member is required to obtain a referral from their participating
primary care physician to their participating provider prior to
receiving this benefit.
5. Casts and dressings.
6. Short term rehabilitation services and Physical therapy (see II.H)
when Member's Primary Care Physician certifies that these services
will result in a significant improvement in Member's condition within
a sixty (60) day period.
7. Emergency care. Member's Primary Care Physician provides or arranges
for on call coverage twenty-four (24) hours a day, seven (7) days a
week.
8. Ambulance service is provided:
a. in an emergency, but subject to the notification requirements set
forth in Section II.G of this Contract; or
b. when certified as medically necessary by Member's Primary Care
Physician and approved in advance by HMO.
9. Health education and information. Periodically health education and
health care information literature is made available to a Member at no
expense to the member.
10. Home Health Services as defined in Section I.A.13, and Hospice
services provided upon the prior written referral of the Member's
Primary Care Physician for the palliative care of a Member's terminal
illness.
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11. Infertility services. except injectables and infertility related
supplies, and other services listed in Section III.B.25.
12. Initial provision of prosthetic appliances and initial provision of
orthopedic braces, with shoes when necessary, used to treat congenital
defects. Instruction and appropriate services required for Member to
properly use the item (such as attachment or insertion). False teeth
and other items listed in Section III.B.13 are excluded.
13. Manipulative Services are available through the Participating Provider
Network upon referral from Member's Primary Care Physician or by
selecting an Osteopathic Physician who provides these services as the
Member's Primary Care Physician.
14. Medical Social Services as listed in Section II.F. Copayment. Member
is responsible for a copayment in the amount shown for Primary Care
Physician visits, routine eye exam visits and routine gynecological
visits on the current Copayment Schedule.
B. Specialist Physician Benefits. Except in an emergency as described in
Section II.G of this Contract, benefits will be provided to the Member by a
Participating Specialist Physician at his office or at a Participating
Hospital outpatient department during office or business hours upon prior
written referral by Member's Primary Care Physician. A referral for the
routine gynecological exam is not required if the Member has chosen a
Participating Gynecologist that is shown on the Member's Identification
Card. Services include but are not limited to the following:
1. Allergy Care (except routine injections, which must be administered by
Member's Participating Primary Care Physician)
2. Anesthesia
3. Cardiology
4. Endocrinology
5. Gynecology and Obstetrics
6. Internal Medicine
7. Neurology
8. Oncology
9. Ophthalmology
10. Oral Surgery (limited to bony impactions of teeth, bone fractures,
removal of tumors and orthodontogenic cysts or other HMO approved
surgical procedures)
11. Orthopedics
12. Otolaryngology
13. Pathology
14. Pediatrics
15. Pulmonology
16. Radiology (except dental x-rays, unless related to covered services)
17. Surgery
18. Urology
Copayment. Member is responsible for a copayment in the amount shown for
Specialist Physician Office Visits on the current Copayment Schedule.
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Emergency. In an emergency as described in Section II.G of this Contract,
the services listed above will be covered without prior written referral,
subject to all conditions and requirements set forth in Section II.G.
C. Inpatient Hospital & Skilled Nursing Facility Benefits. A Member who is
hospitalized by a Participating Physician upon prior written referral from
the Member's Primary Care Physician, provided the admission has been
precertified by HMO, is entitled to the following benefits when medically
necessary only at Participating Hospitals and Participating Skilled Nursing
Facilities (or at non-participating facilities upon prior written
authorization by HMO); however, Participating Skilled Nursing Facilities
benefits are limited to those which are medically necessary and which
constitute Skilled Nursing Care as defined by the Medicare law:
1. Semi-private room and board accommodations
2. Private accommodations will be provided when medically necessary upon
certification of Member's Primary Care Physician. A Member who
occupies a private room without such certification shall be directly
liable to the Hospital or Skilled Nursing Facility for the difference
between payment by HMO to the Hospital or Skilled Nursing Facility of
the per diem or other agreed upon rate for semi-private accommodation
established between HMO and the Participating Hospital or the
Participating Skilled Nursing Facility and the private room rate.
3. General nursing care
4. Use of intensive or special care facilities when medically necessary
5. X-Ray examinations including CAT scans but not dental x-rays
6. Use of operating room and related facilities
7. Magnetic resonance imaging
8. Drugs, medications, biologicals, when medically necessary
9. Cardiography/Encephalography
10. Laboratory testing and services
11. Pre- and post-operative care
12. Special tests when medically necessary
13. Nuclear medicine
14. Physical and rehabilitation therapy as provided by Section II.A.6 and
II.H of this Contract
15. Oxygen and oxygen therapy
16. Anesthesia and anesthesia services
17. Administration and processing of whole blood, blood plasma and blood
derivatives
18. Intravenous injections and solutions
19. Surgical, medical and obstetrical services provided by the
participating hospital
20. Private duty nursing when medically necessary and certified as such by
the Participating Specialist Physician in concurrence with Member's
Primary Care Physician and approved in advance by an HMO Medical
Director.
21. Non-experimental or non-investigational transplants are a covered
benefit. Transplants considered to be non-experimental or
non-investigational by HMO/PA in its sole discretion are kidney
transplants, corneal transplants, liver transplants for children with
biliary atresia, and bone marrow transplants for. certain conditions,
specifically aplastic anemia, leukemia, severe combined
immunodeficiency disease and Wiskott-Xxxxxxx Syndrome.
In addition, HMO will cover the medical and hospital services costs
and related organ acquisition costs for certain other transplants
including but not
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limited to heart, liver transplants other than for children with
biliary atresia and other organ transplants when deemed no longer
experimental or investigational by HMO in its sole discretion subject
to the grievance procedure All transplants must be ordered by Member's
Primary and Participating Specialist Physician and approved by HMO's
Medical Director in advance of the surgery. All transplants must
additionally be performed at hospitals specifically approved and
designated by the HMO to perform these procedures.
Copayment. Member is responsible for a copayment in the amount shown
for Inpatient Services on the current Copayment Schedule.
Emergency. In an emergency as described in Section II.G of this
Contract, the services listed above will be covered without prior
written referral, subject to all the conditions and requirements set
forth in Section II.G.
D. Substance Abuse Benefits
1. Outpatient. Benefits include diagnosis, medical treatment and medical
referral services by Member's Primary Care Physician for the abuse of
or addiction to alcohol or drugs.
Member is eligible for thirty (30) outpatient visits per year for
treatment of substance abuse or dependency upon referral by Member's
Primary Care Physician. Member is additionally eligible upon referral
by Member's Primary Care Physician, for up to thirty (30) more
outpatient full or equivalent partial session visits, which may be
exchanged on a two-for-one basis for up to fifteen (15) non-hospital,
residential alcohol or drug treatment days described in Paragraph 3
below. Treatment for substance abuse or dependency shall be provided
according to an individualized treatment plan, subject to a lifetime
limit of one hundred-twenty (120) visits. Benefits include: (1)
physician, psychologist, nurse, certified addictions counselor and
trained staff services; (2) rehabilitation therapy and counseling; (3)
family counseling and intervention; (4) psychiatric, psychological and
medical laboratory tests; (5) drugs, medicines, equipment use and
supplies.
2. Inpatient. Inpatient care benefits for detoxification, medical
treatment and referral services for substance abuse or addiction. The
following services shall be covered under inpatient treatment: (1)
lodging and dietary services; (2) physician, psychologist, nurse,
certified addictions counselor and trained staff services; (3)
diagnostic x-ray; (4) psychiatric, psychological and medical
laboratory testing; (5) drugs, medicines, equipment use and supplies.
3. Inpatient Non-Hospital Residential Facility. Medical, nursing,
counseling or therapeutic services for substance abuse or dependency
in a residential environment, according to an individual treatment
plan. Upon referral by Member's Primary Care Physician, Member is
eligible for thirty (30) days per year for such residential treatment
in facilities appropriately licensed by the Department of Health. This
benefit is subject to a ninety (90) day lifetime limit. The following
services shall be covered: - (1) lodging and dietary services; (2)
physician, psychologist, nurse, certified addictions counselor and
trained staff services; (3) rehabilitation therapy and counseling; (4)
family counseling and intervention; (5) psychiatric, psychological and
medical laboratory tests; (6) drugs, medicines, equipment use and
supplies.
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Copayment - Member is responsible for copayment in the amount shown
for Inpatient Non-Hospital Services on the current Copayment Schedule.
E. Mental Health Benefits. The following services are made available by the
Participating Mental Health Provider upon referral by the Member's Primary
Care Physician as may be necessary and appropriate for short term
evaluation or crisis intervention, mental health services or both.
1. Outpatient. Each Member is entitled to receive up to twenty 120)
outpatient visits during any period of 365 consecutive days to a
psychiatrist, clinical psychologist, or psychiatric social worker in
individual, group or family therapy sessions.
Copayment. Member is responsible for a copayment for each visit in the
amount shown for Outpatient Mental Health Visits on the current
Copayment Schedule attached to this Contract. A visit is 45-60 minutes
of therapy.
2. Inpatient. A Member is entitled to receive up to thirty-five (35) days
of inpatient care for the treatment of mental or nervous disorders
during any period of 365 consecutive days upon referral by Member's
Primary Care Physician or if provided or arranged for by the
Participating Mental Health Provider. Any inpatient stay without a
prior referral or which is not arranged by the Mental Health Provider
is a non-covered service under this Contract.
Copayment. Member is responsible for a copayment in the amount shown
for Inpatient Services on the current Copayment Schedule.
F. Medical social services and other health services to include:
1. pre- and post-hospital planning;
2. referral to (but not payment for) community health and social welfare
agency services;
3. referral to (but not payment for) related family counseling services
except as specified in Section II.D.
4. referral to family planning services, and referral to and payment for
services of appropriate agencies as necessary; and
5. referral to appropriate Specialists and payment for infertility
services except injectables and infertility related supplies.
G. Emergency Care Benefits - Within and Outside the HMO Service Area.
1. HMO will reimburse Member for the reasonable cost as determined by HMO
of emergency medical and hospital services performed within or outside
the HMO service area by non-participating providers without prior
written referral only if:
a. The service rendered is provided as a benefit under this Contract
and is not a service which is normally treated on a non-emergency
basis; and
b. HMO and Member's Primary Care Physician are notified within 24
hours of the emergency service and HMO is furnished with written
proof of the occurrence, nature and extent of the emergency
services within 30 days of the date that services were rendered.
Failure to
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immediately notify or to furnish written proof within 30 days
will not invalidate or reduce any claim for reimbursement if HMO
determines that Member's failure to do so was reasonable under
the circumstances, but in no event shall reimbursement be made
until HMO receives proper written proof; and
c. The HMO's medical review determines that the Member's symptoms
were severe, occurred suddenly, and immediate medical attention
was sought by Member. Conditions which require immediate
treatment include the following:
1. uncontrolled or excessive bleeding
2. acute pain or conditions requiring immediate attention, such
as suspected heart attack, severe shortness of breath or
appendicitis
3. serious xxxxx
4. poisoning
5. convulsions
6. unconsciousness
2. Reimbursement. HMO may limit reimbursement to the reasonable cost as
determined by HMO for emergency services by a non-participating
provider, located either within or outside the HMO service area, to
those expenses which are incurred up to the time the Member is
determined to be medically able to travel or to be transported to an
HMO Participating Provider. In the event that transportation is
medically necessary, Member will be reimbursed for the reasonable cost
as determined by HMO of same. Reimbursement may be subject to payment
by Member of all copayments which would have been required had similar
benefits been provided during office hours and upon prior written
referral to a Participating Provider.
3. Copayments. Member is responsible for a copayment for each emergency
visit to a physician's office and a copayment for each emergency visit
to a hospital outpatient department or emergency room in the amount
shown on the then current Copayment Schedule. The copayment for an
emergency room visit will not apply in the event that Member was
referred for such visit by the Member's Primary Care Physician for
services that could have been rendered in the Primary Care Physician's
office.
X. Rehabilitation Benefits.
1. Speech Therapy
Speech therapy benefits are available on a short term basis. The
benefit consists of treatment within a 60 day period per incident of
illness, beginning with the first day of treatment, if the Member's
Primary Care Physician certifies that the treatment will result in a
significant improvement of the Member's condition within this time
period and treatment is approved by HMO's Medical Director.
2. Physical Therapy
Physical therapy benefits are available on a short term basis. The
benefit consists of treatment within a 60 day period per incident of
illness, beginning with the first day of treatment, if the Member's
Primary Care Physician certifies that the treatment will result in a
significant improvement
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of the Member's condition within this time period and treatment is
approved by HMO's Medical Director.
3. Occupational Therapy
Occupational therapy benefits are available on a short term basis. The
benefit consists of treatment within a 60 day period per incident of
illness, beginning with the first day of treatment, if the Member's
Primary Care Physician certifies that the treatment will result in a
significant improvement of the Member's condition within this time
period and treatment is approved by HMO's Medical Director.
4. Cardiac Rehabilitation
Cardiac Rehabilitation benefits are available only as part of the
Member's inpatient stay.
5. Pulmonary Rehabilitation
Pulmonary Rehabilitation benefits are available on a short-term basis.
The benefits consist of treatment within a sixty (60) day period per
incident of illness beginning with the first day of treatment. The
Member's Primary Care Physician must certify that the treatment will
result in a significant improvement of the Member's condition within
this time period. The treatment must be approved by the HMO's Medical
Director.
6. Cognitive Therapy
Cognitive therapy benefits are available on a short-term basis. The
benefits consist of treatment within a sixty (60) day period per
incident of illness beginning with the first day of treatment. The
Member's Primary Care Physician must certify that the treatment will
result in a significant improvement of the Member's condition within
this time period. The treatment must be approved by HMO's Medical
Director.
SECTION III -- EXCLUSIONS AND LIMITATIONS
A. In the event that alternative medical services can be provided to a
Member that are equal in the quality of care to be provided, HMO
reserves the right to provide coverage only for the least costly
medical service, as determined by HMO, provided that the medical
service is approved in advance by HMO as a medically appropriate
alternative service.
B. The following are not benefits under this Contract:
1. Any service obtained by or on behalf of a Member without prior
written referral by the Member's Primary Care Physician except in
an emergency situation as described in Section II.G of this
Contract.
2. Plastic or cosmetic surgery (including, but not limited to ear
piercing, rhinoplasty, gynecomastia and reduction mammoplasty)
and surgery or treatment relating to the consequences as a result
of plastic surgery. This exclusion does not apply to surgery to
correct the! results of injuries or congenital defects necessary
to restore normal bodily functions.
3. Unless otherwise stated in this Contract, all dental services
related to the care, filling, removal or replacement of teeth and
treatment of injuries to or
HMO/PA Group Master Contract Page 14
diseases of the teeth, gums and temporomandibular joint,
including but not limited to apicoectomy (dental root resection),
orthodontics, root canal treatment, soft tissue impactions,
temporomandibular joint dysfunction therapy, alveolectomy and
treatment of periodontal disease.
4. Investigational, Ineffective or Experimental surgical or medical
treatments or procedures, research studies, or other experimental
health care procedures including, but not limited to, cancer
chemotherapy protocols, AIDS clinical trials, and I.V. therapies
unless approved by an HMO Medical Director prior to the treatment
being rendered, subject to Section IX.B.
5. Treatment of military service related diseases, disabilities or
injuries for which Member is legally entitled to receive
treatment at government facilities and which facilities are
reasonably available to Member (within a two to three hour drive
time). This exclusion does not apply to the care and treatment of
newborn children as provided under Section VI.B. of this
Contract.
6. Coverage of a non-HMO donor in a transplant procedure unless the
recipient of the transplant is an HMO Member. In the event an HMO
Member is the recipient, coverage will be provided under this
Contract for a live non-HMO donor to the extent benefits are
unavailable from any other source.
7. Except as provided in Section II.C.21., all experimental organ
transplants and procedures and services associated with the
preparation of such transplants.
8. Payment for benefits for which Medicare is the primary payer.
9. Treatment of mental retardation, defects and deficiencies. This
exclusion does not apply to mental health services as described
in Section II.E. or to medical treatment of retarded Members in
accordance with the benefits provided in Section II.
10. Care for conditions that state or local law requires to be
treated in a public facility, including but not limited to mental
illness commitments.
11. Provision of blood, blood plasma, blood derivatives or the cost
of receiving the services of professional blood donors. Only
administration and processing of blood is covered.
12. Routine reduction of nails, calluses and corns which are not
medically necessary.
13. Except as provided in Section II.A. 12 of this Contract,
provision or re placement of the following items are excluded:
arch supports hearing aids
braces TENS units
canes traction apparatus
cervical collars walkers
corrective shoes wheelchairs
corsets other Durable Medical
crutches Equipment (DME), special
elastic hose appliances, supplies or
HMO/PA Group Master Contract Page 15
false teeth equipment
14. Provision of personal convenience items or services such as
telephones, xxxxxx services. guest meals, radio and television
rentals, and other like items and services.
15. Custodial or domiciliary care (as defined in Section I).
16. Weight reduction programs except as provided by HMO.
17. Drugs and medicine except as provided by Section II.C.8 and
Section II.D. of this Contract.
18. Special medical reports not directly related to treatment of the
Member; e.g., employment physicals.
19. Private duty or special nursing care except as provided in
Section II.C and specifically approved in advance by an HMO
Medical Director.
20. Payment for services which are eligible for payment under the
provisions of an automobile insurance contract or pursuant to any
federal or state law which mandates indemnification for such
services to persons suffering bodily injury from motor vehicle
accidents, where permitted by state law.
21. Therapy or rehabilitation, except as provided by Section II.H of
this Contract.
22. Chronic alcoholism or drug addiction treatment, except as
provided by Section II.D of this Contract.
23. Reversal of voluntary sterilization and related follow-up care.
24. Transsexual surgery or related services.
25. InVitro fertilization procedures, related services, infertility
injectables or other supplies, except as provided by Section
II.A.11 of this Contract.
26. Immunizations obtained for the sole purpose of travel.
27. Costs related to any court appearance, proceeding or hearing.
28. Payment for benefits which are compensable under any workmen's
compensation or occupational illness law are not covered services
under this Contract.
29. Surgical operations or procedures for treatment of obesity,
including but not limited to gastric stapling or balloon
procedures, unless medically necessary as determined by an HMO
Medical Director.
30. Orthoptics (a technique of eye exercises designed to correct the
visual axes of eyes not properly coordinated for binocular
vision).
31. All non-surgical medical services, diagnostic or therapeutics
related to temporomandibular joint dysfunction.
HMO/PA Group Master Contract Page 16
DETERMINATIONS REGARDING DENIAL OF BENEFITS DUE TO INAPPROPRIATE USE OF THE HMO
NETWORK ARE AT THE SOLE DISCRETION OF THE HMO.
SECTION IV - MEMBERSHIP ELIGIBILITY REQUIREMENTS
A. Subscriber Eligibility. To be eligible to enroll as a Subscriber, a person
must be:
1. An employee of the Contract Holder eligible on his or her own behalf
to participate in or currently enrolled in a health care plan offered
by Contract Holder to the Group; and
2. a resident in the HMO service area.
B. Dependent Eligibility.
1. To be eligible to enroll as a Dependent, a person must be: a) the
spouse of a Subscriber under this Contract; or b) a dependent
unmarried child [includes natural, xxxxxx, step and legally adopted
children and proposed adoptive children) residing in the HMO service
area who is the age described in the current Schedule of Benefits.
2. Newborn children will be treated as Dependents from birth. This is
subject to enrollment requirements in Section VI.B.
C. Change of Group Eligibility Rules. The eligibility of the Group, the
composition of the Group and the eligibility requirements used to determine
membership in the Group which exist at the effective date of this Contract
are material to the execution of this Contract by HMO. No change in the
eligibility or participation requirements of the Group shall be permitted
to affect eligibility or enrollment under this Contract unless such change
is agreed to by HMO and the Contract Holder, and is not otherwise contrary
to applicable state laws, rules or regulations. Breach of this provision is
considered a material breach of this Contract and may be the basis for
termination under Section XII.B.3.
SECTION V - ENROLLMENT AND ENROLLMENT ELIGIBILITY DATES
A. Enrollment Procedure Any person who satisfies the membership eligibility
requirements described in Section IV is eligible to enroll in HMO in
accordance with Subsection B, below by submitting a completed HMO
enrollment application form to HMO.
B. Enrollment Eligibility Date. The Enrollment Eligibility Date is the date
that a person who satisfies the membership eligibility requirements
described in Section IV is eligible to enroll in HMO.
1. The Enrollment Eligibility Date for any person who satisfies the
membership eligibility requirements described in Section IV on the
Effective Date of this Contract shall be the same date as the
Effective Date of the Contract.
2. The Enrollment Eligibility Date for any person who first satisfies the
membership eligibility requirements described in Section IV after the
Effective
HMO/PA Group Master Contract Page 17
Date of this Contract shall be the first Premium Due Date following
the date that such person satisfied the membership eligibility
requirements.
SECTION Vl - EFFECTIVE DATE OF COVERAGE
A. Effective Date of Coverage Other Than of a Newborn Child. Subject to
payment of applicable premiums as provided by Section X and in accordance
with the applicable provisions and conditions of this Contract, the
effective date of a Member's coverage hereunder is:
1. The Member's Enrollment Eligibility Date (Section V.B above) provided
that his or her completed HMO enrollment application form is received
by HMO within thirty-one (31 ) days of the Member's Enrollment
Eligibility Date; or
2. If a completed HMO enrollment application form is not received by HMO
within thirty-one (31 ) days of the Member's Enrollment Eligibility
Date (Section V.B), the effective date of Member's coverage is the
next Open Enrollment Period during which Member's completed HMO
enrollment application form is received by HMO, unless such member and
dependents have lost medical coverage due to spouse's layoff or
termination of employment.
Employees must apply within thirty-one (31) days of the layoff or
termination of employment and submit evidence of: 1) former medical
coverage through the spouse's employer; and 2) termination of
employment from the spouse's employer.
B. Effective Date of Coverage of a Newborn Child. Coverage of a newborn child
of a Member is effective at the time of birth and shall automatically
extend for a period of 31 days following birth. Coverage shall include
sickness or injury, including medically diagnosed congenital defects, birth
abnormalities, prematurity, and routine nursery care. The Subscriber shall
have the right, within the 31 day period following the birth of the newborn
child, to continue coverage for the child beyond the 31 day period by
enrolling the newborn child as a Dependent Member in HMO, provided that the
Member eligibility requirements as described in Section IV are satisfied,
all premium payments required by Section X are paid for said child, and a
completed HMO enrollment application form, specifically naming the newborn
child to be added, is received by HMO within 31 days following the birth of
the child.
SECTION VII - TERMINATION OF COVERAGE
Coverage of a Member or Members under this Contract will terminate under any of
the following conditions, and termination will be effective on the date
indicated, subject to the conversion privilege in Section VIII of this Contract,
when applicable:
A. In the event that a Subscriber ceases to meet the eligibility requirements
of Section IV.A of this Contract, coverage of Subscriber and Subscriber's
Dependents who are Members, if any, will terminate on the next premium due
date following the date on which the Subscriber ceased to meet the
eligibility requirements.
HMO/PA Group Master Contract Page 18
B. In the event that a Subscriber's Dependent who is a Member pursuant to this
Contract ceases to meet the eligibility requirements of Section IV.B of
this Contract, coverage of such Dependent will cease on the next premium
due date following the date on which the Dependent ceased to meet the
eligibility requirements of Section IV.B.
C. In the event that Group coverage under this Contract terminates pursuant to
Section XII, coverage of all Members under this Contract will terminate as
provided in Section XII.
D. In the event that Subscriber or Subscriber's Dependents who are Members
pursuant to this Contract, if any, fails to make any contribution or
copayment required under this Contract, coverage of Subscriber and
Subscriber's Dependents, if any, will terminate thirty (30) days after
written notice is given to the Subscriber and Contract Holder by HMO of
such failure. At the effective date of such termination, prepayments
received by HMO on account of such terminated Member or Members for periods
after the effective date of termination shall be refunded to Contract
Holder, and HMO shall have no further liability or responsibility with
respect to such Member or Members under this Contract.
E. In the event that a Subscriber becomes covered under an alternative health
benefit plan or under any other plan which is offered by, through or in
connection with the Group in lieu of coverage under this Contract, coverage
of Subscriber and Subscriber's Dependents who are Members pursuant to this
Contract. if any, will terminate under this Contract, effective the date
alternate coverage begins.
F. In the event that a Member acts fraudulently or makes a material
misrepresentation in applying for or obtaining coverage or benefits under
this Contract, or misuses the HMO Identification Card, including but not
limited to allowing or assisting a person other than the Member named on
the Identification Card to obtain HMO benefits, Member's coverage under
this Contract shall be terminated effective immediately upon written
notice. In the absence of fraud or material misrepresentation, all
statements made by any Member or any person applying for coverage under the
Contract will be deemed representations and not warranties. No statement
made for the purpose of obtaining coverage will result in the termination
of coverage or reduction of benefits unless the statement is contained in
writing and signed by the Member, and a copy of same has been furnished to
Member prior to termination.
G. In the event a Member refuses upon request to cooperate and provide any
facts necessary for HMO to administer its Coordination of Benefits or
recovery provisions set forth herein, the coverage of such Member may be
terminated upon thirty (30) days written notice by the HMO.
H. In the event that HMO or Participating Providers, after reasonable efforts,
are unable to establish and maintain what it and Member agree to be a
satisfactory relationship with each other, then the rights of such Member
under this Contract may be terminated on not less than thirty (30) days'
written notice to Member and Contract Holder, subject to the Grievance
Procedure described in Section IX.M. At the effective date of such
termination, prepayments received on account of such terminated Member or
Members for periods after the effective date of termination shall be
refunded to the Contract Holder, and HMO shall have no further liability or
responsibility under this Contract with respect to such Member or Members.
HMO/PA Group Master Contract Page 19
I. In the event the coverage of a Subscriber terminates for any reason listed
in this Section, coverage of Subscriber's dependents who are Members
pursuant to this Contract, if any, will also terminate.
SECTION VIII - CONTINUATION AND CONVERSION
A. Continuation
1. Any Member who is receiving inpatient care in a hospital or skilled
nursing facility on the date coverage under this Contract terminates
is covered in accordance with the Contract until the earlier of i)
when discharged from such inpatient stay, or ii) determination by the
attending physician that care in the hospital or skilled nursing
facility is no longer medically indicated, or iii) when the
contractual benefit has been reached.
2. The continuation of coverage rules of this section, VIII A.2., do not
apply to any Contract Holder who normally employed fewer than 20
employees on a typical business day during the preceding calendar
year. This exception applies to the number of employees employed, not
the number of employees covered by a health plan, and includes
full-time and part-time employees.
If a Member's coverage terminates due to termination of Subscriber's
employment (other than by reason of Subscriber's gross misconduct) or
reduction of hours of Subscriber's employment, Member may elect to
continue coverage for 18 months after eligibility for coverage under
this Contract would otherwise cease.
If Member's coverage terminates due to a) divorce or legal separation,
b) Subscriber's death, c) Subscriber's entitlement to Medicare
benefits, or d) cessation of dependent child status under Section
IV.B. of this Contract, Member may elect to continue coverage for 36
months after eligibility for coverage under this Contract would
otherwise cease.
Continuation coverage ends at the earliest of the following events:
a. The last day of the 18-month period.
b. The last day of the 36-month period.
c. The first day on which timely payment of premium is not made
subject to Section X.A..
d. The first day on which the Contract Holder ceases to maintain any
group health plan.
e. The first day on which a Member is actually covered by any other
group health plan. In the event the Member has a pre-existing
condition, and the Member would be denied coverage under the new
plan for a pre-existing condition, continuation coverage will not
be terminated until the last day of the 18-month continuation
period, or the date upon which the Member's pre-existing
condition becomes covered under the new plan, whichever occurs
first.
f. The date the Member is entitled to Medicare.
g. The date the Member no longer resides in the service area.
The 18-month coverage period may be extended if an event which would
otherwise qualify the Member for the 36 month coverage period occurs
HMO/PA Group Master Contract Page 20
during the 18-month period, but in no event may coverage be longer
than 36 months from the event which qualified the Member for
continuation coverage initially.
In the event a Member becomes disabled within the meaning of the
Social Security Act, and notifies the employer before the end of the
initial 18-month period, continuation coverage may be extended up to
an additional 11 months for a total of 29 months. This provision is
limited to members who are disabled at the time of their qualifying
event and only when the qualifying event is the employees reduction in
hours or termination. The member may be charged a higher rate for the
extended period.
Contract Holder is responsible for providing the necessary
notification to Members as required by the Consolidated Omnibus Budget
Reconciliation Act of 1985 and the Tax Reform Act of 1986. Coverage
for the sixty (60) day period will be extended only where the
Subscriber or Dependent pays the applicable premium charges due within
forty-five (45) days of submitting the application to the Contract
Holder and Contract Holder in turn remitting same to HMO.
Premiums payable to HMO for the continuation of coverage under this
Section shall be due in accordance with the procedures of Section X
and shall be calculated in accordance with applicable federal law and
regulations.
B. Conversion to Individual Coverage. Conversion is not initiated by HMO. The
conversion privilege set forth in this Section must be initiated by the
eligible Member. The Contract Holder is responsible for giving notice of
the conversion privilege in accordance with its normal procedures; however,
in the event continuation coverage ceases pursuant to Section VIII.A.2(a)
or (b), Contract Holder shall notify Member at some time during the 180-day
period prior to the expiration of coverage.
1. Eligibility.
In the event a Member ceases to be eligible for coverage under this
Contract, he or she may, within thirty-one (31) days after termination
of coverage under this Contract, convert to individual membership in
HMO, effective as of the date of such termination, provided that
Member's coverage under this Contract terminated for one of the
following reasons:
a. The Group coverage under this Contract terminated and was not
replaced with continuous and similar coverage by the Contract
Holder; or
b. Subscriber ceased to meet the eligibility requirements of Section
IV.A of this Contract, in which case Subscriber and Subscriber's
Dependents who are Members pursuant to this Contract, if any, are
eligible to convert; or
c. A Dependent ceased to meet the eligibility requirements of
Section IV.B of this Contract because of his or her age or the
death or divorce of Subscriber; or
d. Continuation coverage ceased under subsection (a) or (b) of
Section VIII.A.2 of this Contract.
Any Member who is eligible to convert to individual membership, may do
so in accordance with the rules and regulations governing such items
as initial
HMO/PA Group Master Contract Page 21
payment, the form of the agreement and all terms and conditions
thereunder as HMO may have in effect at the time of Member's
application for conversion, without furnishing evidence of
insurability.
SECTION IX - GENERAL PROVISIONS
A. Identification Card. The Identification Card issued by HMO to Members
pursuant to this Contract is for identification purposes only. Possession
of an HMO Identification Card confers no right to services or benefits
under this Contract, and misuse of such identification card may be grounds
for termination of Member's coverage pursuant to Section VII.F of this
Contract. If the Member who misuses the card is the Subscriber, coverage
may be terminated for the Subscriber as well as any of the Subscriber's
Dependents who are Members. To be eligible for services or benefits under
this Contract, the holder of the card must be a Member on whose behalf all
applicable premium charges under this Contract have been paid. Any person
receiving services or benefits which he or she is not entitled to receive
pursuant to the provisions of this Contract shall be charged for such
services or benefits at prevailing rates.
If any Member permits the use of his or her HMO Identification Card by any
other person, such card may be retained by HMO, and all rights of such
Member and his or her Dependents, if any, pursuant to this Contract shall
be terminated immediately, subject to the Grievance Procedure set forth in
Section IX.M of this Contract.
B. Medical Necessity and Appropriateness. Members will receive designated
benefits under the Contract only when medically necessary and appropriate.
HMO may determine whether any benefit provided under the Contract was
medically necessary and appropriate, and HMO has the option to select the
appropriate Participating Hospital to render services if hospitalization is
necessary. Decisions as to medical necessity are subject to review by the
Quality Assurance Committee of HMO or its physician designee. HMO will not,
however, seek reimbursement from an eligible Member for the cost of any
benefit provided under the Contract that is later determined to have been
medically unnecessary and inappropriate, when such service is rendered by
the primary care physician or a provider referred by the primary care
physician without notifying the member that such benefit would not be
covered under the contract.
C. Hospital Rules. Members are subject to all the rules and regulations of
each hospital and other facility in which benefits are provided.
D. Reports and Records. HMO is entitled to receive from any provider of
services to Member, information reasonably necessary to administer this
Contract subject to all applicable confidentiality requirements as defined
in Section IX.L of this Contract. By accepting coverage under this
Contract, Subscriber, for himself or herself, and for all Dependents
covered hereunder, authorizes each and every provider who renders services
to Member hereunder to disclose all facts pertaining to the care, treatment
and physical condition of Member and render reports pertaining to same to
HMO upon request and to permit copying of Member's records by HMO.
E. Refusal of Treatment. A Member may, for personal reasons, refuse to accept
procedures, medicines, or courses of treatment recommended by a
Participating Physician. If such Participating Physician (after a second
Participating Physician's opinion, if requested by Member), believes that
no professionally acceptable alternative exists, and if after being so
advised, Member still refuses to follow the
HMO/PA Group Master Contract Page 22
recommended treatment or procedure, neither the Physician, nor HMO,
Participating Hospital, Participating Skilled Nursing Facility or
Participating Home Health Agency will have further responsibility to
provide any of the benefits available under this Contract for treatment of
such condition or its consequences or related conditions. HMO will provide
written notice to Member of a decision not to provide further benefits for
a particular condition. The decision is subject to the Grievance Procedure
set forth in Section IX.M of this Contract. Treatment for the condition
involved will be resumed in the event Member agrees to follow the
recommended treatment or procedure.
F. Assignment of Benefits. All rights of Members to receive benefits hereunder
are personal to Member and may not be assigned.
G. Legal Action. No action at law or in equity may be maintained against HMO
for any expense or bill unless brought within the statute of limitations
for such cause of action.
X. Independent Contractor Relationship.
1. No Participating Provider or other provider, institution, facility or
agency is an agent or employee of HMO. Neither HMO nor any employee of
HMO is an agent or employee of any Participating Provider or other
provider, institution, facility or agency.
2. Neither the Group nor the Contract Holder nor a Member is the agent or
representative of HMO, its agents or employees, or an agent or
representative of any Participating provider or other person or
organization with which HMO has made or hereafter shall make
arrangements for services under this Contract.
3. Participating Physicians maintain the physician-patient relationship
with Members and are solely responsible to Member for all medical
services which are rendered by Participating Physicians.
I. Coordination of Benefits With Other Group Health Plans. None of these
coordination of benefits rules will serve as a barrier to the Member first
receiving direct health services from HMO which are covered under this
Contract.
The rules establishing the order of benefit determination between this
Contract and any other plan covering the Member are as follows:
1. The benefits of a plan which does not have a coordination of benefits
with other health plans provision shall in all cases be determined
before the benefits of this Contract.
2. For those plans which have applicable Coordination of Benefit clauses,
the following rules will apply:
a. The benefits of a plan which cover the Member as other than
dependent will be determined before the benefits of a plan which
cover the Member as a dependent;
b. Except as stated in subparagraph (c) below, when a plan and
another plan cover the same child as a dependent of different
parents:
HMO/PA Group Master Contract Page 23
1) The benefits of the plan of the parent whose birthday falls
earlier in a year are determined before those of the plan of
the parent whose birthday falls later in that year; but
2) If both parents have the same birthday, the benefits of the
plan which covered the parent longer are determined before
those of the plan which covered the other parent for a
shorter period of time;
3) If the other plan does not have the rule described above,
but instead has a rule based upon the gender of the parent,
and if, as a result, the plans do not agree on the order of
benefits, the rule in the other plan will determine the
order of benefits;
4) The word "birthday" refers only to the month and day in a
calendar year, not the year in which the person was born.
c. If two or more plans cover a person as a dependent child of
divorced or separated parents, benefits for the child are
determined in this order:
1) First, the plan of the parent with custody of the child;
2) Then, the plan of the spouse of the parent with custody of
the child;
3) Finally, the plan of the parent not having custody of the
child; and
4) If the specific terms of a court decree state that one of
the parents is responsible for the health care expenses of
the child, and the entity obligated to pay or provide the
benefits of the plan of that parent has actual knowledge of
those terms, the benefits of that plan are determined first.
d. The benefits of a plan which covers a person as an employee who
is neither laid-off nor retired (or as that employee's dependent)
are determined before those of a plan which covers that person as
a laid-off or retired employee (or as that employee's dependent).
If the other plan does not have this rule and if, as a result,
the plans do not agree on the order of benefits, this rule (d)
shall be ignored;
e. If none of the above rules determine the order of benefits, the
benefits of the plan which covered an employee, Member, or
Subscriber longer are determined before those of the plan which
covered that person for a shorter time.
3. If a Member who has enrolled under this Contract is entitled to
maternity benefits under another contract or policy of insurance (such
as extended benefits for pregnancies which began while the Member was
enrolled under a previously held policy), HMO will pay, subject to
Copayments under this Contract, the difference between entitlements
under this Contract and entitlements under the other contract or
policy of insurance.
4. Member agrees to permit HMO to coordinate its obligations under this
Contract with payment under any other contract or policy of insurance
that covers Member.
HMO/PA Group Master Contract Page 24
5. For purposes of these provisions, HMO may release to or obtain from
any insurance company or other organization any necessary information,
subject to applicable confidentiality requirements, as defined in
Section IX.L of this Contract. Any Member claiming benefits under this
Contract must furnish to HMO all information deemed necessary by it to
implement this provision.
J. Third Party Liability. With regard to any benefit to a Member under this
Contract, unless unenforceable or prohibited by statute or regulation, HMO
may subrogate and succeed to the Member's right of recovery against any
person or organization. Each Member is required to answer all questions
submitted by HMO concerning any accident, illness or injury, and also to
execute and deliver such instruments and take such actions as HMO may
require to exercise its right of subrogation.
K. Inability to Provide Service. In the event that due to circumstances not
within the reasonable control of HMO, including but not limited to major
disaster, epidemic, complete or partial destruction of facilities, riot,
civil insurrection, disability of a significant part of HMO's Participating
Providers or entities with whom HMO has arranged for services under this
Contract, or similar causes, the rendition of medical or hospital benefits
or other services provided under this Contract is delayed or rendered
impractical, HMO shall not have any liability or obligation on account of
such delay or failure to provide services, except to refund the amount of
the unearned prepaid premiums held by HMO on the date such event occurs.
HMO is required only to make a good-faith effort to provide or arrange for
the provision of service, taking into account the impact of the event.
L. Confidentiality. Information contained in the medical records of Members
and information received from physicians, surgeons, hospitals or other
health professionals incident to the physician-patient relationship or
hospital-patient relationship shall be kept confidential; and except for
use incident to bona fide medical research and education as may be
permitted by law, or reasonably necessary in connection with the
administration of this Contract, or in the compiling of aggregate
statistical data, may not be disclosed without the consent of the Member.
M. Grievance Procedure.
1. Under the provisions of the Pennsylvania HMO Act and Department of
Health Regulations, HMO has promulgated written Grievance Resolution
Procedures (the "Procedures") for use by Members in the event of any
breach of this Contract by HMO or any dissatisfaction, problem or
claim arising from HMO services, benefits or Participating Providers.
Said Procedures are available upon request to any Member or Contract
Holder.
2. In summary form, said Procedures require a Member having an injury,
problem or claim to contact the HMO by telephone or in writing. HMO
will provide a Member requesting specific corrective action with a
decision within 45 days of receipt of the request except where
additional information is necessary. HMO's decision shall become final
and binding unless a formal grievance is filed by the Member within 60
days of the date of the decision. A Grievance Committee shall review
and investigate each grievance within 30 days of receipt unless
additional information necessary to resolve the grievance is not
received during such time. The written decision regarding the
grievance will specify the reasons for the decision and the Member's
appeal rights. The decision of the Grievance Committee shall become
final
HMO/PA Group Master Contract Page 25
and binding unless the Member appeals to the Grievance Appeal
Committee within 30 days of the date of the decision. The Grievance
Appeal Committee, which will be comprised of no less than one-third
HMO members, will hold an informal hearing to consider the appeal. The
Member has a right to attend the hearing, but may choose not to do so.
Upon submission of an appeal, HMO will provide the Member with a copy
of the hearing procedures. The Grievance Appeal Committee will issue a
decision within 10 days of the conclusion of the hearing. The decision
of the Grievance Appeal Committee shall be final and binding unless
the Member appeals to the Department of Health. At each step of the
foregoing process, the Member should be as specific as possible as to
remedy being sought from HMO. In situations involving emergency or
urgently needed care, the Member should so notify HMO so it may handle
the inquiry or grievance under special expedited procedures.
3. Said Procedures are subject to modification or supplementation by
order or direction of the Department of Health. Members have the right
to have an uninvolved HMO representative assist them in understanding
the grievance process.
4. Said Procedures are mandatory and must be exhausted prior to the
filing of an appeal with the Department of Health prior to the
institution of any litigation in court or arbitration regarding either
any alleged breach of this Contract by HMO or the subject matter of
any inquiry, grievance or grievance appeal.
5. The Bureau of Health Financing & Program Development in the
Pennsylvania Department of Health, Room 1026 Health & Welfare
Building, P.O. Box 90, Harrisburg, PA 17108-0090, (000) 000-0000, is
responsible for monitoring HMO's compliance with said Procedures.
N. Clerical Records
1. HMO shall maintain records of the Members.
2. The Group shall forward the information required by HMO in Section XI
of this Contract in connection with the administration of this
Contract.
3. All records of the Group which are incident to the coverage provided
under this Contract shall be available for inspection by HMO at any
reasonable time.
4. HMO shall not be liable for the fulfillment of any obligation
dependent upon such information prior to its receipt in a form
satisfactory to HMO.
5. Incorrect information furnished to HMO may be corrected, provided that
HMO has not acted to its prejudice in reliance thereon. Coverage under
this Agreement shall not be invalidated by failure of the Group due to
clerical error, provided all premiums are properly adjusted and HMO,
in its sole discretion, determines that a clerical error has been
made. However in no case will any changes, additions, or deletions in
HMO's Member list be made effective more than two (2) Premium Due
Dates prior to the date HMO is notified, in a written form
satisfactory to HMO, of the requested change, addition, or deletion.
O. Limitation on Services. Except in cases of emergency as provided under
Section II.G of this Contract, services are available only from
Participating Providers. HMO shall have no liability or obligation
whatsoever on account of any service or benefit
HMO/PA Group Master Contract Page 26
sought or received by a Member from any Physician, Hospital, Skilled
Nursing Facility, Home Health Agency or other person, entity, institution
or organization unless prior arrangements are made by HMO.
SECTION X - PREMIUMS
A. Premiums are payable to HMO on or in advance of each Premium Due Date at
the corporate offices of HMO unless otherwise specified by HMO in writing.
The payment of any premium shall not maintain coverage under this Contract
in force beyond the date when the next premium becomes payable; however, a
thirty (30) day grace period, during which time this Contract will remain
in force, shall be granted for payment of each premium after the first. The
Contract Holder shall remain liable for i) the payment of the premium for
the time coverage was in effect during the grace period, ii) the member
shall remain liable for copayments owed.
B. HMO, upon approval of the State Insurance Department, reserves the right to
fix new premium rates under this Contract at the end of each rate term.
Notice of any new premium rates shall be given to the Contract Holder at
least thirty (30) days prior to the date specified by HMO in order for the
rates to become effective. Payment of the new rate shall be deemed receipt
of notice and acceptance of change in rate.
SECTION XI - GROUP PERSONNEL DATA
A. The Contract Holder shall furnish to HMO each month during the period of
this Contract, on forms approved by HMO, such information as may reasonably
be required for the purpose of enrolling Members of the Group under this
Contract, processing terminations, and effecting changes in family status
and transfer of employment of Members. HMO shall furnish to the Contract
Holder such information concerning enrollment of Members and other matters
as it may reasonably require. Contract Holder is responsible for providing
written notice to the Members of the conversion privilege within 15 days
before or after termination of coverage under this Contract, unless
continuation coverage ceases pursuant to Section VIII.A. (2)(a) or (b), in
which case Contract Holder shall notify Member prior to expiration of the
continuation coverage.
B. Clerical errors or delays in keeping or reporting data relative to coverage
will neither invalidate coverage which would otherwise be in force nor
continue coverage which would otherwise be validly terminated if HMO, in
its sole discretion, determines that a clerical error has been made. Upon
discovery of such errors or delay, an adjustment of charges shall be made.
This provision notwithstanding, in no case will adjustments in coverage or
rates be made effective more than two (2) Premium Due Dates prior to the
date HMO is notified in writing, on a form satisfactory to HMO, of the
requested addition, deletion, or change in coverage.
HMO/PA Group Master Contract Page 27
SECTION XII - TERMINATION OF GROUP COVERAGE AND RENEWAL
A. This Contract may be terminated by HMO or Contract Holder on any premium
due date by giving thirty (30) days' prior written notice.
B. This Contract may be terminated by HMO at any time under the following
circumstances:
1. By giving thirty (30) days' prior written notice to Contract Holder if
Contract Xxxxxx is guilty of fraud or material misrepresentation of
fact in obtaining coverage hereunder: or
2. Upon default in the payment of premiums required under Section X of
this Contract, subject to the thirty (30) day grace period described
in X.A or if the Contract Holder becomes insolvent, files a petition
in bankruptcy, files a petition seeking any reorganization,
arrangement, composition or similar relief under any federal or state
law regarding insolvency or relief for debtors, or makes an assignment
for the benefit of creditors or similar undertaking, or if a receiver,
trustee, or similar officer is appointed for the business or property
of Contract Holder, or if Contract Holder has begun any voluntary or
involuntary liquidation process; or
3. By giving thirty (30) days' prior written notice to Contract Holder if
Contract Holder breaches the terms of Section IV.C.
SECTION XIII - MISCELLANEOUS
A. Contract Holder hereby makes HMO coverage available to persons who are
eligible under Section IV of this Contract. However, this Contract shall be
subject to amendment, modification or termination in accordance with any
provision hereof, by operation of law, by filing with and approval by
applicable public authority. This can also be done by mutual written
agreement between HMO and Contract Holder without the consent of Members.
By electing medical and hospital coverage pursuant to this Contract, or
accepting benefits hereunder, all Members who are legally capable of
contracting, and the legal representatives of all Members who are incapable
of contracting, agree to all terms, conditions and provisions hereof.
B. Members or applicants shall complete and submit to HMO such applications or
other forms or statements as HMO may reasonably request. Members represent
that all information contained in such applications, forms or statements
submitted to HMO incident to enrollment under this Contract or the
administration hereof shall be true, correct, and complete to the best of
Member's knowledge or belief.
C. HMO may adopt policies, procedures, rules and interpretations to promote
orderly and efficient administration of this Contract.
X. Xx agent or other person, except a Vice President or President of HMO, has
authority to waive any condition or restriction of this Contract, to extend
the time for making a payment; or to bind HMO by making any promise or
representation or by giving or receiving any information. No change in this
Contract shall be valid unless evidenced by an endorsement on it signed by
one of the aforesaid officers.
HMO/PA Group Master Contract Page 28
E. This Contract, including the Cover Sheet, constitutes the entire agreement
between the parties hereto pertaining to the subject matter hereof and
supersedes all prior and contemporaneous arrangements, understandings,
negotiations and discussions of the parties with respect to the subject
matter hereof, whether written or oral; and there are no warranties,
representations, or other agreements between the parties in connection with
the subject matter hereof, except as specifically set forth herein. No
supplement, modification or waiver of this Contract shall be binding unless
executed in writing by authorized representatives of the parties.
F. This Contract has been entered into and shall be construed according to
applicable state and federal law.
G. HMO will furnish each Subscriber with a Member Handbook.
UNITED STATES HEALTHCARE SYSTEMS OF PENNSYLVANIA, INC.,
dba THE HEALTH MAINTENANCE ORGANIZATION OF
PENNSYLVANIA, dba
U.S. HEALTHCARE
SCHEDULE OF BENEFITS
PATRIOT X QPOS PLAN
STV GROUP
Effective December 1, 1995
Benefit Copayment
Primary Care Physician Office Visit
During Office Hours $10
Non-Office Hours and Home Visits $15
Specialist Physician Office Visit $15
Outpatient Therapies $15
First OB Visit $15
Routine Gynecological Exam(s) $15
Hospital Outpatient Department Visit $15
and Diagnostic Testing
Outpatient Emergency Services
Hospital Emergency Room or Outpatient $35
Department
Outpatient Mental Health Visits Visits 1-20: $25
Outpatient Substance Abuse Visits Visits 1-60: $15
Outpatient Surgery $0
Group No: US018927-001 , PA05-018927-013, PA03-018927-027, PA04-018927-028,
PA09-018927-029
Form: HMO/PA FLEX-SB-2 (11/93) ID: TRKJM1 Page 1
Inpatient Services
Acute Care $0
Mental Health $0
Substance Abuse Detoxification $0
Substance Abuse Rehabilitation $0
Maternity $0
Skilled Nursing Facility $0
Non-Hospital Services
First course of treatment $0
Second and subsequent courses of treatment 50% of the cost of service
Dependent Eligibility (a) Under 23 years of age, or
(b) 23 years of age or older but
incapable of self-support due to mental
or physical incapacity, either of which
commenced prior to age 23 for
non-student Dependents and prior to age
23 for student Dependents, or
(c) under 23 years of age and attending
a recognized college or university,
trade or secondary school on a full time
basis, and
(d) non-student Dependents will be
covered until the end of the calendar
year after they have reached the age of
23, and
(e) student Dependents will be covered
until the end of the calendar year after
they have reached the age of 23.
Optional Benefits
Routine Eye Exam by Participating $15
Ophthalmologist or Optometrist
Primary Dentist Visit Copayment
(for Preventive Dental Benefit for $5
children, Section II.A.3.g of the
Group Master Contract)
Routine Gynecological Exam(s) One visit per year
Durable Medical Equipment
Copayment $0
Maximum Annual Out-of-Pocket Limit $0
Group No: US018927-001, PA05-018927-013, PA03-018927-027. PA04-018927-028,
PA09-018927-029
Form: HMO/PA FLEX-SB-2 111/93) ID: TRKJM1 Page 2
Prescription Drugs and Medications
Copayment $10
Lens Reimbursement Reimbursement Amount $35
Group No: US018927-001 , PA05-018927-013, PA03-018927-027, PA04-018927-028,
PA09-018927-029
Form: HMO/PA FLEX-SB-2 (11/93) ID: TRKJM1 Page 3
THE HEALTH MAINTENANCE ORGANIZATION OF PENNSYLVANIA
ENDORSEMENT
SECTION Vl - EFFECTIVE DATE OF COVERAGE
Section A.2, Effective Date of Coverage Other Than of a Newborn Child, is
amended to read:
2. If a completed HMO enrollment application form is not received by HMO
within thirty-one (31) days of the Member's Enrollment Eligibility Date
(Section V.B), the effective date of Member's coverage is the next Open
Enrollment Period during which Member's completed HMO enrollment
application form is received by HMO, unless such Member and Dependents have
lost medical coverage due to spouse's layoff or termination of employment.
Employees must apply within thirty-one (31 ) days of the layoff or
termination of employment and submit evidence of 1) former medical coverage
through the spouse's employer and 2) termination of employment from the
spouse's employer.
UNITED STATES HEALTHCARE SYSTEMS OF PENNSYLVANIA. INC..
dba THE HEALTH MAINTENANCE ORGANIZATION OF
PENNSYLVANIA dba U.S HEALTHCARE
E. Mental Health Inpatient Benefit
Section II. E. of the Group Master Contract and the Certificate of Coverage. or
Individual Contract is hereby amended to add:
Member may exchange one (1) Mental Health inpatient benefit day for up to four
(4) outpatient visits. Member may exchange up to a maximum of (10) inpatient
days for a maximum of forty (40) additional outpatient visits under this rider.
Additionally Member may exchange one (1) inpatient day for two (2) days of
treatment in a partial hospitalization program in lieu of hospitalization up to
the maximum benefit limitation.
Requests for a benefit exchange must be initiated by the member's capitated
Mental Health Provider under the guidelines set forth by the HMO. Member must
utilize all outpatient mental health benefits available under the contract and
pay all applicable copayments before an exchange will be considered. The Mental
Health provider must demonstrate medical necessity for extended visits and be
able to support the need for hospitalization if additional visits were not
offered. Request for exchange must be approved in writing by HMO prior to
utilization.
UNITED STATES HEALTHCARE SYSTEMS OF PENNSYLVANIA, INC.
d/b/a THE HEALTH MAINTENANCE ORGANIZATION OF PENNSYLVANIA, INC.
d/b/a U.S. HEALTHCARE
INJECTABLE BENEFITS AMENDMENT
United States Healthcare Systems of Pennsylvania, Inc. d/b/a The Health
Maintenance Organization of Pennsylvania, Inc. d/b/a U.S. Healthcare, ("HMO")
and Contract Holder agree to offer to the HMO Members the following injectable
benefit subject to the following provisions:
A new section II.K is added to the Group Master Contract and the Certificate of
Coverage:
K. Injectables
Unless specifically excluded, and when an oral alternative drug is not
available, injectable medication is a covered benefit, including those
medications intended to be self administered. Medications must be deemed
medically necessary and appropriate to the Member's needs or condition for
covered services, prescribed by a participating provider and approved in
advance of treatment by HMO. If the drug therapy treatment is approved for
self-administration, Member is required to obtain covered medications at a
U.S. Healthcare participating pharmacy designated to fill injectable
prescriptions.
Experimental or investigational drugs or medications or drugs or
medications that have not been proven safe and effective for a specific
disease or approved for a mode of treatment by the FDA and the NIH are not
covered under this contract. The off-label use of injectable drugs or
medications is not covered. Drugs related to the treatment of noncovered
services are not covered. Drugs related to the treatment of infertility,
contraception and performance enhancing steroids are not covered. Needles,
syringes and other injectable aids are not covered.
A copayment for the primary care physician or specialist physician applies
to this benefit when administered in the participating physician's office
as listed on the attached Schedule of Benefits.
SECTION III - EXCLUSIONS AND LIMITATIONS is hereby amended to delete Exclusion
III.B.17 listed in the Group Master Contract and the Certificate of Coverage in
its entirety and replace it with the following exclusion:
17. Drugs and medicine except as provided by Section II.C.8, Section II.D,
or II.K of this Contract.
UNITED STATES HEALTHCARE SYSTEMS OF PENNSYLVANIA, INC.
d/b/a THE HEALTH MAINTENANCE ORGANIZATION OF PENNSYLVANIA, INC.
d/b/a U.S. HEALTHCARE
ENDORSEMENT
HMO and Contract Holder agree to offer to Members the following benefit subject
to the following provisions:
SECTION I - DEFINITIONS is amended to include the following definition:
Infertile condition or Infertility - The condition of a presumably healthy
Member who is unable to conceive or produce conception after a period of one
year if the member is under the age of thirty-five (35), or after a period of
six (6) months if the Member is age 35 or older, of unprotected sexual
intercourse.
Participating Advanced Reproductive Technology ("ART") Specialist - A Specialist
which or who has entered into a contractual agreement with HMO for the provision
of the advanced reproductive technology services covered by this endorsement to
Members on an agreed upon basis.
Infertility Program - A program administered by HMO which consists of:
1. The evaluation of "infertile" Members to determine the appropriate
infertility treatment for a Member; and
2. Determination of eligibility for the ART benefit; and
3. Precertification and approval for the ART benefit; and
4. Case management for the provision of infertility services covered under the
Group Master Contract and Certificate of Coverage and the services listed
hereunder.
Section II.A.11 is hereby amended to add the following additional infertility
services to the Group Master Contract and the Certificate of Coverage:
Limited Advanced Reproductive Technology Benefit
1. Eligibility:
To be eligible under the Infertility Program:
a. Member must be covered under the Group Master Contract and the Certificate
of Coverage as a Subscriber or a Dependent; and
b. Member must be diagnosed as infertile.
The ART benefit is not covered for male members when the cause of infertility is
vasectomy or for female members when the cause of infertility is tubal ligation.
2. Access to the ART Benefit and Precertification:
To obtain the ART benefit described in paragraph 3 hereunder, Member must be:
a. Referred by Member's primary care physician or gynecologist to the
Infertility Program, or Member may directly contact the HMO's Infertility
Program Case Management unit by calling the Solutions number listed on
Members ID card; and
b. Determined to be eligible for the ART benefit after an initial intake
evaluation and consultation with a participating ART Specialist and
recommendation by the ART Specialist that Member be accepted into the
Infertility Program. Eligibility is also based on the participating ART
Specialist's determination of the reasonable possibility of success based
on the Member's medical history and the standards established by HMO; and
c. Pre-certified and approved by HMO for this benefit; and
d. Member has been issued a claim authorization for ART services from the
HMO's Infertility Program Case Management Unit to a participating ART
Specialist. Claim authorizations will only be issued by the Infertility
Program Case Management Unit for all services related to infertility care
and treatment.
3. Benefit:
This benefit covers one (1) egg harvesting and up to two (2) transfers through
InVitro Fertilization (IVF), Zygote Intra-Fallopian Transfer (ZIFT), or Gamete
Intra-Fallopian Transfer (GIFT) only, during each twenty-four (24) month period
from the date of the first visit for actual treatment from the participating ART
Specialist and after the determination of eligibility as described above.
Services under this benefit are only available from the participating ART
Specialists for whom Member has been issued a claim authorization by the
Infertility Program Case Management Unit.
SECTION III - EXCLUSIONS AND LIMITATIONS is hereby amended to delete Exclusion
III.B.25 listed in the Group Master Contract and the Certificate of Coverage in
it's entirety and replace it with the following exclusion:
III.B.25
Infertility injectable medications are not covered. Charges for the freezing and
storage of cryopreserved embryos and charges for storage of sperm are not
covered. Donor costs, including but not limited to the cost of donor eggs and
donor sperm, are not covered. This ART benefit is only available from
participating ART Specialists through the Infertility Program and is excluded
from coverage on a non-referred or out-of-network referred basis. The costs for
ovulation predictor kits are not covered.
UNITED STATES HEALTHCARE SYSTEMS OF PENNSYLVANIA, INC.
d/b/a THE HEALTH MAINTENANCE ORGANIZATION OF PENNSYLVANIA, INC.
d/b/a U.S. HEALTHCARE
ENDORSEMENT
Effective October 1, 1995
Section VIII.A.1 of the Group Master Contract and Certificate of Coverage,
Continuation, is amended to add the following provision:
In the event a Subscriber's employment with Contract Holder is terminated
involuntarily and without cause, Subscriber shall be entitled to continue
coverage (including coverage of covered Dependents) immediately thereafter,
without payment of additional premium, for a period equal to one month (i.e.,
the corresponding day of the following month, for example from February 15th to
March 15th) for each year that Subscriber has continuously (i.e., no lapse of
more than thirty (30) days) maintained coverage with HMO under a Group Contract,
commencing with the date that Subscriber is effective under this Endorsement, to
a maximum of three months of such coverage. All continued coverage utilized by
Subscriber pursuant to this Endorsement shall be deducted from Subscriber's
accumulated eligibility for continued coverage hereunder (i.e., if Subscriber
has used one (1) month of a three (3) month accumulated continued coverage
period, two (2) months will remain until such time as Subscriber again becomes
eligible for three (3) months of continued coverage.) To be eligible for and
obtain such continued coverage an application must be received by HMO within
thirty (30) days after Subscriber's termination of employment and shall include
(x) a signed representation from the Subscriber that the Subscriber is not
eligible for other comprehensive group health coverage (such as through a spouse
or other employer) or Medicare, and (y) a signed written certification from the
Contract Holder that the Subscriber's employment was terminated involuntarily
and without cause. In the event Subscriber exercises Subscriber's COBRA or other
continuation rights under this Contract, continuation of coverage hereunder
shall be in the form of the waiver of the applicable COBRA premium or other
continuation premium.
CORPORATE HEALTH INSURANCE COMPANY
(A Minneapolis, Minnesota Domiciled Company)
Principal Executive Offices:
000 Xxxxx Xxxx
Xxxx Xxxx, Xxxxxxxxxxxx 00000
SUMMARY OF BENEFITS
FOR
COMPREHENSIVE MAJOR MEDICAL
GROUP HEALTH INSURANCE POLICY
This Summary of Benefits describes the benefits available to you under the
Comprehensive Major Medical Group Health Insurance Policy No. PA PA01,018927001,
PA03, 018927-027, PA04, 018927-028, PA05 018927-013, PA09, 018927029, GN01,
018927-003, GN02, 018927-002, GN03, 018927-004, NE01, 018927005, DE01,
018927-006, NH01, 018927-007, MD01,018927-008, DC01, 018927009, Rl01,
018927-010, GA01, 018927-011, MD02, 018927-012, NJ01, 018927025, VA01,
012927-026 (the "Policy") issued by Corporate Health Insurance Company ("CHI" or
the "Company") to STV Group ("the Policyholder").
Every attempt has been made to be informative about benefits available under the
Policy and those areas where a benefit may be lost or denied. However, for a
complete description of the benefits, please review this Summary of Benefits
together with the Policy. The benefits described in this Summary of Benefits are
subject exclusively to the provisions and limitations set forth in the Policy.
The benefits described in this Summary of Benefits are those in effect as of
December 1, 1995.
This Summary of Benefits will not constitute a Certificate unless the
Certificate label is fixed to this Summary.
1
HOW TO SUBMIT CLAIMS FOR BENEFITS
o A notice of claim, which may be obtained from CHI or your human resources
department, must be sent directly to CHI or its designee within 90 days
after an eligible service or supply is received.
o Please be sure to provide all information required by the notice of claim,
including the Policy number and the Policyholder's name and number.
o If you receive a bill for medical services, send it to CHI or its designee
together with the notice of claim.
o Before submitting a claim for medical expenses, review this Summary of
Benefits and the bills you have accumulated. Be sure you are submitting
bills for which benefits are payable under the Policy. Make copies of all
documents you are submitting.
o Bills must be complete. Each bill must be an original and should show:
* Name of eligible person
* Date(s) of service or supply
* Charge for each service or supply
* Diagnosis (reason for treatment)
* Type(s) of charge(s) (CPT-4 code, if any, and/or description of
service(s) provided)
PLEASE NOTE: The following will not be acceptable:
* Canceled checks
* Cash register receipts
* Balance due bills (bills that show only the amount owed)
* Photocopies
Should you need additional copies of the notice of claim, feel free to contact
CHI between 8:00 AM - 5:00 PM (Eastern Standard Time) at 0-000-000-0000 or check
with your human resources department. All payments will be made directly to the
provider, unless you notify CHI in writing otherwise. If you have any questions,
please call or write:
Corporate Health Insurance Company
000 Xxxxx Xxxx, X.X. Box 1109
Blue Bell, Pennsylvania 19422
0 -000-000-0000
INSURANCE POLICY HIGHLIGHTS
ELIGIBILITY
Active employees of the Policyholder and their eligible dependents. Dependent
coverage is limited to employee's spouse and unmarried dependent children up to
age 23; full-time students up to age 23.
PRE-CERTIFICATION
To be eligible for maximum benefits under the Policy, you are required to follow
the procedures for pre-certification set forth below. Pre-certification is
obtained by calling CHI at 0-000-000-0000. Pre-certification is required prior
to receiving any of the eligible services or supplies that require
pre-certification, as noted below in the Schedule of Benefits.
FAILURE TO COMPLY WITH THIS PRE-CERTIFICATION REQUIREMENT WILL RESULT IN A 50%
2
REDUCTION IN YOUR BENEFITS.
SCHEDULE OF BENEFITS
I. DEDUCTIBLE AMOUNT
The following deductible amount (the "Deductible Amount") must be paid by you or
your family (as the case may be) for eligible medical expenses incurred during
any calendar year. Any eligible medical expenses in excess of the applicable
Deductible Amount will be paid by CHI and the covered person in accordance with
the co-insurance and co-payment provisions set forth below in Section II.
Individual: $300
Family: $900
The Deductible Amount is not applicable to certain eligible medical expenses
noted below in Section V, for which you or your family (as the case may be) need
not pay any Deductible Amount prior to becoming entitled to benefits under the
Policy.
II. CO-INSURANCE AND CO-PAYMENT
All eligible medical expenses in excess of the Deductible Amount will be paid by
CHI and you as follows, until at such time during the calendar year you have
paid up to your out-of-pocket maximum amount set forth below in Section III or
CHI has paid the maximum benefits set forth below in Section IV or V:
CHI Pays: 80% of Reasonable & Customary Charges
You Pay: 20% of Reasonable & Customary Charges
Unless specifically required below in Section V, no co-payment will be payable
on any eligible medical expenses. Certain eligible medical expenses specified
below in Section V are not subject to any co-insurance or co-payment provisions.
CHl's obligation to pay eligible medical expenses under the Policy is further
limited by the maximum lifetime individual benefit limitation set forth in
Section IV below and other maximum benefit amounts set forth next to each
eligible medical expense in Section V below.
III. OUT-OF-POCKET MAXIMUM
During any calendar year, you or your family (as the case may be) will not be
required to pay an aggregate amount in excess of the following out-of-pocket
maximum amount (the "Out-of-Pocket Amount"). If during any calendar year you
have paid pursuant to the above co-insurance or copayment provision an aggregate
amount greater than the Out-of-Pocket Amount below, CHI will pay for 100% of the
balance of the eligible medical expenses, up to the amount of the lifetime
individual maximum benefits amount set forth below in Section IV or the maximum
benefit amounts set forth below in Section V (whichever is applicable).
Individual: $1,200
Family: $3,600
Unless otherwise noted below in Section V, the co-insurance and co-payments paid
by the Covered Individual of the Family Unit will be included in the
Out-of-Pocket Amount. However, the Deductible Amount paid by the Covered
Individual or the Family Unit will not be included in the Out-of-Pocket Amount.
3
IV. LIFETIME INDIVIDUAL MAXIMUM BENEFIT
The maximum amount payable by CHI under the Policy for eligible medical expenses
incurred by you or any member of your family (if applicable) shall not exceed
$1,000,000.
4
V. ELIGIBLE MEDICAL EXPENSES
The Policy covers the following eligible services and supplies provided to you
or your covered family members. However, the Policy covers only those services
and supplies which were medically necessary and only up to reasonable and
customary charges, subject to additional restrictions and limitations set forth
below and in the Policy:
COVERED SERVICES LIMITATIONS AND RESTRICTIONS
Acupuncture In lieu of anesthesia only
Ambulance Transportation To and from the nearest facility that can
give necessary treatment
Ambulatory Surgery Pre-Certification required
Anesthesia
Assistant Surgeon Benefits not payable for hospitals where
surgical assistant is routinely available
Birthing Center Benefits not to exceed those otherwise
available for pregnancy under the Policy
Blood or Blood Plasma Must not be replaced on behalf of the
eligible person
Cardiac Rehabilitation Pre-Certification required
Services
Chiropractic Care Pre-Certification required; CHI pays up to a
maximum benefit amount of $1,000 per calendar
year for detection and correction by manual
means of structural imbalance or o
subluxation resulting from or related to
distortion, misalignment or subluxation of or
in the vertical column
Consultation Only for consultation requested by the
attending physician and given while confined
as an in-patient
Diagnostic Services
Durable Medical Equipment Pre-Certification required on items leased or
purchased for more than $1,500
5
Emergency Services Notification must be made within 24
hours of any admission or as soon thereafter
as reasonably possible; Emergency services
must be received within 48 hours after the
onset of the medical emergency
Hemodialysis
Home Health Services Pre-Certification required One visit per day;
up to 4 hours constitute 1 home health care
visit;
Hospice Care Pre-Certification required; Maximum
individual lifetime benefit of $10,000;
Attending physician must certify that the
covered person is terminally ill and must
recommend admission into a hospice care
program
Hospital
Outpatient Care: Pre-Certification required
Inpatient Care: Pre-Certification required
(Room & Board at
Semi-Private Room Rate*)
*Unless Private Room is Medically Necessary
Immunization for No deductible and no co-insurance; Children
Limited to minimum benefits mandated by the
Department of Insurance
Infertility Services to diagnose infertility only; Does
not cover infertility treatment
Inpatient Physician While confined as an inpatient in a hospital
Services or skilled nursing facility
Mammography No deductible and no co-insurance shall be
applied to the charge; Up to 1 routine
mammography per calendar year if the female
eligible person is age 40 or older, and any
additional mammography recommended by a
physician for a female eligible person under
age 40
Maternity-Related Care Notification required soon after
pregnancy is confirmed and within 24 hours
after birth or as soon thereafter as
reasonably possible
Newborn Baby Care
6
Office Visits Only for diagnosis or treatment of an injury
or illness at a physician's office
Organ Transplants Pre-Certification required; Attending
physician must certify medical necessity;
Covered person must be the recipient
Oxygen When prescribed by the attending physician
Papanicolaou Smear Routine pap smear in accordance with the
(Pap Smear) recommendations of the American College of
Obstetricians and Gynecologists. No
deductible or no co-insurance shall be
applied to the charge.
Preventive Care An annual gynecological examination,
including a pelvic examination and clinical
breast examination by a Physician. No
deductible or no co-insurance shall be
applied to the charge.
The charges for immunizations (other than
children's immunizations) and physical
examinations (other than papanicolaou smears
and mammography); Up to maximum benefit of
$150 per individual per calendar year No
deductible or no co-insurance shall be
applied to the charges.
Private Duty Nursing Pre-Certification required;
Must be services of a L.P.N. or R.N. for
non-hospitalized illness or injury
Psychiatric Treatment Includes Mental, Psychoneurotic and
Personality Disorders; Restoration and
reinstatement provision of the Policy does
not apply; Lifetime maximum benefit of
$50,000
Outpatient: Maximum benefit limited to 60 visits per
calendar year; Maximum benefit of $1,500 per
year; CHI pays 50% and You pay 50% Up to $30
per visit
Inpatient: Pre-Certification required; Maximum benefit
limited to 30 days per calendar year
Reconstructive/ Pre-Certification required
Corrective Surgery
Skilled Nursing Facility Pre-Certification required; Maximum benefits
limited to 240 days per calendar year and 35
physician visits per calendar year; Room and
board at semi-private accommodations, unless
isolation is required and the attending
physician orders private accommodations
7
Substance Abuse Pre-Certification required
Treatment
Outpatient Care: Limited to 30 visits per calendar year and 30
additional full visits or equivalent partial
visits, which may be exchanged for up to 15
inpatient rehabilitation days on a 2-for-1
basis
*Inpatient Detoxification: Limited to 7 inpatient days per calendar
year, subject to a lifetime limit of 4
separate admissions
*Inpatient Rehabilitation: Limited to 30 days per calendar year in a
non-hospital substance abuse residential
facility, subject to a lifetime limit of 90
days
*Room and board at Semi-Private room rate.
Therapies Pre-Certification required Includes Cardiac
Rehabilitation, Chemo, Occupational,
Physical, Radiation, Respiratory, and Speech;
Voluntary Sterilizations Does not cover reversal procedures
Vl. EXCLUSIONS
Certain charges and expenses are not covered by the Policy, including those:
o For services or supplies not medically necessary for the diagnosis or
treatment of an illness or injury
o In excess of the reasonable and customary charges or the maximum benefits
provided by this Summary of Benefits
o Caused by war (declared or undeclared) or any act of war
o Suffered while on full-time active duty in the armed forces of any country
or international authority
o Incurred in connection with any injury or illness which is compensable
under any workers' compensation or occupational disease act or law or the
federal Longshoreman's and Harbor Worker's Compensation Act
o For services received in a veteran's administration hospital, a public
health service hospital, or any facility operated by the U.S. government or
any of its agencies, except to the extent that there is an unconditional
requirement to pay these charges
o For certain services received by retirees from armed forces or their
dependents pursuant to and covered by programs established under federal
law
o For the treatment of or care for mental retardation, defects and
deficiency, other than psychiatric treatment specifically covered herein
o For dental services, except for accidental injuries to sound natural teeth
8
o For optical services
o For services rendered by you or your close relative
o For care, services, and supplies not prescribed or rendered by a Physician
o Directly related to attempted suicide or an intentionally self-directed
injury
9
o For provision or replacement of the following items: arch supports; elastic
hose; birth control devices including, but not limited, to IUDs, diaphragms
and condoms; false teeth; braces; traction apparatus; canes; walkers;
corrective shoes; corsets; wigs or cranial prosthesis; diapers; or certain
special appliances, supplies or equipment.
o For custodial care
o For cosmetic surgery, except reconstructive surgery specifically covered by
the Policy
o Resulting from the commission or attempt to commit a felony by the eligible
person
o For certain convenience items or services
o Applied toward satisfaction of the deductible or the co-payment or
coinsurance amount payable by the eligible person
o For blood or blood plasma that is replaced on behalf of the eligible person
o For actual or attempted impregnation or fertilization which involves either
an eligible person or a surrogate as a donor or a recipient
o For examinations, proper adjustment of, or purchase of a hearing aid
o For career and pastoral counseling
o For services or supplies of an educational, experimental or investigatory
nature
o For the reversal of any sterilization procedure performed on any family
member
o For sex transformations or other transsexual surgery or related services
not necessitated by an injury or illness covered by the Policy
o For certain services rendered for academic reasons
o For orthoptic therapy (vision exercises)
o For weight reduction programs and gastric stapling for treatment of obesity
o For certain bereavement counseling service
o For treatment of temporomandibular joint dysfunction with/intra-oral
devices or any other method to alter vertical dimension
o For hypnosis not used as an integral part of a treatment covered by the
Policy
o For telephone consultations, failure to keep a scheduled visit, or
completion of a claim form
o For any services or supplies not specifically described in the Policy
o For any services or supplies covered by any automobile insurance policy up
to the amount of coverage limitation under such policy.
o For prescription drugs
o For orthotic devices
10
CHI shall determine whether a service or supply is covered under or excluded
from coverage under the Policy.
11
PRE-CERTIFICATION
Prior to receiving hospitalization or certain other medical treatment requiring
pre-certification as specified above in the Schedule of Benefits, the covered
person, a member of his or her family, a hospital staff member, or the attending
physician, must notify CHI to pre-certify the admission or treatment.
The Company will reduce the benefits payable under the Policy by 50% if the
procedures for precertification set forth herein are not followed. Each covered
person will be responsible to pay the unpaid balance of the benefits.
To obtain pre-certification, call CHI at 0-000-000-0000. This call must be made:
1. Prior to any planned admission into hospital and prior to receiving
such other eligible treatment that require pre-certification according
to the Schedule of Benefits or the Policy;
2. Within 24 hours after the time of an emergency admission or as soon
thereafter as reasonably possible; and
3. As soon as the attending physician confirms that a covered person is
pregnant and again within 24 hours of the birth or as soon thereafter
as reasonably possible.
When calling CHI, the caller must provide:
1. The covered person's name and the covered person's social security
number;
2. The treating physician's name, address and phone number;
3. The name of the hospital or treatment facility and the anticipated
admission or treatment date; and
4. The Policyholder's name and Policyholder Policy Number.
There is no requirement to call in advance before seeking treatment for an
emergency.
Case Management
Certain medical conditions for which a claim is made under the Policy may be
referred to Case Management (CM).
Only those conditions for which medical expenses are expected to exceed a
certain dollar amount, and for which there is a potential lower cost treatment
alternative, will be referred to CM.
CM is a program which provides a case-by-case analysis and medical treatment
plan suggestions that address the need of catastrophically ill or injured
individuals. It concentrates on severe injuries and illnesses, such as spinal
cord injuries or head trauma, when early intervention and individual case
management will prove effective to a patient's recovery.
The decision to refer any case to CM will remain with CHI, who will rely on the
criteria established by the CM service provider to determine which claims are
recommended for CM, except that no alternative treatment will be provided to the
covered person under CM without prior consent of the covered person and the
attending physician.
In certain instances a recommendation to use alternative treatment not normally
covered by the Policy may be made when such treatment endorses quality care,
medical necessity and cost effectiveness. Under these circumstances, any such
alternative treatment will be covered by the Policy.
12
DEPENDENT ELIGIBILITY
1. Dependent Coverage
(a) Your spouse and dependent children can also be covered under the
Policy.
(b) Your spouse is eligible for dependent coverage unless:
(i) You and your spouse are legally separated or divorced or have
obtained an annulment;
(ii) Both your and your spouse are employees of the Policyholder. You
and your spouse may choose to be covered as individual employees
of the Policyholder, or one may cover the other as a dependent,
but both of them may not cover the other as a dependent;
(iii) Such spouse is in active military service;
(iv) Such spouse is of the same sex; or
(v) Such spouse is not a legal spouse, under the laws of the
Commonwealth of Pennsylvania.
(c) Your natural or legally adopted child is eligible from birth so long
as the child is:
(i) Less than age 23, or if a full-time student, less than age 23;
(ii) Not married; and
(iii) Not on active duty in any of the armed forces.
(d) Child/children under legal guardianship (including xxxxxx children) or
children under court order will be included under the Policy under the
same conditions and restrictions applicable to a covered person's
natural or legally adopted children.
(e) Your spouse and child/rep meeting the requirements described above are
referred to herein as "Eligible Dependents."
2. Enrolling Eligible Dependents
(a) You can enroll for family coverage when you become eligible for
individual coverage.
(b) If you have no dependents when you first enroll but later gain one,
you may enroll for family coverage within 31 days of the date you gain
the dependent. This includes dependents gained by marriage, birth
adoption, legal guardianship or court order. During the first 31 days
after the birth of a child, the child will be automatically covered
for all eligible benefits. For coverage of a child beyond the first 31
days after birth and for coverage of a spouse during and beyond the
first 31 days after marriage, enrollment must be made and the first
premium charge for that dependent must be paid within that 31 day
period.
(c) Note: Except for newborn child's coverage during the first 31 days
after birth, if you do not enroll you dependents within 31 days after
the dependent becomes eligible. satisfactory evidence of good health
for such dependent will be required. If satisfactory evidence of good
health is not provided for such dependent, CHI may reject the
enrollment application for insurance of such dependent under the
Policy. Coverage for
13
such dependent providing satisfactory evidence of good health will
then begin no earlier than the first day of the calendar month
following CHl's approval of the evidence of good health. However, no
evidence of good health will be required for any dependent who enrolls
within such 31 days.
3. When Dependent Coverage Stops
Coverage for dependents shall end when the dependent relationship with you
ends or when your coverage under the Policy ends. When coverage for a
dependent ends, the dependent will have an opportunity to obtain
continuation of medical coverage as provided by the Consolidated Omnibus
Budget Reconciliation Act.
4. Extension of Coverage for Dependents
(a) Under certain circumstances described below, coverage could continue
for an Eligible Dependent after the time coverage would normally stop
under the Policy.
(b) A child who is otherwise eligible and is physically or mentally
incapable of self support upon attaining the limiting age may be
continued under the coverage provided hereunder so long as he or she
remains incapacitated and unmarried at that time subject to your
coverage continuing in effect.
(c) To be eligible for the continued coverage described in this Section of
a dependent child beyond the time coverage would normally end, proof
of his or her incapacity must be submitted to CHI within 31 days after
such dependent's attainment of the limiting age. Proof of the
incapacity will be required from time to time to keep this coverage in
effect. Each time CHI asks for proof that a covered dependent is
incapacitated, CHI may require the covered dependent to have a
physician's examination at the covered person's expense. CHI may
specify the physician.
(e) The continued coverage of a dependent child under this Section
terminates on the earliest of the following dates:
(i) the date such child is no longer incapacitated;
(ii) the date proof of the child's incapacity is not provided when
asked; or
(iii) the date your dependent's coverage otherwise terminates pursuant
to the Policy.
ENROLLMENT CHANGES
Enrollment and benefit coverage under the Policy may be changed only upon a
change in your family status.
A change of family status occurs when:
1. You get married or divorced;
2. Your child is born or legally adopted;
3. Your spouse or child dies; or
4. Your spouse has a loss of group insurance coverage.
14
15
GENERAL PROVISIONS
1. Notice of Claim
Written notice of claim must be furnished to the Company within 90 days after
covered treatment has been rendered to the covered person. A notice of claim
form may be obtained from CHI or the Policyholder. However, in case of a claim
for which the Policy provides any periodic payment contingent upon continued
provision of treatment, this notice may be furnished within 90 days after
termination of each period for which the Company is liable. Failure to furnish
the notice of claim within the time required will not invalidate nor reduce any
claim if it is not reasonably possible to give the notice of claim within 90
days, provided the notice of claim is furnished as soon as reasonably possible.
However, except in the absence of legal capacity of the claimant, the notice of
claim may not be furnished later than one year from the date when the notice of
claim was originally required.
2. Time for Payment of Claim
Benefits payable under the Policy will be paid promptly upon receipt by CHI of
satisfactory notice of claim, unless the Policy provides for periodic payment.
Where the Policy provides for periodic payments, the benefits will accrue and be
paid monthly, subject to satisfactory notice of claim.
3. Payment of Claims
All or any portion of any indemnities provided by the Policy on account of
hospital, nursing, medical or surgical services may, at the Company's option, be
paid directly to the hospital or other persons rendering such services; but it
is not required that the service be rendered by a particular hospital or person.
Any payment made by the Company in good faith pursuant to this provision will
fully discharge the Company's obligation to the extent of the payment. The
covered person may request that payments not be made pursuant to this provision.
The request must be made in writing and must be given to the Company not later
than the time of filing notice of claim. Payment made prior to receipt of the
covered person's written request at the Company's principal executive office
will be deemed to be payment made in good faith.
The covered person shall be responsible for the payment of ail charges for any
service or supply in excess of the reasonable and customary charges or otherwise
not covered by the Policy.
4. Choice of Physician
Each covered person has free choice of any physician, hospital or other
provider.
5. Time Limit on Certain Defenses
No claim for loss incurred after one year from commencement of the individual
covered person's insurance will be reduced or denied on the grounds that the
disease or physical condition existed prior to the commencement of the covered
person's insurance.
6. Incontestability
The validity of your insurance will not be contested, except for non-payment of
premium, after your insurance under the Policy has been continuously in force
for one year during his or her lifetime. No statement made by you relating to
your insurability or that of your dependents will be used in defense to a claim
under the Policy unless: (a) it is contained in a written application signed by
you; and (b) a copy of the application has been furnished to you or your
beneficiary.
7. Misstatements of Age
16
If the age of any covered person has been misstated, an equitable adjustment
will be made in the premiums or, at the Company's discretion, the amount of
insurance payable. Any premium adjustment will be based on the premium that
would have been charged for the same coverage on a covered person of the same
age and similar circumstances.
8. Physical Examination and Autopsy
The Company, at its own expense, will have the right and opportunity to examine
a covered person, when and as often as may reasonably be required during the
pendency of a claim under the Policy and to make an autopsy in case of death,
where it is not forbidden by law.
9. Legal Action
No action at law or in equity may be brought to recover on the Policy unless and
until the expiration of 60 days after notice of claim has been furnished to CHI.
No such action may be brought after the expiration of three (3) years after the
time notice of claim is required to be furnished.
10. Conformity With State Statutes
Any provision of the Policy which, on its effective date, is in conflict with
the statutes of the state in which it is issued, is deemed amended to conform to
the minimum requirements of those statutes.
11. Assignment
No assignment of the Policy, or any part of it, will be binding on the Company
unless approved in writing by the President or Executive Vice President of the
Company. The Company does not assume any responsibility for the validity of any
assignment.
12. Rights of Employees
Neither the Policy nor this Summary of Benefit constitutes a contract of
employment and does not affect the right of the employer to discharge any
employee.
13. Facility of Payment
If, in the opinion of the Company, a covered person is not competent to execute
a valid release for payment of any benefit to which he is entitled under the
Policy, the Company may, but shall not be required to, make payment to such
individual(s) or institution(s) as have assumed the care and support of such
covered person. In the event the covered person dies before payment is made to
him of all benefits to which he is entitled under the Policy, the Company may,
but shall not be required to, make payment to such individual(s) or
institution(s) as may be, in the opinion of the Company, equitably entitled
thereto, including without limitation, individual(s) or institution(s) to which
the covered person may have assigned such benefits prior to his death. Any
payment made in accordance with the foregoing provisions shall fully discharge
the Company to the extent of such payments.
14. Right to Receive and Release Information
For the purpose of determining the applicability of and implementing the terms
of the provisions of the Policy, the Company may release to, or obtain from, any
other plan or policy administrator, insurance company, or other organization or
individual any information, concerning any individual, which the Company
consider to be necessary for those purposes. Any individual claiming benefits
under the Policy will furnish the information that may be necessary to implement
the provisions.
17
SUBROGATION
If any benefit is provided to you under the Policy, CHI will be subrogated and
succeed to your rights of recovery with respect to the services and supplies
involved against a responsible third party and/or insurance company. Please see
the Section entitled "Subrogation" under the Policy to review your rights and
obligations in connection with CHl's subrogation rights.
COORDINATION OF BENEFITS
In addition to the Policy's benefits, the Policy has a Coordination of Benefits
provision. The purpose of this provision is to conserve funds associated with
health care. Coordination of Benefits is applicable only when you, your spouse
or your dependent(s) are eligible for benefits under more than one group health
plan.
When you receive health care services that are also covered under another plan,
a determination is made as to which plan is "primary" and which plan is
"secondary". The primary plan considers the services, without regard to the
secondary plan. The secondary plan will then consider the balances on covered
services according to its own limitations.
If the Policy is determined to be the secondary plan, CHI will not pay more than
it would have had under the Policy there been no other coverage.
The primary plan will be determined in the following order:
1. If the other plan does not include a provision to coordinate benefits,
such plan will be the primary plan.
2. If the other plan does include a provision to coordinate benefits,
then:
A. The plan covering the patient as the covered employee is the
primary plan.
B. Except for situations where the parents of a child are separated
or divorced, the plan of the parent whose date of birth occurs
earlier in the policy year is the primary plan for that child. If
both parents have the same birth date, the plan which covered the
parent longer shall be primary.
Note: In the event this plan is coordinating with a plan that
uses a rule based on the gender of the parent, benefits will be
coordinated as follows:
Except for situations where the parents of a child are separated
or divorced, the plan of the male parent is primary.
C. In those situations where the parents are separated or divorced,
the primary plan is determined as follows:
1) the plan covering the parent with custody of the child is
primary;
2) if the parent with custody of the child has remarried, the
stepparent's plan will pay for covered services before the
plan of the parent without custody; and
3) a court decree may determine the primary plan. You should
advise your employer of any court decree.
18
D. When the determination cannot be made with the above rules, then
the plan that has covered the patient for the longer period of
time will be the primary plan, except:
o the plan which covers the patient as inactive employee (or a
dependent of such a person) is the primary plan over a plan
that covers a patient as a laid-off or retired person (or a
dependent of such a person); and
o if either plan does not have this condition, then it does
not apply and the plan which has been in effect the longer
period of time is primary;
3. If services are provided under a governmental program for which the
covered employee pays a periodic rate, that program is the primary
plan, except when prohibited by law or when the covered employee
elects Medicare as secondary coverage.
At its sole discretion, CHI may pay benefits first and determine liability
later. If CHI pays first and it is determined that the Policy is the secondary
plan, CHI has the right to recover the expense already paid in excess of its
liability as the secondary plan. If the other health care plan is the primary
plan, CHI may limit payment so that CHI will not pay more than the difference,
if any, between the primary plan's payment and CHl's liability under the Policy.
Benefits payable under another plan include benefits that would have been
payable had the claim been duly made. When the Policy is determined to be
primary, but payment was made by another plan, CHI has the right to reimburse
the other plan, the amount which CHI determines is its liability.
CHI may release to or obtain from any person or organization any information
about coverage, expenses and benefits which may be necessary to coordinate
benefits. The covered employee on his/her own behalf and on behalf of their
dependent(s) may be required to furnish information and to take such other
action as is necessary to assure the rights of CHI.
MEDICARE
When a covered person is eligible for Medicare, that person must sign and
deliver an election card to the Company, stating whom that covered person wants
to be his primary insurer. If the covered person elects Medicare as his or her
primary source of coverage and belongs to a group covered by the Policy covering
twenty (20) persons or more, all Policy benefits otherwise payable to that
covered person shall discontinue. If belonging to a covered group of less than
twenty (20) persons, all Policy benefits otherwise payable with respect to the
covered person will be reduced by any service or supply provided, or any
benefits paid or payable, under Part A and Part B of Medicare.
For the purposes of this Section, benefits will be paid on the basis that the
covered person is covered by both Part A and Part B of Medicare. If the covered
person should not receive benefits under either Part A or Part B because of:
(a) failure to enroll when required;
(b) failure to pay any premiums that may be required for full coverage of
the person under Medicare; or
(c) failure to file any written request or claim required for payment of
Medicare benefits;
the Company will make determination of the total benefits that would have been
payable under Medicare in the absence of this failure.
"Part A" means the "Hospital Insurance Benefits for the Aged" portion of
Medicare.
19
"Part B" means the "Supplementary Medical Insurance for the Aged" portion
of Medicare.
20
TERMINATION OF COVERAGE
Subject to certain exceptions:
o Your coverage under the Policy ends immediately when you leave the
employment of the Policyholder. It also ends if such employee is no
longer eligible under the Policy, the Policy is discontinued or, after
a grace period, premiums are not paid.
o Coverage for your dependents end when they no longer meet the
definition of dependents under the Policy or your coverage under the
Policy terminates.
o If coverage under the Policy terminates and you want to continue your
medical coverage and that of your eligible dependents, you may apply
for continued coverage under COBRA or convert your coverage into an
individual policy, as explained in Article IX of the Policy.
CLAIMS APPEAL PROCEDURE -
If your claim has been denied in whole or in part, you will be notified by CHI.
This notice will set forth the reasons for such denial. If you wish to appeal
this decision, you may write to the address which appears on the notice (to the
attention of the person who signed the letter, if any).
It is important for you to understand the reasons for the denial of benefits in
order to decide whether you want to appeal and request that the claim be
reviewed again. You should examine this Summary of Benefits and the Policy,
which are on file with your employer. The Policy is a legal document setting
forth the full terms and conditions of your hospital and professional coverages
and excluded services. You may also request a xxxxxx explanation of the
rejection decision by calling XXX.
You may appeal a denial of benefits within 30 days of the date of the rejection
by sending a letter stating why you think your claim should not have been
denied, including a copy of the denial letter and with any additional claim. Be
sure to include in your letter your Policy number, your Policyholder number,
claim number, if any, your employer's name and the date of services for which
benefits were denied. If you do not appeal within thirty (30) days, the denial
will become final and incontestable.
Upon receipt of your letter and any additional information you provide, your
records will be reviewed; and the results of this review will be sent to you
promptly. In unusual cases, as when review of your claim requires examination by
medical personnel, including consulting physicians, the review may be extended.
No legal action at law or equity may be brought to recover any benefits under
the Policy unless and until the appeal process set forth above has been
exhausted, and in no event prior to the expiration of 60 days after notice of
claim has been furnished to CHI in accordance with the requirements of the
Policy.
21
UNITED STATES HEALTH CARE SYSTEMS OF PENNSYLVANIA, INC.,
d/b/a THE HEALTH MAINTENANCE ORGANIZATION OF
PENNSYLVANIA d/b/a
U.S. HEALTHCARE
FLEX OPTION PLAN
DURABLE MEDICAL EQUIPMENT RIDER
United States Health Care Systems, Inc. d/b/a The Health Maintenance
Organization of Pennsylvania, Inc. d.b.a. U.S. Healthcare ("HMO") and Contract
Holder agree to offer to the HMO Members the following benefit subject to the
provisions listed hereunder:
Durable medical equipment will be provided when medically necessary and required
for therapeutic use as determined by HMO. The wide variety and continuing
development of patient care equipment makes it impractical to provide a complete
listing, therefore, the HMO Medical Director must approve requests on a
case-by-case basis. HMO reserves the right to provide the most cost efficient
and least restrictive level of service or item which can be safely and
effectively provided.
Instruction and appropriate services required for the Member to properly use the
item, such as attachment or insertion, is also covered. Replacement, repairs and
maintenance not provided for under a manufacturer's warranty or purchase
agreement coverage will be a covered benefit when it is functionally necessary
and appropriate.
General guidelines considered are:
1. The device must be medically reasonable and necessary for the
improvement of the patient's condition or must improve or supplement a
bodily function.
2. If the equipment is other than standard (electric, motorized) the
extra features of the equipment must be medically necessary.
3. The duration of medically necessary usage must be established,
especially in those situations where the purchase of the item is
relevant.
4. Item, device or equipment is primarily and customarily used to serve a
medical purpose and generally considered to be safe and effective for
the intended purpose.
5. Items generally not useful to a person in the absence of illness or
injury.
Exclusions:
Air conditioners; Whirlpools; Portable Whirlpool Pump; Chair Lifts;
Communication Aids; Elevators; False Teeth; Massage Devices; Overbed
Tables; Sauna Bath; Telephone Alert Systems; Wigs (except where required by
law). Experimental or investigational devices, items or equipment; Items
that are not primary medical in nature.
Member is responsible for the following copayment, per item $0.
Maximum annual out-of-pocket limit $0.
UNITED STATES HEALTH CARE SYSTEMS OF PENNSYLVANIA, INC.,
dba THE HEALTH MAINTENANCE ORGANIZATION OF
PENNSYLVANIA dba
U.S. HEALTHCARE
FLEX OPTION PLAN
PRESCRIPTION PLAN RIDER
United States Health Care Systems of Pennsylvania, Inc., d/b/a The Health
Maintenance Organization of Pennsylvania d/b/a U.S. Healthcare ("HMO") and
Contract Holder agree to offer to the HMO Members the HMO Prescription Plan,
subject to the following provisions:
SECTION I - DEFINITIONS is amended to include the following definitions:
Participating Pharmacy - a Pharmacy which has contracted with HMO to
provide prescription services to Members.
Average Wholesale Price (AWP) - The published, average price of drugs,
available through wholesale distributors per the Blue Book.
SECTION II - BENEFITS is amended to add the following provision:
I. Prescription drugs and medications, including insulin, when prescribed
by a licensed Physician. Each prescription is limited to a maximum
34-day supply, with up to five (5) refills when authorized by a
licensed Physician. Prescriptions must be filled at the Participating
Pharmacy chosen by the Subscriber, in writing, on forms provided by
HMO, in advance of enrollment in the HMO Prescription Plan. Except for
under Option II.C.3. Generic pharmaceuticals may be substituted for
brand name products, as provided by law, for prescriptions filled
under this rider. There is a $10.00 Copayment, payable directly to the
Participating Pharmacy for each prescription. This Copayment is not
subject to the copayment limitation set forth in the Contract.
ADDITIONAL OPTIONAL BENEFITS
The following benefits/prescriptions are additionally covered as described above
when the corresponding line is appropriately marked:
1. Oral Contraceptives
Exclusion IlI(a) is hereby deleted in its entirety.
2. Diabetic SuppIies
Diabetic Needles and Syringes.
Diabetic test agents, devices and ravage preparations.
Exclusions IlI(c) and (f) are hereby deleted as they relate to
diabetic supplies only
3. Generic/Brand Name Prescriptions
When a generic alternative is available, Member will pay the higher
copayment based on Member's decision to purchase a brand name
prescription according to the following checked option. Member will
not be subject to the higher copayment when a generic brand is not
available.
___$2.50/$7.50; ___$5.00/$10.00; ___$10.00/$15.00;
___$15.00/$20.00.
SECTION II.G, EMERGENCY SERVICES is amended to add:
Emergency prescriptions out of area - If an emergency prescription is
needed when the Member is located beyond a reasonable distance from
his or her Participating Pharmacy, HMO will reimburse, subject to
professional review, 75% of the cost of the prescription, less the
Copayment.
SECTION III - EXCLUSIONS is amended to include the following provision:
32.(a) Oral contraceptives when used for the purpose of birth control;
(b) injectable except for insulin;
(c) needles and syringes including but not limited to diabetic needles and
syringes;
(d) drugs which do not require a prescription even if a prescription is
written;
(e) medical supplies, devices and equipment;
(f) test agents and devices including but not limited to diabetic tests
agents and ravage preparations;
(g) drugs used for cosmetic purposes, including but not limited to Loniten
(Minoxidil) compounded for hair growth;
(h) experimental and/or investigational drugs;
(i) drugs prescribed for uses other then uses approved by the FDA or other
appropriate regulatory agency; and
(j) smoking cessation aids.
SECTION VIII - CONVERSION is amended to read:
Prescription Plan - The conversion privilege does not apply to the HMO
Prescription Plan.
UNITED STATES HEALTH CARE SYSTEMS OF PENNSYLVANIA, INC.,
dba THE HEALTH MAINTENANCE ORGANIZATION OF
PENNSYLVANIA, INC. dba
U.S. HEALTHCARE
FLEX OPTION PLAN
LENS REIMBURSEMENT RIDER
Schedule lI.A.3.f. of this Contract is hereby amended to read:
United States Health Care Systems of Pennsylvania, Inc., d/b/a The Health
Maintenance Organization of Pennsylvania, Inc. dba U.S. Healthcare. ("HMO") and
Contract Holder agree to offer to the HMO Members the following benefit subject
to the following provisions:
f. Routine eye examinations and referral to Member's Participating
Specialist Physician for appropriate vision care when necessary.
Additionally, HMO will reimburse Member up to $35.00 for the purchase
of prescription lenses and frames (including contact lenses). This
allowance is payable once in a twenty-four (24) month period which
commences with the Member's initial use date of this benefit.
CORPORATE HEALTH INSURANCE COMPANY
(A Minneapolis, Minnesota Domiciled Company)
Principal Executive Offices:
000 Xxxxx Xxxx
Xxxx Xxxx, Xxxxxxxxxxxx 00000
COMPREHENSIVE MAJOR MEDICAL
GROUP HEALTH INSURANCE POLICY
NON-PARTICIPATING
This Comprehensive Major Medical Group Health Insurance Policy (the "Policy") is
a legal contract between Corporate Health Insurance Company ("CHI" or the
"Company") and the policyholder indicated on the Schedule of Benefits (the
"Policyholder"), which is set forth in the Summary of Benefits distributed to
each eligible employee of the Policyholder and incorporated herein by reference.
In consideration of a signed application and payment of the required premiums,
the Company agrees to provide insurance for eligible employees of the
Policyholder and their eligible dependents while such persons are covered under
this Policy and arc insured for the applicable coverage. Benefits are subject to
the terms, conditions, exclusions and limitations of this Policy. Certain
identified benefits are subject to pre-certification requirements, which if not
followed will result in reduced benefits.
This Policy takes effect 12 01 a.m. Eastern Standard Time on the Effective Date
at the Policyholder's address.
Corporate Health Insurance Company has caused its President and Secretary to
execute and witness this Policy.
/s/ /s/
Secretary President
TABLE OF CONTENTS
I. General Information 1
II. Eligibility 2
III. Enrollment Changes 5
IV. Policy Benefits and Payments 5
V. Pre-Certification 7
VI. Covered Medical Services 8
VII. General Exclusions 18
VIII. General Provisions 20
IX. Continuation of Coverage 23
X. Coordination of Benefits 26
XI. Medicare 28
XII. Subrogation 29
XIII. Policyholder/Employer Provisions 29
XIV. Definitions 31
I. GENERAL INFORMATION
1. POLICY NUMBER: PA01-018927-001, PA05-018927-013,
PA03-018927-028, PA09-018927-009, GN02-018927-002, NJ01-018927-025,
GN01 -018927-003, GN03 -018927-004, NE01 -018927-005, NH01 -018927-007,
MD01 -018927-008, MD02-018927-012, DC01-018927-009, RI01-018927-010,
GA01-018927-011, VA01-018927-026
2. POLICYHOLDER NUMBER: As listed above
3. NAME AND ADDRESS OF POLICYHOLDER
STV Group
00 Xxxxxxxx Xxxxxx
P.O. Box 459
Pottstown, PA 19464
4. EMPLOYER IDENTIFICATION NUMBER (E.I.N.) ASSIGNED
BY INTERNAL REVENUE SERVICE: NOT AVAILABLE
5. TYPE OF POLICY: Group Health Insurance Policy - Liberty Flex
6. THE NAME, BUSINESS ADDRESS AND TELEPHONE NUMBER OF THE COMPANY:
CORPORATE HEALTH INSURANCE COMPANY
000 Xxxxx Xxxx
P.O. Box 1109
Blue Bell, Pennsylvania 19422
0-000-000-0000
7. POLICY EFFECTIVE DATE: December 1, 1995
8. WAITING PERIOD: Full-Time Active Employees Working 30 Hours or
More Per Week; Eligible for Benefits first of the
- month following Date of Hire
1
II. ELIGIBILITY_
1. Covered Persons
This Policy will cover the following Covered Persons:
(i) all Eligible Employees of the Policyholder and its subsidiaries and
affiliates specifically identified in writing by the Policyholder to
the Company; and
(ii) their eligible Dependents.
2. Eligibility Date
The "Eligibility Date" for each Covered Person will be:
(i) if the Covered Person is an Eligible Employee, the later of the date
of hire by the Policyholder (or, if applicable, the date on which the
waiting period imposed by the Policyholder ends) and the Effective
Date of this Policy; or
(ii) if the Covered Person is an Eligible Dependent, the later of the date
of hire (or, if applicable, the date on which the waiting period
imposed by the Policyholder ends) of the Eligible Employee to whom
such Covered Person is a Dependent and the Effective Date of this
Policy.
3. When Coverage Begins
(a) If an Eligible Employee enrolls on or before the Effective Date of
this Policy, coverage will begin under this Policy on the Effective
Date for such Eligible Employee and any Eligible Dependents of such
Employee identified as Covered Persons in the Policy Enrollment Form.
(b) If an Eligible Employee enrolls after the Effective Date of this
Policy, coverage will begin on the first day of the calendar month
after the Eligible Employee enrolls under this Policy.
(c) An Eligible Employee will be deemed to have enrolled under this Policy
when the Eligible Employee has completed, signed and delivered a
Policy Enrollment Form, identifying any Eligible Dependents as Covered
Persons, to the Company and such Policy Enrollment Form has been
accepted by the Company at its sole discretion.
(d) Should the Eligible Employee not be working full-time on the day he or
she would ordinarily become covered under this Policy, the coverage
for such Employee and any Eligible Dependents will be delayed until he
or she returns to full-time work.
(e) Limitation: Each Eligible Employee will have 31 days from his or her
Eligibility Date to enroll for coverage. No Evidence of Good Health
will be required for any Eligible Employee enrolling within such 31
days. All Eligible Employees enrolling after such 31 days will be
required to submit Evidence of Good Health for his or herself and for
each Eligible Dependent. If such Employee fails to provide Evidence of
Good Health satisfactory to the Company, the Company may reject the
Employee's enrollment application for insurance under this Policy.
Coverage under this Policy for enrollees after such 31 days who
provides satisfactory Evidence of Good Health will begin no earlier
than the first day of the calendar month after CHl's approval of
Evidence of Good Health.
2
(f) For purpose of this Article only, each Eligible Employee who enrolls
under this Policy during any designated open enrollment period of the
Policyholder shall be deemed and treated as a new employee of the
Policyholder.
4. Return to Work After Voluntary Termination of Employment
If an Eligible Employee returns to active full-time employment with the
Policyholder at any time following voluntary termination of employment with
the Policyholder, the waiting period described herein for new Employees
will apply, unless the Eligible Employee returns within 12 months after the
date of the voluntary termination.
5. Dependent Coverage
(a) A Covered Employee's spouse and a Covered Person's dependent children
can also be covered under the Policy pursuant to the terms hereof.
(b) The Covered Employee's spouse is eligible for dependent coverage
unless:
(i) The Covered Employee and his or her spouse are legally separated
or divorced or have obtained an annulment;
(ii) Both the Covered Employee and his or her spouse are employees of
the Policyholder. The Covered Employee and his or her spouse may
choose to be covered as individual employees of the Policyholder,
or one may cover the other as a Dependent, but both of them may
not cover the other as a Dependent;
(iii) Such spouse is in active Military Service;
(iv) Such spouse is of the same sex; or
(v) Such spouse is not a legal spouse, under the laws of the
Commonwealth of Pennsylvania.
(c) The Covered Person's natural or legally adopted child is eligible from
birth so long as the child is:
(i) Less than age 23, or if a full-time student, less than age 23;
(ii) Not married; and
(iii) Not on active duty in any of the armed forces.
(d) Child/children under legal guardianship (including xxxxxx children) or
children under court order will be included under this Policy under
the same conditions and restrictions applicable to a Covered Person's
natural or legally adopted children.
(e) The Covered Employee's spouse and child/rep meeting the requirements
described above are referred to in this Policy as "Eligible
Dependents."
6. Enrolling the Eligible Employee's Eligible Dependents
(a) The Eligible Employee can enroll for family coverage at the same time
he or she becomes eligible for his or her individual coverage.
3
(b) If the Eligible Employee has no Dependents when the Eligible Employee
first enrolls but later gains one, the Eligible Employee may enroll
for family coverage within 31 days of the date the Eligible Employee
gains the Dependent. This includes Dependents gained by marriage,
birth adoption, legal guardianship or court order. During the first 31
days after the birth of a child, the child will be automatically
covered for all eligible benefits. For coverage of a child beyond the
first 31 days after birth and for coverage of a spouse during and
beyond the first 31 days after marriage, enrollment must be made and
the first premium charge for that Dependent must be paid within that
31 day period.
(c) Note: Except for newborn child's coverage during the first 31 days
after birth. if the Eligible Employee does not enroll his or her
Dependents within 31 days after the Dependent becomes eligible,
satisfactory Evidence of Good Health for each Dependent will be
required. If satisfactory Evidence of Good Health is not provided for
such Dependent, the Company may reject the enrollment application for
insurance of such Dependent under this Policy. Coverage for such
Dependent providing satisfactory Evidence of Good Health will then
begin no earlier than the first day of the calendar month following
CHI's approval of the Evidence of Good Health. However, no Evidence of
Good Health will be required for any Dependent who enrolls within such
31 days.
(d) If a Dependent, except a child covered at birth, is confined for
medical care or treatment in any institution or at home when coverage
would normally start, the Dependent will not be covered until given a
final release by a Physician from all such confinement.
7. When Dependent Coverage Stops
Except as otherwise specifically provided in this Policy, coverage for
Dependents shall end when the dependent relationship with the Eligible
Employee ends or when coverage for the Eligible Employee of whom such
person is a Dependent ends. When coverage for a Dependent ends, the
Dependent will have an opportunity to obtain continuation of medical
coverage as provided by the Consolidated Omnibus Budget Reconciliation Act
(COBRA). For more information on COBRA and the right to continued medical
coverage, see Section 1 of Article IX of this Policy.
8. Extension of Coverage for Dependents
(a) Under certain circumstances described below, coverage could continue
for an Eligible Dependent after the time coverage would normally stop
under this Policy.
(b) A child who is otherwise eligible hereunder and is physically or
mentally incapable of self support upon attaining the limiting age may
be continued under the coverage provided hereunder so long as he or
she remains incapacitated and unmarried at that time, subject to the
coverage of the Covered Employee to whom such child is dependent is
continuing in effect.
(c) To be eligible for the continued coverage described in this Section of
a Dependent child beyond the time coverage would normally end, proof
of his or her incapacity must be submitted to CHI within 31 days after
such Dependent's attainment of the limiting age. Proof of the
incapacity will be required from time to time to keep this coverage in
effect. Each time CHI asks for proof that a Covered Dependent is
incapacitated, CHI may require the Covered Dependent to have a
Physician's examination at the Covered Person's expense. CHI may
specify the Physician.
(d) The continued coverage of a dependent child under this Section shall
terminate on the earliest of the following dates:
4
(i) the date such child is no longer incapacitated according to the
Policy;
(ii) the date proof of the child's incapacity is not provided when
asked; or
(iii)the date his or her Dependent's coverage terminates pursuant to
Article II, Section 7 or Article XIII of this Policy.
III. ENROLLMENT CHANGES
Enrollment and benefit coverage under this Policy may be changed only upon a
change in family status of the Covered Employee.
A "change of family status" occurs when:
1. A Covered Employee gets married or divorced;
2. A Covered Employee's child is born or legally adopted;
3. A Covered Employee's spouse or child dies; or
4. A Covered Employee's spouse has a loss of group insurance coverage.
Unless otherwise permitted under Article II, a Covered Employee may change his
or her benefit coverage or enroll new Dependents only if Evidence of Good Health
has been submitted and approved by CHI for each individual involved.
Furthermore, if a Dependent of a Covered Employee, other than a newborn child,
is confined in a Hospital, Skilled Nursing Facility, at home or any other
institution on the date coverage would become effective, then such coverage will
be postponed until the day after the Dependent is no longer so confined and a
final release from such confinement is provided by the Physician.
IV. POLICY BENEFITS AND PAYMENTS
If, as a result of an illness or injury, a Covered Person incurs eligible
medical expenses which exceed the Deductible Amount set forth in the Schedule of
Benefits during a calendar year, the Company will pay for such excess in
accordance with the co-payment and co-insurance provisions of the Schedule of
Benefits, subject to all other terms and conditions set forth in this Policy.
1. Deductible Amount
The Deductible Amount is the specified amount of eligible expenses which a
Covered Person or a Family Unit (as the case may be) is required to pay before
CHI pays any benefits under this Policy. Covered expenses which are used in
satisfying the Deductible Amount must be incurred and applied to such deductible
within the applicable calendar year.
The Deductible Amount applies to each Covered Person, subject to any family
Deductible Amount set forth in the Schedule of Benefits, if applicable. The
Deductible Amount must be satisfied once each calendar year, except for:
(a) the Common Accident Provision: if the Deductible Amount applies to
accident expenses and if two or more members of one family incur
covered expenses because of disabilities resulting from injuries
5
sustained in any one accident, the Deductible Amount will be applied
only once with respect to all covered expenses incurred as a result of
the accident; and
(b) the Carryover Provision: if any part or all of the Deductible Amount
has been satisfied during the last three months of such calendar year,
the Deductible Amount for the next calendar year will be reduced by
the amount applied.
The Deductible Amount is not applicable to certain eligible medical expenses
noted in the Schedule of Benefits, for which you or your family member need to
pay any Deductible Amount prior to being paid benefits under the Policy.
2. Co-Payment and Co-Insurance
After the applicable Deductible Amount has been paid by the Covered Person or
the Family Unit (as the case may be), the eligible expenses for Covered Medical
Services will be paid by CHI and the Covered Persons in accordance with the
co-payment and co-insurance provisions set forth in the Schedule of Benefits.
Certain Covered Medical Services will be subject to co-insurance provisions,
which require the payment obligations in excess of the Deductible Amount to be
shared between CHI and the Covered Person in accordance with percentages of
Reasonable and Customary Charges set forth in the Schedule of Benefits. Certain
other Covered Medical Services will be subject to co-payment provisions, which
require an initial sum specified in the Schedule of Benefits to be paid by the
Covered Person and the balance of Reasonable and Customary Charges to be paid by
CHI.
Certain Covered Medical Services specified in the Schedule of Benefits may not
be subject to co-insurance or copayment requirements.
3. Out-of-Pocket Maximum
During any calendar year, the Covered Person or the Family Unit (as the case may
be) will not be required to pay an aggregate amount in excess of the
out-of-pocket maximum amount specified in the Schedule of Benefits (the
"Out-of-Pocket Amount"). If during any calendar year the Covered Person or the
Family Unit (as the case may be) has paid pursuant to the above co-insurance or
co-payment provision an aggregate amount greater than the Out-of-Pocket Amount,
CHI will pay for 100% of the balance of the eligible expenses, up to the amount
of the maximum benefit amounts set forth in the Schedule of Benefits.
The co-insurance and co-payments paid by the Covered Person or the Family Unit
will be included in the Out-of-Pocket Amount. However, the Deductible Amount
paid by the Covered Person or the Family Unit will not be included in the
Out-of-Pocket Amount.
4. Maximum Benefits
The benefits payable under this Policy for all eligible medical expenses
incurred by any Covered Person shall not exceed the applicable maximum benefits
specified in the Schedule of Benefits. Such maximum benefits may be in the form
of a maximum amount payable during lifetime or a specified period or in the form
of a maximum number of days or visits for which benefits are payable under the
Policy. Different Covered Medical Services may be subject to one or more
different maximum benefits.
5. Restoration and Reinstatement
If a Covered Person has received his or her maximum benefits under the Policy,
then on the first day of each calendar year $1,000 shall be reinstated, but in
no event shall the reinstated amount exceed the applicable maximum benefits set
forth in the Schedule of Benefits. However, any Covered Person who wishes
immediate reinstatement of the full Policy maximum shall again be entitled to
receive full benefits by submitting Evidence of Good Health at his or her own
expense. The new maximum benefits will take effect on the first day of the month
6
following CHI's approval at its sole discretion of Evidence of Good Health. This
restoration and reinstatement provision will not apply to certain Covered
Medical Services, as specified in the Schedule of Benefits.
6. Re-Entry Into Policy
Any person who was formerly covered under the Policy, either as an Eligible
Employee or as a Dependent, and who again becomes covered hereunder within a
one-year period from the termination date of his or her previous coverage,
either as an employee or as a Dependent, shall not have his or her full maximum
benefits restored solely by reason of the fact that s/he has become covered for
a second or subsequent time. The maximum benefits with respect to such person,
as set forth in the Schedule of Benefits, shall be reduced by any benefits
previously paid under this Policy.
V. PRE-CERTIFICATION
When a Physician recommends that a Covered Person be hospitalized or receive
certain other medical services or supplies specified in the Schedule of
Benefits, there are certain procedures that must be followed.
The Covered Person, a member of his or her family, a hospital staff member, or
the attending Physician, must notify CHI to pre-certify the admission or
treatment, as the case may be, prior to receiving any of the services or
supplies that require pre-certification pursuant to the Schedule of Benefits or
this Policy.
The Company will reduce the benefits payable under this Policy by the percentage
set forth in the Schedule of Benefits if the procedures for pre-certification
set forth herein are not followed. Each Covered Person will be responsible to
pay the unpaid balance of the benefits.
To obtain pre-certification, call CHI at 0-000-000-0000. This call must be made:
1. Prior to any planned admission into Hospital and prior to receiving
such other eligible services or supplies that require
pre-certification according to the Schedule of Benefits or this
Policy;
2. Within 24 hours after the time of an emergency admission or as soon
thereafter as reasonably possible; and
3. As soon as the attending Physician confirms that a Covered Person is
pregnant and again within 24 hours of the birth or as soon thereafter
as reasonably possible.
When calling CHI, the caller must provide:
1. The Covered Person's name and the Covered Person's social security
number;
2. The treating Physician's name, address and phone number;
3. The name of the Hospital or treatment facility and the anticipated
admission or treatment date; and
4. The Policyholder's name and Policyholder Policy Number.
There is no requirement to call in advance before seeking treatment for an
emergency.
Large Case Management
Certain medical conditions for which a claim is made under the Policy may be
referred to Large Case Management (LCM).
Only those conditions for which Covered Medical Expenses are expected to exceed
a certain dollar amount, and for which there is a potential lower cost treatment
alternative, will be referred to LCM.
7
LCM is a program which provides a case-by-case analysis and medical treatment
plan suggestions that address the need of catastrophically ill or injured
individuals. It concentrates on severe injuries and illnesses, such as spinal
cord injuries or head trauma, when early intervention and individual case
management will prove effective to a patient's recovery.
The decision to refer any case to LCM will remain with CHI, who will rely on the
criteria established by the LCM service provider to determine which claims are
recommended for LCM, except that no alternative treatment will be provided to
the Covered Person under LCM without prior consent of the Covered Person and the
attending Physician.
In certain instances a recommendation to use alternative treatment not normally
covered by the Policy may be made when such treatment endorses quality care,
Medical Necessity and cost effectiveness. Under these circumstances, any such
alternative treatment will be covered by the Policy.
VI. COVERED MEDICAL SERVICES
Subject to the terms, conditions, exclusions and limitations set forth in the
Schedule of Benefits (including the copayment, co-insurance and maximum benefit
amounts set forth therein) and in this Policy, the Company will pay and provide
to each Covered Person the benefits described below.
This Policy does not cover charges in excess of Reasonable and Customary Charges
(as defined herein) and does not provide benefits for service" or supplies other
than those Medically Necessary (as defined herein). Therefore, the term
"charges" used below shall refer only to Reasonable and Customary Charges for
Medically Necessary services or supplies. The coverage under this Policy is also
subject to other exclusions set forth in Article VII of this Policy.
Acupuncture
The charges for the administration of acupuncture when provided for pain
management in lieu of anesthesia.
Alcoholism and Drug Addiction Treatment
For alcoholism and drug addiction treatment, please refer to "Substance Abuse
Treatment" below.
Ambulance Transportation
The charges for ambulance service. Coverage is limited to transportation to and
from the nearest facility that can give necessary care and treatment.
Ambulatory Surgery
The charges for services and supplies furnished in connection with performance
of a surgical procedure at an Ambulatory Surgical Facility or the outpatient
department of a Hospital.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 0-000-000-0000 prior to
treatment. The Company will reduce the benefits under this Policy by the
percentage or dollars (as the cage may be) set forth in the Schedule of Benefits
if the procedures for pre-certification are not followed.
Limitations/Exceptions
Coverage is limited to charges for the following:
8
1. Services and supplies furnished by the Ambulatory Surgical Facility or
Hospital on the date of the procedure;
2. Services of the operating Physician for performing the procedure and
for:
a. Related pre- and post-operative care; and
b. The administering of an anesthetic; and
3. Services of any other Physician for the administering of a general
anesthetic.
This Policy does not cover Ambulatory Surgery charges incurred:
(a) For the services of a Physician who renders technical assistance: to
the operating Physician, unless required in connection with the
procedure; or
(b) While the Covered Person is confined as a full-time Inpatient in a
Hospital.
Anesthesia
The charges for the administration of anesthetics by a Physician (other than the
surgeon, assistant surgeon or the attending Physician) or registered nurse
anesthetist (R.N.A.).
Assistant Surgeon
The charges for the professional services of a legally qualified Physician to
render technical assistance to the operating surgeon when Medically Necessary in
connection with a surgical procedure performed. However, no benefits are payable
for surgical assistance rendered in hospitals where it is routinely available as
a service provided by a hospital intern, resident or house officer. The
assistant surgeon's charges are determined by using the surgeon's Reasonable and
Customary Charges.
Birthing Center
The charges for services and supplies furnished by a Birthing Center for:
1. Prenatal care;
2. Delivery of a child or children; and
3. Post-partum care rendered within twenty-four (24) hours after the
delivery.
Also included are charges for the services shown below if received in connection
with the above services and supplies furnished by the Birthing Center:
1. Charges by the operating Physician or certified nurse midwife for:
a. Performing an obstetrical procedure;
b. Related pre- and post-operative care; and
c. Administering an anesthetic.
2. Charges by any other Physician for the administering of a general
anesthetic.
Limitations/Exclusions
This Policy does not cover Birthing Center charges incurred:
1. For the services of a Physician or certified nurse midwife who renders
technical assistance to the operating Physician; or
2. For which pregnancy-related expenses are not covered under this
Policy.
9
Blood and Blood Plasma
The charges for blood and blood plasma, and blood plasma expanders when not
replaced on behalf of the Covered Person.
Cardiac Rehabilitation Services
The charges for cardiac rehabilitation therapy rendered by a licensed therapist,
when prescribed by and provided under the supervision of the attending
Physician.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 0-000-000-0000 prior to
receiving services. The Company will reduce the benefits under this Policy by
the percentage or dollars (as the case may be) set forth in the Schedule of
Benefits if the procedures for pre-certification are not followed.
Chemotherapy
The charges for the treatment of malignant disease by chemical or biological
antineoplastic agents for cancer chemotherapy and cancer hormone treatments and
for services which have been approved by the United States Food and Drug
Administration for general use in treatment of cancer, whether performed in a
Physician's office, as an Inpatient or Out-Patient at a Hospital, or in any
other medically appropriate treatment setting.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 0-000-000-0000 prior to
treatment. The Company will reduce the benefits under this Policy by the
percentage or dollars (as the case may be) set forth in the Schedule of Benefits
if the procedures for pre-certification are not followed.
Chiropractic Care
The charges for detection and correction by manual means of structural imbalance
or subluxation resulting from or related to distortion, misalignment or
subluxation of or in the vertical column.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 0-000-000-0000 prior to
treatment. The Company will reduce the benefits under this Policy by the
percentage or dollars (as the case may be) set forth in the Schedule of Benefits
if the procedures for pre-certification are not followed.
Consultation
The charges for consultation services by a Professional Provider, provided that
the consultation services are given to the Covered Person at the request of the
attending Physician while confined as an Inpatient in a Hospital, a Skilled
Nursing Facility or a Substance Abuse Treatment Facility.
Consultation consists of an examination of the Covered Person and a review of
his or her x-ray and laboratory examinations and medical history, but not staff
consultations required by hospital rules and regulations.
Diagnostic Services
The charges for Diagnostic Services.
10
Durable Medical Equipment
The charges for rental or initial purchase (or necessary repair) of Durable
Medical Equipment prescribed by a Physician for the treatment of an Illness or
Injury. It does not include any changes made to the Covered Person's home,
automobile, or personal property, such as air conditioning or remodeling. Rental
coverage is limited to the purchase price of the Durable Medical Equipment.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 0-000-000-0000 prior to
leasing or purchasing any equipment in excess of $1,500. The Company will reduce
the benefits under this Policy by the percentage or dollars (as the case may be)
set forth in the Schedule of Benefits if the procedures for pre-certification
are not followed.
Emergency Services
The charges for Emergency Services received within 48 hours after the onset of a
Medical Emergency. Surgery (e.g., suturing, burn care, fracture care, etc.)
payment will be made as a surgical benefit.
After being admitted into a facility for Emergence Services, CHI must be
notified at 0-000-000-0000 within 24 hours of the admission or as soon as
reasonably possible. The Company will reduce the benefits under this Policy by
the percentage or dollars (as the case may be) set forth in the Schedule of
Benefits if the procedures for such notification are not followed.
Hemodialysis
The charges for hemodialysis treatment.
Home Health Services
The charges for Home Health Services provided by a licensed Home Health Agency
pursuant to a Home Health Plan.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 0-000-000-0000, and CHI
must approve the Home Health Plan, prior receiving Home Health Services. The
Company will reduce the benefits under this Policy by the percentage or dollars
(as the case may be) set forth in the Schedule of Benefits if the procedures for
pre-certification are not followed.
Limitations/Exclusions
Coverage is limited to one visit per day. Each period of up to four (4) hours or
less will be considered one visit, and each visit by a Home Health Agency is
counted as one visit.
Hospice Care
The charges for Hospice Services if the attending Physician certifies that the
Covered Person is a Terminally Ill Person and recommends admission into a
Hospice Care Program.
To qualify for payment under the Policy, Hospice Services must be:
1. Provided while the Terminally Ill Person is a Covered Person;
2. Provided within six (6) months of the Terminally Ill Person's entry or
re-entry (after a remission period) in the Hospice Care Program; and
3. Furnished or arranged by a Hospice.
11
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 0-000-000-0000, and CHI
must approve the Hospice Care Program, prior receiving Hospice Services. The
Company will reduce the benefits under this Policy by the percentage or dollars
(as the case may be) set forth in the Schedule of Benefits if the procedures for
pre-certification are not followed.
Limitations/Exclusions
Coverage is limited to one or more of the following charges:
1. For the confinement of a Terminally Ill Person as an Inpatient in a
Hospice facility;
2. For Home Health Services furnished to the Terminally Ill Person in the
person's home;
3. For social services furnished to the Terminally Ill Person or to the
Family Unit by a Social Worker;
4. For palliative care (medication/treatment directed toward relief); or
5. For respite care.
Hospital
The charges for Out-Patient services and supplies, and the following Inpatient
charges when a Covered Person is confined in a Hospital:
1. Room and board and general nursing care charges for semi-private
accommodations (designated as such by the Hospital) or, if the Covered
Person utilizes private accommodations because the Covered Person's
medical condition requires isolation for his or her health and the
attending Physician orders such private accommodations, charges for
private accommodations; and
2. Charges for all other hospital services and supplies, including
special meals and dietary services, medicines, laboratory tests, use
of operating rooms and special equipment, anesthetics and x-rays,
provided and billed by hospital.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to hospital admission as an Inpatient. The Company will
reduce the benefits under this Policy by the percentage or dollars (as the case
may be) set forth in the Schedule of Benefits if the procedures for
pre-certification are not followed.
Limitations/Exclusions
The Policy does not cover hospital charges for any day that the Covered Person
does not receive any medical treatment after being admitted to a Hospital.
Immunization for Children
The charges for child immunization, up to the minimum benefits mandated by the
Pennsylvania Department of Health.
Coverage will be provided for those child immunizations, including the
immunizing agents, which as determined by the Department of Health, conform to
the standards of the U.S. Department of Health and Human Services. These
benefits will be exempt from Deductible Amounts and other dollar limits.
12
Infertility Services
The charges for services to diagnose infertility. Services to treat infertility
are not covered by this Policy.
Inpatient Physician Services
The charges for medical treatment given by the attending Physician to a Covered
Person while confined as an Inpatient in a Hospital or Skilled Nursing Facility.
Limitations/Exclusions
Inpatient Physician services coverage does not include charges for:
1. Surgical services;
2. Diagnostic Services;
3. Maternity services;
4. Any therapy;
5. For psychiatric treatment; or
6. Treatment rendered to a Covered Person who has exceeded the maximum
number of days of confinement or the maximum benefit amount for
Inpatient Physician services, as set forth in the Schedule of
Benefits.
Mammography
The charges for female Covered Person's expenses for mammography services, up to
one routine mammography every calendar year if the Covered Person is age 40 or
older. In addition, any mammography recommended by a Physician.
Maternity-Related Care
The charges for female Covered Person's expenses incurred as a result of
pregnancy, miscarriages and Medically Necessary and elective abortions. Life
threatening abortions will be covered as any other surgery.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must notify CHI at 0 000-000-0000 as soon as
pregnancy is confirmed and within 24 hours after birth of a child or as soon
thereafter as reasonably possible.
Mental or Nervous Disorders
For coverage of mental or nervous disorder, please refer to "Psychiatric
Treatment" below.
Newborn Baby Care
The charges for care of newborn children, including Hospital charges for nursery
room and board and miscellaneous expenses.
Occupational Therapy
The charges for occupational therapy rendered by a licensed therapist for
Illnesses and Injuries of the Covered Person.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to treatment. The Company will reduce the benefit under
this Policy by the percentage or dollars (as the case may be) set forth in the
Schedule of Benefits if the procedures for pre-certification are not followed.
13
Limitations/Exclusions
Coverage is limited only to treatment for up to such number of days per incident
of Illness or Injury set forth in the Schedule of Benefits, beginning with the
first day of treatment.
Office Visits
The charges for diagnosis or treatment of any Injury or Illness at a Physician's
office.
Organ Transplants
The charges for services which are directly and specifically related to organ
transplant when performed at a Hospital. Where the Covered Person is the
recipient, coverage hereunder includes the hospitalization of donors, and for
those hospital services directly and specifically related to the transplantation
of the organ to the Covered Person, to the extent that the Covered Person
(recipient) would be entitled to such benefits and the donor is not otherwise
insured or covered by another health care plan.
The purchase price of the organ is not covered under this Policy. Coverage under
this Policy is limited to organ transplants meeting the following requirements:
1. The attending Physician certifies that the organ transplant is
Medically Necessary;
2. The covered Person must be the recipient; and
3. The transplant is accepted by the general medical community at the
time of the procedure as appropriate treatment for the specific
conditions of the Covered Person.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to treatment. The Company will reduce the benefits under
this Policy by the percentage or dollars (as the case may be) set forth in the
Schedule of Benefits if the procedures for pre-certification are not followed.
Oxygen
The charges for oxygen and the rental equipment for its administration when
prescribed by the attending Physician.
Xxxxxxxxxxxx Xxxxx (Pap Smear)
The charges for a female Covered Person's expenses for a routine pap smear in
accordance with the recommendations of the American College of Obstetricians and
Gynecologists.
Physical Therapy
The charges for physical therapy rendered by a licensed therapist for Illnesses
and Injuries of the Covered Person.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to receiving services The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Preventive Care
The charges for an annual gynecological examination, including a pelvic
examination and clinical breast examination by a Physician.
14
The charges for immunizations (other than immunization for children covered
elsewhere in this Policy) and physical examinations (other than papanicolaou
smears and mammography covered elsewhere in this Policy) by a Physician, subject
to the limitations set forth in the Schedule of Benefits.
Private Duty Nursing
The charges for private duty professional nursing services from a L.P.N. or R.N.
for a Covered Person's non-hospitalized acute-illness or injury
Private duty nursing care furnished for Custodial Care is not covered.
The Covered Person, a member of his or her family, a hospital member; but
preferably the attending Physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Psychiatric Treatment
The charges for the following Inpatient and Out-Patient services for a Covered
Person for the treatment of a Mental Illness.
Inpatient: The hospital services and supplies provided to a Covered Person for
the treatment of a Mental Illness while confined as an Inpatient at a Hospital
or a Psychiatric Hospital.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at 1
000-000-0000 prior to admission. The Company will reduce the benefits under this
Policy by the percentage or dollars (as the case may be) set forth in the
Schedule of Benefits if the procedures for pre-certification are not followed.
Out-Patient: The following Out-Patient services for the treatment of a Mental
Illness rendered by a licensed psychiatrist, psychologist, psychotherapist or
psychiatric Social Worker at a Mental Health Treatment Facility:
1. Oral and written diagnostic tests;
2. Consultation visits;
3. Diagnostic visits;
4. Physician's personal treatment visits; and
5. Group therapy.
Radiation Therapy
The charges for the treatment of any Illness or Injury by x-ray (but not dental
x-rays, unless directly related to a Covered Medical Service), gamma ray,
accelerated particles, mesons, neutrons, radium or radioactive isotopes,
including the cost of radioactive materials.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
15
Reconstructive/Corrective Surgery
The charges for reconstructive surgery if such surgery is required to:
1. To restore normal functions of a body part (other than a tooth or
structure that supports the teeth) which is malformed as a result of a
birth defect or as a direct result of Illness or Injury or surgery
performed to treat an Illness; or
2. Repair an Injury which occurs while the person is covered under this
Policy. Surgery must be performed in the calendar year of the accident
which causes the Injury or in the next calendar year.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to receiving surgery. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Reconstructive surgery coverage does not include Cosmetic Surgery.
Respiratory Therapy
The charges for respiratory therapy rendered by a licensed therapist for
Illnesses and injuries of the Covered Person.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at 1
000-000-0000 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Skilled Nursing Facility
The charges listed below when a Covered Person is confined as an Inpatient in a
Skilled Nursing Facility while recovering from an Illness or Injury. Coverage is
limited to services and supplies furnished while the Covered Person is under
continuous care of his or her Physician, requires 24-hour nursing care and the
confinement in a Skilled Nursing Facility is required by his or her Physician:
1. Room and board and general nursing care charges for semi-private
accommodations (designated as such by the Hospital) or, if the Covered
Person utilizes private accommodations because the Covered Person's
medical condition requires isolation for his or her health and the
attending Physician orders such private accommodations, charges for
private accommodations; and
2. Charges for all other skilled nursing services and supplies, including
special meals and dietary services and medicines.
Skilled Nursing Facility care coverage does not include Custodial Care.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending Physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to admission. The Company will reduce the benefits under
this Policy by the percentage or dollars (as the case may be) set forth in the
Schedule of Benefits if the procedures for pre-certification are not followed.
Speech Therapy
16
The charges for speech therapy rendered by a qualified speech therapist to
restore or rehabilitate any speech loss or impairment caused by Injury or
Illness, a previous speech therapeutic process, or as a result of surgery for an
Injury or Illness.
The Covered Person, a member of his or her family, a hospital staff member, but
preferably the attending physician, must obtain pre-certification by CHI at
0-000-000-0000 prior to receiving services. The Company will reduce the benefits
under this Policy by the percentage or dollars (as the case may be) set forth in
the Schedule of Benefits if the procedures for pre-certification are not
followed.
Substance Abuse Treatment (including Alcoholism and Drug Addition)
The charges for the following Inpatient and Out-Patient services to treat
Substance Abuse or Dependency, subject to the limitations set forth below and
any additional limitations set forth in the Schedule of Benefits:
1. Out-Patient Care: Covered Medical Services include the following
Out-Patient services in a Substance Abuse Treatment Facility for
treatment for medical conditions resulting from the Substance Abuse or
Dependency: (1) Physician, psychologist, nurse, certified addictions
counselor and trained staff services; (2) rehabilitation therapy and
counseling; (3) family counseling and intervention; (4) psychiatric,
psychological and medical laboratory tests; and (5) drugs, medicines,
equipment use and supplies.
Each Covered Person is eligible for thirty (30) Out-Patient full
visits per calendar year. Each Covered Person is also eligible for
thirty (30) additional Out-Patient full visits or equivalent partial
visits per calendar year at a Substance Abuse Treatment Facility,
which may be exchanged on a two-for-one basis for up to fifteen (15)
non-hospital, residential alcohol or drug treatment days described in
Paragraph 3 below. Treatment for Substance Abuse or Dependency shall
be provided according to an individualized treatment plan, subject to
a lifetime limit of one hundred and twenty (120) Out-Patient full
visits or equivalent partial visits.
2. Inpatient Detoxification: Covered Medical Services include the
following Inpatient services at a Hospital or a Substance Abuse
Treatment Facility for detoxification and treatment for medical
conditions resulting from the Substance Abuse or Dependency: (1)
lodging and dietary services; (2) Physician, psychologist, nurse,
certified addictions counselor and trained staff services; (3)
diagnostic x-ray; (4) psychiatric, psychological and medical
laboratory testing; (5) drugs, medicines, equipment use and supplies.
Each Covered Person is eligible for seven (7) Inpatient days of per
calendar year, subject to a lifetime limit of four (4) separate such
admissions. Inpatient rehabilitation beyond detoxification in the
Hospital is not covered hereunder.
3. Inpatient Rehabilitation: Covered Medical Services include the
following Non-Hospital Substance Abuse Residential Facility care: (1)
lodging and dietary services; (2) Physician, psychologist, nurse,
certified addictions counselor and trained staff services; (3)
rehabilitation therapy and counseling; (4) family counseling and
intervention; (5) psychiatric, psychological and medical laboratory
tests; and (6) drugs, medicines, equipment use and supplies.
Each Covered Person is eligible for thirty (30) days per calendar year
for such residential treatment in a Non-Hospital Substance Abuse
Residential Facility, subject to a lifetime limit of ninety (90) days
of such services.
4. Court-ordered chemical dependency admissions are covered but only to
the extent of the covered benefits described above.
In the case of Paragraph 2 or 3 above, the Covered Person, a member of his or
her family, a hospital staff member, but preferably the attending Physician,
must submit to CHI prior to treatment a certificate from a Physician that the
Covered Person is suffering from Substance Abuse or Dependency and needs
treatment.
17
Voluntary Sterilization
The charges for male or female voluntary sterilization procedures. The Policy
will not cover reversal procedures.
VII GENERAL EXCLUSIONS
This Policy Does Not Cover Charges, Expenses or Costs:
1. For services or supplies not Medically Necessary for the diagnosis or
treatment of an Illness or Injury.
2. Which exceeds the Reasonable and Customary Charges or exceeds the
maximum benefit amounts set forth in the Schedule of Benefits.
3. Caused by war (declared or undeclared) or any act of war.
4. Suffered while on full-time active duty in the armed forces of any
country or international authority.
5. Incurred in connection with any injury or illness which is compensable
under any workers' compensation or occupational disease act or law or
the federal Longshoreman's and Harbor Worker's Compensation Act.
6. For services received in a veteran's administration hospital, a public
health service hospital, or any facility operated by the U.S.
government or any of its agencies, except to the extent that there is
an unconditional requirement to pay those charges.
7. For medical and dental care received by retirees from armed forces or
their dependents pursuant to and covered by programs established under
federal law.
8. For the treatment of or care for mental retardation, defects and
deficiency, except that this exclusion does not apply to Mental
Illnesses specifically covered in Article VI.
9. For dental services related to the care, filling, removal or
replacement of teeth and treatment of injuries to or diseases of the
teeth and gums, including but not limited to apicoectomy (dental root
resection), orthodontics, root canal treatment, soft tissue
impactions, alveolectomy, augmentation and vestibuloplasty treatment
of periodontal disease, and dental implants, except for accidental
injuries to sound natural teeth.
10. For optical services: The Policy does not cover charges for
examinations to determine the need for (or change of) eyeglasses or
lenses of any type except initial replacements for loss of the natural
lens, eye surgery such as radial keratotomy when the primary purpose
is to correct myopia (nearsightedness), hyperopia (farsightedness) or
astigmatism (blurring), or exams for the correction of vision and
radial keratotomy eye surgery to improve visual acuity.
11. For services rendered by the Covered Person or his or her Close
Relative.
12. For medical services or supplies not prescribed or rendered by a
Physician.
13. Directly related to attempted suicide or an intentionally
self-inflicted injury (whether sane or insane).
14. For provision or replacement of the following items arch supports;
elastic hose; birth control devices including, but not limited, to
IUDs, diaphragms and condoms; false teeth; braces; traction apparatus;
canes; walkers; corrective shoes; corsets; wigs or cranial prosthesis;
diapers; special appliances, supplies or equipment. This exclusion
does not apply to Durable Medical Equipment specifically covered by
Article VI.
18
15. For Custodial Care.
16. For Cosmetic Surgery, except reconstructive surgery specifically
covered by Article VI.
17. Resulting from the commission of or attempt to commit a felony by the
Covered Person.
18. For personal convenience items or services such as telephones, xxxxxx
services, meals, formulas, radio and television rentals, homemaker
services and other like items and services.
19. Applied toward satisfaction of the Deductible Amount or the co-payment
or co-insurance amount payable by the Covered Person.
20. For blood, blood plasma and blood products that are replaced on behalf
of the Covered Person.
21. For actual or attempted impregnation or fertilization which involves
either a Covered Person or a surrogate as a donor or a recipient.
22. For examinations, adjustment of, or purchase of a hearing aid.
23. For career and pastoral counseling.
24. For services or supplies of an Educational, Experimental or
Investigative nature.
This exclusion includes, but is not limited to:
- All phases of clinical trials.
- All treatment protocols based upon or similar to those used in
clinical trials.
- Drugs approved by the Federal Food and Drug Administration under its
- Treatment Investigatory New Drug regulation or equivalent.
- Federally approved drugs used for treatment indications not
generally recognized by the medical community.
25. For the reversal of any sterilization procedure or any related care.
26. For sex transformations or other transsexual surgery or related
services not necessitated by an Injury or Illness covered by this
Policy.
27. For services rendered for academic reasons.
28. For orthoptic therapy (vision exercises).
29. For Prescription Drugs, except that this exclusion does not apply to
Prescription Drugs provided during treatment of an Illness or Injury
while confined as an Inpatient.
30. For weight reduction programs and gastric stapling for treatment of
obesity.
31. Infertility services, including but not limited to, In-Vitro
fertilization procedures, Gamete Intrafallopian Transfer (GIFT),
Zygote Intrafallopian transfer (ZIFT) and other similar or related
services; and infertility injectables or other infertility-related
supplies.
32. For bereavement counseling services, except as specifically provided
for under the Hospice Services in Article Vl.
33. For treatment of temporomandibular joint dysfunction with/intra oral
devices or any other method to alter vertical dimension.
19
34. For hypnosis not used as an integral part of a Covered Medical Service
covered under Article VI.
35. For telephone consultations, failure to keep a scheduled visit, or
completion of a claim form.
36. For any services or supplies not specifically described herein.
37. For services or supplies covered by any automobile insurance policy up
to the amount of coverage limitation under such policy.
38. For orthotic devices.
The Company shall determine whether a service or supply is covered under this
Policy or excluded from coverage under this Policy.
VIII. GENERAL PROVISIONS
1. Notice of Claim
Written notice of claim must be furnished to the Company within 90 days after
Covered Medical Services have been rendered to the Covered Person. A notice of
claim form may be obtained from CHI or the Policyholder. However, in case of a
claim for which the Policy provides any periodic payment contingent upon
continued provision of Covered Medical Services, this notice may be furnished
within 90 days after termination of each period for which the Company is liable.
Failure to furnish the notice of claim within the time required will not
invalidate nor reduce any claim if it is not reasonably possible to give the
notice of claim within 90 days, provided the notice of claim is furnished as
soon as reasonably possible. However, except in the absence of legal capacity of
the claimant, the notice of claim may not be furnished later than one year from
the date when the notice of claim was originally required.
2. Time for Payment of Claim
Benefits payable under the Policy will be paid promptly upon receipt by CHI of
satisfactory notice of claim, unless the Policy provides for periodic payment.
Where the Policy provides for periodic payments, the benefits will accrue and be
paid monthly, subject to satisfactory notice of claim.
3. Payment of Claims
All or any portion of any indemnities provided by the Policy on account of
hospital, nursing, medical or surgical services may, at the Company's option, be
paid directly to the hospital or other persons rendering such services; but it
is not required that the service be rendered by a particular hospital or person.
Any payment made by the Company in good faith pursuant to this provision will
fully discharge the Company's obligation to the extent of the payment. The
Covered Person may request that payments not be made pursuant to this provision.
The request must be made in writing and must be given to the Company not later
than the time of filing notice of claim. Payment made prior to receipt of the
Covered Person's written request at the Company's principal executive office
will be deemed to be payment made in good faith.
The Covered Person shall be responsible for the payment of all charges for any
service or supply in excess of the Reasonable and Customary Charges or otherwise
not covered by this Policy.
4. Renew and Appeal Procedures
Reviews of Pre-Certification Denials
20
If a Covered Person is denied coverage for a procedure during the
pre-certification process described in Article V, the Covered Person will be
advised of the reason(s) for the denial and of his or her right to a prompt
review by a person who did not participate in the denial decision.
If a review is requested, in addition to reviewing the reasons for the denial,
CHI may discuss the case with the treating Physician in an effort to agree on
care that would be covered under the Policy.
If the review does not result in a satisfactory resolution, the Covered Person
will receive a written notice explaining the reason(s) for the denial.
Appeals of Denied Claims or Other Denials
If a Covered Person is denied coverage for a claim or denied coverage for a
procedure during pre-certification process, the Covered Person will be advised
in writing of the reason(s) for the denial. This notice will set forth the
reasons for such denial. If the Covered Person wishes to appeal this decision,
the Covered Person may write to the address which appears on the notice (to the
attention of the person who signed the letter, if any).
The Covered Person may appeal a denial of benefits within 30 days of the date of
the rejection by sending a letter stating why the Covered Person thinks the
claim should not have been denied, including a copy of the denial letter and
with any additional claim. The Policyholder number, claim number, if any, and
the date of service for which benefits were denied must be included will become
final and incontestable.
Upon receipt of the letter and any additional information the Covered Person
provides, the Covered Person's records will be reviewed; and the results of this
review will be sent to the Covered Person promptly. In unusual cases, as when
review of the claim or denial of coverage requires examination by medical
personnel, including consulting physicians, the review may be extended.
5. Choice of Physician
Each Covered Person has free choice of any Physician, Hospital or other
provider.
6. Time Limit on Certain Defenses
No claim for loss incurred after one year from commencement of the individual
Covered Person's insurance will be reduced or denied on the grounds that the
disease or physical condition existed prior to the commencement of the Covered
Person's insurance.
7. Contract
The entire contract between the Company and the Policyholder consists of the
Policy, the Summary of Benefits and the applications of the Policyholder and
each Covered Employee. All statement contained in the applications will, in the
absence of fraud, be deemed representations and not warranties. No statement
made by an applicant for insurance will be used to void the insurance or reduce
the benefits, unless contained in a written application and signed by the
applicant. No agent has the authority to make or modify the Policy, or to extend
the time for payment of premiums, or to waive any of the Company's rights or
requirements.
No modification of the Policy will be valid unless evidenced by an endorsement
or amendment of the Policy, signed by an executive officer of the Company and
delivered to the Policyholder.
8. Incontestability
The validity of a Covered Person's insurance will not be contested, except for
non-payment of premium, after his or her insurance under the Policy has been
continuously in force for one year during his or her lifetime. No statement
21
made by a Covered Employee relating to his or her insurability or that of his or
her Dependents will be used in defense to a claim under the Policy unless: (a)
it is contained in a written application signed by the Covered Employee; and (b)
a copy of the application has been furnished to the Covered Employee or to his
or her beneficiary.
9. Misstatements of Age
If the age of any Covered Person has been misstated, an equitable adjustment
will be made in the premiums or, at the Company's discretion, the amount of
insurance payable. Any premium adjustment will be based on the premium that
would have been charged for the same coverage on a Covered Person of the same
age and similar circumstances.
10. Physical Examination and Autopsy
The Company, at its own expense, will have the right and opportunity to examine
a Covered Person, when and as often as may reasonably be required during the
pendency of a claim under the Policy and to make an autopsy in case of death,
where it is not forbidden by law.
11. Legal Action
No action at law or in equity may be brought to recover on the Policy unless and
until the expiration of 60 days after notice of claim has been furnished to CHI
in accordance with the requirements of this Policy. No such action may be
brought after the expiration of three (3) years after the time notice of claim
is required to be furnished.
12. Conformity With State Statutes
Any provision of the Policy which, on its Effective Date, is in conflict with
the statutes of the state in which it is issued, is hereby amended to conform to
the minimum requirements of those statutes.
13. Assignment
No assignment of the Policy, or any part of it, will be binding on the Company
unless approved in writing by the President or Executive Vice President of the
Company. The Company does not assume any responsibility for the validity of any
assignment.
14. Rights of Employees
This Policy does not provide any benefit not specifically described herein. This
Policy does not constitute a contract of employment and does not affect the
right of the employer to discharge any Employee.
15. Facility of Payment
If, in the opinion of the Company, a Covered Person is not competent to execute
a valid release for payment of any benefit to which he is entitled under this
Policy, the Company may, but shall not be required to, make payment to such
individual(s) or institution(s) as have assumed the care and support of such
Covered Person. In the event the Covered Person dies before payment is made to
him of all benefits to which he is entitled under the Policy, the Company may,
but shall not be required to, make payment to such individual(s) or
institution(s) as may be, in the opinion of the Company, equitably entitled
thereto, including without limitation, individual(s) or institution(s) to which
the Covered Person may have assigned such benefits prior to his death. Any
payment made in accordance with the foregoing provisions shall fully discharge
the Company to the extent of such payments.
22
16. Right to Receive and Release Information
For the purpose of determining the applicability of and implementing the terms
of the provisions of the Policy, the Company may release to, or obtain from, any
other plan or policy administrator, insurance company, or other organization or
individual any information, concerning any individual, which the Company
consider to be necessary for those purposes. Any individual claiming benefits
under this Policy will furnish the information that may be necessary to
implement the provisions.
17. Deductible Amounts
For each Covered Medical Expense, the individual Deductible Amount stated in the
Schedule of Benefits must be incurred with respect to a Covered Person before
benefits become payable. If, during a calendar year, such deductibles are equal
to the family Deductible Amount shown in the Schedule of Benefits, no further
deductible amount shall apply with respect to any remaining expenses incurred by
members of that Family Unit during the remainder of that calendar year.
18. Incorporation of Summary of Benefits
The Summary of Benefits is hereby incorporated in and made a part of this
Policy.
IX. CONTINUATION OF COVERAGE
1. Consolidated Omnibus Budget Reconciliation Act of 1985, As Amended ("COBRA")
Upon timely notice from the Employer, CHI will make available continuation
coverage, as required by COBRA, for all Covered Persons determined to be
qualified beneficiaries, as defined in Subsection 162(k)(7)(B) of the Internal
Revenue Code, as amended from time to time, and Subsection 607(3) of the
Employee Retirement Income Security Act (ERISA), as amended from time to time.
The Employer shall retain full responsibility for notifying Covered Persons of
their rights to continuation coverage and administering the exercise of
continuation rights, as required by COBRA. CHI shall have no obligation to
ensure that any notices received from the Employer comply with the requirements
of COBRA. For purposes of COBRA, CHI is not the plan administrator.
A. Each Covered Employee has a right to continue coverage if:
1. Employment with the Employer ends for a reason other than gross
misconduct; or
2. Work hours are reduced which result in a loss of coverage.
B. Each Covered Dependent has a right to continue coverage if:
1. The Covered Employee's employment with the Employer ends for a
reason other that gross misconduct;
2. The Covered Employee's work hours are reduced;
3. The Covered Employee dies;
4. In the case of the Covered Employee's spouse, when such spouse
ceases to be an Eligible Dependent as a result of divorce or
legal separation;
5. The Covered Employee becomes entitled to Medicare; or
23
6. In the case of a Dependent child, when such child no longer
satisfies the eligibility requirements for coverage as an
Eligible Dependent under this Agreement.
Similar rights may apply to certain retirees and their dependents if the
employer commences certain bankruptcy proceedings and these individuals lose
coverage.
Under COBRA, the Covered Employee or a family member has the responsibility
to inform the Employer of a divorce, legal separation, or a child losing
dependent status under the Employer's health plan within 60 days of the later of
the date of the event or the date on which coverage would end under the plan
because of the event. The Employer has the responsibility to notify the Employer
of the Covered Employee's death, termination of employment, reduction in hours
or Medicare entitlement.
When the Employer is notified that one of these events has happened, the
Employer will in turn notify the qualified beneficiary within 14 days of the
notification that he/she has the right to choose continuation coverage. The
qualified beneficiary has at least 60 days from such notification or the
qualifying event, whichever date is later, to inform the Employer of his or her
decision to elect continued coverage. The qualified beneficiary will then have
45 days after notifying the Employer of his or her decision to pay the
retroactive premium.
In the case of the Covered Employee's termination of employment or
reduction in work hours, the coverage may be continued for up to 18 months. The
18 months of coverage may be extended to 36 months if one of the other events
described in Part B above occurs to a dependent within the initial 18 months of
coverage. The qualifying events listed in Part B, other than B(1) and B(2), will
entitle the dependents for up to 36 months of continuation coverage. The 18
months may also be extended to 29 months if an individual is determined to have
been disabled for Social Security disability purposes at the time of the initial
qualifying event and the Employer is notified of the disability of the Social
Security Administrator determination within 60 days of its disability
determination. The affected individual must also notify the Employer within 30
days of any final determination that the individual is no longer disabled.
However, coverage will cease earlier if one of the following events occurs:
1. The Employer ceases to provide any group health insurance to any of
its employees;
2. The qualified beneficiary fails to make timely payments of any premium
required;
3. The qualified beneficiary is covered under another group health plan
that does not contain any exclusion or limitation with respect to any
preexisting condition that the qualified beneficiary may have.
4. The qualified beneficiary is entitled to benefits under Medicare; or
5. The qualified beneficiary extended coverage for up to 29 months due to
a disability and there has been a final determination that the
qualified beneficiary is no longer disabled.
2. Employee Conversion Option
When a Covered Employee's coverage under this Policy terminates for reasons
other than failure to make the required premium contributions, the benefits may
be converted to an individual policy (the "Converted Policy.) issued by the
Company.
This conversion privilege is available:
(a) to an Eligible Employee if s/he has been continuously insured under this
Policy for at last three (3) months immediately prior to the termination;
24
(b) to an Eligible Dependent spouse if the coverage terminates because of his
or her spouse/Employee's death, or because of divorce or annulment of
marriage; and
(c) to an Eligible Dependent child if the coverage terminates because of the
Eligible Dependent's age or because of the death of his or her
parent/Covered Employee.
The conversion privilege is not available to any Covered Person if:
(i) if the Covered Person is, or is eligible to be, within 31 days of
termination of coverage under this Policy, covered for similar benefits by:
(1) another group plan, medical service subscriber contract, medical
practice or other prepayment plan, or (2) any governmental program;
(ii) if issuing the Converted Policy to the Covered Person would result in
over-insurance, as determined by CHI; or
(iii) if coverage under the Policy terminated because any required premium
contribution was not paid when due.
Application and payment of the first premium under the Converted Policy must be
made to the Company within 31 days immediately following termination of coverage
under this Policy.
If continuation of coverage as described above is elected, this conversion
option will apply at the end of the maximum continuation period under this
Policy.
The Converted Policy will be issued as follows:
(A) The Covered Policy will in the form CHI has them available for conversion
which is most similar to the coverage being converted. The coverage under
the Converted Policy may be different from the coverage provided under this
Policy;
(B) The Converted Policy may exclude any condition for which the Covered Person
was not covered under this Policy, provided a 12-month period has not
elapsed from the original Effective Date of this Policy; and
(C) The premium payable for the Converted Policy will be based on the CHI's
rate then applicable to the class of risk to which the Covered Person
belongs, the age of the Covered Person, and the form and amount of coverage
provided, on the effective date of the Converted Policy.
If the Covered Employee and one or more of his Dependents were covered by the
Policy, the Converted Policy must cover all previously insured Covered Persons
who are eligible for conversion coverage. The Company may, at its option, issue
a separate Covered Policy to cover any Dependent.
3. Extension of Benefits Upon Termination of Policy
Except as set forth below, if the Covered Person is an Inpatient on the day
coverage under this Policy terminates, the benefits of coverage under this
Policy shall be provided until the earlier of:
A. the date on which the maximum amount of benefits under this Policy has been
paid; or
B. the date on which the Inpatient stay ends; or
C. the 90th day after the date of termination.
If this Policy is terminated because the Employer participates in or obtains
medical coverage under a health benefit plan or arrangement made available by
another organization, the liability of CHI shall cease as of the date of such
termination, and no benefits will be provided for any services or supplies
provided after such date.
25
X. COORDINATION OF BENEFITS
All benefits provided under this Policy are subject to this Article, and
will not be increased by virtue of this Article.
1. Definitions
In addition to the Definitions set forth in Article XV of this Policy, the
following definitions only apply to this Article:
a. "Plan" means any plan providing benefits or services for or by reason of
medical or dental care or treatment, which benefits or services are
provided by:
(1) group, blanket or franchise insurance coverage;
(2) service plan contracts, group practice, individual practice and other
prepayment coverage;
(3) any coverage under labor-management trusteed plans, union welfare
plans, employer organization plans, or employee benefit organization
plans; or
(4) any coverage under governmental programs, and any coverage required or
provided by any statute.
The term "Plan" shall exclude any school accident-type coverages or group or
group-type hospital indemnity benefits of S100 per day or less.
b. "Dependent" means, for any Plan, any person who qualifies as a Dependent
under that Plan.
c. "Allowable Benefits" means the eligible charges for Covered Medical
Services under this Policy.
d. "Benefits Paid or Payable" means the amounts actually paid for Covered
Medical Services.
2. Effect on Benefits
a. This Article shall apply in determining the benefits of this Policy
if, for Covered Medical Services received, the sum of the Benefits
Payable under this Policy and the Benefits Payable under other Plans
would exceed the Allowable Benefits.
b. Except as provided in Subsection c. of this Section 2, the Benefits
Payable under this Policy for Covered Medical Services will be reduced
so that the sum of the reduced benefits and the Benefits Payable for
Covered Medical Services under other Plans does not exceed the total
of Allowable Benefits.
c. If: (1) the other Plan contains a provision coordinating its benefits
with those of this Policy and its rules require the benefits of this
Policy to be determined first, and (2) the rules set forth in
Subsection e. of this Section 2 require the benefits of this Policy to
be determined first, then the benefits of the other Plan will be
ignored in determining the benefits under this Policy.
d. If the other Plan does not include a coordination of benefits
provision, such Plan will be primary.
e. If the other Plan does include a coordination of benefits provision:
(1) The Plan covering the patient other than as a Dependent will be
primary.
(2) Where both Plans cover the patient as a dependent child, the Plan
covering the patient as a dependent child of a parent whose date
of birth, excluding year of birth, occurs earlier in a calendar
year shall be the primary Plan. But, if both parents have the
same birthday,
26
the Plan which covered the parent longer will be the primary
Plan. If the parents are separated or divorced, the following
will apply:
(a) The Plan which covers the child as a Dependent of the parent
with custody will be the primary Plan.
(b) If the parent with custody has remarried, the Plan which
covers the child as a Dependent of the stepparent with
custody will determine its benefits before the Plan covering
the child as a Dependent of the parent without custody.
(c) Where there is a court decree which establishes financial
responsibility for the health care expenses of the dependent
child, the Plan which covers the child as a Dependent of the
parent with such financial responsibility will be the
primary Plan as long as the Plan of that parent has actual
knowledge-of the court decree.
(d) If the specific terms of the court decree state that the
parents shall share joint custody, without stating that one
of the parents is responsible for the health care expenses
of the child, the plans covering the child shall follow the
order of benefit determination rules outlined in the first
paragraph of 2. e. 2).
In the event CHI is coordinating with a Plan that uses the
male/female rule regarding dependent children, the introductory
paragraph of this clause (2) shall be replaced with to the
following introductory paragraph:
Where both Plans cover the patient as a dependent child, the
Plan covering the patient as a dependent child of a male
will be the primary Plan, except that if the parents are
separated or divorced, the following will apply:
(3) Where the determination cannot be made in accordance with. clause (1)
or (2) above, the Plan which has covered the patient for the longer
period of time will be the primary Plan; provided that,
(a) the benefits of a plan covering the person as an employee
other than a laid-off or retired employee or as the
Dependent of such person shall be determined before the
benefits of a plan covering the person as a laid-off or
retired employee as a Dependent of such person; and
(b) if either Plan does not have a provision regarding laid-off
or retired employees, and, as a result, the benefits of each
plan are determined after the other, then the provisions of
clause (3)(a) above shall not apply.
f. Services provided under any governmental program for which any periodic
payment of rate is made by the Covered Person shall always be the
primary Plan, except when prohibited by law, or when the Covered Person
has elected Medicare secondary.
3. Facility of Payment
Whenever payments should have been made under this Policy in accordance with
this Article, but the payments have been made under any other Plan, CHI has the
right to pay to any organization that has made such payment any amount it
determines to be warranted to satisfy the intent of this Article. Amounts so
paid shall be deemed to be Benefits Paid under this Policy and to the extent of
the payments for Covered Medical Services, CHI shall be fully discharged from
liability under this Policy.
4. Right of Recovery
27
a. Whenever payments have been made by CHI for Covered Medical Services
in excess of the maximum amount of payment necessary at that time to
satisfy the intent of this Article, irrespective of to whom paid, CHI
shall have the right to recover the excess from among the following,
as CHI shall determine: any person to or for whom such payments were
made, any insurance company, or any other organization.
b. The Covered Employee, personally and on behalf of his or her Covered
Dependents shall, upon request, execute and deliver such documents as
may be required and do whatever else is reasonably necessary to secure
CHI's rights to recover the excess payments.
5. CHI shall not be required to determine the existence of any Plan or
amount of Benefits Payable under any Plan except this Policy, and the
payment of benefits under this Policy shall be affected by the Benefits
Payable under any and all other Plans only to the extent that CHI is
furnished with information relative to such other Plans by the Employer
or Covered Person or any other insurance company or organization or
person.
6. When the benefits are reduced under the primary Plan because a Covered
Person does not comply with the Plan articles, or does not maximize
benefits available under the primary Plan, the amount of such reduction
will not be considered an Allowable Benefit. Examples of such
provisions are those related to second surgical opinions and
pre-certification of admissions and services.
7. CHI may, without the consent or notice to any person, release to or
obtain from any other insurance company, or other organization or
person, any information, with respect to any Covered Person which XXX
xxxxx necessary to determine the applicability of, and implement the
terms of, this Article, or any similar provision of any other Plan. Any
person claiming benefits under this Policy will furnish to CHI any
information necessary to implement this Article.
XI. MEDICARE
When a Covered Person is eligible for Medicare, that person must sign and
deliver an election card to the Company, stating whom that Covered Person wants
to be his primary insurer. If the Covered Person elects Medicare as his primary
source of coverage and belongs to a group covered by the Policy covering twenty
(20) persons or more, all Policy benefits otherwise payable to that Covered
Person shall discontinue. If belonging to a covered group of less than twenty
(20) persons, all Policy benefits otherwise payable with respect to the Covered
Person will be reduced by any service or supply provided, or any benefits paid
or payable, under Part A and Part B of Medicare.
For the purposes of this Article, benefits will be paid on the basis that the
Covered Person is covered by both Part A and Part B of Medicare. If the Covered
Person should not receive benefits under either Part A or Part B because of:
(a) failure to enroll when required;
(b) failure to pay any premiums that may be required for full coverage of
the person under Medicare; or
(c) failure to file any written request or claim required for payment of
Medicare benefits;
the Company will make determination of the total benefits that would have been
payable under Medicare in the absence of this failure.
"Part A" means the "Hospital Insurance Benefits for the Aged" portion of
Medicare.
"Part B" means the "Supplementary Medical Insurance for the Aged" portion of
Medicare.
28
XII. SUBROGATION
In the event of any payment under the Policy, the Company will, to the extent of
the payment under the Policy, be subrogated to all the rights of recovery of the
Covered Person arising out of the acts or omissions of any person or
organization. The Covered Person xxxxxx agrees to reimburse the Company for any
benefits paid hereunder, out of any moneys recovered from any person or
organization as the result of judgment, settlement or otherwise. After any
benefits under this Policy are paid by the Company, the Covered Person also
agrees to execute and deliver all necessary instruments and to furnish such
information and such reasonable assistance as may be required to facilitate
enforcement of its rights hereunder. In the event the Company recovers an amount
greater than the benefit paid, the excess, will be paid to the Covered Person.
The Covered Person shall do nothing after loss to prejudice these rights. This
Article will not apply, however, to a recovery obtained by any Covered Person
from any insurance company on a policy under which the Covered Person is
entitled to indemnity as a named insured person or an insured Dependent of a
named person. For purposes of this Article only, "Covered Person" will include
anyone receiving payment under the Policy, either directly or indirectly.
This Article does not pertain to medical malpractice insurance pursuant to
Pennsylvania Law, Chapter 4, Article VI, Section 602 (40 P.S. Section 1301.602),
and is limited for Pennsylvania No-Fault Insurance pursuant to Pennsylvania Law
Chapter 4, Article VI(J), Section III(4) (40 P.S. Section 1009. 111), as now
constituted or later amended.
The Subrogation rights under this Article shall be enforced only to the extent
and at those times permitted by law and shall not be enforceable to the extent
prohibited by any Pennsylvania statute or regulation.
XII. POLICYHOLDER/EMPLOYER PROVISIONS
Premiums
1. The premiums for this Policy shall be based upon the administrative
requirements of CHI and the cost of Covered Medical Services and shall be
payable in advance according to the mode of payment agreed upon. At the end
of the first calendar year or at any time thereafter, the premiums for this
Policy may be readjusted by CHI based upon the experience under the Policy.
2. The Employer is solely responsible for the payment of premiums with respect
to its Covered Employees and their Covered Dependents. Payment shall be
made directly to CHI.
3. The first premium will be the sum of the individual premiums determined by
applying the premium rates, shown in the initial schedule of premium rates,
to the amount of insurance then in force at the respective ages of the
Covered Persons insured on the Effective Date of the Policy. The premium
for each successive month will be the sum of the individual premiums
determined by applying the premium rates then in effect to the amount of
insurance then in force at the respective ages of the Covered Persons
insured on the premium due date.
4. The premium rates will be guaranteed for the first twelve (12) months
following the issuance of the Policy. CHI reserves the right to change,
after such guaranteed period, the premium rates by written notice to the
Policyholder at least thirty (30) days prior to the date of the change.
5. Any change in premium rates necessitated by an amendment of the Policy will
be effective on the effective date of the amendment. If the effective date
of the amendment is any day other than the premium due date, then a pro
rata premium adjustment will be made to the applicable month.
6. There will be no premium adjustment for Covered Person who may be added or
terminated between premium due dates. If notice of a Covered Person's
termination received by CHI more than thirty (30) days after their
termination, any unearned premium will be credited only from the first
premium due date prior to the receipt of such notice. This provision will
not extend the Covered Person's insurance beyond the termination date.
29
Grace Period
If the Policyholder has not previously given written notice to CHI that the
Policy is to be discontinued, the grace period of thirty one (31) days will be
granted to the Policyholder for payment of every premium after the first
premium. During the grace period, the Policy will continue in force, unless
prior to the date payment was due the Policyholder gave timely written notice to
CHI that the Agreement is to be canceled. If the premiums are not paid within
the grace period, the Policy will be discontinued, but the Policyholder will
still be liable to CHI for all unpaid premiums, including the premiums for the
grace period. If during the grace period CHI receives written notice from the
Policyholder that the Policy is to be discontinued, the Policy will be
discontinued on the date notice is received, but the Policyholder will still be
liable to CHI for the payment of all premiums then unpaid, together
with a pro rata premium for the period commencing with the date on which the
last premium became due and ending with the date of receipt of written notice by
XXX.
Term of Policy and Right to Terminate
This Policy is issued for an indefinite term, commencing on the Effective Date
shown on the face page. The Policy continues in force, so long as premiums are
paid when due, until terminated in accordance with the terms of this Policy.
The Policyholder may terminate the Policy by giving written notice to CHI.
Termination by the Policyholder will be effective on the latter of: (a) the day
specified in the notice; or (b) the day the notice is received by CHI. CHI may
terminate any or all insurance under the Policy, as of any premium due date, by
giving written notice to the Policyholder at least thirty (30) days prior to
that date.
Notice
Written notice to the Policyholder will be deemed to be effective on the date it
is placed in the United States mail, postage prepaid and properly addressed to
the principal place of business of the Policyholder. Notice will be deemed to be
properly addressed if it reflects the last address provided to CHI by the
Policyholder.
Individual Certificates
CHI will issue a Summary of Benefits, describing the insurance protection to
which each Covered Person is entitled and to whom payable. Copies of the Summary
of Benefits will be issued to the Policyholder for delivery to each Covered
Employee.
Registry
The Policyholder shall furnish CHI with:
(a) the names of all individuals initially eligible for insurance or who
later become eligible for insurance under the Policy, even if they do
not become insured;
(b) the names of all Covered Persons who become insured or whose insurance
terminates, together with the respective date; and
(c) any information required to initiate, maintain or terminate coverage
on each Eligible Person.
CHI will have the right, at reasonable times, to inspect all books and records
of the Policyholder which relate to the insurance under the Policy.
30
XIV. DEFINITIONS
For the purposes of this Policy, unless the context clearly indicates otherwise,
the following words and phrases have the following meanings. The following words
and phrases are not intended to imply that coverage for them is provided under
this Policy.
Ambulatory Surgical Facility - A specialized facility licensed, where required,
to render surgical procedures on an Out-Patient basis, which has an
organized staff of Physicians, has been approved by the Joint
Commission on Accreditation of Health Care Organizations, the
Accreditation Association for Ambulatory Healthcare, Inc., or CHI, and
which:
1. has permanent facilities and equipment for the primary purpose of
performing surgical procedures on an Out-Patient basis;
2. provides treatment by or under the supervision of Physicians and nursing
services whenever the patient is in the facility;
3. does not provide Inpatient accommodations;
4. provides the full-time services of one or more RNs for patient care in the
operating rooms and in the post-anesthesia recovery room; and
5. provides at least one operating room and at least one post-anesthesia
recovery room; is equipped to perform diagnostic x-ray and laboratory
examinations; and has available trained personnel and necessary equipment
to handle foreseeable emergencies;
6. maintains a written agreement with at least one Hospital in the area for
immediate acceptance of patients who develop complications or require
post-operative confinement; and
7. is not, other than incidentally, a facility used as an office or clinic for
the private practice of a Professional Provider.
Birthing Center - A free-standing facility licensed, where required, to provide
maternity care, which:
1. Is organized and staffed to provide prenatal care, delivery and immediate
post-partum care;
2. Is directed by at least one Physician who is a specialist in obstetrics and
gynecology;
3. Has a Physician or certified nurse midwife present at all births and during
the immediate post-partum period;
4. Has at least two (2) beds or two (2) birthing rooms for use by patients
while in labor and during delivery;
5. Has the capacity to administer a local anesthetic and to perform minor
surgery. This includes episiotomy and repair of perineal tear;
6. Accepts only patients with low risk pregnancies; and
7. Has a written agreement with a Hospital in the area for emergency transfer
of a patient or a child.
CloseRelative - The Covered Person, his or her spouse, a child, brother,
sister, or parent of the Covered Person or his or her spouse.
31
Company - Corporate Health Insurance Company, a Minnesota corporation, and its
successor, if any.
Co-payment - The flat, fixed-dollar amount which shall be payable by a Covered
Person pursuant to this Policy to a provider of services or supplies, regardless
of, but not in excess of, the charge for such services or supplies, such amount
to be set forth in the Schedule of Benefits with respect to applicable Covered
Medical Service.
Cosmetic Surgery - Any surgery not Medically Necessary, including, without
limitation, ear piercing, rhinoplasty or lipectomy, except cosmetic surgery
resulting from the complication of such Cosmetic Surgery.
Covered Dependent - Any Eligible Dependent whose coverage became effective and
has not terminated.
Covered Employee - Any Eligible Employee whose coverage became effective and has
not terminated.
Covered Person - Any Eligible Employee or Eligible Dependent whose coverage
became effective and has not terminated.
Covered Medical Services - Those services and supplies which are Medically
Necessary and are otherwise covered by this Policy and for which charges are
Reasonable and Customary.
Custodial Care - Any type of care that does not require the skills of technical
or professional personnel or are not furnished by or under the supervision of
such personnel or does not otherwise meet the requirements of post-hospital
Skilled Nursing Facility Care. Custodial Care includes, but is not limited to:
o Help in walking, getting into or out of bed, bathing, dressing, eating and
other functions of daily living of a similar nature;
o General supervision of exercise programs including carrying out of
maintenance programs of repetitive exercises that do not need the skills of
a therapist and are not skilled rehabilitation services;
o Bowel training and management;
o General safety/health precautions and preventive procedures such as turning
to prevent bedsores; and
o Providing patient recreation and/or companionship.
Deductible Amount - The amount of charges for Covered Medical Services a Covered
Person must incur and pay during the calendar year under this Policy. The
Deductible Amount will differ depending upon whether the Covered Person is
covered under an individual coverage or a family coverage. If covered under an
individual coverage, the Covered Person must pay the Deductible Amount for
"individual," as set forth in the Schedule of Benefits, before becoming entitled
to benefits under the Policy. If covered under a family coverage, the Covered
Person and his or her Family Unit must pay the Deductible Amount for "family,"
as set forth in the Schedule of Benefits, before becoming entitled to benefits
under the Policy.
Dentist - Licensed Doctor of Dental Surgery or Doctor of Dental Medicine.
Dependent - Includes a spouse or child, whether by birth or adoption, of an
Eligible Employee.
Detoxification - The process whereby an alcohol or drug intoxicated or alcohol
or drug dependent person is assisted, in a facility licensed by the Department
of Health, through the period of time necessary to eliminate, by metabolic or
other means, the intoxicating alcohol or drug, alcohol or drug dependent factors
or alcohol in
32
combination with drugs, as determined by a licensed Physician, while keeping the
physiological risk to the patient at a reasonable minimum.
Diagnostic Services - the following procedures prescribed by a Professional
Provider because of specific symptoms to determine a definite condition or
disease. Diagnostic Services include, but are not limited to:
A. diagnostic radiology, consisting of x-ray, ultrasound and nuclear medicine;
B. diagnostic pathology, consisting of laboratory and pathology tests;
C. diagnostic medical procedures, consisting of ECG, EEG, and other diagnostic
medical procedures; and
D. allergy testing consisting of percutaneous, intracutaneous and patch tests.
Durable Medical Equipment - Equipment prescribed by the attending Physician
which is:
- Not primarily and customarily used for non-medical purposes;
- Designed for prolonged use; and
- For a specific therapeutic purpose in the treatment of an Illness or
Injury.
Durable Medical Equipment includes, but are not limited to, prosthetic
appliances and orthopedic braces.
Educational - a service or supply the primary purpose of which is to provide the
Covered Person with any of the following training in the activities of daily
living: instruction in scholastic skills such as reading and writing;
preparation for occupation; or treatment for learning disabilities.
Eligible Dependent - Any Eligible Employee's Dependent who satisfies the
eligibility requirements of Article I.
Eligible Employee - Any active employee full-time of the Policyholder who
regularly works at least 30 hours per week and otherwise satisfies the
eligibility requirements of Article I.
Emergency Services - Medical services required for the initial treatment of a
Medical Emergency. These services shall not include treatment for occupational
injury for which benefits are covered under workers' compensation law or similar
occupational disease law. The condition of the Covered Person must be of
sufficient severity to warrant immediate attention.
Employer - The Policyholder.
Evidence of Good Health - A statement from an Eligible Employee or an Eligible
Dependent attesting to the "good health" of such person or his or her Eligible
Dependents. A standard form available from the Policyholder's human resources
department will be provided for this purpose. The Eligible Employee or the
Eligible Dependent is responsible for any and all related costs.
Experimental or Investigative - the use of any treatment, procedure, facility,
equipment, drug, or drug usage device or supply which the general medical
community does not accept as standard medical treatment of the condition being
treated, or any such items requiring federal or other governmental agency
approval which approval has not been granted at the time the services were
rendered.
Family Unit - A Covered Employee and his or her Covered Dependents.
Home Health Agency - Any organization certified as a home health agency under
the Medicare law or otherwise approved by CHI for the delivery of non-Physician
patient care in the home of a Covered Person.
33
Home Health Plan - A program for care and treatment of a Covered Person
established and approved in writing by such Covered Person's attending
Physician, together with such Physician's certification that the proper
treatment of the Injury or Illness would require confinement as a resident
Inpatient in a Hospital or confinement in a Skilled Nursing Facility the absence
of services and supplies provided as part of the Home Health Plan.
Home Health Services - Those items and services defined as "home health
services" in the Medicare law and set forth in 42 CFR Part 417.101 et seq.
Hospice - A facility which is licensed as such, where required, and provides
short periods of stay for a Terminally Ill Person in a home-like setting for
either direct care or respite care. This facility may be either free-standing or
affiliated with a Hospital. It must operate as an integral pan of the Hospice
Care Program.
Hospice Care Program - A formal program directed by a Physician to help care for
a Terminally Ill Person. This may be through either:
o A centrally-administrated, medically directed and nurse coordinated program
which
- Provides a coherent system primarily of home care; and
- Is available 24 hours a day, seven (7) days a week; or
o Confinement in a Hospice.
The program must meet standards set by the National Hospice Organization and
approved by CHI. If such a program is required by a state to be licensed,
certified, or registered, it must also satisfy such requirement.
Hospice Services - Services and supplies furnished or arranged by a Hospice to a
Terminally Ill Person.
Hospital - An institution accredited as a Hospital by the Joint Commission on
Accreditation of Health Care Organizations, the Bureau of Hospitals of the
American Osteopathic Association or under Medicare Law, or as otherwise
determined by CHI as meeting reasonable standards, which:
1. is a duly licensed, where required, and
2. is primarily engaged in providing Inpatient-diagnostic and surgical and
therapeutic services for the diagnosis, treatment and care of injured or
ill persons by or under the supervision of Physicians, and
3. provides 24-hour nursing service by or under the supervision of Registered
Nurses; and
4. is not a Skilled Nursing Facility, Custodial Care home, health resort, spa
or sanitarium, place for rest, place for the treatment of Mental Illness,
place for the treatment of Substance Abuse or Dependency, Hospice,
rehabilitation center, or place for the treatment of pulmonary
tuberculosis.
Illness - Sickness or disease which requires medical service or supply covered
by this Policy.
Injury - Bodily harm which results from an accident and which requires medical
service or supply covered by the Policy.
Inpatient - A person who is admitted to a Hospital, a Psychiatric Hospital, a
Skilled Nursing Facility or a Substance Abuse Treatment Facility and incurs room
and board charges.
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L.P.N. - A full-time licensed practical nurse, other than a Close Relative, who
is recognized by the state in which care is given as qualified to perform
limited nursing functions.
Medical Emergency - a sudden, unexpected onset of a medical condition
manifesting itself by acute symptoms or a traumatic bodily injury resulting from
an accident, which is of sufficient severity that the absence of immediate
medical attention could reasonably result in:
1. Death of the Covered Person;
2. Serious harm the Covered Person's health; or
3. Serious or permanent impairment to bodily functions or any bodily organ or
part.
The non-availability of a private Physician or the fact that the Physician may
refer the Covered Person to the emergency room does not, by itself, constitute a
Medical Emergency. Medical Emergencies include, but are not limited to:.
(a) uncontrolled or excessive bleeding;
(b) suspected heart attack;
(c) inability to breath;
(d) appendicitis;
(e) serious xxxxx;
(f) poisoning;
(g) severe pain and suffering; and
(h) convulsion or unconsciousness
Medically Necessary - Medical service or supply which is provided by a
Professional Provider for the diagnosis or the direct care and treatment of a
Covered Person's Injury or Illness and which is:
1. Appropriate for the symptoms and diagnosis or treatment of the Covered
Person's Injury or Illness; and
2. In accordance with current standards of good medical practice.
Confinement as an Inpatient in a Hospital or other facility is considered
Medically Necessary when the Covered Person needs to be confined because of the
nature of the services being delivered the Covered Person or when treatment for
his or her condition cannot be given safely and adequately if performed on an
Out-Patient basis.
Medicare - The programs health care for the aged and the disabled established by
Title XVIII of the Social Security Act, as first enacted by the Social Security
Amendment of 1965 or as later amended.
Mental Illness - An emotional, nervous or mental disorder means a neurosis,
psychoneurosis, psychopathy or psychosis and mental, emotional or nervous
disorder without demonstrable organic origin.
Mental Health Treatment Facility - A facility, licensed by the Department of
Health, for the care or treatment of person with a Mental Illness and in which
services are provided by or under the supervisions of a Physician.
Military Service - Service in any Army, Navy, Air Force, Marines, Coast Guard,
or other branch of the military.
Non-Hospital Substance Abuse Residential Care - The provision of medical,
nursing, counseling or therapeutic services to patients suffering from alcohol
or drug abuse or dependency in a residential environment, according to
individualized treatment plans.
Out-Patient - A patient who receives diagnosis or treatment at a facility, but
does not incur room and board charges.
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Physician - A person, other than a Close Relative of the Covered Person, who is
duly licensed member of a medical profession and is practicing within the scope
of his or her license.
Policy - this Comprehensive Major Medical Group Health Insurance Policy issued
by the Company to the Policyholder.
Policy Enrollment Form - A printed form approved by CHI that an Eligible
Employee must complete, execute and deliver to CHI to be eligible for coverage
under this Policy.
Policy Year - The twelve (12) month period commencing on a date agreed to
between the Policyholder and CHI or, if no such agreement exists, the twelve
(12) month period of January l through December 31 inclusive.
Pre-Certification - A certification that a Covered Person must obtain prior to
receiving any of the services or supplies that are identified by the Schedule of
Benefits or this Policy as needing a Pre-Certification, which certifies the
proposed Hospital admission and length of stay as Medically Necessary.
Prescription Drugs - Drugs and medicines which require a prescription by a
Physician to dispense and are approved by the U.S. Food and Drug Administration
for general use in treating the illness or injury for which they are prescribed.
Prescriptions Drugs include oral contraceptives and vitamins.
Professional Provider - a person or practitioner licensed, where required, and
performing services within the scope of such licensure. The Professional
Providers include:
- R.N. - optometrist
- chiropractor - physical therapist
- clinical laboratory - Physician
- Dentist - podiatrist
- nurse midwife - psychologist
Psychiatric Hospital - An institution which is primarily engaged in providing
diagnosis and therapeutic services for the Inpatient treatment of Mental
Illnesses and meets all of the following requirements:
1. Services are provided by or under the supervision of a Physician;
2. Provides continuous nursing services under the supervision of an RN.; and
3. Is not a Skilled Nursing Facility, Custodial Care home, health resort,
place for rest, place for the treatment of Substance Abuse or Dependency,
Hospice, rehabilitation center, or place for the treatment of pulmonary
tuberculosis.
R.N. - A registered nurse, other than a Close Relative, who is licensed in the
state in which care is given to perform all nursing functions.
Reasonable and Customary Charge - Any charge which, as determined by CHI, does
not exceed (i) the usual or customary fee for comparable service or supply
charged by other providers of similar services or supplies in the area where the
service or supply is provided and who have training, experience and professional
standing comparable to those of the actual provider of the service or supply or
(ii) if no comparison exists, the reasonable fee (which may differ from the
usual or customary fee) determined by CHI after considering unusual clinical
circumstances and/or the actual cost of equipment and facilities involved in the
treatment. When determining whether a charge is Reasonable and Customary, CHI
may consider the severity of the condition being treated and any complications
and unusual circumstances that may be involved.
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Schedule of Benefits - The Schedule of Benefits set forth in the Summary of
Benefits, which summarizes the benefits payable under the Policy. The terms of
the Schedule of Benefits will be individually tailored to each Policyholder.
Semi-Private - A two (2) bed room in a Hospital. If the facility has no such
rooms, the rate most commonly charged by similar institutions in the same
geographic area.
Skilled Nursing Facility - An institution or a distinct part of an institution
which is licensed, where required, or approved under state or local law, and
which is primarily engaged in providing skilled nursing care and related
services (on an Inpatient basis to patients requiring 24-hour skilled nursing
but not requiring confinement in an acute care Hospital) as a skilled nursing
facility, extended care facility, or nursing care facility approved by the Joint
Commission on Accreditation of Health Care Organizations or the Bureau of
Hospitals of the American Osteopathic Association, or as a certified skilled
nursing facility under Medicare law, or as otherwise determined by CHI to meet
the reasonable standards applied by any of the aforesaid authorities.
A Skilled Nursing Facility does not include a rest home, a home for the aged, a
place for Custodial Care or educational care, or a treatment facility for
alcoholism, drug addiction, or mental illness.
Social Worker - A duly licensed or certified social worker with at least two (2)
years or three thousand (3,000) hours of post-masters clinical social work
practice in a clinical program established by the state regulatory board or
agency.
Substance Abuse or Dependency - Any use of alcohol or drugs which produces a
pattern of pathological use causing impairment in social or occupational
functioning or which produces physiological dependency evidenced by physical
tolerance or withdrawal.
Substance Abuse Treatment Facility - A Hospital or non-Hospital facility,
licensed by the Department of Health, for the care or treatment of alcohol or
drug dependent persons, except for transitional living facilities.
Terminally Ill Person - A Covered Person who life expectancy is six (6) months
or less, as certified by the attending Physician.
TotalDisability or Totally Disabled - A Covered Employee shall be considered
totally disabled if, as a result of an illness or injury, he or she is unable to
engage in any gainful occupation for which s/he is reasonably fitted by
education, training, or experience, and is not performing work of any kind for
wage or profit. A Covered Dependent will be considered totally disabled if,
because of an illness or injury, he or she is prevented from engaging in all the
normal activities of a person of like age and sex.
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