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Lincoln National Administrative Services Corporation ri LINCOLN
Lincoln National Life Insurance Company NATIONAL
Lincoln National Health Plan EMPLOYEE BENEFITS
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February 20, 1992 •ocIO
Patti May ! � �
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O B 758 Weld County
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Greeley, CO 80632 kll
Dear Patti :
Enclosed are amendments to the Master Group Contract and Evidence of Coverage
which comprise your contract with Lincoln National Health Plan (HMO) .
The amendment to the Master Group Contract replaces Section Vi , Continuation of
Coverage Under State Law. The amendment to the Evidence of Coverage, in addition
to replacing the portion of Section VI mentioned above, also entirely replaces
Sections II and III . These changes are administrative corrections only and do
not affect eligibility of benefits. Please file these amendments with your
contract .
Also enclosed is a copy of the revised Prescription Medication Addendum to the
Master Group Contract and Evidence of Coverage. The new addendum replaces the
Prescription Addendum you received with your Master Group Contract . Please file
this revised addendum with you contract for future reference.
Your employees should have received their 1992 Evidence of Coverage and we are
In the process of sending the Evidence of Coverage amendment and an amendment to
the Prescription Medication Addendum to affected members. We have enclosed a
sample of this for your Information.
You are a valued client of Lincoln National Health Plan and we appreciate the
opportunity to serve you. If you have any questions, please call your Service
Representative at 223-9898 or 1-800-999-5309.
Sincer, y,
Pat Bode
Service Representative
Fort Collins Field Office
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2627 Redwing Rd. 7979 East Tufts Avenue 5725 Mark Dabling Blvd. --
Suite 120 Suite 700 Suite 150 188
Fort Collins, CO 80526 Denver,CO 80237 Cob. Springs, CO 80919
(303)223-9898 (303)779-4700 (719)548-8700
•
Lincoln National Health Plan of Colorado
Master Group Contract
Amendment I (Effective 01/01/92)
Design I - 6729(10/91) Design III - 6910(10/91) Design IV - 6928(12/91)
Design Va - 6752(10/91) Design VIa - 6753(10/91) Design IXa - 6754(10/91)
Design X - 6730(10/91)
This amendment replaces Section VI, Continuation Coverage, Part II: Continuation of Coverage Under State Law.
Part II: Continuation of Coverage Under State Law
An Enrollee whose Coverage ends under the Contract may be entitled to elect continuation Coverage under state law, if the
Enrolling Unit is not subject to the requirements of COBRA, or as an alternative to COBRA when both state law and
COBRA apply.
The Enrollee's Coverage must have ended due to termination of employment. The Enrollee shall not be entitled to
continuation Coverage under state law if:
a. Health Services Fees for Coverage up to the termination date have not been paid by or on
behalf of the Enrollee; or
b. the Enrollee has not been continuously covered under the Contract, or under any coverage
plan providing similar coverage which the contract replaced, for at least six (6) months
immediately prior to termination from employment; or
c. the Enrollee is covered by Medicare of Medicaid; or
d. the entire Contract is discontinued.
The Enrollee must elect continuation Coverage and pay Health Services Fees due within twenty (20) days from the date of
termination from employment.
Continuation of Coverage under state law will end after a period of ninety(90) days after the date Coverage would have ended,
or until the Enrollee is reemployed,whichever occurs first. At the end of the ninety(90) day continuation period under state
law, the Enrollee or the Enrolled Family Dependents are entitled to conversion privileges as described below.
Coverage may be continued for enrollees working 40 hours or more when the working hours are reduced to less than 30 hours
because of economic conditions. Coverage may also be continued for such enrollees enrolled family dependents.
Coverage may be continued provided:
1. the enrollee has been continuously covered under the Contract,or under any coverage plan
providing similar coverage which the Contract replaced, for at least six (6) months
immediately prior to the reduction in working hours;
2. the enrolling unit has imposed the reduction in hours due to economic conditions;
3. the enrolling unit intends to restore the enrollee to a full 40 hour work schedule as soon as
economic conditions improve; and
4. the applicable Health services Fees are paid.
•
Lincoln National Health Plan of Colorado
Evidence of Coverage
Amendment I (Effective 01/01/92)
Design I - 6729(10/91) Design III - 6910(10/91) Design IV - 6928(12/91)
Design Va - 6752(10/91) Design Via - 6753(10/91) Design IXa - 6754(10/91)
Design X - 6730(10/91)
This amendment replaces Sections II and III entirely and Section VI,Continuation Coverage,Part II:Continuation of Coverage
Under State Law.
Section II
ENROLLMENT AND EH'_ECTIVE DATE OF INDIVIDUAL COVERAGE
A. Enrollment
Eligible Persons may enroll themselves and their Family Dependents in PLAN during the Initial Eligibility
Period or during an Open Enrollment Period specified by PLAN by submitting application on a form
provided or approved by PLAN. In addition, new Eligible Persons may be enrolled in PLAN within 31 days
of the date on which they first become Eligible Persons, and new Family Dependents may be enrolled in
PLAN within 31 days of the date on which they first become Family Dependents, except that Family
Dependents who are newborn children are covered at the moment of birth. Except during the time periods
set forth in this paragraph,Eligible Persons and/or Family Dependents may not enroll in PLAN without the
express written authorization of PLAN and evidence of insurability.
The Enrolling Unit shall notify PLAN in writing within sixty (60) days of the effective date of enrollments,
terminations or other changes; provided,however, that the Enrolling Unit shall notify PLAN in writing each
month of any changes in the Coverage classification of any Enrollee.
B. Effective Date of Coverage
Coverage for an Eligible Person and his or her Family Dependents, if any, is effective on the date specified
by Enrolling Unit and PLAN, provided that PLAN receives a properly completed individual enrollment
application that was submitted to PLAN according to the enrollment provisions of Section ILA of the
Contract; and provided, however, that:
1. No Coverage shall be effective until the Contract takes effect;
2. No Family Dependent shall be covered under the Contract until the Eligible Person is
covered.
3. If an Enrollee acquires a new Family Dependent by reason of adoption or marriage, then
Coverage for that Family Dependent shall take effect on the date that the new Family
Dependent is adopted or married, if PLAN and Enrolling Unit is notified by the Enrollee
of the adoption or marriage within thirty-one (31) days of occurrence; and any necessary
adjustments to Health Services Fees have been made.
4. If an Enrollee acquires a new Family Dependent who is a newborn child,then Coverage for
that Family Dependent shall take effect at the moment of birth and remain in effect for
thirty-one (31) days beyond the date of birth. To continue Coverage for that Family
Dependent,the Enrollee shall notify PLAN and Enrolling Unit of the newborn child's birth
and the name; and make any necessary changes in the Coverage classification and Health
Services Fees.
5. Health Services for medical conditions arising prior to the effective date of Coverage and
resulting in Confinement are covered as of the effective date only if the Covered Person
notifies PLAN of Confinement within forty-eight(48)hours of the effective date,or as soon
thereafter as is reasonably possible, and if Health Services are received in accordance with
the terms, conditions, exclusions and limitations of the Contract.
Section III
,
•
PROCEDURES FOR REIMBURSEMENT OF ELIGIBLE EXPENSES
Reimbursement of Eligible Expenses
PLAN shall reimburse for Eligible Expenses incurred with non-participating providers only for MEDICALLY NECESSARY
EMERGENCY SERVICES OR SERVICES AUTHORIZED OR APPROVED BY PLAN in accordance with the terms of
the Contract.
Participating Providers are responsible for submitting written proof of loss for Eligible Expenses directly to PLAN on the
Covered Person's behalf. In the event a Covered Person is billed by a Participating Provider for Eligible Expenses, the
Covered Person should contact PLAN.
Written proof of loss for services rendered by non-participating providers,satisfactory to PLAN,shall be furnished at PLAN's
office within ninety(90) days after the date of such loss. Failure to furnish proof within the time required shall invalidate or
reduce Coverage unless it was not reasonably possible to have given proof within ninety (90) days or, in the absence of legal
capacity of the Covered Person, later than one (1) year from the time in which proof is otherwise required.
All Eligible Expenses shall be paid within sixty (60) days of receipt by PLAN of proof of loss. Where applicable, Eligible
Expenses shall be paid to the Enrollee. Subject to written authorization from an Enrollee, all or a portion of any Eligible
Expenses due may be paid directly to the provider of the Health Services.
Copayment Reimbursement
PLAN shall reimburse for amounts of Copayment Charges paid by an Enrollee in any Contract Year that exceed 200%of the
total annual Health Services Fees paid to PLAN during the same period on behalf of the Enrollee through the Enrolling Unit.
In those cases where the Enrollee has enrolled his or her Family Dependents with PLAN,PLAN shall reimburse for amounts
of Copayment Charges paid by all Covered Persons in the family unit in any Contract Year that exceed 200% of the total
annual Health Services Fees paid to PLAN through the Enrolling Unit during the same period.
Written notice that excess amounts of Copayment Charges have been paid by the Enrollee or by all Covered Persons in the
same family unit must be sent to PLAN. Such notice must (1) include proof satisfactory to PLAN of the payment of
Copayment Charges, and (2) be provided to PLAN not later than ninety (90) days after the end of the Contract Year. The
amount of any excess Copayment Charges will be paid within sixty(60) days of receipt of written notice by PLAN that excess
Copayment Charges have been paid by Covered Persons.
Limitation of Actions
No action at law or in equity shall be brought to recover on the Contract by a Covered Person prior to the expiration of sixty
(60) days after proof of loss has been filed in accordance with the requirements of the Contract, nor shall such action be
brought at all unless brought within three (3) years after the time written proof of loss is required by the Contract.
Section VI
Part II: Continuation of Coverage Under State Law
An Enrollee whose Coverage ends under the Contract may be entitled to elect continuation Coverage under state law,if the
Enrolling Unit is not subject to the requirements of COBRA, or as an alternative to COBRA when both state law and
COBRA apply.
The Enrollee's Coverage must have ended due to termination of employment. The Enrollee shall not be entitled to
continuation Coverage under state law if:
4 "I': "` a.T,1), ' Health Services Fees for Coverage up to the termination date have not been paid by or on 4 c
,.,R , ;, behalf of the Enrollee; or -/
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b. the Enrollee has not been continuously covered under the Contract, or under any coverage
plan providing similar coverage which the contract replaced, for at least six (6) months
immediately prior to termination from employment; or
c. the Enrollee is covered by Medicare of Medicaid; or
d. the entire Contract is discontinued.
The Enrollee must elect continuation Coverage and pay Health Services Fees due within twenty (20) days from the date of
termination from employment.
Continuation of Coverage under state law will end after a period of ninety(90)days after the date Coverage would have ended,
or until the Enrollee is reemployed,whichever occurs first. At the end of the ninety(90) day continuation period under state
law, the Enrollee or the Enrolled Family Dependents are entitled to conversion privileges as described below.
Coverage may be continued for enrollees working 40 hours or more when the working hours are reduced to less than 30 hours
because of economic conditions. Coverage may also be continued for such enrollees enrolled family dependents.
Coverage may be continued provided:
1. the enrollee has been continuously covered under the Contract,or under any coverage plan
providing similar coverage which the Contract replaced, for at least six (6) months
immediately prior to the reduction in working hours;
2. the enrolling unit has imposed the reduction in hours due to economic conditions;
3. the enrolling unit intends to restore the enrollee to a full 40 hour work schedule as soon as
economic conditions improve; and
4. the applicable Health services Fees are paid.
PRESCRIPTION MEDICATION ADDENDUM RX 5
In consideration of the Health Services Fees to be paid, the Master Group Contract and
Evidence of Coverage are hereby amended by the attachment thereto of this Addendum.
Section I of this Contract, entitled "Definitions" shall be modified by the following
additions:
"Drug Formulary", if enacted, is a listing of Prescription Medications approved for
use by PLAN which may be dispensed through Participating Pharmacies to a Covered
Person. When Designated by PLAN, a generic equivalent shall be dispensed. This
list shall be subject to periodic review and modification by PLAN.
"Participating Pharmacy" means a pharmacy which has entered into a service
agreement with PLAN to provide Prescription Drug services to Covered Persons.
"Participating Provider" means a Participating Hospital, Participating Pharmacy,
Participating Physician, and any other Health Services provider who/which has
entered into a service agreement with PLAN to provide Health Services to Covered
Persons.
"Prescription Medication" means a drug or medication which bears the federal
legend "Federal law prohibits dispensing without prescription", which can under
federal or state law be dispensed only pursuant to a prescription order. This
definition includes insulin, compounded prescriptions or formulas which must be
prepared by a pharmacist subject to a prescription order.
"Prescription Order or Refill" means the authorization for a Prescription Medication
issued by a Participating Physician who is duly licensed to make such an
authorization in the ordinary course of his or her professional practice.
The "Relationships Between Parties" subsection of Section VIII shall be modified by the
following addition:
"The Participating Pharmacy is solely responsible for the pharmacy services provide&
to any Covered Person."
Section X.B.2.a. of this Contract, entitled "Hospital and Related Services" shall be modified
by the following addition:
3) Outpatient Prescription Medications provided by a Participating Hospital or
Participating Alternate Facility in conjunction with emergency services for the
same condition, not to exceed a consecutive seven (7) day supply.
COPAYMENT CHARGE: $5.00 per Prescription Order or Refill
6826(1/92) (over)
-Section X.E. of this Contract, entitled "Miscellaneous Health Services", shall be modified
by the following addition:
8. Prescription Medications
Prescription Medications which have been prescribed under the direction of
the Participating Primary Care Physician and obtained through a Participating
Pharmacy. Prescription Medications shall, in all cases, be dispensed in
generic equivalent form, or in accordance with the PLAN Drug Formulary,
if enacted, and as amended from time to time, or upon PLAN approval.
COPAYMENT CHARGE: $5.00 per Prescription Order or Refill, or
the average retail price, whichever is less:
For a single Copayment Charge, a
Covered Person may obtain one of the
following:
• up to a consecutive thirty-four (34) day supply of
medication;
* up to one (1) cycle supply of oral contraceptives.
A COVERED PERSON SHALL PAY TO A PARTICIPATING
PHARMACY 100% OF THE ADDITIONAL COST OF ANY
PRESCRIPTION MEDICATION WHICH, AT THE REQUEST OF THE
COVERED PERSON OR PHYSICIAN, IS NOT DISPENSED
ACCORDING TO THE CURRENT PLAN DRUG FORMULARY,OR ITS
GENERIC EQUIVALENT, UNLESS APPROVED IN ADVANCE BY
PLAN.
The "Exclusions" subsection of Section X shall be modified by the following addition:
The following are excluded:
27. Contraceptive supplies or devices (except diaphrams and birth control pills),
drug and supplies not requiring a prescription order (including but not limited
to aspirin, antacids, oxygen, benzoyl peroxide preparations, medicated soaps,
syringes other than insulin syringes and bandages), food supplements,
antabuse, methodone, nicotine gum, minoxidil topical preparations,
experimental drugs, drugs determined by PLAN to be ineffective and
prescription medications related to health services which are not covered
under the contract.
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Lincoln National Health Plat. of Colorado
Prescription Medication Addedurn
Amendment I (Effective 1/1/92)
Rx 3 - 6825, Rx 5 - 6826, Rx 7 - 6649, Rx 10 - 6731
This amendment contains language that is to be added to your Prescription Medication
Addendum.
this Contract, entitled "Definitions" art 'ifi a th following additions:
Section I of en+.il_d shall be modified by the ..4..:t:o.._.
"Drug Formulary", if enacted, is a listing of Prescription Medications approved for
use by PLAN which may be dispensed through Participating Pharmacies to a Covered
Person. When designated by PLAN, a generic equivalent shall be dispensed. This
list shall be subject to periodic review and modification by PLAN.
Section X.E. of this Contract, entitled "Miscellaneous Health Services", shall be modified
by the following addition:
Prescription Medications shall, in all cases, be dispensed in generic equivalent form, or in
accordance with the PLAN Drug Formulary, if enacted, and as amended from time to time,
or upon PLAN approval.
A COVERED PERSON SHAT I PAY TO A PARTICIPATING PHARMACY 100% OF
THE ADDITIONAL COST OF ANY PRESCRIPTION MEDICATION WHICH,AT T-IE
REQUEST OF THE COVERED PERSON OR PHYSICIAN, IS NOT DISPENSED
ACCORDING TO THE CURRENT PLAN DRUG FORMULARY, OR ITS GENERIC
EQUIVALENT, UNLESS APPROVED IN ADVANCE BY PLAN.
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