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Home My WebLink About20013461.tiff RESOLUTION RE: APPROVE GROUP MASTER CONTRACT FOR HEALTH CARE PROGRAM AND AUTHORIZE CHAIR TO SIGN - BLUE CROSS AND BLUE SHIELD OF COLORADO WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Group Master Contract for the Health Care Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, and Blue Cross and Blue Shield of Colorado, commencing January 1, 2002, with further terms and conditions being as stated in said contract, and WHEREAS, after review, the Board deems it advisable to approve said contract, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Group Master Contract for the Health Care Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, and Blue Cross and Blue Shield of Colorado be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said contract. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 19th day of December, A.D., 2001. BOARD OF COUNTY COMMISSIONERS WELD CO TY, COLORADO 1861 - 4..,,��•-' M. ei e, air aw�'n� Y to the Board d Glenn Vaad, Pro-rem /.egriblerk to the Board 4 ` t ' l w e William H. Jerke APPy2V AST • EXCUSED DATE OF SIGNING (AYE) myomeyN r!E. fl bert D. Maden Date of signature: C h/o 41/0O-- 2001-3461 e fC- f/ PE0019 A Group Health Care Program Group Master Contract HMO abh ea, ppp 3, Colorado 2001-3461 ® ® An hidependent Licensee of the Blue Cross and Blue Shield Association HMO COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION-ACCEPTANCE 1 SECTION II. GENERAL AGREEMENTS 1 Contract effective date 1 Anniversary date 1 Employee 1 Employer 1 Remittance 1 Benefit booklet 1 Group administrator 2 Assignment 2 Contract provision changes 2 Notices 2 Governing Laws 2 Attorneys' fees and expenses 2 Enforcement of the contract 3 Interpretation of the contract 3 Termination of the contract 3 Reinstatement of contract 3 SECTION III. PREMIUM: CHANGES, PAYMENT, TERMINATION FOR NON-PAYMENT, REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE4 Changes 4 Payment 4 Termination for non-payment 4 Refund of membership premium 4 Cashing of check not acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Notification of cessation of membership 5 Acceptance of contract 5 Group eligibility requirements 5 BLUH119G.COC Boa r HMO Anthem® d ® Colorado Addendum to Application An Anthem Company GROUP NUMBER ANNIVERSARY MONTH ADDENDUM EFFECTIVE DATE C07720 January 1, January 1, 2002 This Addendum is issued to:Weld County Government ("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT) 'his Addendum amends provisions of the Application. If we approve this Addendum, we will return the approved Addendum with the effective late completed. The Addendum will become a part of the Contract. If we do not approve this Addendum, it will be returned. Other than pecifically amended herein, the terms and provisions of the Application and Contract shall remain in full force and effect. ;LASSIFICATION OF EMPLOYEES ELIGIBLE—The Employer requires that all eligible Employees have a regular work week of at least 20 hours per week. Eligible Employees do not include those on a temporary or substitute basis. 'he Employer hereby certifies the following number of Employees in each category below: Total Employees employed by the employer working at least 20 hours per week(include those not yet eligible) Enrolling for overage Total Eligible Employees who have met probationary period Enrolled elsewhere COBRA or Colorado State law continuation of coverage enrollees No other coverage Other,please explain: )EPENDENTS—Unmarried dependent children are covered until the end of the month in which they become age 19,or 25 if financially lependent upon the parent. 'ROBATIONARY PERIOD 1rt of the month following first full pay period worked,employer assigns effective date. )ROUP HEALTH COVERAGE APPLIED FOR BlueAdvantage HMO Plan No. 15-1-15/25/40 BlueAdvantage Point of Service Plan No. 15-1-15/25/40$250 deductible BlueAdvantage Custom Plus Deductible $200 single$400 family Coinsurance 80%to$5,000/$10,000 Eighteen months pre-existing clause for late entrants with no prior coverage for the Custom Plus. )PTIONAL GROUP BENEFIT INFORMATION Optional Chemical Dependency Rehabilitation Program Other Eve Health Network eve exam once every 24 months LEMARKS Retirees age 55 through 64 will have an option to continue health insurance coverage until the date their age changes to 65,provided hey meet the following criteria and stipulations: a) Eligible employees must retire from county service with at least ten years of service, or be a county elected official for at least one full four- year term. b) Eligible employees must be enrolled in the county's health insurance plan at the time of retirement or leave of county office. c) Dependent coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county office. d) Coverage for the eligible employee and dependents will only be provided until the employee reaches age 65, or becomes eligible for health insurance coverage with another employer, or becomes eligible for Medicaid or Medicare coverage before attaining the age of 65. Dependent coverage if still applicable will be offered under the same terms of COBRA offered employee's dependents. e) The county will offer to the retirees the same coverage at the same rates as regular county employees at the same time. The county will be responsible for paying the 40%surcharge of the premium,and the county contribution for the employee and dependents in the same manner as provided regular employees. I) After COBRA, dependents will have the same conversion rights as regular employees and dependents. The Employer understands that if we approve this Addendum,the employer agrees to be bound by the terms of the Contract and this Addendum. Dated at this I / day of (''E:-7Yl /�y� //�, 20G'By '/�q S GNA RE OF AUTHORIZED PERSON TITLE Appro1Je�and ccepted by C, o ado and them Blue Cross and Blue Shield By I A Date December 7, 2001 CHIEF PERA NG OFFI E HMO COLORADO •MVII�/W`.C AJJ A By M7 Date December 7, 2001 C F OPERATING OFFI R-ANTHEM BLUE CROSS AND BLUE SHIELD Weld County Govt lIMO Colorado0V Anthem V Addendum to Application GROUP NUMBER ANNIVERSARY MONTH ADDENDUM EFFECTIVE DATE CohDao I-I I-i-G! PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE.DO NOT TYPE—DO NOT TEAR FORM APART Complete all information on this Addendum to Application (Addendum)if you are completingthe Application.lf you have previously submitted an Addendum,complete only information that is relevant to the change.If a change is not indicated,the previous Addendum will remain in effect. rti'ANGE, ZndIca e4ve 8i re,g ''ya 5h :i w l �G (i .J, `ht :-. ii�ev'x r EY*,." zw �+ �..�' )₹5cEFiI at n v s r" .Kn ,n gyi Ya 'n lfa ptil r3f a �, st P Claas" citt'$tvo#,Emp�ayeea Elrgrb�l yf7 tipendehCA �tatronary � Ap ed Far l l :s""O F00",411,, '�' o(*atGr6uP BEnp64k; E(' (YE Blititl 1100400,991 1PN't w,9wnef,0411eh r„` c trans.. �+.ti ...i.S i t. 0454 7014_ 50,-t..,h Tg 0:AA.n This Addendum is issued to:Weld County Government ("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT) This Addendum amends provisions of the Application.If we approve this Addendum,we will return the approved Addendum with the effective date completed.The Addendum will become a part of the Contract.If we do not approve this Addendum,it will be returned.Other than specifically amended herein,the terms and provisions of the Application and Contract shall remain in full force and etTect. CLASSIFICATION OF EMPLOYEES ELIGIBLE—The Employerrequires that all eligible Employees have a regular work week of at least 20 hours per week(minimum of 24 hours per week).Eligible Employees do not include those on a temporary or substitute basis.If other Eligibility,please explain The Employer hereby certifies the following number of Employees in each category below: Total Employees employed by the employer working at least 24 hours per week(include those not yet eligible) Enrolling for coverage _Total Eligible Employees who have met probationary period _Enrolled elsewhere COBRA or Colorado State law continuation of coverage enrollees No other coverage Other,please explain: DEPENDENTS—Unmarried dependent children are covered until the end of the month in which they become age 19,or 25 if financially dependent upon the parent. PROBATIONARY PERIOD I"of the month following first full pay period worked,employer assigns effective date. GROUP HEALTH COVERAGE APPLIED FOR(select only one): BlueAdvantage HMO Plan Plan No. 15-1-15/25/40#of Employees enrolling BlueAdvantage Point of Service Plan No. 15-1-15/25/40$250 deductible#of Employees enrolling BlueAdvantage Custom Plus Deductible $200 single$400 family Coinsurance 80%to$5,000/$10,000 #of Employees enrolling Eighteen months pre-existing clause for late entrants with no prior coverage for the Custom Plus. OPTIONAL GROUP BENEFIT INFORMATION • -171, Optional Chemical Dependency Rehabilitation Program ry Other Eye Health Network eye exam once every 24 months REMARKS Retirees age 55 through 64 will have an option to continue health insurance coverage until the date their age changes to 65,provided they meet the following criteria and stipulations: a) Eligible employees must retire from county service with at least ten years of service,or be a county elected official for at least one full four-year term. b) Eligible employees must be enrolled in the county's health insurance plan at the time of retirement or leave of county office. c) Dependent coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county office. d) Coverage for the eligible employee and dependents will only be provided until the employee reaches age 65,or becomes eligible for health insurance coverage with another employer,or becomes eligible for Medicaid ro Medicare coverage before attaining the age of 65.Dependent coverage if still applicable will be offered under the same terms of COBRA offered employee's dependents. e) The county will offer to the retirees the same coverage at the same rates as regular county employees at the same time.The county will be responsible for paying the 40%surcharge of the premium,and the county contribution for the employee and dependents in the same manner as provided regular employees. t) After COBRA,dependents will have the same conversion rights as regular employees and dependents. The Employer understands that if we approve this Addendum,the employer agrees to be bound by the terms of the Contract and this Addendum. Dated� Gree a Co lorado this 90th day of Ortnhar 20 nn B -4 4,1 -/A /,� Gf(/L Chair, Board of County Commissioners SIG URE OF A H//// ZED PERSON TITLE Approved and c ted by MOColorado'Sn nth lue Cross and due Shield I 1�,, ac on By l \(){ Date (t^FC7CX/'1 /5/ acon CHI N MO COLORADO By W Qu41 Date SHIELD CC—O fry, c�()CTo CHIEF OP I F AN amyLNE Weld County Davi • BlueAdvantage Application For BlueAdvantage Qa INTERNAL USE ONLY From HMO Colorado" ti An Independent Licensee of the Blue Cross GROUP NUMBER ANNIVERSARY MONTH CONTRACT EFFECTIVE DATE et and Blue Shield Association Co'nan l PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE.DO NOT TYPE—DO NOT TEAR FORM APART Application for BlueAdvantage (Application)group coverage is hereby made for eligible Employees of the Employer. If this Application is approved by HMO Colorado and Anthem Blue Cross and Blue Shield(if applicable),this coverage will be issued to: Weld County Government ("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT) 915 10th Street Greeley Co 806631 (PHYSICAL ADDRESS—STREET,CITY,STATE,ZIP CODE) (MAILING ADDRESS—IF DIFFERENT) NOTE: 'We,""Us,"and"Our"refer to HMO Colorado For group sizes of 51 or more Employees,BlueAdvantage is federallyqualiried in Adams, Arapahoe,Boulder,Clear Creek,Crowley,Denver,Douglas,El Paso,Fremont,Gilpin,Huerfano,Jefferson,Larimer,Otero,Pueblo,Teller and Weld counties.For groups with 51 or more employees,counties not listed are not federally qualified.For group sizes of 50 or fewer Employees, BlueAdvantage is a not a federally qualified HMO product.When the product is not federally qualified,BlueAdvantage coverage can differ from those required by federal HMO laws and regulations.'We,""Us,"and"Our"also refers to Anthem Blue Cross and Blue Shield if coverage is provided for BlueAdvantage Custom Plus coverage. IN CONSIDERATION of the submission of this Application by the Employer, approval thereof by us, and of the payment of premiums in accordance with the Group Master Contract(Contract),we agree to provide group coverage as described in the Contract,the Benefit Booklet, and this Application and the Addendum to the Application for BlueAdvantage(Addendum),for any eligible enrolled Employees and eligible enrolled dependents,and the Employer agrees to abide by the terms,conditions,and limitations contained in such documents. GENERAL AGREEMENT 1. NATURE OF BUSINESS(please be specific):County Government Type of organization:0 Proprietorship 0 Corporation 0 Partnership 2. Do you have current coverage in force? 0 Yes No,if"Yes"do you intend to cancel that coverage? 0 Yes 0 No. If you are applying for or retaining other group health coverage in ad lion to this coverage on some or all Employees specify coverage(s),Carrier,amounts,and give details: _ 3. Do you intend to enroll retirees under this group health Plan?(Retirees may encoil for ioverage if there are 51 or more Employees enrolled under this coverage.) g Yes 0 No If"Yes,"give details: WO f"I Or I Vrf) 4. CONTRIBUTION—The Employer will be required to contribute a minimum of 50%toward the Employee's single or 50%of the Employees portion of the family-cost of membership premiums. 5. PREMIUMS—It is understoodthat the premiums quoted may change based on the actual enrollment of the group.Premiums will be billed by us monthly,and will be reviewed in accordance with the Contract and State or Federal requirements. 6. CLASSIFICATION OF EMPLOYEES ELIGIBLE—All eligible Employees of the Employer who have a regular work week as stated on the Addendum,shall be eligible to enroll.If the Employer reduces the working hours of such Employees to less hours per week than stated on the Addendum,coverage will be continued for such Employees and their dependents under the same conditions and for the same premium, if the following conditions are met and the Employer so certifies: (a) The covered Employee has been continuously employed as an Employee of the Employer and has been insured under the group Contract,or under any group Contract providing similarbenefits which said group Contract replaces,for at least six months immediately prior to such reduction in working hours; (b) The Employer has imposed such reduction in working hours due to economic conditions;and (c) The Employer intends to restore the Employee to a full work week schedule as soon as economic conditions improve. 7. ENROLLMENT PERCENTAGE REQUIREMENTS— For all size groups to apply for and retain group coverage and rates if we are the sole carrier,the Employer agrees to maintain the following enrollment percentage requirements,based on TOTAL ELIGIBLE EMPLOYEES: • Group size 50 or fewer Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES • Group size 51 or more Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES,with no less than 50%of TOTAL ELIGIBLE EMPLOYEES. To arrive at NET ELIGIBLE EMPLOYEES,Employees covered elsewhere with the following types of groupinsurancemay be excluded,unless uch coverage is offered through THE EMPLOYER: A Blue Cross and Blue Shield Plan; A Health Maintenance Organization; The Federal Employees Program; Indian Health Services; Federal Peace Corps; Colorado Uninsurable Health Insurance Plan,or Through a commercial carrier. Weld Cty App.wpd FORM NO.96064(REV.11/97) NOTE: In the event the group does not meet the minimum enrollment requirements,we reserve the right to accept this Application with prior underwriting approval. In all cases the Employer must meet the minimum enrollment and eligibility requirements according to HMO Colorado underwriting regulations and policies and Colorado State law. If we are a dual carrier,to apply for and retain group coverage and rates,a minimum of three Employees must be enrolled at all times.When we are a dual carrier,the enrollment percentage requirements do not apply If the number of eligible Employees enrolled does not comply with the required percentage,we reserve the right to cancel the Contract upon thirty day advance written notice. Employers with 50 or fewer Employees may also be,sole proprietor's,a single full time Employee of a subchapter S or C corporation, Iimitedliabilitycompany,or a partnership that has carried on significant business activity for a period of at least one year prior to application for coverage. The Employer agrees and warrants that no person who is not an eligible member under this provision will be listed,named,or otherwise represented by it in any way to be an eligible member,and that the Employer will not remit membership premiums for any such person or participant or assist in obtaining or maintaining a Benefit Booklet for such ineligible person. The Employer agrees to maintain complete records and to furnish to us,upon request,such information as may be requested by us for our underwriting review. The Employer further agrees to permit a payroll audit by us or by a representative appointed by us.This may include a request for business tax records. 8. DEPENDENT—Dependent children are covered until they attain the age as stated on the Addendum. 9. PROBATIONARY PERIOD—Probationaryperiod selection is as stated on the Addendum.There will be one open enrollment on the group's Anniversary Date for the BlueAdvantage HMO Plan and/or BlueAdvantage Point-of-Service Plan. For BlueAdvantage Custom Plus,late entrants with prior coverage can be added at the group's anniversary date.In addition,if BlueAdvantage Triple Option coverage is selected by the Employer,members will be allowed to choose between the HMO Plan,Point-of-Service,and Custom Plus coverage(for Employers with 50 or fewer employees only out-of-state employees can enroll in the Custom Plus). 10. GROUP HEALTH COVERAGE APPLIED FOR—Coverage selection is as stated on the Addendum. COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL EMPLOYERS OF 2-50 EMPLOYEES, INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN,UPON THE REQUEST OFA SMALL EMPLOYER TO THE ENTIRE SMALL GROUP, REGARDLESS OF THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN THE GROUP.BUSINESS GROUPS OF ONE CANNOT BE REJECTED UNDER A BASIC OR STANDARD HEALTH BENEFIT PLAN. 11. Employer represents,agrees,and warrants that the Employer is in compliance with all applicable local,state,and federal laws,rules and regulations,including but not limited to COBRA,the Family Medical Leave Act,TEFRA, DEFRA, and OBRA.To the extent any part of this application is inconsistent with such laws,rules,and regulations,such provision shall not be deemed a part of this application.However, the application shall be otherwise enforceable.If the Employer has agreed to have us perform specific billing and notification duties related to COBRA,such information will be stated on the Addendum. Masoud Shirazi-Shirazi&Assoc (970)356-5151 _ BROKER TELEPHONE NUMBER 1770 251h Avenue#302 Greeley Co 80631 STREET,CITY,STATE,ZIP CODE The Employer represents,agrees,and warrants that the information contained in this Application is true and correct and forms an essential basis for our issuance of the Contract.EVEN THOUGH THIS APPLICATION IS SUBMITTED WITH PROPOSED PREMIUMS OR OTHER FUNDS,THERE WILL BE NO COVERAGE UNTIL THIS APPLICATION IS APPROVED BY US. If we approve this Application,we will send you a Contract of which this Application will become a part.Your prior coverage should not be cancelled until you have been notified that your Application has been accepted.No agent can bind coverage,set an effective date,or waive or alter any provision of this Application.The Contract will specify the effective date of group coverage. If we do not approve this Application,the submitted funds will be retumed to the Employer. The Employer understands that if we approve this Application,the Employer agrees to be bound by the terms of the Contract. Date Gree e , olorado this 30th day of October i&c 2000 Chiar. Board of County Commissioners SIGNAT RE OF AUT RIZED PERSON TITLE Approved and e ted b HMO Colorado Blue Cross d Blue Shield By Date ©!4fJ11: - /c QrrY) C IEFOPERATI F(FIkistwevcss)viHMO COLORADO By p Date (1("4-OO.r )y �rflfl CHIEF OPERA G OFFICER- TH B E UEIELD Weld Cry App.wpd FORM NO.96064(REV.11/97) HMO COLORADO GROUP MASTER CONTRACT NO. 02-00772002 For Weld County Government Employer C07720 Group Number SECTION I. APPLICATION-ACCEPTANCE The application and addendum for group health coverage ("application/addendum") executed by the employer has been accepted by HMO Colorado (sometimes referred to as "we," "us," and"our"). Such application/addendum and their contents are incorporated in this group master contract("contract"). In the event of any inconsistency between the terms of the application/addendum and the terms of the contract, the terms of the contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the employer's employees and their dependents. Such persons, when covered hereunder, are referred to as "members." 1. Contract effective date. The effective date of the contract shall be 12:01 A.M. on the first day of January, 2002, at Denver, Colorado; the contract shall continue to remain in effect on an annual basis from year to year thereafter unless terminated in accordance with the provisions of the contract. 2. Anniversary date. The anniversary date is the effective date for (i) coverage; (ii) changes to group enrollment and benefit eligibility implemented by the employer; and(iii) the date a group is due for appropriate renewal rating. 3. Employee. An employee as defined in the application/addendum as eligible for enrollment; the employee is the individual who is employed by the employer. 4. Employer. The employer or organization with whom HMO Colorado has contracted, and by reason of the contract the employees and their dependents become eligible for the coverage and benefits described in the contract. 5. Remittance.The employer shall pay to us monthly and prior to the first day in each month, the required premium on behalf of all enrolled employees and dependents who meet the eligibility requirements specified in the group application/addendum and benefit booklet that are incorporated in this contract. 6. Benefit booklet.The definitions and other terms of the benefit booklet are incorporated herein by reference. su H119G Coc 1 7. Group administrator. The employer will designate a person as the principal contact for all matters pertaining to HMO Colorado group coverage. That person will assist employees in the administration and payment of claims. It is understood that HMO Colorado is not the "administrator" within the meaning of the Employee Retirement Income Security Act (ERISA). 8. Assignment.None of the rights,benefits, duties, or obligations of the employer shall be assigned without the prior written consent of a duly authorized officer of HMO Colorado. Any attempted assignment will be void. 9. Contract provision changes. a. This contract, the benefit booklet and any amendments thereto, and the group application/addendum constitute the entire agreement between the parties hereto and supersede all other contracts, either oral or in writing, between the parties with respect to the subject matter hereof. No course of action, usage or custom or internal policy of HMO Colorado may amend or become a part of this contract. Except as provided in paragraphs b. and c.immediately below, no change or modification to this contract shall be valid unless the same is in writing and signed by the parties hereto. b. During the initial annual term or any renewal annual term of the contract, the provisions of this contract may be amended at any time by an endorsement signed only by a duly authorized officer of HMO Colorado. When the endorsement has been so signed, the endorsement shall be deemed a part of the contract, effective as of the date specified by the endorsement. c. Any amendment resulting from state or federal law, or regulation, or ruling or approval by the Commissioner of Insurance of the State of Colorado may be made at any time by endorsement to the contract signed only by a duly authorized officer of HMO Colorado and shall become effective as of the effective date of such law, regulation, ruling, or approval. 10. Notices. All notices to HMO Colorado shall be sent by United States mail or personal delivery to HMO Colorado, 700 Broadway, Denver, CO 80203-3441. All notices to employees or the employer shall be sent by United States mail to the last address appearing in the records of HMO Colorado or by personal delivery to the office of the employer.The employer shall notify members in the event that this contract is terminated within ten (10) days of the date that the employer has notice that this contract is to be or has been terminated, whichever occurs first. If the employer has engaged the services of a broker/consultant, then delivery of all notices to the named broker/consultant meets the requirements of this contract. Notice shall be effective upon mailing. Notice mailed to the employer or broker/consultant shall be deemed effective notice to each employee. However, the employer agrees to post each notice promptly in a place reasonably calculated to facilitate the employees' reading of the notice. The employer agrees to hold us harmless for its failure to provide notice to the employees of any contract provision changes or termination. 11. Governing Laws. This contract is made and delivered in the State of Colorado, and will be interpreted and enforced so as to remain in compliance with Colorado statutes and regulations. Nothing contained herein shall be interpreted to mean that HMO Colorado is doing business in any other state of jurisdiction. Any legal action against us must be brought in the City and County of Denver, Colorado. 2 BLUa119G.COC • 12. Attorneys' fees and expenses. a. Should it become necessary for either party to this contract to seek the assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless HMO Colorado from its costs including losses, claims, settlements,judgments, or fees, including attorneys' fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder, the employer's obligation to indemnify us shall apply only to costs incurred after this contract has been cancelled or terminated. 13. Enforcement of the contract. Failure of HMO Colorado or the employer to enforce any of the provisions of this contract shall not constitute a waiver of rights for that or subsequent breaches. 14. Interpretation of the contract.This contract shall not be interpreted against any party for the reason of having prepared its language and provisions.Rather,it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this contract and sound principles of contract interpretation. 15. Termination of the contract. The employer may terminate the contract at any time during its term upon giving 30 days advance written notice of termination to HMO Colorado. A group which voluntarily cancels coverage will not be considered for re-enrollment until a two-month period has elapsed from the date of cancellation.Such re-enrollment shall be subject to then current operating procedures and underwriting regulations of HMO Colorado. HMO Colorado may terminate the contract at any time during its term for (i) employer's failure to make timely payment of amounts due hereunder, (ii) failure of the group to meet eligibility requirements, (iii) failure of the group to maintain enrollment percentage requirements, as provided in the application/addendum, or (iv) misrepresentation of material facts or any other breach of the contract; any such termination shall be subject to the terms of the contract and any endorsements. 16. Reinstatement of contract.HMO Colorado, at its sole option, may reinstate this contract after it has been terminated. We may impose such conditions on the contract's reinstatement as we deem appropriate, including,without limitation, acceptable health statements. It is understood, however, that there is no right to reinstatement, and any reinstatement will be in the sole discretion of HMO Colorado. BLUH119G.COC 3 SECTION III. PREMIUM: CHANGES, PAYMENT, TERMINATION FOR NON-PAYMENT, REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 1. Changes.HMO Colorado may change monthly premium as outlined in any endorsements to this contract. HMO Colorado reserves the right to review monthly premium whenever a group, section, or classification of employees is added to or deleted from enrollment under the contract. The employer shall notify HMO Colorado no later than 30 days prior to the effective date of such addition or deletion, and any change in monthly premium which may be required as the result of an increased or decreased total group enrollment will become effective on the same date as such addition to or deletion from total enrollment under the contract. This provision shall apply regardless of the employer's normal rate review date or any other advance rate notification agreement which may be in effect between HMO Colorado and the employer. 2. Payment. Initial premium shall become payable on or before the effective date of the contract. Subsequent premium shall be payable on or before the first of each month thereafter. Eligibility of members, claims processing, and payment will be suspended if premium is not timely paid. In no event shall coverage under the contract become effective until we accept the application/addendum and payment of the initial premium is received by HMO Colorado. 3. Termination for non-payment. The contract shall terminate by its own terms if premium is not paid on or before 30 days after the first day of the month, and no notice of cancellation other than this provision shall be required. However, we may by sending notice thereof terminate this contract before 30 days after the first day of the month if premium is not paid on or before the first day of the month. When the contract is terminated or cancelled, the effective date of such cancellation or termination shall be the date to which membership premium was last paid. Members shall no longer be eligible to receive covered health services and all claims shall be refused when dates of service are beyond the last day of the month for which payment has been received. Claims that we deny because the employer fails to submit premium payments in a timely manner should be submitted for payment to, and may be the responsibility of, the employer. 4. Refund of membership premium. a. If the employer terminates the coverage of a member or terminates this contract for any reason, a refund of membership premium paid beyond the first of the month following the termination date will be granted only if written notification of termination is received by HMO Colorado at least 30 days before the termination date, covered health services have not been provided and benefit payments have not been made for services rendered subsequent to the termination date. If notification of termination is received less than 30 days before the termination date, no refund of membership premium will be made and coverage shall cease on the first of the month following the termination date. b. If HMO Colorado terminates coverage of a member or terminates this contract for any reason, a refund of membership premium paid beyond the termination date will only be granted if covered health services have not been provided and benefit payments have not been made for services rendered subsequent to the termination date. 4 BLUHI19G.coc 5. Cashing of check not acceptance. It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility.All employees,who have a regular work week as indicated on the application and/or addendum, paid for such employment by the employer, and listed as an employee on the employer's State unemployment insurance tax returns, and the dependents of the employees, are eligible to enroll for membership under the contract. We may inspect such records, public and private, as are necessary to verify employment. Applications of employees and dependents at open enrollment must be received prior to the anniversary date to be effective on the anniversary date. If applications are not received prior to the anniversary date, they will not be effective until the next anniversary date. 2. Notification of cessation of membership. The employer shall advise us when the employer has notice that a member is no longer employed by the employer or otherwise does not satisfy membership requirements. The employer shall so notify us, at the latest, by the first day of the month after a member ceases to be employed by employer or otherwise ceases to meet membership requirements. Such coverage shall terminate at the end of the month in which the member is no longer employed or does not satisfy membership requirements. The employer agrees that no person will be kept on the employer's payroll or otherwise be represented as an employee of the employer for the purpose of obtaining or maintaining coverage when no longer eligible for such coverage hereunder. The employer agrees to observe the terms thereof, and hold us harmless for all costs incurred, including attorneys' fees, in the defense of any claim or suit brought at any time by a person who is ineligible for coverage. 3. Acceptance of contract.The employer's signature on the group application/addendum and this contract constitutes acceptance of this contract. 4. Group eligibility requirements. If the employer does not comply with the group eligibility requirement, we reserve the right to cancel the contract upon 30 days advance written notice. Weld bunts Government HMO COLORADO By *--7,/ ..Q,/6/ By . Pi / Caroline Matthews Printed or Typed Name Printed or Typed Name r �5f� � 1 L� l / (Title) L.-11I 1 id 1 G ape (Title) Chief Operating Officer .A.,77 /0/ (Date) (Date) November 8, 2001 BLUHI19G.COC 5 6 BLUH119G.COC eb,. cc LIMO Colorado 4.3.diu.iwtamitsaisis=mdiaimishiduairs HMO Colorado 700 Broadway Denver, Colorado 80203 ENDORSEMENT NO.: 1 TO GROUP MASTER CONTRACT NO.: 02-00772002 The Contract identified above is hereby amended by this endorsement which is issued to form part of the Contract between Anthem Blue Cross and Blue Shield (Anthem BCBS) and Weld County Government (the Employer), effective as of the Contract Effective Date as follows: For the period beginning on the Contract Effective Date (January 1, 2002) and ending on December 31, 2002, paragraph 1. Changes of Section of Section III. Premiums Changes, Payment, Service Date, Termination For Non-Payment, Retroactive Refund of Membership Premium, Cashing for Check Not Acceptance of the Contract, shall be replaced in its entirety with the following provision: 1. (a) Subject to the provisions of subparagraph(c),below,the premiums specified in Exhibit A to this endorsement shall remain in effect for a period of 12 months from January 1, 2002. (b) Notwithstanding the provisions of subparagraphs(a)and(b),above,Anthem BCBS may change the monthly premiums due hereunder, effective immediately, whenever (i) benefits are changed by endorsement or by federal or state law; or (ii) the number of Employees covered under the Contract in any given month differs from the number of Employees covered under the Contract as of the Contract Effective Date by 20% of enrollment. (c) For the period beginning on January 1, 2002, the Employer shall remit an advanced check for premiums of $260,000 to Anthem BCBS/HMOC upon signature of this Endorsement or no later than January 31, 2002. This payment will be used to offset the fully insured equivalent required rate increase of 10.66% for the period of January 1, 2002 through December 31, 2002. 2. For the period beginning on the Contract Effective Date (January 1, 2000) and ending on December 31, 2002, paragraph 20. Termination of Contract of Section II. General Agreements,of the Contract shall be amended by adding the following sentence to the end of subparagraph (b) of paragraph 20: "Notwithstanding the foregoing, Anthem BCBS agrees not to terminate this Contract solely because of poor claims experience of Employees and Dependents covered under this Contract." 3. Effective on the earlier of(i) any date on which Anthem BCBS changes the premiums due hereunder in accordance with the provisions of subparagraph 1(c)(ii) of Section III of the Contract, as amended above, or (ii) two years from the Contract Effective Date, the provisions of this endorsement shall be of no further effect and the original provisions of paragraph 1 of Section III and paragraph 20.of Section II of the Contract shall be reinstated as if they had never been amended. 4. Except as otherwise specifically amended hereby, all terms and conditions of the Contract shall remain in full force and effect. Weld County 2°"yr Rate Guar.wpd Weld Cou Government Anth '..:A31ue Cross and.Blue Shield (Group me)v 7 , ,� By 21/ v% By U''r� '. �► 71/, '•3 (4 el (e Caroline Matthews Printed or Typed Name / Printed or Typed Name (Title) OA �-t. , R J fkk' 114 C ,7) • (Title) Chief Operating Officer Date ),?V 1? c i Date November 8, 2001 Weld County 2""yr Rate Guar.wpd +Q HMO 71� Colorado Anthem,4g, An Anthem Company ANTHEM BLUE CROSS & BLUE SHIELD Account Name: WELD COUNTY GOVERNMENT Account No.: C07720 EXHIBIT A Rates Effective: January 1, 2002 Annual Renewal: January 1 Account Executive: Mike Rankin MONTHLY HEALTH RATES BlueAdvantage Triple Option Employee Employee Employee Modified Plan Only &Spouse &Child(n) Family Blue Advantage 15/1/15-25.40 HMO $15 Office Visit Copay $100 Inpatient Deductible $15-25-40 Prescription Copay Fully Insured Equivalent Rates $240.82 $481.64 $462.37 $708.85 BILLED RATES $224.36 $448.73 $430.78 $660.41 HMO COBRA Rate(Direct Bill) $245.64 $491.27 $471.62 $723.03 Blue Advantage 15/1/15-2540 POS $15 Office Visit Copay $100 Inpatient Deductible $15-25-40 Prescription Copay $250 Opt-out Deductible Fully Insured Equivalent Rates $253.37 $557.41 $532.08 $817.19 BILLED RATES $236.05 $519.31 $495.70 $761.33 POS COBRA Rate(Direct Bill) $258.44 $568.56 $542.72 $833.54 Custom Plus $200/$400 Deductible 80%Coinsurance $15-25-40 Prescription Copay Fully Insured Equivalent Rates $319.10 $631.82 $599.91 $912.88 BILLED RATES $297.28 $588.62 $558.89 $850.46 Custom Plus COBRA Rate(Direct Bill) $325.48 $644.45 $611.91 $931.14 BENEFIT SUMMARY: Dependent Children Covered to End of Month,Age 25 Substance Abuse Rider Included Vision through Eye Health Network (HMO&POS Plans) These rates assume a $260,000 advance premium payment to Anthem Blue Cross and Blue Shield on or before January 31, 2002. No 2003 rate cap. RENEWAL (4 Tier) October 11. 2001 Independent licensees of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service,Inc. 0 Registered marks Blue Cross and Blue Shield Association. Anthems 0 d A Group Health Care Program Group Master Contract THE ANTHEM BLUE CROSS AND BLUE SHIELD GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION-ACCEPTANCE 1 SECTION II. GENERAL AGREEMENTS 1 Contract Effective Date 1 Anniversary Date 1 Annual Renewal Date 1 Employee 1 Employer 1 Remitting Agent 1 Remittance 1 Membership Certificate Terms 2 Group Administrator 2 Assignment 2 Contract Provision Changes 2 Reserve Funds 2 Notices 2 Governing Laws 2 Attorneys' Fees and Expenses 3 Warranties and Representations 3 Enforcement of the Contract 3 Interpretation of the Contract 3 BlueCard Program. 3 Termination of Contract 4 SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 4 Changes 4 Payment 4 Service Date 4 Termination for Non-Payment 4 Retroactive Refund of Membership Premium 5 Cashing of Check Not Acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Receipt of Applications 5 Notification of Cessation of Membership 5 0C8Sfl,0.Ca i HMO Anthem. V. . Colorado Addendum to Application An Anthem Company GROUP NUMBER ANNIVERSARY MONTH ADDENDUM EFFECTIVE DATE C07720 January I, January I, 2002 This Addendum is issued to:Weld County Government ("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT) his Addendum amends provisions of the Application. If we approve this Addendum, we will return the approved Addendum with the effective ate completed. The Addendum will become a part of the Contract If we do not approve this Addendum, it will be returned. Other than aecifically amended herein,the terms and provisions of the Application and Contract shall remain in full force and effect LASSIFICATION OF EMPLOYEES ELIGIBLE—The Employer requires that all eligible Employees have a regular work week of at least 20 hours per week. Eligible Employees do not include those on a temporary or substitute basis. he Employer hereby certifies the following number of Employees in each category below: _Total Employees employed by the employer working at least 20 hours per week(include those not yet eligible( Enrolling for average _Total Eligible Employees who have met probationary period Enrolled elsewhere _COBRA or Colorado State law continuation of coverage enrollees No other coverage _Other,please'explain: IEPENDEWTS—Unmarried dependent children are covered until the end of the month in which they become age 19, or 25 if financially ependent upon the parent. ROBATIONARY PERIOD let of the month following first full pay period worked,employer assigns effective date. POUP HEALTH COVERAGE APPLIED FOR BlueAdvantage HMO Plan No. 15-1-15/25/40 BlueAdvantage Point of Service Plan No. 15-1-15/25/40$250 deductible BlneAdvantage Custom Plus Deductible $200 single$400 family Coinsurance 80%to$5,000/$10,000 Eighteen months pre-existing clause for late entrants with no prior coverage for the Custom Plus. IPTIONAL GROUP BENEFIT INFORMATION Optional Chemical Dependency Rehabilitation Program Other Eye Health Network eve exam once every 24 months :EM AIL=Retirees age 55 through 64 will have an option to continue health insurance coverage until the date their age changes to 65,provided aey meet the following criteria and stipulations: a) Eligible employees must retire from county service with at least ten years of service, or be a county elected official for at least one full four- year term. b) Eligible employees must be enrolled in the county's health insurance plan at the time of retirement or leave of county office. c) Dependent coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county office. d) Coverage for the eligible employee and dependents will only be provided until the employee reaches age 65, or becomes eligible for health insurance coverage with another employer, or becomes eligible for Medicaid or Medicare coverage before attaining the age of 65. Dependent coverage if still applicable will be offered under the same terms of COBRA offered employee's dependents. e) The county will offer to the retirees the same coverage at the same rates as regular county employees at the same time. The county will be responsible for paying the 40%surcharge of the premium, and the county contribution for the employee and dependents in the same manner as provided regular employees. f) After COBRA, dependents will have the same conversion rights as regular employees and dependents. The Employer understands that if we approve this Addendum,the employer agrees to be bound by the terms of the Contract and this Addendum. // / /- ,, Dated at 6 taiP I, d ( 10 this /5/ day of eeri Yi L-77 2001 By � / �'i l— 8c,1 LOe f el t 4�ym,v) �`�� S GNATURE OR AUTHORIZED PERSON TITLE Approeiand cepted by Y o ado and them Blue Cross and Blue Shield i By Date December 7, 2001 .HIEF P tJFFIjHMO COLORADO By Date December 7, 2001 • C OPERATING OFFI —ANTHEM BLUE CROSS AND BLUE SHIELD Weld County Govt HMO Colorado 0V Anthem; l! Addendum to Application • • GROUP NUMBER ANNIVERSARY MONTH ADDENDUM EFFECTIVE DATE Col)na J PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART Complete all information on this Addendum to Application (Addendum)if you are completing the Application.If you have previously submitted an Addendum,complete only information that is relevant to the change.If a change is not indicated,the previous Addendum will remain in effect. CHANGE' lndtcate one more_ �� ` - - S A Classtfica[ion.ofEmployees Eltgtble d O_Dependen[Age -O Probationary Period C•Coverage-Apptmd For=� '". C Optional Group Benefit"4C,COBRA`:Billing Notification...O New ownership • , — - - -.}- # .'s This Addendum is issued to:Weld County Government ("THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT) This Addendum amends provisions of the Application.If we approve this Addendum,we will return the approved Addendum with the effective date completed.The Addendum will become a part of the Contract.If we do not approve this Addendum,it will be retumed.Other than specifically amended herein,the terms and provisions of the Application and Contract shall remain in full force and effect. CLASSIFICATION OF EMPLOYEES ELIGIBLE—The Employerrequires that all eligible Employees have a regular work week of at least 20 hours per week(minimum of 24 hours per week). Eligible Employees do not include those on a temporary or substitute basis.If other Eligibility,please explain The Employer hereby certifies the following number of Employees in each category below: _Total Employees employed by the employer working at least 24 hours per week(include those not yet eligible) Enrolling for coverage _Total Eligible Employees who have met probationary period Enrolled elsewhere COBRA or Colorado State law continuation of coverage enrollees _No other coverage Other,please explain: DEPENDENTS—Unmarried dependent children are covered until the end of the month in which they become age 19,or 25 If financially dependent upon the parent. PROBATIONARY PERIOD I"of the month following first full pay period worked,employer assigns effective date. GROUP HEALTH COVERAGE APPLIED FOR(select only one): BlueAdvantage HMO Plan Plan No. 15-I-15/25/40#of Employees enrolling BlueAdvantage Point of Service Plan No. 15-1-15/25/40$250 deductible 4 of Employees enrolling BlueAdvantage Custom Plus Deductible $200 single$400 family Coinsurance 80%to$5,000/$10.000 4 of Employees enrolling Eighteen months pre-existing clause for late entrants with no prior coverage for the Custom Plus. OPTIONAL GROUP BENEFIT INFORMATION Optional Chemical Dependency Rehabilitation Program $ Other Eve Health Network eve exam once every 24 months REMARKS Retirees age 55 through 64 will have an option to continue health insurance coverage until the date their age changes to 65,provided they meet the following criteria and stipulations: a) Eligible employees must retire from county service with at least ten years of service.or be a county elected official for at least one full four-year term. b) Eligible employees must be enrolled in the county's health insurance plan at the time of retirement or leave of county office. c) Dependent coverage will be provided for eligible employees dependents who are enrolled at the time of retirement or leaving of county office. d) Coverage for the eligible employee and dependents will only be provided until the employee reaches age 65,or becomes eligible for health insurance coverage with another employer,or becomes eligible for Medicaid ro Medicare coverage before attaining the age of 65.Dependent coverage if still applicable will be offered under the same terms of COBRA offered employee's dependents. e) The county will offer to the retirees the same coverage at the same rates as regular county employees at the same time.The county will be responsible for paying the 40%surcharge of the premium,and the county contribution for the employee and dependents in the same manner as provided regular employees. t) After COBRA,dependents will have the same conversion rights as regular employees and dependents. The Employer understands that if we approve this Addendum,the employer agrees to be bound by the terms of the Contract and this Addendum. Dated at Greeley./ Cola'/PR o this • lOth day of flrrnhor 20 flp By d V. \R/�-L(yl/ Chair. Board of County Commissioners SIGNATU OF AUTHO D PERSON- • -- TITLE Approved and ac fed by O Colorado an n e e Cross and Blue‘Shield I \ By //�� Date 0 (4OOA--. lr-1 ano 0 HI —HMO COLORADO By ( Date Or a-r- 1c1 !�iOcn CHIEF OP AN"QkjE CRNeB'nrlu BLUE SHIELD Weld County Con as v49 BlueAdvantage Application For BlueAdvantage (7 9 ti From HMO Colorado' INTERNAL USE ONLY An Independent Licensee of the Blue Cross GROUP NUMBER ANNIVERSARY MONTH CONTRACT EFFECTIVE GATE ® 61 and alue Shield Anoci.don Co Mn1 -( !-l-G! • PLEASE PRINT FIRMLY TO ENSURE THAT ALL COPIES ARE LEGIBLE. DO NOT TYPE—DO NOT TEAR FORM APART Application for BlueAdvantage (Application) group coverage is hereby made for eligible Employees of the Employer. If this Application is approved by HMO Colorado and Anthem Blue Cross and Blue Shield(if applicable),this coverage will be issued to: Weld County Government ('THE EMPLOYER"—CORRECT LEGAL NAME OF ACCOUNT) 915 10'"Street Greeley Co 806631 (PHYSICAL ADDRESS—STREET,CITY,STATE,ZIP CODE) (MAILING ADDRESS—IF DIFFERENT) NOTE: "We,""Us,"and"Our"refer to HMO Colorado.For group sizes of 51 or more Employees,BlueAdvantage is federallyqualified in Adams, Arapahoe,Boulder,Clear Creek,Crowley,Denver,Douglas,El Paso, Fremont,Gilpin,Huerfano,Jefferson,Lorimer,Otero,Pueblo,Teller and Weld counties.For groups with 51 or more employees,counties not listed are not federally qualified.For group sizes of 50 or fewer Employees, BlueAdvantage is a not a federally qualified HMO product.When the product is not federally qualified,BlueAdvantage coverage can differ from those required by federal HMO laws and regulations.'We,""Us,"and"Our"also refers to Anthem Blue Cross and Blue Shield if coverage is provided for BlueAdvantage Custom Plus coverage. IN CONSIDERATION of the submission of this Application by the Employer, approval thereof by us, and of the payment of premiums in accordance with the Group Master Contract(Contract),we agree to provide group coverage as described in the Contract,the Benefit Booklet, and this Application and the Addendum to the Application for BlueAdvantage(Addendum), for any eligible enrolled Employees and eligible enrolled dependents,and the Employer agrees to abide by the terms,conditions,and limitations contained in such documents. GENERAL AGREEMENT I. NATURE OF BUSINESS(please be specific):County Govermment Type of organization:❑Proprietorship O Corporation O Partnership 2. Do you have current coverage in force? O Yes CANo,if'Yes"do you intend to cancel that coverage? O Yes O No. If you are applying for or retaining other group health coverage in addition to this coverage on some or all Employees specify coverage(s),Carrier,amounts,and give details: 3. Do you intend to enroll retirees under this group health Plan?(Retirees m5ylenroll f r coverage if there are 51 or more Employees enrolled under this coverage.) AYes O No If"Yes,"give details: S24- arid G-'7'9(t/1'Y) 4. CONTRIBUTION—The Employer will be required to contribute a minimum of 50%toward the Employee's single or 50%of the Employees portion of the family-cost of membership premiums. 5. PREMIUMS—It is understoodthat the premiums quoted may change based on the actual enrollment of the group.Premiums will be billed by us monthly,and will be reviewed in accordance with the Contract and State or Federal requirements. 6. CLASSIFICATION OF EMPLOYEES ELIGIBLE—All eligible Employees of the Employer who have a regular work week as stated on the Addendum,shall be eligible to enroll.If the Empioyerreduces the working hours of such Employees to less hours per week than stated on the Addendum,coverage will be continued for such Employees and their dependents under the same conditions and for the same premium, if the following conditions are met and the Employer so certifies: (a) The covered Employee has been continuously employed as an Employee of the Employer and has been insured under the group Contract,or under any group Contract providing similarbenefitswhich said group Contract replaces,for at least six months immediately prior to such reduction in working hours; (b) The Employer has imposed such reduction in working hours due to economic conditions;and (c) The Employer intends to restore the Employee to a full work week schedule as soon as economic conditions improve. 7. ENROLLMENT PERCENTAGE REQUIREMENTS— For all size groups to apply for and retain group coverage and rates if we are the sole carrier,the Employer agrees to maintain the following enrollment percentage requirements,based on TOTAL ELIGIBLE EMPLOYEES: • Group size 50 or fewer Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES • Group size 51 or more Employees must have 75%enrollment based on NET ELIGIBLE EMPLOYEES,with no fess than 50%of TOTAL ELIGIBLE EMPLOYEES. To arrive at NET ELIGIBLE EMPLOYEES,Employees covered elsewhere with the following types of groupinsurancemay be excluded,unless such coverage is offered through THE EMPLOYER: • A Blue Cross and Blue Shield Plan; • A Health Maintenance Organization; • The Federal Employees Program; • Indian Health Services; • Federal Peace Corps; • Colorado Uninsurable Health Insurance Plan,or • Through a commercial carrier. Weld Cly App.wpd FORM NO.96064(REV.11/97) NOTE: In the event the group does not meet the minimum enrollment requirements,we reserve the right to accept this Application with prior underwriting approval. In all cases the Employer must meet the minimum enrollment and eligibility requirements according to HMO Colorado underwriting regulations and policies and Colorado State law. If we are a dual carrier,to apply for and retain group coverage and rates,a minimum of three Employees must be enrolled at all times.When we are a dual carrier,the enrollment percentage requirements do not apply If the number of eligible Employees enrolled does not comply with the required percentage,we reserve the right to cancel the Contract upon thirty day advance written notice. Employers with 50 or fewer Employees may also be,sole proprietor's,a single full time Employee of a subchapter S or C corporation, Iimitedliabilitycompany,or a partnership that has carried on significant business activity for a period of at least one year prior to application for coverage. The Employer agrees and warrants that no person who is not an eligible member under this provision will be listed,named,or otherwise represented by it in any way to be an eligible member,and that the Employer will not remit membership premiums for any such person or participant or assist in obtaining or maintaining a Benefit Booklet for such ineligible person. The Employer agrees to maintain complete records and to furnish to us,upon request,such information as may be requested by us for our underwriting review. The Employer further agrees to permit a payroll audit by us or by a representative appointed by us.This may include a request for business tax records. 8. DEPENDENT—Dependent children are covered until they'attain the age as stated on the Addendum. 9. PROBATIONARY PERIOD—Probationary period selection is as stated on the Addendum.There will be one open enrollment on the group's Anniversary Date for the BlueAdvantage HMO Plan and/or BlueAdvantage Point-of-Service Plan. For BlueAdvantage Custom Plus,late entrants with prior coverage can be added at the group's anniversary date.In addition,if BlueAdvantage Triple Option coverage is selected by the Employer,members will be allowed to choose between the HMO Plan,Point-of-Service,and Custom Plus coverage(for Employers with 50 or fewer employees only out-of-state employees can enroll in the Custom Plus). 10. GROUP HEALTH COVERAGE APPLIED FOR—Coverage selection is as stated on the Addendum. COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL EMPLOYERS OF 2-50 EMPLOYEES, INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN,UPON THE REQUEST OF A SMALL EMPLOYER TO THE ENTIRE SMALL GROUP, REGARDLESS OF THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN THE GROUP.BUSINESS GROUPS OF ONE CANNOT BE REJECTED UNDER A BASIC OR STANDARD HEALTH BENEFIT PLAN. I I. Employer represents,agrees,and warrants that the Employer is in compliance with all applicable local,state,and federal laws,Hiles and regulations,including but not limited to COBRA,the Family Medical Leave Act,TEFRA, DEFRA, and OBRA.To the extent any part of this application is inconsistent with such laws,rules,and regulations,such provision shall not be deemed a part of this application.However, the application shall be otherwise enforceable.If the Employer has agreed to have us perform specific billing and notificationduties related to COBRA,such information will be stated on the Addendum. Masoud Shirazi-Shirazi&Assoc (970)356-5151 _ BROKER TELEPHONE NUMBER 1770 25thAvenue#302 Greeley Co 80631 STREET,CITY,STATE,ZIP CODE The Employer represents,agrees,and warrants that the informationcontained in this Application is true and correct and forms an essential basis for our issuance of the Contract.EVEN THOUGH THIS APPLICATION IS SUBMITTED WITH PROPOSED PREMIUMSOR OTHER FUNDS,THERE WILL BE NO COVERAGE UNTIL THIS APPLICATION IS APPROVED BY US. If we approve this Application,we will send you a Contract of which this Application will become a part.Your prior coverage should not be cancelled until you have been notified that your Application has been accepted.No agent can bind coverage,set an effective date,or waive or alter any provision of this Application.The Contract will specify the effective date of group coverage. If we do not approve this Application,the submitted funds will be retumed to the Employer. The Employer understands that if we approve this Application,the Employer agrees to be bound by the terms of the Contract. Dated at Greeley, C 1O a o this 30th day of Orr-oiler �dR 9(1O(1 By J Chair. Board of County Commissioners SIGNATURE OF AUTH fnjit1yvt,sd ZEPERSON, TITLE Approved an pled HMO brad Blue Shield 1 By Date QC't(1 6c.-- )4, CHIEF PERA —HMO C ORADO By Date Or -O'\ III` N arCG CHIEF OPE TING OFFICER-ANTHEM LUE CROSS AND BLUE SHIELD Weld Cry App.wpd FORM NO.96064(REV.11/97) ANTHEM BLUE CROSS AND BLUE SHIELD GROUP MASTER CONTRACT NO. 02-00772001 For Weld County Government Employer C07720 Group Number SECTION I. APPLICATION-ACCEPTANCE The Application for Group Health Coverage ("Application") executed by the Employer has been accepted by Anthem Blue Cross and Blue Shield(sometimes referred to as"we," "us,"and"our"). Such Application and its contents are incorporated in this Group Master Contract("Contract").In the event of any inconsistency between the terms of the Application and the terms of the Contract, the terms of the Contract will control. SECTION II. GENERAL AGREEMENTS The purpose of this Contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the Employer's Employees and their Dependents. Such persons, when covered hereunder, are referred to as "Members." 1. Contract Effective Date.The effective date of the Contract shall be 12:01 A.M. on the first day of January, 2002, at Denver, Colorado; the Contract shall continue to remain in effect on an annual basis from year to year thereafter unless terminated in accordance with the provisions of the Contract.. 2. Anniversary Date. The Anniversary Date is the effective date for (i) enrollment or coverage changes to the Employee's Membership or (ii) to group enrollment and benefit eligibility implemented by the Employer. 3. Annual Renewal Date.The date a group is due for rate modification through application of the appropriate renewal rating formulas. 4. Employee.An Employee as defined in the Application as eligible for enrollment; the Employee is the Subscriber, and Identification Cards for the Employee and his or her covered Dependents are issued in the name of the Employee as the Subscriber. 5. Employer. The Employer or organization with whom Anthem Blue Cross and Blue Shield has contracted, and by reason of the Contract the Employees and their Dependents become eligible for the coverage and benefits described in the Contract. 6. Remitting Agent.The Employer agrees to (i) act as remitting agent for the enrolled Members, (ii) make payroll deductions for that part of premium not otherwise provided for, and(iii)remit all premiums to us not later than the due date for each remitting period. 7. Remittance. The Employer shall pay to us monthly, in advance, required premiums on behalf of all enrolled Employees and Dependents who meet the eligibility requirements specified in the Application. �,„�. 1 8. Membership Certificate Terms.The definitions and other terms of the Membership Certificate are incorporated herein by reference. 9. Group Administrator. The Employer will designate a person as the principal contact for all matters pertaining to Anthem Blue Cross and Blue Shield group coverage.That person will assist Employees in the administration and payment of claims. It is understood that Anthem Blue Cross and Blue Shield is not the "administrator" within the meaning of the Employee Retirement Income Security Act (ERISA). 10. Assignment.None of the rights,benefits,duties,or obligations of the Employer may be assigned without the prior written consent of a duly authorized officer of Anthem Blue Cross and Blue Shield. Any attempted assignment will be void. 11. Contract Provision Changes. a. This Contract constitutes the entire agreement between the parties hereto and supersedes all other contracts, either oral or in writing, between the parties with respect to the subject matter hereof. No course of action, usage or custom or internal policy of Anthem Blue Cross and Blue Shield may amend or become a part of this Contract. Except as provided in paragraphs b. and c. immediately below, no change or modification to this Contract shall be valid unless the same is in writing and signed by the parties hereto. b. During the initial annual term or any renewal annual term of the Contract, the provisions of this Contract may be amended at any time by an endorsement signed only by a duly authorized officer of Anthem Blue Cross and Blue Shield. When the endorsement has been so signed, the endorsement shall be deemed a part of the Contract, effective as of the date specified by the endorsement. c. Any amendment resulting from state or federal law, or regulation, or ruling or approval by the Commissioner of Insurance of the State of Colorado may be made at any time by endorsement to the Contract signed only by a duly authorized officer of Anthem Blue Cross and Blue Shield and shall become effective as of the effective date of such law, regulation, ruling, or approval. 12. Reserve Funds.Neither any Member nor the Employer shall be entitled to share in any reserve or other funds that may be accumulated or otherwise owned by Anthem Blue Cross and Blue Shield, unless and until a right to share in such funds is granted in writing by the Board of Directors of Anthem Blue Cross and Blue Shield. 13. Notices.All notices to Anthem Blue Cross and Blue Shield shall be sent by United States mail or personal delivery to Anthem Blue Cross and Blue Shield, 700 Broadway, Denver, CO 80273. All notices to Employees or the Employer shall be sent by United States mail to the last address appearing in the records of Anthem Blue Cross and Blue Shield or by personal delivery to the office of the Employer. The Employer shall notify Members in the event that this Contract is terminated within ten(10) days of the date that the Employer has notice that this Contract is to be or has been terminated, whichever occurs first. If the Employer has engaged the services of a broker/consultant, then delivery of all notices to the named broker/consultant meets the requirements of this Contract. Notice shall be effective upon mailing. Notice mailed to the Employer or broker/consultant shall be deemed effective notice to each Employee. However, the Employer agrees to post each notice promptly in a place reasonably calculated to facilitate the Employees' reading of the notice. 14. Governing Laws. This Contract is made and delivered in the State of Colorado, and will be interpreted and enforced so as to remain in compliance with Colorado statutes and regulations. Nothing contained herein shall be interpreted to mean that Anthem Blue Cross and Blue Shield is doing business in any other state or jurisdiction. Any legal action against us must be brought in the City and County of Denver, Colorado. .=COC 2 • Should any provision of this Contract in any way contravene the laws of Colorado or the United States of America, such provision shall not be deemed a part of the Contract. However, the Contract shall be otherwise enforceable. 15. Attorneys' Fees and Expenses. a. Should it become necessary for either party to this Contract to seek the assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the Contract,the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless Anthem Blue Cross and Blue Shield from its costs including losses, claims, settlements,judgments, or fees, including attorneys' fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this Contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder, the Employer's obligation to indemnify us shall apply only to costs incurred after this Contract has been canceled or terminated. 16. Warranties and Representations. The Employer acknowledges that no warranties or representations other than those contained in this Contract have been made or given by Anthem Blue Cross and Blue Shield or its representatives or, if so given,have not been relied upon by the Employer. 17. Enforcement of the Contract.Failure of Anthem Blue Cross and Blue Shield or the Employer to enforce any of the provisions of this Contract shall not constitute a waiver of rights for that or subsequent breaches. 18. Interpretation of the Contract. This Contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this Contract and sound principles of contract interpretation. 19. BlueCard Program. The calculation of subscriber liability for covered services for claims incurred outside the geographic area Anthem Blue Cross and Blue Shield serves and processed through the BlueCard Program typically will be at the lower of the provider's billed charges or the negotiated rate Anthem Blue Cross and Blue Shield pays the on-site Blue Cross and/or Blue Shield Plan. The negotiated rate paid by Anthem Blue Cross and Blue Shield to the on-site Blue Cross and/or Blue Shield Plan for health care services provided through the BlueCard Program may represent either (i) the actual price paid on the claim, or (ii) an estimated price that reflects adjusted aggregate payments expected to result from settlements or other non-claims transactions with all of the on-site Plan's health care providers or one or more particular providers, or (iii) a discount from billed charges representing the on-site Plan's expected average savings for all of its providers or for a specified group of providers. Plans using either the estimated price or average savings factor methods may prospectively adjust the estimated or average price to correct for over-or underestimation of past prices. In addition, statutes require Blue Cross and/or Blue Shield Plans in a small number of states to use a basis for calculating member/subscriber liability for covered services that does not reflect the entire savings realized or expected to be realized on a particular claim. Thus, when your covered employees/subscribers receive covered services in these states, their subscriber liability for covered services will be calculated using these states' statutory methods. �M®=C« 3 20. Termination of Contract. a. The employer may terminate the contract at any time during its term upon giving 30 days advance written notice of termination to Anthem Blue Cross and Blue Shield. A group who voluntarily cancels coverage will not be considered for re-enrollment until a two-month period has elapsed from the date of cancellation. Such re-enrollment shall be subject to then current operating procedures and underwriting regulations of Anthem Blue Cross and Blue Shield. b. Anthem Blue Cross and Blue Shield may terminate the Contract at any time during its term for (i) Employer's failure to make timely payment of amounts due hereunder, (ii) failure of the group to meet eligibility requirements, (iii) failure of the group to maintain enrollment percentage requirements,as provided in the Application,or(iv)misrepresentation of material facts or any other breach of the Contract. c. Anthem Blue Cross and Blue Shield, at its sole option, may reinstate this Contract after it has been terminated. We may impose such conditions on the Contract's reinstatement as we deem appropriate, including, without limitation, acceptable health statements. It is understood, however, that there is no right to reinstatement, and any reinstatement will be in the sole discretion of Anthem Blue Cross and Blue Shield. SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 1. Changes.Anthem Blue Cross and Blue Shield may change monthly premium as outlined in any endorsements to this Contract. Anthem Blue Cross and Blue Shield reserves the right to review monthly premium whenever a group, section, or classification of Employees is added to or deleted from enrollment under the Contract. The Employer shall notify Anthem Blue Cross and Blue Shield no later than 30 days prior to the effective date of such addition or deletion,and any change in monthly premium which may be required as the result of an increased or decreased total group enrollment will become effective on the same date as such addition to or deletion from total enrollment under the Contract.This provision shall apply regardless of the Employer's normal rate review date or any other advance rate notification agreement which may be in effect between Anthem Blue Cross and Blue Shield and the Employer. 2. Payment. Initial premium shall become payable on or before the effective date of the Contract. Subsequent premiums shall be payable on or before the established Service Date of each month thereafter. Claims processing and payment will be suspended if premium is not timely paid. In no event shall coverage under the Contract become effective until we accept the Application and payment of the initial premium is received by Anthem Blue Cross and Blue Shield. 3. Service Date.The Service Date is the 1st or 16th day of the month as established for the group for billing purposes (the "due date"). 4. Termination for Non-Payment. The Contract shall terminate by its own terms if premium is not paid on or before 30 days after the Service Date, and no notice of cancellation other than this provision shall be required. However,we may by sending notice thereof terminate this Contract before 30 days after the Service Date if premium is not paid on or before the Service Date. When the Contract is terminated or canceled,the effective date of such cancellation or termination shall BCBS1122000C 4 be the date to which membership premium was last paid. All claims shall be refused when dates of service are beyond the last "paid-to-date" of coverage according to the records of Anthem Blue Cross and Blue Shield. 5. Retroactive Refund of Membership Premium. a. A retroactive refund of membership premium paid beyond the date of termination will be granted if written notification is received by Anthem Blue Cross and Blue Shield at least one month before the termination date and benefit payments have not been made on behalf of a Member's claim for services rendered subsequent to the termination date. b. If notification is received less than one month before the termination date, no refund of membership premium will be made. Failure to comply with this provision shall negate any claim by, or on behalf of, the Employer or the Member for a retroactive refund of membership premium. 6. Cashing of Check Not Acceptance.It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility. All Employees, who have a regular work week as indicted on the application and addendum, paid for such employment by the employer, and listed as an Employee on the Employer's State unemployment insurance tax returns, and the Dependents of the Employees, are eligible to enroll for membership under the Contract.We may inspect such records,public and private, as are necessary to verify employment. 2. Receipt of Applications. Applications for Employees' coverage must be received by us within 30 days of the Contract Effective Date or within 30 days of eligibility for coverage, whichever is later. If the application is not received within this time period,the Employee is subject to current underwriting, state or federal law for provisions for late enrolles. 3. Notification of Cessation of Membership. Employer shall advise us when Employer has notice that a Member is no longer employed by Employer or otherwise does not satisfy membership requirements. Employer shall so notify us, at the latest, by the first Service Date after a Member ceases to be employed by Employer or otherwise ceases to meet membership requirements. Employer agrees that no person will be kept on Employer's payroll or otherwise be represented as an Employee of the Employer for the purpose of obtaining or maintaining coverage hereunder. The Employer agrees to observe the terms thereof, and hold us harmless for all costs incurred, including attorneys' fees, in the defense of any claim or suit brought at any time by a person ineligible for coverage. Wounty Government CR0 $AND BLUE.SHIELD By 4#ame) ILCRT mow°VV ff�� V , r%r?/ Caroline Matthews Printed or Typed Name Printed or Typed Name (Title) 1 h (1-tie , TJ cl H>P /CY /u `✓1'i i,i (Title) Chief Operating Officer (Date) / /0/0 / (Date) November 8, 2001 BUM=CSC 5 BCBS9220.00C 6 PROGRAM ARRANGED BY Anthem Blue Cross and Blue Shield 700 Broadway Denver, Colorado 80273 Phone: 831-2131 ®Registered Marks Blue Cross and Blue Shield Association BC us nccoc • ENDORSEMENT NO.: 1 TO GROUP MASTER CONTRACT NO.: 02-00772001 The Contract identified above is hereby amended by this endorsement which is issued to form part of the Contract between HMO Colorado (HMOC) and Weld County Government (the Employer), effective as of the Contract Effective Date as follows: For the period beginning on the Contract Effective Date (January 1, 2002) and ending on December 31, 2002, paragraph 1. Changes of Section of Section III. Premiums Changes, Payment, Service Date, Termination For Non-Payment, Retroactive Refund of Membership Premium, Cashing for Check Not Acceptance of the Contract, shall be replaced in its entirety with the following provision: 1. (a) Subject to the provisions of subparagraph(c),below,the premiums specified in Exhibit A to this endorsement shall remain in effect for a period of 12 months from January 1, 2002. (b) Notwithstanding the provisions of subparagraphs (a) and (b), above, HMOC may change the monthly premiums due hereunder, effective immediately, whenever (i) benefits are changed by endorsement or by federal or state law; or (ii) the number of Employees covered under the Contract in any given month differs from the number of Employees covered under the Contract as of the Contract Effective Date by 20% of enrollment. (c) For the period beginning on January 1, 2002, the Employer shall remit an advanced check for premiums of $260,000 to Anthem BCBS/HMOC upon signature of this Endorsement or no later than January 31,2002.This payment will be used to offset the fully insured equivalent required rate increase of 10.66% for the period of January 1, 2002 through December 31, 2002. 2. For the period beginning on the Contract Effective Date (January 1, 2000) and ending on December 31, 2002, paragraph 20. Termination of Contract of Section II. General Agreements,of the Contract shall be amended by adding the following sentence to the end of subparagraph (b) of paragraph 20: "Notwithstanding the foregoing, HMOC agrees not to terminate this Contract solely because of poor claims experience of Employees and Dependents covered under this Contract." 3. Effective on the earlier of(i)any date on whichHMOC changes the premiums due hereunder in accordance with the provisions of subparagraph 1(c)(ii)of Section III of the Contract, as amended above, or (ii) two years from the Contract Effective Date, the provisions of this endorsement shall be of no further effect and the original provisions of paragraph 1 of Section III and paragraph 20. of Section II of the Contract shall be reinstated as if they had never been amended. 4. Except as otherwise specifically amended hereby, all terms and conditions of the Contract shall remain in full force and effect. Weld County 2o°yr Rate Guar.wpd Weld County G rnment HMO. oiorado (Group Name 11.'' . , By_ f ,U By ' r •JALLAkiZ l,V-i-`i Oil 4 d). ..T (2,e/Itc Caroline Matthews _ di or Typed Name Printed or Typed Name (Title) (,. 14+ Z I 0( Ilk /d'/ 7i'J' - (Title) Chief Operating Officer Date O1 / t Date November 8. 2001 Weld County 2e°yr Rate Guar.wpd OA HMO A„r� Colorado nthela 4!IV An Anthem Company ANTHEM BLUE CROSS & BLUE SHIELD Account Name: WELD COUNTY GOVERNMENT Account No.: C07720 EXHIBIT A Rates Effective: January 1, 2002 Annual Renewal: January 1 Account Executive: Mike Rankin MONTHLY HEALTH RATES BlueAdvantage Triple Option Employee Employee Employee Modified Plan Only &Spouse &Child(n) Family Blue Advantage 15/1/15-25-40 HMO $15 Office Visit Copay $100 Inpatient Deductible $15-25-40 Prescription Copay Fully Insured Equivalent Rates $240.82 $481.64 $462.37 $708.85 BILLED RATES $224.36 $448.73 $430.78 $660.41 HMO COBRA Rate(Direct Bill) $245.64 $491.27 $471.62 $723.03 Blue Advantage 15/1/15-25-40 POS $15 Office Visit Copay $100 Inpatient Deductible $15-25-40 Prescription Copay $250 Opt-out Deductible Fully Insured Equivalent Rates $253.37 $557.41 $532.08 $817.19 BILLED RATES $236.05 $519.31 $495.70 $761.33 POS COBRA Rate(Direct Bill) $258.44 $568.56 $542.72 $833.54 Custom Plus $200/$400 Deductible 80%Coinsurance $15-25-40 Prescription Copay Fully Insured Equivalent Rates $319.10 $631.82 $599.91 $912.88 BILLED RATES $297.28 $588.62 $558.89 $850.46 Custom Plus COBRA Rate(Direct Bill) $325.48 $644.45 $611.91 $931.14 BENEFIT SUMMARY: Dependent Children Covered to End of Month,Age 25 Substance Abuse Rider Included Vision through Eye Health Network (HMO& POS Plans) These rates assume a $260,000 advance premium payment to Anthem Blue Cross and Blue Shield on or before January 31, 2002. No 2003 rate cap. RENEWAL (4 Tier) October 11, 2001 Independent licensees of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service,Inc. ®Registered marks Blue Cross and Blue Shield Association. ( ICS . ,,, HMO Colorado �'� An Anthem Company 'K a.a rx'ffi aA A 0a:et Sad �tt ` �. meta M ry, "4 A 1 x 4•4a. osay f wl a ar x: +.. x � as a:. t f r a .. r^ . ' r„g `'� '•' k;:k"xe writ• i dlf 1 • • '. S t mbi I. a- d � e< m l rY 4 t• '4,.., l. tit 'vxo.i + Pe a � A Guide to Your Benefits You've made a good decision in choosing Colorado BlueAdvantage HMO Plan HMO Co Dada Ilan Ineepa�nrlicensee of the tea Goss aM BWe Shield Association J FeAiarere0 mesa Blue Cross an0 Blue Shield Astor HMO °°a Colorado An Anthem Company Vision Exam Rider Limitations and Exclusions Notice of Amendment to your HMO Colorado • Equipment — We will not pay for lens, frames, or Certificate contact lens. We will Pay for eyeglasses or contact lenses and the necessary prescriptions as defined in Your HMO Colorado Certificate is hereby amended as Supplies Equipment and Appliances. follows: • Special Procedures — We will not pay for special In the section entitled Covered Services, is amended to procedures such as orthoptics, vision training, or vision include Vision Exam benefits as follows: aids. Vision Exam In the same section under Preventive, Routine, and Family Planning Services, the exclusion for routine vision exams is Definition deleted. Ophthalmology—A branch of medical science dealing with the structure, function, and diseases of the eye. An ophthal- This Amendment is part of and to be read in conjunction mologist must be licensed to practice ophthalmology. with your Certificate. Insert this Amendment inside your Certificate. Optometry — An examination of the eye for defects or faults re in refraction anpto the ist must olicensec to l ice or exercises. An optometrist must be licensed to practice \,� I�� optometry. NjuLiA4JUG"I\ Medical-Surgical Benefits We allow benefits for one eye examination or routine Caroline Matthews refractive examination once every 24 consecutive months Chief Operating Officer when performed by an ophthalmologist or optometrist. HMO Colorado 98148(4-01) 769 r; Colorado An Anthem Company Colorado Health Plan Description Form HMO Colorado BlueAdvantage HMO Plan No. 15-145125140 PART A:TYPE OF COVERAGE 1. TYPE OF PLAN Health maintenance organization (HMO) 2. OUT-OF-NETWORK CARE COVERED?1 Only for emergency and urgent care 3. AREAS OF COLORADO WHERE PLAN IS Plan is available throughout Colorado AVAILABLE PART B:SUMMARY OF BENEFITS Important Note:This form is not a contract, it is only a summary. The contents of this form are subject to the provisions of the policy, which contains all terms,covenants and conditions of coverage.Your plan may exclude coverage for certain treatments,diagnoses,or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed(e.g., plans may require prior authorization, a referral from your primary care physician,or use of specified providers or facilities). Consult the actual policy to determine the exact terms and conditions of coverage. IN-NETWORK ONLY(OUT-OF-NETWORK CARE IS NOT COVERED EXCEPT AS NOTED) 4. ANNUAL DEDUCTIBLE a) Individual No Deductibles b) Family 5. OUT-OF-POCKET ANNUAL MAXIMUM2 a) Individual Two times individual annual premium b) Family Two times individual annual premium 6. LIFETIME OR BENEFIT MAXIMUM PAID No lifetime maximum BY THE PLAN FOR ALL CARE 7A.COVERED PROVIDERS HMO Colorado Managed Care Network. See provider directory for complete list of current providers. 7B. With respect to network plans,are all No the providers listed in 7A accessible to me through my primary care physician? 8. ROUTINE MEDICAL OFFICE VISITS $15 per visit copay 9. PREVENTIVE CARE a) Children's services $15 per visit copay b) Adults'services $15 per visit copay 10. MATERNITY a) Prenatal care $15 per visit copay b) Delivery&inpatient well baby $100 per admission copay care HMO CdO,wa is en ridepenbrit licensee W the Blue Cross and BI,-Shelf M+mahw®Registered make slue CMS.and Blue SM1I W NmoXm 96780_H151152540(Rev.1-01) 1 IN-NETWORK ONLY(OUT-OF-NETWORK CARE IS NOT COVERED EXCEPT AS NOTED) 11. PRESCRIPTION DRUGS Level of coverage and restrictions on prescriptions a) Inpatient care No copay(100%covered) b) Outpatient care Tier 1 generic formulary$15,tier 2 brand formulary$25,tier 3 non-formulary$40,per prescription up to a 34-day supply. c) Prescription Mail Service Tier 1 generic formulary$30,tier 2 brand formulary$50,tier 3 non-formulary$80, per prescription up to a 90-day supply. For drugs on our approved list,contact Customer Service at 1-800-334-6557.Covered only when received from a participating pharmacy. 12. INPATIENT HOSPITAL $100 per admission copay 13. OUTPATIENTIAMBULATORY SURGERY $25 per procedure copay 14. LABORATORY AND X-RAY No copay(100%covered) 15. EMERGENCY CARES $50 per emergency room visit copay(waived if admitted)in or out-of-network 16. AMBULANCE $50 per trip copay(waived if admitted) 17. URGENT,NON-ROUTINE,AFTER $30 per urgent care visit copay(urgent care may received from your PCP or from an HOURS CARE urgent care center)in or out-of-network 18. BIOLOGICALLY-BASED MENTAL Coverage is no less extensive than the coverage provided for any other physical illness. ILLNESS CARE4 19 OTHER MENTAL HEALTH CARE a) Inpatient care 50%of billed charges(limited to 45 full or 90 partial days per calendar year) b) Outpatient care $10 per visit copay(visits 1-5) $25 per visit copay(visits 6-20) 20. ALCOHOL&SUBSTANCE ABUSE 50%of billed charges(covered only for short-term detoxification,rehabilitation not covered) 21. PHYSICAL,OCCUPATIONAL,AND SPEECH THERAPY a) Inpatient $100 per admission copay(limited to 30 days per injury or illness) b) Outpatient $15 per visit copay(limited to 30 treatments per injury or illness) 22. DURABLE MEDICAL EQUIPMENT No copay(100%covered)(limited to$1,000 payment per calendar year, combined with oxygen(line 23)),except for prosthetic devices which are not subject to the maximum payment but do reduce the maximum payment of$1,000. 23. OXYGEN No copay(100%covered)(limited to$1,000 payment per calendar year,combined with durable medical equipment dine 22)) 24. ORGAN TRANSPLANTS a) Major Organ Transplant Inpatient $100 per admission copay Outpatient $15 per visit copay (limited to$1 million payment per transplant combined in and out-of-network) b) Other Transplants Inpatient $100 per admission copay Outpatient $15 per visit copay 25. HOME HEALTH CARE No copay(100%covered) 26. HOSPICE CARE No copay(100%covered) 27. SKILLED NURSING FACILITY CARE No copay(100%covered)(limited to 30 days per calendar year) 28. DENTAL CARE No coverage.Available as a separate dental care plan. 29. VISION CARE Vision One Eye-Care program offers discounts on exams and hardware. 30. CHIROPRACTIC CARE No coverage 31. SIGNIFICANT ADDITIONAL COVERED BlueCares for You Program SERVICES(list up to 5) When a member desires another professional opinion,they may obtain a second opinion. 96780_H151152540(Rev.1-01) 2 PART C:LIMITATIONS AND EXCLUSIONS 32. PERIOD DURING WHICH PRE-EXISTING CONDITIONS ARE Not applicable; plan does not impose limitation periods for pre- NOT COVERED.5 existing conditions. 33. EXCLUSIONARY RIDERS.Can an individual's specific,pre- No existing condition be entirely excluded from the policy? 34. HOW DOES THE POLICY DEFINE A"PRE-EXISTING Not applicable. Plan does not exclude coverage for pre-existing CONDITION"? conditions 35. WHAT TREATMENTS AND CONDITIONS ARE EXCLUDED Exclusions vary by policy. List of exclusions is available immediately UNDER THIS POLICY? upon request from your carrier, agent,or plan, sponsor(e.g., employer). Review them to see if a service or treatment you may need is excluded from the policy. PART D: USING THE PLAN IN-NETWORK 36. Does the enrollee have to obtain a referral Yes,except obstetrical or gynecological care and eye care for a medical condition, andlor prior authorization for specialty which can be provided by a participating provider within the HMO Colorado network, care in most or all cases? without a referral.Also mental health care can be provided without a referral by a participating provider when authorized by the behavioral health administrator. 37. Is prior authorization required for surgical Yes procedures and hospital care(except in an emergency)? 38. If the provider charges more for a covered No service than the plan normally pays,does the enrollee have to pay the difference? 39. What is the main customer service 303-831.0161 or 1-800-334-6557 number? 40. Whom do I write/call if I have a complaint HMO Colorado,Complaints and Appeals or want to file a grievance?6 700 Broadway Denver, CO 80273 303-831-0161 or 1-800-334-6557 41. Whom do I contact if I am not satisfied with Write to:Colorado Division of Insurance the resolution of my complaint or ICARE Section grievance? 1560 Broadway, Suite 850 Denver, CO 80202 42. To assist in filing a grievance,indicate the Policy form#'s 97000 form number of this policy;whether it is Group—all sizes individual,small group,or large group; and if it is a short-term policy. PART E:COST 43.What is the cost of this plan? Contact your agent,this insurance company,or your employer,as appropriate,to find out the premium for this plan. In some cases,plan costs are included with this form. PART F:PHYSICIAN PAYMENT METHODS,AND PLAN EXPENDITURES FOR HEALTH EXPENSES,ADMINISTRATION AND PROFIT Any person interested in applying for coverage,or who is covered by,or who purchased coverage under this plan may request answers to the questions listed below.The request may be made orally or in writing to the agent marketing the plan or directly to the insurance company and shall be answered within five(5)working days of the receipt of the request. • What are the three most frequently used methods of payment for primary care physicians? • What are the three most frequently used methods of payment for physician specialists? • What other financial incentives determine physician payment? • What percentage of total Colorado premiums are spent on health-care expenses as distinct from administration and profit? 96780_H151152540(Rev.1-01) 3 "'Network" refers to a specified group of physicians,hospitals,medical clinics and other health care providers that your plan may require you to use in order for you to get any coverage at all under the plan,or that the plan may encourage you to use because it may pay more of your bill if you use their network providers(i.e.,go in-network)than if you don't(i.e.,go out-of-network). 2"Out-of-pocket maximum"The maximum amount you will have to pay for allowable covered expenses under a health plan,which may or may not include the deductible or copayments,depending on the contract for that plan. 3"Emergency care"means services delivered by an emergency care facility which are necessary to screen and stabilize a covered person. The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life-or limb threatening emergency existed. 4"Biologically based mental illnesses"means schizophrenia,schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder,and panic disorder. 5 Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had.Ask your carrier or plan sponsor(e.g.,employer)for details. 6 Grievances. Colorado law requires all plans to use consistent grievance procedures.Write the Colorado Division of Insurance for a copy of those procedures. 96780_H151152540(Rev.1-01) 4 M 00 HO Anthem .•: 9 Colorado An Anthem Company Colorado Health Plan Description Form HMO Colorado/Anthem Blue Cross and Blue Shield BlueAdvantage Point-of-Service Plan No. 15-1-15/25/40-P250 PART A:TYPE OF COVERAGE 1. TYPE OF PLAN Point of service(i.e.,an HMO plan with some out-of-network benefits) 2. OUT-OF-NETWORK CARE COVERED?1 Yes, but the patient pays more for out-of-network care 3. AREAS OF COLORADO WHERE PLAN IS Plan is available throughout Colorado AVAILABLE PART B: SUMMARY OF BENEFITS Important Note:This form is not a contract, it is only a summary. The contents of this form are subject to the provisions of the policy, which contains all terms,covenants and conditions of coverage.Your plan may exclude coverage for certain treatments,diagnoses,or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed(e.g.,plans may require prior authorization,a referral from your primary care physician,or use of specified providers or facilities). Consult the actual policy to determine the exact terms and conditions of coverage. IN-NETWORK OUT-OF-NETWORK 4. ANNUAL DEDUCTIBLE a) Individual No Deductibles $250 b) Family $500 Aggregate 5. OUT-OF-POCKET ANNUAL MAXIMUM2 a) Individual Two times individual annual premium $2,500+Deductible b) Family Two times individual annual premium $5,000+Deductible 6. LIFETIME OR BENEFIT MAXIMUM No lifetime maximum $1,000,000 per member PAID BY THE PLAN FOR ALL CARE 7A.COVERED PROVIDERS HMO Colorado Managed Care Network. All providers licensed or certified to provide See provider directory for complete list of covered benefits. current providers. 7B. With respect to network plans, No Not applicable.This is not a network plan. are all the providers listed in 7A accessible to me through my primary care physician? 8. ROUTINE MEDICAL OFFICE $15 per visit copay 70%after deductible VISITS 9. PREVENTIVE CARE a) Children's services $15 per visit copay 70%, not subject to deductible for children up to age 13;not covered after age 13. b) Adults'services $15 per visit copay 70%after deductible for annual gynecological exam.All other preventive care is not covered. 10. MATERNITY a) Prenatal care $15 per visit copay 70%after deductible b) Delivery&inpatient well $100 per admission copay 70%after deductible baby care Independent licensees of the Blue Crone and Blue Shield Aseaiatim Anthem Blue Cross and Blue Slrleld is the trade name of Rocky Mountain HauJtal and MaioS Sedne,Inc.B Registered malts Blue Crass and Blue Shield Assousunn 96794_P151152540(Rev.1-01) 1 • IN-NETWORK OUT-OF-NETWORK 11. PRESCRIPTION DRUGS Level of coverage and restrictions on prescriptions a) Inpatient care No copay(100%covered) 70%after deductible b) Outpatient care Tier 1 generic formulary$15,tier 2 brand Not covered formulary$25,tier 3 non-formulary$40,per prescription up to a 34-day supply. c) Prescription Mail Service Tier 1 generic formulary$30,tier 2 brand Not covered. formulary$50,tier 3 non-formulary$80,per prescription up to a 90-day supply. For drugs on our approved list,contact Customer Service at 1-800-334-6557. Covered only when received from a participating pharmacy. 12. INPATIENT HOSPITAL $100 per admission copay 70%after deductible 13. OUTPATIENTIAMBULATORY $25 per procedure copay 70%after deductible SURGERY 14. LABORATORY AND X-RAY No copay(100%covered) 70%after deductible 15. EMERGENCY CARES $50 per emergency room visit copay Covered as in-network (waived if admitted) 16. AMBULANCE $50 per trip copay(waived if admitted) Covered as in-network 17. URGENT,NON-ROUTINE,AFTER $30 per urgent care visit copay(urgent care 70%after deductible HOURS CARE may received from your PCP or from an urgent care center) 18. BIOLOGICALLY-BASED MENTAL Coverage is no less extensive than the Coverage is no less extensive than the ILLNESS CARE° coverage provided for any other physical coverage provided for any other physical illness. illness. 19. OTHER MENTAL HEALTH CARE a) Inpatient care 50%of billed charges(limited to 45 full or Not covered 90 partial days per calendar year) b) Outpatient care $10 per visit copay(visits 1-5) Not covered $25 per visit copay(visits 6-20) 20. ALCOHOL&SUBSTANCE ABUSE 50%of billed charges Not covered (covered only for short-term detoxification, rehabilitation not covered) 21. PHYSICAL,OCCUPATIONAL, AND SPEECH THERAPY a) Inpatient $100 per admission copay(limited to 30 70%after deductible(limited to 30 days per days per injury or illness) injury or illness) a) Outpatient $15 per visit copay(limited to 30 treatments 70%after deductible(limited to 30 per injury or illness combined in and out-of- treatments per injury or illness combined in network) and out-of-network) 22. DURABLE MEDICAL EQUIPMENT No copay(100%covered)(limited to$1,000 70%after deductible(limited to$1,000 payment per calendar year,combined with payment per calendar year,combined with oxygen(line 23)except for prosthetic oxygen (line 23))except for prosthetic devices which are not subject to the devices which are not subject to the maximum but do reduce the maximum maximum but do reduce the maximum payment of$1,000 and combined in and payment of$1,000 and combined in and out-of-network) out-of-network) 23. OXYGEN No copay(100%covered)(limited to$1,000 70%after deductible(limited to$1,000 payment per calendar year,combined with payment per calendar year,combined with durable medical equipment(line 22)and durable medical equipment(line 22)and combined in and out-of-network) combined in and out-of-network) 96794_P151152540(Rev.1-01) 2 IN-NETWORK OUT-OF-NETWORK 24. ORGAN TRANSPLANTS a) Major Organ Transplant Inpatient $100 per admission copay Covered as in-network when preauthorized Outpatient $15 per visit copay and delivered in a HMO Colorado organ (limited to$1 million payment per transplant transplant facility(limited to$1 million combined in and out-of-network) payment per transplant combined in and out-of-network). b) Other Transplants Inpatient $100 per admission copay 70%after deductible Outpatient $15 per visit copay 70%after deductible 25. HOME HEALTH CARE No copay,100%covered) 70%after deductible 26. HOSPICE CARE No copay :100%covered) 70%after deductible 27. SKILLED NURSING FACILITY No copay(100%covered)(limited to 30 70%after deductible(limited to 30 days per CARE days per calendar year combined in and calendar year combined in and out-of- out-of-network) network 28. DENTAL CARE No coverage.Available as a separate No coverage.Available as a separate dental care plan. dental care plan. 29. VISION CARE Vision One Eye-Care program offers Vision One Eye-Care program offers discounts on exams and hardware. discounts on exams and hardware. 30. CHIROPRACTIC CARE No coverage No coverage 31. SIGNIFICANT ADDITIONAL BlueCares for You Program BlueCares for You Program COVERED SERVICES(list up to 5) When a member desires another When a member desires another professional opinion,they may obtain a professional opinion,they may obtain a second opinion. second opinion. For services covered under this rider,a member is not required to get a PCP referral,which is required under the regular BlueAdvantage HMO Plan coverage.A member may also choose to receive covered services from a provider who is not in the HMO Colorado network. PART C: LIMITATIONS AND EXCLUSIONS 32. PERIOD DURING WHICH PRE-EXISTING Not applicable;plan does not impose limitation periods for pre-existing CONDITIONS ARE NOT COVERED.5 conditions. 33. EXCLUSIONARY RIDERS.Can an No individual's specific,pre-existing condition be entirely excluded from the policy? 34. HOW DOES THE POLICY DEFINE A"PRE- Not applicable. Plan does not exclude coverage for pre-existing conditions EXISTING CONDITION"? 35. WHAT TREATMENTS AND CONDITIONS Exclusions vary by policy. List of exclusions is available immediately upon ARE EXCLUDED UNDER THIS POLICY? request from your carrier,agent,or plan, sponsor(e.g.,employer).Review them to see if a service or treatment you may need is excluded from the policy. PART D: USING THE PLAN IN-NETWORK OUT-OF-NETWORK 36. Does the enrollee have to obtain a Yes,except obstetrical or gynecological care Yes, unless the provider participates referral and/or prior authorization for and eye care for a medical condition,which with Anthem Blue Cross and Blue specialty care in most or all cases? can be provided by a participating provider Shield. within the HMO Colorado network,without a referral.Also mental health care can be provided without a referral by a participating provider when authorized by the behavioral health administrator. 37. Is prior authorization required for Yes Yes surgical procedures and hospital care(except in an emergency)? 96794 2151152540(Rev.1-01) 3 IN-NETWORK OUT-OF-NETWORK 38. If the provider charges more for a No Yes, unless the provider participates covered service than the plan with Anthem Blue Cross and Blue normally pays,does the enrollee Shield. have to pay the difference? 39. What is the main customer service 303-831-0161 or 1-800-334-6557 number? 40. Whom do I writelcall if I have a HMO Colorado, Complaints and Appeals complaint or want to file a 700 Broadway grievance?6 Denver,CO 80273 303-831-0161 or 1-800-334-6557 41. Whom do I contact if I am not Write to:Colorado Division of Insurance satisfied with the resolution of my (CARE Section complaint or grievance? 1560 Broadway, Suite 850 Denver,CO 80202 42. To assist in filing a grievance, Policy form#'s 97000/96055 indicate the form number of this Group—all sizes policy;whether it is individual,small group,or large group;and if it is a short-term policy. PART E: COST 43.What is the cost of this plan? Contact your agent,this insurance company,or your employer,as appropriate,to find out the premium for this plan. In some cases,plan costs are included with this form. PART F: PHYSICIAN PAYMENT METHODS,AND PLAN EXPENDITURES FOR HEALTH EXPENSES, ADMINISTRATION AND PROFIT Any person interested in applying for coverage,or who is covered by,or who purchased coverage under this plan,may request answers to the questions listed below.The request may be made orally or in writing to the agent marketing the plan or directly to the insurance company and shall be answered within five(5)working days of the receipt of the request. • What are the three most frequently used methods of payment for primary care physicians? • What are the three most frequently used methods of payment for physician specialists? • What other financial incentives determine physician payment? • What percentage of total Colorado premiums are spent on health-care expenses as distinct from administration and profit? 1"Network" refers to a specified group of physicians,hospitals, medical clinics and other health care providers that your plan may require you to use in order for you to get any coverage at all under the plan,or that the plan may encourage you to use because it may pay more of your bill if you use their network providers(i.e.,go in-network)than if you don't(i.e.,go out-of-network). 2"Out-of-pocket maximum"The maximum amount you will have to pay for allowable covered expenses under a health plan,which may or may not include the deductible or copayments,depending on the contract for that plan. 3"Emergency care"means services delivered by an emergency care facility which are necessary to screen and stabilize a covered person. The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life-or limb threatening emergency existed. 4"Biologically based mental illnesses"means schizophrenia,schizoaffective disorder,bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder,and panic disorder. 5 Waiver of pre-existing condition exclusions.State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had.Ask your carrier or plan sponsor(e.g.,employer)for details. 6 Grievances. Colorado law requires all plans to use consistent grievance procedures.Write the Colorado Division of Insurance for a copy of those procedures. 96794_P151152540(Rev.1-01) 4 Anthem...9 An Independent licensee of the Blue Cross and Blue Shield Association Anthem Blue Goss and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service.Inc. ®Registered marks Blue Cross and Blue Shield Association Colorado BlueAdvantage Pont-of-Service Rider Anthem®•U An independent licensee of the Blue Cross and Blue Shield Association Anthem Blue Cross and Blue Shield is the trade name of Both Mountain Hospital nsa Medical Service.Inc. ®Beg stared marks Blue Cross and Blue Shield Assoc at on Colorado BlueAdvantage Point-of-Service Rider Point-of-Service Rider to BlueAdvantage HMO Plan Benefit Booklet Your BlueAdvantage HMO Plan Benefit Booklet is hereby amended in accordance with the Group Master Contract issued by HMO Colorado (HMOC) on behalf of Anthem Blue Cross and Blue Shield (Anthem BCBS) and your employer to include this BlueAdvantage Anthem BCBS Plan Point-of-Service Rider. Benefits are underwritten by Anthem Blue Cross and Blue Shield(Anthem BCBS). HMOC (or its designee) is an agent for Anthem BCBS for administrative functions under this rider. The benefits of this rider are subject to all provisions of the BlueAdvantage HMO Plan Benefit Booklet unless otherwise stated. This rider is effective on the date it is incorporated into your employer's Group Master Contract or your effective date of coverage,whichever is later. Sincerely, Caroline Matthews Chief Operating Officer Anthem Blue Cross and Blue Shield 96055(Rev 1-01) i Customer Service: (800)334-6557 or(303)831-0161 Your Point-or-Service Rider at a Glance Point-of-Service Rider • Your Point-of-Service Rider at a Glance The BlueAdvantage Anthem BCBS Plan Point-of-Service Rider is designed to give members the choice of receiving covered services outside of regular BlueAdvantage HMO Plan requirements. For services covered under this rider, a member is not required to get a PCP referral, which is required under the regular BlueAdvantage HMO Plan cov- erage. A member may also choose to receive covered ser- vices from a provider who is not in the HMOC network. In other words, the member chooses the level of coverage re- ceived at the "point of service."We will not deny or restrict your coverage to the BlueAdvantage HMO plan coverage or this Rider. If a member obtains nonemergency services without first visiting his/her PCP or obtaining a refer al from his/her PCP, medically necessary services may be available as "point-of- service" benefits under this rider, subject to deductible and coinsurance. Note: Many point-of-service benefits require prior authorization. See Section 2: How the Point-of-Service Rider Works. Not all covered services that are described in the BlueAdvantage HMO Plan Benefit Booklet are covered under this rider. See Section 4: Point-of-Service Rider General Pi-elusions for a list of services that are not covered. When you have questions or concerns, customer service wants to know. Your comments and suggestions are wel- come.Listening to you helps improve customer service. Your customer service representative is knowledgeable about your point-of-service covered services, procednres, and providers. (Please have your ID card handy when calling a customer service representative.) Address: HMO Colorado Customer Service 700 Broadway Denver,Colorado 80273 Hours: 9:30 A.M.to 4:30 P.M.(Monday—Friday) Phone number: (800)334-6557 or(303)831-0161 96055(Rev 1-01) Customer Service:(800)334-6557 or(303)831-0161 Table of Contents Point-of-Service Rider Table of Contents 1: How to Use This Point-of-Service Rider 1 2: How the Point-of-Service Rider Works 2 Services Not Covered Under This Rider 2 Provider Choices 2 Member's Payment Responsibility for Services 3 Benefit Period 3 Cost-Sharing Features 3 Maximum Lifetime Benefit 4 Prior Authorization 4 3: Point-of-Service Rider Covered Services 6 4: Point-of-Service Rider General Exclusions 7 5: Point-of-Service Rider General Provisions 8 6: Point-of-Service Rider Glossary 9 96055(Rev 1-01) iii Customer Service: (800)334-6557 or(303)831-0161 Notes 96055(Rev 1-01) iv Customer Service: (800)334-6557 or (303)831-0160 • Section 1: How to Use This Point-of-Service Rider Point-of-Service Rider 1 : How to Use This Point-of-Service Rider When Services Are Covered Under This Rider This BlueAdvantage Anthem BCBS Plan Point-of-Service Rider provides coverage for certain services that are not • obtained in accordance with the rules and procedures of the BlueAdvantage HMO Plan Benefit Booklet. All provisions of your BlueAdvantage HMO Plan Benefit Booklet are used to determine whether services are covered under this rider, except for provisions that impose requirements for service or referral by your PCP, or unless specifically addressed in this rider. A member will receive the most comprehensive level of coverage by following the BlueAdvantage HMO Plan procedures. If the member receives services that are not provided by an HMOC PCP or that are provided by an HMOC par- ticipating provider without a PCP referral or that are provided by a non-participating provider, these services may be eligible for coverage under this rider. Covered services under this rider are subject to a calendar year deductible and the member must pay a specified percent- age of the covered charges for covered services(coinsur- ance). Also, not all services that are covered by the BlueAdvantage HMO Plan are covered under this rider. Prior Authorization Required For certain services covered under this rider and for all inpatient admissions, members are required to obtain prior authorization from BMOC. We will indicate when covered services require prior authorization. 96055(Rev 1-01) 1 Customer Service: (800)334-6557 or(303)831-0161 Section 2: How the Point-of-Service Rider Works Point-of-Service Rider 2: How the Point-of-Service Rider Works • When you enroll in the BlueAdvantage HMO Plan, you Participating Providers • must choose a primary care provider(PCP)for each covered Members can take advantage of participating provider agree- member of your family. If the PCP provides care or refers ments that Anthem BCBS has with many providers throughout the member to a specialist or hospital for covered services, Colorado. When services are covered under this rider and are the member receives full BlueAdvantage HMO Plan received from a provider who participates with Anthem benefits,according to the terms of the BlueAdvantage HMO BCBS: Plan Benefit Booklet. Life-threatening emergency care received without a PCP referral is covered under the • The provider agrees to accept payment under this rider BlueAdvantage HMO Plan. plus the member's deductible, coinsurance, and penalty amounts,if any,as payment in full for covered services. A member receiving certain types of care without a referral (The provider may request payment for deductible, from his/her PCP will receive "point-of-service" coverage, coinsurance, and penalty amounts at the time services subject to a calendar year deductible and coinsurance. are delivered.) Services for which a member has not obtained a referral ■ The member does not file claim forms;the participating from his/her PCP are subject to the terms and conditions of provider files for the member. In return, the provider this rider and are not eligible for regular coverage under the will be paid directly for covered services. BlueAdvantage HMO Plan Benefit Booklet—regardless of whether or not such services are received from an HMOC Nonparticipating Providers participating provider. A nonparticipating provider does not have a contractual agreement with Anthem BCBS. When covered services are Services Not Covered Under This received from a nonparticipating provider: Rider ■ The member is responsible for paying all billed charges Some services covered under the BlueAdvantage HMO to the provider, which may include amounts greater Plan Benefit Booklet are not covered under this rider. than Anthem BCBS's maximum allowable fee. A These services are covered only if they are obtained in accor- member will always pay applicable deductibles, co- dance with the procedures specified in the BlueAdvantage insurance,and penalty amounts. HMO Plan Benefit Booklet. See Section 4: Point-of-Service Rider General Exclusions for a list of services that are not • Members may have to file their own claims. Payment covered. for covered services is usually made directly to the member. (See Section 6: Claims Payments and Appeals Provider Choices in your BlueAdvantage HMO Plan Benefit Booklet.) Providers (physicians, hospitals, and other health care facilities and professionals) may have a participating Choosing a Provider — Provider Directories provider agreement or no agreement with Anthem BCBS. Your provider choice — participating or nonpartici- (Those with no agreement are referred to as nonpartici- pating—can make a difference in the amount you pay. pating providers.) Therefore, before choosing a provider for health care ser- vices, you may want to check your Anthem BCBS provider With this BlueAdvantage Anthem BCBS Plan Point-of- directory. Service Rider, members have the flexibility to choose pro- viders that are either inside or outside Anthem BCBS's If you do not have a current directory, contact customer participating provider network. However, members can service or your group administrator for a complete list of reduce their out-of-pocket expenses by using par- participating providers. ticipating providers. If Anthem BCBS does not have a participating provider for a covered service, arrangements Although a directory is current as of the date published, will be made to make sure that the member pays no more it is subject to change without notice. To verify a provid- than what the member would have paid for such covered er's current status with Anthem BCBS, or if you have any service if it had been received from a participating provider. questions about how to use a directory, contact a customer service representative. 96055(Rev 1-01) 2 Customer Service: (800)334-6557 or(303)831-0161 Section 2: How the Point-of-Service Rider Works Point-of-Service Rider Member's Payment Responsibility for the family deductible on your group's Colorado Health Plan Services Description Form. When you obtain most services under your BlueAdvantage Once a family member has met his/her ovum deductible, that HMO Plan Benefit Booklet, you pay only a copayment to person cannot contribute any more toward the family deduct- ' your HMOC provider. When you obtain services covered ible. Only that one person is eligible for benefits until one or under this rider, however, the provider may require that you more additional family members meet the other half of the pay in full for these services first,before filing your claim. family deductible. The contracts between HMOC and its providers include a Carryover Deductible Credit — On January 1 of each "hold harmless" clause which provides that a BlueAdvantage calendar year, HMOC will review the amounts applied to a HMO Plan member cannot be liable to the provider for member's point-of-service deductible during the last three moneys owed by HMOC for health care services covered months of the previous calendar year. Any amounts applied under the BlueAdvantage HMO Plan Benefit Booklet. for services received from October 1 through December 31 Services covered under this rider are not subject to this clause; of the previous year will be carried over and applied to the a nonparticipating provider may seek payment directly from member's deductible requirement for the new calendar year. the member and a participating provider may seek payment for deductible,coinsurance or non-covered services. Coinsurance Under this rider,the member is responsible for paying a per- Benefit Period tentage of the covered charges, called "coinsurance," after The benefit period is the calendar year: January 1 through the calendar year deductible is met. Please refer to your December 31 of the same year. The initial benefit period is Colorado Health Plan Description Form for copayment and coinsurance information. (Note: No coinsurance is required from a member's effective date through December 31 of the same year. (A member's initial benefit period may be less for nonemergency services received from a nonparticipating than 12 months.) Some benefits are limited to a specific dol- facility,but payment may be reduced; see Nonparticipating lar amount or number of days or visits allowed during a Facility Services,earlier in this section,for details.) benefit period. See your Colorado Health Plan Description Form for benefit details. Out-of-Pocket Limit This rider also includes an out-of-pocket limit designed to protect you from catastrophic health care expenses. After the Cost Sharing Features out-of-pocket limit is reached, payment will be made which This rider requires that the member share the cost of certain will satisfy the remaining payment obligations up to the health care expenses. This section describes the different maximum allowable fee for the remainder of that calendar cost-sharing methods. year. Calendar Year Deductible The out-of-pocket limit includes only the point-of-service Each member must pay a deductible each calendar year coinsurance. It does not include copayments for prescrip- before payment for covered services begins under this rider. tion drugs or regular BlueAdvantage LIMO Plan benefits, Your group's Colorado Health Plan Description Form penalty amounts (see Prior Authorization in this section), indicates the amount of your deductible. The deductible deductible amounts, expenses in excess of the maximum requirements must be met before a member begins paying allowable fee,or expenses for noncovered services. coinsurance for point-of-service benefits. The deductible is waived for routine immunizations and well-child care visits Individual Out-of-Pocket Limit — Each member meets for children up to age 13. (Copayments for BlueAdvantage his/her annual out-of-pocket limit after coinsurance amounts HMO Plan covered services do not count toward the for his/her covered services equal the individual "point-of- calendar year deductible.) service" out-of-pocket limit shown on the group's Colorado Health Plan Description Form. Individual Deductible—Each member's calendar year de- ductible is the amount specified on the group's Colorado Family Out-of-Pocket Limit — All covered family mem- Health Plan Description Form. bers meet the annual out-of-pocket limit when the combined coinsurance amounts for two or more family members reach Family Deductible — All covered family members meet the amount specified as the family "point-of-service" out- the deductible when the combined deductible amounts for of-pocket limit on the group Colorado Health Plan Descrip- two or more family members reach the amount specified as Lion Form. 96055(Rev 1-01) 3 Customer Service: (800)334-6557 or(303)831-0161 Section 2: How the Point-of-Service Rider Works Point-of-Service Rider If any one family member's out-of-pocket reaches the individ- vider is nonparticipating, you are responsible for obtaining ual limit, the out-of-pocket for that member is met and no prior authorization before treatment begins for the outpatient additional amounts may be applied to the family out-of-pocket services and surgical procedures listed below, or payment by that member for the remainder of the calendar year. will be reduced or denied as explained under Obtaining Prior Authorization, below. Maximum Lifetime Benefit • The maximum amount that will be paid for all services covered chiropractic services, only if your group has purchased under this rider is $1,000,000 per member per lifetime. The the optional Chiropractic services benefit. See your maximum lifetime benefit includes all covered charges less Colorado Health Plan Description Form to determine deductible,coinsurance, and penalty amounts, if any. Any pay- if purchased. ments made by HMOC under the BlueAdvantage HMO Plan • physical rehabilitation (physical, occupational, or speech Benefit Booklet do not contribute to the $1,000,000 point-of- therapy) service maximum lifetime benefit. • home health services Prior Authorization Members must obtain prior authorization before certain • hospice services services are received, or payment for covered services will be reduced as explained below. • durable medical equipment purchase or rental There is no coverage or payment for any service, • ambulatory or outpatient surgery procedure,admission,or portion of an admission that is not medically necessary. • cochlear implantation of a hearing device (such as an electromagnetic bone conductor) to facilitate communi- Nonemergency Admissions — If your provider is partici- cation for the profoundly hearing impaired, including pating the provider is responsible for obtaining prior autho- any necessary training required to use the device rization before you are admitted as an inpatient to a hospital or other treatment facility in these nonemergency situations. • reconstructive surgery (such as septoplasty or the sur- If your provider is nonparticipating, you are responsible for gical reconstruction of the nasal septum) obtaining prior authorization before being admitted as an in- patient to a hospital or other treatment facility for a non- • surgery for obesity, including the surgical treatment of emergency for these situations, or payment will be reduced morbid obesity (morbid obesity means the state of being or denied as explained under Obtaining Prior Authorize- either twice the ideal body weight or 100 pounds over lion below: ideal body weight) • a provider recommends that a member be admitted as Obtaining Prior Authorization an inpatient To obtain prior authorization, you or your provider must call the HMOC health services department (1-800-526-4662 or • a member is transferred from one inpatient facility to 303-831-4115, Monday through Friday, 8 A.M. to 4:30 P.M., another Mountain Time) before receiving the service. The health services representative will explain prior authorization re- • a member is readmitted as an inpatient for any reason quirements and ask for information about your provider and (other than an emergency) the proposed services or admission. If the provider has not already requested authorization for the proposed services, a Routine newborn care admissions do not require prior representative will call his/her office for mom information. authorization if the newborn is discharged before or on the The member and his/her provider will be notified by mail of same date as the mother. If the newborn remains in the hos- authorization decisions. The member's treatment may be re- pital after the mother is discharged, the member must call viewed at periodic intervals to ensure services continue to be HMOC within 48 hours of the mother's discharge to notify covered. HMOC of the newborn's continued inpatient stay. Outpatient Services and Surgical Procedures — If your provider is participating, the provider must obtain prior authorization before treatment begins for the outpatient services and surgical procedures listed below. If your pro- 96C S(Rev 1-01) 4 Customer Service: (800)334-6557 or(303)831-0161 • Section 2: How the Point-of-Service Rider Works Point-of-Service Rider Penalty for Not Obtaining Prior Authorization — If authorization for a nonparticipating provider is not obtained in advance, but the member chooses to receive the services anyway,payment may be reduced: • If there has been no prior authorization for services that would have been authorized if a request had been received, coinsurance for covered services will be increased by an additional 20 percent. For example, if the point-of-service coinsurance (the percent of covered charges that the member pays) is 30 percent, it will be increased to 50 percent. This penalty amount is in addi- tion to all deductible and coinsurance requirements. If the member's out-of-pocket limit is reached, the penalty amount for covered services received without prior authorization will be 20 percent coinsurance. • If prior authorization is denied or if the services would not have been authorized if a request had been received, all related claims will be denied. My penalty amounts the member pays do not contribute to the member's out-of-pocket limit. Prior authorization determines only the medical necessity of a service or an admission and an allowable length of stay. If a member loses coverage under this rider, no payments will be made for services received or admissions beginning after coverage ends—even if prior authorization was obtained. 96055(Rev 1-01) 5 Customer Service: (800)334-6557 or(303)831-0161 Section 3: Point-of-Service Rider Covered Services Point-of-Service Rider 3: Point-of-Service Rider Covered Services Point-of-Service Benefits Covered services with limits include: Members receive point-of-service benefits for covered services that are not provided by an HMOC PCP or are provided without • chiropractic services, only if your group has purchased PCP referral. Point-of-service benefits are available under this the optional chiropractic services benefits. See your rider for all covered services under the BlueAdvantage HMO Plan Colorado Health Plan Description Form to determine Benefit Booklet, except for specified services listed as excluded if purchased (see Section 4:Point-of-Service Rider General Exclusions). ■ durable medical equipment(outpatient) Point-of-service benefits are subject to deductible and co- insurance, and the prior authorization procedures described in • home health care Section 2:How the Point-of-Service Rider Works.Some covered services are limited to a certain number of visits or a certain • physical rehabilitation (physical, occupational, and maximum payment limit,For specific deductible and coinsurance speech therapy) amounts,and benefit limitations, see your Colorado Health Plan Description Form. When a member calls HMOC for prior authorization,he/she may ask about visit or maximum payment limitations. All services are also subject to Section 4:General Exclusions in your BlueAdvantage HMO Plan Benefit Booklet,which explains The member is responsible for charges for services that the services,situations,and related expenses that are not covered. exceed the maximum number of visits or maximum payment limitations. Combined BlueAdvantage HMO Plan and Point-of-Service Limitations Annual Gynecological Exam Certain covered services have a limited number of visits A member may receive her annual gynecological exam and/or maximum benefit payment limit (see your Colorado under this Point-of-Service Rider. Contraceptive devices Health Plan Description Form). A member may receive that can be purchased at a physician's office are also these covered services as follows: covered under this rider. (Birth control pills and devices can be purchased through the BlueAdvantage HMO Plan Retail • Chiropractic services, only if your group has purchased Pharmacy and Prescription Mail Services Programs.) the optional Chiropractic services benefit. See your Colorado Health Plan Description Form to determine Hospice Services if purchased. A member may receive hospice care under this Point-of- Service Rider. In addition to the benefits provided in your • all of these covered services under the BlueAdvantage BlueAdvantage HMO Plan Benefit Booklet, bereavement HMO Plan Benefit Booklet,or support services for the family during the three month period following the death of the member are covered up to a total • all of these covered services under the Point-of-Service payment of$1,150. Rider,or Preventive Child Care Services • part of these covered services under the BlueAdvantage Services are covered for age-appropriate routine immuniza- HMO Plan Benefit Booklet, and part under the Point- tions and well-child care visits up to age 13. Benefits are not of-Service Rider,until the combined number of visits or subject to the deductible,but are subject to the coinsurance. payments reach the specified limit. For example, if a member receives prior authorization for a covered service that has a 10-visit maximum, the member may visit his or her PCP six times for the services and visit a provider without a PCP referral for the remaining four visits. The member may use any such combination of BlueAdvantage HMO Plan Benefit Booklet and BlueAdvantage Anthem BCBS Plan Point-of-Service Rider benefits,up to the limit. 96055(Rev 1-01) 6 Customer Service: (800)334-6557 or(303)831-0161 Section 4: Point-of-Service Rider General Exclusions Point-of-Service Rider 4: Point-of-Service Rider General Exclusions Section 4: General Exclusions in your BlueAdvantage HMO Plan Benefit Booklet applies to this Point-of-Service Rider. In addition, this Point-of-Service Rider includes the following exclusions: Duplication—If a member receives services that are covered under the BlueAdvantage HMO Plan Benefit Booklet, those services will not be covered under this rider. Excluded Services — The following services and supplies are not covered under this rider, but may be covered under your BlueAdvantage HMO Plan Benefit Booklet when provided by your PCP or with a PCP referral: • Ambulance Services (emergency ambulance services are covered under your BlueAdvantage HMO Plan Benefit Booklet) • Chemical Dependency or Rehabilitation Treatments • Infertility Services • Major Organ Transplants • Mental Illness Treatments that are non-biologically based • Preventive Care Services for members over the age of 13, with the exception of annual gynecological exam- inations (i.e., routine physical examinations for adults, screening mammography, routine hearing examinations, and adult immunizations) • Skilled Nursing Facility Care Prior Authorization—Certain services require prior autho- rization in advance. If the member chooses to receive the services without obtaining prior authorization for nonpartici- pating providers, payment may be reduced. All nonemer- gency inpatient admissions,physical rehabilitation (physi- cal, occupational, and speech therapy), durable medical equipment,and home health care require prior authoriza- tion. See Prior Authorization in Section 2: How the Point- of-Service Rider Works for a list of services requiring prior authorization and details on how to obtain authorization and for information on the penalty amounts for not obtaining prior authorization. 96055(Rev 1-01) 7 Customer Service: (800)334-6557 or(303)831-0161 Section 5: Point-of-Service Rider General Provisions Point-of-Service Rider • 5: Point-of-Service Rider General Provisions All provisions of your BlueAdvantage HMO Plan Benefit How We Calculate Deductible, and • Booklet are used to determine whether services are covered under Coinsurance this rider,except for those provisions that impose requirements for service or referral by your PCP,or unless specifically addressed in Anthem BCBS has worked with physicians,hospitals,pharmacies, and other providers of health care in an attempt to control the costs this rider of health care. As part of this effort, many providers agree to How and Where to Send Claims control costs by giving discounts to Anthem BCBS. Most other Ifyougo to a insurers maintain similar arrangements with providers. participating provider, the provider will file your loons. In their contracts,participating providers agree to accept Anthem BCBS's maximum allowable fee as payment in full for covered HMOC or its designee administers claims under this rider as the services. For example, your physician may charge $100 for a agent for Anthem BCBS.Submit claims to: procedure,and the maximum allowable fee is $85. Your deduct- HMO Colorado ible and coinsurance are based on the maximum allowable fee of 700 Broadway,Suite 612 $85, not the physician's charge of $100, so if you use a Denver,CO Suite participating provider, you save money. Anthem BCBS 8027determines a maximum allowable fee for all procedures preformed in accordance with the provisions of Section 6: Claims Payment by providers. and Appeals in your BlueAdvantage HMO Plan Benefit Booklet. In addition to accepting Anthem BCBS's maximum allowable fee, We are not required to honor an assignment of benefits to many participating providers, such as providers participating in nonparticipating providers. We may honor an assignment ofBlueAd to benefits to nonparticipating providers at our sole discretion.If we Anthem vantage ThesePo additional-Service,also give additional help control discounts is pay you directly, you will be responsible for paying the nonpar- BCBS. discounts help control the costs ticipating provider of services for all charges. of health care and allow your employer or Anthem BCBS to offer more extensive benefit plans with lower deductibles and coinsurance.These discounts are taken into account in a variety of How Payments Are Madewa After a claim has been processed,the met will receive an ex- ys in determining the amount you pay for health care. planation of benefits (EOB). (When the member is a dependent Using the example described above, if your participating phy- child of divorced parents, the custodial parent may receive the sician charges$100 for a procedure and the maximum allowable EOB.)Payments for covered services usually are sent directly to fee is$85,your deductible and coinsurance are subtracted from participating providers and the member receives an EOB that ex- the$85,and the balance is the responsibility of Anthem BCBS. plains the payment.If payment for covered services is sent to the The participating provider may have member, the check is attached to the EOB. The EOB indicates P P g agreed to an additional what services were covered and what services,if any,were not. d t, which is calculated after the maximum allowable fee, deeductiducts ble, and coinsurance. For this example we will use an additional discount of 10 percent. Anthem BCBS would refill- Anthem BCBS's payment to providers is based upon provider burse the participating provider the balance of the maximum agreements and the covered charges as determined by Anthem allowable fee, minus your deductible, coinsurance, and minus BCBS. The member is responsible for paying all deductible the additional 10 percent. The amount of the additional dis- amounts,coinsurance,penalty amounts,and expenses for noncov- counts if any,varies by provider and by the type of health care ered services.Payments for covered services received from a ran- you have with Anthem BCBS. As this example participating provider are usually made to the member,who is also p shows, responsible for paying the provider,including any amounts greater ofcertainlc discounts are edno passed directly on to you for purposes than Anthem BCBS's maximum allowable fee.Anthem BCBS is of calculating tics your deductible, and coinsurance. If you do not use a participating provider, any amount over the maximum not required to honor an assignment of benefits from nonparti- allowable fee is your responsibility. cipating providers. Anthem BSBS may honor an assignment of benefits to nonparticipating providers at our sole discretion If we You benefit from all provider discounts.Discounts allow Anthem pay you directly, you will be responsible for paying the non- BCBS or your employer to offer more extensive plans with lower participating provider for all charges. deductibles and coinsurance amounts and make it possible to offer Benefit payments for members who are eligible for Medicaid are a lower-cost benefit plan to you or your employer. Without Provider discounts,employers might have to choose either a less • paid to the Colorado Department of Health Care Policy and extensive plan offering fewer benefits or pass the additional costs Finance or providers when required by law. on to employees, thus increasing the cost of their health care coverage. 96055 (Rev 1-01) 8 Customer Service: (800)334-6557 or(303)831-0161 • Section 6: Point-of-Service Rider Glossary Point-of-Service Rider 6: Point-of-Service Rider Glossary This section defines certain words used in this rider that are either not defined in the Glossary of your BlueAdvantage HMO Plan Benefit Booklet or are used in a different way in your BlueAdvantage HMO Plan Benefit Booklet. Please see the Glossary of your BlueAdvantage HMO Plan Benefit Booklet for additional definitions. Anthem Blue Cross and Blue Shield (Anthem BCBS) — Means Rocky Mountain Hospital and Medical Service, Inc., a Colorado insurance company doing business as Anthem Blue Cross and Blue Shield (also referred to as Anthem BCBS). Billed Charge— the amount billed by the provider for the service or supply. The billed charge may be different from the maximum allowable fee. If the provider is nonpartici- pating, the member is responsible for the billed charge, regardless of the maximum allowable fee or the amount of the benefit payment. Coinsurance—An arrangement by which a member pays a certain percentage of covered charges for covered services under this rider,after the deductible is satisfied. Covered charges— For some facilities and/or pharmacies, the billed charges. For all other providers, the lesser of billed charges or the maximum allowable fee. Deductible — A specified amount of covered charges that each member must pay for covered services provided under this rider within a calendar year before any payments will be made by Anthem BCBS. Maximum allowable fee — The amount determined by Anthem BCBS to be a reasonable and adequate allowance for a covered service. Anthem BCBS's determination of a maximum allowable fee is the maximum amount Anthem BCBS approves for any particular service. Deductible and coinsurance or other cost-sharing amounts are based on this allowance and are the amounts the member pays to the provider. Nonparticipating provider — An appropriately licensed health care provider who has not entered into an agreement with Anthem BCBS. The member is responsible to the nonparticipating provider for all charges, regardless of Anthem BCBS's maximum allowable fee or the amount of the benefit payment. The provider's charge may exceed the Anthem BCBS maximum allowable fee. 96055 (Rev 1-01) 9 Customer Service: (800)334-6557 or(303)831-0161 Welcome Welcome to the BlueAdvantage HMO Plan from HMO Colorado, Inc. (HMOC) — your partner in health care. By encouraging physicians, hospitals, other providers, and members to work together, HMOC works to maintain reasonable health care costs. Please take a few minutes to get to know BlueAdvantage and your coverage, including limitations and exclusions, by reviewing this important document and any enclosures. Learning how the BlueAdvantage HMO Plan works can help you make the best use of your health care plan. Thank you for selecting BlueAdvantage for your health care coverage. Sincerely, Nit"4 )tfakjutuiv3 Caroline Matthews Chief Operating Officer HMO Colorado,Inc. Acceptance of coverage under this certificate constitutes acceptance of its terms, conditions, limitations, and exclusions. Members are bound by all of the terms of this certificate. Your health benefit plan coverage is defined in the following documents: • this certificate,the Colorado Health Plan Description Form, and any amendments or endorsements • the enrollment/change form(s)for the employee and his/her dependents • the identification card In addition,the employer has important documents that are part of the terms of the health benefit plan: • the Group Master Application from the employer • the Group Master Contract between HMOC and the employer The above documents constitute all of the terms and conditions of your health benefit plan. No change or modification to any of these documents will be valid unless the change or modification is in writing and signed by an officer of HMOC. HMO Colorado and anyone acting on its behalf, has full and final discretionary authority over the administration of the Group Master Contract and Certificate, including but not limited to,the power to: • construe,interpret,and apply the provision of the Group Master Contract and certificate; • determine questions concerning eligibility for participation,benefit coverage or the amount of any benefits payable; • take all other actions necessary to carry out the provision of the Group Master Contract and the Certificate;and • perform the HMO Colorado duties thereunder. HMO Colorado's actions shall be binding upon all interested parties. 97000(Rev. 5-01) i Customer Service (800)334-6557 or(303)831-0161 Member Rights and Responsibilities BlueAdvantage HMO Member Rights and Responsibilities Member Rights As a member of BlueAdvantage HMO you are entitled to the following rights: • The right to be treated with respect and with the recognition of personal dignity and the need for privacy. • The right to participate with practitioners in decision-making regarding your health care. • The right to candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage. • The right to refuse recommended medical treatment or procedures. • The right to confidentiality of information concerning your health, illness,and treatment. • The right to voice complaints or appeals about the managed care organization or the care provided. • The right to offer suggestions for changes in the plan's quality improvement policies and procedures. • The right to information about the managed care organization, its services,the practitioners and providers providing care, and the rights and responsibilities of members. Member Responsibilities As a member of BlueAdvantage HMO you have the following responsibilities: • The responsibility to follow instructions and guidelines given by those providing health care services. • The responsibility to provide complete health status information needed by your health care provider in order to care for you. • The responsibility to keep appointments for care and to give required notice when canceling. • The responsibility to pay the applicable copayment at the time services are rendered. • The responsibility to read and understand all materials concerning your health coverage and to share this information with your health care provider. • The responsibility to notify your PCP within 48 hours after receiving emergency care without a referral. • The responsibility to treat your providers and HMOC staff with respect and recognition of personal dignity. 97000(Rev. 5-01) ii Customer Service (800)334-6557 or(303)831-0161 Your Plan at a Glance BlueAdvantage HMO Your Plan at a Glance Every BlueAdvantage member must select a primary care may ask to see it. Have it handy when you call for an provider (PCP) from the HMOC provider network. (If a appointment and show it to the receptionist when you sign in PCP is not selected, the member will be covered for for an appointment. emergency care only.) Benefit limitations A PCP provides basic health services, and other medical To be considered covered services,any services received must care, and recommends and oversees any care provided by be medically necessary or covered as appropriate preventive, other health care providers. A member needing nonemer- routine, or family planning services. Services must also be gency hospital care or wanting to see a health care provider performed, prescribed, directed, or authorized by the other than his/her own PCP, must first obtain a PCP member's PCP (limited exceptions are described in Section referral before receiving the service. If a member does not 3: Covered Services). For additional exclusions and receive a referral for services performed by any provider limitations,also see Section 4:General Exclusions. other than his/her PCP, the plan will not cover those services. (For limited exceptions, see Section 3: Covered Visiting your PCP Services.) To avoid possible delays when scheduling an appointment with your PCP, follow these steps: If we do not have an HMOC provider for a covered service, we will arrange to make sure that you pay no more than what ■ For routine appointments, call your PCP's office and you would have paid for such covered service if it had been identify yourself as a BlueAdvantage member to sche- received from an HMOC provider. HMOC will not deny or dule an appointment. restrict in-network covered benefits to a member solely because the member obtained treatment outside the network. • For sudden illnesses, call your PCP's office and identify yourself as a BlueAdvantage member. You will be given Personal care network instructions to follow. Not all members choose a PCP that is part of a personal care network, a personal care network is a specific network of If you need to cancel an appointment,notify your PCP as soon providers covering a geographic service area. It includes one as possible, but at least 12 hours before the scheduled hospital and certain PCPs and specialists. Once a member appointment. You may be charged a fee for a missed appoint- enrolls with a PCP, he/she will belong to that PCP's ment. This plan will not pay for such a charge. If you are personal care network and must obtain all health care going to be late for an appointment, please notify your PCP, services through that personal care network. If your PCP is who may ask you to reschedule. not part of a personal care network, your PCP will refer you to the appropriate specialist within the HMOC network. Mental illness or chemical dependency care When you need care for mental illness (whether biologically Referrals are restricted to those specialists who belong to the based or non-biologically based) or chemical dependency, member's personal care network (limited exceptions are all services must be preauthorized by the HMOC behavioral described in Section 3: Covered Services). Except for health administrator prior to receiving services. Contact a emergency care,all inpatient and outpatient services must be Customer Service representative for the phone number of received through a member's personal care network. Note: the administrator. If you and your dependents choose PCPs in different personal care networks, be aware that each member of your Routine care family may be required to go to different hospitals for care. Routine care is service for conditions not requiring immediate attention and can usually be received in the In some parts of the HMOC service area, all specialty and PCP's office, or services that are usually done periodically facility services may not be available in a member's personal care network. In these circumstances, the PCP will within a specific time frame(e.g., immunizations or physical exams). Routine care is performed during your PCP's refer the member outside of his/her personal care network. normal business hours. Your identification card Urgent/after-hours care Your identification (ID) card shows that you are a member You must call your PCP for instructions to receive medical of this plan and provides the information needed when you require services. Always carry your ID card; any provider care after your PCP's normal business hours or on weekends 97000(Rev. 5-01) iii Customer Service (800) 334-6557 or(303)831-0161 Your Plan at a Glance BlueAdvantage HMO and holidays, or to receive urgent care within the HMOC procedures, and providers. (Please have your ID card handy service area for a condition that is not life threatening but when calling a customer service representative.) Your that requires prompt medical attention. If you are outside the satisfaction is HMOC's goal — so call when you have a HMOC service area, services covered under this certificate question or complaint. that are received from a participating BlueCard provider are also covered services. See "Emergency and Urgent/After- Address: HMO Colorado Hours Care" in Section 3: Covered Services for important 700 Broadway details. Denver,Colorado 80273 Hours: 9:30 A.M.to 4:30 P.M.Monday—Friday Emergency care Phone number: (800)334-6557 or You may get immediate care from any provider for (303)831-0161 emergency care. However, you should always contact your PCP within 48 hours of the emergency, unless your For additional information on HMOC (including the condition makes it impossible to do so. For details, please BlueCares for You Program, which provides tips on getting read "Emergency and Urgent/After-Hours Care" in Section and staying healthy, and our on-line provider directories), 3: Covered Services. visit our world wide web site at: www.anthem.com Specialist or referral care Network Access Plan Except for emergency care, you must obtain a referral from HMOC strives to provide an extensive provider network that your PCP before seeing any other provider. Coverage will adequately addresses members health care needs. The be provided only for covered services received from a Network Access Plan describes HMOC's provider network specialist if your PCP refers you to that specialist before standards for ensuring network sufficiency in service, you receive the care (limited exceptions are described in access, and availability, as well as assessment procedures to Section 3: Covered Services). Do not make a second ensure that the network continues to meet member needs. To appointment with a specialist if only one visit is authorized. request a copy of this document, call (800) 334-6557. This If you receive nonemergency services before consulting document is available for your in-person review at 700 with your PCP, coverage will not be available and you Broadway in Denver, Colorado, in the Customer Service will be responsible for the entire cost of the services. Department, fourth floor. Nonparticipating provider services How We Pay Providers Services performed by a nonparticipating provider(one who HMOC works with physicians, hospitals, pharmacies, and has not contracted with HMOC) will be covered only in an other providers of health care in an attempt to control the emergency as described under "Emergency and cost of health care. As part of this effort, most providers that Urgent/After-Hours Care" in Section 3: Covered Services or contract with HMOC agree to control costs by giving when approved in advance by HMOC. discounts to HMOC. Hospital admissions The discounts range from paying a fixed amount per day for a hospital admission to paying a provider a fixed amount per HMOC has contracted with specific hospitals to provide month for each member who has selected that provider as care to plan members. This plan will cover your nonemergency inpatient stay if you are admitted by your his/her primary care physician. PCP or by a specialist to whom your PCP has referred you for care. The admission must be prior authorized by HMOC The copayments and coinsurance amounts listed on your and you must be admitted to a participating hospital. In most Colorado Health Plan Description Form are the dollar cases, this will be your personal care network hospital. amounts you are responsible for paying the provider (Your PCP is responsible for obtaining all necessary prior regardless of any discounts that HMOC may have negotiated authorizations from HMOC,) with a provider. You benefit from provider discounts. Discounts allow When You Have Questions or Concerns, HMOC to offer more extensive benefit plans with lower Customer Service Wants to Know copayments and make it possible to offer a lower-cost HMOC welcomes your comments and suggestions. benefit plan to you or your employer. Without provider Listening to you helps improve customer service. When discounts, employers might have to choose either a less appropriate, your concerns will be shared with your PCP. extensive plan offering fewer benefits or pass the additional Your customer service representative is knowledgeable costs on to employees,thus increasing the cost of health care about the benefits of your plan, covered services and coverage. 97000(Rev. 5-01) iv Customer Service(800)334-6557 or(303)831-0161 Table of Contents BlueAdvantage HMO Table of Contents 1: How to Use This Certificte 1 2: How the Plan Works 2 3: Covered Services 5 Ambulance Services 5 Chemical Dependency Treatments 5 Optional Chemical Dependency Rehabilitation 6 Optional Chiropractic Services 7 Dental-Related Services 7 Diagnostic Services 8 Emergency and Urgent/After-Hours Care 9 Home Health Care 10 Hospice Care 11 Hospital/Other Facility Services 12 Kidney Dialysis 13 Maternity and Newborn Care 14 Mental Illness Treatments 15 Office, Outpatient,and Home Care 16 Physical Rehabilitation, Inpatient and Outpatient 17 Prescription Drugs 19 Preventive,Routine,and Family Planning Services 22 Supplies, Equipment,and Appliances 24 Surgical Services 25 Transplants 27 Therapies: Chemotherapy and Radiation 29 TMJ Services 30 4: General Exclusions 31 5: Coordination of Benefits and Subrogation,,,35 6: Claims Payment and Appeals 38 7: Enrollment and Termination Information ,,,42 8: General Provisions 47 9: Glossary 50 97000(Rev. 5-01) v Customer Service(800)334-6557 or(303)831-0161 Section 1: How to Use This Booklet BlueAdvantage HMO 1 : How to Use This Certificate This certificate describes the benefits available to members Customer Service of this plan and benefit limitations and exclusions. It also If you have any questions about your coverage, call HMOC's describes optional benefits that may or may not have been Customer Service Department. For your convenience, the local chosen by your group. and toll-free customer service numbers arc printed at the bottom of every page in this certificate. Colorado Health Plan Description Form In addition to this certificate, you should have a group Address: HMO Colorado Colorado Health Plan Description Form that shows specific 700 Broadway copayment amounts and benefit options and/or coverage Denver,Colorado 80273 variables chosen by your group. If you do not have a Hours: 9:30 A.M.to 4:30 P.M. summary, please contact an HMOC customer service repre- Phone number: (800)334-6557 or sentative. You will receive a new Colorado Health Plan (303)831-0161 Description Form if changes arc made to your health care plan. Looking Up Information This certificate is designed to make it easy for you to deter- mine your benefits. For example, if you need to know what surgical services are covered, turn to Section 3: Covered Services. In Section 3, the "Surgical Services" subsection defines what a surgical service is. The subsection also describes your benefits and lists the most important limitations and exclusions to that particular service. Section 4: General Exclusions lists other limitations and exclusions which apply to all services, whether or not these items are listed separately within any subsection of Section 3: Covered Services. Optional Coverage and Group Variations Some coverage is optional and may or may not have been chosen by your group. Other coverage features may vary from group to group (for example, dependent age limits). Coverage that is optional and variable coverage features are identified in this certificate. When you see these Sections, check your separately issued group Colorado Health Plan Description Form to determine which optional coverages and variable coverage features are available to you through your group. Call Within 48 Hours After receiving emergency care, members are asked to con- tact their PCP within 48 hours. For all other services you must contact your PCP before receiving services. (See Section 3:Covered Services for exceptions). 97000(Rev. 5-01) 1 Customer Service(800)334-6557 or(303)831-0161 Section 2: How the Plan Works BlueAdvantage HMO 2: How the Plan Works Identification Card another, contact the former PCP. You are responsible for any charges related to transferring medical records.) Your identification (ID) card shows that you are a member of a plan administered by HMOC and provides the Any referrals provided by a member's previous PCP must be information needed when you require services. Always carry reviewed by the new PCP. New referrals must be issued by your ID card; any provider may ask to sec it. Have your ID the new PCP before referral care will be covered. card handy when you call for an appointment and show it to the receptionist when you sign in for an appointment. Note: Changing PCPs may result in changing your personal care network also. If your personal care network changes, the Enrollment/Change Form hospital where you receive care may change and the special- If you change your membership in any way, such as adding ists to whom you may be referred may change. For informa- or deleting dependents or changing PCPs, you must fill out tion on personal care networks,call HMOC customer service. and submit an enrollment/change form to HMOC or to your employer. This form is available from your employer or can Change of Residence Within areas serviced by an be obtained by calling the HMOC Customer Service HMOC PCP, if a member changes primary residence or Department. place of employment to a location that is not convenient to his/her current PCP's office, the member may choose a new PCP Selection and Changes PCP nearer to the new residence or place of employment. The member must notify HMOC within 31 days of a In order to receive covered services, a member must choose change in residence or place of employment by submitting a primary care provider (PCP). When a member needs any an enrollment/change form. nonemergency medical care, the member must first contact his/her chosen PCP (limited exceptions are described in In-State Student Care Program — The In-State Student Section 3: Covered Services). The PCP will make necessary Care Program enables a member who is a full-time student arrangements for the member's care. to select a PCP with an office convenient to the student's residence during the school year. Selecting a PCP At the time of enrollment, each member must select a PCP. If a student's residence and school are both within the HMOC Family members are not required to choose the same PCP. service area but are not close enough geographically to be They may select their own PCPs individually. If a PCP is serviced by the same personal care network, the student can not chosen, the member will be covered for emergency care choose a "primary" PCP either near his/her residence or near only.Also,a PCP must be chosen for an eligible newborn his/her school.For example,if the student chooses a"primary" before its birth to ensure continuous coverage from PCP near his/her home, the student must contact HMOC birth, customer service when at school so that a"secondary"PCP can be authorized for the student. In this example, the "secondary" Please refer to your HMOC provider directory for a list of PCP can only provide routine and urgent care services when the PCPs. Some providers are listed as accepting established student is at school. If the student needs specialty services, the patients only. However, if you intend to select a PCP that "primary"PCP must be contacted.The member must contact an indicates no patient limitations (and you are not already an HMOC customer service representative prior to receiving established patient of the PCP being chosen), you should services from the"secondary"PCP or coverage will be denied. call the provider to confirm that he/she is still accepting new patients. If the HMOC service area covers the residence or school but not both, the student must select a PCP within the HMOC Changing PCPs service area to provide all services and referrals. If the stu- A member may select a new PCP by requesting the change dent is outside the HMOC service area and requires urgent on an enrollment/change form or by calling HMOC custo- or after-hours care, refer to "Emergency and Urgent/After- mer service and notifying them of the change. A new ID Hours Care"in Section 3: Covered Services. card will be sent to the member confirming the PCP change. Copayment The effective date of all member-requested PCP changes will be the first day of the month following approval. (To Copayment the predetermined fixed-dollar amount a member must pay to receive a specific service. Copayment have medical records transferred from one physician to 97000(Rev. 5-01) 2 Customer Service(800)334-6557 or(303)831-0161 Section 2: How the Plan Works BlueAdvantage HMO may also mean a defined percentage of charges a member If a member chooses to see any other provider — even must pay to receive a specific covered service. an HMOC participating provider— without a referral, the member will be responsible for all charges. (See Copayments may be required for covered services. Copay- Section 3: Covered Services for exceptions.) ments for specific services are listed in the Colorado Health Plan Description Form. The referral indicates the number of visits approved and the time period in which the member must receive the care. If Members are responsible for making copayments directly to only one visit is authorized, a second visit will not be HMOC participating providers at the time of service. covered. The member is responsible for all visits in excess of those authorized and for any care received before or The contracts between HMOC and its providers include a"hold after the specified time period. A standing referral for medi- harmless"clause which provides that a BlueAdvantage member cally necessary treatment may be authorized for ongoing cannot be liable to the provider for moneys owed by HMOC for care. health care services covered under the BlueAdvantage HMO Plan Certificate. Note: A referral is not required to visit a participating OB/GYN,certified nurse midwife, or eye care provider. The Services from nonparticipating providers are covered only member must choose an OB/GYN, certified nurse midwife, under limited circumstances; nonemergency services from optometrist, or ophthalmologist provider within the HMOC nonparticipating providers are not covered unless speci- network. fically authorized by HMOC before services are received. However, when prior authorized or for emergency care (as Nonemergency Hospital Admissions defined in Section 3), copayments for covered services received from a nonparticipating provider are the same as HMOC has contracted with specific hospitals to provide for covered services received from an HMOC participating care to plan members. The plan will cover an inpatient stay provider. if a member is admitted to an HMOC participating facility by his/her PCP or by a specialist to whom the PCP has Members are always liable for a provider's full billed referred the member. However, all such admissions must be charge for any noncovered services, and for services prior authorized by HMOC before the member is admitted. received without a PCP's referral or HMOC approval. Emergency Hospital Admissions Out-of-Pocket Limit For emergency care (as defined in the Glossary), members Once copayments paid by a member during a calendar year for may get immediate care from any provider (see "provider" basic health services (as defined in federal regulations) reach as defined in the Glossary); however, the member's PCP twice the total annual premium that is normally charged for a should be contacted within 48 hours of the emergency to single member under this plan, no further copayments will be arrange follow-up care, unless the nature of the illness or due for the remainder of the year. Any copayments over that injury makes it impossible to do so. For details, see amount will be refunded to the employee if the refund is "Emergency and Urgent/After-Hours Care" in Section 3: requested within 45 days after the end of the calendar year.It is Covered Services. the member's responsibility to determine when the out-of- pocket limit has been reached; therefore, members should Authorizations to Obtain Care maintain accurate records of copayment amounts. Prior authorizations from HMOC are required before a Specific information on copayments and annual premium member can receive certain services or services outside of can be obtained from a customer service representative. the member's personal care network. The member's PCP is responsible for obtaining all necessary prior authorizations. PCP Referrals Services requiring prior authorization include, but are not limited to: A member must receive a referral from his/her PCP before receiving nonemergency care from another provider. The • services performed by a provider outside the member's PCP will phone or fax the referral information to HMOC. personal care network HMOC or its designee will mail a confirmation referral form or a denial of the referral request to the member, the PCP, ■ elective hospital admissions and the specialist. Retroactive referrals are not covered; all referrals must be obtained before receiving services. • home health care 97000(Rev. 5-01) 3 Customer Service(800)334-6557 or(303)831-0161 Section 2: How the Plan Works BlueAdvantage HMO • hospice care complicated discharge planning needs, or have the potential for high-cost medical expenses. Cost-effective alternative • inpatient and outpatient surgery care arrangements can then be made. Special care arrange- ments are coordinated with the provider, the patient, and the • durable medical equipment patient's family, and may include coverage for services that are not ordinarily covered. The above list is not complete, other services may require prior authorization.Your PCP is responsible for Cost-Effective Alternatives obtaining these authorizations. Check with your PCP, HMOC may use prudent business judgment by making limited specialist, or an HMOC customer service representative if exceptions to the terms of this plan. When the cost of equiva- you want to know whether or not a particular service will lent services from different providers or suppliers varies require HMOC's prior authorization. Services requiring prior authorization are subject to review and change by significantly,HMOC may take these variations into considera- HMOC. tion in determining covered services. Such decisions will be made only after establishing the cost effectiveness of a medically necessary service and with the member's agree- Your BlueCares for You Program ment. Any such decisions will not, however, prevent HMOC Maintaining quality health requires a 24-hours-a-day pro- from administering this plan in strict accordance with its terms active approach to life. As a BlueAdvantage member, you in other situations. HMOC may discontinue making a limited can take part in BlueCares for You — a program of health exception to the plan when it determines that the service is no management services designed to reduce health risks, and longer cost effective. provide educational services. Advance Benefit Information The health management programs are designed to manage If a member wants to know whether a service will be the member's use of health care services by informing, covered before receiving that service or filing a claim for it, educating and supporting patients during every step in the HMOC may require a written request. HMOC may require a health care decision-making process and in the prevention of illness and injury. One such program is BlueCares for written statement from the provider identifying the circum- Babies, a preconception and prenatal health education stances of the case and the specific services that will be program designed to help member's have a healthy provided. pregnancy. BlueCares for Babies can be reached at (303) 764-7066 or(877)CAL-BLUE(877-225-2583). Medical Management Medical management activities include utilization management, case management and disease management. These activities ensure that members and providers are guided through the appropriate utilization of medical services, promoting timely interventions and alternatives as health services are provided by maximizing the benefits available under the member's health plan. The interventions utilized will ensure that our members and providers achieve the highest quality outcomes possible. This is accomplished by processes, which link health care providers, and members in collaborative effort to achieve medically appropriate quality care in all delivery settings. Special emphasis is placed on individual needs such as age, progress of treatment and psychosocial situations as well as facilitating access to care that is appropriate in setting and intensity throughout the episode of care. Personal Benefits Management Personal benefits management is an individualized case management program that, as early as possible, identifies patients who may require long-term hospitalization, have 97000 (Rev. 5-01) 4 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO 3: Covered Services This section describes the covered services and the coverage Urgent/After-Hours Care,"later in this section,for details on options available to you.Topics are arranged in alphabetical order. obtaining emergency care. To be considered covered services,services must be medically necessary or covered as appropriate preventive, routine, or Outside of the HMOC service area: Ambulance trans- family planning services and performed,prescribed,directed, portation is covered only in an emergency situation. Sec or authorized by the member's PCP(exceptions are described "Emergency and Urgent/After-Hours Care," later in this under"Maternity and Newborn Care"and "Preventive, Routine, section, for details on obtaining emergency care. and Family Planning Services"). Services performed by a nonpar- ticipating provider will be covered only in an emergency as Air ambulance: Ground ambulance is usually the approved described in this section under "Emergency and Urgent/After- method of transportation. Air ambulance transportation must Hours Care,"or when approved in advance by HMOC. meet the definition of"ambulance,"and is covered only when terrain, distance, or the member's physical condition requires All services listed in this section are subject to Section 4: the use of air ambulance services, or for high-risk maternity General Exclusions, which explains the services, situations, and newborn transport to tertiary care facilities. and related expenses that are not covered. HMOC will determine, on a case-by-case basis, when trans- Benefit Period portation by air ambulance is covered. If HMOC determines Coverage for some services is limited to a specific dollar that ground ambulance services could have been used, the amount or number of days or visits allowed during a eaten- amount considered for coverage will be limited to the cost of dar year benefit period: January 1 through December 31 of ground ambulance services. the same year. The initial benefit period is from a member's effective date of coverage through December 31 of the same Limitations and Exclusions year. (A member's initial benefit period may be less than The following services are not covered services: 12 months.) For exceptions to this definition, see "Major Organ Transplants"and"Hospice Care"in this Section 3. • commercial transport, private aviation, or air taxi ser- vices Maximum Benefits There is no lifetime maximum benefit under this plan. Certain • transportation services that are not specifically listed as covered services described in this section have maximum covered, such as private automobile, public transporta- benefit limits per admission, per calendar year, or during a tion,or wheelchair ambulance lifetime. • ambulance services required only because other transpor- Ambulance Services tation was not available or for the patient's convenience Definitions Chemical Dependency Treatments Ambulance — a specially designed and equipped vehicle used only for transporting the sick and injured. It must have Definitions customary safety and lifesaving equipment such as first-aid Chemical dependency includes both alcoholism and supplies and oxygen equipment. The vehicle must be substance abuse. operated by trained personnel and licensed as an ambulance. Alcoholism and substance abuse conditions defined by Benefits patterns of usage that continue despite occupational, social, Within the HMOC service area:When the member cannot be marital, or physical problems that are related to abnormal use of alcohol or other substances. These conditions may safely transported by any other means in a nonemergency situation, medically necessary ambulance transportation by a also be defined by significant risk of severe withdrawal participating ambulance service provider to a participating symptoms if the use of alcohol or other substance is hospital with appropriate facilities, or from one participating discontinued. hospital to another,may be covered. Detoxification — treatment for withdrawal from the In an emergency situation, the plan covers participating and physiological effects of alcohol or drugs. nonparticipating ambulance services. See "Emergency and 97000(Rev. 5-01) 5 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Inpatient care—care provided by a physician, hospital, or treatment is considered to be inpatient care,and is subject to the alcoholism treatment center for services provided while a same copayments as inpatient care. member is confined as an inpatient in a hospital or alcohol/substance abuse treatment center. Aftercare — a structured program of reinforcement following the initial treatment period. This is an outpatient program and is Outpatient care care provided by a physician, hospital, an integral part of the total episode of care. Aftercare programs alcoholism treatment center, or other provider in the vary and may last up to six months.The cost may be included in provider's office or in a facility when the member is not the total billed charge for the treatment program or billed confined as an inpatient. separately. If billed separately, the applicable outpatient copayment will apply. Benefits Medical Detoxification: Contact the HMOC behavioral Benefits health administrator for preauthorization and selection of a All chemical dependency services must be prior authorized provider before care is received. Call an HMOC Customer by the member's PCP, HMOC, and HMOC's behavioral Service representative for the phone number of the health administrator. If the member does not complete the administrator. entire treatment program, the member will be responsible for paying billed charges for all services related to the This plan will cover services only for medically necessary chemical dependency episode, regardless of when the inpatient room expenses and ancillary services related to the member receives services. See your Colorado Health Plan medical detoxification(usually limited to three to five days) Description Form for copayment information. from the effects of alcoholism or substance abuse, and received at a participating facility (see definitions under Inpatient care: Inpatient care for each member is limited to a "Hospital/Other Facility Services"). total of 45 full inpatient days or 90 partial inpatient days per admission for room expenses and ancillary services. The 45 Limitations and Exclusions full inpatient or 90 partial inpatient days will be reduced by The following services are not covered services: any full or partial days used for inpatient mental illness. Physician visits received during a covered admission are also • services provided or billed by a school, halfway house, covered. or residential treatment center, or members of their staffs One inpatient day is defined as admission to a facility for a minimum of 24 hours of treatment. Day treatment is covered • the cost of any damages to a treatment facility caused only when the member receives care through a day treatment by the member program.Two day treatments equal one full inpatient day.One- day treatment is usually no less than three and no more than 12 • long-term care (when the member requires long-term hours of therapy per day. care or other therapeutic resources, HMOC will refer the member to the appropriate community resource, but Family counseling related to the member's inpatient chemical will not be responsible for the cost thereof) dependency treatment is available to the family of any member, when directed by the provider(no additional copayments apply). • treatment of chronic alcoholism, drug abuse, or other chronic substance abuse, including rehabilitation (for Outpatient care: Outpatient care, including chemical possible benefits, see "Optional Chemical Dependency dependency testing and monitoring, is subject to a maximum of Rehabilitation,"below) 20 visits per calendar year. See your Colorado Health Plan Description Form for copayment and payment limit information. OPTIONAL BENEFIT Optional Chemical Dependency Rehabilitation — Check your Limitations and Exclusions Colorado Health Plan Description Form to determine if The following inpatient and outpatient services are not covered purchased services: Optional Chemical Dependency Rehabilitation Definitions • outpatient diagnostic services, except testing and moni- Day treatment—care provided after release as an inpatient or toring (for covered diagnostic services, see "Diagnostic as an altemative to inpatient care.Care consists of group and/or Services"in this Section 3) individual therapy, usually no less than three and no more than twelve hours per day, during which meals are provided. Day 97000(Rev. 5-01) 6 Customer Service(600)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO • services related to medical detoxification (those services are When necessary radiology services (e.g., X-rays) for covered under"Medical Detoxification,"above) chiropractic care are not done in the chiropractor's office, the member's PCP must authorize the services. All • discharge day expenses radiology services for chiropractic care must be performed at an HMOC-participating radiology facility. • court-ordered treatment that would otherwise not be covered Members may self-refer for chiropractic services to HMOC- participating providers; a referral from the member's PCP is • services provided or billed by a school, halfway house, or not required. However, all chiropractic services must be residential treatment center,or members of their staffs authorized by HMOC or its designee before the member receives such services. Chiropractic services received • the cost of any damages to a treatment facility caused without prior authorization are not covered under the by the member BlueAdvantage HMO Plan. • long-term care associated with chemical dependency Obtaining Prior Authorization: To obtain prior authori- (when the member requires long-term care or other zation, you must call the HMOC health services department therapeutic resources, HMOC will refer the member to (I-800-526-4662 or 303-831-4115, Monday through Friday, the appropriate community resource, but will not be 8 A.M. to 4:30 P.M., Mountain Time) before receiving the responsible for the cost thereof) service. The health services representative will explain prior authorization requirements and ask for information about • inpatient and outpatient charges associated with any your provider and the proposed services. If the provider has episode of substance abuse for which the member did not already requested authorization for the proposed not complete the prescribed continuum of care services, a representative will call his/her office for more information. The member and his/her provider will be OPTIONAL BENEFIT notified by mail of authorization decisions. The member's treatment may be reviewed at periodic intervals to ensure Optional Chiropractic Services Check your Colorado services continue to be covered. Health Plan Description Form to determine ifpurchased Optional Chiropractic Services Limitations and Exclusions Definitions The following chiropractic services are not covered Chiropractic services — Any service or supply admin- services: istered by a licensed doctor of chiropractic medicine(D.C.) ▪ Services not directly related to the treatment of a specific neuromusculoskeletal system diagnosis Benefits • Covered services or supplies administered by a participating Surgical services provided by a chiropractor chiropractor who acts within the scope of licensure and • according to the standards of chiropractic medicine in Services provided by a nonparticipating chiropractor Colorado are a benefit on an outpatient basis if necessary for • Services that have not received prior authorization from the treatment of an illness or accidental injury. Covered services include limited office visits with manual HMOC manipulation of the spine, X-ray of the spine, and physical therapy modalities and procedures. Dental-Related Services Coverage is limited to a maximum of 20 visits per calendar Definitions year. (If a member visits a chiropractor more than once in a Accidental injury — a bodily condition that is not the single day, each such visit will be counted as one visit.) result of illness but is caused solely by external, traumatic, Services must be for the treatment of a neuromusculoskeletal and unforeseen means. Accidental injury does not include condition and must begin within six months from the date on disease or infection. Dental injury caused by chewing, which the condition first occurred. Coverage will only be biting, or malocclusion is not considered an accidental considered in instances where improvement would not injury. normally be expected to occur without intervention by a chiropractor. Dental services—services performed for treatment of con- ditions related to the teeth or structures supporting the teeth. 97000(Rev. 5-01) 7 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Sound natural teeth — teeth that are whole, without • Laboratory and pathology services — testing proce- impairment, without periodontal disease or other conditions, dures required for the diagnosis or treatment of a and not in need of treatment for any reason other than the condition. Generally, these services involve the analysis accidental injury. of a specimen of tissue or other material removed from the body. IN For services related to oral surgery, see "Surgical Services: X-ray and radiology services — services including the Oral Sure in this section. use of radiology, nuclear medicine, and ultrasound Surgery" equipment to obtain a visual image of internal body organs For services related to the treatment of the temporo- and structures,and the interpretation of these images. mandibular joint,see "TMJ Services"in this section. For coverage information on invasive diagnostic surgical Benefits procedures such as biopsies and endoscopies, see "Surgical Services"in this section. Dental Accidents: Coverage is limited to the stabilization and prompt repair as a result of an accidental injury to sound For services related to the treatment of an accidental injury natural teeth or related body tissue. Only dental services or other emergency, also see "Emergency and Urgent/After- related to such injury received within 72 hours of the Hours Care"in this section. accident will be covered. Dental services and restoration received after 72 hours are not covered. This certificate Coverage for diagnostic services received during a covered provides coverage for health conditions and should not be inpatient admission is described under "Hospital/Other considered as your primary dental plan. Facility Services"in this section. Hospitalization for Dental Services: Coverage is available For allergy and infertility testing benefits, see "Office, for inpatient hospital room expenses and ancillary services Outpatient, and Home Care"in this section. associated with dental services only if the patient has a non- dental, physical condition, such as hemophilia or heart disease, For routine Pap tests, routine prostate exams, routine that makes hospitalization medically necessary. This plan does physicals, or preventive care, see "Preventive, Routine, and not cover any costs associated with the dental service itself(e.g., Family Planning Services"in this section. anesthesia, operating and recovery room charges, surgeon and anesthesiologist fees). Dental Anesthesia: Anesthesia services for dental care, and Benefits associated hospital or facility charges for anesthesia services Coverage is available for diagnostic services, including pre- are covered for children who are disabled, very young, admission testing, received in the emergency room or medically compromised, or because local anesthesia is inef- outpatient department of a hospital or other facility, an fective. This includes children who need anesthesia to independent lab or x-ray clinic,or in a provider's office. perform dental care because they are extremely uncoopera- tive,unmanageable,anxious,uncommunicative,or who have To be a covered service, tests must be required to detect or sustained extensive orificial and dental trauma. diagnose a known or suspected illness, monitor a covered preg- nancy, or diagnose an accidental injury (with the exception of Diagnostic Services screening mammograms and prostate-specific antigen tests). All diagnostic tests must be ordered by the member's PCP or Definitions referral provider in order to be considered a covered service. Diagnostic services—procedures or services ordered by a provider to determine a definite condition or disease, Covered services include: including: • radiology,ultrasound,and nuclear medicine tests • Diagnostic medical procedures — procedures that require the use of technical equipment for evaluation of • laboratory and pathology tests body systems; examples: electrocardiograms (EKGs) and electroencephalograms(EEGs). 97000(Rev. 5-01) 8 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO • EKG, EEG, and other electronic diagnostic medical but intends to return within a reasonable period of time (no procedures longer than 90 days). • audiometric (hearing) and vision tests required for the Benefits diagnosis and/or treatment of an accidental injury or an Emergency Care: Emergency care, like all other care, illness needs to be coordinated by the member's PCP whenever possible, even if the member is outside the HMOC service • mammography screenings based on medically accepted area. The PCP may direct a member to receive necessary standards as follows: at least one baseline for women medical services at an emergency room or urgent care between ages 35-39 and annually for women 40 and over center. (or younger if risk factors are present for breast cancer) If emergency care results in an immediate admission to the • prostate-specific antigen (PSA) blood test, based on the hospital, the member will be responsible only for the following guidelines: inpatient hospital copayment. (There will be no separate • at least one screening per year for men age 50 and copayment requirement for emergency room or ambulance older services if the member is directly admitted as an inpatient.) • at least one screening per year for men age 40-50, if risk factors for prostate cancer are present Emergency care within HMOC's service area: ■ If cardiopulmonary resuscitation (CPR)is necessary Diagnostic services related to a noncovered service are not or if there is an immediate threat to life or limb,call covered. 911. Emergency and Urgent/After-Hours • tf, because of the severity of the medical problem, Care you are unable to reach your personal care network hospital, go to the nearest medical facility. Unless Except as set forth below, HMOC will not cover care your condition makes it impossible to do so, you provided outside the HMOC service area if the need for the should notify your PCP within 48 hours of receiving care could have been foreseen by the member, or if the the care. Use of an emergency center for nonemer- member could have traveled to the PCP's office without gency services is not covered. medical harm. • If you do not call 911, call your PCP's office for Definitions instructions. Emergency care means the sudden, and at the time, unexpected onset of a health condition that requires immediate Emergency care outside HMOC's service area: medical attention, where failure to provide medical attention • If cardiopulmonary resuscitation (CPR)is necessary would result in serious impairment to bodily functions or serious or if there is an immediate threat to life or limb,call dysfunction of a bodily organ or part,or would place the persons 911. health in serious jeopardy. HMOC covers emergency services necessary to screen and stabilize a member without prior ■ If you do not call 911, go to the nearest medical authorization from HMOC if a prudent lay person having average facility.Unless your condition makes it impossible to knowledge of health services and medicine and acting reasonably do so, you should notify your PCP within 48 hours would have believed that an emergency medical condition or life of receiving the care to arrange follow-up services. or limb threatening emergency existed. Use of an emergency center for nonemergency services is not covered. Follow up services outside Urgent care — situations that are not life threatening but the member's service area are not covered if the require prompt medical attention to prevent a serious deter- member could have returned to his/her service area ioration in a member's health(e.g.,high fever,cuts requiring to receive care without medically harmful results. stitches). After-hours care — office services requested after a provider's normal or published office hours or on weekends and holidays. Temporarily absent—circumstances such as a vacation or trip in which the member has left the HMOC service area 97000(Rev. 5-01) 9 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO When you receive the itemized bill from the hospital, send it services, physical therapy, occupational therapy, and speech to HMOC. HMOC requires proof of payment to reimburse therapy. you directly. Otherwise,HMOC will reimburse the provider. You will be responsible for the emergency care copayment Skilled nursing care — care that can be provided only by only. someone with at least the qualifications of a licensed practical nurse(L.P.N.)or registered nurse(R.N.). Urgent/After-Hours Care Within HMOC's Service Area: Urgent and after-hours care received within the HMOC service area is covered when it is provided by the member's For coverage for medical equipment or supplies not PCP or by a network provider or network urgent care center. covered as home health care services, see "Supplies, Equipment, and Appliances"in this section. Urgent/After-Hours Care Outside HMOC's Service Area: • When a member is temporarily absent from the HMOC service area (90 days or less), urgent/after-hours medi- Benefits cal care may be covered in several different ways: Home health services are covered if the services are • In an emergency go the nearest medical facility provided under the direction of the patient's PCP and • If you are not having an emergency, call your PCP nursing management is through a participating home health for a referral and/or prior authorization for urgent/ agency. Registered nurses must coordinate the services on after hours care behalf of the home health agency and the patient's PCP. • After contacting your PCP, call the BlueCard Program to find the names and addresses of nearby The following home health care services are covered when participating doctors and hospitals by calling 1- provided during a covered visit in the patient's home: 800-810-BLUE (1-800-810-2583). You can also find names and addresses of nearby doctors and ■ skilled nursing care provided on an intermittent basis by hospitals using the BlueCard Doctor and Hospital a registered nurse or licensed practical nurse Finder Web site at(www.BCBS.com) • The BlueCard Program will tell you if there is a • physical, occupational, and respiratory (inhalation) participating provider in your area. When you therapy, by licensed or certified physical, occupational, arrive at the participating doctor's office or hos- and respiratory therapists, and speech therapy provided pital,simply present your HMO Colorado ID card by an American Speech and Hearing Association • If there is not a BlueCard participating provider certified therapist nearby, call your PCP for a referral for service. If you do not receive a referral from your PCP before • administration of oxygen the care is given, you are responsible for the entire cost of the service. ■ intravenous medications and other prescription drugs ordinarily not available through a retail pharmacy. Limitations and Exclusions Some medications and prescription drugs may require The following services are not covered services: prior authorization by HMOC (if drugs are not provided by the home health care agency, see "Prescription • follow-up care as a result of an emergency, if the Drugs"in this section) member could have returned to his/her service area to receive care without medically harmful results • physician home visits • services received outside the member's service area if Limitations and Exclusions the member could have foreseen the need for this care The following services are not covered services: before leaving his/her service area • custodial care (see "Custodial Care" in Section 4: Home Health Care General Exclusions)• Definitions • care that is provided by a nurse who ordinarily resides Home health services — the following services provided in the patient's home or is a member of the patient's under a plan of care by a licensed home health agency to a immediate family member in his/her place of residence: skilled nursing 97000 (Rev. 5-01) 10 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO • food or meal services other than dietary counseling and hospice to determine the appropriateness of continuing hospice care. • care related to noncovered services or surgical procedures Coverage for hospice care is available for the following services during a covered home visit: • personal comfort or convenience items or services, including homemaker services • physician visits by hospice physicians Hospice Care • skilled nursing services of a registered nurse or a licensed practical nurse Definitions Hospice care an alternative way of caring for terminally ill • medical supplies and equipment used during a covered individuals in the home or institutional setting, which stresses visit (if supplies are not provided by the hospice palliative care as opposed to curative or restorative care. Hospice agency, see "Supplies, Equipment, and Appliances" in care focuses on the patient/family as the unit of care and addresses this section) physical, social, psychological, and spiritual needs of the patient. Supportive services are offered to the family before the death of • drugs and medications for the terminally ill patient (if the patient. drugs are not provided by the hospice agency, see "Prescription Drugs" in this section) Benefit period — a period of time during which hospice services are covered. A benefit period is defined as beginning • respite care for a period not to exceed five continuous on the date the PCP or attending physician certifies that the days for every 60 days of hospice care no more than member is terminally ill and has a life expectancy of six two respite care stays are available during a hospice months or less,and ending six months after it began or on the benefit period(respite care provides a brief break from death of the patient,if sooner. total caregiving by the family) Palliative care — care that controls pain and relieves • services of a licensed therapist for physical, occupa- symptoms but does not cure. tional,respiratory,and speech therapy Skilled nursing care — care that consists of services that ■ medical social services provided by a qualified individual can be provided only by someone with at least the with a degree in social work, psychology, gr p y gy, or counseling, qualifications of a licensed practical nurse (L.P.N.) or or the documented equivalent in a combination of registered nurse(RN.). education,training,and experience(such services must be provided at the recommendation of a physician for Terminally ill patient a patient with a life expectancy of purposes of assisting the member or family in dealing six months or less as certified in writing by the attending with a specified medical condition) and bereavement physician. support services. • services of a home health aide under the supervision of For coverage of medical equipment not covered as hospice a registered nurse and in conjunction with skilled care, see "Supplies, Equipment, and Appliances" in this nursing care section. • nutritional guidance and support, such as intravenous feeding and hyperalimentation Benefits Benefits are also available for inpatient hospice accommo- Inpatient and home hospice services for a terminally ill dations and services. member during a hospice benefit period are covered when provided by a hospice program prior authorized by HMOC. Limitations and Exclusions The following services are not covered services: If the patient requires an extension of the hospice benefit period, the hospice agency must provide a new treatment • food services and meals,other than dietary counseling plan and the attending physician must recertify the patient's condition to HMOC. HMOC will work with your Physician 97000(Rev. 5-01) 11 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO • services or supplies for personal comfort or convenience, charge of a specific case) or the PCP. The consulting including homemaker and housekeeping services, except physician often has specialized skills that are helpful in in crisis periods or in association with respite care diagnosing or treating the patient's illness or injury. • private duty nursing General condition— a disease, illness, or other condition not related to nervous or mental illness, alcoholism, or • pastoral and spiritual counseling substance abuse. • supportive services provided to the family of a Medical care nonsurgical health care services provided terminally ill patient when the patient is not a member for the prevention, diagnosis, and treatment of illness, of this plan injury,and other general conditions. Hospital/Other Facility Services Outpatient services Charges for services received in the outpatient department of a hospital,emergency room, birthing Definitions center, ambulatory surgical facility, freestanding dialysis Room expenses expenses that include the cost of the facility,or other covered outpatient treatment facility. patient's room, general nursing services, and meal services for the patient. Special care unit a designated unit that has concentrated For coverage of services related to alcoholism, substance facilities, equipment, and supportive services to provide an abuse, or mental illness, see "Chemical Dependency intensive level of care for critically ill patients. Examples of Treatments"or "Mental Illness Treatments"in this section. special care units are intensive care unit (ICU), cardiac care unit(CCU), subintensive care unit,and isolation room. If services are related to a dental procedure, also see "Dental-Related Services"for additional information and Ancillary services services and supplies (in addition to limitations. room expenses) that a facility regularly makes available for the treatment of a patient's condition. Such services include, For emergency services, also see "Emergency and but are not limited to: Urgent/After-Hours Care"in this section. • use of operating room, recovery room, emergency For inpatient treatments related to hospice care, see room,treatment rooms,and related equipment "Hospice Care"in this section. • intensive and coronary care units This section also applies to maternity-related services received inpatient, outpatient, or in a freestanding facility • drugs and medicines such as a birthing center. See "Maternity and Newborn Care"in this section for more information. • medical supplies (including dressings and supplies, sterile trays,casts,and splints used in lieu of a cast) For services related to occupational, physical, or speech therapy, see "Physical Rehabilitation, Inpatient and Outpa- tient"in this section. • durable medical equipment owned by the facility and used during a covered admission See other subheadings in this section for limitations and exclusions that apply to the specific type of service required, • diagnostic and therapeutic services such as "Surgical Services. • blood processing and transportation costs, blood For coverage of supplies and equipment not specifically handling charges,and administration covered under "Hospital/Other Facility Services," see "Supplies, Equipment, and Appliances,"in this section. Skilled nursing facility — a state-licensed facility provid- ing inpatient nursing care at the level that requires a registered nurse to deliver or supervise the delivery of care for a continuous 24-hour period. Benefits Inpatient Medical/Surgical Services: When a member Consultation — a service provided by another physician at receives acute inpatient surgical or medical care in a hospital the request of the attending physician (the physician in 97000 (Rev. 5-01) 12 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO for a general condition, covered services received during the (for example, sec "Diagnostic Services" in this section) or admission include: on special circumstances(see "Emergency and Urgent/After Hours Care"in this section). • nonprivate or special care unit room expenses Limitations and Exclusions • other ancillary services provided by the facility The following services arc not covered services: Nonparticipating facility services are covered for emergency • private room expenses, unless the patient's medical care only or when prior authorized by HMOC. See condition requires isolation to protect him/herself or "Emergency and Urgent/After-Hours Care"in this Section 3. other patients from exposure to dangerous bacteria or diseases (conditions that require isolation include, but Outpatient services: charges for services received in the are not limited to, severe bums and conditions that outpatient department of a hospital, emergency room, birthing require isolation according to public health laws) center,ambulatory surgical facility,freestanding dialysis facility, or other covered outpatient treatment facility. • admissions related to noncovered services or proce- dures(see"Dental-Related Services,"in this section, for Coverage for outpatient ancillary services and related physician exception) or other professional provider services for the treatment of illness,accidental injury,or a covered pregnancy depends on the • discharge day expenses type of service received(for example,see"Diagnostic Services" in this section)or on special circumstances(see"Emergency and • admissions primarily for physical rehabilitation (see Urgent/After-Hours Care"in this section). "Physical Rehabilitation, Inpatient and Outpatient" for covered services) Skilled Nursing Facility Admissions: When prior autho- rized by HMOC, coverage is available to each member for • extended care facility admissions or admissions to up to 30 days per calendar year in a participating skilled similar institutions nursing facility. Covered services include semiprivate room expenses and ancillary services. • consultations or visits related to any noncovered ser- vices Physician Services:With the exception of dental-related services (see "Dental-Related Services" in this section), the following • inpatient physician services received on a day for which services when required for a general condition and received on a facility charges were denied covered inpatient hospital day are also considered covered services(and are not subject to an additional copayment): • telephone consultations • visits that are not related to hospice care (see "Hospice Kidney Dialysis Care" in this section for benefits) and that are for a condition requiring only medical care Definitions Dialysis — the treatment of an acute or chronic kidney • consultations (including second opinions) and, if sur- ailment during which impurities are removed from the body gery is performed, inpatient visits by a provider who is with dialysis equipment. not the surgeon and who provides medical care not related to the surgery (for benefits for the surgeon's services,see"Surgical Services"in this section) When received during a covered admission and billed as part of the facility service, dialysis will be paid in the same • medical care requiring two or more physicians at the manner as the room expenses and other ancillary services same time because of multiple illnesses (see "Hospital/Other Facility Services"in this section). • medical care for an eligible newborn (also see "Maternity and Newborn Care"in this section) Outpatient services: Coverage for outpatient ancillary ser- vices and a related physician or other professional provider services for the treatment of illness, accidental injury, or a covered pregnancy depends on the type of service received 97000(Rev. 5-01) 13 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Benefits All of the following therapeutic services are covered when Please refer to Section 7: Enrollment and Termination lnfor- performed by a participating dialysis provider or, when mation under "Adding a Newborn or Adopted Child"for preauthorized by HMOC, in the patient's home: details on newborn coverage. • hemodialysis For coverage of infertility treatment, see "Office, Out- patient, and Home Care"in this section. • peritoneal dialysis See other subheadings in this section for limitations that apply to • the cost of equipment rentals and supplies for use in services received during a pregnancy or by a newborn, such as home dialysis "Diagnostic Services;"or"Hospital/Other Facility Services." Maternity and Newborn Care For services related to cleft palate treatment jOr a newborn, Definitionssee "Surgical Services"in this section. Maternity services — services and supplies required by a member for the diagnosis and care of a pregnancy (excluding over the counter products), including Benefits complications of pregnancy, and for routine delivery Maternity Services: Once a member's pregnancy is services(including scheduled C-sections). confirmed by her PCP or participating OB/GYN provider, the member may choose either her PCP or a participating Routine newborn care—includes: OB/GYN provider to provide maternity care. A member may also obtain care from a certified nurse. A referral is not • routine hospital nursery services for a newborn required if the member chooses an HMOC participating OB/GYN provider to provide maternity services. • routine physician care of a newborn in the hospital after delivery Under Family or Parent/Child coverage, an unmarried, dependent daughter also has coverage for maternity services. • pediatrician standby care at a cesarean section A newborn child of an unmarried dependent son or daughter does not qualify as a dependent under this plan. • services related to circumcision of a male newborn Coverage for maternity services and complications of Complications of pregnancy—includes: pregnancy include: • Conditions(when the pregnancy is not terminated)whose • hospital charges for semiprivate room expenses and diagnoses are distinct from pregnancy but are adversely ancillary services, including the use of labor, delivery, affected by pregnancy or are caused by pregnancy, such or recovery rooms as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical condi- ■ prenatal medical care tions of comparable severity, but shall not include false labor, occasional spotting, physician-prescribed rest • maternity-related diagnostic tests during the period of pregnancy, morning sickness, hyper- emesis gravidarum, preeclampsia, and similar conditions • routine or complicated delivery (including postnatal associated with the management of a difficult pregnancy medical care), including cesarean section not constituting a nosologically distinct complication of pregnancy ■ necessary anesthesia services by a provider qualified to perform such services • Non-elective cesarean section, ectopic pregnancy, which is terminated, and spontaneous termination of ■ services of a physician who actively assists the operating pregnancy, which occurs during a period of gestation in surgeon in performing a covered delivery or other which a viable birth is not possible maternity-related procedure when the procedure requires an assistant 97000(Rev. 5-01) 14 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO • spontaneous termination of pregnancy prior to full term Limitations and Exclusions The following services are not covered services: • elective or therapeutic abortions if requested prior to the 12th week of gestation or up to viability after 12 weeks • care for deliveries outside of the service area within five if medically necessary and performed prior to the end of weeks of the anticipated delivery date the first trimester. Elective termination in the absence of other complicating medical problems must be per- • adoption or surrogate expenses formed in an outpatient setting when authorized by the member's PCP or as a self referral to a participating Mental Illness Treatments OB/GYN physician. Definitions If maternity coverage changes during a pregnancy, the Mental illness—a clinically significant behavioral or psycho- member receives the coverage in effect on the day the ser- logical syndrome or pattern that is associated with distress or vice is received. Maternity services are covered as any other disability, or with a significantly increased risk of suffering medical/surgical or general condition. For example, under death, pain, disability, or an important loss of freedom, and for this plan, the member is responsible for a hospital copay- which improvement can be expected with treatment. HMOC ment for facility services and for office visit copayments for defines mental illness based on the Diagnostic and Statistical prenatal and postnatal maternity care. Manual of Mental Disorders (Fourth edition DSM III) published by the American Psychiatric Association. We may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the Biologically based mental conditions are considered medical mother or newborn child to less than 48 hours following a conditions and not mental illness. Biologically based mental vaginal delivery, or less than 96 hours following a cesarean illness means schizophrenia, schizoaffective disorder, bipo- section. The mother's or newborn's attending provider, after lar affective disorder, major depressive disorder, specific consulting with the mother, may discharge the mother or her obsessive-compulsive disorder and panic disorder. newborn earlier than 48 hours(or 96 hours if applicable). In any case, HMOC may not, under Federal law require the Mental illness does not include certain conditions,such as: provider obtain authorization from us for prescribing a length of stay not in excess of 48 hours(or 96 hours). ■ alcohol abuse Note: The BlueCares for Babies preconception and prenatal ■ chemical dependency health education program is designed to help members have a healthy pregnancy. For details, see "Your BlueCares for ■ sexual deviation You Program" in Section 2: How the Plan Works or call an HMOC customer service representative. Inpatient care—care provided by a physician, hospital, or treatment facility for services provided while a member is Newborn Care: This plan provides coverage for a dependent confined as an inpatient in a hospital or other treatment child's initial routine newborn care. Copayment amounts are facility. Partial hospitalization is also considered to be inpa- based on the type of service received. However, no additional tient care. Partial hospitalization is no less than three and no hospital copayment will be required if the newborn is more than twelve hours of continuous psychiatric care in a discharged on the same day as the mother. The employee must hospital. Two partial hospitalization days equal one full enroll his/her newborn child for coverage within 31 days of inpatient day. the child's birth. Outpatient care— care provided by a physician, hospital, Nonroutine Newborn Care: An eligible newborn is also or other provider in the provider's office, the outpatient covered for nonroutine medical or surgical services. Copay- department of a hospital, other facility, or the patient's ment amounts will be based on the type of service received. home. For example, if surgery is required, see "Surgical Services" in this section for additional information. Also, an addi- tional hospital copayment will apply to the newborn's covered facility charges if the newborn remains in the For the treatment of alcoholism and/or substance abuse, see "Chemical Dependency Treatments"in this section. hospital longer than his/her mother. 97000(Rev. 5-01) 15 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Benefits ■ the cost of any damages to a treatment facility caused Inpatient Mental Illness Treatments: Contact the HMOC by the member behavioral health administrator for preauthorization and selection of a provider before care is received. Call an HMOC Office, Outpatient, and Home Care Customer Service representative for the phone number of the administrator. Definitions Eye care services means those health care services Care provided by a physician, hospital, or treatment facility for related to the examination,diagnosis,treatment and manage- services provided while a member is confined as an inpatient in ment of conditions and diseases of the eye and related a hospital or other treatment facility. Partial hospitalization is structures. This excludes health care services rendered in also considered to be inpatient care. Partial hospitalization is no conjunction with a routine vision exam or the filling of less than three and no more than twelve hours of continuous prescriptions for corrective eyewear. psychiatric care in a hospital. Two partial hospitalization days equal one full inpatient day. General condition — a disease, illness, or other condition not related to nervous or mental illness, alcoholism, or Benefits for HMOC-authorized inpatient care for non-biologically substance abuse. based conditions are limited for each member to a total of 45 full days or 90 partial days each calendar year for room expenses Medical care — nonsurgical services provided for the and ancillary services received in a facility(see definitions under prevention, diagnosis, and treatment of illness, injury, and "Hospital/Other Facility Services") and include physician visits other general conditions. received during a covered admission day. After-hours care — office services requested after normal If a member is admitted for an inpatient medical/surgical or published office hours or services requested on weekends admission and subsequently needs to be transferred to an and holidays. inpatient psychiatric unit, or vice versa, each portion of the inpatient confinement will be considered a separate admission, Infertility the inability to produce children after one year subject to its own copayment level(see your group's Colorado of sexual activity not protected by contraception; causes of Health Plan Description Form). infertility can be male-or female-specific. Outpatient Mental Illness Treatments: Coverage is limited per calendar year to 20 visits for the outpatient care,evaluation, See other subheadings in this section for limitations that diagnosis, and/or treatment of non-biologically based mental apply to special circumstances or to other services received illness. Services rendered by psychiatrists, psychologists, during a provider visit, such as "Emergency and Urgent/ licensed family therapists,and social workers are included in the After-Hours Care," "Diagnostic Services," or "Supplies, 20 visits. Equipment, and Appliances." Limitations and Exclusions For visits related to home health or hospice care, see The following services are not covered services: "Home Health Care"or "Hospice Care"in this section. • services provided or billed by a school, halfway house, or For coverage of inpatient physician visits, see "Hospital/ residential treatment center or members of their staff Other Facility Services"in this section. • court-or police-ordered treatment that would not otherwise For the treatment of alcoholism, substance abuse, or mental be covered illness, see "Chemical Dependency Treatments"or "Mental Illness Treatments"in this section. • biofeedback For routine physicals, immunizations, other preventive ser- • psychoanalysis or psychotherapy that a member may use as vices, and family planning services, see "Preventive, credit toward earning a degree or furthering his/her Routine, and Family Planning Services"in this section. education For services related to a dental accident, oral surgery, or • hypnotherapy TMJ disorders, see "Dental-Related Services," "Surgical Services: Oral Surgery,"or "TMJ Services"in this section. • marital counseling 97000(Rev. 5-01) 16 Customer Service(800) 334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Benefits surgical sterilization is described under 'Preventive, Coverage is available for medical care for general condi- Routine,and Family Planning Services") tions if necessary for the treatment of an illness, disease, or • replacement of deficient naturally occurring hormones, injury. Covered services include: if there is documented evidence of a deficiency of the hormone being replaced (hormonal manipulation and • office, urgent care center, home, and hospital emer- excess hormones to increase production of mature ova gency room visits and examinations—when not related for fertilization are not covered) to hospice care or payable as part of a surgical proce- dure (see "Hospice Care" and "Surgical Services" in Female members are not required to obtain a PCP-referral this section) for the services of a participating OB/GYN provider. Also see "Maternity and Newborn Care" and "Preventive, • consultations and second surgical opinions Routine,and Family Planning Services." • therapeutic injections administered in a provider's Limitations and Exclusions office or in a facility Coverage is not available for any service related to infertility that is not listed as a covered service above, • medically necessary hearing examinations (nonroutine, including,but not limited to: nonscreening) • artificial insemination, test tube fertilization, drugs for • medically necessary eye examinations for eye care ser- induced ovulation, or other artificial methods of vices (nonroutine, nonscreening). Members are not conception required to obtain a PCP referral for services from participating optometrists or ophthalmologists. ■ in-vitro fertilization with husband or other donor sperm and any related services After-Hours Care: To receive office services after hours, call your PCP (or the physician who is on-call for the PCP) • in-vivo fertilization with husband or other donor sperm and request instructions. See "Emergency and Urgent/After- and any related services Hours Care"for details. • Gamete Intrafallopian Transfer(GIFT) or Zygote Intra- Allergy Care: Coverage is available for the following fallopian Transfer(ZIFT)and any related services allergy care services: • cost of donor sperm • direct skin (percutaneous and intradermal) and patch allergy tests and RAST(radioallergosorbent testing) Physical Rehabilitation, Inpatient and • allergy injections administered in a provider's office or Outpatient in a facility Definitions Physical rehabilitation — a broad term used to describe • charges for allergy serum occupational, physical, and speech therapy techniques. Phy- sical rehabilitation does not include chemical dependency Infertility Services:Covered infertility services are rehabilitation. • diagnosis of infertility causes,limited to: Occupational therapy — the use of rehabilitative techni- • one laparoscopy ques to improve a patient's functional ability to live • one hysteroscopy independently. • one hysterosalpingogram • one endometrial biopsy Physical therapy — the use of physical agents to treat • appropriate evaluation of hormonal status disability resulting from disease or injury. Physical agents • a maximum of three semen analyses include heat, cold, electrical currents, ultrasound, ultraviolet radiation,and therapeutic exercise. • treatment of infertility, limited to: • surgical treatment(e.g.,opening an obstructed fallopian Speech therapy — services used for the diagnosis and tube,epididymis,or vas deferens),when the obstruction treatment of speech and language disorders. is not the result of a surgical sterilization (coverage for 97000 (Rev. 5-01) 17 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO For children up to age 5, when prescribed and/or provided For additional limitations and exclusions for hospital/ by a physician for a congenital defect or birth abnormality, facility services, see "Hospital/Other Facility Services" in coverage is limited to 20 treatments each for inpatient and this section. outpatient care for physical therapy, occupational therapy, or speech therapy. Limitations and Exclusions Benefits The following services are not covered services: To be considered covered services,outpatient occupational, phy- sical,and speech therapies must meet the following conditions: ■ cardiac rehabilitation programs • there is a documented condition or delay in recovery • maintenance therapy or care provided after the patient that can be expected to improve with therapy within 60 has reached his/her rehabilitative potential as deter- days of the initial referral (except for children to age 5); mined by HMOC (see "Maintenance Therapy" in and Section 4: General Exclusions) • improvement would not normally be expected to occur • any diagnostic, therapeutic, rehabilitative, or health without intervention. maintenance service provided at or by a health spa or fitness center, even if the service is provided by a All physical rehabilitation treatments must be prior licensed or registered provider authorized by HMOC. Physical rehabilitation required due to reinjury or aggravation of an old injury must be prior • any therapeutic exercise equipment prescribed for home authorized again by HMOC, even if therapy was authorized use (e.g.,treadmill,weights) for the original injury. • speech therapy or diagnostic testing related to the fol- All of the following rehabilitation services are covered when lowing conditions: performed in the outpatient or inpatient department of a hos- • learning disorders, whether or not they accompany pital,freestanding treatment facility or clinic,or a provider's mental retardation office, when prescribed and/or provided by the member's • deafness PCP or a participating physician: • personality, developmental, behavioral, voice, or rhythm disorders when these conditions are not the • occupational therapy performed by a licensed occu- direct result of a medical syndrome or condition as pational therapist diagnosed by the members PCP, neurologist, or other related physician specialist • physical therapy performed by a physician, licensed physi- • stuttering,at any age cal therapist, or other professional provider licensed as a • disorders of cognitive etology physical therapist, including six osteopathic manipulative therapy (OMT) treatments per calendar year when pre- ■ long-term occupational, physical, or speech therapies scribed and/or provided by the member's PCP (therapies are considered long-term if the member's PCP and/or other professional provider does not believe • speech therapy,evaluation, and treatment,performed by significant improvement is possible within a 60-day a licensed and accredited speech/language pathologist period) Coverage is limited to 30 treatment days for inpatient phy- • occupational, physical, or speech therapy for chronic sical rehabilitation (physical, occupational, and/or speech conditions therapy) per illness or injury, except for children to age 5. The services must be received within six months from the • chiropractic services date on which the illness or injury occurred. • chronic pain management Coverage is limited to 30 treatments for outpatient physical rehabilitation (physical, occupational, and/or speech • services for sensory integration disorder therapy) per illness or injury except for children to age 5. The services must be received within six months from the date on which the illness or injury occurred. 97000(Rev. 5-01) 18 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Prescription Drugs dispensed in the same dosage form (tablet, capsule, cream) as the counterpart brand name drug. On average, generic Definitions drugs cost about half as much as the counterpart brand name Brand Name Prescription Drug— the initial version of a drug. Generic prescription drug identified on the formulary medication developed by a pharmaceutical manufacturer, or by HMOC as a prescription drug with a tier 1 copayment as a version marketed under a pharmaceutical manufacturer's listed on the Colorado Health Plan Description Form. own registered trade name or trademark. The original man- ufacturer is granted an exclusive patent to manufacture and Mail Service a prescription drug program which offers a market a new drug for a certain number of years. After the convenient means of obtaining maintenance prescription patent expires, if FDA requirements are met any manu- drugs by mail if the member takes prescription drugs on a facturer can produce the drug and sell under its own brand regular basis. Covered prescription drugs are ordered name, or under the drug's chemical name (Generic). Brand directly from the licensed pharmacy mail service which has name prescription drugs will be designated by HMOC as entered into a reimbursement agreement with us, and sent follows: directly to the members home. • Formulary brand name prescription drug identified on Maintenance Prescription Drug prescription drugs that the formulary by HMOC as a prescription drug with a are used on a continuing basis for the treatment of a chronic tier 2 copayment as listed on the Colorado Health Plan illness, such as heart disease, high blood pressure, arthritis Description Form and/or diabetes. • Non-Formulary brand name prescription drug not Network Pharmacy—means a pharmacy acceptable as a par- identified on the formulary by HMOC with a Tier 3 ticipating pharmacy by HMOC to provide covered drugs to Copayment as listed on the Colorado Health Plan Members under the terms and conditions of this subsection. Description Form Non-Network Pharmacy — a pharmacy which does not Copayment the predetermined fixed-dollar amount participate in this program. which the member must pay for each separate prescription drug order,maintenance prescription drug order or refill of a New FDA Approved Drug Product or Technology—the covered drug. first release of the brand name product or technology upon the initial FDA New Drug Approval. Other applicable FDA Formulary a listing of prescription legend drugs which approval for its biochemical composition and initial includes brand and generic equivalents, insulin, medical sup- availability in the marketplace for the indicated treatment plies and devices which may be periodically amended, which and use. New FDA Approved Drug Product or Technology providers should use in prescribing prescription drugs. Drugs does not include: placed on the formulary are chosen by a Pharmacy & Thera- peutics Committee. When a drug is considered for the formu- • new formulations lary, inclusion of the drug is typically examined relative to similar drugs on the formulary. Entire therapeutic classes are ■ a new dosage form or new formulation of an active periodically reviewed. This review may result in deletion or ingredient already on the market non formulary status of drugs in a particular therapeutic class, in an effort to continually promote the most clinically useful • already marketed drug product but new manufacturer and cost effective agents. Drugs evaluated by the Pharmacy& Therapeutics Committee may not be added to the formulary • a product that duplicates another firm's already mar- due to belief that the drug offers no known clinical or cost keted drug product (same active ingredient, formula- advantage over comparable formulary drugs, or there is cur- tion,or combination) rently insufficient scientific information to determine the drug's appropriate clinical role. • already marketed drug product,but new use Generic Prescription Drug — drugs which have been ■ a new use for a drug product already marketed by the determined by the FDA to be bioequivalent to brand name same or a different firm;or drugs and are not manufactured or marketed under a registered trade name or trademark. A drug whose active ■ newly introduced generic medication (generic medica- ingredients duplicate those of a brand name drug and is its [ions contain the same active ingredient as their bioequivalent, generic drugs must meet the same FDA counterpart brand-named medications) specifications for safety, purity and potency and must be 97000 (Rev. 5-01) 19 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Pharmacy and Therapeutics Committee—a committee of Please ask your provider or network pharmacist to check physicians and pharmacists who review literature and studies with us to verify formulary drugs, any quantity limits, or which address the safety, efficacy, approved indications, appropriate brand or generic drugs recognized under the adverse effects,contraindications,medical outcome,and phar- certificate and prior authorization requirements. macoeconomics. The committee will develop, review and/or approve guidelines related to how and when certain drugs Covered Services include only: and/or therapeutic categories will be approved for coverage. • prescription legend drugs Prescription Legend Drug — a medicinal substance, ■ injectable insulin and syringes used for administration dispensed for outpatient use, which under the Federal Food, of insulin Drug & Cosmetic Act is required to bear on its original packing label, "Caution: Federal law prohibits dispensing ■ oral contraceptive drugs without a prescription." Compounded medications which contain at least one such medicinal substance are considered ■ Certain supplies and equipment obtained by mail service to be prescription legend drugs. Insulin is considered a or from a pharmacy (such as those for diabetes and Prescription Legend Drug under this certificate. asthma). Contact HMOC to determine approved covered supplies Prescription Order—a written request by a physician for a drug or medication and each authorized refill for same. If certain supplies, equipment or appliances are not obtained by mail service or from a pharmacy then they may be Prior Authorization—the process applied to certain drugs covered as medical supplies,durable medical equipment and and/or therapeutic categories to define and/or limit the con- appliances instead of under prescription drug benefits under ditions under which these drugs will be covered. The drugs other sections of this certificate. and criteria for coverage are defined by the Pharmacy and Therapeutics Committee. Copayment— Each prescription order may be subject to a copayment. If the prescription order includes more than one Pharmacy—an establishment licensed to dispense prescrip- covered drug or supply a separate copayment will apply to tion drugs and other medications through a duly licensed each covered drug or supply. Please see the Colorado pharmacist upon a physician's order. A pharmacy may be a Health Plan Description Form for the applicable copay- network provider or a non-network provider. ment. Days Supply — The number of day's supply of a drug Coverage for prescription drugs administered by a hospital, which you may receive is limited to a 34-day supply or no home health agency, hospice, or skilled nursing facility more than 120 in quantity. For oral contraceptives, the during a covered admission is not available under this supply is limited to one menstrual cycle(normally 28 days). "Prescription Drugs" section. See other headings in this section for drugs used during a covered admission or home Formulary — HMOC follows a drug formulary in health/hospice visit. determining payment and covered services. You will be responsible for an additional copayment amount depending on whether a formulary or non-formulary drug is obtained. Please see the Colorado Health Plan Description Form. Benefits Prescription drugs, unless otherwise stated below, must be Payment of Benefits — The amount of benefits paid is medically necessary and not experimental/investigative, in based upon whether you receive covered services from a order to be a covered service. For certain prescription drugs, network pharmacy, a non-network pharmacy, or a mail the prescribing physician may be asked to provide additional service program. It is also based upon whether you obtain a information before HMOC can determine medical necessity. generic or brand name prescription legend drug and whether HMOC may, in its sole discretion, establish quantity limits formulary prescription legend drugs were dispensed. Please for specific prescription drugs. Covered services will be see the Colorado Health Plan Description Form for the limited based on medical necessity, quantity limits estab- applicable amounts. lished by HMOC, or utilization guidelines. Prior authoriza- tion may be required for certain drugs. 97000(Rev. 5-01) 20 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Brand name prescription drugs are designated as follows: Network Pharmacy — Present your written prescription order from your physician and your identification card to the • formulary brand name means a brand name prescription pharmacist at a network pharmacy. The Pharmacy will file drug identified on the formulary by HMOC as a your claim for you. You will be charged at the point of prescription drug with a tier 2 copayment purchase for applicable copayment amounts. • non-formulary brand name means a brand name drug If you do not present your identification card, you will have which is not identified on the formulary by HMOC; it to pay the full cost of the prescription. If you do pay the full has a tier 3 copayment charge, ask your pharmacist for an itemized receipt and submit it to us with a written request for refund. You will be If you choose a brand name drug, or your provider prescribes reimbursed based on the charge for the covered drug, less a brand name drug and a generic formulary drug is available, the network pharmacy discount payable after review and you pay the brand formulary tier 2 copayment plus the retail approval of the claim, less the applicable tier 1,tier 2, or tier cost difference between the brand name drug and generic 3 copayment. substitute. If you choose a non-formulary drug, or your provider prescribes a non-formulary drug and a generic Non-Network Pharmacy — You are responsible for pay- formulary or brand formulary drug is available, you pay the ment of the entire amount charged by the non-network phar- non-formulary tier 3 copayment plus the retail cost difference macy. You must submit a prescription drug claim form to us between the non-formulary drug and the brand or generic for reimbursement consideration. These forms are available substitute. If no generic drug equivalent is available,the tier 2 from us or from your employer. You must complete the top or tier 3 copayment will apply, however, you are not section of the form and ask the pharmacist to complete the responsible for the retail cost difference as described above. bottom section. If for any reason the bottom section of this form cannot be completed by the pharmacist, you must The amounts for which you are responsible are shown in the attach an itemized receipt to the claim form and submit to Colorado Health Plan Description Form. No payment will us. The itemized receipt must show: be made by us for any covered service unless the charge exceeds any applicable copayment for which you are • name and address of the Pharmacy responsible. • patient's name Copayment amounts for prescription drugs, other than those which are flat dollar amounts, are calculated based upon the • prescription number applicable network pharmacy contracted rates for covered services provided to you prior to subtracting your copay- • date the prescription was filled ment amount, if covered services are obtained through a network pharmacy. If covered services are obtained through • name of the drug a non-network pharmacy, then copayment amounts for pre- scription drugs, other than those which are flat dollar ■ cost of the prescription amounts, are calculated based upon the non-network pharmacy's billed charges. Any discounts, rebates or other • quantity of each covered drug or refill dispensed funds received by us from drug manufacturers or similar vendors are not included in copayment calculations,whether You will be reimbursed based on the charge for the covered or not covered services are rendered by a network pharmacy. drug, less the network pharmacy discount payable after review and approval of the claim , less the applicable tier I, For covered services provided by a network pharmacy or tier 2, or tier 3 copayment. through mail service, you are responsible for all copayment amounts. Mail Service — Complete the Order and Patient Profile Form. You will need to complete the patient profile infor- For covered services provided by a non-network pharmacy, mation only once. You may mail written prescriptions from • you are responsible for all charges. Our reimbursement is your physician, or have your physician fax the prescription explained below. to the mail service. Your physician may also phone in the prescription to the mail service pharmacy. You will need to How to Obtain Prescription Drug Benefits — How you submit the applicable copayment amounts to the mail service obtain your benefits depends upon whether you go to a when you request a prescription or refill. The member's network or a non-network pharmacy. copayment is the same as for prescriptions filled at a net- work pharmacy for a 34-day supply,and two times that for a 97000(Rev. 5-01) 21 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO 60- or 90-day supply. Class II prescription drugs will only Drug when prescribed in accordance with the terms be dispensed in a 34-day supply. of this section • Therapeutic devices or appliances, including sup- Limitations and Exclusions port garments and other nonmedicinal sub- • Appetite suppressants—Drugs prescribed for weight stances(regardless of intended use) control or appetite suppressants are not covered • Drugs and supplies unless specifically included as a covered drug • Contraceptives — We will not pay for contraceptive devices provided through a pharmacy, regardless of • Prescriptions —Nonprescription and over-the-counter intended use including but not limited to IUD's, drugs, including herbal or homeopathic preparations, diaphragms, cervical caps, Levonorgestrel (Norplant), and Prescription Drugs that have over-the-counter and injectable contraceptives. For covered contracep- bioequivalents are not covered even if written as a tive devices see "Preventive, Routine, and Family prescription. Drugs not requiring a prescription by Planning Services" federal law (including drugs requiring a prescription by state law, but not federal law) are not covered, except • Cosmetic services Tretinoin (sold under such brand for injectable insulin. Some prescription drugs may not names as Retin-A®) for cosmetic purposes,medications be covered even if you receive a prescription order from or preparations used for cosmetic purposes (such as your physician preparations to promote hair growth, including but not limited to Rogaine®, preparations for preventing hair • Prior Authorization Prescription drugs which are growth, including but not limited to Viniqa®, or not prior authorized by HMOC are not considered medicated cosmetics)are not covered covered drugs eligible for reimbursement under this section, unless otherwise specified in the this section • FDA Approval Any new FDA Approved Drug Product or Technology (including but not limited to ■ Quantity—Prescription Drugs which are dispensed in medications, medical supplies, or devices) available in quantities which exceed the applicable limits estab- the marketplace for dispensing by the appropriate lished by HMOC,at its sole discretion are not covered source for the product or technology, including but not limited to pharmacies, for the first six months after the • Refills—Refills in excess of the number the prescrip- product or technology received FDA New Drug Appro- tion drug or maintenance prescription drug order calls val or other applicable FDA approval. HMOC may at for or refilled after one year from the date of such order its sole discretion, waive this exclusion in whole or in part for a specific New FDA Approved Drug Product or ■ Sexual dysfunction—Prescription Drugs approved by Technology the FDA or otherwise, intended for the treatment of sexual dysfunction or inadequacies, regardless of origin • Fertility drugs—Fertility medications or non-fertility or cause (including drugs for the treatment of erectile drugs used to treat infertility are not covered dysfunction)are not covered • Formulas/Vitamins — Benefits are not allowed for ■ Smoking cessation — Nicorette, nicotine patches, or special formula food or food supplements, vitamins, any other drug containing nicotine or other smoking folicacid or minerals, except for legend prenatal deterrent medications are not covered vitamins • Travel—Prescription Drugs dispensed for the purpose • Other non-covered items — Benefits are not allowed of international travel are not covered for: • Delivery charges Preventive, Routine, and Family • Charges for the administration of any drug planning Services • Drugs consumed at the time and place where dispensed or where the prescription order is issued, Definitions including but not limited to samples provided by a Preventive care services — those professional services Physician rendered for the early detection of asymptomatic illnesses or • Antibacterial soap/detergent, toothpaste/gel, shampoo, abnormalities and to prevent illness or other conditions. or mouthwash/rinse • Hypodermic needle, syringe, or similar device, Family planning—use of contraceptive techniques. except when used for administration of a Covered 97000(Rev. 5-01) 22 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Guidelines are provided to the PCP by HMOC based upon recommendations of the American Academy of Pediatrics, For routine mammograms and prostate screening, see "Diagnostic Services-earlier in this section. American Board of Family Practice, the United States Task Force Guide to Preventive Services, and the Center for For infertility services, see "Office, Outpatient, and Home Disease Control. Care-in this section. Additional services, when provided by the member's PCP, For information about your BlueCares for You programs, are covered under this provision and include: see "Your BlueCares for You Program" in Section 2: How the Plan Works. • prostate examinations • annual gynecological examination—breast and pelvic exam- inations, annual Pap tests, and fitting for contraceptive Benefits - devices (see"Family Planning,"below)for women(a female Your PCP plays a key role coordinating all of your health member may receive such services from her PCP or go care. Your PCP will provide much of your care, including directly to an OB/GYN HMOC provider who participates). routine physical examinations, immunizations, health educa- tion and counseling, and family planning services. Your • pediatric and adult immunizations PCP is also responsible for referring you to a specialist when necessary and for authorizing care ordered by the specialist, • age-appropriate vision and hearing screening exams such as hospice care, home health, and surgery. You must receive a referral in order to receive benefits for nonemer- Family Planning: Covered family planning services are: gency care provided by anyone other than your PCP. Limited exceptions are made for specified early detection ■ injection of Depo-Provera for birth control purposes services listed below, all female reproductive system services received from a participating OB/GYN physician, • fitting of a diaphragm or cervical cap certified nurse midwife, or eye care received from a participating optometrist or ophthalmolgist. ■ surgical implantation and removal of a NORPLANT device Physical Exams and Early Detection Services: Preventive care services are covered only when provided by the • fitting,inserting,or removing IUDs member's PCP and in accordance with the following guidelines: ■ the purchase of IUDs, diaphragms, NORPLANT devices, and cervical caps provided by a physician in • six well-baby exams for babies ages 0-11 months his/her office • children ages 12-23 months,three exams ■ surgical sterilization (e.g., tubal ligation or vasectomy) and related services • children ages 2-6, yearly exams Female members are not required to obtain a PCP referral • children ages 7-18, one exam every two years for the services of a participating OB/GYN or certified nurse midwife provider. • adults ages 19-34,one exam every five years Note: Birth control pills are also covered; see "Prescription • adults ages 35-59,one exam every two years Drugs"earlier in this section. • adults age 60 and over,one exam every year Health Education: Health education provided by a member's PCP is covered, and may include information on Preventive care services by the member's PCP may be achieving and maintaining physical and mental health and provided during visits for reasons other than preventive preventing illness and injury. Members who have been examinations and may be applied to the member's maximum diagnosed as diabetic may receive coverage for diabetic number of preventive care visits. education classes, including medical nutrition therapy, 97000(Rev. 5-01) 23 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Limitations and Exclusions The following services are not covered services: f/ oxygen is administered by a home health care agency, also see "Home Health Care"in this section. • immunizations required for international travel if supplies or equipment are furnished by a hospice agency. • services related to routine physical or screening exams also see "Hospice Care"in this section. and immunizations given primarily for insurance, licensing, employment, school, camp, weight reduction For supplies or equipment used during an inpatient stay or programs, sports,or for any nonpreventive purpose outpatient hospital visit, see "Hospital/Other Facility Ser- vices"in this section. • preventive care services in excess of maximum limi- tations • hearing aids or any related service or supply Benefits When medically necessary and ordered by an HMOC par- • routine vision exams to determine prescriptions for ticipating provider, the following items are not subject to the lenses durable medical equipment payment limit: • nonscreening hearing exams • durable medical equipment owned by the facility and medical supplies used during a covered admission or • services provided by an OB/GYN physician for primary during a covered outpatient visit care (e.g., cold or flu symptoms, or abdominal pain) without a PCP referral • medical supplies (including casts, dressings, and splints used in lieu of casts) used during covered outpatient • reversals of sterilization procedures visits • over-the-counter contraceptive products such as con- • surgically implanted prosthetics or devices preautho- doms and spermicide rized by HMOC • preconception, paternity, or court-ordered genetic coun- The following durable medical equipment are subject to the seling and testing (e.g., tests or discussion of family benefit payment limit shown in the Colorado Health Plan history or test results to determine the sex or physical Description Form except for prosthetic arms and legs: characteristics of an unborn child) • oxygen and oxygen equipment Supplies, Equipment, and Appliances • orthopedic appliances Definitions Durable medical equipment any equipment that can with- • crutches stand repeated use, is made to serve a medical purpose, and is generally considered useless to a person who is not ill or injured. • the rental,or at the option of HMOC,the purchase of durable medical equipment, including repairs, when prescribed by a Medical supplies expendable items (except prescription physician or other professional provider and required for drugs)required for the treatment of an illness or injury. therapeutic use(e.g.,wheelchairs and walkers) Prosthesis — any device that replaces all or part of a • prostheses and orthopedic appliances or devices (e.g., missing body organ or body member. surgical brassiere after mastectomy, or neck brace); their fitting, adjustment, repairs, or replacement because of Orthotics—a removable device used to support and brace wear or a change in the member's condition which neces- weak or ineffective joints or muscles. sitates a new appliance in accordance with Medicare guidelines. Prosthetic arms and legs are applied to the Orthopedic appliance—a rigid or semirigid support(exclud- benefit payment limit,however,they are not subject to the ing orthotics)used to eliminate, restrict, or support motion of a benefit payment limit. part of the body that is diseased,injured,weak,or deformed. 97000(Rev. 5-01) 24 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Limitations and Exclusions ment of fractures and dislocations; electrical, chemical, or Coverage is not available for items such as, but not limited medical destruction of tissue; endoscopic examinations; to: anesthetic epidural procedures; other invasive procedures. Covered surgical services also include usual and related local • air conditioners, biofeedback equipment, exercise anesthesia, and pre- and post-operative care, including equipment, humidifiers, purifiers, self-help devices, and recasting. whirlpools Anesthesia general anesthesia produces unconsciousness • deluxe equipment, such as motor-driven wheelchairs, in varying degrees with muscular relaxation and a reduction chair-lifts, or beds, when standard equipment is or absence of pain. Regional or local anesthesia produces available and adequate similar effects to a limited region of the body without causing loss of consciousness. Anesthesia is administered by • eyeglasses and contact lenses and the costs related to a physician or certified registered nurse anesthetist(CRNA). prescribing or fitting of contact lenses (except for aphakia or keratoconus) Surgical assistance — required surgical services provided by an assistant to the primary surgeon during a covered • hearing aids,related services,and supplies surgical procedure. • comfort items such as bedboards, waterbeds, hospital Reconstructive surgery — surgery that improves or beds, flotation mattresses, bathtub lifts, over-bed tables, restores bodily function to the level experienced before the adjustable beds,telephone arms event which necessitated the surgery, or in the case of a congenital defect, to a level considered normal. Such sur- • cost of repairs that exceeds the rental price of another genes may have a coincidental cosmetic effect. unit for the estimated period of need or that exceeds the Congenital defect—any condition, present from birth, that purchase price of a new unit is significantly different from the common form; for • medical equipment such as sphygmomanometers and example, a cleft palate or certain heart defects. Disorders stethoscopes due to inappropriate growth are not considered congenital. • supplies not authorized by the member's PCP or the referral provider, including items used for comfort, If you undergo a surgical procedure in a hospital(inpatient convenience,or personal hygiene or outpatient) or other facility, see "Hospital/Other Facility Services"in this section for more information. • syringes and needles for self-administering covered drugs, medicine, or insulin (for possible coverage, see For maternity-related services, also see "Maternity and "Prescription Drugs") Newborn Care"in this section. • contraceptive devices (for coverage, see "Preventive, For services related to infertility treatments, see "Office, Routine, and Family Planning Services" or "Prescrip- Outpatient, and Home Care" earlier in this section. tion Drugs") Coverage for surgical sterilization is described under "Preventive, Routine, and Family Planning Services." • medical supplies and orthopedic appliances that can be purchased over-the-counter, including but not limited to For the treatment of accidental injuries to the jaws, mouth, colostomy bags, catheters, dressings for bed sores and or teeth, or for the surgical or nonsurgical treatment of TM7 bums,gauze,and bandages disorders or injuries, see "Dental-Related Services" or "TMJ Services"in this section.. • orthotics,whether functional or otherwise For services required as a result of a cleft palate or cleft lip, Surgical Services see "Reconstructive Surgery,"below Definitions Surgical services—any of a variety of technical procedures for treatment or diagnosis of anatomical disease or injury including, but not limited to: cutting; microsurgery (use of scopes); laser procedures; grafting, suturing, castings; treat- 97000(Rev. 5-01) 25 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Benefits A member born with a cleft lip or cleft palate is eligible for Coverage is available for surgical services received as part the following medically necessary services: of a covered hospital admission day or in a provider's office or clinic, urgent care center, hospital outpatient department • oral and facial surgery, surgical management, and or emergency room,or an ambulatory surgical facility. follow-up care by plastic surgeons and oral surgeons Covered surgical services include: • prosthetic treatment such as obturators, speech appli- ances,and feeding appliances • surgeon's charges for a covered surgical procedure • orthodontic treatment • necessary anesthesia services by a provider qualified to perform such services during a covered surgical proce- • prosthodontic treatment durc • rehabilitative speech therapy • services of a professional provider who actively assists the operating surgeon in the performance of a covered • otolaryngology treatment surgical procedure when the procedure requires an assistant • audiological assessments and treatment Oral Surgery: This plan will cover services for mouth Limitations and Exclusions conditions (excluding teeth and gums) arising from disease, The following services are not covered services: trauma, injury, or congenital defect, if determined to be medically necessary. Upper or lower jaw augmentations or • cosmetic procedures and related expenses reductions are not covered (including orthognathic jaw surgery). ■ obesity treatment, unless for the surgical treatment of morbid obesity for which a prior authorization, in Reconstructive Surgery: Reconstructive surgery that is writing,has been received from HMOC required due to an accidental injury, disease process or its treatment, or functional congenital defect (which was • refractive keratoplasty, including radial keratotomy, or existing at or dating from birth),is a covered service. any procedure to correct visual refractive defect (except for aphakia or keratoconus Reconstruction of the breast on which a mastectomy has been performed, surgery and reconstruction of the other breast to • sex change operations or complications arising from produce a symmetrical appearance are covered services. transsexual surgery Benefits are provided for prostheses and physical complica- tions for all stages of mastectomy, including lymphedemas. • subsequent surgical procedures to correct further injury Benefits are provided as any other physical illness, subject to or illness resulting from the member's noncompliance the same copayments. If a member chooses not to have surgi- with prescribed medical treatment or to care for or cal reconstruction after a mastectomy, HMOC will provide correct a complication due to a previous noncovered coverage for external prostheses. procedure Further, the member or physician must obtain a prior authori- • services of an assistant only because the hospital or zation, requested in writing, from HMOC before the recon- other facility requires such services, or services per- structive service is provided. Reconstructive surgeries formed by a resident, intern, or other salaried employee provided without prior authorization from HMOC are or person paid by the hospital not covered. • services of more than one assistant unless the procedure Cleft lip or cleft palate : A cleft palate is a birth deformity is identified by HMOC as requiring the services of more in which the palate (the roof of the mouth) fails to close. A than one assistant cleft lip is a birth deformity in which the lip fails to close. • local anesthesia (coverage for surgical procedures includes an allowance for local anesthesia because it is considered a routine part of the surgical procedure) 97000(Rev. 5-01) 26 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO • services of a physician who is on standby unless the When HMOC decides that a proposed transplant is not procedure is identified by HMOC as requiring the ser- medically necessary or is experimental or investigational vices of a standby physician(standby means a physician treatment, that is a decision of coverage. You and your is available if services arc needed) physician must ultimately decide your course of treatment. However,HMOC will not pay for transplant procedures that • services for upper or lower jaw augmentations or it determines are experimental or investigational, or not reductions even if the condition is due to a genetic medically necessary. characteristic(including orthognatic jaw surgery) Benefits • replacement of a previously approved implant for Bone Marrow, Cornea, Kidney, and Specified Liver cosmetic purposes Transplants: The following transplant procedures are covered under this provision. References to bone marrow or Transplants bone marrow transplants (either allogenic or autologous) Definitionsinclude all other related procedures for harvesting stem cells or other cells to be used as an adjunct to or in support of Transplant —a surgical process that involves the removal chemotherapy(including high-dose chemotherapy): of an organ, tissue or cells from one person and placement of the organ into another. Transplant can also mean removal • bone marrow transplant for a member with aplastic of organs, tissue or cells from a person for the purpose of anemia, leukemia, severe combined immunodeficiency treatment and reimplanting the removed organ or tissue into disease,or Wiskott-Aldrich syndrome the same person. • corneal transplant General Coverage for Transplants—Transplants must be pre-approved by HMOC. Transplant procedures, and treat- • kidney transplant ment of various cancers (or other conditions) using high dose chemotherapy together with bone marrow transplants, • liver transplant for a child under age 18 with congenital are constantly changing and are subject to medical studies. biliary atresia However, HMOC will only cover those transplants that are not experimental or investigational as defined in this plan. HMOC has the discretion and authority under this plan to When [re transplant recipient is a member, the surgical determine medical necessity and if the transplant proposed e storage, and transportation costs directly related to the donation of an organ or bone marrow to be used in a for you is experimental or investigational. covered transplant are considered covered services. Cover- age is not available for donor costs for a member who When HMOC makes a determination, HMOC's medical director, a licensed physician, evaluates each proposed donates an organ to be used in a transplant procedure. P Y course of treatment. For the evaluation the medical director reviews For covered transplants, when the recipient is a member, current medical literature about the proposed treatment and transportation costs to and from the hospital for the recipient the "TEC Criteria" which are developed through the Tech- are also covered. If the recipient is a minor, transportation nology Evaluation and Coverage (TEC) program of the Medical Advisory panel of the Blue Cross and Blue Shield costs for two adults e accompany the recipient are also Association. (This panel regularly reviews current scientific covered. This coverage includes all reasonable and neces- published peer literature on transplants, including bone sary travel and lodging expenses (up to $10,000 per marrow transplants with high dose chemotherapy, for various transplant). medical conditions.) The director will also use HMOC's intemal medical policies, review your medical records, and Major Organ Transplants: Coverage is available for talk to your physician(s). services and supplies related to a major organ transplant, limited to one or more of the following: Based on all this information, HMOC will make a decision U heart whether or not the proposed procedure will be covered under this plan. Transplants which are experimental or • heart-lung investigational under the five criteria set out under the heading "Experimental/Investigational" of Section 4 of the Plan General Exclusions, will not be covered. liver (for a child under age 18 with congenital biliary atresia, see "Bone Marrow, Cornea, Kidney, and Speci- fied Liver Transplants,"above,for benefits) 97000(Rev. 5-01) 27 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO • lung (see below) also apply toward the maximum lifetime benefit for major organ transplants. • pancreas-kidney A service or supply is considered transplant-related if it To be considered covered services, services must be related directly relates to a transplant covered under this "Major to a covered major organ transplant, coordinated by the Organ Transplants" provision, and is received during the member's PCP,and authorized by HMOC. transplant benefit period(up to five days before,or within one year following,the transplant).Services after one year PCP Referral and Prior Authorization Required. The for a major organ transplant are covered subject to the member is responsible for ensuring that a referral is received provisions of the certificate for covered services. from his/her PCP and for getting prior authorization from Exception: A pretransplant evaluation may be received more HMOC before scheduling a pretransplant evaluation. A case than five days prior to a transplant and be considered manager will be assigned to the member and must later be transplant-related (this exception does not extend to travel contacted with the results of the evaluation. Coverage will required to receive a pretransplant evaluation). Covered not be allowed for a pretransplant evaluation if prior services received during the evaluation will be subject to the authorization is not received from HMOC. maximum lifetime benefit for major organ transplants and subject to the limitations of this "Major Organ Transplants" If the member is a candidate for a transplant, he/she must provision. ensure that prior authorization for the actual transplant is received from HMOC. None of the coverage described If a member receives a covered transplant under this plan here will be available unless the member has this prior (e.g., heart transplant) and later requires another transplant authorization. of the same type(e.g., another heart transplant), the covered charges for the new transplant are applied to the remaining Facility Must be Approved by HMOC. Coverage is (if any) maximum lifetime benefit available for the available only when the transplant is performed at a facility transplant. with a transplant program approved by HMOC. The mem- ber's case manager will work with the member's provider to Payments under this "Major Organ Transplants" provision determine the most appropriate facility for the procedure. are not applied to other specified benefit maximums and Call the HMOC health services department for information member copayments are not applied to the out-of-pocket on HMOC-approved programs. limit listed in this certificate. Effect of Medicare Eligibility on Coverage.Members who Recipient Travel and Lodging. If the transplant recipient are now eligible for — or are anticipating receiving eligi- must temporarily relocate outside of his/her city of residence bility for— Medicare benefits are solely responsible for to receive a covered major organ transplant, coverage is contacting Medicare to ensure that the transplant will be available for travel to the city where the transplant will be eligible for Medicare benefits. (If Medicare is the primary performed, and for reasonable lodging expenses for the carrier when the transplant is received but benefits are recipient and one additional adult. (If the transplant recipient denied by Medicare, coverage may also be denied by is a dependent child under the age of 18, coverage is HMOC even if the member obtained prior authorization available for travel and lodging expenses for two adults to for the transplant.) accompany the member.) Maximum Lifetime Benefit for Major Organ Trans- Travel and lodging expenses for the recipient and the plants. Coverage for a covered major organ transplant and accompanying adult(s) are limited to a lifetime maximum all transplant-related services, including travel, lodging, and benefit of $10,000 per transplant — which is part of the donor expenses or organ procurement costs is limited to a maximum lifetime benefit for major organ transplants under maximum lifetime benefit for major organ transplants of this "Major Organ Transplants" provision. Lodging expenses $1,000,000 per member per transplant. are further limited to a maximum of$100 per day. Amounts applied toward the maximum lifetime benefit for The member is responsible for monitoring the accumulation major organ transplants include all covered charges for of expenses and for submitting documentation (with transplant-related services less the member's copayment properly itemized receipts) to support travel expenses. No amounts, any hospitalizations and medical services related benefits will be paid until after services are received. to the transplant, and any subsequent hospitalizations and medical services related to the transplant. The $10,000 Travel expenses incurred by a donor are not applied to the travel and lodging and the$25,000 donor expense coverages member's lifetime travel and lodging expenses benefit 97000(Rev. 5-01) 28 Customer Service (800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO maximum but are applied to both the maximum lifetime • care for the complications of noncovered transplants, or benefit for major organ transplants and to the $25,000 follow-up care related to such transplants maximum donor surgery benefit(see below). • transplant-related services if the member did not receive Coverage is not available for travel costs associated with a prior authorization from HMOC for the transplant pretransplant evaluation if the travel occurs more than five days prior to the actual transplant. • expenses incurred by an HMOC member for the donation of an organ to another person (such expenses Organ Procurement or Donor Expenses for Major should be paid by the transplant recipient) Organ Transplants. Organ procurement and donor expenses are covered up to a maximum benefit of$25,000 • drugs that are self-administered or for use while at home per transplant— which is part of the maximum lifetime (these services may be covered elsewhere in this benefit for major organ transplants. certificate; see"Prescription Drugs" in this section) Organ acquisition/procurement costs for the surgical removal, • food, beverage, or meal expenses (other than those storage, and transportation of a heart, liver, lung, pancreas, or incurred at a hospital as part of covered room and board kidney acquired from a cadaver are covered. expenses); laundry or dry cleaning expenses; phone calls;day care expenses;personal convenience items If there is a living donor that requires surgery to make an organ available (e.g., liver or kidney), coverage is available • lodging expenses charged to the member only because only for expenses incurred by the donor for surgery benefits are available under this provision (such as (including necessary travel), organ storage expenses, and lodging received from a member of the patient's family, inpatient follow-up care. or from any other person charging for accommodations in a place that does not ordinarily take in lodgers in Donor expenses are paid only after the transplant recipient's return for payment) initial claims for the transplant have been processed. No coverage is available to the donor after he/she has been • taxicab or bus fare, vehicle rental expenses, parking discharged from the transplant facility. expenses,moving expenses Limitations and Exclusions Therapies: Chemotherapy and The following services are not covered services: Radiation • transplant-related services if the actual transplant was Definitions performed at a facility that does not have an Chemotherapy — drug therapy administered as treatment HMOC-approved transplant program for malignant conditions and diseases of certain body systems. • with the exception of a pretransplant evaluation, services received more than five days prior to or one Radiation therapy — X-ray, radon, cobalt, betatron, telo- year following a covered transplant (these services may cobalt, and radioactive isotope treatment for malignant be covered elsewhere in this certificate) diseases and other medical conditions. • transplant-related services in excess of any maximum benefit amounts When received during a covered admission and billed as part of the facility service, therapy charges will be paid in • the implantation of artificial organs or devices (e.g., the same manner as the room expenses and other ancillary mechanical heart) services (see "Hospital/Other Facility Services" in this section). • nonhuman organ transplants • any transplant not specifically listed will be subject to medical policy and criteria 97000 (Rev. 5-01) 29 Customer Service(800)334-6557 or(303)831-0161 Section 3: Covered Services BlueAdvantage HMO Benefits Treatment of malignant disease by standard chemotherapy and/or radiation therapy are covered when performed in the outpatient department of a participating hospital, freestanding treatment facility or clinic, provider's office, or the patient's home. When chemotherapy is used in conjunction with bone marrow transplant, stem cell or other supporting treatment it is subject to the terms and conditions applicable to transplants under surgical services,as well as all other conditions and terms of the plan. TMJ Services Definitions Temporomandibular joint (TMJ) syndrome — a condition in which the member may have painful temporomandibular joints, tenderness in the muscles that move the jaw, clicking of joints,or limitation ofjaw movement. For coverage of other oral surgery services, see "Surgical Services:Oral Surgery"in this section. Benefits This plan does not cover any services related to therapy or surgery of the temporomandibular joint. HMOC covers treatment of temporomandibular joint when there is a demonstrated medical condition such as a acute fracture or tumor, and only when the treatment is prior authorized by HMOC. 97000(Rev. 5-01) 30 Customer Service(800) 334-6557 or(303)831-0161 Section 4: General Exclusions BlueAdvantage HMO 4: General Exclusions These general limitations and exclusions apply to all Convalescent Care or Rest Cures — This plan does not services listed in this certificate. This plan will not cover cover convalescent care or rest cures. any services not authorized by the member's primary care provider (PCP), except as set forth in Section 3: Covered Cosmetic Surgery—Cosmetic surgery is beautification or Services. aesthetic surgery to improve an individual's appearance by surgical alteration of a physical characteristic. This plan This plan does not cover any service or supply not specifically does not cover cosmetic surgery for psychiatric or psycho- listed as a covered service in this certificate.If a service is not logical reasons, or to change family characteristics or condi- covered,then all services performed in conjunction with that tions due to aging. This plan does not cover services related service are not covered. to cosmetic surgery, or required as a result of noncovered cosmetic surgery. This plan will not cover any of the following services, supplies,situations,or related expenses: Examples of cosmetic procedures arc: orthognathic jaw sur- gery; reconstruction of surgically induced scars; breast aug- Acupuncture — This plan does not cover acupuncture, mentation, rhinoplasty, surgical alteration of the eye, and whether for medical or anesthetic purposes. surgical correction of prognathism, or those procedures that HMOC determines are not required to materially improve Artificial Conception—This plan does not cover artificial the physiological function of an organ or body part. insemination, "test tube" fertilization, drugs for induced ovulation, or other artificial methods of conception. See Custodial Care—This plan does not cover custodial care, "Office, Outpatient, and Home Care" for a complete list of or care in a place that serves the patient primarily as a covered infertility treatments. residence when the patient does not require skilled nursing. This plan does not cover services to assist the member in Auto Accident Injuries — This plan does not cover ser- activities of daily living (such as sitters or homemaker's vices resulting from an automobile accident that are covered services), or services not requiring the continuous attention under applicable no-fault insurance laws. (See Section 5: of skilled medical or paramedical personnel, regardless of Coordination of Benefits and Subrogation.) where they are furnished and by whom they were recom- mended. Before Effective Date — This plan does not cover any service received before the member's effective date of Dental Services — This plan does not cover dental treat- coverage. ment and surgery, including but not limited to extraction of teeth,or devices or splints. Biofeedback—This plan does not cover services related to biofeedback. Domiciliary Care —This plan does not cover domiciliary care or care provided in a residential institution, treatment Blood, Plasma,or Derivatives—This plan does not cover center, halfway house, or school because a member's own whole blood, blood plasma, and blood derivatives. Blood is home arrangements are not available or are unsuitable, and available through community services. consisting chiefly of room and board, even if therapy is included. Chemical Dependency Rehabilitation — This plan does not cover inpatient or outpatient chemical dependency Duplicate (Double) Coverage This plan does not cover rehabilitation unless your group chose the optional services already covered by other valid coverage,or services "Chemical Dependency Rehabilitation" coverage. (Your already paid under Medicare or, in groups of 20 or more Colorado Health Plan Description Form will indicate if this employees, that would have been paid if the member was coverage is available to you.) entitled to Medicare, had applied for Medicare, and had claimed Medicare benefits, and is not subject to Medicare Chiropractic Services — This plan does not cover chiro- Secondary Payer (MSP) provisions. See Section 5: practic services unless your group chose the optional Coordination of Benefits and Subrogation for more infor- "Chiropractic Services" coverage. (Your Colorado Health mation. Plan Description Form will indicate if this coverage is available to you.) 97000 (Rev.5-01) 31 Customer Service (800)334-6557 or(303)831-0161 Section 4: General Exclusions BlueAdvantage HMO Experimental or Investigative Procedures or Services -- Hypnosis— This plan does not cover hypnosis or services This plan does not cover any treatment, procedure, facility, related to hypnosis, whether for medical or anesthetic equipment, drug, device, or supply not accepted as standard purposes. medical practice, as determined by HMOC, and thus con- sidered experimental or investigative. In addition, if federal Intractable Pain — This plan does not cover services for or other government agency approval is required for use of the treatment of intractable pain. Intractable pain means a any items and such approval was not granted at the time pain state in which the cause of the pain cannot be removed services were administered, the service is experimental and and which in the generally accepted course of medical will not be covered. To be considered standard medical practice no relief or cure of the cause of the pain is possible practice and not experimental or investigative, treatment or none has been found after reasonable efforts including, must meet all five of the following criteria: but not limited to, evaluation by the attending physician and one or more physicians specializing in the treatment of the • A technology must have final approval from the appro- area, system,or organ of the body perceived as the source of priate government regulatory bodies. the pain. • The scientific evidence as published in peer-reviewed Late Claims Filing — This plan does not cover services literature must permit conclusions concerning the effect submitted for coverage determination more than six months of the technology on health outcomes. after the date of service. • The technology must improve the net health outcome. Learning Deficiencies and Behavioral Problems — This plan does not cover special education, counseling, therapy, • The technology must be as beneficial as any established diagnostic testing, or care for learning deficiencies or alternatives. behavioral problems, whether or not associated with a manifest mental disorder,retardation, or other disturbance. • The improvements must be attainable outside the investigational settings. Maintenance Therapy — This plan does not cover any treatment that does not significantly enhance or increase the Also, the service must be medically necessary and not patient's function or productivity, or care provided after the excluded under any provision of this plan. patient has reached his/her rehabilitative potential, unless therapy is received during an approved hospice benefit Genetic Counseling and Testing—This plan does not cover period. In the case of a dispute about whether the patient's services including but not limited to preconception, patemity, rehabilitative potential has been reached, the member is court-ordered genetic counseling and testing, or testing for responsible for furnishing documentation from the patient's inherited susceptibility (e.g., tests, or discussion of family his- physician supporting that the patient's rehabilitative poten- tory or test results, to determine the sex or physical charac- tial has not been reached. teristics of an unborn child). Genetic tests to evaluate risks for certain types of conditions may be covered based on medical Medically Unnecessary Services — This plan does not policy review and criteria, and after appropriate prior authori- cover services that are not medically necessary as defined in zation. the Glossary unless such services are specifically listed as covered in this certificate (e.g., see "Preventive, Routine, Government Institution and Facility Services — This plan and Family Planning Services" in Section 3: Covered does not cover outpatient services or supplies furnished by a Services). military medical facility operated by, for, or at the expense of federal, state, or local governments or their agencies, when the HMOC determines whether a service or supply is medically service is provided without charge. This plan does not cover necessary,and,therefore,whether the expense is covered.The fact services or supplies furnished by a Veterans Administration that a provider has prescribed, ordered, recommended, or facility for a service-connected disability or while in active approved a service or supply does not make it medically necessary military service. or make the expense a covered service,even though it is not speci- fically listed as an exclusion. Hair Loss Treatments — This plan does not cover wigs, artificial hairpieces, hair transplants or implants, or medica- tion used to promote hair growth or control hair loss, even if there is a medical reason for hair loss. 97000 (Rev. 5-01) 32 Customer Service(800)334-6557 or(303)831-0161 Section 4: General Exclusions BlueAdvantage HMO No Legal Payment Obligation—This plan does not cover review, filling out of claim forms, or copies of medical services for which the member has no legal obligation to pay records or that are free, including: • interest expenses • charges made only because coverage is available under this plan • modifications to home, vehicle, or workplace to accommodate medical conditions • services for which the member has received a profes- sional or courtesy discount ■ membership fees at spas, health clubs, or other such facilities even if medically recommended— regardless • services provided by the member for him-/herself or a of the therapeutic value covered family member,or by a person ordinarily resid- ing in the patient's household,or by a family member ■ personal convenience items such as air conditioners, humidifiers, or physical fitness exercise equipment, or Noncovered Providers of Service — This plan does not personal services such as haircuts, shampoos and sets, cover services prescribed or administered by a: guest meals,and radio or television rentals • member of the patient's immediate family or a person ■ voice synthesizers;other communication devices normally residing in the patient's home • homeopathy,herbology,naturopathic medicine,Chinese • physician, other person, supplier, or facility not medicine,ayurvedic medicine specifically listed as covered in this certificate, such as a(n): Nonparticipating Provider Services—This plan does not • health spa or health fitness center (whether or not cover nonemergency services provided by a nonparticipating services are provided by a licensed or registered provider unless prior authorized by HMOC. provider) • school infirmary • When an HMOC participating provider resigns from the • halfway house HMOC provider network, services rendered by the • massage therapist, manual healing nonparticipating provider beyond 90 days are no longer • private sanitarium covered. • extended care facility • residential treatment center (facility where the pri- • The member will be financially responsible for the mary services are the provision of room and board services unless referred to the provider in advance by and constant supervision or a structured daily routine his/her PCP,or if the service did not require a referral. for a person who is impaired but whose condition does not require acute care hospitalization) Nutritional Therapy — This plan does not cover vitamins, • dental or medical department sponsored by or for dietary/nutritional supplements, special foods, baby formulas, an employer, mutual benefit association, labor mother's milk, or diets even if the substance is prescription and union,trustee,or any similar person or group the sole source of nutrition. Nonmedical Expenses — This plan does not cover non- Orthotics — This plan does not cover orthotics whether medical expenses,including but not limited to: functional or otherwise. • adoption expenses Post-Termination Services — When your coverage is ter- minated for any reason other than nonpayment of premium, • educational services and supplies not provided by the fraud or abuse, we shall provide for continued care for the member's PCP member being treated at an inpatient facility until the member is discharged subject to the terms of the certificate. • vocational or training services and supplies Benefits under the certificate end for any other reason except as stated above. • mailing and/or shipping and handling expenses Private Duty Nursing Services—This plan does not cover • charges for such expenses as missed appointments, private duty nursing services. provision of medical information to perform admission 97000 (Rev. 5-01) 33 Customer Service(800)334-6557 or(303)831-0161 Section 4: General Exclusions BlueAdvantage HMO Sex-Change Operations — This plan does not cover prescriptions associated with such procedures, and costs services related to sex-change operations or reversals of related to the prescribing or fitting of contact lenses. See such procedures. "Preventive, Routine, and Family Planning Services" in Section 3: Covered Services for additional information. Sexual Dysfunction — this plan does not cover services, supplies, or prescription drugs for the treatment of sexual War-Related Conditions— This plan does not cover any dysfunction. service required as the result of any act of war, or for any illness or accidental injury sustained during combat or active Taxes — This plan does not cover sales, service, or other military service. taxes imposed by law that apply to covered services. Weight-Loss Programs — This plan does not cover Therapies (Other) — This plan does not cover therapies weight-loss programs, dietary control, or obesity treatment, and self-help programs other than the therapies listed as except medically necessary surgical treatment of morbid covered services in this certificate. Noncovered therapies obesity when the treatment is authorized by HMOC before include but are not limited to: treatment begins. • recreational, sex,primal scream,sleep,and Z therapies Work-Related Conditions — This plan does not cover services resulting from work-related illness or injury. This • self-help, stress management, smoking cessation, and exclusion from coverage applies to all work-related illness weight-loss programs or injury, and includes charges resulting from occupational accidents or sickness covered under: • transactional analysis, encounter groups, and transcen- dental meditation(TM) ■ occupational disease laws • sensitivity or assertiveness training and rolfing • employer's liability • religious counseling • municipal,state,or federal law(except Medicaid) • wellness programs not specifically listed as covered in • Workers' Compensation Act this certificate In order to obtain payment for a work-related illness or • educational programs such as behavior modification, injury, the member must pursue his/her rights under the cardiac rehabilitation classes, or pulmonary rehabili- Workers' Compensation Act or any of the above provisions tation classes (Some educational programs provided by which apply, including filing an appeal. This plan may cover a member's PCP may be covered; see "Preventive, certain services during that appeal process on the condition Routine, and Family Planning Services" in Section 3: that the member signs an agreement to pay HMOC 100 per- Covered Services for details.) cent of the amount paid for such claims by the other coverage. • splint therapy This plan does not cover charges for services resulting • vision therapy from a work-related illness or injury,even if: • sensory integration therapy ■ the member fails to file a claim within the filing period allowed by the applicable law Travel and Lodging Expenses—This plan does not cover travel and lodging expenses except as described under • the member obtains care which is not authorized by "Surgical Services"in Section 3: Covered Services. Workers' Compensation insurance Vision — This plan does not cover any services related to • the member's employer fails to carry the required Workers' refractive keratoplasty (surgery to correct nearsightedness), Compensation insurance;in this case,the employer may be including radial keratotomy or any procedure designed to liable for any employee's work-related illness or injury correct farsightedness or astigmatism(except for aphakia or expenses keratoconus). This exclusion also applies to eyeglasses, contact lenses (even if there is a medical diagnosis which ■ the member fails to comply with any other provisions of prevents the member from wearing contact lenses), the law 97000(Rev. 5-01) 34 Customer Service (800)334-6557 or(303)831-0161 Section 5: Coordination of Benefits and Subrogation BlueAdvantage HMO 5: Coordination of Benefits and Subrogation Coordination of Benefits (COB) ■ Coverage of the plan covering the Medicare beneficiary This plan contains a coordination of benefits (COB) as the active or retired employee. provision that prevents duplication of payments. When a If the member has other valid coverage, contact the other member is eligible for coverage under any other valid carrier's customer service department to determine if the coverage, the total payments from the other valid coverage other coverage is primary or secondary to Medicare. There and this coverage cannot exceed what the plan would pay as are many federal regulations regarding Medicare Secondary primary coverage. Payer provisions, and other coverage may or may not be subject to those provisions. Other valid coverage means any of the following plans that provide full or partial coverage or services for hospital, Dependent Child If the member who receives care is a surgical,medical,vision, or dental care or treatment: dependent child, the coverage of the parent whose birthday falls earlier in the calendar year pays first. If the other • group insurance coverage coverage does not follow the birthday rule, then the father's coverage pays first. • group service plan contract, group practice, group indi- vidual practice,and other group prepayment coverages Dependent Child, Parents Separated or Divorced If • any group coverage under labor-management trustee plans, two or more plans cover a member as a dependent child of union welfare plans, employer organization plans, employee divorced or separated parents, payment for the child is coordinated in the following order: benefit organization plans, or self-insured employee benefit plans ■ Court-Decreed Obligations. Regardless of which parent has custody, if a court decree specifies which Other valid coverage does not include school accident parent is financially responsible for the child's health policies or Medicaid. care expenses,the coverage of that parent pays first. If a member is covered by both Medicare and this health • Custodial/Noncustodial. The plan of the custodial care plan and is subject to Medicare Secondary Payer parent pays first. The plan of the spouse of the custodial provisions, special COB rules apply. Contact an HMOC parent pays second. The plan of the noncustodial parent customer service representative for more information. pays last. The following rules determine which coverage pays first: • Joint Custody. When a court decree specifies that the parents share joint custody, without stating that one of No COB Provision— If the other valid coverage does not the parents is responsible for the health care expenses of include a COB provision, that coverage pays first and this the child, the plans covering the child follow the rules health care plan pays secondary. that are applicable to children whose parents are not separated or divorced. Employee/Dependent —If the member who received care is covered as the employee under one coverage and as a Active/Inactive Employee — If the member who received dependent under another, the employee's coverage pays care is covered as an active employee under one coverage first. Exception: If the member is also a Medicare and as an inactive employee under another, the coverage beneficiary, and Medicare is secondary to the plan covering through active employment pays first. Likewise, if a member the person as a dependent of an active employee, then the is covered as the dependent of an active employee under one order of coverage determination is: coverage and as the dependent of the same but inactive employee under another, the coverage through active • Coverage of the plan of an active worker covering the employment pays first. 1f the other plan does not have this Medicare beneficiary as a dependent; rule and if,as a result, the plans do not agree on the order of coverage,the next rule applies. • Medicare; Longer/Shorter Length of Coverage—When none of the above applies, the plan in effect for the longest continuous period of time pays first. (The start of a new plan does not 97000 (Rev. 5-01) 35 Customer Service(800)334-6557 or(303)831-0161 Section 5: Coordination of Benefits and Subrogation BlueAdvantage HMO include a change in the amount or scope of a plan's cover- benefits paid to the member or on his/her behalf. If HMOC age,a change in the entity that pays,provides,or administers provides payment, HMOC also has a direct priority lien the plan's coverage, or a change from one type of plan to against any money the member may recover from a third another.) party, any source related to that third party, or any other source, as a result of the condition or injury. HMOC's lien How Benefits Are Paid must be satisfied by the member regardless of the amount When this plan is the primary plan, benefits will be paid recovered. according to the terms of this certificate. When this plan is the secondary plan, HMOC may reduce its benefits so that If a third party is or may be liable for the cost of or charges the total benefits paid or provided by all plans during a for any covered services, the following actions must be claim duration period are not more than the total allowable taken: expenses. • The member must promptly notify HMOC of the claim When HMOC is secondary, all provisions (such as using a against the third party. PCP or HMOC participating provider, and the referral process)must be followed. Failure to do so may result in no • The member or his/her attorney must provide for benefits from HMOC. payment to HMOC of the amount of benefits paid by HMOC in any settlement with the third party, the third Responsibility for Timely Notice party's insurance carrier, or any other source (such as This plan is not responsible for coordination of benefits if uninsured motorist coverage held by the member). timely information has not been provided by the com- plaining party regarding the application of this provision. • pIf the member receives money for the claim by suit, settlement, or otherwise, the member must reimburse Facility of Payment HMOC first for the amount paid under this plan or an Whenever payments that should have been made by HMOC agreed upon pro rata share. The member may not have been made under any other plan, HMOC will have the exclude recovery for HMOC payments from any type of right to pay to that other plan any amount HMOC damages or settlement recovered. determines to be warranted to satisfy the intent of this provision. Any amount so paid will be considered to be The member must cooperate in every way necessary to benefits paid under the agreement, and with that payment help HMOC enforce its subrogation rights. HMOC will fully satisfy its liability under this provision. The member may not take any action that might prejudice Right of Recovery HMOC's subrogation rights. Whenever payments for covered services have been made by the plan and those payments are more than the maximum When a member fails to cooperate in satisfying HMOC's payment necessary to satisfy the intent of this provision, subrogation interest, and HMOC must file a lawsuit against the member or the third party in order to enforce its rights regardless of who was paid, HMOC has the right to recover the excess amount from any persons to or for whom those under this provision, the member or any dependent of payments were made, or from any insurance company, his/hers receiving payment under this plan will be responsible for attorneys' fees and costs incurred by HMOC. service plan,or any other organizations or persons. Third-Party Liability — Subrogation Automobile No-Fault Insurance Third-party liability exists when someone else is or may be Provisions legally responsible for a member's condition or injury. If a Services resulting from an automobile accident that are member suffers any illness or injury for which a third party covered under applicable No-Fault insurance laws are not may be responsible and if this plan has paid benefits for that covered. This section explains how this plan will coordinate illness or injury, HMOC will have the right to recover all its coverage with the coverage of an automobile No-Fault benefits paid, or which may become payable, for that illness insurance policy. or injury. A complying policy is an insurance policy approved by the When a third party is liable for the costs of any covered ser- Colorado Division of Insurance that provides at least the vice,HMOC has subrogation rights. This means that HMOC minimum coverage required by law, and one which is has the right, either as co-plaintiff or by direct suit, to subject to the Colorado Auto Accident Reparations Act enforce the member's claim against a third party for the (No-Fault). Any state or federal law providing similar 97000(Rev. 5-01) 36 Customer Service(800)334-6557 or(303)831-0161 Section 5: Coordination of Benefits and Subrogation BlueAdvantage HMO coverage through legislation or No-Fault statute is also vehicle accident if that member is not covered by a considered a complying policy. complying policy. How Benefits Are Coordinated With In that event, HMO Colorado may exercise its subrogation Complying Policies rights under"Third-Party Liability Subrogation,"above. Benefits under this plan will be coordinated with the minimum coverages required under the Colorado Auto This Automobile No-Fault Act will apply only where Accident Reparations Act (No-Fault), 10-4-701 through allowed under state law. 10-4-723, Colorado Revised Statutes 1973, as amended, whether or not the member has auto insurance. If a complying policy provides coverages in excess of the minimums required by state law, then this plan will coordinate benefits with the amount of coverage provided. What This Plan Will Pay This plan will pay up to the complying policy's deductible amount for those services that are covered under this plan. After this plan pays up to the complying policy's deductible amount, the complying policy is primary and is responsible for all benefits payable under the No-Fault statute. If there is more than one complying policy, each will have to pay its maximum No-Fault statutory coverages before this plan will become liable for any further payments. If there is a complying policy in effect, and the member waives or fails to assert his/her rights to such benefits, this plan will not pay benefits that could be available under a complying policy. HMO Colorado may require proof that the complying policy has paid all benefits required by law prior to making any payments on the member's behalf. Upon payment, HMO Colorado will be entitled to exercise its rights under this plan and under the No-Fault law. The member must fully cooperate to make sure that the complying policy has paid all required benefits. HMO Colorado may require the member to take a physical examination in disputed cases. In order for HMOC to pay for any covered service, after the complying policy has paid all required benefits, the member must then comply with the terms of this certificate (includ- ing payment up to the complying policy's deductible). If the Member Does Not Have a Complying Policy This plan will pay benefits for injuries received by the member while he/she is riding in or operating a motor vehicle which he/she owns if it is not covered by an Auto- mobile No-Fault complying policy as required by law. Benefits will also be available under the terms of this plan for injuries sustained by a member who is a nonowner operator, passenger, or pedestrian involved in a motor 97000(Rev. 5-01) 37 Customer Service(800)334-6557 or(303)831-0161 Section 6: Claims Payment and Appeals BlueAdvantage HMO 6: Claims Payment and Appeals This section explains when you need to file a claim to receive Your claim must be filed within six months after the date of reimbursement for covered services and how to do so. service. Any claims filed after this limit may be refused, unless HMOC is satisfied that there is a valid reason why Acceptable Claims you could not submit your claim within this time limit. Your claim will be processed within 60 days after HMOC receives Because HMOC participating providers handle the it. HMOC will send you written notice of any processing paperwork for members, HMOC does not have standard claim forms. However, if you receive covered services from delays. This written notice gives HMOC one more 60-day a nonparticipating or out-of-area provider, you must submit period to process the claim. itemized bills containing the following information: The payment right a g yment for covered services may be assigned • member's number to, and thereby payment made directly to, a nonparticipating provider of care,but the assignment must be in writing. • member's and employee's name and address All coverages described in this certificate are personal to the • member's age and relationship to the employee member. Neither these coverages nor HMOC payments may be assigned to any person, corporation, or entity, unless it is a • date(s)of service or purchase nonparticipating provider.Any attempted assignment will be void. If anyone other than a member attempts to use this coverage, it will be considered fraud or material misrepresentation in the use of • diagnosis and type of treatment services or facilities,which may result in cancellation of coverage for the member and appropriate legal action by HMOC. • procedure and amount charged Benefit payments for members eligible for Medicaid are • itemization of charges paid to the Colorado Department of Health Care Policy and • accident or surgery date(when applicable) Finance or providers when required by law. • name and address of provider Overpayments If this plan makes an erroneous payment, HMOC reserves • copayment paid,if any the right to recover the payment from the member. The providers of care may also seek recovery of billed charges Prescription drug bills must include pharmacy name and from the member for any services received. HMOC also address, drug name, prescription number, and amount reserves the right to offset amounts paid in error against new charged. The bill or receipts must be issued by the claims, and to take legal action to correct payments made in pharmacy. For the mailing address and claim forms, contact error. HMOC customer service. Complaint Procedures If you want reimbursement for covered charges which you have Complaints paid, please submit proof of payment such as receipts and P cancelled checks with those items listed above. Balance due If you have a complaint about any aspect of our service or statements are not acceptable. All information on the itemized claims processing, please contact a Customer Service statements must be readable. If information is missing or is not Representative at HMO Colorado at the phone number listed readable,then HMOC will return it to you or to the provider. on your identification card. For purposes of this document,a grievance is a complaint about the quality of care or service received from a provider. You may also send a written Where and When to Send Your Claim complaint or grievance to the following address: Make copies of the itemized bills for your own records and HMO Colorado send the original bills to: Customer Service Department HMO Colorado,Inc. 700 Broadway 700 Broadway,Suite 612 Denver,CO 80273 Denver,CO 80273 97000(Rev. 5-01) 38 Customer Service(800)334-6557 or(303)831-0161 Section 6: Claims Payment and Appeals BlueAdvantage HMO A trained representative will work to clear up any confusion 20 workdays of receipt of your appeal request. Non-utilization and resolve your difficulties. Your written grievance will be review appeals will typically be resolved within 30 workdays. investigated by our Quality Management Department. If you are not satisfied with the decision of HMO Colorado Level 2 Appeal—This is an appeal that has not been resolved Customer Service,you may file an appeal as explained below. to the member's satisfaction under the Level I Appeal process. The panel of reviewers shall include a minimum of three people Appeals and may be composed of employees of HMO Colorado who Definitions have appropriate professional expertise. A majority of the panel Utilization Review — means a set of formal techniques shall be comprised of persons who were not previously involved designed to monitor the use of, or evaluate the clinical in the dispute. However,a person who was previously involved necessity, appropriateness, efficacy, or efficiency of, health with the dispute may be a member of the panel or appear before care services, procedures or settings. Techniques include the panel to present information or answer questions. In the case ambulatory review, prospective review, second opinion, of utilization review denials,HMO Colorado shall ensure that a certification, concurrent review, case management, majority of the persons reviewing the appeal are health care discharge planning, or retrospective review. Utilization professionals who have appropriate expertise. Such reviewing review also includes reviews for the purpose of determining health care professionals shall meet the following criteria: coverage based on whether or not a procedure or treatment is considered experimental or investigational in a given • Have not been involved in the care previously circumstance (except if it is a specific certificate exclusion) and reviews of a covered person's medical circumstances • Are not a member of the board of directors of the health when necessary to determine if an exclusion applies in a plan. given situation. • Have not been involved in the review process for the Appeals covered person previously If you wish to file an appeal regarding a benefit denial based on utilization review, you may file an appeal without • Do not have a direct financial interest in the case or in first going through the above complaint process. You may the outcome of the review. also file an appeal after going through the complaint pro- cess. To give notice of an appeal you must send your However, a person who was previously involved may be a request in writing. Your written appeal should outline the member of the panel to present information or answer problem, describe your previous efforts to resolve the questions. HMOC shall issue a copy of the written decision matter, and request another review. Any supporting docu- to the covered person and to a provider who submits a ments should be enclosed with your letter. The appeal grievance on behalf of a covered person. HMO Colorado will should be addressed as follows: make a written response to your appeal within 35 workdays of receipt of your appeal request. HMO Colorado Appeals Department A member or member's representative has the right to request 700 Broadway CAT 0430 an expedited appeal of a utilization review decision when the Denver,CO 80273 time frames for a standard review would: seriously jeopardize the life or health of the covered person;jeopardize the covered To ensure a thorough, unbiased review, you may access two person's ability to regain maximum function;or for persons with levels of appeal. In the case of a benefit denial based on a disability, create an imminent and substantial limitation on utilization review, a Independent External Review appeal is their existing ability to live independently. Typically the also available to you. decision will be made within 72 hours. Expedited appeals will be evaluated by an appropriate clinical peer or peers who were Level 1 Appeal—This is an appeal in which HMO Colorado not involved in the initial denial. HMO Colorado will not appoints an intemal person or persons,not involved in the initial provide an expedited review for retrospective denials. determination to review HMO Colorado's position. However,a person that was previously involved with the denial may answer Members have the right to participate in person or via questions. The person(s)appointed to review a Level 1 Appeal conference call in the Level 2 Appeals meetings. Members may involving utilization review issues shall consult with an be assisted by anyone of their choosing to help them with their appropriate clinical person or person's in the same specialty as appeal. would typically manage the case being reviewed. For utilization review issues,you will receive a response to your appeal within Independent External Review— These are conducted by independent external review entities, which are selected by the 97000 (Rev. 5-01) 39 Customer Service (800)334-6557 or(303)831-0161 Section 6: Claims Payment and Appeals BlueAdvantage HMO Colorado Division of Insurance. Independent external review Legal Action appeals are available only in those circumstances where benefits Before you take legal action on a claim decision: were denied based on utilization review and which have gone through the company's Level 2 Appeal process. To request an ■ You must first follow the appeal process outlined above independent external review for a utilization review denial, you in Complaint Procedures. or your representative must complete and submit your written request on a form entitled "Request for Independent External • You must meet all requirements of this certificate. Review of Carrier's Final Adverse Determination". This form is available through the Customer Service Department; see your • No action in law or in equity shall be brought to recover identification card for the phone number. The request must be on this certificate prior to the expiration of 60 calendar made to us within 60 calendar days after the date of receipt of a days after written proof of loss has been filed in notice of our Level 2 Appeal denial. The Division of Insurance accordance with the requirements of this Certificate. No will assign an independent review entity to conduct the review. such action shall be brought at all unless brought within The independent reviewer's decision will be made within 30 three years of the time within which written proof of working days after we receive your request for such a review. loss has been filed as required by the certificate. This timeframe may be extended up to 10 working days for the consideration of additional material if requested by the reviewer. Refusal to Follow Recommended Expedited Independent External Review— Expedited Treatment reviews may be requested by a covered member or the If a member refuses treatment that has been recommended by an member's representative if the covered person has a medical HMOC participating provider, the provider may decide that the condition where the timeframe for a standard external member's refusal compromises the provider-patient relationship review would: seriously jeopardize the life or health of the and obstructs the provision of proper medical care. Providers will covered person; jeopardize the covered person's ability to try to render all necessary and appropriate professional services regain maximum function; or for persons with a disability, according to a member's wishes,when they are consistent with the create an imminent and substantial limitation on their provider's judgment. If a member refuses to follow the recom- existing ability to live independently. The covered person's mended treatment or procedure, the member is entitled to see request must include a physician's certification that the another provider of the same specialty for a second opinion. The person's medical condition meets the criteria for expedited member can also pursue the appeal process. If the second reviews. The request must be made on the form referenced provider's opinion upholds the first provider's opinion and the in the paragraph above. Determinations will be made by the member still refuses to follow the recommended treatment, then independent external review entities within seven working the member's coverage may be terminated by HMOC following a days after we receive your request for an expedited review. 30-day notice to the member. If coverage is terminated, neither This timeframe may be extended for an additional five HMOC nor any provider associated with HMOC' will have any working days for the consideration of additional information further responsibility to provide care to the member. if requested by the reviewer. An expedited external review may not be provided for retrospective denials. HMOC may also cancel any member's coverage who acts in a disruptive manner that prevents the orderly operation of Before legal action is taken on a claim decision, you must any HMOC participating provider. follow the appeals process stated above. Arbitration Procedures Catastrophic Events If any party involved is not satisfied with the decision of In case of fire, flood, war, civil disturbance, court order, HMOC as explained above under"Complaints", he/she may strike, or other cause beyond HMOC provi control, HMOC may pursue the remedies available under the Employee Retire- be unable to process claims or provide prior authorization for services on a timely basis. No suit or action in law or ment Income Security Act of 1974 (ERISA) or binding arbitration, whichever is applicable to the member's plan. equity may be taken against HMOC because of a delay Any party alleging a claim against HMOC, including a claim caused by any of these events. for denial of benefits or coverage, must follow the "Complaint" process before instituting a legal proceeding, If, due to circumstances not within the control of HMOC or suit or arbitration against HMOC. an HMOC participating provider, such as partial or com- plete destruction of facilities, war, riot, prevailing insurrec- tion, disability of an HMOC participating provider, or similar case, the provision of medical services is delayed or rendered impractical, HMOC or the provider will have no 97000(Rev. 5-01) 40 Customer Service(800)334-6557 or(303)831-0161 Section 6: Claims Payment and Appeals BlueAdvantage HMO liability or obligation on account of delay or failure to provide medical service. No suit or action in law or equity may be taken against HMOC due to delay on account of any of these events. HMOC and HMOC participating providers will, however,make a good-faith effort to provide services. Research Fees HMOC reserves the right to charge an administrative fee when extensive research is necessary to reconstruct information that has already been provided to a member in explanations of benefits,letters,or other forms. Sending Notices All notices to the member are considered to be sent to and received by the member when deposited in the United States mail with first class postage prepaid and addressed to either the member at the latest address on HMOC membership records or to the member's employer. Nothing in this paragraph will create any notice obligations or fiduciary duties for HMOC except those expressly identified in this certificate. Member's Legal Expense Obligations The employee and his/her dependents are liable for any actions that may prejudice HMOC's rights under this plan. If HMOC must take legal action to uphold its rights and prevails in that action, HMOC will be entitled to receive and the member will be required to pay HMOC's legal expenses, including attorneys' fees and court costs. 97000 (Rev. 5-01) 41 Customer Service(800)334-6557 or(303)831-0161 Section 7: Enrollment and Termination Information BlueAdvantage HMO 7: Enrollment and Termination Information Who Is Eligible Medicare eligibility. The member should then contact All employees living within the HMOC service area, who his/her employer to discuss coverage options. have a regular workweek as specified in the Group Master If an employee qualifies under the provisions of federal law Contract are eligible for coverage. To find out the number of hours you must work per week in order to qualify, for the working aged (TEFRA), then the working employee q fy, contact g spouse age 65 or over and/or his/her age 65 or over may your employer. continue coverage under this health care plan. If a TEFRA- Other persons in a nonemployee relationship with the group eligible Medicare beneficiary selects Medicare as his or her or business may also be eligible for coverage, if specified in primary coverage, coverage under this plan ends for this the Group Master Contract(e.g., member. retirees or COBRA-eligible members). Special Medicare Secondary Payer (MSP) rules apply if a HMOC reserves the tight to verify an employee's eligibility for member is receiving benefits from Medicare due to a dis- ability or end-stage renal disease. Contact your employer for coverage by requesting proof that a valid employer-employee relationship exists and that the employee otherwise meets the more information and for eligibility guidelines that apply to eligibility requirements as stated in the Group Master Contract you. and the employee's application. The employer has agreed to For groups with fewer than 20 employees and all other permit HMOC to perform payroll audits. groups not subject to MSP provisions, when a member becomes eligible for Medicare Part A and/or Part B, cover- Eligible Dependents age under this certificate will continue, but benefits will be A dependent child's eligibility is subject to an age coordinated with Medicare with this coverage being second- limitation. ary to any Medicare coverage. Eligible dependents include: Notification of Eligibility Changes • a legal spouse An employee must notify HMOC within 31 days following any changes that may affect his/her or a dependent's eligibility • an unmarried child under 19 years of age and unmarried by indicating such changes on an enrollment/change form. It is child under 24 years of age who is financially dependent also the employee's responsibility to notify HMOC of any upon the parent. At the end of the month of the limiting change to a member's name or address. age, as appropriate, the child is automatically removed from coverage as a dependent We must receive substan- When Coverage Begins tiating documentation of financial dependency. Your employer will determine the effective date of your coverage according to the provisions of the Group Master • an unmarried child of any age who is medically certified Contract. Your ID card will also indicate the member's as disabled and dependent upon the parent. We must effective date of coverage. receive notice of the condition. This plan does not cover any service received before the Note: A child includes, natural-born children of the sub- member's effective date of coverage. Also, if the employee's scriber or the subscribers spouse, adopted children, a child prior coverage has an extension of benefits provision, HMOC placed for adoption, or a child required to be covered will not cover charges incurred after a member's effective date because of a court order pursuant to state law. A child does under this plan that are covered under the prior coverage. If a not include grandchildren or other children unless legal member is receiving inpatient care on the effective date of guardianship has been established pursuant to state law. We coverage, services will be covered under this certificate if the may request proof that a child qualifies as an eligible member receives services from an HMOC provider. dependent. Application for Coverage Medicare-Eligible Members Eligible employees can apply for coverage for themselves and Before a member becomes age 65, or if any member quali- fees for Medicare benefits, the member is responsible for their eligible dependents by submitting an enrollment applica- tion to this plan within 31 days after becoming eligible. contacting the local Social Security office to establish Employees may also apply within 31 days of acquisition for 97000(Rev. 5-01) 42 Customer Service (800)334-6557 or(303)831-0161 Section 7: Enrollment and Termination Information BlueAdvantage HMO coverage of newly acquired dependents (such as a newborn following the marriage or acquisition (charges related to child, a child placed in the employee's home for the purpose labor and delivery due to the birth are not covered). of adoption, an adopted child, or a new spouse). When dependents are added, you may need to change to suitable When an employee is required by court or administrative coverage based on the number of family members being order to provide coverage for an eligible dependent, the covered. Dependent coverage is effective on the date the eligible dependent may be enrolled within 31 days of such dependent became eligible. With the exception of members order. If not specified in the court order, the eligible who did not enroll when initially eligible because they had dependent's effective date of coverage will be the date of other group coverage which was subsequently lost,application HMOC's receipt of the court order. (HMOC must receive a for coverage from late applicants will be accepted during open copy of the court order.) enrollment. See"Late Applicants,"below. Late Applicants With some employer groups, premium may be determined Anyone eligible who did not enroll during the group's initial by the age of the subscriber, with premium set by age enrollment, within 31 days of becoming eligible, or within brackets. We may change premium when you change to a 31 days of a special enrollment is considered a late applicant new age bracket. If upon enrollment the age of the and will not be allowed to enroll until the group's next open subscriber is misstated, all amounts payable for the correct enrollment. For example, a newborn child added to coverage age shall be adjusted and billed to the group. more than 31 days after birth or a child placed in the employee's home for the purpose of adoption added more Open Enrollment than 31 days after legal adoption is a late applicant. A new An open enrollment period (usually 30 days prior to the employee or a new spouse added to coverage more than renewal date) will be held annually or at other times as 31 days after becoming eligible is also a late applicant. mutually agreed upon by the employer and HMOC. During the open enrollment period, any eligible employee and/or If an employee enrolls as a late applicant, eligible depen- his/her eligible dependents may enroll as members under dents seeking coverage at the same time will also be late this plan. applicants. Switch Enrollment Adding a Newborn or Adopted Child If your group provides a multiple choice health care program The employee must enroll a newborn child, a child placed to its members,during group renewal covered employees may for adoption, or an adopted child within 31 days of the switch coverage for themselves and their covered dependents, child's birth, placement, adoption. (A newborn child of an to another product offered by the group. unmarried dependent son or daughter does not qualify as a dependent under this plan.) Special Enrollment If the employee declined enrollment for him/herself or his/her The following rules apply to newborn children from birth dependents because of other coverage, the employee and and to adopted children from the earlier of the date of adop- dependents may enroll in the future in this plan provided that the tion or placement for adoption as certified by the public or employee requests enrollment within 31 days after the other private agency making the placement: coverage involuntarily ends. The other coverage must be lost due to termination of employment or eligibility, reduction in the • Under Individual coverage, an employee's newborn number of hours the employee works,the involuntary termination child, adopted child, or a child placed in the employee's of creditable coverage, death of a spouse, legal separation or home for the purpose of adoption, will be covered divorce, or the contribution towards the coverage terminating. automatically until the newbom child is 31 days old or the Coverage with HMOC will be effective the day following the loss child has been with the employee for 31 days; however, of other coverage. If the other coverage that is lost is COBRA or the employee must submit an enrollment/change form to state continuation coverage,enrollment can only be requested after notify HMOC of the birth, adoption, or intended exhausting COBRA or state continuation coverage. adoption,and select a PCP for the child. A special enrollment can also occur when an employee who If the child is to continue coverage beyond the 31st day, was previously not enrolled, marries or has a new child (as a the employee must notify HMOC within 31 days after result of marriage, birth, adoption or when a child who is the child's birth, adoption, or placement in the home. under the age of 18 is placed in the employee's home for the The employee must change to suitable coverage within purpose of adoption.)The employee and any dependents can that same 31-day period and agree to pay the premium enroll within 31 days of the marriage or acquisition of the for such coverage beginning on the 32nd day. dependent. Coverage with HMOC will be effective the day 97000(Rev.5-01) 43 Customer Service(800)334-6557 or(303)831-0161 Section 7: Enrollment and Termination Information BlueAdvantage HMO • Under Family coverage, an employee's newborn child, covered on the date the leave of absence begins through the adopted child,or child placed in the employee's home for the end of the month during which the leave begins. During a purpose of adoption, will be covered automatically until the leave of absence covered by the FMLA or state or federal newborn child is 31 days old or the child has been with the law, coverage will continue as provided by law. Contact employee for 31 days; however, the employee must submit your employer for information. an enrollment/change form to notify I-ItvfOC of the birth, adoption, or intended adoption, and select a PCP for the Coverage Termination child. Any member losing eligibility under this plan may be able to continue as a group member for a limited period of time. To ensure that coverage is provided beyond the first 31 Contact your employer for information on continuation of days, the employee must submit an enrollment/change BlueAdvantage HMO Plan coverage under Colorado law or form to HMOC within 30 days of birth, adoption, or placement in the home. federal law (Consolidated Omnibus Budget Reconciliation Act of 1985—COBRA). Note: The coverage established for a child during the initial 31-day period is identical to that of the employee. All ser- This plan does not cover services, even if prior authorized vices provided during the first 31 days of coverage are sub- by HMOC, that are received after a member's coverage ject to the terms of this certificate, including all applicable under this health care plan is terminated -- even if the copayments. services were made necessary by an accident, illness, or other event that occurred while coverage was in effect, or If an employee does not change coverage or add the child to the member was hospitalized at the time of termination. existing coverage within 31 days of birth, adoption, or placement for adoption, the child will be considered a late When Coverage Ends applicant and coverage for the child cannot be added until If a member does not elect or does not qualify for the group's next open enrollment. continuation coverage, coverage for any member (including dependents)ends on the earliest of the following dates: If the mother of the newborn is a dependent child of the employee (i.e., the newborn is the grandchild of the • When the member's group gives HMOC 30 days' employee),benefits are not available for the newborn. advance written notice of termination. Removing a Dependent From • The end of the month following the employee's Coverage termination of employment. If the group fails to notify HMOC within 30 days to remove an ineligible person To remove a dependent from coverage, the employee must from coverage, HMOC reserves the right to recover any complete and submit an enrollment/change form. HMOC payment made on the employee's or his/her dependent's must receive this form within 31 days following the behalf. effective date of the change. If an employee fails to timely remove an ineligible dependent,HMOC and the providers of • The date group coverage is discontinued for the entire care may recover benefits erroneously paid to the employee group or for the employee's enrollment classification. on behalf of the removed member. • When the member moves and therefore neither resides nor BMOC will not refund membership premiums paid in works within the HMOC service area, unless the member is advance on behalf of the removed member if: continuing coverage under COBRA continuation.The mem- ber must notify HMOC within 31 days of such a change in • the enrollment/change form is not received within 31 location. Coverage will end on the last day of the month in days of the effective date of change; or which the change of residence is reported;until that time,the only out-of-area services covered will be emergency care • any claims or capitation amounts have been paid on (see the Glossary). Nonemergency care will not be behalf of the removed member during the period for covered. which premiums have been paid. If a member does not notify HMOC of a change of resi- Leave of Absence dence or workplace to an area outside of the HMOC service area, and HMOC later becomes aware of the For a leave of absence not covered by the Family and Medical Leave Act (FMLA) or by state of federal law, coy- change, the member's dat coverage may be retroactively cr erage may continue for employees and eligible dependents terminated to the date of the change of residence or 97000(Rev. 5-01) 44 Customer Service(800)334-6557 or(303)831-0161 Section 7: Enrollment and Termination Information BlueAdvantage HMO place of employment. The member will be liable to specified on your Colorado Health Plan Description HMOC and/or the providers for payment for any Form. services covered in error. • The date of a final divorce decree or legal separation for • Upon the employee's death (surviving eligible depen- a dependent spouse. dents remain covered through the last-paid billing period). • When the employee notifies HMOC in writing to end coverage for a dependent. • When HMOC does not receive the premium payment on time. Except for termination of the Group Master Contract or termination due to loss of eligibility, HMOC will not termi- • When there is a misrepresentation or improper use of the nate a member's coverage without giving the member Group Master Contract,certificate, or ID card,the improper 30 days' written notice. Also, if the employer fails to submit filing of claims, or false or incomplete information is premium payments to HMOC on a timely basis, coverage presented on the enrollment/change form. The employee is will terminate for all affected members as of the end of the liable for any benefit payments made as a result of such last-paid billing period.HMOC will notify the members of improper actions. HMOC has the right to void the coverage any conversion of coverage rights. of a member who engages in fraudulent conduct relating to claims or application for coverage under the certificate, as Conversion Coverage determined by HMOC. Members who were covered under the group health program • When Medicare becomes the member's primary coy- may change to group conversion coverage with HMOC when this group health program ends, for any reason, other erage, unless the member is in a group with fewer than 20 employees (see "Medicare-Eligible Members," ear- than replacement by the employer with another group tier in this section). policy, or fraud and abuse in procuring and using the coverage. • In accordance with "Refusal to Follow Recommended Treatment" in Section 6: Claims Payment and Appeals, HMOC must receive the application for group conversion coverage within 31 days after group coverage is terminated. when the member is unable to establish a positive The member must pay group conversion premium from the patient-physician relationship with a PCP. date of such termination. • When the member acts in a disruptive manner that prevents the orderly business operation of any HMOC Group conversion is not available to former employees of a participating provider or is dishonestly attempting to group and their dependents in the following situation: gain a financial or material advantage. • When an employee is not a group member by virtue of • When HMOC ceases operations. HMOC will be obli- not having been covered under the group plan at the gated for services for the rest of the period for which time of termination of coverage. premiums were already paid. • When a dependent was not covered through the group at • When the member is no longer eligible for this group the time of the employee's termination of coverage. coverage under the terms of the Group Master Contract. • When the employer group cancels and replaces cover- In addition, coverage will end for any dependent on the age with another insurance carrier or self-insures. earliest of the above dates or the earliest of the following • When there is fraud and abuse in procuring and using dates: coverage. • When the dependent child marries. • When an employee or dependent is eligible for Medi- • At the end of the last-paid billing period for dependent care Part A and/or Part B at the time of eligibility for group conversion coverage. Contact HMOC for cover- coverage. age options available. • When the dependent no longer qualifies as a dependent under the plan or reaches the dependent age limit 97000(Rev. 5-01) 45 Customer Service (800)334-6557 or(303)831-0161 Section 7: Enrollment and Termination Information BlueAdvantage HMO NOTE: If you do not want or are not eligible for conversion coverage, HMOC will consider applications for enrollment of members as new nongroup members under then-available coverage, rates, and benefits. HMOC will accept your appli- cation subject to applicable rules for non-group coverage. Membership Records HMOC will keep membership records, and the employer will periodically forward information to HMOC to admin- ister the coverage of this plan. All records concerning your membership in HMOC are available for your inspection during normal business hours given reasonable advance notice. Certificates of Coverage • When an individual leaves HMOC, they are entitled to receive a certificate of coverage which will identify the length of the individuals credited coverage under the plan. This Certificate of Coverage is needed when the individual enrolls with another plan that may impose a pre-existing condition waiting period. 97000(Rev. 5-01) 46 Customer Service(800)334-6557 or(303)831-0161 Section 8: General Provisions BlueAdvantage HMO 8: General Provisions Advance Directives setting forth the services to which members are entitled and, An advance directive is a written instruction, such as a living for each member,a BlueAdvantage identification card. will or durable power of attorney for health care, recognized under state law relating to the provision of health care when Disclaimer of Liability the individual is incapacitated. HMOC has no control over any diagnosis, treatment, care, or other service provided to a member by any facility or The law provides anyone with the right to determine whether professional provider, whether participating or not, and is health care services should or should not be provided if not liable for any loss or injury caused by any health care he/she were to become incapacitated. These advance direc- provider by reason of negligence or otherwise. tives will guide health care providers. HMOC encourages the member to discuss this with the PCP. Execution of Papers On behalf of yourself and your dependents you must, upon Binding Arbitration request, execute and deliver to HMOC any documents and The "Binding Arbitration" provision is applicable to all papers necessary to carry out the provisions of this plan. governmental plans, church plans, and plans maintained outside the United States primarily for the benefit of persons Fraudulent Insurance Acts substantially all of whom are nonresident aliens. If a dispute It is unlawful to knowingly provide false, incomplete, or about coverage, benefits, or handling of claims continues misleading facts or information to an insurance company after the member has followed and exhausted the "Com- for the purpose of defrauding or attempting to defraud the plaint Procedures" set forth in Section 6, the issue or claim company. Penalties may include imprisonment,fines,denial must be submitted to binding arbitration. Any such of insurance,and civil damages.Any insurance company or arbitration will be governed by the procedures and rules agent of an insurance company who knowingly provides established by the American Arbitration Association. To the false, incomplete, or misleading facts or information to a extent applicable, Colorado law governing arbitration will policyholder or claimant for the purpose of defrauding or govem. Members may obtain a copy of the Rules of attempting to defraud the policyholder or claimant with Arbitration from a customer service representative. regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of The decisions in arbitration are binding upon both the insurance within the department of regulatory agencies. member and HMOC. Judgment on the award given in arbi- tration may be enforced in any court that has proper Independent Contractors authority. The relationship between HMOC and its HMOC partici- pating providers is that of independent contractors; physi- Damages, if any, are limited to the amount of the benefit cians and other providers are not agents or employees of payment in dispute plus reasonable costs. HMOC is not HMOC,and HMOC and its employees are not employees or liable for punitive damages or attorney fees. agents of any HMOC participating provider. HMOC will not be liable for any claim or demand on account of damages Changes to the Certificate arising out of, or in any manner connected with,any injuries HMOC may amend this certificate when authorized by an suffered by the member while receiving care from any officer of HMOC. Any amendment will be provided to the HMOC participating provider. employer within 60 days following the effective date of the amendment. The relationship between HMOC and the group is that of independent contractors; the employer is not an agent or No employee of HMOC may change this certificate by employee of HMOC, and HMOC and its employees are not giving incomplete or incorrect information, or by contra- employees or agents of the employer. dieting the terms of this certificate. Any such situation will not prevent HMOC from administering this certificate in Non-Contestable strict accordance with its terms. This certificate shall not be contested except for nonpayment of premiums by the employer, after it has been in force for Delivery of Documents two years from its date of issue. No statement made for the HMOC will issue to the employer, or mail to the member's purpose of effecting coverage under the certificate with address as listed on the enrollment/change form, a certificate respect to a member shall be used to avoid the insurance 97000(Rev. 5-01) 47 Customer Service(800)334-6557 or(303)831-0161 Section 8: General Provisions BlueAdvantage HMO with respect to which statement was made or to reduce A member must provide HMOC with whatever information benefits under such certificate after such insurance had been is necessary to determine coverage. HMOC may obtain in force for a period of two years during such member's information from any insurance company, organization, or lifetime, unless such statement is contained in written instru- person when such information is necessary to carry out the ment signed by the member making such statement and a provisions of this plan. Such information may be exchanged copy of that instrument is or has been furnished to the without consent of,or notice to,the member. member making the statement or to the beneficiary of any such member. Members agree to cooperate at all times (including while hospitalized) by allowing HMOC access to their medical Pilot Programs records to investigate claims or issues of quality of care, and HMOC may occasionally develop pilot programs to test verify information provided on the enrollment/change form different services or recognize different providers. The fact and/or health statement. Members also agree to execute that a pilot program may exist does not guarantee that all whatever documents are necessary in order for HMOC to members are eligible for coverage of pilot program services, determine coverage under this plan. If a member does not or that such services will be covered permanently. cooperate, the member forfeits all rights to benefit payments on those claims subject to investigation and acknowledges Release of Information that his/her coverage may be cancelled. Ordinarily, HMOC will not release medical information without the member's written consent. That information is To help HMOC determine which services qualify for strictly confidential. Patients are given the opportunity to coverage, members authorize all providers of health care approve or refuse the release of medical information. We services to provide HMOC with any medically related have policies and procedures in place on how to obtain information pertaining to their treatment. consent for member medical information,how members may access their medical records and how we protect access to Members waive all provisions of law that are subject to waiver, and which otherwise restrict or prohibit providers of member medical information. However, a BlueAdvantage member authorizes HMOC to release medical information health care services or supplies from disclosing or testifying without notice or consent when they signed the enrollment to such information. application for the following situations: Statement of ERISA Rights • Peer and utilization review boards and/or HMOC The group health care coverage provided by your employer medical consultants need such information, or such may be part of an employee welfare benefit plan governed information is needed for quality assurance activities to by the Employee Retirement Income Security Act of 1974 ensure that the member is getting appropriate and (ERISA). The statement of ERISA rights is applicable to all medically necessary care and that services are among plans except governmental plans, church plans, and plans those covered by this plan. maintained outside the United States primarily for the benefit of persons substantially all of whom are nonresident • HMOC receives a judicial or administrative subpoena aliens. As a participant in an ERISA plan,you are entitled to for such information. certain rights and protections under ERISA. ERISA provides that all plan participants be entitled to: • The Colorado Division of Insurance requests such information ■ Examine at the plan administrator's office, without charge, copies of all documents filed by the plan with • The information is required for coordination of benefits. the U.S. Department of Labor, such as detailed annual reports and plan descriptions. • The information is requested or provided in connection with group utilization data. We will not provide • Obtain copies of all plan documents and other plan member identifiable information in connection with this information upon written request to the plan administra- data unless we receive your consent. tor. The administrator may make a reasonable charge for the copies. If it is necessary for us to provide member identifiable medical or other information we will contact you for your • Receive a summary of the plan's annual financial consent, unless we are required by law to release such report. The plan administrator is required by law to fur- information. nish each participant with a copy of this summary annual report. 97000(Rev. 5-01) 48 Customer Service(800)334-6557 or(303)831-0161 Section 8: General Provisions BlueAdvantage HMO In addition to creating rights for plan participants, ERISA Utilization Review and Quality Management imposes duties upon the people who are responsible for the Medical records, claims, and requests for covered services operation of the employee benefit plan. The people who may be reviewed to establish that the services are/were operate your plan, called "fiduciaries" of the plan, have a medically necessary, delivered in the appropriate setting, duty to do so prudently and in the interest of you and other and consistent with the condition reported and with plan participants and beneficiaries. No one, including your generally accepted standards of medical and surgical employer or any other person, may fire you or otherwise practice in the area where performed. discriminate against you in any way to prevent you from obtaining health care benefits or exercising your rights under ERISA. If your claim for a benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have the right to have the plan review and reconsider your claim. You must follow the "Complaint Procedures"set forth in Section 6. Under ERISA, there are steps you can take to enforce the above rights after you have exhausted the "Complaint Procedures." For instance, if you request materials from the plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $100 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits that is denied or ignored, in whole or in part,you may file suit in federal court after you have exhausted the "Complaint Procedures" set forth in Section 6. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who, if anyone, should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose,the court may order you to pay these costs and fees. If you have any questions about your plan, contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, contact the nearest Area Office of the U.S. Labor-Management Services Administra- tion, Department of Labor. Please be advised that this plan document gives the plan administrator or fiduciary discretionary authority to deter- mine eligibility for benefits or to construe the terms of the plan.The plan specifically reserves to the plan administrator or fiduciary, the discretion and authority to make such determinations. HMOC is not the administrator of your employer's plan, but is a fiduciary. Contact your employer to find out who is the plan administrator. 97000(Rev. 5-01) 49 Customer Service (800)334-6557 or(303)831-0161 Section 9: Glossary BlueAdvantage HMO 9: Glossary This section defines certain words used throughout the jeopardy. HMOC covers emergency services necessary to certificate. Reading this section will help you understand screen and stabilize a member without prior authorization the rest of the certificate. You may also want to refer back from HMOC if a prudent lay person having average to this section to find out exactly how—for the purposes knowledge of health services and medicine and acting of this certificate—a word is used. reasonably would have believed that an emergency medical condition or life or limb threatening emergency Admission — the period of time between the date a existed. patient enters a facility as an inpatient and the date he or she is discharged as an inpatient. Employee the individual whose employment or other status, except for family dependency, is the basis for After-hours care — office services requested after a enrollment eligibility. The term"employee"may also encom- provider's normal or published office hours or services pass other persons in a relationship with the employer,such as requested on weekends and holidays. retirees, members of the board of directors, etc., if eligible under terms of the Group Master Contract. The term Authorization—see"Prior authorization,"below. "employee" may also refer to a member enrolled as a COBRA participant. Billed charges—the full amount the provider charges for a particular service. Experimental or investigative see "Experimental or Investigative Procedures or Services" in Section 4: Certificate—this document, which explains the benefits, General Exclusions. limitations, exclusions, terms, and conditions of the member's health coverage. The final interpretation of any Facility—see"Provider,"below. specific provision contained in this certificate is governed by the Group Master Contract. Group a bona fide employer covering employees of such employer for the benefit of persons other than the Colorado Health Plan Description Form The employer; or an association, including a labor union, that schedule that defines the member's copayment require- has a constitution and bylaws and is organized and ments and optional coverages, along with an overview of maintained in good faith for purposes other than that of covered services. obtaining insurance. Copayment — the amount the member must pay for a Group Master Contract — a contract for health care covered service. Copayments are listed on the Colorado services which by its terms limits eligibility to members of Health Plan Description Form and are either a predeter- a specified group. The Group Master Contract includes mined fixed-dollar amount or a percentage of billed the group application for coverage and may include charges. coverage for dependents. Covered services — services and supplies which are HMO Colorado(HMOC)—a federally qualified health provided to a member and for which HMOC has an maintenance organization organized under the laws of the obligation to pay under the terms of this certificate. State of Colorado except as described below. Dependent a person entitled to apply for coverage as For employers with 50 or fewer employees,the BlueAdvantage specified in Section 7: Enrollment and Termination HMO plan is not federally qualified. Information. For employers with 51 or more employees,the BlueAdvantage Effective date of coverage 12:01 A.M. of the date on HMO plan is federally qualified in the following Colorado which coverage for a member begins. counties: Emergency care — Means the sudden, and at the time, Adams Arapahoe Boulder Clear Creek unexpected onset of a health condition that requires Crowley Denver Douglas El Paso immediate medical attention, where failure to provide Fremont Gilpin Huerfano Jefferson medical attention would result in serious impairment to Larimer Otero Pueblo Teller bodily functions or serious dysfunction of a bodily organ Weld or part, or would place the persons health in serious 97000 (Rev. 5-01) 50 Customer Service(800)334-6557 or(303)831-0161 Section 9: Glossary BlueAdvantage HMO For employers with 51 or more employees, if a county is ■ provided for the diagnosis, or the direct care and not listed above, this BlueAdvantage HMO Plan is not treatment of the member's condition, illness, disease, federally qualified,but does meet all the requirements of a or injury; federally qualified plan. • in accordance with standards of sound medical HMOC participating provider—either a facility, such as practice; a hospital, or a professional provider, such as a physician, that has entered into an agreement with HMOC to bill ■ not primarily for the convenience of the member, the directly, and to accept this plan's payment (provided in member's family,or the member's provider; and accordance with the provisions of the contract) plus the member's copayment as payment in full for covered ser- ■ the most appropriate supply or level of service that vices. HMOC will pay the participating facility or pro- can safely be provided to the member. When applied fessional provider directly. BMOC may add, change, or to hospitalization, this also means that the member delete specific providers at its discretion or recommend a requires inpatient acute care due to the nature of the specific provider for specialized care as medical necessity services rendered or of the member's condition, and warrants. the member cannot receive safe or adequate care as an outpatient. HMOC service area — the geographic area where BMOC is licensed to conduct business. Note: BMOC's decision as to whether a service is medi- cally necessary is based on generally accepted medical or HMO-USA a national network of Blue Cross and Blue surgical standards. Coverage for services that are not Shield-sponsored HMOs through which nationwide urgent medically necessary may be denied either before or after care services are available to BlueAdvantage members. they are rendered. • Hospital — a health institution offering facilities, beds, The fact that a physician may prescribe, order, recom- and continuous services 24 hours a day, seven days a mend, or approve a service does not, by itself, make it week. The hospital must meet all licensing and certifi- medically necessary or a covered service,even though it is cation requirements of local and state regulatory agencies. not specifically listed as an exclusion. Identification card (ID card) — the card BMOC issues Member—the employee or any eligible dependent who to the employee and each of his/her dependents that is enrolled for coverage under this plan in accordance with identifies the cardholder as a BlueAdvantage member. the terms of the Group Master Contract. Inpatient—a patient in residence in a hospital or facility Member's service area — the geographic area serviced for at least one full night. Any services received as an by the member's personal care network. inpatient are inpatient services (also, see "Admission" in this section). Nonparticipating provider — an appropriately licensed health care provider that has not contracted with HMOC. Maternity any condition that is related to pregnancy. Except as described in Section 3: Covered Services, Maternity care includes prenatal and postnatal care, and BMOC will not cover services provided by a non- care for the complications of pregnancy, such as ectopic participating provider. The member will be financially pregnancy, spontaneous abortion (miscarriage), elective responsible for such services unless referred to the abortion, or cesarean section. See "Maternity and provider by his/her PCP, and then only if the referral is Newborn Care" in Section 3: Covered Services for more approved by HMOC or if a service does not require a information. referral. Medically necessary A term used to describe Open enrollment — a period of time (usually 30 days) technologies, services, or supplies received from a before the renewal date of the group during which eligible provider that BMOC determines are: employees and dependents may select BlueAdvantage coverage. • medically appropriate, considering the patient's age and health, for the symptoms and diagnosis or Out-of-area services — those covered services that are treatment of the condition,illness, disease,or injury; provided to a member when the member is outside the HMOC service area. See"BMOC service area,"above. 97000(Rev. 5-01) 51 Customer Service(800)334-6557 or(303)831-0161 Section 9: Glossary BlueAdvantage HMO Pay, paid, or payment—to satisfy a debt or obligation. • Referral provider: a provider to whom a PCP has HMOC may satisfy its responsibility to providers for referred a member for consultation and/or treatment. covered services under this certificate by making a monthly fixed payment to the provider, by a negotiated Referral—a written authorization form from a member's discount arrangement, by an actual dollar payment, or by PCP or from HMOC,received in advance of services, that any combination of these three arrangements. allows a member to receive services from a provider other than the member's PCP. Personal care network — a specific network of pro- viders covering a geographic service area. It includes one Routine care — services for conditions not requiring hospital and certain PCPs and specialists. In some parts of immediate attention and that can usually be received in the the HMOC service area, all specialties and facility PCP's office,or services that are usually done periodically services may not be available in the member's personal within a specific time frame(e.g., immunizations,physical care network. In these circumstances, the member's PCP exams). may refer the member outside of his/her personal care network. Service area—see"HMOC service area,"above. Physician — a doctor of medicine or osteopathy who is Urgent care—situations that are not life-threatening but licensed to practice medicine under the laws of the state or require prompt medical attention to prevent serious jurisdiction where the services are provided. deterioration in a member's health. Plan the benefits, copayments, exclusions, and limita- tions described in this certificate and administered by HMOC. Prior authorization — a requirement for approval from HMOC before delivery of certain types of services. Before the service is received, the physician must obtain written approval for coverage. Provider—a term used to describe any of a wide variety of people or facilities that render health care services. Many of the different providers are defined here. • Facility provider:an alcohol or drug treatment center,day surgery or ambulatory surgery center,home health agency, skilled nursing facility, hospital, or other facility that is licensed or certified to perform designated,covered health care services by the state or jurisdiction where services are provided. • Primary care provider(PCP): a physician(or group of physicians) who has contracted with HMOC to supervise, coordinate, and provide initial and basic care to members, initiate a referral for specialist care, and maintain continuity of patient care. • Professional provider: a physician or other profes- sional provider who is licensed, certified, or registered by the state or jurisdiction where services are provided to perform designated, covered health care services, and who is recognized by HMOC as a health care provider. Ancillary providers, such as professional suppliers of medical supplies and equipment may be considered professional providers. 97000(Rev. 5-01) 52 Customer Service(800)334-6557 or(303)831-0161 Hello