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Home My WebLink About000191.tiff TAKECARE OF COLORADO,INC EVIDENCE OF COVERAGE AND OWNER'S MANUAL SIGNATURE SHEET The attached Evidence of Coverage and Owner's Manual (Group Agreement) and this Signature Sheet collectively constitute a contract (Agreement) between TakeCare of Colorado, Inc. (TakeCare), and the Subscribing Group named below for the provision of specified healthcare benefits to eligible persons electing to enroll hereunder as Subscribers and Dependents. 1. SUBSCRIBING GROUP: A. The name, address, and group number(s) of the Subscribing Group are as follows: Weld County, Colorado Mr. Donald Warden P.O. Box 75 (303)457-1001 915 Tenth Street Greeley, Colorado 80632 Group Number(s): NC - 503,Denver- 744,CS - 1031, PPO - 50158 B. The following entities affiliated with the Subscribing Group shall be deemed to be included within it for purposes of this Agreement: N/A C. The number of employees of the Subscribing Group who are eligible to enroll as Subscribers is 950 and the SIC Code of the Subscribing Group is 900. 2. EltECTIVE DATE: This Agreement takes effect 12:01 a.m. on January 1, 1994, and will remain in effect through 11:59 p.m. on December 31, 1994, subject to the terms and conditions. 3. COVERAGE: Plan type: 9T EOC number and edition date: 7560 (1994) Schedule of Benefits number and edition date: 7564 (1994) Optional benefits: Rx 5T,7567 (1994) 4. MONTHLY RATE SCHEDULE: Employee only $144.29 Employee, spouse and dependents (Family) $398.24 191 5. PAYMENT ARRANGEMENT/ELIGIBILITY The following specifies payment arrangements as well as conditions of eligibility for enrollment as a Subscriber that are in addition to the conditions enumerated in Chapter 4 of the Group Agreement(and, to the extent that any of the following conditions contradict the terms of chapter 4, the following shall prevail: New employees are eligible on the first day of the month occurring on or following the date of hire and a full monthly premium will be charged. Employees will be covered through the end of the month in which employment terminates and a full monthly premium will be charged. 6. UNDERWRITING CONDITIONS The Subscribing Group (A)represents that the underwriting conditions listed below exist as of the effective date noted in paragraph 2 above, and (B) covenants that all such underwriting conditions shall continue to be met at all times while this agreement is in force: Subscribing group must contribute for all subscribers at least 75% of"Employee" monthly rate or 50% of"Employee and one or more dependent" monthly rate. If TakeCare (HMO) is part of a multi-option plan offering a TakeCare Preferred/Indemnity plan the Subscribing Group must have at least 75% participation of all eligible employees. Military employees or employees covered by a spouse's plan will not be counted as an eligible employee for the purpose of this minimum participation requirement. The minimum number of enrolled employees between the HMO and PPO/Indemnity plans cannot be less than 25 lives. Additionally, TakeCare reserves the right to re-evaluate the risk at any premium due date based upon substantial changes to other assumptions including, but not limited to, a change in demographics; divisions added or deleted; or the offering of an additional employer sponsored health plan. Notwithstanding any other provision of this Agreement,TakeCare may terminate this Agreement on any premium due date if any underwriting condition listed above is not then being met and notice of intention to terminate has been given to the Subscribing Group at least 30 days in advance. 7. OPEN ENROLLMENT PROVISIONS: The Group enrollment Period shall be December 1994. 8. OTHER PROVISIONS: Eligible dependents will be covered as outlined in Chapter 4 of the Agreement. Payment arrangements for newly acquired dependents shall be the same as for newly hired employees as described in number 5, PAYMENT ARRANGEMENTS/ELIGIBILITY. 1/6/94 9. GOVERNING LAW: This Agreement shall be governed by and construed in accordance with the internal laws of the State of Colorado. 10. COUNTERPARTS: This Agreement may be executed in two or more counterparts, each of which shall constitute an original but all of which shall constitute one and the same instrument. IN WITNESS WHEREOF, TakeCare and the Subscribing Group have caused this Agreement to be executed by their respective authorized representatives thereunto duly authorized. SUBSCRIBING GROUP TAKECARE AUTHORIZED REPRESENTATIVE pp AUTHORIZED REPRESENTATIVE By: /L41 !/iLi( By: Y-4,4491464- 01/.51/94 Chairman, Weld County Title: Board of Commissioners Title: 2'f cdd?Y ,4''t.GZGto, Date: 01/26/94 Date: i ATTEST: Autediglaah, WELD COUNTY CLERK TO THE ABOARD BY: `�� '^-g 6i d /N-KX l.L/ DEPUTY CL9 O THE BOARD abr Taking Care of Colorado, One Person at a Time. 1994 Evidence of Coverage and Owner's Manual TABLE OF CONTENTS CHAPTER ONE HOW TO USE THIS MANUAL Welcome to TAKECARE 1 Manual Organization 1 Symbols and Typefaces 2 Symbols 2 Typefaces 3 Other TAKECARE Materials 3 Enrollment Packet 3 CHAPTER TWO INFORMATION LOCATOR 4 CHAPTER THREE HOW TAKECARE BENEFITS YOU Live Well With TAKECARE 10 How to Determine Benefits 10 How to Use Your Plan 10 Your ID Card: Passport to Living Well 11 Your PCP: Key to Your Health Care 11 Your Plan: The Benefits of TAKECARE 12 Special Health Care Needs 12 Specialty Care Referrals 12 Emergency or Urgent Care 13 TAKECARE Service Area 13 Your Rights and Responsibilities 14 CHAPTER FOUR YOUR RIGHTS AND RESPONSIBILITIES Internal Table of Contents 15 CHAPTER FIVE WHAT IS COVERED: YOUR SCHEDULE OF BENEFITS Internal Table of Contents 40 CHAPTER SIX OPTIONAL BENEFITS A. Eyewear 66 A.1 Prescription Glasses or Prescription Contact Lenses 66 B. Outpatient Prescription Drugs 66 B.1 Medications/Refills--Standard Quantities 66 B.2 Medications/Refills--Other Quantities 67 B.3 Generic Equivalents 67 B.4 Delivery Charge 67 B.5 Abuse 67 B.6 Outpatient Prescription Drugs Benefits Outside the TAKECARE Service Area 68 B.7 Outpatient Prescription Drugs Not Covered 68 CHAPTER SEVEN DEFINITION OF TERMS 69 CHAPTER EIGHT HOW TO GET HELP Membership Services 74 American Vision Services 74 Form Number: 7560 (1994) How to Use This Manual 1 CHAPTER ONE HOW TO USE THIS MANUAL Welcome to TAKECARE Your health is important to us. To help you make the best use of your TAKECARE health care benefits, we have provided this manual. It contains valuable information that will enable you to use TAKECARE efficiently and effectively. When you enrolled, you received a packet of information including details about the plan your employer has selected and rosters of contract providers. This manual contains additional information about TAKECARE services and benefits that you need to know to best use your TAKECARE coverage. Please keep it with your enrollment packet so you have all TAKECARE information in one place. If you do not have an enrollment packet, or need updated materials, contact Membership Services (see Chapter Eight, How to Get Help). n Manual Organization The following is a brief explanation of the information in each chapter in your manual and how you can use it. Chapter Two Information Locator ro This is a very important tool in your manual that enables you to find the information you need quickly. s, Subjects are listed alphabetically so you can see what related information is included and where it is s' located. r, Use the Information Locator whenever you are looking up information in the manual, to see where °z various kinds of information about your subject are located and what related subjects may be included. NOTE: The Information Locator is included to assist you in finding information about your plan and is not a part of your contract with TAKECARE. Chapter Three How TAKECARE Benefits You This chapter tells you how to use your plan and how to select and work with your Primary Care Physician(PCP). Read this chapter when you receive this manual and any time you need to clarify how your TAKECARE coverage works. Chapter Four Your Rights and Responsibilities This outlines the general provisions of the Agreement you have with TAKECARE, including specific legal requirements that you and TAKECARE must observe. Look in this chapter when you want to know the rules about such subjects as who is eligible, when coverage begins, and other general information about what you are entitled to and what you are required to do under the provisions of your legal agreement with TAKECARE. 2 How to Use This Manual TAKECARE Chapter Five What Is Covered: Your Schedule of Benefits This chapter details the services that are covered under your plan, as well as those services excluded from coverage under your plan. In this chapter, using the Information I orator, you can seP what is included for any benefit. If you do not find a listing for the type of health care coverage you are looking for, check Section X., General Exclusions. Chapter Six Optional Benefits This chapter explains the TAKECARE optional benefits, each of which may or may not be part of your group plan depending on which optional benefits your employer has selected. Check your enrollment packet, with your employer, or with Membership Services to find out if your plan includes these benefits. Chapter Seven Definition of Terms This chapter lists and defines terms that are used in a particular way in this manual. Use this chapter any time there are terms that are unclear to you, or to clarify the exact legal meaning of a term. Chapter Eight How to Get Help This chapter explains who to contact for information and questions. You can reference this chapter when you need the Membership Services' phone number or hours. Symbols and Typefaces Symbols and typefaces identify specific information in your manual. The following are the symbols and typefaces used: Symbols NOTE: Symbols are provided to assist you in finding information about your plan and are not part of your contract with TAKECARE. $0 Check Copayment Schedule This identifies benefits for which there might be a copayment. Consult your TAKECARE ID card or your copayment schedule for the copayment, if any, that applies to your plan. Please note that the office visit copayment applies whenever an office visit occurs in conjunction with a covered service. eVariable Benefits This identifies benefits that may not be covered in your plan at the request of your group. Check with your employer's benefit or personnel office. Pr How to Use This Manual 3 Typefaces Document Names Document names are printed in a different typeface; for example, Evidence of Coverage and Owner's Manual. Phone Numbers Phone numbers are printed in bold; for example, (800) 255-1139. Special Emphasis Information Information that is important for you to note is printed in italic; for example, ask the out-of-area provider to send the bill directly to TAKECARE Membership Services. Other TAKECARE Materials This manual is your primary resource for information about TAKECARE and your benefits. But the following materials also provide valuable information that you will need to use TAKECARE effectively. Enrollment Packet This is the folder you received when you enrolled in TAKECARE. It contains the following: • Benefit Description This summarizes the major features of your plan. It is not intended to replace this manual, which contains the complete provisions of your plan. • Service Area Map and Zip Code Listing Provides a map of the TAKECARE service area for your HMO coverage and lists the zip codes in the service area. • Provider Directory Lists by city all of the participating Primary Care Physicians and hospitals associated with TAKECARE. • Optional benefits descriptions Each of these, which may or may not be in your packet, depending on your plan, summarizes optional benefits your employer has selected to be included in your plan. These summaries are not intended to replace the Evidence of Coverage and Owner's Manual, which contains the complete provisions of your optional benefits, if any. • Enrollment Application The golden rod copy of your TAKECARE enrollment application has important information on the back about your membership conditions. Materials are updated periodically. Contact Membership Services for replacement or updated copies (see Chapter Eight, How to Get Help). A. 4 Information Locator TAKECARE CHAPTER TWO c Cardiac INFORMATION LOCATOR EKG benefits 53Limits to Rehabilitation benefits 56 Medications,Optional outpatient prescription drug benefits 67 A Rehabilitation benefits 56 Chemotherapy Abuse Benefits 56 Not Covered your plan 20 59 See Substance Abuse 54 Childbirth Active Work Status See Maternity 52 Definition of 69 Children Eligibility and 28 See Dependents 28 Reduced working hours and 38 Chiropractors Acupuncture Not covered 61 Not covered 61 Chronic Care Acute Care Definition of 69 Definition of 69 Claims Addresses Denial of 11, 39, 44 TakeCare 74 Payments 39, 45 Subscriber/member address change 14, 74 Cleft Lip, Cleft Palate 55 Agreement Newborn benefits 55 TakeCare's 16 Not covered 55 Definition of 16, 69 Clinics Effective period 16, 27, 29 Not covered 61 Exceptions to 60 Pain clinic benefits 42 Member's 16, 17 M Comprehensive Rehabilitation Facility y Termination of 34, 35 Benefits 53 Alcohol Confinement See Substance Abuse 54 Effect on eligibility 27 Allergy Effect on termination 35, 37 Treatment benefits 51 Contact Lenses 5 Allowable Expense Exam benefits 45 cDefinition of 22 Fitting, not covered 45 Ambulance Continuation Coverage 5 Benefits inside service area 43 Availability of 17 $ Benefits outside service area 44 Constructive election 18, 19 j Anesthesiologist Conversion to nongroup coverage 19 Benefits 52, 56 Definition of 69 g Appointments Premiums for 19 Missed,Charges not covered 61 Rules for 17, 36 Associated Coverage Contraceptives Definition of 69 See Family Planning 67 Contract B Dates 11 Baby Definition of 16 See Newborns 52 Termination 35 Benefits Contract Provider Of your plan 12 Definition of 69 Blood Contract providers Benefits 48 TakeCare not liable for 33 Not covered 48,61 Definition of 33 Bone Release of information 33 Broken, See Medical Emergencies 43 Contract Year Dental implants not covered 56 Availability 19 Marrow transplant benefits 58 Definition of 70 Screws 56 Conversion Coverage Breast Definition of 20, 70 Augmentation, not covered 56 Coordination of Benefits and Subrogation Mammogram benefits 53 Agent Orange treatment 61 Mastectomy 55 Applicability 21 Reconstructive surgery benefits 55 Asbestosis 61 Reconstructive surgery not covered 56 Definitions 21 • Surgical bras 55 Determining order of benefits 22 Effect on the Benefits of the Plan 24 Facility of payment 24 General information 20 Information Locator 5 Right to receive and release information 24 Of Agreement 27 Right to recover excess payments 24 Of dependent coverage 28 Subrogation 26 Electrocardiogram(EKG) With Motor Vehicle No-Fault Insurance 24 Benefits 53 With Workers' Compensation 25 Electroencephalogram(EEG) Copayment References Benefits 53 Definition of 12, 70 Eligibility Due at time of service 12 For individual coverage 19 For conversion plan 20 Of dependents 28 For emergencies 13, 44, 45 Of subscribers 28 For medications 67, 68 Emergencies For newborns 52 Ambulance benefits 43, 45 For your plan 12 Copayments 13, 45 Limit of 39 Follow-up care benefits 45 Nonpayment of 36 Inside service area 13, 43 Outpatient injectables 50 Not covered 44 Short-term cardiac rehabilitation 56 Oral and dental surgery benefits 55 Symbol for variable copayment benefits 2 Outside service area 13, 44, 68 Cornea Respiratory therapy benefits 57 Transplant benefit 59 Emergency Covered Benefit Medical,Definition of 71 Definition of 70 Employee Custodial/Maintenance Care Termination of coverage 18 Not covered 47, 62 Enrollment Application 3 D Effective date 27 Dental Group open enrollment 29 Cleft lip/palate benefits 55 Initial enrollment 29 Inpatient medical consultation 55 Limit of 30 Not covered 62 Of dependents 14 Oral surgery benefits 55 Other enrollment 30 Dependents Packet 3 Change of status 14, 17, 64 Epidemics Definition of 70 Limits of benefits 65 Eligibility 18, 19, 28, 30, 38 Equipment Eligibility, Age limit exception 29 See Durable Medical Equipment and Supplies 43 Enrollment 27 See Supplies 61 Termination of,Required 36 Exams Termination of, Voluntary 36 Eye 45 Detoxification Hearing 46 Benefits 54 Physical 51 Diet Exclusions Clinics not covered 51 Definition of 70 Counseling benefits 51 General 60 Counseling not covered 51 Outpatient prescription drugs 68 Dietitian services 49 Experimental Procedures/Devices/Drugs Disaster Not covered 62 Limits of benefits 65 Extended Care Drugs Benefits 53, 65 Abuse rehabilitation benefits 54 Limits to benefits 53 Abuse rehabilitation not covered 54 Eyes See Skilled Nursing Facility 53 Generics recommended 67 y In hospital 48 Limits to benefits 66 In skilled nursing facility 53 Preventive care examination benefits 45 Optional outpatient prescription drugs benefits 66 Routine examination benefit 45 Optional outpatient prescription drugs not covered 68 Vision Therapy 58 Therapy for infertility not covered 46 Eyewear Durable Medical Equipment Following cataract surgery 61 Authorization for benefits 43 Definition of 70 Limits to benefits 43 Family Planning Benefits 46 E - Infertility benefits 46 Eating Disorders Infertility not covered 46 Clinics not covered 42 Not covered 46 Effective Date/Period Oral contraceptives 67 Definition of 70 Sterilization 46 6 Information Locator TAKHCAR Tubal ligation 46 Vasectomy 46 Follow-Up Care Kidney Emergency benefits 45 Hemodialysis 57 Limits to benefits 45 Transplant benefits 59 G L Group Open Enrollment Laboratory Definition of 71 Benefits 48, 50, 53 See Enrollment 29 Radiological services 53 Growth Hormones Level of Care Benefits 51 Definition of 71 Limitations j� Regarding contract providers 30 Hearing To benefits 30, 31 Examination benefits 46 To conversion rights 20 Heart Limits Definition of 71 Transplant benefits 59 General limits to benefits 64 Hemodialysis To enrollment 30 Benefits 57 To substance abuse benefits 54 HMO To therapy benefits 47 Definition of 71 Litigation Home Health Care See Member Claims Review 31 In a disaster or epidemic 65 Liver Nursing care benefits 46 Transplant benefits 60 Nursing care benefits, Definition of 73 Location Care Therapy benefits 47 Definition of 71 Training for 47 Hospice Care M Benefits 47 Maintenance Care Definition of 71 Definition of 71 Hospital Mammogram Definition of 71 Benefits 53 Hospital Inpatient Care Mastectomy Alcohol/drug rehabilitation 54 Benefits 55 Ancillary services benefits 48 Maternity Blood benefits 48 Delivery,Benefits 52 Discharge planning 49 Delivery,Not covered 52 Emergency copayment waived 13, 44 Home health care benefits 53 Implants benefits 49 Postpartum benefits 52 Not covered 48, 49 Prenatal benefits 53 Nursing services 49 See Newborns 52 Oral and dental surgery benefits 55 Medicaid Psychiatric care 50 Continuation of coverage with 18 Room and board benefits 49 Coordination of benefits with 21, 22 Supplies 49 Medical Director Hypnosis Approval of 43, 47, 51, 53, 56, 61 Not covered 58 Medical Emergency Definition of 71 Medically Necessary ID Card Definition of 72 Lost/stolen 14 Medicare Misuse of 14, 37 Continuation of coverage with 18 Unauthorized use 14, 38 Coordination of benefits with 22 Use of 11, 14, 39, 67 Definitionof 72 Immunizations Medicare Member Benefits 52 Definition of 72 Not covered 52 Member Claims Review Process 31 Implants Benefits 49 Members Address 3, 13, 14, 39 Not covered 49, 56 Infertility Agreement of 16, 17 See Family Planning 46 Definition of 72 Effective date of coverage,Dependents 28 • Intensive Care Benefits 49 Effective date of coverage,Newborns 27 Definition of 71 Effective date of coverage, Subscriber 27 Enrollment 29, 71 Information Locator 7 Identification. See ID Card 2 P Responsibilities 12, 14, 44 Pain Clinics See Subscribers 16, 17 Benefits 42 Termination date,Dependents 32, 35, 36, 37 Limits to benefits 42 Termination date,If previously confined 37 Participating Physician/Participating Specialist Termination date, Subscriber 35, 37, 38, 39 Definition of, See Primary Care Physician 72 Membership Services Pathology How to contact 11, 74 Service benefits 50 Reporting change of address 14, 74 Pharmaceuticals Reporting lost/stolen ID card 14 See Drugs 66 Mental Health Services Physical Exams Inpatient psychiatric care benefits 50 Benefits 51 Limits to benefits 50 Physician Services Not covered 50 Allergy treatment benefits 51 Outpatient care benefits 50 Dietary counseling benefits 51 Outpatient pain clinic psychiatric care benefits 42 Exams and consultation 51 Psychological testing not covered 58 Substance Abuse 54 Growth hormones benefits 51 Health appraisals benefits 52 N House calls 51 Immunizations benefits 52 Newborns In hospital 51 Cleft lip/palate benefits 55 Not covered 51, 52 Coverage begins 27 Second opinion(consultation) 51 Effective date of coverage 28 Surgical benefits(in/outpatient) 52 Newborn benefits 52 Well-baby care benefits 52 Postpartum benefits 52 Plan Prenatal services benefits 53 Definition of 72 Well-baby care benefits 52 Postpartum Services No-Fault Insurance(Motor Vehicle) Benefits 52 Coordination of benefits 24 Pregnancy Notice See Maternity 52 Addresses for 39 Premiums Of termination 35 For continuation coverage 17 Nursing Late charges 32 Home health care benefits 46 Nonpayment 32, 34, 35 Hospital inpatient care benefits 49 Payments 32 Limits to benefits 47 Prescription Drugs Private duty, definition of 72 See Drugs 66 Service not covered 47, 49 Preventative Care Services benefits 46 Eyes 45 Skilled nursing care, definition of 73 Hearing 46 Skilled nursing facility 53 Primary Care Physician (PCP) Changing 74 0 Choosing 11 Occupational Therapy Contact for urgent care 13 Benefits 47 Definition of 72 Limits to benefits 57 Failure to establish relationship 37 Operating Room Notify in emergency 13 Benefits 49 Private Duty Nursing Optional Benefits Definition of 72 Eyewear 66 Prosthesis How to determine if you are covered 2, 3, 66 Cleft lip/palate benefits 55 Outpatient prescription drugs 66 Dental not covered 62 Oral Contraceptives External extremity 43 Optional outpatient prescription drugs benefits 67 Medically necessary dental 55 Oral Surgery Not covered 61 See Dental 55 Psychiatric Care Orthodontics See Mental Health 50, 51 Dental surgery benefits 55 Psychological Testing Orthopedic Braces Not covered 58 Benefits 43 Outpatient Prescription Drugs Q Optional benefit 66 Qualified Beneficiary Oxygen Definition of 72 Benefit 43 Hospital care 48 8 Information Locator TAKE( R Conversion coverage 19 Eligibility 28 Radiology Enrollment 30 Benefits 48, 53 Legally separated 28 Records Qualified beneficiary 72 Access to records 33 Statutes Confidentiality 33, 50 Conformity with 17 Primary Care Physician establishes 11 Sterilization Release of information 33 See Family Planning 46 When changing primary care physicians 12 Subacute Care Facilities Redetermination of Status Benefits 54 Definition of 72 Subrogation Referrals See Coordination of Benefits and Subrogation 20 By Primary Care Physician 12, 72 Subscriber Rehabilitation Continuation of coverage 17 Alcohol abuse benefits 54 Conversion 19 Alcohol/drug not covered 54 Definition of 73 Cardiac benefits 56 Reduced working hours 38 Covered under no-fault insurance 24 See Members 17 Drug abuse benefits 54 Termination of coverage 18 Hemodialysis therapy benefits 57 Subscribing Group Not covered 58 Agreement of 16 Occupational therapy benefits 47, 57 Amendment/termination of Agreement 16 Physical therapy benefits 47, 57 Contract obligations 33 Respiratory therapy benefits 57 Definition of 73 Speech therapy benefits 57 Effective date of coverage 70 Rehabilitation Care Notification of changes 39 Definition of 72 Responsibilities 28, 29, 32-34 Relationship Between Parties Termination of coverage 18, 34, 35 TakeCare's responsibility 34 Substance Abuse Description of 33 Detoxification 54 Liability 33 Inpatient alcohol-drug rehabilitation 54 Subscribing group's responsibility 34 Limits to benefits 54 Respiratory Therapy Outpatient alcohol-drug rehabilitation 54 Benefits 48, 57 Supplies Respite Care Benefits 47, 49, 53, 56, 57 Definition of 72 Not covered 26, 61, 68 Not covered, Take-home 49 S Optional outpatient prescription drugs benefits 66, Surgery Second Opinion Breast reconstructive benefits 55 Surgery 51 Cleft lip/palate 55 Service Area Dental, Not covered 62 Definition of 72 Implant benefits 49 Description of 13 In/outpatient benefits 52 Emergency services inside of 13 Not covered 49, 55, 56 Emergency services outside of 13 Operating room benefits 49 Urgent care services inside of 13 Oral and dental benefits 55 Urgent care services outside of 13 Physician services 52 Signature Sheet Plastic benefits, not covered 56 Definition of 73 Services 56 Skilled Nursing Care Supplies 49 Definition of 73 Voluntary sterilization 46 Home health care 46 Surgical Bras Skilled Nursing Facility Benefits 55 Benefits 49, 53 Symbols Exams/consultations 51 Check copayment schedule 2 Not covered 53 Use of 2 See Nursing 73 Variable benefit 2 Skin Grafts Benefits 59 Specialists. See Referrals 12 Speech Therapy TakeCare Benefits 48, 57 Agreement of 16 For cleft lip/palate 55 Definition of 69 Spouse Termination Addition to coverage 32 By written notice 35 Common Law 28 Confinement at termination 35 Due to nonpayment 34 Continuation coverage 17 I r Information Locator 9 General information 35 W Refunds 35 Well-Baby Care Benefits not paid after 61 See Newborns 52 Confinement at termination 37 Workers' Compensation Continuation of coverage 17 Coordination of benefits 25 Due to failure to establish PCP relation 37 Due to inappropriate behavior 37 X Due to misuse of ID card 14, 37 Due to nonpayment of copayments 36 X-Rays 53 Due to providing false information 37 Dental,Not covered 62 Due to reduced working hours 38 See Radiology 53 Due to refusal of compliance 37 Due to relocation 38 Notification of 34 Refunds for dependent coverage 36 Required termination of dependent coverage 36 Termination date 35 Voluntary termination 36 Therapies Cardiac benefits 56 Hemodialysis benefits 57 Home health care benefits 47 Limits to benefits 56, 57 Mental health 50, 51 Not covered 47, 58 Occupational benefits 57 Physical benefits 57 Respiratory benefits 57 Therapies 57 Speech 57 Total Parenteral Nutrition Not covered 61 Training For hemodialysis 57 For home health care 47 Transplants Bone marrow benefits 58 Cornea 59 Heart 59 Liver 59 Skin grafts 59 Not covered 59 Travel/Transportation Expenses Not covered 62 Treatment Alternatives Explained 60 Tubal Ligation See Family Planning 46 U_ Urgent Care Procedures 13 Urgently Needed Services Definition of 73 V Variable Benefits Abortion/family planning 46 AlcohoUdrug rehabilitation 54 Determining if your plan includes 2 Infertility 46 Symbol for 2 Vasectomy See Family Planning 46 Vision See Eyes 66 f 10 How TAKECARE Benefits You TAKECARI CHAPTER THREE HOW TAKECARE BENEFITS YOU Live Well With TAKECARE The information in this chapter is designed to help you understand and use your TAKECARE coverage efficiently and effectively. It explains the rules for using your TAKECARE plan and how to get the services you need, and tells you how to select and work with your Primary Care Physician(PCP). TAKECARE is a Federally qualified and State licensed Health Maintenance Organization (HMO). TAKECARE is a working partnership between its members and a network of more than 1,900 health care physicians, including PCPs (who are internists, pediatricians, and family practitioners) and specialists. As an HMO, TAKECARE's obligation to its members is to furnish benefits in the form of medical services through its contract providers. Therefore, it is important to you that you follow TAKECARE procedures and use the providers that have contracts with TAKECARE. O NOTE: TAKECARE contract providers are independent contractors and are not agents or employees of ihe 0 TAKECARE. How to Determine Benefits 0 The terms and provisions of this Manual control the type and scope of benefits available to a member. The manual must be read as a whole to accurately determine benefits. When reading a coverage ti section, you must also read what is not covered, any limitations and read the separate general exclusions and general limits sections (Sections X. and Y.) to determine what, if any, services are excluded or limited. N 2 For example, Section U.2, in Chapter Five, explains the services covered for Chemotherapy. Section V X., General Exclusions, excludes coverage of chemotherapy or radiation therapy requiring a bone marrow or stem cell transplant or stem cell rescue for the treatment of any disease, including breast and other solid tumor cancers. As you can see, it is important that you read this Manual in its entirety to accurately determine what i covered and what services are excluded, and/or limited. How to Use Your Plan We look forward to working with you to help you stay healthy. You should feel secure knowing you TAKECARE health plan provides thorough coverage. Now you need to know how to use these resources wisely, because then we can assure you quality care at the lowest cost. Here are some important things you should remember: • Carry and use your ID card. • Select your PCP right away and call him/her first when you need care. • Know the covered benefits under your plan. How TAKECARE Benefits You 11 Your ID Card: Passport to Living Well Keep your TAKECARE ID card with you at all times. It is your passport to high-quality medical and emergency care. Each covered member of your family will receive an ID card. At the time of services, the card must be shown to identify yourself or your family member as a TAKECARE member. If you fail to do so, or misrepresent your membership status, claims payment may be denied. Your PCP: Key to Your Health Care The relationship between our members and their PCPs is the cornerstone of our success at TAKECARE. We believe that having one good doctor to look over your health care needs is better than having several doctors who know very little about you. This relationship is designed to make you more comfortable and secure in the quality of services you need for your best health. Think of your PCP as your partner in your personal health care management, providing most of your care and coordinating any other care as necessary. Your PCP will develop a central collection point for your detailed health-history records. This provides a more thorough understanding of your and your dependents' needs. Your PCP will also handle the paperwork and billing directly with TAKECARE. If you do receive a bill for covered services, please mail it to TAKECARE with your membership number (usually the subscriber's Social Security number)from your ID card. Covered medical services, except true emergency care, must be provided or referred by your PCP. Having a PCP is essential to using the advantages of your TAKECARE coverage. Please keep in mind that TAKECARE is not responsible for charges incurred when a member misses an appointment or cancels a scheduled service. Selecting Your PCP You need to choose a PCP in order to receive TakeCare covered benefits, except true emergency services. Each family member may select a different PCP. If you have not yet chosen a PCP, please do so right away by calling our Membership Services Department. They can assist you in selecting a PCP so when services are needed, you know who to call. Working With Your PCP When you need medical care, call your PCP and he/she will make the necessary arrangements for treatment. Remember that your PCP must arrange a referral before you see a specialist, or TAKECARE is not responsible for any charges. This rule guarantees your access to care and provides you with professional guidance to the right kind of care. Your PCP cannot authorize a referral after the fact. If you choose to see a doctor who does not participate in the TAKECARE system or if you see a specialist without a referral from your PCP, you will be responsible for all of the charges for all services, including hospital care. TAKECARE has no obligation to pay these charges, which can accumulate much more rapidly than you anticipate. Note that in a case of a life or limb threatening emergency, you may go to any physician or facility, and special procedures apply. See the Emergency or Urgent Care section in this chapter. 12 How TAKECARE Benefits You TAxEC Changing Your PCP When you want to change your PCP, call Membership Services immediately. The change will take effect the first day of the following month. To transfer your records, contact your former PCP and follow his/her procedures. Remember that any specialist physician referrals will need to be renewed by your new PCP. You w need to contact him/her before you receive further specialist care. Your Plan: The Benefits of TAKECARE You can have the confidence of knowing that you will receive quality care and service with your TAKECARE coverage. The quality of your care is monitored under our Quality Assurance Program. It is important for you to be familiar with your copayments. Copayments are intended to remind members that they share the responsibility for health care costs with their doctors, hospitals and TAKECARE. Copayments should always be made to the contract provider at the time you receive service. You may require medically necessary services that are not covered under your group plan. Thereto] it is essential that you understand which benefits and copayment obligations apply to you. To find o check the following: • Chapter Five, What Is Covered, in this manual • Materials (usually a Comparison of Benefits) provided by your employer • Your TAKECARE ID card • Your employer's benefit or personnel office When in doubt, call TAKECARE. Your PCP or specialty care physician is the authority on the management of your health. TAKECARE administration is the best source of information about your health care plan Agreement. Each has a different responsibility to you. For more information, see Chapter Eight, How to Get Help. Special Health Care Needs Specialty Care Referrals TAKECARE's referral system for specialty care is designed to ensure that you get quality care. Havir your PCP involved in working with specialists is like having a built-in second opinion from someone you know and trust. Should your PCP decide that you need to see a physician specialist, he/she will arrange for a referral a participating specialist for a one-time visit or for a specific period of time. When you receive a co of the referral, be sure to note the time limit. TAKECARE will not cover services beyond the time limit. Your PCP cannot authorize or extend a referral after the fact. Without a referral, TAKECARE cannot cover any of the expenses of the physician specialist or related hospital care and charges. If you change your PCP, all specialist referrals become invalid. In orde for continuing visits to your specialist(s) to be covered, a new referral must be obtained from your r PCP. How TAKECARE Benefits You 13 Emergency or Urgent Care Emergency Care Inside the TAKECARE Service Area In a life or limb threatening emergency, go to the nearest hospital emergency room or other facility for treatment. In the case of a life or limb threatening emergency you have the option of calling the emergency telephone access number 911 or its local equivalent. Make sure your PCP is notified by the following business day so that he/she can authorize the emergency visit as well as coordinate whatever care you need and schedule any follow-up treatment. Urgent Care Inside the TAKECARE Service Area When you need urgent care, call your PCP first. Ask your PCP about after-hours and "on-call" procedures now, before you need these services. Your physician can assess the situation and decide if emergency care is needed. Many times the situation may be distressing but not actually life or limb threatening. Emergency Care Outside the TAKECARE Service Area In a life or limb threatening emergency, go to the nearest hospital emergency room or other facility. You should contact Membership Services (see Chapter Eight, How to Get Help) as soon as practical, but no later than 48 hours after treatment begins. Urgent Care Outside the TAKECARE Service Area In addition to our standard coverage for emergency services, urgently needed services or follow-up care to emergency services received outside the service area are covered to a maximum TAKECARE payment of$250 per person per contract year. Ask the out-of-area provider to send the bill directly to TAKECARE Membership Services Department at P.O. Box 35801, Colorado Springs, CO 80935-3801. If the provider demands payment at the time of service, TAKECARE will reimburse you for covered services up to $250 over the copayment amount. TAKECARE will pay for any treatment that is a covered benefit resulting from an unforeseen medical emergency when received from a licensed medical practitioner anywhere in the world. Copayments There are two copayment levels for emergency services. The higher copayment applies when services are obtained in a hospital emergency room or other emergency facility that charges a facility charge; the lower copayment applies when the emergency services are obtained in a physician office setting or other medical facility that does not charge a facility charge. Thus, it is to your advantage to visit your PCP's office or other medical facility when you have a choice. If a member is admitted as an inpatient to a hospital directly from the emergency room, the emergency copayment is waived. TAKECARE Service Area The TAKECARE service area includes the following Colorado counties: Adams El Paso Pueblo Arapahoe Fremont Teller Boulder Huerfano Weld Crowley Jefferson Denver Larimer Douglas Otero There is a service area map with zip codes in your enrollment packet. 14 How TAKECARE Benefits You TAKEC Your Rights and Responsibilities We're committed to developing and maintaining a good working partnership with you. As a member we want you to know that you can expect certain rights from TAKECARE and that you have certain responsibilities. And, we want to know if we're not meeting your expectations. This chapter, and Chapter Four, Your Rights and Responsibilities, explain TAKECARE's responsibilit to you and your obligations to TAKECARE. Following are some of the rights to which you are entitle along with some of your responsibilities. You have: • The responsibility to choose a Primary Care Physician. • The right to voice any concerns you may have about TAKECARE or the care that you receive. • The right to receive nonproprietary information about TAKECARE, our benefits and services, az our providers. • The right to work with your physician on decisions regarding your health care and treatment.I return, you have the responsibility to provide relevant information to your PCP and to follow health guidelines and instructions from health professionals. • The responsibility to respect the rights of other patients, members, providers and/or staff. • The responsibility to provide accurate information pertinent to your health care and your coverage with TAKECARE both prior to services being rendered and any time while you are a member of TAKECARE. In addition, please be aware of the following: • Notify Membership Services if you change your address. Otherwise, TAKECARE is not rayons* if you do not receive updated information. • Notify Membership Services if you lose your ID card--your ID card is essential for your acceg to benefits! • You cannot let any unauthorized individual use your ID card. If you do, TAKECARE will not! for the services so obtained and you risk termination of your coverage and possible legal actin • You must submit an enrollment change form to TAKECARE when you have a change in depend status. You can get these forms from your employer. it w Your Rights and Responsibilities 15 TABLE OF CONTENTS CHAPTER FOUR YOUR RIGHTS AND RESPONSIBILITIES A. Agreement 16 I.3 Level II 31 A.1 Agreement Effective Period 16 I.4 Arbitration 31 A.2 Agreement Inclusions 16 1.5 Appeal of Final Decisions 31 A.3 Amendment/Termination of Agreement . . 16 I.6 Other Litigation-- Limitations 32 A.4 TAKECARE's Agreement 16 J. Premiums 32 0 A.5 Member's Agreement 16 J.1 Payments 32 A.6 Conformity With Statutes 17 J.2 Late Charges 32 B. Continuation of Coverage 17 J.3 Nonpayment 32 B.1 Availability 17 J.4 Clerical Errors 32 13.2 Continuation of Coverage Rules 17 K. Records 33 B.3 Groups of 20 or More Employees 18 K.1 Confidentiality 33 13.4 Groups of Fewer than 20 Employees . . . 18 K.2 Release of Information 33 B.5 Premiums for Continuation of Coverage . 19 K.3 Access to Records 33 13.6 Constructive Election 19 L. Relationship Between Parties 33 B.7 Conversion to Nongroup Coverage . . . . 19 L.1 Description 33 C. Conversion 19 L.2 Liability 33 C.I Subscriber 19 L.3 TAKECARE's Responsibility 34 C.2 Spouse 19 L.4 Subscribing Group's Responsibility . . . . 34 C.3 Children 19 L.5 ERISA 34 C.4 Availability 19 M. Termination of Group Coverage 34 C.5 Limitations 20 M.1 Nonpayment 34 C.6 Election 20 M.2 Misstatements/Omissions 34 C.7 Out-of-Area 20 M.3 Written Notice 35 D. Coordination of Benefits and Subrogation . . . . 20 M.4 Refunds 35 D.1 Coordination of Benefits 20 M.5 Confinement at Termination 35 D.2 Motor Vehicle No-Fault Insurance 24 M.6 Continuation of Coverage 35 D.3 Workers' Compensation 25 M.7 Termination of Benefits 35 D.4 Subrogation 26 N. Termination of Individual Coverage 35 E. Effective Date of Coverage 27 N.1 Termination Date 35 E.1 Effective Date 27 N.2 Voluntary Termination of E.2 Addition of Dependents 27 Dependent Coverage 36 E.3 Previous Confinement 27 N.3 Required Termination of F. Eligibility 28 Dependent Coverage 36 F.1 Subscriber 28 N.4 Refunds for Dependent Coverage 36 F.2 Dependents 28 N.5 Nonpayment of Copayments 36 F.3 Active Military Duty and Military Reservists 29 N.6 Refusal of Compliance 37 F.4 Proof of Eligibility 29 N.7 Failure to Establish PCP Relationship . . . 37 G. Enrollment 29 N.8 Inappropriate Behavior 37 G.1 Initial Enrollment 29 N.9 False Information 37 G.2 Group Open Enrollment 29 N.10 Confinement at Termination 37 G.3 Other Enrollment 30 N.11 Misuse of ID Card 37 G.4 Limit of Enrollment 30 N.12 Reduced Working Hours 38 H. Limitations 30 N.13 Relocation 38 H.1 Contractual Arrangements 30 N.14 General Information 38 H.2 Contract Providers 30 O. Miscellaneous 39 I. Member Claims Review 31 O.1 Claims 39 1.1 Review 31 O.2 Copayment Limit 39 1.2 Level I 31 O.3 Member Identification 39 16 Your Rights and Responsibilities TA CHAP 1 ER FOUR YOUR RIGHTS AND RESPONSIBILITIES A. Agreement A.1 Agreement Effective Period A.1.1 This Agreement will be in effect for one year from the date hereof or the date specified on the Signature Sheet, subject to Section M., Termination of Group Coverage. A.2 Agreement Inclusions A.2.1 This Agreement, consisting of Chapters Three, Four, Five, Six and Seven in this manual, Evide Coverage and Owner's Manual, along with the Evidence of Coverage and Owner's Man Signature Sheet, the application of the subscribing group and the individual applications of the members, and any written amendments, constitutes the entire contract between the parties. A.3 Amendment/Termination of Agreement A.3.1 This Agreement may be amended, changed, or terminated as stated in this Agreement or by mud agreement between TAKECARE and the subscribing group, without the consent or agreement of it members or any person having a beneficial interest in it. Any change or amendment will not aff services provided before the date of the change. A.3.2 The terms and provisions of this Agreement control the type and scope of benefits available to a member. No representative or agent of TAKECARE can amend this Agreement by giving oral ad, incomplete or incorrect information, or by contradicting the provisions of this Agreement. TAKE will not deviate from the provisions of this Agreement. A.4 TAKECARE's Agreement A.4.1 TAKECARE of Colorado, Inc., dba TAKECARE Colorado (TAKECARE), a Colorado corporation, i Federally qualified, state-licensed health maintenance organization (HMO). TAKECARE and/or it: assigns will professionally and consistently administer this Agreement as explained in this manual will be done according to the specific definitions of terms used in this Agreement, as described it Chapter Seven of this manual, Definition of Terms, and according to applicable State and Federa and regulations. A.4.2 In compliance with federal and state law, TAKECARE shall not discriminate on the basis of age, s color, race, disability, marital status, sexual preference, religious affiliation, or public assistance A.5 Member's Agreement A.5.1 By choosing the coverage specified in this Agreement, paying the premium, or accepting benefits accordance with this Agreement, all members or their legal representatives expressly agree to all conditions and provisions of this Agreement. A.5.2 The member must pay the copayments applicable to the plan under which he/she is enrolled. Copayments should be paid to the provider at the time of service. F- Your Rights and Responsibilities 17 A.6 Conformity With Statutes A.6.1 Any provision of this Agreement which, on its effective dates, is in conflict with the applicable statutes of the jurisdiction in which it is delivered, is hereby amended to conform with the minimum requirements of such statutes. A.6.2 TAKECARE will modify enrollment and eligibility criteria applicable under this Agreement to allow the Subscribing Group to meet the legal requirements of the Family and Medical Leave Act (29 U.S.C. Section 2601, et. seq.). B. Continuation of Coverage B.1 Availability B.1.1 Colorado law, Section 10-8-116 C.R.S., and Federal law, Title X, Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended, require continuation coverage be made available to subscribers and their dependents when the subscriber is terminated or some other qualifying event occurs that would cause the subscriber or member to lose coverage. Continuation coverage means you have the right to continue your TAKECARE group coverage at your own expense, even if you are no longer eligible for coverage paid by your employer. It is TAKECARE's opinion that the Federal law, COBRA, will take precedence over the Colorado law except for groups of fewer than twenty (20) employees, church groups, or any subscribers terminated for gross misconduct. B.1.2 To the extent required by either Federal or State law, continuation coverage will be made available under this Agreement. B.1.3 Continuation coverage is not automatic. The subscriber or dependent must be eligible, must elect to take the coverage, must complete an enrollment application, and must pay the necessary premiums. B.1.4 There are certain events that will terminate the continuation coverage before the end of the continuation period. These events are outlined in the State and Federal legislation. B.2 Continuation of Coverage Rules B.2.1 This Section summarizes the various provisions of the law. It is a general notice of the member's rights and should not be regarded as a complete discussion of the applicable provisions. B.2.2 Continuation of health plan coverage is available to subscribers and their qualified beneficiaries, which include spouse and dependent children. This coverage is based on certain qualifying events. B.2.3 There are two categories of groups: • Groups of twenty (20) or more employees • Groups of fewer than twenty (20) employees, church groups, or any subscribers terminated for gross misconduct B.2.4 If a qualifying event occurs, the subscribing group/plan administrator will supply members with individual notice and a form to elect continuation coverage. Plan members must make their election within sixty (60) days of the later of the following: • The date of termination of coverage under this Agreement • The date the member receives notice of the right to continuation of coverage B.2.5 For dissolution of marriage, legal separation, or changes in dependent status, the member must notify the subscribing group/plan administrator within sixty (60) days of the event. 18 Your Rights and Responsibilities TAKECARI B.2.6 Qualified beneficiaries who relocate outside the TAKECARE service area are entitled to retain their TAKECARE coverage subject to the conditions of this Agreement. With the exception of benefits listed in Section D., Emergencies Outside the TAKECARE Service Area, all covered services must be obtained within the TAKECARE service area through a participating Primary Care Physician (PCP). B.3 Groups of Twenty (20) or More Employees B.3.1 The length of continuation of coverage and the qualifying events, and the qualified beneficiaries for groups of twenty (20) or more employees are shown in this table. Continuation Qualifying Events Period Qualified Beneficiary GROUPS OF 20 OR MORE: 1. Termination except for gross misconduct . . 18 months Subscriber, spouse, and/or or reduction of working hours of subscriber other dependent 2. Death of subscriber 36 months Spouse and/or other dependents 3. Dissolution of marriage or legal separation . 36 months Spouse and/or other of subscriber from subscriber's spouse dependents 4. Subscriber becomes entitled to Medicare . . 36 months Spouse and/or other dependents 5. Dependent child ceases to be a dependent . 36 months Dependent child child under the requirements of the health care plan 6. Social Security determines a qualified . . . . 29 months Disabled beneficiary beneficiary is disabled at the time of termination or reduction of working hours, except when termination or reduction of working hours is due to gross misconduct B.4 Groups of Fewer than Twenty (20) Employees B.4.1 For groups with fewer than twenty (20) employees, church groups, or any employees terminated for gross misconduct, the continuation period is 180 days from termination of employment. B.4.2 For groups with fewer than twenty (20) employees, church groups, or any subscribers terminated for gross misconduct, a terminated subscriber may elect to receive continuation coverage for the member and/or dependents if: • The group contract has not been terminated in its entirety by the subscribing group. • Any premium or contribution required from or on behalf of the subscriber has been paid in full to the termination date. • The subscriber has been continuously covered under the group service contract or its predecessor contract for a minimum of six (6) months. • The subscriber is not entitled to Medicare or Medicaid coverage. • The subscriber elects within twenty (20) days from the date of termination of employment (30 days if the subscribing group fails to provide proper notice) to accept continuation coverage and pays 100% of the required monthly premium for the requested coverage. Your Rights and Responsibilities 19 B.4.3 Within ten (10) days of the date of termination, the subscribing group will provide the subscriber with written notice of his/her right to elect continuation coverage, the amount of the monthly payment required from the subscriber, the place of payment, and deadline for receiving payment and the fact that loss of coverage will result if payment is not received by the deadline. B.5 Premiums for Continuation of Coverage B.5.1 For groups with twenty (20) or more employees, the premium may be up to 102% of the premium being paid before the qualifying event occurred with one exception. For a disabled beneficiary, the premium may be increased from 102% to 150% for months 19-29 of continuation coverage. B.5.2 A qualified beneficiary must pay current premiums for continuation coverage no later than forty-five (45) days after the beneficiary's election to continue coverage. B.6 Constructive Election B.6.1 If before making an election for continuation coverage and during the election period, a subscriber or qualified beneficiary uses services from the health plan, this use will be considered a constructive election. The subscriber or qualified beneficiary is obligated to pay the applicable premium for the period during which coverage was provided. B. 7 Conversion to Nongroup Coverage B.7.1 At the end of the continuation period, the subscriber or qualified beneficiary has the option to convert to nongroup coverage generally available under the plan. C. Conversion C.1 Subscriber C.1.1 Any subscriber who is no longer eligible for coverage as part of a subscribing group may convert to individual conversion membership without regard to health status or requirement for health care services. C.2 Spouse C.2.1 If the subscriber's spouse is no longer covered under this Agreement solely because of divorce or the subscriber's death, and does not elect continuation coverage, he/she may convert to conversion coverage as explained in Subsection C.1, Subscriber, above. C.3 Children C.3.1 If a dependent child is no longer covered under this Agreement solely because he/she no longer meets the requirements for coverage as a dependent as defined in Section F., Eligibility,and does not elect continuation coverage, he/she may convert to conversion coverage as explained in Subsection C.1, Subscriber, above. C.4 Availability C.4.1 Any subscriber on continuation coverage may convert to conversion coverage without regard to health status or requirement for health care services. Notification of conversion rights will be given during the 180 days preceding the expiration of the continuation coverage. 20 Your Rights and Responsibilities TAKECM C.4.2 The subscriber must convert his/her membership according to the rules and regulations that TAKECARE has in effect at the time of application for conversion. C.4.3 Conversion coverage offers basic benefits with different copayments and requires a quarterly premium paid in advance. C.5 Limitations C.5.1 Notwithstanding Subsections C.1-C.3 in this Section, a subscriber and/or dependents will have no conversion rights if the subscriber is no longer eligible to continue as a member of the subscribing group for any of the following reasons: • Termination of entire group • Termination for nonpayment of applicable premiums or copayments • Termination due to failure to comply with recommended procedures or treatments • Permanent relocation out of the TAKECARE service area • Gross abuse of TAKECARE's plan rules and regulations • Falsifying membership information C.6 Election C.6.1 The member must convert his/her membership within thirty-one(31) days of the date he/she becomes ineligible. The conversion is effective retroactive to the date of ineligibility. C. 7 Out-Of-Area C.7.1 TAKECARE may designate an insurance carrier to provide conversion benefits to those persons who cease to be eligible for coverage because they no longer maintain residence within the service area. Benefits, terms, and premiums of the conversion contract will be determined by the designated insurance carrier. D. Coordination of Benefits and Subrogation D.1 Coordination of Benefits NOTE: TAKECARE coverage as a secondary payor generally requires that the member utilize TAKECARE participating providers to ensure coverage. D.1.1 General D.1.1.1 TAKECARE will follow coordination of benefits guidelines promulgated by the Colorado Division of Insurance to establish the order of carrier responsibility in coordinating benefits with other Plans in force for members, including members covered by more than one policy with TAKECARE. "Plan" is defined below. D.1.1.2 The benefits available to members under any other Plan will be coordinated pursuant to the provisions of this Section to avoid duplicate payment to members for the same or similar benefits or services. D.1.1.3 In the event that the order of benefit determination rules set forth in this Section D. differ from those permitted by Colorado Insurance Regulation 4-6-2, or any successor regulation, then the order of benefit determination rules set forth herein will be construed as if their terms comported with the minimum requirements of that regulation. 11111 Your Rights and Responsibilities 21 D.1.2 Applicability D.1.2.1 This Coordination of Benefits ("COB") provision applies to this Plan when a subscriber or the subscriber's covered dependent has health care coverage under more than one Plan. "Plan" and "This Plan" are defined below. 1.1.2.2 If this COB provision applies, the order of benefit determination rules should be looked at first. The order of benefit determination rules are stated in Subsection D.1.4, Order of Benefit Determination Rules. Those rules determine whether the benefits of This Plan are determined before or after those of another Plan. The benefits of This Plan: • Will not be reduced when, under the order of benefit determination rules, This Plan determines its benefits before another Plan; but • May be reduced when, under the order of benefits determination rules, another Plan determines its benefits first. The above reduction is described in Subsection D.1.5, Effect on the Benefits of This Plan. D.1.3 Definitions The following definitions will apply to this Section: D.1.3.1 "Plan" is any of the following which provides benefits, indemnification or services for, or because of, medical or dental care or treatment covered by This Plan: • Group insurance or group-type coverage (including other TAKECARE coverage), whether insured or uninsured. This includes prepayment, group practice or individual practice coverage. It also includes coverage other than school accident- type coverage. • Coverage under a governmental Plan, or coverage required or provided by law. This does not include a state Plan under Medicaid(Title XIX, Grants to States for Medical Assistance Programs of the United States Social Security Act, as amended from time to time). • Individual automobile "no-fault" or traditional "fault" type contracts. • Hospital indemnity benefits in excess of$100 per day. Each contract or other arrangement for coverage under any bulleted item above is a separate Plan. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate Plan. D.1.3.2 "This Plan" refers to the covered benefits for health care services of the Evidence of Coverage of which this Section is a part. D.1.3.3 "Primary Plan/Secondary Plan" The order of benefit determination rules state whether this Plan is a Primary Plan or a Secondary Plan as to another Plan covering the person. When This Plan is a Primary Plan, its benefits are determined before those of the other Plan and without considering the other Plan's benefits. When This Plan is a Secondary Plan, its benefits are determined after those of the other Plan and may be reduced because of the other Plan's benefits. When there are more than two Plans covering the individual, This Plan may be a Primary Plan as to one or more other Plans, and may be a Secondary Plan as to a different Plan or Plans. 1 22 Your Rights and Responsibilities TAKECAIU D.1.3.4 "Allowable Expense" means a necessary, reasonable and customary item of expense for health care; when the item of expense is covered at least in part by one or more Plans II covering the individual for whom the claim is made. The difference between the cost of a private hospital room and cost of semi-private hospital room is not considered an Allowable Expense under the above definition unless the patient's stay in a private hospital room is medically necessary either in terms of generally accepted medical practice or as specifically defined in the Plan. When a Plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an Allowable Expense and a benefit paid. When benefits are reduced under a Primary Plan because a covered individual does not comply with the Plan provisions, the amount of such reduction will not be considered an Allowable Expense. Examples of such provisions are those related to second surgical opinions, precertification of admissions or services, and preferred provider arrangements. D.1.3.5 "Claim Determination Period" means a calendar year. However, it does not include any part of a year during which an individual has no coverage under This Plan, or any part oft year before the date this COB provision or a similar provision takes effect. D.1.4 Order of Benefit Determination Rules D.1.4.1 General. When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan which has its benefits determined after those of the other Plan unless: • The other Plan has rules coordinating its benefits with those of This Plan, and both those rules and This Plan's rules, D.1.4.2 below, require that This Plan's benefits be determined before those of the other Plan; or • The other Plan is a governmental Plan or coverage required or provided by law, and This Plan is required by law or regulation to be the Primary Plan. A basis for a claim under a governmental Plan can exist when a member is covered or eligible for coverage under that Plan, whether or not the member applies for or receives benefits thereunder. The conditions shown are current examples (subject to change) of some of the areas in which this Plan is required to be the Primary Plan o The member is covered under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). o The member is covered under Medicaid. o The member is age 65 or older, is enrolled as a subscriber or as a dependent of a subscriber (of any age) in the group coverage of a subscribing group with twenty (20) or more employees and elects coverage under This Plan as primary to Medicare. o The member is a disabled Medicare beneficiary (other than an End Stage Renal Disease beneficiary) and is enrolled in a group coverage of a subscribing group with 100 or more employees. o The member is entitled to Medicare benefits solely on the basis of End Stage Renal Disease, in which case This Plan will be primary for the first eighteen (18) months (or such period of time as Medicare regulations may require) of treatment; after the initial period, the benefits under This Plan will be reduced to the extent that they duplicate any benefits provided or available under Medicare, if the member is covered or eligible to be covered under Medicare. D.1.4.2 Rules. This Plan determines its order of benefits using the first of the following rules which applies: ri: Your Rights and Responsibilities 23 Rule a: Non-Dependent/Dependent. The benefits of the Plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the Plan which covers the individual as a dependent. Rule b: Dependent Child/Parents not Separated or Divorced. Except as stated in Rule c. below, when This Plan and another Plan cover the same child as a dependent of different persons, called "parents": • The benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the parent whose birthday falls later in the year; but • If both parents have the same birthday, the benefits of the plan which covered one parent longer are determined before those of the Plan which covered the other parent for a shorter period of time. However, if the other plan does not have the rule described in the first bulleted item immediately above, but instead has a rule based upon the gender of the parent, and if, as a result, the Plans do not agree on the order of benefits, the rule of the other Plan will determine the order of benefits. Rule c: Dependent Child/Separated or Divorced. If two or more plans cover an individual as a dependent child of divorced or separated parents, benefits for the child are determined in this order: • First, the Plan of the parent with custody of the child; • Then, the Plan of the spouse of the parent with the custody of the child; and • Finally, the Plan of the parent not having custody of the child. However, if the specific terms of a court decree state that one of the parents is responsible for the health care expense of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. The Plan of the other parent will be the Secondary Plan. This paragraph does not apply with respect to any Claim Determination Period or Plan Year during which any benefits are actually paid or provided before the entity has that actual knowledge. Rule d: Joint Custody. If the specific terms of a court decree state that the parents will share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the Plans covering the child will follow the order of benefit determination rules outlined in Rule b. Rule e: Active/Inactive Employee. The benefits of a Plan which covers a person as an employee who is neither laid off nor retired (or as that employee's dependent) are determined before those of a Plan which covers that person as a laid off or retired employee (or as that employee's dependent). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, then Rule e is ignored. Rule 1: Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the benefits of the Plan which covered an employee, member or subscriber longer are determined before those of the Plan which covered that individual for the shorter term. 24 Your Rights and Responsibilities TAKECARE D.I.5 Effect on the Benefits of This Plan D.1.5.1 When This Section Applies. This Subsection D.1.5 applies when, in accordance with Subsection D.1.4, Order of Benefit Determination Rules, This Plan is a Secondary Plan as to one or more other Plans. In that event the benefits of This Plan may be reduced under this Section. Such other Plan or Plans are referred to as "the other Plans" in D.1.5.2 immediately below. D.1.5.2 Reduction in This Plan's Benefits. The benefits of This Plan will be reduced by the sum of: • The benefits that would be payable for the Allowable Expense under This Plan in the absence of this COB provision; and • The benefits that would be payable for the Allowable Expenses under the other Plans, in the absence of provisions with a purpose like that of this COB provision, whether or not a claim is made, exceeds those Allowable Expenses in a Claim Determination Period. In that case, the benefits of This Plan will be reduced so that they and the benefits payable under the other Plans do not total more than those Allowable Expenses. Only the amount of benefit actually paid by This Plan may be charged against any applicable benefit limit under This Plan. D.I.6 Right to Receive and Release Needed Information Certain facts are needed to apply these COB rules. TAKECARE has the right to decide which facts it needs. It may get needed facts from or give them to any other organization or individual. TAKECARE need not tell, or get the consent of, or provide notice to, any individual to do this. Each individual claiming benefits under This Plan must give TAKECARE any facts it needs to pay the claim. 111.7 Facility of Payment A payment made under another Plan may include an amount that should have been paid under This Plan. If it does, TAKECARE may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under This Plan. TAKECARE will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made" means reasonable cash value of the benefits provided in the form of services. D.1.8 Right of Recovery If the amount of the payments made by TAKECARE is more than it should have paid under the COB provision, it may recover the excess from one or more of: • The individuals it has paid or for whom it has paid; • Insurance companies; or • Other organizations. The "amount of payments made" includes the reasonable cash value of an benefits r form of services. any p ovtded in the D.2 Motor Vehicle No-Fault Insurance D.2.1 Under Colorado law, if a member owns and operates a motor vehicle on the public highways, the ' member is required to have no-fault insurance, which covers certain medical and rehabilitation h expenses incurred if a member or others are injured in an automobile accident. cop Your Rights and Responsibilities 25 D.2.2 TAKECARE is required by law to coordinate its coverage with a member's no-fault insurance. This means that if a member is injured in an automobile accident, the automobile no-fault insurance will pay first, and TAKECARE will provide coverage only if the amount of no-fault coverage is insufficient to pay for all of the medical expenses. D.2.2.1 Coverage under this Agreement includes the amount of the deductible under the no- fault coverage. D.2.3 If a member is injured while riding in or operating a vehicle owned by the member, and the vehicle is not covered by no-fault insurance as required by law, benefits under this Agreement will not be available to the member, up to the minimum amount of no-fault insurance coverage required by law. D.2.3.1 If the no-fault insurance policy provides coverage in excess of the minimum required by law, TAKECARE will coordinate benefits with the amount of coverage provided. D.2.3.2 TAKECARE's denial of benefits will not apply to any member injured in an automobile accident if the injured member is a non-owner operator, passenger, or pedestrian and the vehicle is not covered by no-fault insurance. D.2.4 If there is an automobile policy in effect, and the member waives or fails to assert his/her rights to the no-fault benefits, TAKECARE will not pay the benefits that would have been available under the no-fault policy. D.2.5 TAKECARE reserves the right to require proof that the automobile policy has paid all benefits required by law before TAKECARE pays any benefits. D.2.6 If there is more than one automobile policy in force, TAKECARE will coordinate with complying no-fault policies as required by the state of Colorado. D.2.7 After benefits under the no-fault policy have been exhausted, coverage under the terms of this Agreement will be available only if the member obtains all medical care for covered benefits in compliance with this Agreement from or through a participating PCP. D.3 Workers' Compensation D.3.1 TAKECARE will not provide benefit services or supplies required as a result of a work-related illness or injury. This applies to illness or injury resulting from occupational accidents or sickness covered under any of the following: • Occupational disease laws • Employer's liability • Federal, State, or municipal law • The Workers' Compensation Act D.3.2 To recover benefits for a work-related illness or injury, the member must pursue his/her rights under the Worker's Compensation Act or any of the above provisions that may apply to the illness or injury. This includes filing an appeal with the Industrial Commission, if necessary. D.3.2.1 When a legitimate dispute exists as to whether an injury or illness is work-related, TAKECARE will provide benefits during the appeal process if the member signs an agreement to reimburse TAKECARE for 100% of the benefits provided. D.3.3 TAKECARE will not provide benefit services for a work-related illness or injury even under the following circumstances: D.3.3.1 The member fails to file a claim within the filing period allowed by law. 26 Your Rights and Responsibilities TAKECA7 D.3.3.2 The member obtains care that is not authorized by Workers' Compensation. D.3.3.3 The member fails to comply with any other provisions of the law. D.3.3.4 The member has a choice of providers, which includes a TAKECARE provider, elects to ua a non-participating provider and the claim is subsequently denied by Workers' Compensation. D.3.4 Benefits will not be denied to a subscriber whose employer has not complied with the laws and regulations governing Worker's Compensation Insurance, provided that such subscriber has sought and received services under the provisions of this Agreement. D.4 Subrogation D.4.1 TAKECARE will not cover any services or supplies for which a third party is liable or has agreed to make payment. In such cases, all of the following will apply: D.4.1.1 The member will promptly notify TAKECARE of any claim against the third parties. D.4.1.2 The member will cooperate in every necessary way to help TAKECARE enforce its right to pursue and collect from the third party. D.4.1.3 The member will hold recovery proceeds in trust for TAKECARE. D.4.1.4 TAKECARE will be subrogated and will succeed to any member's right of recovery from a third party for the amount of actual expenses paid by TAKECARE, as well as future medica expenses not yet incurred, which are related directly to the injury or illness and are the responsibility of a third party. D.4.1.5 The member will reimburse TAKECARE as explained below. D.4.1.6 When the member has received payment from the third party, as a result of judgement, settlement, or otherwise, the member will first reimburse TAKECARE for the amount of actual expenses paid. An agreement pertaining to a fair present value payment or trust account to cover future medical expenses will be established by TAKECARE and the membe in the event of a lump sum award or settlement of a claim for future medical expenses. In the absence of such an agreement, TAKECARE will exclude coverage for future medical expenses related to the injury or illness up to the amount of the award. D.4.1.7 The member will retain only the portion of the judgement, settlement, or other recovery that remains after TAKECARE has been reimbursed, regardless of whether the member has been fully compensated by the third party for damages. D.4.1.8 TAKECARE will be reimbursed subject to reduction equal to TAKECARE's pro rata share of the attorney's fees and costs incurred by the member in obtaining the recovery. D.4.1.9 If attorneys' fees are to be paid on a contingency, TAKECARE's reimbursement amount wit be reduced by its pro rata share of the attorneys' fees but in no event to exceed thirty-three percent (33%) of TAKECARE's recovery. TAKECARE will not pay or contribute any part GI the attorneys' fees or costs except by allowing this prorated reduction. D.4.1.10 Should a member refuse or fail, for any reason, to pursue his rights, then TAKECARE will have the right to initiate an action as subrogee in the member's name or in TAKECARE's name, at TAKECARE's election, to recover benefits provided under this Agreement and the member will cooperate fully in the pursuit of any such action. Your Rights and Responsibilities 27 D.4.1.11 The member will, on request, execute and deliver whatever documents or whatever else TAKECARE determines is necessary to carry out the provisions of this Subsection. D.4.1.12 The provisions of this Section are binding on all members by virtue of Subsection A.5, A.6, Member's Agreement. However, TAKECARE may condition the payment of benefits on the member's (or his/her personal representative's) express written acceptance of the provisions of this Section. E. Effective Date of Coverage E.1 Effective Date E.1.1 Subject to the terms of Sections F., Eligibility,and G., Enrollment, in this chapter, when an individual submits a written application for him/herself or for him/herself and dependents on or before he/she is eligible to enroll, coverage will become effective on the first day of the month after he/she becomes eligible or as indicated on the Signature Sheet. E.2 Addition of Dependents E.2.1 To enroll a new dependent acquired through marriage or birth, the subscriber must submit written application for dependent coverage within thirty-one(31) days after the marriage or birth. Coverage will be effective retroactively to the date of the marriage or birth. E.2.2 To enroll a new dependent acquired through legal adoption, the subscriber must submit written application for dependent coverage within thirty-one(31) days of when the child is placed in the physical custody of the subscriber, within the subscriber's home. The subscriber also must submit a copy of the adoption papers. Coverage will be retroactively effective to the date of placement. E.2.3 Newborns are covered for the first thirty-one(31) days of life, regardless of whether the subscriber applies for continued coverage beyond the first thirty-one(31) days PROVIDED that all medical care for covered benefits for the newborn is obtained in compliance with this Agreement from or through a participating provider. For continuing coverage beyond the first thirty-one(31) days of life, the subscriber must make written application for dependent coverage within the required thirty-one(31) days. E.2.4 If, following acquisition of a new dependent(s), the subscriber fails to submit a written application for dependent coverage as required in this Section, the new dependent(s) cannot be enrolled prior to the next group open enrollment period. E.3 Previous Confinement E.3.1 If an eligible new member or a subscriber who is on active work status (as defined in Chapter Seven, Definition of Terms) is confined to a hospital or institution on the proposed effective date of coverage under this Agreement, coverage under this Agreement will become effective upon that date subject to reduction for benefits under the prior carrier's period of extension or accrued liability, PROVIDED he/she obtains all medical care for covered benefits in compliance with this Agreement and from or through a participating Primary Care Physician (PCP) and, PROVIDED that he/she notifies TAKECARE of the confinement within forty-eight(48)hours of the proposed effective date. This Subsection shall be applied in a manner necessary to conform to the requirements of Colorado law, Section 10-16-106, C.R.S. AIM 28 Your Rights and Responsibilities TAKECAPo F. Eligibility F.1 Subscriber F.1.1 To be eligible to enroll as a subscriber, an individual must be an employee on active work status with the subscribing group. The subscribing group must give TAKECARE a definition of active work status when it submits the group application, otherwise TAKECARE will use the definition in Chapter Seven, Definition of Terms. F.1.2 If an individual is not on active work status on the date his/her coverage is to begin, coverage will not begin until the date he/she does attain active work status. F.1.3 All eligible employees and their eligible dependents must reside inside the TAKECARE service area. For legally required exceptions to this provision, see Section B., Continuation of Coverage, in this chapter. F.2 Dependents NOTE: The dependent eligibility conditions included in the HMO Evidence of Coverage and Owner's Manual Signature Sheet supersede the eligibility conditions referenced in this Section, if different from those conditions stated here. Check with your employer or Membership Services for information regarding the dependent age limit(s) or other dependent eligibility information applicable to your employer group. F.2.1 A subscriber's spouse is eligible to enroll as a dependent. F.2.2 Unless otherwise specified in the Signature Sheet, common law spouses will be considered eligible dependents if evidence satisfactory to TAKECARE is furnished upon request. F.2.3 Legal separation does not constitute ineligibility. The Subscribing Group may elect, however, to deny eligibility to legally separated spouses. Legal separation is a qualifying event for COBRA. F.2.4 A subscriber's children are eligible to enroll as dependents through the month in which they reach the age of 23, provided they meet the following criteria: F.2.4.1 They are natural, legally adopted, or step-children, who have never married, OR They are children who have never married for whom the subscriber has assumed permanent legal guardianship. Legal evidence of the adoption, guardianship and custody, such as a certified copy of a court order, must be furnished to TAKECARE on request. F.2.4.2 They must be principally dependent upon the subscriber for maintenance and support. F.2.4.3 They cannot be regularly employed by one or more employers on a basis of thirty (30) or more hours per week. F.2.4.4 They must reside inside the TAKECARE service area, or be enrolled as a full-time student (at least twelve credit hours) at a high school, college, university, vocational, or secondary school. Verification of academic enrollment must be provided to TAKECARE on request. F.2.5 Newborns of the subscriber are covered from the date of birth. This does not include an adopted child before the child is placed in the employee's home and physical custody as explained in Section E., Effective Date of Coverage. Your Rights and Responsibilities 29 F.2.6 Regardless of age, any natural, adopted, or step-child(ren), of the subscriber, or child(ren) for whom the subscriber has assumed permanent legal guardianship, as described above, are eligible if they became mentally retarded and/or physically handicapped and incapable of self-support before the age of 23 while residing with the subscriber. Proof of such incapacity and dependency must be furnished at least annually as requested by TAKECARE, and as may be required by the subscribing group. Such dependents are the only exception to the age limitation described above. F.3 Active Military Duty and Military Reservists F.3.1 Unless otherwise specified in the Signature Sheet, subscribers or covered dependents who are called to active military duty will no longer be considered eligible under TAKECARE, but may elect continuation of coverage under COBRA. The waiting period will be waived for those returning from active duty if application is made within thirty-one(31) days following the date of re-employment. F.3.2 Military Reservists returning to work from active duty yin the Armed Forces may have coverage reinstated, for themselves and any eligible dependent provided: F.3.2.1 such individual was eligible under the plan on the day employment with his or her employer ended due to being called to active duty in the Armed Forces; and F.3.2.2 such individual becomes re-employed with his/her employer within ninety (90) days of his/her discharge, or within one (1) year if such individual was hospitalized on the date of his/her discharge; and F.3.2.3 the individual applies for coverage subject to the enrollment requirements outlined in this Agreement. F.3.3 The coverage provided under this provision will be the benefits currently provided by TAKECARE. If an individual returns to active employment within the same contract year, eligible charges accumulated toward the satisfaction of provisions such as full payment provisions or contract year maximums will be taken into consideration when determining benefits available for the remainder of the contract year. F.4 Proof of Eligibility F.4.1 All members and applicants for coverage under this Agreement must complete and submit to TAKECARE all applications, medical review questionnaires, or other forms or statements that TAKECARE may reasonably request to determine eligibility. G. Enrollment G.1 Initial Enrollment G.1.1 Subscribers and dependents will be enrolled under this Agreement when they first become eligible or as described in Subsection G.2.I below. They must submit completed enrollment application forms to the subscribing group or as otherwise directed by TAKECARE. Promptly after receiving the form, the subscribing group will forward it to TAKECARE. G.1.1.1 All members and applicants for coverage under this Agreement must complete and submit to TAKECARE all applications, medical review questionnaires, or other forms or statements that TAXXECARE may reasonably request to determine eligibility. G.2 Group Open Enrollment G.2.1 The subscribing group will offer coverage as described in this Agreement to all eligible individuals under conditions no less favorable than those for any other alternate health care plan it makes available. AIM 30 Your Rights and Responsibilities TAKECA G.2.2 There will be a group enrollment period annually, during which the subscribing group will offer to all eligible individuals on active work status the choice of enrollment, for themselves and their dependem in TAKECARE or any other alternate health care plans available through the subscribing group. G.3 Other Enrollment G.3.1 Eligible individuals may enroll in TAKECARE outside the group enrollment period when newly eligible in the following situations: G.3.1.1 The spouse of a subscriber has coverage through his/her employment, and dependents of the subscriber are covered under the spouse's insurance. Then the spouse involuntarily loses this coverage. At this time, the spouse, if alive, and any dependents of the subscrib previously covered by the spouse's insurance may enroll in TAKECARE as dependents, wit the consent of the subscribing group. G.3.1.2 An individual employed by a TAKECARE subscribing group was covered under his/her spouse's coverage through the spouse's employment. Then the spouse involuntarily loses this coverage. At this time, the individual, his/her spouse, and any dependents of the individual may enroll in TAKECARE, with the consent of the subscribing group. G.3.2 For both situations just listed, TAKECARE reserves the right to make it a condition of enrollment that TAKECARE receives written proof of loss of coverage due to one of the following circumstances: • Termination of job or reduction in hours • Insurance carrier termination of coverage for the spouse's employer • Death of the spouse, leaving other dependents without coverage G.3.3 For the situations just listed, for the individuals to be eligible to enroll with TAKECARE, the individui must submit a change card to TAKECARE through the subscribing group within thirty-one(31) days from the date of the spouse's loss of coverage. Coverage with TAKECARE becomes effective the first day following termination of previous coverage. G.4 Limit of Enrollment G.4.1 If it becomes necessary for TAKECARE to limit enrollment of additional members in order to maintain suitable level of medical and hospital care, TAKECARE can limit enrollment in a manner that may suppress the eligibility or enrollment provisions of this Agreement. H. Limitations H.1 Contractual Arrangements H.1.1 TAKECARE will use its best efforts to make contractual arrangements with participating physicians, hospitals, and contract providers and to assure that members receive the benefits covered under the terms of this Agreement. If TAKECARE's best efforts are not sufficient due to a circumstance beyond its control, TAKECARE will assume the financial responsibility for providing the covered benefits through the end of the month in which the circumstance occurs. During this period, TAKECARE will have the right to authorize and direct where the services will be performed. H.2 Contract Providers H.2.1 The specific contract providers associated with TAKECARE, both individuals, organizations, and institutions, may be subject to change. A subscriber may contact TAKECARE for the latest update to t Provider Directory. Your Rights and Responsibilities 31 L Member Claims Review L 1 Review I.1.1 The TAKECARE Membership Services Department will attempt to resolve complaints through research and informal discussion. The member will be notified of the resolution of the complaint no later than thirty (30) days after the complaint is received. If the member is not satisfied with the decision, a written request may be sent to the Membership Services Department to initiate the formal member claims review process. A written request must be submitted to TAICECARE within ninety (90) days of the action or claim denial, whichever is later. L2 Level I I.2.1 The Member Relations Committee will investigate and respond to the member within thirty (30) days after receiving the request. If the member is not satisfied with the decision of the Member Relations Committee, the member can proceed to Level II if new or additional information becomes available. [3 Level II I.3.1 Only if new or additional information becomes available, the member may submit a written request for review by a Formal Member Appeals Panel. This Panel consists of individuals, providers, and TAKECARE senior management who have knowledge of the benefit and medical areas involved in the grievance. The member is invited to meet with the Panel to present the grievance. A written determination of the Panel's findings is then sent to the member within thirty (30) days after the Panel meeting. 14 Arbitration I.4.1 If a member has exercised all of the steps of the formal member claims review process and is not satisfied with the resolution of any claim under $50,000, the member may pursue binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association or such other form of alternative dispute resolution(e.g. mediation) as the member and TAKECARE may agree upon in writing. Judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction. This process will be paid for equally by TAKECARE and the member, with each party responsible for costs for its own experts, evidence and legal counsel. LS Appeal of Final Decisions L5.1 Prior to commencing litigation for matters not subject to binding arbitration, the member expressly agrees to exhaust his/her other administrative remedies within TAKECARE. After TAKECARE issues its final decision, the member and TAKECARE expressly and mutually agree that no legal proceeding appealing or otherwise challenging such final decision shall be filed or maintained, unless such suit or action shall be commenced within six (6) months after the date of the final decision. 32 Your Rights and Responsibilities TAKECti I.6 Other Litigation -- Limitations I.6.1 TAKECARE and the member expressly and mutually agree that no claim or cause of action, regardless of theory, arising under this Agreement, including but not limited to bad faith, outrageous conduct or other tort claims related to performance or non-performance of this Agreement, shall be initiated or sustained against TAKECARE, unless such suit or action shall be commenced within six (6) months afte said cause of action accrues. A claim or cause of action shall accrue on the date the event, notice, injury or breach is made, known, discovered or should have been discovered by the exercise of reasonable diligence. After the expiration of the six (6)-month period, the lapse of time shall be taken and deemed as conclusive evidence of the extinguishment of any claim or cause of action, any statute limitations to the contrary not withstanding. TAKECARE shall be entitled to recover its fees and costs, including attorney's fees for any action commenced in violation of this Section. In all the instances, attorney's fees and costs shall be awarded as provided by law. J. Premiums J.1 Payments J.1.1 The subscribing group must remit to TAKECARE, for each member, the monthly premiums specified a the Signature Sheet. J.1.2 Changes in monthly premium amounts will take effect as specified under Payment Arrangements on tl Signature Sheet. J.1.3 The monthly premiums must be prepaid for each month of coverage; they are due on or before the fii day of the month for which covered benefits are to be prepaid and provided. J.1.4 Only members for whom the stipulated premium is actually received will be entitled to benefits hereunder, and then only for the period for which such premium is received. J.1.5 If the addition of a new dependent, as explained in Section E., Effective Date of Coverage, results in change to the premium rate, the new rate will become effective as of the new dependent's effective date. J.2 Late Charges 3.2.1 Premium payments due on the first of the month but not paid may be subject to a one and one-half percent per month late charge. J.3 Nonpayment J.3.1 If any required premium is not received by TAKECARE, all rights to coverage for members whose premiums have not been received will terminate at the end of the month or period for which the last full monthly premium was received by TAKECARE. J.4 Clerical Errors J.4.1 Clerical error shall not deprive the member of coverage under this Agreement. Failure to report the termination of coverage shall not continue such coverage beyond the date it is scheduled to terminate according to the terms of this Agreement. Upon discovery of a clerical error, an appropriate adjustment in the premium(s) shall be made. However, no such adjustment in premium(s) or coverag shall be granted by TAKECARE to the subscribing group for more than sixty-two(62) days of coverag prior to the date TAKECARE was notified of such clerical error. Your Rights and Responsibilities 33 K. Records K.1 Confidentiality K.1.1 Privileged information from medical records of members, including mental health records, and information about the physician-patient relationship will be confidential. TAKECARE will not voluntarily disclose this information without prior written consent of the member except for use of the medical records necessary to administer this Agreement; use of the medical records for medical research and education; bona fide peer review during records review or utilization review programs established to promote quality medical care; provision of statistical utilization data to the subscribing group; use of the medical records for a bona fide medical emergency; and any other exceptions provided by law. Where the release of names or identifying demographic information is not necessary to the function being performed, such information will not be released. K.2 Release of Information K.2.1 Members may be required to release privileged or confidential information necessary to determine benefits on claims. If this information is not released, TAKECARE may withhold payment for the claims. K.2.2 To help determine claims payment, members automatically authorize all contract providers to give TAKECARE any medically related information about their treatment. K.3 Access to Records K.3.1 Either the subscribing group or TAKECARE will keep member eligibility records. Upon request, the subscribing group will submit to TAKECARE or give TAKECARE reasonable access to these records. K.3.2 The subscribing group shall furnish TAKECARE with all information, authorization, and supporting documentation which TAKECARE may reasonably require with regard to any matters pertaining to this Agreement. All documents furnished to the subscribing group by the member in connection with coverage under this Agreement, and the subscribing group's payroll and any other records pertinent to the coverage under this Agreement shall be open for inspection by TAKECARE at any reasonable time. L. Relationship Between Parties L.1 Description L.1.1 TAKECARE's contract providers are independent contractors; they are neither agents nor employees of TAKECARE. Also, neither TAKECARE nor TAKECARE employees are employees of the contract providers. L.2 Liability L.2.1 TAKECARE is not liable for acts or omissions of any contract providers or their employees. L.2.2 The subscribing group and its members are not agents or representatives of TAKECARE, and they are not liable for any acts or omissions by TAKECARE or its agents or employees, or those of current or future contract providers associated with TAKECARE. 34 Your Rights and Responsibilities TAKECAB L.3 TAKECARE's Responsibility L.3.1 TAKECARE agrees to indemnify and hold harmless the subscribing group, its directors, officers, employees, and any member from all damages, claims, lawsuits, settlements,judgements, costs, penalties, and related expenses, including attorney's fees for damages to any member resulting from th wrongful failure of TAKECARE to make payment for services pursuant to the terms of this Agreement, so long as TAKECARE is notified promptly in writing of any such claims and given the authority, information, and assistance (at TAKECARE's expense) for the defense of same. L.4 Subscribing Group's Responsibility L.4.1 The subscribing group agrees to engage TAKECARE, as described in this Agreement, to provide for necessary medical and hospital services to members who voluntarily enroll under this Agreement; the employer agrees to pay a predetermined monthly premium as explained in this Agreement. L.4.2 The subscribing group agrees to indemnify and hold harmless TAKECARE for covered benefits rendered to or on behalf of terminated subscribers and/or ineligible dependents, beyond the date of subscriber and/or dependent termination of coverage if the subscribing group or subscriber is delinquent in notifying TAKECARE of the change in status. Notification will be considered delinquent if not received by TAKECARE within thirty-one(31) days of change in status. L.4.3 Notice given by TAKECARE to an authorized representative of the subscribing group shall be deemed notice to all affected enrollees and their enrolled family dependents in the administration of this Agreement, including the termination of this Agreement or the termination of individual coverage. L.4.4 Within thirty-one(31) days following receipt of notification, the subscribing group shall apprise TAKECARE of enrollments, terminations or other changes. No adjustment in premium(s) or coverage shall be granted by TAKECARE to the subscribing group for more than thirty-one(31) days of coverage prior to the date TAKECARE was notified of the change. L.5 ERISA L.5.1 If this health plan is an employee welfare benefit plan of the employer under the Employee Retirement Income Security Act of 1974 (ERISA), the employer shall be the Plan Administrator. TAKECARE wit administer all health care claims under this plan and will provide the employer with health plan information to assist the employer in meeting ERISA reporting requirements. M. Termination of Group Coverage M.1 Nonpayment M.1.1 If a subscribing group defaults on payment of the monthly premium, TAKECARE will terminate this Agreement for all members after giving the subscribing group ten (10) days written notice. Termination will be effective at the end of the period for which monthly premiums have been paid. M.2 Misstatements/Omissions M.2.1 TAKECARE shall have the right to rescind this agreement as of the date of inception for any material misstatement or omission of facts in the group application or any supporting documents. M.2.2 Any claims that have been paid will be deducted from premiums received. M.2.3 Claims paid in excess of premiums received will be the responsibility of the subscribing group. col Your Rights and Responsibilities 35 M.3 Written Notice M.3.1 The subscribing group or TAKECARE may terminate this Agreement on the anniversary of the effective date of coverage for the subscribing group with at least thirty (30) days written notice prior to the anniversary or as specified on the Signature Sheet. M.3.2 Either party may terminate this Agreement at any other time with ninety (90) days written notice or as specified on the Signature Sheet. M.3.3 This Agreement will be terminated if required at any time by order of the Colorado Commissioner of Insurance. M.4 Refunds M.4.1 If TAKECARE terminates coverage for the entire subscribing group, any prepayment of premium for the period(s) after termination will be prorated to the termination date, unless benefits have been paid for that period. M.5 Confinement at Termination M.5.1 If a member is confined to a hospital or institution when coverage for the entire group terminates, the member's coverage terminates upon the effective date of the succeeding carrier's coverage, end of the episode of illness, as evidenced by the date of discharge, or twelve (12) months, whichever date occurs earlier, PROVIDED that the employer replaces this coverage with a group plan of similar benefits within thirty-one(31) days of termination. If the employer does not replace this coverage, coverage under this Agreement will terminate on the group termination date. This Subsection shall be applied in a manner necessary to conform to the requirements of Colorado law, Section 10-16-106 C.R.S. M.6 Continuation of Coverage M.6.1 When coverage for the subscribing group terminates, no member is entitled to conversion coverage. M. 7 Termination of Benefits M.7.1 Except as provided in Subsection M.5, no benefits will be payable under this Agreement for any service provided to members after the date of termination of the entire subscribing group. M.7.2 TAKECARE reserves the right to recover from members any costs incurred by TAKECARE for services provided after the termination date. N. Termination of Individual Coverage N.1 Termination Date N.1.1 Coverage of any member will end on the earliest one of the following dates: • The last day of the month in which the subscriber terminates employment • The last day of the month that the required monthly premium has been paid • The last day of the month in which the member requests cancellation of coverage • The date specified on the Signature Sheet • The last day of the month in which the subscribing group's coverage is involuntarily terminated • On a termination date as explained in Section M., Termination of Group Coverage, in this chapter • Immediately upon notice of termination of a member by TAKECARE as explained later in this Section TAKECARE 36 Your Rights and Responsibilities N.2 Voluntary Termination of Dependent Coverage N.2.1 Subscribers may voluntarily terminate an enrolled dependent's coverage at any time by submitting an enrollment change form. N.2.1.1 The termination is effective on the last day of the month in which TAKECARE receives the enrollment change form. N.3 Required Termination of Dependent Coverage N.3.1 Subscribers must terminate dependent's coverage because of the dependent's death, divorce, marriage, induction into active military service, or failue to maintain the eligibility conditions described in Section F., Eligibility. The subscriber must submit an enrollment change form to TAXECARE within thirty-one (31) days of the change in status. N.3.1.1 The termination is effective on the last day of the month in which the change in status occurred, regardless of whether the subscribing group gives TAKECARE timely notice of the change. N.3.2 The subscriber shall be responsible for any services provided to a dependent during any period the dependent does not meet the eligibility requirements stated in this chapter. The subscribing group agrees to assist TAKECARE in obtaining reimbursement for any amounts paid when a subscriber's dependent is not eligible. N.3.3 All dependents coverage terminates on the day the subscriber becomes ineligible for coverage as explained in this Section and Section F., Eligibility,in this chapter, excepting the provision explained in Subsection N.12, Reduced Working Hours. NOTE: Availability of continuation coverage under COBRA legislation and State law is explained in Section B., Continuation of Coverage, in this chapter. N.4 Refunds for Dependent Coverage N.4.1 TAKECARE will refund a maximum of one month's premium, if paid in advance for a dependent whose coverage is terminated, if the following are true: N.4.1.1 Notification of the change is received by TAKECARE within thirty-one(31) days of the change. N.4.1.2 TAKECARE has not paid any claims for the dependent within the thirty-one(31) days. N.4.1.3 Termination of the dependent results in a change to the premium rate. N.5 Nonpayment of Copayments N.5.1 If a member does not pay a required copayment or does not make satisfactory arrangements to pay the copayment, TAKECARE may terminate the subscriber and any of his/her dependents with not less than ten (10) days written notice. N.5 .1.1 If termination of a member results from failing to pay a required copayment, the subscribe _ TAKECARE plan, in ' /her dependents will not be eligible to re enroll, in any any of his/her Pe any capacity, until the copayment has been paid in full. MINIM Your Rights and Responsibilities 37 N.6 Refusal of Compliance N.6.1 If a member refuses to accept or comply with recommended procedures and/or treatment incident to a physician/patient or hospital/patient relationship, including leaving an inpatient facility against medical advice, and in the judgement of two or more participating physicians, no professionally acceptable covered treatment alternatives exist, then the member will be so advised. N.6.2 If the member still refuses to accept the recommended procedure and/or treatment, then the contract provider, hospital, and TAKECARE will have no further liability or responsibility to provide care for the condition under treatment and/or the member may be terminated after not less than ten (10) days written notice. N. 7 Failure to Establish PCP Relationship N.7.1 If a member is unable to establish and maintain a satisfactory physician-patient relationship with a participating physician, then the rights of the member under this Agreement may be terminated with not less than thirty (30) days written notice from TAKECARE to the member and the subscribing group, subject to the TAKECARE member appeals procedure explained in Section I., Member Claims Review. N.8 Inappropriate Behavior N.8.1 If the member's behavior is disruptive, unruly, abusive, or uncooperative to the extent that continued membership would seriously impair TAKECARE's ability to furnish services to the member or other members, TAKECARE may terminate coverage for the member after not less than ten (10) days written notice. N.8.1.1 If possible, TAKECARE will make a good faith effort to resolve the problem, including the use or attempted use of its internal member appeals procedure. TAKECARE will consider whether the member's behavior is the result of a reaction to treatment or medication or due to mental illness. N.9 False Information N.9.1 TAKECARE may immediately terminate coverage for a member for obtaining or attempting to obtain services or benefits under this Agreement by means of false, misleading, or fraudulent information, acts, or omissions. N.10 Confinement at Termination N.10.1 If a member is confined to a hospital or institution on the member's termination date, coverage under this Agreement will terminate on the termination date. HOWEVER, if a member remains confined after the termination date, the continued confinement shall be deemed a constructive election of continuation coverage under Subsection B.6. N.10.2 Prenatal and maternity care are not considered confinement. Therefore, TAKECARE will not continue coverage past the termination date for a member receiving prenatal or postnatal care. N.11 Misuse of ID Card N.11.1 TAKECARE ID cards are solely for identification. Possession of a card does not ensure eligibility and/or rights to service or other benefit. 38 Your Rights and Responsibilities TAKECARE N.11.2 The holder of a TAKECARE ID card must be a member for whom all premiums under this Agreement have been paid. N.11.2.1 If a member permits the use of his/her TAKECARE ID card by any other person, the card will be reclaimed by TAKECARE and all rights of the member and his/her dependents under this Agreement will be immediately terminated. N.11.2.2 Payment for services or other benefits received improperly through the use of an ID card are the financial obligation of the individual who used the ID card improperly. N.12 Reduced Working Hours N.12.1 If a subscriber's working hours are reduced by his/her employer to less than twenty (20)hours per week, then the subscriber is no longer on active work status. The subscribing group may contract with TAKECARE to continue coverage for the subscriber and his/her dependents, for the same premium and under the same terms of this Agreement if all of the following conditions are true: N.12.1.1 The subscriber has been continuously employed as a full-time employee of the subscribing group and has been a subscriber covered under this Agreement, or under any former agreement providing similar benefits which this Agreement replaces, for at least six (6) months immediately before the reduction in working hours. N.12.1.2 The reduction in working hours is due to economic conditions. N.12.1.3 The employer intends to increase the subscriber's working hours to the full forty (40) hour work schedule as soon as economic conditions improve. NOTE: An employee who is no longer on active work status may be entitled to continuation coverage as explained in Section B., Continuation of Coverage, in this chapter. N.13 Relocation N.13.1 If a member relocates outside of the TAKECARE service area, coverage will terminate on the last day of the month in which he/she leaves the service area. N.13.2 If a subscriber has been transferred for employment outside of the service area by the subscribing group employer, but the subscriber's dependents temporarily remain in the service area, coverage may continue for the dependents until the end of the month in which they also leave the service area. N.14 General Information N.14.1 Except as specifically described in this Section, all rights to covered benefits will end on the effective date of termination. N.14.2 TAKECARE reserves the right to recover from the subscriber the reasonable value of any benefits provided by TAKECARE and incurred by the subscriber or his/her dependents after termination of their coverage under this Agreement. N.14.2.1 If the subscriber fails to reimburse TAKECARE for any amounts paid following the member's termination, the subscriber, member and any of their dependents will not be eligible to re-enroll, under any TAKECARE plan, in any capacity, until such reimbursement to TAKECARE has been made. Your Rights and Responsibilities 39 N.14.3 A member's termination of coverage will not affect any pending claim. A pending claim will include only those services and supplies provided before the termination date. N.14.4 The provisions of this Section are overridden by the provisions of Section B., Continuation of Coverage, and Section C., Conversion, as applicable. 0. Miscellaneous 0.1 Claims O.1.1 A claim paid and/or submitted by subscribers for a covered service must be submitted to TAKECARE within twelve (12) months after the date of the service, or reimbursement will not be made. 0.2 Copayment Limit O.2.1 After a single subscriber or subscriber with dependent coverage demonstrates that the total copayments paid during any contract year exceed 200% of the total monthly annualized rate of a plan with no copayments, no additional copayments for the subscriber or dependents need be paid for the remainder of the contract year. 0.3 Member Identification O.3.1 At the time of service, a member must identify him/herself to a hospital or contract provider as a TAKECARE member. If he/she does not do so, or if the member misrepresents his/her membership status, claims payment may be denied. 0.4 Notice O.4.1 Any notice under this Agreement must be deposited in the U.S. mail, postage prepaid; or hand- delivered; or sent via electronic facsimile transmission; or via overnight courier service and addressed as follows: • To TAKECARE at: TAKECARE P.O. Box 35801 Colorado Springs, Colorado 80935-3801 • To a subscribing group: Address as indicated on the Signature Sheet • To a member at: Member's address of record NOTE: TAKECARE will not be responsible for a member's failure to have a TAKECARE ID card or for any inconvenience, misunderstanding, or cost incurred by a TAIMECARE member when the member does not have his/her current address of record on file. O.4.2 Except as otherwise specifically provided in this Agreement, all notices will be considered effective on delivery. • 1 40 What Is Covered: Your Schedule of Benefits TAKECARE TABLE OF CONTENTS CHAPTER FIVE WHAT IS COVERED: YOUR SCHEDULE OF BENEFITS A. Clinics 42 M. Mental Health Services/Psychiatric Care 50 A.1 Pain Clinics 42 M.1 Inpatient Psychiatric Care 50 A.2 Clinics Not Covered 42 M.2 Outpatient Psychiatric Care 50 B. Durable Medical Equipment 43 M.3 Psychiatric Services Not Covered 50 B.1 Durable Medical Equipment 43 N. Physician Services 51 B.2 Authorization 43 N.1 Allergy Treatment 51 B.3 Orthopedic Braces 43 N.2 Dietary Counseling 51 C. Emergencies Inside TAKECARE N.3 Exams and Consultation i2 Service Area 43 (Office, In/Outpatient) 51 y C.1 Ambulance 43 N.4 Growth Hormones 51 v C.2 Medical Emergencies 44 N.5 Health Appraisals 52 C0 D. Emergencies Outside TAKECARE N.6 Immunizations 52 Service Area 44 N.7 Surgical (In/Outpatient) 52 te D.1 Ambulance 44 N.8 Well-Baby Care 52 y D.2 Medical Emergencies 45 O. Pregnancy/Maternity/Newborn Services 52 D.3 Follow-Up Care to Emergency Services O.1 Newborn 52 `" and Urgently Needed Services 45 O.2 Delivery 52 L D.4 Claims 45 O.3 Postpartum 52 . E. Eye Examinations 45 O.4 Prenatal Services 53 yE.1 Preventive Care 45 P. Radiology 53 E.2 Routine Examinations 45 P.1 Services 53 v 0 F. Family Planning 46 Q. Skilled Nursing Facility/Extended Care 53 V F.1 Family Planning 46 Q.1 Extended Care Services 53 u. F.2 Infertility 46 R. Subacute Care Facilities 54 tt G. Hearing Tests 46 R.1 Services 54 G.1 Preventive Care 46 S. Substance Abuse 54 63 H. Home Health Care 46 S.1 Alcohol-Drug Rehabilitation 54 i H.1 Nursing Care Services 46 S.2 Detoxification 54 y H.2 Therapy S.3 Inpatient Alcohol-Drug Rehabilitation 54 0 (Physical, Occupational, and/or Speech) . 47 S.4 Outpatient Alcohol-Drug Rehabilitation 54 rt V H.3 Training for Home Care 47 T. Surgery 55 I. Hospice Care 47 T.1 Breast Surgery 55 I.1 Services at Home or Hospice Facility . . . 47 T.2 Oral and Dental Surgery 55 J. Hospital Care 48 T.3 Services 56 J.I Ancillary Services 48 T.4 Surgery Not Covered 56 J.2 Blood 48 U. Therapies/Rehabilitation 56 J.3 Discharge Planning 49 U.1 Cardiac 56 J.4 Implants 49 U.2 Chemotherapy 56 J.5 Nursing Services 49 U.3 Hemodialysis 57 J.6 Room and Board 49 U.4 Occupational/Physical 57 J.7 Supplies 49 U.5 Radiation Therapy 57 K. Injectables 49 U.6 Respiratory 57 K.I Outpatient Injectables 49 U.7 Speech 57 L. Laboratory/Pathology 50 U.8 Therapies/Rehabilitation Not Covered . . . 58 L.1 Services 50 What is Covered: Your Schedule of Benefits 41 V. Transplants 58 V.1 Covered Transplants 58 V.2 Bone Marrow 58 V.3 Cornea 59 V.4 Heart 59 V.5 Kidney 59 V.6 Liver 59 V.7 Skin Grafts 59 V.8 Transplants Not Covered 59 V.9 Transplant Guidelines 60 W. Treatment Alternatives 60 W.1 Treatment Alternatives 60 X. General Exclusions 60 X.1 Services Not Covered 60 X.2 Dental Services Not Covered 62 X.3 Experimental, Investigational, Unproven, Unusual, or Not Customary Treatments, Procedures, Devices and/or Drugs Not Covered 62 Y. General Limits 64 Y.1 Cumulative Benefits 64 Y.2 Circumstances Beyond TAiECAiE's Control 65 Y.3 Major Disaster or Epidemic 65 7 42 What Is Covered: Your Schedule of Benefits TAKECARE CHAPTER FIVE WHAT IS COVERED: YOUR SCHEDULE OF BENEFITS The following services are covered benefits when medically necessary, if provided, or properly arranged for with a participating provider, by the member's participating Primary Care Physician (PCP) unless excluded or limited by any Section in this Agreement including, but not limited to Section X., General Exclusions, or Section Y., General Limits. TAKECARE may determine medical necessity by using precertification programs as deemed appropriate by TAKECARE. A. Clinics A.1 Pain Clinics A.1.1 Outpatient services must be requested in writing by the PCP. This request must include supporting second opinions from two participating specialists, one of whom is a licensed mental health provider. Any psychotherapy and/or physical therapy sessions as a part of the program will be counted toward the Pain Clinics limit listed below. LIMITS: • Treatment may not be started prior to written authorization from TAKECARE • In no event will TAKECARE pay more than $2,000 toward the covered charges resulting from one referral during any contract year to a pain clinic, center, or facility NOT COVERED: • Convenience items and meals • Pain centers, facilities, clinics, or centers involved in treatment of pain are not covered for inpatient care A.2 Clinics Not Covered A.2.1 Special service clinics, centers, or programs on an inpatient or outpatient basis. This includes, but is not limited to clinics, centers, or programs for: • Disassociated disorders • Eating disorders • Headaches • Lactation • Long-term brain injury • Post-traumatic stress • Premenstrual syndrome (PMS) • Senior services • Stress management What is Covered: Your Schedule of Benefits 43 B. Durable Medical Equipment B.1 Durable Medical Equipment B.1.1 Durable medical equipment, including oxygen, is to enable a patient who otherwise would have to be treated in an acute care or rehabilitative facility to be cared for outside such an institution. At TAKECARE's discretion, this equipment may be rented or purchased. LIMIT: $1,000 per member per contract year B.1.2 Coverage of external extremity prosthetics will be considered under the provisions of Section W., Treatment Alternatives, up to $1,000 applicable to the Durable Medical Equipment maximum. NOT COVERED: Penile prostheses and prostheses for cosmetic purposes B.2 Authorization B.2.1 Durable medical equipment, including oxygen, must be authorized for a specified period of time in advance in writing by TAKECARE's Medical Director. The authorization will specify whether purchase or rental is approved. After the initial authorized period of coverage, continuation is subject to written reauthorization in advance for another specified period. B.3 Orthopedic Braces B.3.1 Orthopedic braces when prescribed by a participating physician and preauthorized by TAKECARE, obtained through a designated provider and that meet all of the following criteria: a. are required to support or correct a defect of form or function or a permanently non-functioning or malfunctioning body part, and b. are medically approved and in general use for the specific condition, and c. are primarily and customarily used either as an alternative to surgery or to speed recovery of a patient who has had surgery, and d. can withstand repeated use, and e. are not generally useful to a patient in the absence of an injury or illness. B.3.2 Fitting and adjustment of covered braces. B.3.3 Repair or replacement of covered braces unless necessitated by misuse or covered by any other insurance plan or other arrangement. TAKECARE may replace or repair a brace at its discretion. LIMIT $250 per member per contract year. Coverage under this benefit applies to the $1,000 Durable Medical Equipment maximum NOT COVERED: Dental braces, orthotic devices for podiatric use and arch support, braces used as aids in sports and activities, corsets and other non-rigid appliances C. Emergencies Inside TAKECARE Service Area C.1 Ambulance C.1.1 Medically necessary ambulance service when the destination is an acute care facility, for any of the following: 1 44 What Is Covered: Your Schedule of Benefits TAKECARE • Movement from the place where the member was injured in an accident or became ill to a facility for treatment • If medically necessary care is not available at a hospital or hospice, movement to the nearest hospital where the medically necessary care may be given • When ordered by the member's attending physician, movement from the hospital to another institution or from the member's home for emergency situations NOT COVERED: Ambulance service provided due to the absence of another medically appropriate form of transportation or for the member's convenience. C.2 Medical Emergencies C.2.1 Hospital outpatient care in an emergency room or in a minor emergency facility when authorized by the member's PCP for the treatment of illness or injury. C.2.2 Life or limb threatening emergencies are exempt from prior authorization by the member's PCP for the treatment of illness or injury. However, under all circumstances, the member's PCP must be notified of the visit by the following business day. C.2.3 There are two copayment levels for emergency services: • The higher copayment applies when services are obtained in a hospital emergency room or other emergency facility that charges a facility charge. • The lower copayment applies when the emergency services are obtained in a physician's office outside normal business hours or other medical facility that does not charge a facility charge. If a member is admitted as an inpatient to a hospital directly from the emergency room, the emergency copayment is waived. C.2.4 Unauthorized use of the emergency facility will be reviewed by TAICECARE. Payment of claims may be denied and may be the member's personal responsibility. C.2.5 In a life or limb threatening emergency the member will have the option of calling the emergency telephone access number 911 or its local equivalent. C.2.6 If the member is hospitalized in a non-participating facility, TAKECARE may elect to transfer the member to a participating hospital as soon as it is medically appropriate. If the member chooses to remain in a non-participating facility after being notified of the intent to transfer the member to a participating facility, further services will not be covered. NOT COVERED: • Follow-up care in the emergency facility • Emergency visits made in non-life or limb threatening situations without the member's participating PCP's authorization. In this instance, the member will be liable for the entire charge for the visit and for any unauthorized care resulting from it. • Emergency room services obtained during normal physician office hours, except in the event of a life or limb threatening emergency or when preauthorized by the PCP. D. Emergencies Outside TAIECARRE Service Area % D.1 Ambulance D.1.1 Medically necessary ambulance service under emergency conditions arising from an accident, acute illness or injury and when the destination is an acute care facility. What is Covered: Your Schedule of Benefits 45 fir D.2 Medical Emergencies D.2.1 If a member receives medically necessary emergency care outside the TAKECARE service area, the member will be entitled to reimbursement for: • Reasonable charges for hospital services that are covered benefits • Reasonable charges for professional services that are covered benefits, including sales tax in states where such tax is allowed by law • Ambulance service resulting from an accident, acute illness, or injury • Reasonable charges for transportation authorized by TAKECARE to return the member to a TAKECARE participating hospital, less the cost of the member's normal return trip D.2.2 There are two copayment levels for emergency services: • The higher copayment applies when services are obtained in a hospital emergency room or other emergency facility that charges a facility charge. • The lower copayment applies when the emergency services are obtained in a physician's office or other medical facility that does not charge a facility charge. If a member is admitted as an inpatient to a hospital directly from the emergency room, the emergency copayment is waived. TAKECARE must be notified within forty-eight(48)hours of a hospital admission outside the service area. pi. D.3 Follow-Up Care to Emergency Services and Urgently Needed Services D.3.1 Follow-up care to emergency services received outside the service area or urgently needed services (as defined in Chapter Seven, Definition of Terms). LIMIT: A maximum TAKECARE payment of$250 per person per contract year D.4 Claims D.4.1 A claim paid and/or submitted by subscribers for a covered service must be submitted to TAKECARE within twelve (12) months after the date of the service, or reimbursement will not be made. E. Eye Examinations E.1 Preventive Care E.1.1 Routine visual acuity exams for members under eighteen (18) years old. ® „ir E.2 Routine Examinations E.2.1 Routine eye examinations, including refractions for prescription lenses, once in every twenty-four(24) months at TAKECARE designated facilities. E.2.2 Eye examinations to determine the prescription for corrective lenses, eyeglasses, or contact lenses. NOTE: A referral from the PCP is not required for this benefit, but the member must obtain an authorization number from American Vision Services to present to the provider. See Chapter Eight, How To Get Help, for information. NOT COVERED: • Fitting contact lenses • Vision therapy • Radial keratotomy and keratomilieusis 46 What Is Covered: Your Schedule of Benefits TAKECAR F. Family Planning F.1 Family Planning F.1.1 Voluntary family planning to include: • Family planning counseling • Information on birth control • IUDs and implantable contraceptive devices, including their insertion and removal • Fitting of diaphragms and cervical caps • Costs related to an elective abortion LIMIT: Two (2) elective abortions per member per lifetime • Pre- and post-abortion counseling • Surgical procedures causing permanent sterilization, including vasectomies and tubal ligations NOT COVERED: • Diaphragms and cervical caps except as covered under the optional prescription drug benefit purchased by the subscribing group • Pregnancy test kits and ovulation kits • Reversal of voluntary sterilization and related procedures % F.2 Infertility F.2.1 Limited infertility services when preauthorized, including testing, artificial insemination, appropriate medical advice, and instruction in accordance with accepted medical practice. LIMIT: Treatment for infertility is covered only for members who have been diagnosed as biologically infertile in accordance with accepted medical practice. NOT COVERED: • In vitro fertilization(test tube babies), the Gamete Intrafallopian Transfer (G.I.F.T.) procedure, other ovum transplant procedures, surrogate parentage, drug therapy for infertility, and related costs of each • Procedures considered to be experimental • The cost related to donor sperm and donor ova (collection, preparation, storage, etc.) • Infertility services for members who have undergone a voluntary sterilization procedure G. Hearing Tests G.1 Preventive Care G.1.1 Examinations to determine the need, if any, for hearing correction. NOT COVERED: • Hearing aids and evaluation for hearing aids H. Home Health Care H.1 Nursing Care Services H.1.1 Skilled nursing care at home when prescribed and deemed medically necessary for treatment of a covered illness or injury. H.1.2 Home health care services are provided only when and as long as the following two conditions are met simultaneously: What is Covered: Your Schedule of Benefits 47 • The patient's participating PCP prescribes a specific home care plan to be provided and sets forth the length of time deemed medically necessary to complete the treatment plan. This plan must be approved in writing by TAKECARE and periodically reviewed and reauthorized by TAKECARE or an agent acting on TAKECARE's behalf. • The services are provided by a Medicare certified home health agency selected or approved by TAKECARE. NOT COVERED: • Custodial and maintenance care • Homemaker services H.1.3 Periodic assessment visits by either a physician or a licensed nurse to determine the patient's condition, progress, and level of care needs. LIMIT: After the period of time specified in the prescribed treatment plan, continuation of care depends on a reevaluation of the patient's status for medical necessity. H.2 Therapy (Physical, Occupational, and/or Speech) H.2.1 These benefits are covered as part of home health care only if the patient is homebound and have applicable limits as explained in Section U., Therapies/Rehabilitation. H.3 Training for Home Care H.3.1 One-time training for a family member, household resident, or nonprofessional person employed by the patient or family. This training covers the services necessary to the custodial or maintenance levels of care. L Hospice Care L1 Services at Home or Hospice Facility I.1.1 Services covered in home or hospice facility include: • Nursing care provided by or under the supervision of a registered nurse • Home health aide services under the supervision of an RN or specialized rehabilitative therapist • Respiratory therapy and inhalation services • Nutrition counseling by a nutritionist or dietitian • Physical therapy, occupational therapy, speech therapy, and audiology • Individual, family, and caregiver counseling • Medical social services • Bereavement support services for the member's family • Continuous home care or short-term inpatient care provided in a participating hospice inpatient unit, hospital, or skilled nursing facility as required for pain control or symptom management • Inpatient hospice care will be provided when: • there are no suitable caregivers available to provide care in the home • it is determined that home hospice is impractical because the member is unmanageable by the person(s) who regularly assist with home care • Medical supplies ordinarily furnished by the hospice agency, including prescription drugs and biologicals • Respite care LIMIT: Inpatient respite care is limited to five (5) continuous days per occurrence 48 What Is Covered: Your Schedule of Benefits TAKECARE I.1.1.1 For hospice care to be covered, services must be provided by or under the direction of the member's PCP, who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six (6) months or less. The physician must submit a written plan of care. I.1.1.2 The member must choose to receive hospice care instead of standard benefits for the terminal illness. It is important for the member to realize that hospice care is for terminal conditions and that the hospice benefit structure is based upon the concept that those members receiving hospice care choose not to avail themselves of other health care benefits for care related to the terminal condition. While receiving hospice care, in the member's home or in a hospice facility, if a member requires treatment for a condition not related to the terminal illness, TAKECARE will continue to pay for all covered services. I.1.1.3 The coverage of these services will not prevent TAKECARE from re-evaluating the member's status and subsequently redetermining the status of care. NOT COVERED: • Services and supplies related to the terminal condition that are not a part of hospice care • Services of a caregiver other than as provided by the hospice agency as part of this benefit, including, but not limited to, someone who lives in the member's home or someone who is a relative of the member • Domestic or housekeeping services that are unrelated to the member's care • Services that provide a protective environment where no professional skill is required, such as companionship or sitter services • Services not directly related to the medical care of the member including, but not limited to: • Estate planning, drafting of will, or other legal services • Funeral counseling or funeral arrangements or services • Food services such as Meals on Wheels • Transportation services, except covered benefits for necessary professional ambulance services ve J. Hospital Care J.1 Ancillary Services J.1.1 Hospital ancillary services, including laboratory, pathology, radiology, radiation therapy, respiratory therapy, and physical, occupational, and speech therapy. J.1.2 Oxygen, other gases, drugs, medications, and biologicals as prescribed. NOT COVERED: Take-home drugs J.2 Blood J.2.1 Processing and administration of blood and blood plasma. J.2.2 Drawing and storage of the member's blood or blood products when prescribed by a participating physician and used as replacement therapy for a covered procedure. NOTE: Also see X.1.18 under Section X., General Exclusions. NOT COVERED: • Blood, blood plasma, or products derived in whole or in part from blood or blood plasma • Special handling fees What is Covered: Your Schedule of Benefits 49 J.3 Discharge Planning J.3.1 Coordinated discharge planning services. J.4 Implants J.4.1 Devices that are medically necessary and must be implanted by surgical means. These may include pacemakers, replacement joints, and permanent replacement lenses following cataract surgery. NOT COVERED: • Experimental or cosmetic implants • Penile implants • Cochlear implants and all associated costs for these implants J.5 Nursing Services J.5.1 General nursing care. J.5.2 Intensive care services when medically necessary. NOT COVERED: Private duty nursing J.6 Room and Board J.6.1 The following provided by a hospital or a skilled nursing facility: • Accommodations necessary for covered services, including bed, meals, and services of a dietitian • Use of operating and specialized treatment rooms • Use of intensive care facilities • Use of room and bed for prescribed observation services NOT COVERED: • Personal comfort and convenience items, such as television, telephone, guest meals, articles for personal hygiene, and any other similar incidental services and supplies • Private room except when medically necessary J. 7 Supplies J.7.1 Surgical and anesthetic supplies furnished by the hospital as a regular service. NOT COVERED: Take-home supplies K. Injectables K.1 Outpatient Injectables K.1.1 Outpatient injectables approved by the Food and Drug Administration(FDA) for the given diagnosis or protocol, when oral administration of prescribed medication is not medically appropriate. K.1.1.1 Services include administration, supplies and medical monitoring when administered in the physician's office. 7 50 What Is Covered: Your Schedule of Benefits TAKECnitE K.1.2 Outpatient injectables obtained by the member through a pharmacy must be preauthorized and are subject to the applicable copayment. A copayment will be collected for the standard trade size package, but not less than a one (1) week supply. (Exception: Imitrex. A copayment will be collected for the standard trade size package. If multiple trade size packages of Imitrex are dispensed, one copayment will be collected for every two trade size packages.) No more than a thirty (30) day supply will be dispensed at one time. L. Laboratory/Pathology L.1 Services L.1.1 Preventive diagnostic services in accordance with criteria established by TA XECARE. M. Mental Health Services/Psychiatric Care NOTE: Refer to Subsection K.1.1 in Chapter Four for information on Confidentiality of Medical Records. fir M.1 Inpatient Psychiatric Care M.1.1 Medically necessary inpatient psychiatric care. LIMITS: • Maximum of forty-five (45) days for inpatient care per contract year • Maximum of ninety (90) partial hospitalization days per contract year NOTE: "Partial hospitalization" is defined as treatment for at least three (3) hours, but not more than twelve (12)hours, in a 24-hour period. fir M.2 Outpatient Psychiatric Care M.2.1 Medically necessary outpatient psychiatric care. M.3 Psychiatric Services Not Covered M.3.1 Court-ordered psychiatric therapy or psychiatric therapy as a condition of parole or probation. M.3.2 Psychological testing of a member that is requested by or for a third party. M.3.3 Counseling related to consciousness raising, for borderline intellectual functioning, for occupational problems, or for activities of an educational nature. M.3.4 Vocational or religious counseling. M.3.5 Developmental disorders including, but not limited to reading, arithmetic, language, or articulation disorders. M.3.6 IQ testing. M.3.7 Lifestyle and personal growth counseling. M.3.8 Early infant stimulation. • What is Covered: Your Schedule of Benefits 51 M.3.9 Counseling for autism. M.3.10 Counseling for transsexualism. M.3.11 Cognitive skills rehabilitation. M.3.12 Psychotherapy credited toward earning a degree or required for education purposes. M.3.13 Psychosurgery. N. Physician Services N.1 Allergy Treatment N.1.1 Outpatient allergy treatment and allergy treatment materials. N.2 Dietary Counseling N.2.1 One dietary counseling session when regulation of the diet is a significant part of the treatment program for a pathological state or illness. LIMIT' One visit per contract year NOT COVERED: Dietary counseling for obesity, including weight reduction programs fir N.3 Exams and Consultation (Office, In/Outpatient) N.3.1 Physician's services including time for visits and examinations, consultation, and personal attendance with the patient in the physician's office, or in a hospital or skilled nursing facility if the member is in for a nonsurgical reason. N.3.2 Physician's visits to the member's home when medically necessary and only if the member is too ill or disabled to go to the physician's office. N.3.3 Medical consultation services, including charges made by a physician for a second or third surgical opinion. NOT COVERED: • Expenses for medical and/or hospital services incurred prior to membership in TAKECARE or services provided after TAKECARE coverage or eligibility terminates • Examination for employment, licensing, insurance, adoption purposes, or examination or treatment ordered by a court • Expenses for medical reports, including preparation and presentation • Expenses for examinations conducted for the purpose of medical research N.4 Growth Hormones N.4.1 Growth hormones on a limited basis when preauthorized by TAKECARE's Medical Director. 52 What Is Covered: Your Schedule of Benefits TAKECARE� N.5 Health Appraisals N.5.1 Periodic health appraisals for children and adults that include all tests routinely made in connection with such health appraisals. The frequency of the health appraisals as a benefit will be established by TAKECARE. N.6 Immunizations N.6.1 Pediatric and adult immunizations in accordance with the recommendations of the American Academy of Pediatrics and the United States Public Health Service. N.6.2 Immunizations required for travel by the U.S. Department of Public Health. NOT COVERED: Immunizations that are recommended because of increased risk due to type of employment N. 7 Surgical (In/Outpatient) N.7.1 Surgical services in the hospital, in the office, or in a licensed outpatient surgical facility. This may include, when medically required: • A surgical assistant • Anesthesiologist services See Section T., Surgery, for details about surgery benefits. fir N.8 Well-Baby Care N.8.1 Well-baby care visits in a physician's office during the first twenty-four(24) months of life. O. Pregnancy/Maternity/Newborn Services 0.1 Newborn 0.1.1 Hospital care and services for newborn infants of subscribers. NOTE: No inpatient copayment, if applicable, will apply for the newborn if he/she is discharged with the mother, if the mother is a member. However, any applicable inpatient copayment will apply if the newborn remains hospitalized, is hospitalized after the mother's discharge, or if the mother is not a TAKECARE member. 0.2 Delivery 0.2.1 Hospital obstetrical delivery care and services for covered female members. NOT COVERED: • Home delivery • Normal delivery outside of the TAKECARE service area NOTE: Normal delivery is generally considered to be within five (5)weeks of the expected due date. 0.3 Postpartum 0.3.1 Complete hospital and outpatient postpartum care and services for covered female members. The office visit copayment applies to postpartum visits in the physician's office. What is Covered: Your Schedule of Benefits 53 O.3.2 Mothers with newborns released from the hospital in accordance with TAKECARE guidelines are entitled to one (1)visit by a registered nurse as well as the services of a homemaker for four (4) hours on two (2) days within thirty(30) days following delivery. The homemaker may perform such duties as grocery shopping, preparing meals, laundry, and light housekeeping. iirt 0.4 Prenatal Services O.4.1 Prenatal care and services for covered female members. O.4.2 Amniocentesis based on criteria established by TAKECARE. The participating physician must request this procedure and provide the necessary information to TAKECARE. NOT COVERED: • Any procedure intended solely for sex determination • Birthing classes Nos P. Radiology P.1 Services P.1.1 Radiological services, such as electrocardiography (EKG), electroencephalography (EEG), and the use of radioactive isotopes. P.1.2 Preventive diagnostic services in accordance with criteria established by TAKECARE. This includes, but is not limited to mammograms, chest x-rays, electrocardiograms, and laboratory services. Q. Skilled Nursing Facility/Comprehensive Rehabilitation Facility/Extended Care Q.1 Extended Care Services Q.1.1 Skilled nursing facility, extended care facility, and comprehensive rehabilitation facility or unit services as follows: • Only on order of the participating PCP when approved by the TAKECARE Medical Director, and • Only when significant measurable improvement can be anticipated Q.1.2 Services include accommodations, meals, general nursing care, medical supplies and equipment ordinarily furnished by the facilities, and all prescribed drugs and biologicals. LIMITS: • During each contract year, up to 120 days of these prescribed services at approved facilities • The member's status may also be reevaluated and, if it is determined that the status of the care is no longer acute, it may not be covered. NOT COVERED: • Custodial care • Maintenance care • Convalescent care • Chronic care • Private duty nursing • Personal comfort or convenience items, such as television or telephone • Private room, except when medically necessary AWE 54 What Is Covered: Your Schedule of Benefits TAKECARE R. Subacute Care Facilities R.1 Services R.1.1 Subacute care facility services following hospitalization, including accommodations, meals, general nursing care, medical supplies and equipment ordinarily furnished by the facility and prescribed drugs and biologicals. LIMIT: Up to sixty (60) days per contract year at an approved subacute care facility. S. Substance Abuse NOTE: Refer to Subsection N.6 in Chapter Four for information on Refusal of Compliance. ® 11 Alcohol-Drug Rehabilitation S.1.1 A course of treatment may be either inpatient or outpatient or a combination of both if authorized by TAKECARE. LIMITS: • One course of treatment per contract year • Two courses of treatment for each member during his/her lifetime NOT COVERED: • Alcoholism and drug addiction treatment on court order or as a condition of parole or probation • Maintenance or aftercare following a rehabilitation program • Any charges incurred for this benefit if the full course of treatment is not completed • Nutritional based therapy for alcoholism or other chemical dependency S.2 Detox(cation S.2.1 Services for detoxification are limited to removal of the toxic substance or substances from the system, including diagnosis, evaluation, and care of emergency or acute medical conditions. p1.3 Inpatient Alcohol-Drug Rehabilitation S.3.1 Alcohol-drug inpatient rehabilitation services at the facility designated by TAICECARE. Inpatient services are those services provided to members who reside for the course of their treatment program at the program site. LIMIT: Services are covered at the designated facility up to a maximum of twenty-one (21) days per contract year or until the participating provider has determined satisfactory completion of the inpatient program, whichever is less. 14 Outpatient Alcohol Drug Rehabilitation S.4.1 Alcohol-drug outpatient rehabilitation services at the facility designated by TAKECARE. Outpatient services are those services provided to members who are living at home and receiving services at the program site on an ambulatory basis. What is Covered: Your Schedule of Benefits 55 T. Surgery T.1 Breast Surgery T.1.1 The cost of preauthorized reconstructive breast surgery following a mastectomy. Breast reconstruction is covered only if: • The member was a member at the time of mastectomy • The mastectomy was performed as a result of diagnosed cancer • Reconstruction was included as a part of the original treatment plan for the mastectomy NOT COVERED: Breast prosthesis as part of reconstructive surgery T.1.2 The cost of surgical bras, including external prosthesis, in lieu of reconstructive breast surgery will be covered if: • The member was a member at the time of mastectomy • The mastectomy was performed as a result of diagnosed cancer LIMITS: • Two (2) surgical bras initially following breast surgery • One replacement bra is covered up to $250 per member every twenty-four(24) months T.2 Oral and Dental Surgery T.2.1 Oral surgery and certain medical service charges associated with dental services only as follows: • Emergency treatment received within twenty-four(24) hours of the occurrence of accidental injury to the jaw or mouth. NOT COVERED: Follow-up dental restoration procedures • Treatment for tumors of the mouth when cancer is suspected • Treatment of congenital conditions of the jaw that may be demonstrated to cause actual significant deterioration in the member's physical condition because of inadequate nutrition or respiration li • Cleft lip, cleft palate, or any condition or illness that is related to or developed as a result of the cleft lip or cleft palate will be considered to be compensable for coverage under the provisions of Colorado law for newborn children born while covered under this Agreement with cleft lip or cleft palate or both, the following care and treatment to the extent medically necessary and when ordered by a participating physician: o Oral and facial surgery, surgical management, and follow-up care by plastic surgeons and oral surgeons o Prosthetic treatment such as obturators, speech appliances, and feeding appliances o Medically necessary orthodontic treatment o Medically necessary prosthodontics treatment o Habilitative speech therapy o Otolaryngology treatment o Audiological assessments and treatment NOT COVERED: If a dental insurance policy including, but not limited to a self-funded plan is in effect at the time of the birth, or is purchased after the birth of a child with cleft lip or cleft palate or both, no benefit under this Agreement will be provided for any orthodontics or dental care needed as a result of the cleft lip or cleft palate or both. T.2.2 During an inpatient admission for a covered dental problem, medical consultation and diagnostic procedures ordered by the medical consultant related to a strictly medical condition. 56 What Is Covered: Your Schedule of Benefits TAKECARE NOT COVERED: • Orthognathic surgery • Metallic bone cylinder implants (bone screws) T.3 Services T.3.1 Surgical services in the hospital, physician's office, or in a licensed outpatient surgical facility. This includes the services of a surgical assistant and anesthesiologist with surgical services when medically necessary. • T.4 Surgery Not Covered T.4.1 Plastic, reconstructive or cosmetic surgery, including skin lesions that are removed for cosmetic purposes. Exceptions for reconstructive surgery must be approved in writing by TAKECARE and will be considered only when performed primarily to improve the physical health and function of the patient. Any non-covered services received prior to written approval will not be reimbursed by TAKECARE and will be the financial responsibility of the member. T.4.2 Reconstructive nasal surgery, including rhinoplasty. T.4. 3 Revis ion of a previ ous procedureperformed for cosm etic metic purposes including, p rp but not limited to breast augmentation. T.4.4 Surgical treatment for obesity, except for cases that meet the standards of medically necessary care as accepted by TAKECARE for cases of morbid obesity and that are then preauthorized in writing by TAKECARE's Medical Director. T.4.5 Reconstructive surgery which does not correct or materially improve a physiological function. T.4.6 However, the expenses of plastic, reconstructive or cosmetic surgery will be covered if the surgery is performed as soon as medically feasible and it is medically necessary for either of the following reasons: • To repair an injury sustained while the member is a member of TAKECARE but no later than one (1) year following the accident • The correction of a congenital defect that results in a physical functional defect of a covered child II U. Therapies/Rehabilitation U.1 Cardiac U.1.1 Short-term cardiac rehabilitation program on a copayment basis. This is at an approved facility for the short-term follow-up of acute care for a myocardial infarct or cardiac revascularization procedure. This benefit is an extension of the treatment for an inpatient acute care episode and must begin within two (2) months of discharge from the acute care facility. LIMIT: A maximum of$1,000 within a ninety (90) day period U.2 Chemotherapy U.2.1 Outpatient injectable chemotherapy, when oral administration of prescribed medication is not medically appropriate. What is Covered: Your Schedule of Benefits 57 U.2.2 Services and materials for chemotherapy. NOTE: Also see X.1.18 under Section X., General Exclusions U.3 Hemodialysis U.3.1 All necessary services for hemodialysis for chronic renal diseacr and for kidney transplants, including training and expendable medical supplies. U.4 Occupational/Physical U.4.1 Short-term, outpatient occupational and physical therapy by licensed therapists who are under contract or approved by TAKECARE. This short-term, outpatient physical therapy is for treatment of acute conditions that are subject to significant improvement within two (2) months of when treatment begins. LIMITS: • Not to exceed twenty (20) sessions per acute condition • Requires prior written authorization of an approved treatment plan by TAKECARE U.4.2 The member's status may be reevaluated and, if it is determined that the condition is no longer acute, it may not be covered. U.5 Radiation Therapy U.5.1 Services for radiation therapy. NOTE: Also see X.1.18 under Section X., General Exclusions. U.6 Respiratory U.6.1 Respiratory therapy by a licensed respiratory therapist on an outpatient basis is limited to emergency care. U. 7 Speech U.7.1 Services of licensed speech therapists who are under contract or approved by TAKECARE. This therapy is a benefit only for the short-term rehabilitation required immediately following these acute episodes: stroke, accidental brain injury (not occuring during birth), and surgery involving the larynx. The goal of this therapy is a significant improvement of a member's condition within two (2) months. NOTE: See Subsection T.2 for information on coverage of speech therapy for cleft lip and/or cleft palate. LIMITS: • Not to exceed twenty (20) sessions per acute condition • Requires prior written authorization of an approved treatment plan by TAKECARE • The member's status may be reevaluated and, if it is determined that the condition is no longer acute, it may not be covered NOT COVERED: Speech therapy related to a developmental or communication delay 58 What Is Covered: Your Schedule of Benefits TAKECARE U.8 Therapies/Rehabilitation Not Covered U.8.1 Special evaluation and/or therapy for: • Behavior disorders • Communication delay • Learning disability • Mental retardation and related conditions • Motor dysfunction • Multiple handicaps • Perceptual disorders • Post-traumatic stress • Sensory deficit • Sex addiction • Speech (except as covered in Subsections U.7 or T.2) • Vision U.8.2 Special evaluations and therapies including: • Behavioral training • Biofeedback (except as covered under pain clinics) • Cognitive therapy • Coma stimulation • Developmental and neuroeducational testing or treatment • Educational studies • Hearing therapy • Hypnotherapy • Myofunctional therapy • Neuromuscular rehabilitation for chronic conditions • Psychological testing • Sleep therapy • Vision therapy/orthoptics • Vocational rehabilitation V. Transplants V.1 Covered Transplants V.1.1 All necessary services for covered transplants at designated transplant facilities. Covered services include the directly related, reasonable medical and hospital expenses of the donor. V.1.2 Coverage will be restricted to transplant services provided to the donor and recipient only when the recipient is a TAKECARE member. V.1.3 Neither TAKECARE nor its contract providers will be responsible to furnish a donor or to assure the availability or capacity of designated facilities. V.2 Bone Marrow V.2.1 Allogeneic bone marrow transplants for members with aplastic anemia, leukemia, severe combined II immunodeficiency disease or Wiskott-Aldrich Syndrome. 7 What is Covered: Your Schedule of Benefits 59 V.2.2 Autologous bone marrow transplants for members with acute leukemia in remission, resistant non- Hodgkin's lymphomas or those who have a poor prognosis following an initial response, recurrent or refractory neuroblastoma, advanced Hodgkin's disease who have failed conventional therapy and have no HLA-matched donor. NOT COVERED: Chemotherapy requiring a bone marrow transplant for breast cancer and other solid tumors NOTE: Also see X.1.18 under Section X., General Exclusions. V.3 Cornea V.3.1 Cornea transplants. V.4 Heart V.4.1 Heart transplants for members who have had at least twelve (12) full months of continuous membership. V.5 Kidney V.5.I Covered services are provided, only upon referral by the member's participating PCP, at community transplant facilities within the service area that are approved by TAKECARE and are approved for participation in the Medicare program. V.5.2 Referrals are subject to determination by a participating provider that the service referred represents the preferred method of treatment. V.5.3 If, after referral, the contract provider determines that the member does not satisfy its criteria for the service involved, TAKECARE's obligation is limited to paying for covered services provided prior to such determination, plus covered services subsequently provided that are covered in whole or in part under Medicare. V.6 Liver V.6.1 Liver transplants for children under age 18 with biliary atresia or other end-stage liver disease. V. 7 Skin Grafts V.7.1 Skin grafts. NOT COVERED: Skin grafts performed for cosmetic purposes V.8 Transplants Not Covered V.8.1 The following are not covered transplants: • Heart/lung • Lung • Multiple organs • Pancreas • Non-human and artificial organs and their implantation • Other transplants not listed in this Agreement as covered benefits 60 What Is Covered: Your Schedule of Benefits TAKECARE V.9 Transplant Guidelines V.9.1 The following guidelines apply to transplants: • Any request for a covered transplant, except cornea transplants and skin grafts, must be made in writing to the TAKECARE Medical Director. • The TAKECARE Medical Director will issue a written response within thirty (30) days. • Written preauthorization of any covered transplant benefit must be given prior to initiation of services. • TAKECARE will not cover services received prior to issuance of its written preauthorization. W. Treatment Alternatives W.1 Treatment Alternatives W.1.1 Treatment alternatives and limited adaptations to coverage under this Agreement are reserved to the sole discretion of TAKECARE. While this Agreement is the definitive statement of TAKECARE's legal obligation to provide benefits, experience has shown that there may be unusual and extraordinary circumstances that are not contemplated by this Agreement. Therefore, TAKECARE specifically reserves the right, at its sole discretion and based on prudent business and medical judgment (with the input of its Medical Director), to adapt the coverage and benefits set forth in this Agreement. W.1.2 Such decisions will be made exclusively by TAKECARE based upon the medical and cost effectiveness of alternatives, probable outcome of a medically necessary service, and consultation with the member or member's representative. The fact that TAICECARE makes an adaptation to this Agreement will not require or act as precedent requiring that it make future adaptations in similar or other situations, or otherwise be prevented from administering this Agreement in strict accordance with its terms. W.1.3 In addition, TAICECARE may, at its sole discretion, reevaluate and discontinue any adaptation granted under this provision if it determines that the original basis for granting the adaptation is no longer valid and supportive of the adaptation or is no longer likely to lead to measurable improvement in the health of the member. X.1.4 Any request for coverage of treatment alternatives and/or limited adaptations to this Agreement must be made in writing, by a participating physician or a member, to TAKECARE's Medical Director. The coverage decision will be made by TAKECARE. TAKECARE will provide a written response; only services specifically authorized and received after the member's receipt of the written response will be covered. TAKECARE shall have the sole discretionary authority to interpret this plan and determine all questions arising in the administration, interpretation, and application of the plan, and all such determinations shall be final, conclusive, and binding. X. General Exclusions X.1 Services Not Covered X.1.1 Any service that is: • Not included in this Agreement, even though provided or referred by a TAKECARE physician • Not reasonably and medically necessary, even if listed as a covered service in this Agreement • Not required in accordance with accepted standards of medical, surgical, or psychiatric practice, even though provided or referred by a TAKECARE physician • Not selected by the subscribing group • Required only for the convenience of the member or the member's physician What is Covered: Your Schedule of Benefits 61 X.1.2 Services that TAICECARE has no legal obligation to cover: • Free clinics • Government free programs • Any charge made solely because the member has the benefit covered by TAKECARE X.1.3 All medical and hospital care associated with conditions for which written preauthorization by the Plan Medical Director is required and was not received; and/or for which treatment by participating physicians or hospital was required but was not so provided. X.1.4 Expenses for medical and/or hospital services incurred prior to membership in TAKECARE or services provided after TAKECARE coverage or eligibility terminates. X.1.5 Braces and artificial limbs (except as described in Section B., Durable Medical Equipment). Artificial aids, prosthetic devices, corrective appliances, breast pumps and medical supplies including, on an outpatient basis, enthral feeding substance and infant formula. X.1.6 Total parenteral nutrition(TPN) except when the need for TPN results from a condition diagnosed after the date of TAKECARE enrollment and when administered in lieu of hospitalization. X.1.7 Services of chiropractors. X.1.8 Acupuncture. X.1.9 Sex transformation procedures, services, and supplies. X.1.10 Sexual dysfunction or inadequacy procedures, services, and supplies, including penile implants/prosthesis. X.1.11 Post-mortem testing. X.1.12 Charges for missed appointments in provider's offices and/or charges incurred when scheduled services are canceled by the member. X.1.13 Services that TAKECARE members are entitled to as a result of class action or special group settlements, for example, Agent Orange treatment programs and asbestosis indemnification funds. If specific treatment facilities are not stipulated by the responsible agency or group, TAKECARE will provide the services contingent on either coordination of benefits or the subrogation rights explained in Chapter Four, Your Rights and Responsibilities, Section D., Coordination of Benefits and Subrogation. X.1.14 Blood, blood plasma, or products derived in whole or in part from blood or blood plasma, and special handling fees. X.1.15 Take-home drugs. X.I.16 Gene manipulation therapy. X.1.17 Eyeglasses or contact lenses except as covered as a supplemental benefit purchased by the subscribing group or as required following cataract surgery. When prescribed following cataract surgery with an intra ocular lens implant, eyeglasses are covered up to $125 per pair and must be obtained through participating providers. Coverage of glasses is limited to one pair per surgery and a maximum of two pairs per lifetime. Coverage does not include special treatment for eyeglasses including, but not limited to tinting and scratch resistant coatings. MIN 62 What Is Covered: Your Schedule of Benefits TAKECARE X.1.18 Bone marrow or stem or progenitor cell transplants or rescue procedures and any related services. Chemotherapy or radiation therapy for which a bone marrow or stem or progenitor cell transplant or rescue is required or recommended, for the treatment of any disease, including, but not limited to, breast cancer (except for those specific diseases named in Section V.2). The procedure is excluded whether the bone marrow or stem or progenitor cells are taken from the member (autologous)or a third-party (allogeneic) or from the bone marrow or peripheral blood supply. The entire procedure hereby excluded is frequently referred to as a Bone Marrow Transplant (BMT) or High Dose Chemotherapy with Autologous(Self) Bone Marrow Transplant or HDC/ABMT. (It may also be known as autologous stem or progenitor cell support or rescue, hematopoietic stem or progenitor cell rescue and peripheral stem or progenitor cell rescue, all of which may be accompanied by the term high dose chemotherapy.) X.1.19 Outpatient prescription drugs unless covered under the optional prescription drug benefit purchased by the subscribing group. X.1.20 Personal comfort or convenience items or services obtained or rendered in or out of a hospital or other facility, such as television, telephone, guest meals, articles for personal hygiene, and any other similar incidental services and supplies. X.1.21 Services rendered by a provider with the same legal residence as the member, or a member of the member's family, including spouse, brother, sister, parent or child. X.1.22 Custodial, maintenance, convalescent and/or domiciliary care, respite care (except as specifically provided for in the hospice section of this Agreement), rest cures, whether furnished in the home or in an institution, including a nursing home or similar facility. X.1.23 Travel or transportation expenses (except ambulance service as specifically provided in this Agreement) even though prescribed by a physician or to reach a participating or designated TAKECARE facility. X.2 Dental Services Not Covered X.2.1 These include, but are not limited to: • General dental services and dental x-rays, including treatment on or to the teeth or gums • Any services customarily provided by a general dentist, an oral surgeon, or any other dental specialist • Any procedure involving osteotomy of the jaw • Periodontal treatment and/or surgery • Treatment or care for overbite or underbite • Treatment or care for maxillary and mandibular osteotomies, and jaw or orthognathic conditions • Dental prosthetics and metallic bone cylinder implants (bone screws) • Hospital costs for dental surgery or other dental reasons • Orthodontic treatment, orthognathic surgery, splint therapy and associated costs of each related to the treatment for misalignment or similar malfunction of the jaw joint, commonly known as temporomandibular joint problems or TM1 syndrome X.3 Experimental, Investigational, Unproven, Unusual, or Not Customary Treatments, Procedures, Devices, and/or Drugs Not Covered X.3.1 Treatments, procedures, devices and/or drugs shall be deemed excluded as experimental, investigational, unproven, unusual, or not customary if: • it cannot be lawfully marketed without the approval of the Food and Drug Administration (FDA) or other governmental agency and such approval has not been granted at the time of its use or proposed use, or What is Covered: Your Schedule of Benefits 63 • it is the subject of a current investigational new drug or new device application on file with the FDA, or • it is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or research arm of a Phase III clinical trial, or • it is being provided pursuant to a written protocol which describes among its objectives, determinations of safety, toxicity, effectiveness or effectiveness in comparison to conventional alternatives, or • it is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations, particularly those of the FDA or the Department of Health and Human Services (HHS), or • the predominant opinion among experts as expressed in the published authoritative literature is that usage should be substantially confined to research settings, or • if the predominant opinion among experts as expressed in the published authoritative literature is that further research is necessary in order to define safety, toxicity, effectiveness or effectiveness compared with conventional alternatives, or • it is not a covered benefit under Medicare as determined by the Health Care Financing Administration (HCFA)of HHS, or • it is experimental, investigational, unproven, unusual or not customary or is not a generally acceptable medical practice in the predominant opinion of independent experts, or • a majority of a representative sample of not less than three health insurance or benefit providers or administrators consider the requested treatment, procedure, device or drugs to be experimental, investigational, unproven, unusual or not customary based upon criteria and standards regularly applied by the industry, or • it is not experimental or investigational in itself pursuant to the above, and would not be medically necessary, but for being provided in conjunction with the provision of a treatment, procedure, device or drug which is experimental, investigational, unproven, unusual or not customary. X.3.2 Determinations under this Section will be based on the following: • the member's medical records, • the protocol(s) pursuant to which the treatment is to be delivered, • any informed consent documents the member is required to read and/or execute, as a condition of receiving the treatment, • the published authoritative medical or scientific literature regarding the procedure at issue as applied to the member's medical condition, • regulations, bulletins, letter rulings or other official actions and publications issued by the FDA, HHS, HCFA, the National Institutes for Health (NIH), the National Cancer Institute(NCI) or other applicable regulatory agencies, • the opinions of independent experts, • materials prepared by, for or on behalf of other health insurance or benefit providers and administrators concerning the requested treatment, procedure, device or drug, and/or • recognized technology assessments or evaluations by private or federal entities (e.g. Blue Cross & Blue Shield Association, American Medical Association, Office of Technology Assessment) • other materials that, in the exercise of TAxECARE's discretion, are relevant. IY. IMO 64 What Is Covered: Your Schedule of Benefits TAKECARE X.3.3 No treatment, procedure, device and/or drug excluded by this Section X.3 on the inception date of this Agreement shall be covered because it subsequently ceases to meet the criteria of this Section during the remaining contract year, unless TAKECARE issues a written amendment expressly making it a covered benefit. X.3.4 Treatments, procedures, devices and/or drugs considered to be experimental, investigational, unproven, unusual, or not customary include, but are not limited to: • Orthomolecular medicine • Holistic medicine • Environmental medicine • Chelation therapy, unless medically necessary for the treatment of metal poisoning • Cytotoxin testing • Hair analysis • Colonies • Gene manipulation therapy • Chemotherapy requiring a bone marrow transplant for breast cancer and other solid tumors • Transplants not specifically listed as covered • Medications that are experimental, investigative, or used in ways not approved by the Food and Drug Administration (FDA). Medications included in these categories are those prescribed for: o Use in dosage forms not commercially available o Use by routes of administration not approved by the FDA o Non-FDA approved indications • Naturopathic services • Megavitamin therapy X.3.5 TAKECARE shall have the discretionary authority to interpret this plan and determine all questions arising in the administration, interpretation, and application of the plan including determining what procedures, devices or drugs are experimental, investigational, unusual, not customary, or unproven. All such determinations shall be final, conclusive, and binding. Y. General Limits Y.1 Cumulative Benefits Y.I.1 Any service provided a subscriber or dependent during a contract year is limited cumulatively to these benefits covered in this Agreement. The following changes in a member's status may not increase any restriction or limitation on the number of services or benefits a member can receive in a contract year: • From subscriber to dependent • From dependent to subscriber • From group coverage to continuation coverage, individual plan coverage, or conversion coverage • From employer group contract to another employer group contract Y.1.2 If both this Agreement and the associated coverage have a maximum amount payable or other benefit limit for a particular service in a contract year, then any benefits provided under the associated coverage for that service will apply toward the maximum amount payable or other benefit limit under this Agreement. When the cumulative benefits provided under both coverages reach the applicable maximum or limit for the service under this Agreement, no further benefits will be payable for that service under this Agreement. What is Covered: Your Schedule of Benefits 65 Y.2 Circumstances Beyond TAKECARE'S Control Y.2.1 If, due to circumstances not reasonably within the control of TAKECARE, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, disability of a significant part of hospital or physicians associated with TAKECARE, or similar causes, the rendition or provisions of benefits covered hereunder is delayed or rendered impractical, hospitals and physicians associated with TAKECARE will use good faith effort to provide benefits covered hereunder, but neither TAKECARE, hospitals, nor any physician associated with TAKECARE will have any other liability or obligation on account of such delay or such failure to provide covered benefits. 17.3 Major Disaster or Epidemic Y.3.1 If a major disaster or epidemic occurs, physicians and hospitals will provide medical and hospital services and arrange extended care services and home health services as far as is practical according to their best judgement. These services will be within the limitation of available facilities and personnel, but neither TAKECARE, hospitals, nor any physician associated with TAKECARE, has any liability or obligation for delay or failure to provide or arrange for any such services to the extent the disaster or epidemic causes unavailability of facilities or personnel. 3 66 Optional Benefits TAKECARE CHAPTER SIX OPTIONAL BENEFITS The following services are optional covered benefits that you have only if they have been selected by your employer as part of the subscribing group's plan and if obtained from participating providers. To find out if these benefits apply to your plan, check the following: • Your TAKECARE ID card • Your employer's benefit or personnel office A. Eyewear A.1 Prescription Glasses or Prescription Contact Lenses A.1.1 Prescription glasses or prescription contact lenses once in every twenty-four(24) months. NOTE: A referral from the PCP is not required for this benefit, but the member must obtain an authorization number y from American Vision Services to present to the provider. See Chapter Eight, How To Get Help, for information. LIMIT.: A maximum of$125 per person on a one-time basis toward the total purchase price at TAKECARE designated facilities for the twenty-four(24) month period. r NOT COVERED: • Glasses or contact lenses ordered before the effective date of coverage or after the termination of coverage • Nonprescription frames and lenses including, but not limited to sunglasses, photosensitive, or anti- c) reflective lenses B. Outpatient Prescription Drugs , The following services are covered benefits if obtained inside the TAKECARE service area, on order of a licensed dentist or a TAKECARE participating physician or approved non-participating physician, unless otherwise listed as not covered in this Section, or the X., General Exclusions Section of Chapter Five, What Is Covered: Your Schedule of Benefits. TAKECARE may determine medical necessity by using precertification programs as deemed appropriate by TAKECARE. TAKECARE, through its Pharmacy and Therapeutics Committee, has developed and maintains a prescription drug formulary. This formulary is provided to each participating physician and lists TAKECARE's preferred prescription medications. In some of the outpatient prescription drug benefit plans offered by TAKECARE, coverage and the copayment may vary depending on whether the prescribed medication is listed on the formulary. Refer to your ID card for information regarding which copayments apply to your plan. B.1 Medications/Refills--Standard Quantities B.1.1 Prescribed medications and refills dispensed through participating pharmacies for outpatient use, dispensed for 100 units or a thirty (30) day supply, whichever is less. No more than a thirty (30) day supply may be dispensed at one time. Optional Benefits 67 B.1.2 The following maintenance medications can be obtained in 100 unit quantities even if this exceeds a thirty(30) day supply. However, a copayment must be paid for each thirty(30) day supply of these medications: • Cardiac glycosides(Digitalis preparations) • Thyroid preparations (natural and synthetic) • Anti-diabetic drugs (oral hypoglycemics only) • Anti-epileptic drugs • Glaucoma medications • Commercially prepared estrogen tablets B.1.3 The following maintenance medications will be dispensed in 300 unit quantities, or a thirty(30) day supply, whichever is less. A copayment will be required for each thirty(30) day supply or 100 units, whichever quantity is less, of these medications: • Anti-epileptic drugs • Digestive enzymes • Methylphenidate(Ritalin) B.2 Medications/Refills--Other Quantities B.2.1 Oral contraceptives (birth control pills)and medications including, but not limited to ear drops, bulk containers, etc., will be dispensed in the standard trade-package size, or in a lesser size if specified by the prescribing physician. Topical medications (creams, ointments, etc.) will be dispensed in the standard trade-package size not to exceed a 60-gram package, or in a lesser size if specified by the prescribing physician. B.2.2 Liquid medications(cough syrups, shampoos, etc.) are limited to one pint, but not more than the standard trade-package size, or in a lesser size if specified by the prescribing physician. B.2.3 Aerosols or inhalers (asthma medications, steroid spray, etc.) are limited to one standard trade-package size per applicable copayment. B.2.4 Insulin is limited to two (2)vials per applicable copayment. B.2.5 The participating pharmacist is authorized to limit the quantity dispensed to a reasonable carry-over supply if the member cannot present his/her current TAKECARE ID card and the pharmacist cannot confirm eligibility because it is outside of TAKECARE's normal business hours. The member may return at a time when membership can be confirmed, and obtain the remainder of the prescribed quantity. No copayment will be charged for the return visit. B.3 Generic Equivalents B.3.1 Generic equivalents or TAKECARE's preferred brand will be used when available. If the member or physician insists on a brand-name drug for whatever reason, the member is responsible for the additional cost between the generic equivalent and the brand-name drug. B.4 Delivery Charge B.4.1 If the participating pharmacy routinely charges all its customers for delivery service, the member must pay the delivery charge in addition to the applicable copayment. B.5 Abuse B.5.1 Drug utilization will be periodically monitored for all members. A consistent pattern of early refills or other abuse may lead to suspension of the member's outpatient prescription drugs benefit. 7 68 Optional Benefits TAtcECARE B.6 Outpatient Prescription Drugs Benefits Outside the TAKECARE Service Area B.6.1 A prescription resulting from an emergency episode is a covered benefit, only if the member has the optional outpatient prescription drugs benefit. The normal applicable outpatient prescription drugs benefit copayment applies. LIMIT: A seven (7)day supply LIMIT: Prescription medications the member already takes on a regular basis are not covered if obtained outside the TAKECARE service area. B. 7 Outpatient Prescription Drugs Not Covered B.7.1 The following are not covered benefits with the optional outpatient prescription drugs benefit: • Aging of the Skin - Products: All professional, ancillary and facility services or products relating to the diagnosis and treatment to retard or reverse the effects of aging of the skin • Appetite Suppressants: Drugs used to decrease appetite • Cosmetic Aids and Dietary Products: Cosmetic products, health or beauty aids, including anabolic agents used for body building, and dietary or nutritional products and food supplements, whether prescription or nonprescription • Diabetic Supplies: All diabetic supplies such as insulin pens, penfils, pumps, and glucose testing materials, except insulin vials and insulin syringes and needles • Fertility Drugs: Drug therapy for infertility • Hair Loss: Drugs used in the treatment of hair loss • Injectables: Medications for injection except insulin, glucagon and bee sting kits • Non-FDA Approved Indications/Uses: Medications that are experimental, investigational, or used in ways not approved by the Food and Drug Administration (FDA). Medications included in these categories are those prescribed for: • Use in dosage forms not commercially available • Use by routes of administration not approved by the FDA • Non-FDA approved indications • Non-Drug Items: Non-drug items such as stockings, support garments and other therapeutic devices or appliances, even though a prescription may be required • Over the Counter Medications: Medications which can be obtained without a prescription or medications for which there is a therapeutic equivalent available over the counter, except insulin • Progesterone and Estrogen Products: Specially compounded progesterone and estrogen products including progesterone suppositories • Smoking Cessation: Smoking cessation drugs and/or aids • Take-Home Use From a Facility: Drugs received from a hospital, skilled nursing facility, convalescent home or similar facility for take-home use • Vitamins and Minerals: Vitamins and minerals, except when requiring a prescription • Medications when used for the purpose(s) of recreation and/or travel, other than those medications required for travel by the U.S. Department of Public Health • Non-formulary dual source brand name products • Medications related to health services which are not covered under this Agreement • Other Exclusions and Limitations: All exclusions and limitations as listed in this Agreement apply to the outpatient prescription drug benefit Definition of Terms 69 CHAPTER SEVEN DEFINITION OF TERMS These terms are used in this Agreement and any supplements, amendments, or riders to this Agreement according to the specific definitions given here. Active Work Status The status of any subscriber who has physically reported for and performed the duties for which he/she was hired by the employer and is considered by the employer to be actively at work. Acute Care A pattern of health care in which a patient is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials. Unlike chronic care, acute care is often necessary for only a short time. Acute Condition An acute (immediate and severe) episode of illness or the treatment of injuries related to an accident ro or other trauma, or during recovery from surgery. et r, Agreement The written documents, issued by TAICECARE to the subscribing group, consisting of: Chapters Three, 7 Four, Five, Six, and Seven of the Evidence of Coverage and Owner's Manual, the Evidence of Coverage and Owner's Manual Signature Sheet, the application of the subscribing group, the d individual applications of the members, and any written amendments constitute the entire contract between the parties. Associated An out-of-network supplement purchased by the subscribing group and entered into concurrently with Coverage this TAKECARE HMO Agreement. rc Calendar The period from January 1 of any year through December 31 of the same year. During the first year Year an individual is a member, a calendar year means the period from his/her effective date of coverage through December 31 of that year. Chronic Care A pattern of care that focuses on long-term care of individuals with chronic (long-standing, persistent) diseases or conditions. It includes care specific to the problem as well as other measures to encourage self-care, to promote health, and to prevent loss of function. Common Law Evidence of cohabitation as husband and wife, and general reputation that the two individuals are Marriage living together as husband and wife and claiming to be such. By general reputation is meant the understanding among the neighbors and acquaintances with whom the parties associate in their daily lives, that they are living together as husband and wife, and not that they are merely living together. Common Law Party to a common law marriage. Spouse Continuation Coverage provided to a terminated subscriber and/or his/her eligible dependents as mandated or Coverage required by Section 10-17-135 C.R.S., Title X, Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, or any other applicable law. Contract Provider Any hospital, skilled nursing facility, extended care facility, individual, organization, or agency licensed in the State of Colorado that has a contractual arrangement with TAICECARE for the provision of services under the TAKECARE HMO Agreement. 7r■ 70 Definition of Terms TAKECARE Contract Year The period that begins on the effective date of coverage for the subscribing group and ends on the day before the anniversary date of the effective date of coverage. Conversion The coverage available to members as described in Chapter Four, Your Rights and Responsibilities, Coverage Section C., Conversion. Copayment The predetermined amount or percentage to be paid by the member for a specific service. It will not exceed the amount permitted by applicable regulation. Cosmetic Those procedures which change physical appearance, but which do not correct or materially improve Procedures a physiological function, and therefore are not medically necessary. Coverage The right of a member to receive services provided under this Agreement, subject to the terms, limits, and exclusions of this Agreement. Covered Benefit A medically necessary service that is specifically provided for under the provisions of this Agreement. A covered benefit must always be medically necessary; but not every medically necessary service is a covered benefit. For example, some elements of custodial or maintenance care, which are excluded from coverage, may be medically necessary, but nevertheless are not covered. Custodial Care Any skilled or non-skilled health services, or personal comfort or convenience related services, which provide general maintenance, supportive, preventive and/or protective care. Custodial care: • does not seek a cure. • can be provided in any setting. • may be provided between periods of acute or intercurrent health care needs. • is care provided to an individual whose health services requirements are stabilized and whose current medical condition is not expected to significantly and objectively improve or progress over a specified period of time. Custodial care may include the supervision or participation of a physician, licensed nurse, or registered therapist as necessary or desirable services. The mere participation of these professionals does not preclude the services as being custodial in nature. If the nature of the services can be safely and effectively performed by a trained non-medical person, the services are custodial. Further, custodial care and the nature of those services are not altered by the availability of the non-medical person. Custodial care may also be referred to as maintenance, domiciliary, respite, and/or convalescent care. Dependent My member of a subscriber's family who meets applicable requirements of Chapter Four, Your Rights and Responsibilities, Section F., Eligibility,who is enrolled under this Agreement, and for whom the monthly premium has been received by the TAKECARE. Designated A facility named as such by TAKECARE which has entered into an agreement with or on behalf of Transplant Facility TAKECARE to render services for transplants which are not experimental/investigational and which are covered under this Agreement. Durable Medical Items of medical equipment owned or rented that are placed in the home of the patient to facilitate Equipment treatment and/or rehabilitation. Generally, these are items that can withstand repeated use, are primarily and customarily used to serve a medical purpose, are usually not useful to an individual in the absence of illness or injury. Effective Date of The date that coverage under this Agreement becomes effective. The effective date of coverage for Coverage the subscribing group is shown on the Signature Sheet. The effective date of coverage for a member is in the subscribing group's records. Eligible Employee An employee of the subscribing group who meets the eligibility requirements specified in the Signature Sheet, and who resides within the service area. Exclusion Any provision of this Agreement whereby coverage for a specific service or condition is entirely eliminated regardless of medical necessity. Definition of Terms 71 Group Open That time when eligible persons may enroll themselves and eligible dependents under this Agreement Enrollment Period by submitting an enrollment application to TAKECARE. HMO Health Maintenance Organization Hospice Care A system, both inpatient and outpatient, of supportive and palliative family-centered care designed to assist the terminally ill individual to be comfortable and to maintain a satisfactory lifestyle through the terminal phases of dying. Hospital An institution licensed and operated pursuant to law which is primarily engaged in providing health services on an inpatient basis for the care and treatment of injured or sick individuals through medical, diagnostic and surgical facilities (including a surgical facility which has a bona fide arrangement, by agreement or otherwise, with an accredited hospital to perform such surgical procedures) by, or under the supervision of, a staff of physicians and which has twenty-four(24) hour nursing services. A hospital is not primarily a place for rest or custodial care of the aged, and is not a nursing home, convalescent home or similar institution. A "participating hospital" is one that is accredited as a hospital by the Joint Commission on Accreditation of Health Care Organizations and maintains contractual arrangements with TAKECARE. Intensive Care Constant, complex, detailed health care requiring special training and provided in various acute, life threatening conditions. Level of Care The intensity of effort required to diagnose, treat, preserve, or maintain any member's current physical or emotional status. Depending on what the current level of care is determined to be, from time to time, TAKECARE will have complete, limited, or no responsibility to provide the services appropriate for that level. Redetermination of status and the appropriate level of care will be made by the participating primary care physician and TAKECARE. Most limitations of or exclusions to TAKECARE's responsibility at each level of care are included in each section of Chapter Five, What Is Covered. Terms commonly used to identify levels of care include: acute, chronic, emergency, rehabilitation, intensive, custodial, domiciliary, maintenance, skilled nursing, private duty nursing, and hospice. Life or Limb An event or condition which the member reasonably believes threatens his or her life or limb in such Threatening a manner that a need for immediate medical care is created to prevent death or serious impairment of Emergency health. Limits Any provision, other than an exclusion, which restricts coverage under this Agreement, regardless of medical necessity. Location of Care The setting in which covered services, appropriate for the member's current level of care, are provided. Terms commonly used to identify locations of care include: physician's office, outpatient department or facility, emergency room or facility, general/acute care hospital, rehabilitation hospital, psychiatric hospital, specialty hospital, skilled nursing facility, and home. Maintenance Care All services that are provided solely to maintain a patient's condition at the level to which it has been restored or stabilized, and from which level no significant practical improvement can be expected. Medical Director The physician so named by TAKECARE as the Medical Director, or his or her designee. Medical Emergency The sudden and unexpected onset of a life or limb threatening condition for which the member requires immediate medical or surgical attention. To qualify as a medical emergency, medical attention must be obtained within twenty-four(24) hours after onset. Heart attacks, strokes, poisoning, loss of consciousness or respiration, and convulsions are examples of medical emergencies. However, TAKECARE may determine that other similar acute conditions are medical emergencies. 72 Definition of Terms TAKECARE Medically Any health care service required to preserve the member's health as determined by acceptable Necessary standards of medical practice. See definition of Covered Benefit. Medicare Part A (hospital coverage) and Part B (physician coverage) of the insurance program established by Title XVIII, United States Social Security Act, as later amended, 42 U.S.C. Sections 1394, et seq. Medicare Member Any member entitled to benefits under both parts of Medicare (part A--hospital coverage, part B-- physician coverage). Member Any individual meeting the definition of either a dependent or subscriber. Participating Any physician, physician specialist, hospital, skilled nursing facility, extended care facility, Provider individual, organization, agency or other provider who/which has entered into a contractual arrangement with TAKECARE to provide health services to members. Plan Any insurance policy, self-funded plan, welfare plan, trustee plan, or prepaid medical plan or program. Premium The monthly fee required for each subscriber and each member in accordance with the terms of this Agreement. Primary Care A physician so designated by TAKECARE who: Physician • Supervises, coordinates, and provides medical care to members • Initiates all referrals for specialist care • Maintains continuity of patient care Private Duty Full-shift, continuous attention of a licensed nurse. Nursing Qualified Any individual who, on the day before a qualifying event, is covered under a group health plan Beneficiary maintained by the employer of a covered employee. This can be: • The covered employee • The spouse of the covered employee • The dependent child of the covered employee Qualifying Event A qualifying event refers to an occurrence which triggers a person's right to continuation of coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended. Reasonable Charges The amount of a provider's bill that can be reasonably justified by the circumstances involved. Such circumstances include the level of care and experience needed, the prevailing or common cost of the supplies and services and any other factors that determine value. Reconstructive Surgery performed on abnormal structures of the body, caused by congenital defects, developmental Surgery abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Redetermination of The right of and process by which TAKECARE may review the level of care to identify changes in a Status member's status and prognosis. This may result in a different determination of level of care and a different level of TAKECARE's responsibility for covered benefits. Each such determination will supersede earlier determinations and TAKECARE's obligation for coverage provided. Rehabilitative Care The restoration of an individual to normal or near-normal function following a disabling disease, injury, or addiction. Respite Care The provision of infrequent and temporary substitute care in a patient's home or licensed care facility for the purpose of relieving the patient's family or other caregiver for unforeseen emergencies and the daily demands of care for the patient. Service Area The geographic area encompassing Adams, Arapahoe, Boulder, Clear Creek, Denver, Douglas, El Paso, Elbert, Gilpin, Grand, Jefferson, Larimer, Summit, Teller, and Weld Counties of the State of Colorado. ,LLx a- Definition of Terms 73 Signature Sheet The Evidence of Coverage and Owner's Manual Signature Sheet that forms a part of this Agreement. A signed copy of the Signature Sheet is maintained in the subscribing group's files. Skilled Nursing Those home health care services that: Care • Can only be provided by an RN or LPN • Can produce the best possible and most timely outcome for a disease process and/or treatment regimen according to a professional assessment and plan • Cannot be made available outside of the home because of the immediate home-bound nature of the member • Can furnish reliable information to the participating physician and TAKECARE's Medical Director sufficient for proper determination of the status of the member's condition and the level of care required for that condition Subacute Care A facility which provides a pattern of health care in which a patient is treated for an ongoing Facility condition as a result of an acute injury or illness. A subacute facility specializes in care which does not require acute hospitalization but is more intensive than can be provided in a skilled nursing facility. Subrogation The assumption by a third party of another's legal right to collect a debt or damages. Subscriber A person who meets applicable requirements of Chapter Four, Your Rights and Responsibilities, Section F., Eligibility, enrolls hereunder, and for whom the monthly premium has been received by TAKECARE. To be eligible to enroll as a subscriber, an individual must be an employee of the subscribing group with active work status, and must reside in the TAKECARE service area. For legally required exceptions to the provision, see Chapter Four, Your Rights and Responsibilities , Section B., Continuation of Coverage. To be eligible to enroll as a subscriber, an individual must be an employee of the subscribing group on active work status and must reside in the service area. Subscribing Group The contract holder who has elected coverage for a group of subscribers and their family dependents as described in this Agreement, and who has signed the applicable Signature Sheet. TakeCare TAKECARE of Colorado, Inc., dba TAKECARE Colorado, a Colorado corporation is a Federally qualified, state-licensed health maintenance organization. Urgently Needed Benefits covered under this Agreement that are required in order to prevent serious deterioration of a Services member's health that results from an unforeseen illness or injury if: • The member is temporarily absent from TAKECARE's service area • The receipt of the health care service cannot be delayed until the member's return to the TAKECARE service area 74 How to Get Help TAKECARE CHAPTER EIGHT HOW TO GET HELP Membership Services You can contact TAICECARE's Membership Services department for assistance concerning anything about TAKECARE and your benefits. The following are examples of the subjects you might call about: • You have changed your address. • You cannot find a specific detail about your coverage in your Evidence of Coverage and Owner's Manual. • You want to change your Primary Care Physician (PCP). • You need an updated copy of the Provider Directory. The Membership Services staff can usually answer your question while you are on the line. If not, they will get the answer you need and promptly return your call. To Call You may call Membership Services at 1-800-255-1139 Monday through Friday during the hours of 8 a.m. to 5 p.m. Call early to receive the most prompt service. Please have your membership number 4j (usually the subscriber's Social Security number) from your ID card ready. c To Write If you need to write to Membership Services please note your membership number (usually the subscriber's Social Security number) from your ID card on any correspondence. The following is the address for Membership Services: TAKECARE Membership Services P.O. Box 35801 Colorado Springs, CO 80935 American Vision Services In Metro Denver (303) 238-0397 In Southern Colorado (719) 520-5210 In Northern Colorado (303) 221-2318 In Greeley (303) 352-1063 1 Advance Directives (Living Will/Medical Durable Power of Attorney/CPR Directive): Your Rights G. a O 6 2 TakeCare Policy for Implementing Advance Directives (Living Wills/Durable Power of Attorney/ CPR Directive) On December 1, 1991, the requirements for advance directives under the Omnibus Budget Reconciliation Act of 1990 (OBRA 1990) took effect. As of that date, Medicare and Medicaid-certified hospitals, Health Maintenance Organizations, plus other medical facilities are now required under law to provide to individuals information about advance directives. To comply with the law, TakeCare is providing to you information on the State of Colorado's law on advance directives, including the right to accept or refuse treatment, and the right to execute advance directives. The advance directive information is being provided to TakeCare subscribers at the time of enrollment. We ask that the subscribers share this information with their spouses and/or any other adult family members. Should a TakeCare member execute an advance directive, your physician or any other medical provider including Medicare and Medicaid certified hospitals, skilled nursing facilities, home health agencies, hospice programs, and ambulance personnel should be informed in order to include a notation in your medical record accordingly. A copy of your executed advance directive should be sent to your primary care physician, not TakeCare. Your decision to execute an advance directive has no effect on your TakeCare benefits or eligibility. TakeCare will not discriminate against a member based on whether he/she has or has not executed an advance directive. Photocopies can be made of these forms for other members of your family. If you have any questions, please contact Membership Services at 1-800-255-1139. 3 Introduction to Advance Directives Your right to make medical care decisions includes the giving of"advance directives" which are written instruc- tions concerning your wishes about your medical treatment. These instructions are used in the event you become unable to make health care decisions for yourself. You must be given information on advance directives by Medicare and Medicaid funded hospitals, nursing homes, HMO's, hospices, and home health care and personal care programs. Please understand that you are not required to have any advance directives in order to receive care and treatment. You must only be informed about them. Whether or not you have advance directives, you will receive the medical care and treatment appropriate for your condition and consistent with your consent. Advance directives from another state are presumed to comply with Colorado law. Because an advance directive tells your wishes regarding medical care, it may be honored wherever you are, if it is made known. If you spend a great deal of time in more than one state, you may wish to consider having your advance directive meet the laws of both states as much as possible. You should prepare advance medical directives before you get too sick to think or communicate clearly. The kinds of advance medical directives recognized in Colorado are the "living will" (which applies in cases of terminal illness), the "medical durable power of attorney" (which allows your named agent to make decisions for you if you become unable to make them) and "the CPR directive" (which allows you to reject cardiopulmonary resuscitation). If you have prepared and signed a living will, medical durable power of attorney and/or CPR directive, these documents will speak for you if you become unable to think clearly or speak for yourself. These documents do not take away your right to decide what you want, if you are able to do so. Living Wills A living will is a document you sign telling your doctor not to use artificial life support measures if you become terminally ill. Your living will does not go into effect until two doctors agree in writing that you have a terminal condition, as defined by Colorado law. In Colorado living wills may also be used to stop tube feeding and other forms of artificial nourishment, but only if your living will clearly says so, and you have a terminal illness. If you are able to swallow food and/or fluids, your living will won't prevent you from being fed. In any case, artificial feeding will be used if necessary to relieve pain. Two witnesses must sign your living will. The following cannot sign; patients in the facility in which you are receiving care, your doctor or his or her employees, employees of the facility or agency providing your care, your creditors, or people who may inherit your money or property. Your doctor, lawyer, health care facility, other health organizations or an office supply store may have living will forms for you to complete. Appendix A is a sample living will consistent with Colorado law. This sample or other versions meeting Colorado requirements are acceptable. Legal assistance is not required to complete a living will. If you have legal questions you may want to talk with a lawyer. 7 4 You can cancel ("revoke") or change your living will at any time. You can do this by destroying it. You may also sign a statement that you no longer want it or you may prepare a new one. If you cancel or change your living will, tell your family, your doctor, and anyone who has a copy of it that it has been canceled or changed. Medical Durable Power of Attorney A medical durable power of attorney is only used for making health care decisions. There are other types of durable powers of attorney which allow an agent to make many decisions for you, including financial. A medical durable power of attorney is a document you sign naming someone to make your health care decisions for you. This person is your agent. Your agent will make medical decisions for you if you become temporarily or permanently unable to make them yourself. A medical durable power of attorney can cover more health care decisions than a living will and is not limited to terminal illnesses. Putting your instructions into your medical durable power of attorney for your agent to follow tells him or her what you really want. You can make your medical durable power of attorney so that your agent can make health care decisions for you as soon as you sign it or only when you become unable to make your own decisions. The medical durable power of attorney discussed in this brochure is the type which becomes effective only when you become unable to make your own health care decisions. If you want information on the other type of medical durable power of attorney you may want to talk to a lawyer. A sample medical durable power of attorney can be found as Appendix B. You can appoint anyone to be your health care agent as long as that person is at least 18 years old, mentally competent and willing to be your agent. Your agent does not have to live in Colorado, although you may want to choose someone nearby. If you choose your spouse, you need to know that divorce, dissolution, annulment or legal separation automatically revoke the appointment, unless otherwise provided in the power of attorney. You should remember to make a new one if this happens. Your medical durable power of attorney should contain the following information: • The name, address, and telephone number of the person you choose as your agent, and your second choice of agent to act if your first agent is unable to act for you. • Any instructions about any treatment you want to receive or wish to avoid, such as surgery or chemotherapy. It is very important to state if your agent may or may not refuse life sustaining treatment such as artificial feeding, kidney dialysis or breathing support. It is important to talk with your doctor, your family and your agent about your medical care choices and your advance directives. Resuscitation Resuscitation is an attempt to revive someone whose heart and/or breathing has stopped, using special drugs and/ or machines or very firm pressing on the chest. In the hospital it is often called CPR (which stands for Cardio Pulmonary Resuscitation). Most health care facilities have a policy which requires that resuscitation be done unless there are written physician orders to the contrary. Colorado law lets you sign a CPR directive containing your directions for receiving CPR (you don't want it "DNR" or want it only under limited circumstances). A sample CPR Directive can be found as Appendix C. 5 To better understand resuscitation, please read the following: Q: What is the meaning of DNR? A: It stands for Do Not Resuscitate. DNR,No COR, No Code, No CPR are different ways of stating if my heartbeat or breathing stops, no one should attempt to start it again. Q: Why would a person request a DNR order? A: There are three primary reasons: 1. The person's condition is such that there is no medical treatment that would start the heart or breathing again. In other words, it is the doctor's professional opinion that resuscitation won't work. 2. The patient refuses resuscitation because his/her illness is at a point where death may be expected or welcomed. This is the patient's personal decision. 3. Many very frail elderly patients, or other patients, have executed CPR directives. Sometimes they are not ill at the time the directive is written, but they may have had small strokes, a weak heart, hardening of the arteries, failing liver or kidneys, or other conditions. They realize that death comes to everyone. When it does the heart stops. They do not believe this calls for resuscitation treatment for them. They know that after resuscitation some people are paralyzed, forever unconscious, or unable to speak or understand. They have judged for themselves that they have had a full life and they are ready to accept a natural death. Those who do not feel this way would execute a CPR directive asking that they be resusci- tated under certain circumstances. Q: What happens if there is no CPR directive? A: The law will assume consent for CPR and there will almost always be an attempt to resuscitate. Hospitals and nursing homes respond as if all patients are known to all doctors, nurses or attendants. Because it is an emergency when a patient stops breathing or the heart stops beating, they do not have time to find out all about the patient's condition. They will attempt resuscitation unless there is a CPR directive order to tell them not to try. Q: How do I find out whether this concerns me? A: If your doctor has never talked to you about this, ask him or her whether your health condition makes this something important to think about at this time. Q: I'm fine now. What about future illnesses? A: There are several ways to make your wishes for future medical care known. They are called advance directives. With these directives or instructions you can tell your health care providers your wishes (often known as a "living will"), you can name someone to make health care decisions for you if you are unable to do so (known as a"medical durable power of attorney"), or you can request that CPR not be performed or be performed only in certain circumstances (known as "CPR directive"). See the portion of this document on "Living Wills,"/"Medical Durable Powers of Attorney" and "CPR Directives." 6 Surrogate and Guardians Colorado does have a law automatically allowing the people closest to you to decide who will be a surrogate or proxy decision-maker. These "interested persons," which may be a spouse, parent, adult children, sibling, grandchild or close friend, can meet and select a proxy decision-maker to carry out your wishes for medical treatment and make decisions for you. If the interested persons cannot agree on a legally authorized proxy decision-maker to make decisions for you, any person interested in your care may have to apply to a court to have a guardian appointed for you. The guard- ian and the court would then decide what action to take in your best interests. A guardian is a person appointed by a court to assist with the personal affairs of a person who is unable to make his or her own decisions. The law regards a person as being unable to make personal decisions if he or she lacks sufficient understanding or capacity to make or communicate responsible decisions concerning himself or herself. This may result from mental illness, mental retardation, physical illness or disability, chronic use of drugs and/or alcohol, or other causes. A person who is subject to a guardianship is called a "ward." Any person age 21 or over, or an appropriate agency which is willing to serve, may be appointed as a guardian. A guardian is not required to provide for a ward out of his or her own funds, nor is he or she required to live with the ward. In addition, a guardian is not responsible for a ward's behavior. Guardianship can be shared by more than one individual. Generally the duties of a guardian are to determine where the ward should live; to arrange for necessary care, treatment or other services for the ward, and to see that the basic daily personal needs of the ward are met, including food, clothing and shelter. A guardian may manage financial matters for the benefit of a ward with limited assets. Guardianship is the most restrictive protection which can be provided for a person who is unable to make his or her own decisions and should be used as a last resort. In Summary • You must be given information about advance directives. • You do not need to have or make advance directives for admission to a facility or to receive care. • Talk to your doctor about medical conditions which might make advance directives useful. • Talk with your health care providers and your family, or person you want to make decisions if you become disabled, about your wishes and beliefs. Ask if they will honor them. Make sure that copies of your advance directives are included in your medical records. It is your responsibility to provide these copies to your health care providers. • You should be given written information about your health care providers' policies and procedures regarding advance directives. • You do not need to use a lawyer to complete your living will, medical durable power of attorney or CPR directive. If you have legal questions, however, you may wish to talk to a lawyer. • If you have a living will, medical durable power of attorney, or CPR directive, give a copy of it to your doctor; your family; your agent, if applicable; and to your health care facility. Talk with your doctor; family; and agent, if applicable, while you're still in good health, so they will understand what you want. APPENDIX A Living Will Declaration as to Medical or Surgical Treatment I, ,being of sound mind and at least eighteen years of age, direct that my life shall not (Same of declarant) be artificially prolonged under the circumstances set forth below and hereby declare that: 1. If at any time my attending physician and one other physician certify in writing that: a. I have an injury, disease or illness which is not curable or reversible and which, in their judgment, is a terminal condition; and b. For a period of seven consecutive days or more, I have been unconscious, comatose or otherwise incompetent so as to be unable to make or communicate responsible decisions conceming my person; then I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the terms of this declaration; it being understood that life-sustaining procedures shall not include any medical procedure or intervention for nourishment considered necessary by the attending physician to provide comfort or alleviate pain. However, I may specifically direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration. 2. In the event that the only procedure I am being provided is artificial nourishment, I direct that one of the following actions be taken: (initials of declarant) a. Artificial nourishment shall not be continued when it is the only procedure being provided; or (initials of declarant) b. Artificial nourishment shall be continued for days when it is the only procedure being provided; or (initials of declarant)c.Artificial nourishment shall be continued when it is the only procedure being provided. 3. I execute this declaration as my free and voluntary act this day of , 19 By Declarant The foregoing instrument was signed and declared by to be his/her declaration, in the presence of us, who, in his/her presence, in the presence of each other, and at his/her request, have signed our names below as witnesses, and we declare that, at the time of the execution of this instrument, the declarant, according to your best knowledge and belief, was of sound mind and under no constraint or undue influence. We further declare that we are not: 1) The declarant's physician or employees of his/her physician; 2)employees or patients of the health care facility in which the declarant is a patient; or 3) beneficiaries or creditors of the estate of the declarant. APPENDIX A Dated at , Colorado, this day of , 19 (Signature of witness) (Signature of witness) Address: Address: STATE OF COLORADO, County of Subscribed and sworn to or affirmed before me by , the declarant, and and, , witnesses, as the voluntary act and deed of the declarant, this day of , 19 My commission expires: j I Notary Public yi APPENDIX B Medical Durable Power of Attorney for Health Care Decisions INFORMATION ABOUT THE FOLLOWING IMPORTANT LEGAL DOCUMENT Before signing this document, it is very important for you to know and understand these facts: • This document gives the person you name as your agent the power to make health care decisions for you if you cannot make the decisions yourself. • After you have signed this document, you still have the right to make health care decisions for yourself if you are able to do so. • You may state in this document any type of treatment that you want to receive or want to avoid. If you want your agent to make decisions about life sustaining treatment, it is best to so state in your medical durable power of attomey. • You have the right to take away the authority of your agent unless you have been determined to be incompetent by a court. If you withdraw (revoke) the authority of your agent, it is recommended that you do so in writing and give copies to all those who received the original document. If you named your spouse as agent, divorce, dissolution, annulment or legal separation will automatically remove the appointment unless otherwise provided in the power of attorney. • You should not sign this document until it has been fully explained to you. You may wish to talk to a lawyer. • This is a sample of a medical durable power of attorney. It may not meet your needs. Be sure the form you sign meets your needs. APPENDIX B Medical Durable Power of Attorney for Health Care Decisions 1, , hereby appoint: Name Home Telephone Number Work Telephone Number Home Address as my agent to make health care decisions for me if and when I am unable to make my own health care decisions. This gives my agent the power to consent to giving, withholding or stopping any health care, treatment, service or diagnostic procedure. My agent also has the authority to talk with health care personnel, get information and sign forms necessary to carry out those decisions. If the person named as my agent is not available or is unable to act as my agent, then I appoint the following person(s) to serve in the order listed below: I!� 1. 2. Name Name Home Address Home Address Work Telephone Number Work Telephone Number Home Telephone Number Home Telephone Number By this document I intend to create a Medical Durable Power of Attorney which shall take effect upon my incapacity to make my own health care decisions and shall continue during that incapacity. My agent shall make health care decisions as I may direct below or as I make known to him or her in some other way. If I have not expressed a choice about the health care in question, my agent shall base his/her decision on what he/she believes to be in my best interest. (A) Statement of desires concerning life-prolonging care, treatment, services and procedures: (B) Special provisions and limitations: 1 APPENDIX B BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT. I sign my name to this form on: at: Date Address Signature of person creating Medical Durable Power of Attorney WITNESSES I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowl- edged this Medical Durable Power of Attorney in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as the agent by this document, nor am I the patient's health care provider, or an employee of the patient's health care provider. FIRST WITNESS SECOND WITNESS Signature: Signature: Home Address: Home Address: Print Name: Print Name: Date: Date: (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) I further declare that I am not related to the patient by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of his/her estate under a will now existing or by operation of law. Signature: Signature: WITNESS WITNESS APPENDIX C CPR Directive 1, , being of sound mind and at least eighteen (18) years of age, for myself or for the principal named below for whom 1 am authorized to make medical decisions, direct that cardio-pulmonary resuscitation ("CPR") be administered only as directed below, and hereby provide the following required information: I. Person who is subject to this CPR Directive: a. (name) b. (date of birth) c. (sex) 2. Identifying information: a. (eye color) b. (hair color) c. (race or ethnic origin) 3. Hospice program enrolled in (if any): a. (name of program) 4. Attending physician (generally should be your PCP) a. (name) b. (address) c. (phone number) 5. Signature of declarant or agent: Date (declarant or agent-attach agency authorization) 6. Person's directive regarding administration of CPR: 7. Attending physician's countersignature (No. 6 above): (attending physician's signature) n T **arc C 'Lido -go\ides J fu' ran c of fatihtc immediately TakeCare Colorado covers medical Lnc c\um, a unc oleic \Hits unauthoriicd emergency room treatment for and special r ( uc 'both in t ut out of die medically necessary life- or limb threatening hospital a 11rth tikeL are (olorado. you emergencies only. All other emergency room will have the .Idvantage of km'wing the cost of visits must be authorized by your primary care sour healthcare scrcices in advance. Devut. physician before the visit takes place. von know how n.,rch each visit will cost.you do not hasc of delay the healthcare senkes you A good doctor patient relationship is important. need 'odas 1'u will also find preventive care if. for :ray reason. you wish to transfer to a such as Chcc k-up,.Immunizations and well-haby different primary care physician,you may do so tare arc covered. ho either calling or writing TakeCare Membership Services Department.Your transfer will he effective The quality of healthcare you and your family the first day of the month following our receipt receis e I, important to you and to us. TakeCare of your notification of transfer. Colorado contracts with established physicians. hospitals and medical facilities in your area. Your member identification card is your passport professionals with whom you are already familiar. to TakeCare Colorado. Always present your II) Physicians.specialists and medical facilities must card at the time of service. You will not have to meet our high standards. Their practices are fill out a claim form every time you receive monitored and reviewed continually, and they healthcare services because we have made are recredentt;lled every two years to make arrangements with our participating doctors and sure thev continue to meet requirements. medical facilities to complete any necessary paperwork for you to receive your benefits. So, Your key to this system is the 1'akecare Colorado you can concentrate on getting better instead of primary care physician you personally choose worrying about paperwork. from our network. Each member of your family can select a different primrn care physician. Our Membership Services Department is a special one that meets his or her individual needs. staff of people who give you prompt, personal attention whenever you have a question.concern Your primary care physician is responsible for or problem. For additional information. please your basic healthcare needs and referring you to read your TakeCare Colorado Evidence of Coyer- specialists or arranging hospitalization. if neces- age and Owner's Manual or call Membership sun°. It you or a family member have an urgent Services at medical need call your primary care physician 1.800-255-1139. for instruction. Any illness or injury can be frightening. but not all conditions are life- or limb-threatening. In a life- or limb-threatening emergency call 911 or go to the nearest hospital Hello