HomeMy WebLinkAbout921070.tiff RESOLUTION
RE: APPROVE 1993 MASTER GROUP CONTRACT AND AUTHORIZE CHAIRMAN TO SIGN -
TAKECARE OF COLORADO, INC.
WHEREAS, the Board of County Commissioners of Weld County, Colorado,
pursuant to Colorado statute and the Weld County Home Rule Charter, is vested
with the authority of administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with the 1993 Master Group Contract
Application with TakeCare of Colorado, Inc. , commencing January 1, 1993, and
ending December 31, 1993, with the further terms and conditions being as stated
in said contract, and
WHEREAS, after review, the Board deems it advisable to approve said
contract, a copy of which is attached hereto and incorporated herein by
reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the 1993 Master Group Contract Application with TakeCare,
Colorado, Inc. be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign said contract.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by the following vote on the 4th day of November, A.D. , 1992.
} BOARD OF COUNTY COMMISSIONERS
ATTEST: f i���
�tz " `� yS" WELD COUNTY, COLORADO
/4C At14 6614 :::y4
Weld County Clerk to the Board
Geoor e Keredy, Chairman
BY: � = .A, k-te r...tcr-�,
Deputy Cl≥ to the Board Constance L. Harbert, Pro-Tem
APPROVED AS T FORM:
C. W. Kir
) er0
/
County Attorney Gor a
W. H. e ster
921070
•
MASTER GROUF 7NTRACT APPLICATION
TAKECARE OF COLORADO, INC.
The entirecont act,consisting of the attached Master Group Contract(MGC),Evidence of Coverage(EOC),applicable Addenda,if any,and this Master Group CcnvactAppllcaticn,
has been entered into betweenTakeCare of Colorado,Inc.,and(name below).In consideration of the Health Services Fee to be paid toTakeCare of Colorado,Inc.,by Enrolling
Unit on behalf of eligible Enrollees and Enrolled Family Dependents,TakeCare of Colorado,Inc.agrees to arrange Medically Necessary Health Services as specified herein,in
accordance with the terms,conditions,limitations and exclusions of this contract
1) NAME AND ADDRESS OF GROUP: 2) GROUP NUMBER(S):
Weld County HMO — Northern Colorado Spa
915 10th Street HMO — Denver 744
P.O. Box 758 HMO — Colorado Springs 1031
Greeley, CO 80632 PPO 50158
3)GROUP RENEWAL DATE January 1
Month Day
4) ELIGIBILITY: In addition to the requirements herein,employee eligibility will be as follows:Part—time employees (those
working 20 or more hours per week, but less than 40) and full—time employees will
be eligible for benefits.
5) NEWLY HIRED ELIGIBLE EMPLOYEES AND TERMINATED EMPLOYEES:In addition to the requirements herein,eligible employees
will have coverage provided and Health Services Fees due as follows: Newly hired eligible employees will
have coverage effective the first of the month following employment through a full
pay—period (the 16th through the 15th) if application is made within 31 days. A
full monthly fee will be charged. See attachment #2 for termination of coverage
due to employment termination.
6)GROUP OPEN ENROLLMENT PERIOD:Membership applications,subject to the terms of the attached contract,shall be accepted as
follows: In November for a January 1 effective date.
7)OTHER ATTACHMENTS: Attachment 1 and 2.
8)COVERAGE: EQQ. MGC Contract Tvoe(Medical) Monthly Fee Fmolover Contrib.
U Design I 6729(10/91) 6755 (10/91) Emp.Only $ 136.25 $See Attach 1
❑Design VA 6752 (10/91) 6756 (10/91) Emp. & 1 Fam. Dep. $ 376.05 $ II
❑Design VIA 6753(10/91) 6757(10/91) Emp. & Children $ 376.05 $ ,r
13 Design IXA 6754(10/91) 6758(10/91) Emp.,Spouse& Children $ '376.05 $ rt
❑Design X 6730(10/91) 6759(10/91)
ta
ID
The foregoing rates shall remain effective subject to the terms and conditions of the attached contract and any attachment specified on this
page through December 31, 1993
9)SUPPLEMENTAL ADDENDUM:
Lei Prescription Drug Addendum Rx5 6826(10/91) ❑
❑Prescription Drug Addendum Rx7 6649 (10/91) ❑
❑Prescription Drug Addendum Rx10 6731(10/91) ❑
❑Preventive Dental Addendum 6079 (5/90)
❑Basic 6640(12/88) Contract Tvoe(Dental) Monthly Fee Employer Contrib.
❑Comprehensive 6641 (12/88) Emp.Only $ $
❑Comprehensive Orthodontic 6642 (12/89) Emp. & 1 Fam. Dep. $ $
❑Medicare Supplement 6643 ( ) Emp. & Children $ $
❑Durable Medical Equipment 6631 (12/88) Emp.,Spouse&Children $ $
10) Minimum Number of Enrollees 10 (ten)
a
11) Executed in Colorado effective as of: January 1, 1993 �.
ENROLLING UNIT C a: iiiiitpip& 90, INC. p
tst� u G ///O'�/(DD /0-.30 te7
uredAut bed epreeematbe) ///0�f/L/� (Date) (Signature of Authorized Representative) (Dale)
George Kennedy Stephen T. O'Dell
(Type or Print Above Name) (Type or Print Above Name)
Chair of the Board of County Camissioners President
(Tele) (Title)
fie38(8/92) White:TakeCare Enrollment pepanmant •Yellow:TakeCare-Regbnal Marketing Dept. Pink:Employer 9 in ig 1 73
Attachment w1
WELD COUNTY
For Contract Year January 1 through December 31, 1993
Employer contribution to the cost of TakeCare Colorado, Design Plan 9A, Rx5.
For employees who work:
40 + hours: $130.25
30 — 40 hours: $ 97.69
20 — 30 hours: $ 65.13
921O7O
Red'cine Rd. -9-0 R. Tufts Venue >T:5 Alark Dabling Bl d. -?U A'. Alain Street
Suite 1:i Suite -00 Suite _00 Suite =00
Fort Collins. CO Denser, CO 50'_3- Colonist() Springs, CO 50019 Pueblo. CO SIlmi
r 31131 .'_3`)59N (31131 -70-r-ni) ( 19) ii5-S-00 (-191 ;-1_-_os;
lti.LL.; c ',eiI ;,r. .:
Attachment *2
Contract Year January 1 - December 31, 1993
WELD COUNTY
TERMINATION OF COVERAGE: Terminated employees will have coverage through the end of the month In which
termination occurs if the termination date is the first through the fifteenth of the month, or through
the end of the following month if the termination date Is the sixteenth through the last day of the
month. A full monthly premium will be charged (through the employer) for the month coverage
terminates.
:(c: Redwing Rd. "9-9 [:. fufts :Avenue i;?5 \lark Dabling Blvd. -_(l N. Main Street
Suite 120 Suite -0(1 Suite 2_00 Suite 22(10
Fart ( ollins. CO Denser. CO 5IC3- Colorado Springs. CO S((919 Pueblo, CO ~1011'7,
L(i3) 3AY)5 (,Oil --9.4-1111 (]9) ',.-k.•C)0 ("19) G.}?.:6SS
9?-(4 7;3
are
LINCOLN NATIONAL HEALTH PLAN OF COLORADO
CT DESIGN IXw
As of August 1, 1992 the name of our health MASTER GROUP CONTRA
plan has changed to TakeCare of Colorado, (Herein called the Contract)
Inc., from Lincoln National Health Plan.
with the Enrolling Unit to provide the
called PLAN)hereby agrees. and itio pros of this
Lincoln National Health Plan n Colorado (herein subject to die terms.conditions.exclusions
Health Services set forth herein to Covered Persons
Contract. a em of the required Contras(]target
on of the Enrolling Unit's application and payment
ym .
application is attached to and is made a part of this Contact.
This Contract is made in cotisnderati Thas specified herein-A copy of the enforce by the timely payment
on theAppli�on�willbecontinued provided herein
of
ihe Contract retCecc°sn whe en
due,subject don of this Cook as
of the required Contract Charges wbea due. to termination
All Coverage under this Contract shall begin and end at. 12:01 a.m.Mountain Time.
This Contract is delivered in and governed by the laws of the State of Colorado.
As of August 1. ]992 the name of our heal
plan has changed to TakeCare of Colorad
CONTENTS Inc., from Lincoln National Health Play
Section
Definitions of Terms Used in this Contract.......... ................... ..........
Section II Entailment and Effective Date of Individual Coverage...........................6
Section III 6
Procedures for Reimbursement of Eligible Expenses..............................
Section IV
Coordination of Benefits and
Subrogation............... ...................
Section V Complaint and Grievance Ptocertes.......................................................11'
Section VI 11
Termination of Individual Coverage.........................................
Section VII
ContractCharges.....................................................................................1
5
Section VIII
GeneralProvisions..................................................................................1
6
•
Section IX Health Services .............................................18
procedures for Obtaining
Section X Schedule of Benefits and Exclusions............._.......................................
20
Section I
DEFINITIONS
"Acute Mental Disorder"means a condition determined by the Mental Health Provider o be psychological in gym'and
a short duration. when such Addendum is signed by
which A nas an immediate onset and if any,of Health Services coveted only
mcans an attached description, Health Services Fees.
"Addendum"dm" em of additional
PLAN. and subject to PaYm bee 31 of any Y�
this Conttacx for the diagnosis"Calendar Year" means the period froma January 1 through es caves Classification the of Diseases of
Services"chemical
means sg dependency
a classified in the International
"chemical Dependencyo and�ical or drug deQenr! ed
the U.S. Depattmem of Health and Human Services. bouts a Hospital or Participattn8 Skilled
stay of mom than eighteen (18)
".Confinement" means an tminset=nP� a
Nursing Facility. means a defective development or formation of a part of the body which is determined by
"Congenital Anomaly" at the time of birth.
Physician w have been present
the application of the Enrolling Unit.ther conditions betty ad
Contract"means the Master Group Cent gig benefits.exclUst°°s
andN and the
by PLAN which constitrtte the agreem Enrolled Family Dep��•
Enrolling nit
the yam of the Health Serviaa Fee for all Enrollees and
"Contract Charge mans the
effective date of this Contracts
t t
"Contract Years" and"Contract Months" are determined Services Fee.worth�Coveted Person is em of at
in addition to the HPerson t for the
pay for eta certain Health
metros the charge. under this Contract �e of service.The total CopaYm�Charge
pay for Health to the provider of the aylnotex 2�of the totalUmt those caste Health Services e d
PLAN Chatee is any behalf o fteat may through the Enro g aid o any
Cotrtraa owhere tt
paid bye Y Covered Person herring the same period Faonmily behalf pendents with the CovetedPerson total Copaymeac C th Services an Coln to PI-e
byralllx Covered Persons in the family unit exceed Enrollee-is
the totalannualthe recovery of Fees d to P1 A
du all ring the setup period through the Enrolling Unit The Errro is responsible do not correct
Charges. (See Section IlL) physical appearance, but which
which improve pN sisal a .
"Cosmetic temetic improve pnaph means those
function,procedures am not Medically subject to
materially a physiological provided under this Contact,����
a Covered Person to Health Services Health Services the following conditions:(a) ,any of termination condo
"Coverage" means the entitlement by provided prior to the date tha-
whenterms limitations, Health Services must be P ices d prior
ust be provided that
my the rminations a ndit
and exclusions of this Connect and
Covi
two(2)
Contract is in effect:(b) in Section II.
Person, and meets l eligib of ility
requirements rementdascdeesscnb d while Coverage of
person, and all eligibility tech fled Family Dependent,but applies only
"Covered Person"means either the Enrollee or an Enrolled
is determined by the Menem Health provider
person under this Contract is in effect. functioning of the individual.
n-term care for a condition which normal daily
"Crisis in nn" means a sudden onset and arts the oal in developing immediate of coping individual.
psychological n r native,and which has assistance se
Intervention services include evaluation and oes. ���oRm�,does e,,o�c�es-tL�n lled Health"Custodial Cate"means any skilled��wr.�or supportive.--...preventivef acme or protective health`'rite,_Af sr u
. . __�l.n Alnr `^ _
current medical,condition is
are stabilized and whose The absence of such not individual whose Health Service's requirementsrogre over a specified penod of time.
e or progress erred throuBiiPenodic
is provided to improvemenctedt
an mdt se upon improve may or objectively documented of a
to significantly �objectively
predictable medical oucco supervision participation imp m will be based Custoal Care . Ie include d the The mere participation anon ofof these
roveme licensed use professionals and Plan- ar or desirable assessment by stored therapist ascnecessary m nature and if the nacuie the services can be safely an
nurse. o test Furze of r.Custodial Care and land
physician. preclude theson-med c being services ate custodial
nt
professionals does not non-medical person.,�on-medical Pe�°n' but not
off those e performed not altered
the availability
provided by or under the dliecnon of a Dentist^including
of services are altered by mouth
Treatment or Care"means all services P or soft tissues of the
,Dental Surgery, procedure which involves the hardand qualified to provide Dental Surgery
limited to my surgical
..DDS:', who is dulylicensed
rcec�a.
,Dentist" means any d°r °ladental
of jurisdiction in which treatment into an agseema'
"Designated
Treatment or Care under Hospital named as such by PLAN.whit ch
entered
i into
anagr en an
••Designated elf of PLAN
r Facility"
Services for organ transplants which are
with or on behalf of PLAN an withstand Rid�and is not disp°�e.is use
which are covered under this Contractand is apPrpPna
"Durable oserveMedicalEqupoS stn"means e ly not useful equipment.to in the absence of a Sickness or Injury,� generally not
to serve a medical put'Pox• covered under this Contra
for use in the home. d specific to the service area for Health Services
G
"Eligible Expenses"are�fees established who ce meets
the eligibility
�P�'�et°her
lling Unit or other personer we
specified pegibed in theca"application
� Yahis m °�the who t Sees who work or am er work lessPLAN han p� d
at in eligible
a prior
approved in wr tin g by PLAN Enrolled Eligible Persons w g�resi Area. id
mn�mems.Part _ writing bS��PLAN.Enrolled Participator re the Service bAreashaRlyd��°�y for Health �,PLAN,
xi
of an Emergm'ay,or upon prior written approval or Mental Illness which arises sudd
in the event from Injury.Sickness, whit
nonresulimg to �life or health of a Covered
"Emergency"require •means a serious andme treatment to avoid jeopardy annrson.
an Emery
and requites Healthimmediate Le caretrzaServices and supplies tied for the tie meat of to the wadi
those Health sery �terrjieotrsetof an for thericy.
..Emerge er Services" four(24)hours
whicharegenerallYPt�dddn°laterthaniwe CY-"tract- this Contract
Copayment Charles as described in this for Coverage under
who is enrolled
,•mss a Family Dependent
Contract-
"Enrolled Family Dependent"
Enrollee"means an Eligible Person who is enrolled for Coverage under this Contract
or other entity with whom this Contract is made.
..Enrolling Unit"meamis the employer psychiatric pris eRs'rreamtents,devices ar
Procedures"me �s medical.surgical fir
incd by the medical comm.,
therapies) as detemi ht to change, mm
"Experimental regimes roveuPrce investigational drugs and drug the rig .,
large, including
ingibut o(including Administration.PLAN reserves the righ if a particularP
but not limited to the Food and Drug Unproven. Contact PLAN Unproven.
large, includingExperimental or Unp Ex erimental or
pharmacological regime is considered to be Pr dependentct»ld(°
time,the procedures considered to be P✓ and w
"Family arm device,or p Enrollee's legal spouse or(2)an unmarried depende ,
llee has e01( )anu red gi'a s
astep stepchild,
legally adopted ed a child,
or who is(1)f the Enrollee or the Enrollee for
child,aa child fwhom ryyanco trot)of either utter a Enrol
a stepchild,legally tit paten Enrollee unless PLAN approves for g arrangements.Services
spc
Enrollee has legal a place residence is with the the Se a shall be covered only rio Health
ngPP�ree
(3)Pa whose principaltempo y reside outside of Sthe oruponprior
.
�enmof an Emergency,Dependents who tempo SetviceArea.ubjecttothe conditions and limitationsf:�
Participating Providers tnilx..Y.Yient. is subject to the following J"-- 70
1. The term"Family Dependent" shall not include any unmarried dependent
child 19 years of age or older.
ed dependent child 19 years of age or older but less
2. The term"Family Dependent'shall not include any unmarri
titan 23 years of age unless:
a. The child is not regularly employed on a full-time basis: and
b. The child is a Full-time Student and evidence satisfactory to PLAN is furnished upon request: and
c. The child is primarily dependent upon the Enrollee for support and maintenance and evidence satisfactory
to PLAN is furnished upon request and
3. The Enrollee shall be responsible reimbursement from the not
for any Health Services s providedP to the child obtaining at a time when the child did not
satisfy these conditions.The Enrolling Unit agrees
for such Health Services. course of study or training
"Full-time Student" means a person who is enrolled and attending full-time in a recognized
at
1. an accredited high school or vocational school:
2. an accredited college or university: or school.
3. a licensed technical school.beautician school, automotive school. or similar training school.
or
at the end of the Contract Month during wwhic rson ce ontinues n aes or
oA person ceases to be a Full-time Student therwise ceases ttibe tiro��inaawd3aat the instinuiononaful eb ad nni� uebeaFull-
established by the institution.unless
Full-
time Student during periods of vacation of vacation.
Full-
time Student immediately following the periodto the extent that such
lies covered under this Contract except
"Health Services"means the are �or �under this Contract
health care services and supplies Enrollee and each Enrolled Family Dependent in
for each
"Health Services Fee means the monthly requiredfee
accordance with the terms of this Contract. in providing Health Services on an
to law which is primarily engaged . tic and surgical on an
or sick individuals through medical.dia@ans
"Hospital means an institution operated pursuantcontract or with an accredited hospital
i-
Inpatient(including basis for the i al facility and treatment wcha of a injured arrangement,bywhich has twenty-four(gal
tiesefrmsuch
a surgical which has a bona fideuper sion of,a staff of Physicians [rha of Healthcare
(2 )
to perform sac ser tea►procedures)accred t d as a r Hospital o supervision b the Joi Commission
are of the aged.Accreditation
s not na of Hea home,
hour izatiog red as ore by
Organizations. A Hospital is not primarily a place for rest or Custodial
convalescent home or similar institution. PLAN and theEnrolling Unit during which Eligib'•
"Initial Eligibility Period"means the period of time determined by
Persons may enroll themselves and Family Dependents under this Contract."Injury"means bodily damage other than Sickness(excluding medical malpractice),including all related conditions an
recurrent symptoms, not otherwise excluded under this Contract
"Medical Director" means the Physician so named by PLAN as the Medical Director, or his or her designee.
meet tl
PLAN to be necessary
Necessity t done on a case-by-case to be necessary
fact that
"Medically needs
an iv means those on Services which are i deistermined by Necess. �a that
procedure or treatment does not mean that it is Medically dent's 'Itdadon.
itic
basic health needs of individual.Determination of Medical bed course of treatment
�for the pa solely I
the
has performed be ed o prescribed h thea iagosis of.and prescribed or not at requited c�
the service must ea nsconsistent than
convenience
of the patient or his or her Physicianof 8 appropriate:
be required for reasons other n reasons and(3)be performed in most cost efficient type s �, ti 70
"Medicate" means Pats A and Pan B of the insurance program established by Title XVIII.United States Social Security
Act. as later amended. 42 U.S.C. Sections 1394. et seq. into a service agreement with
or individual who has entered
"Mental Health Provider" meens the Health
organization. entity es
Dependency Services covered under this Contract.
supplies coveted under this Contract for the diagnosis and treatment
PLAN to arrange er ices" the Mental Health Services and Chemical of Health
oMe ent Health Services"means shose in the and
of Mental Illnesses which are classified in the International Classification of Diseases of the U.S. Department
and Human Services. s chologicai ongin or effect including
"Mental Illness" means a physical or mental condition having an emotional or psychological
Y
alcoholism and chemical or drug dependency.
"Open Enrollment Period"means an annual period thirty-one(31)days in duration.subsequent to the Initial Eligibility
Period.determined by PLAN and the Enrolling Unit during which Eligible Persons may enroll themselves and Family
Dependents under this Contract. facility designated as such by a Hos-
meansanon-Hospitalhealthcarefacility,oradjtmct , reschegnes surgical services.
"Participating l (1) provides
or services on an outpatient basis: p or diagnostic e services.and
Eml which Health provides one or more of care the following secvi uled rehabilitative.laboratory.
Em has
Services.service urgent are en wiserth
PLANes,or topr provide
has entered into a agreement with to provide Health Services to Covered Persons.
i"Participating dug ua Healththe Agency"
means a program which is(1)engaged in providing home health care services and
is authorized pursuant to the law of jurisdiction in whichueamtentis received,and(2)has entered into a service agreement
with PLAN to provide Health Services to Covered Persons. with PLAN to provide Health Serv-
ices"Participating Hospital"means a Hospital which has entered into a service agreement
ices to Covered Persons. with PLAN to provide Health
"Participating Physician"means any Physician who has entered
into a service agreement
Services to Covered Persons. pr>�mitiacely includes pediatrics.internal
Physician whose practice into a Primary Care Physician serv-
ice a Primary Care o y,or
means any
medicine.obstetrics/gynecology.or family or general medicine,and who has entered
agreement with PLAN to provide Health Services to Covered Persons' any other Health Service provider
"Participating Provide?'means a Participating Hospital.Participating Physician.and
who/which has entered into a service agreement with PLAN to provide Health Services to Covered Persons.
home facility which is(1)licensed and operated in
means a Hospital or nursing is Medicare ap is(1) aan t pera intc
"Participating w Skilled Nursing Faction which treatment
accordance Teem n law o P uAN to p�ide Health S races to Covered Persons.
a service agreement with PLAN to p who is duly licensed and qualifies
"physician"means any doctor of medicine."M.D.",or doctor of osteopathy,
"D.O:•,
under the law of jurisdiction in which treatment is received.
"Reasonable and Customary Chargcs"means fees for covered Health Services and supplies which do not exceed the fec
that the provider would charge any oit,cr payer for the same services. u Sickness.orCongzn
"Reconstructive Surgery"means any Medically Necessary surgery which is incidental to an Injury
tal Anomaly and whose purpose is to restore normal physiological functioning to the involved part of the body.
"Semi-private Accommodations" means a room with two or more beds in a Hospital or Participating Skilled Nursi'
Facility. agencies. Contact PLAN
"Service Area" means the geographic area served by PLAN. as approved by regulatory
determine the precise geographic area served by PLAN.
"c:,.,.,,PcC" means nhvsical illness or disease. or pregnancy, but does not include Mental Mn „D'
Section 11
ENROLLMENT AND EFFECTIVE DATE OF INDIVIDUAL COVERAGE
A. Enrollment
Eligible Persons may enroll themselves and their Family Dependents in PLAN during the Initial Eligibility Period
or during an Open Enrollment Period specified by PLAN by submitting application on a form provided or approved
by PLAN. In addition,new Eligible Persons may be enrolled in PLAN within 31 LAN daysof te date
toon which.they first which
become Eligible Persons.and new Family Dependents may be enrolled in newborn 1 days o are covered at the
they first become Family Dependents,except that Family DependEligible l Persons and/or Family
moment of birth. Except during the time periods set forth in this paragraph.
Dependents may not enroll in PLAN without the express written authorization of PLAN and evidence of insurability.
The Enrolling Unit shall notify PLAN in writing within sixty (60) days of the effective date of enrollments.
terminations or other changes:provided.however.that the Enrolling Unit shall notify PLAN in writing each month
of any changes in the Coverage classification of any Enrollee.
B. Effective Date of Coverage
Coverage for an Eligible Person and his or her Family Dependents. if any, is effective on the date specified by
Enrolling Unit and PLAN.provided that PLAN receives a property completed individual enrollment application that
was submitted to PLAN according to the enrollment provisions of Section II.A of this Contract: and provided.
however, that
1. No Coverage shall be effective until this Contract takes effect
2. No Family Dependent shall be covered under this Contract until the Eligible Person is coveted.
anew Family Dependent by reason of adoption or marriage.then Coverage forthat Family
3. If an Enrollee d acquiresent is adopted or married, if PLAN and
Dependent shall take effect on the date that the new Family Dependent .one(31)days of occurrence;
Enrolling Unit is notified by the Enrollee of the adoption or marriage within thirty
and any necessary adjustments to Health Services Fees have been made.
4. If an Enrollee acquires anew Family Dependent who is a newborn child.then Coverage for t�oDependent
shall take effect at the moment of birth and remain in effect for thirty-one(31)days bey
continue Coverage for that Family Dependent.the Enrollee shall notify PLAN and Enrolling Unit of the newborn
child's birth and the name: and make any necessary changes in the Coverage classification and Health Services
Fees.
5. Health Services for medical conditions arising prior to the effective date of Coverage and resulting in
Confinement are covered as of the effective date only if the Covered Person notifies PLAN of Cand ifHealth m wi
forty-eight(48)hours of the effective date,or as soon thereafter as is reasonably possible,
Services
are received in accordance with the terms, conditions. exclusions and limitations of this Contract.
Section III
PROCEDURES FOR REIMBURSEMENT OF ELIGIBLE EXPENSES
Reimbursement of Eligible Expenses
PLAN shall reimburse for Eligible Expenses incurred with non-participating providers only for MEDICALLY NECES-
SARY EMERGENCY SERVICES OR SERVICES AUTHORIZED OR APPROVED BY PLAN in accordance with the
terms of this Contract 0na 0170
directly to PLAN N an the
Participating Providers are i 3 u1eible for submitting written proof of loss for Eligible Expenses o the
_ _ r Dorrenn cc hided by a Participating Provider for Eligible Expenses.
Written proof of loss for services rendered by non-participating providers. satisfactory to PLAN, shall be furnished at
PLAN's office within ninety(90)days after the date of such loss.Failure to furnish proof within the time required shall
invalidate or reduce Coverage unless it was not reasonably possible to have given proof within ninety(90)days or.in the
absence of legal capacity of the Covered Person.later than one(1)year from the time in which proof is otherwise required.
All Eligible Expenses shall be paid within sixty(60)days of receipt by PLAN of proof of loss.Where applicable.Eligible
Expenses shall be paid to the Enrollee. Subject to written authorization from an Enrollee. all or a portion of any Eligible
Expenses due may be paid directly to the provider of the Health Services.
Copayment Reimbursement
PLAN shall reimburse for amounts of Copayment Charges paid by any Enrollee in any Contract Year that exceed 200%
of the total annual Health Services Fees paid to PLAN during the same period on behalf of the Enrollee through the
Dependents with PLAN. PLAN shall
Enrolling Unit In those cases where the Enrollee has enrolled his or her Family that
reimburse for amounts of Copayment Charges paid by all Coveted Persons in the family unit in any Contract Year exceed 200%of the total annual Health Services Fees paid to PLAN through the Enrolling Unit during the same period.
Written notice that excess amounts of Copayment Charges have been paid by the Enrollee or by all Covered Persons in
the same family unit must be sent to PLAN. Such notice must(1) include proof satisfactory to PLAN of the payment of
Copayment Charges,and(2)be provided to PLAN not later than ninety(90)days after the end of the Contract Year.The
amount of any excess Copayment Charges will be paid within sixty(60)days of receipt of written notice by PLAN that
excess Copayment Charges have been paid by Covered Persons.
Limitation of Actions
No action at law or in equity shall be brought to recover on the Contract by a Covered Person prior to the expiration of
sixty(60)days after proof of loss has been filed in accordance withthe requicemems of the Contract.nor shall such action
be brought at all unless brought within three(3) years after the time written proof of loss is required by the Contract
Section IV
COORDINATION OF BENEFITS AND SUBROGATION
Coordination of Benefits
A. Applicability
1. This coordination of benefits("COB")provision applies to This Plan when an Enrollee or the Enrollee's Enrolled
Family Dependents have health care coverage under more than one coverage plan. "Coverage plan" and"This
Plan" are defined below. nation rules ould be ose rules
2. If determine s w etaarproviston applies,the benefits of This Plan are determinede order of benefit rbefore or after those of looked
r coverage plan.The
benefits of This Plan:
(a) Shall not be reduced when,under the order of benefit determination rules,This Plan determines its benefits
before another coverage plan: but
(b) May be reduced when,under the order of benefits determination rules,another coverage plan determines its
benefits first.The above reduction is described in subsection D"Effect on the Benefits of This Plan."
B. Definitions
1. "Coverage plan"is any of these which provides benefits or services for,or because of,medical or dental care or
treatment JSv�.i, £7
(a\ nmun insurance or ttroup-rytx coverage. whether insured or uninsured. This includes prepayment. group
__s...,.I .,.-.-:,ienr_rvne coverage.
(b) Coverage under a governmental plan,or coverage required or provided by law.This does not include a state
plan uoder Medicaid Mee XDC.Grants to States for MedicalAssistance Programs,of the United States Social
Security act. as amended from time to time).
Each contract or other arrangement for coverage under (a) or (b) is a separate coverage 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 cov-
erage plan.
2. "This Plan" is the part of this group Contract that provides benefits for health care expenses.
3. "Primary Plan/Secondary Plan": The order of benefit determination rules state whether This Plan is a Primary
Plan or Secondary Plan as to another coverage plan covering the person.
When This Plan is a Primary Plan,its benefits are determined before those of the other coverage plan and without
considering the other coverage plan's benefits.
When This Plan is a Secondary Plan,its benefits are determined after those of the other coverage plan and may
be reduced because of the other coverage plan's benefits.
When there are more than two coverage plans covering the person.This Plan may be a Primary Plan as to one
or more other coverage plans, and may be a Secondary Plan as to a different coverage plan or plans.
4. "Allowable Expense"means a necessary. reasonable and
item of customary item of expense for health care: when the
expense is covered at least in part by one or mote coverage plans covering the person for whom the claim
is made.
The difference between the cost of private accommodations in a Hospital and the cost of Semi-private Accom-
modations in a Hospital 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 coverage plan.
taco C18geplanprovides 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.
5. "Claim Determination Period"means a Calendar Year. However, it does not include any part of a year during
which
ich<person has no Coverage under This Plan,or any pan of a year before the date this COB provision or a
provision takes effect.
C. Order of Benefit Determination Rules
1. General. When there is a basis for a claim under This Plan and another coverage plan.This Plan is a Secondary
Plan which has its benefits determined after those of the other coverage plan, unless;
(a) The other coverage plan has rules coordinating its benefits with those of This Plan; and
(b) Both those rules and This Plan's rules,in subsection 2 below,require that This Plan's benefits be determined
before those of the other coverage plan.
2. Rules. This Plan determines its order of benefits using the first of the following rules which applies:
(a) Non-DepEndent/Dependent The benefits of the coverage plan which covers the person as an employee,
member or subscriber(that is,other than as a dependent)are determined before those of the coverage plan
which covers the person as a dependent
(b) Dependent Child/Parents not Separated or Divorced.Except as stated in Paragraph(2)(c)below,when This
Plan and another coverage plan cover the same child as a dependent of different persons,called"gtrAts"•
G) The benefits of the coverage e--70
plan of the parent whose birthday falls earlier in a year are determined be-
fore those of the coverage nian of♦/.a ____—
(ii) If both parents have the same birthday,the benefits of the coverage plan which covered one parent longer
are determined before those of the coverage plan which covered the other parent for a shorter period of
time.
However.if the other coverage plan does not have the rule described in(i)immediately above,but instead
has a rule based upon the gender of the parent,and if.as a result,the coverage plans do not agree on the
order of benefits, the rule in the other coverage plan will determine the order of benefits.
(c) Dependent Child/Separated or Divorced.If two or more coverage plans cover a person as a dependent child
of divorced or separated parents, benefits for the child are determined in this order.
(i) First, the coverage plan of the parent with custody of the child:
(ii) Then, the coverage plan of the spouse of the parent with the custody of the child: and
(iii)Finally, the coverage 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 coverage plan are determined first The coverage plan of the
other parent shall be the Secondary Plan.
This paragraph does not apply with ieapcc.t to any Claim Determination Period or plan year during which any
benefits are actually paid or provided before the entity has that actual knowledge.
(d) Active/Inactive Employee. The benefits of a coverage 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 coverage plan
which covers that person as a laid off or retired employee(or as that employee's dependent). If the other
coverage plan does not have this rule, and if, as a result, the coverage plans do not agree on the order of
benefits, this rule(d) is ignored.
(e) Longer/Shorter Length of Coverage.If none of the above rules determines the order of benefits,the benefits
of the coverage plan which covered an employee,member or subscriber longer are determined before those
of the coverage plan which covered that person for the shorter term.
(f) No-Fault Automobile Insurance.Your benefits wide this PLAN will be coordinated with minimum coverages
required under the Colorado Auto Accident Reparations Act(No-Fault).
WHAT IF YOU FAIL TO PURCHASE THE REQUIRED NO-FAULT COVERAGE ON YOUR AUTO-
MOBILE
The benefits of this PLAN will not be available to you to the extent of minimum benefits required by the"No-
Fault" Law for injuries suffered by you while operating or riding in a motor vehicle owned by you if said
vehicle is in operation on the public highways of this State and such vehicle is not covered by No-Fault Auto-
mobile Insurance as required by Law.This denial of benefits does not apply to any other person injured in
a motor vehicle accident if the injured person is a non-owner operator, passenger or a pedestrian and such
other person is not covered by No-Fault Automobile Insurance.
D. Effect on the Benefits of This Plan
1. When This Subsection Applies. This subsection D applies when, in accordance with subsection C "Order of
Benefit Determination Rules,"This Plan is a Secondary Plan as to one or more other coverage plans.In that event
the benefits of This Plan may be reduced under this subsection. Such other coverage plan or plans are referred
to as "the other coverage plans"in subsection 2 immediately below.
2. Reduction in This Plan's Benefits.The benefits of This Plan will be reduced when the sum of:
(a) The benefits that would be payable for the Allowable Expense under This Plan in the absence of this COB
provision: and
As of August 1, 1992 the name of our health
plan has changed to TakeCare of Colorado,
Inc., from Lincoln National Health Plan. :RIPTION MEDICATION ADDENDUM RX 5
In consideration of the Health Services Fees to be paid, the Master Group Contract and
Evidence of Coverage are hereby amended by the attachment thereto of this Addendum.
Section I of this Contract, entitled "Definitions" shall be modified by the following
additions:
"Drug Formulary", if enacted, is a listing of Prescription Medications approved for
use by PLAN which may be dispensed through Participating Pharmacies to a Covered
Person. When Designated by PLAN, a generic equivalent shall be dispensed. This
list shall be subject to periodic review and modification by PLAN.
"Participating Pharmacy" means a pharmacy which has entered into a service
agreement with PLAN to provide Prescription Drug services to Covered Persons.
"Participating Provider" means a Participating Hospital, Participating Pharmacy,
Participating Physician, and any other Health Services provider who/which has
entered into a service agreement with PLAN to provide Health Services to Covered
Persons.
"Prescription Medication" means a drug or medication which bears the federal
legend "Federal law prohibits dispensing without prescription", which can under
federal or state law be dispensed only pursuant to a prescription order. This
definition includes insulin, compounded prescriptions or formulas which must be
prepared by a pharmacist subject to a prescription order.
"Prescription Order or Refill" means the authorization for a Prescription Medication
issued by a Participating Physician who is duly licensed to make such an
authorization in the ordinary course of his or her professional practice.
The "Relationships Between Parties" subsection of Section VIII shall be modified by the
following addition:
"The Participating Pharmacy is solely responsible for the pharmacy services provided
to any Covered Person."
Section X.B.2.a. of this Contract, entitled "Hospital and Related Services" shall be modified
by the following addition:
3) Outpatient Prescription Medications provided by a Participating Hospital or
Participating Alternate Facility in conjunction with emergency services for the
same condition, not to exceed a consecutive seven (7) day supply.
COPAYMENT CHARGE: $5.00 per Prescription Order or Refill
6826(1/92)
(over)
Section X.E. of this Contract, entitled "Miscellaneous Health Services", shall be modified
by the following addition:
8. Prescription Medications
Prescription Medications which have been prescribed under the direction of
the Participating Primary Care Physician and obtained through a Participating
Pharmacy. Prescription Medications shall, in all cases, be dispensed in
generic equivalent form, or in accordance with the PLAN Drug Formulary,
if enacted, and as amended from time to time, or upon PLAN approval.
COPAYMENT CHARGE: $5.00 per Prescription Order or Refill, or
the average retail price, whichever is less:
For a single Copayment Charge, a
Covered Person may obtain one of the
following:
• up to a consecutive thirty-four (34) day supply of
medication;
' up to one (1) cycle supply of oral contraceptives.
A COVERED PERSON SHALL PAY TO A PARTICIPATING
PHARMACY 100% OF THE ADDITIONAL COST OF ANY
PRESCRIPTION MEDICATION WHICH, AT THE REQUEST OF THE
COVERED PERSON OR PHYSICIAN, IS NOT DISPENSED
ACCORDING TO THE CURRENT PLAN DRUG FORMULARY,OR ITS
GENERIC EQUIVALENT, UNLESS APPROVED IN ADVANCE BY
PLAN.
The "Exclusions" subsection of Section X shall be modified by the following addition:
The following are excluded:
27. Contraceptive supplies or devices (except diaphrams and birth control pills),
drug and supplies not requiring a prescription order(including but not limited
to aspirin, antacids, oxygen, benzoyl peroxide preparations, medicated soaps,
syringes other than insulin syringes and bandages), food supplements,
antabuse, methodone, nicotine gum, minoxidil topical preparations,
experimental drugs, drugs determined by PLAN to be ineffective and
prescription medications related to health services which are not covered
under the contract.
As of August 1, 1992 the name of our health coin National Health Plat. of Colorado
plan has changed to TakeCare of Colorado,
Inc., from Lincoln National Health Plan. Prescription Medication Added=
Amendment I (Effective 1/1/92)
Rx 3 - 6825, Rx 5 - 6826, Rx 7 - 6649, Rx 10 - 6731
•
This amendment contains language that is to be added to your Prescription Medication
Addendum.
Section I of this Contract, entitled "Definitions"shall be modified by the following additions:
"Drug Formulary", if enacted, is a listing of Prescription Medications approved for
use by PLAN which may be dispensed through Participating Pharmacies to a Covered
Person. When designated by PLAN, a generic equivalent shall be dispensed. This
list shall be subject to periodic review and modification by PLAN.
Section X.E. of this Contract, entitled "Miscellaneous Health Services", shall he modiEed
by the following addition:
Prescription Medications shall, in all cases, be dispensed in generic equivalent for or in •
accordance with the PLAN Drag Formulary, if enacted, and as amended from time to time,
or upon PLAN approval.
A COVERED PERSON SHALL PAY TO A PARTICIPATING PHARMACY 100% OF
THE ADDITIONAL COST OF ANY PRESCRIPTION MEDICATION WHICH,AT THE
REQUEST OF THE COVERED PERSON OR PHYSICIAN, IS NOT DISPENSED
ACCORDING TO THE CURRENT PLAN DRUG FORMULARY, OR ITS GENERIC
EQUIVALENT, UNLESS APPROVED IN ADVANCE BY PLAN.
"ATIONAL HEALTH PLAN OF COLORADO
As of August 1, 1992 the name of our health
plan has changed to TakeCare of Colorado, EVIDENCE OF COVERAGE DESIGN IXA
Inc., from Lincoln National Health Plan.
Lincoln National Health Plan of Colorado (herein called PLAN)hereby agrees to provide the Health Services set forth
in this Evidence of Coverage,which details your rights and obligations as a PLAN Covered Person. It is important that
you READ YOUR EVIDENCE OF COVERAGE CAREFULLY and familiarize yourself with its terms and conditions.
CONTENTS
Section I
Definitions of Terms Used in this Evidence of Coverage 2
Section II
Enrollment and Effective Date of Individual Coverage 6
Section III
Procedures for Reimbursement of Eligible Expenses 7
Section IV
Coordination of Benefits and Subrogation 8
Section V
Complaint and Grievance Processes 11
Section VI
Termination of Individual Coverage 12
Section VII
Contract Charges 15
Section VIII
General Provisions 15
Section IX
Procedures for Obtaining Health Services 17
Section X
Schedule of Benefits and Exclusions 19
INTRODUCTION
PLAN hereby certifies that the Enrollee and the Enrollee's Enrolled Family Dependents,if any, for whom the required
Health Services Fee has been paid are entitled to Coverage under the Master Group Contract(referred to in this Evidence
of Coverage as the"Contract") designated on the identification card.
Coverage under PLAN is subject to the teens,conditions,exclusions,and limitations of the Contract. As an Evidence of
Coverage,this document summarizes the provisions of the Contract but does not constitute the Contract of Coverage.The
Contract may be examined by any Enrollee at the office of the Enrolling Unit during regular business hours.
This Evidence of Coverage replaces and supersedes any Evidence of Coverage which may have been previously issued
to the Enrollee by PLAN.
32" 070
6754 (10/91)
How to Use this Evidence of Coverage
This Evidence of Coverage should be read and re-read in its entirety. Many of the provisions of this Evidence of Cov-
erage are interrelated; therefore, reading just one or two provisions may give a misleading impression to the reader.
Many words used in this Evidence of Coverage have special meanings. These words will appear in capitals, and are
defined for you. By using these definitions, you will get the clearest picture of what is being said.
From time to time,the Contract may be amended.When that happens,a new Evidence of Coverage or Amendment pages
for this Evidence of Coverage will be sent to you.Your Evidence of Coverage should be kept in a safe place for your future
reference.
In order to avoid being faced with responsibility for payment of bills for non-covered services,you must always 1)make
certain that your Participating Primary Care Physician provides or arranges all of your Health Services,and 2)verify that
Health Services are rendered by Participating Providers or that a referral to a non-participating provider has been
authorized in writing by PLAN.This verification may be accomplished by asking the health care provider at the time an
appointment is scheduled, or by calling PLAN or the Participating Primary Care Physician.
Identification Card
Show your PLAN identification card every time you request health care services.If you do not,you may be responsible
for payment of bills sent by the health care provider.
If your Family Dependents are covered,you have received additional PLAN identification cards.Your identification card
is needed for your PLAN provider to bill PLAN and not you.
Section I
DEFINITIONS
"Acute Mental Disorder'means a condition determined by the Mental Health Provider to be psychological in nature,and
which has an immediate onset and a short duration.
"Addendum"means an attached description,if any,of Health Services covered only when such Addendum is signed by
PLAN, and subject to payment of additional Health Services Fees.
"Calendar Year"means the period from January 1 through December 31 of any year.
"Chemical Dependency Services"means services and supplies covered under the Contract for the diagnosis and treatment
of alcoholism and chemical or drug dependency as classified in the International Classification of Diseases of the U.S.
Department of Health and Human Services.
"Confinement" means an uninterrupted stay of more than eighteen (18) hours in a Hospital or Participating Skilled
Nursing Facility.
"Congenital Anomaly" means a defective development or formation of a part of the body which is determined by a
Physician to have been present at the time of birth.
"Contract"means the Master Group Contract, the application of the Enrolling Unit,Addenda, and amendments signed
by PLAN which constitute the agreement regarding the benefits,exclusions and other conditions between PLAN and the
Enrolling Unit.
"Contract Charge"means the sum of the Health Services Fee for all Enrollees and Enrolled Family Dependents.
"Contract Years" and"Contract Months"are determined from the effective date of the Contract.
"Copayment Charge"means the charge,in addition to the Health Services Fee,which the Covered Person is required to
pay for certain Health Services provided under the Contract.The Covered Person is responsible for the payment of any
-2 -
Copayment Charge directly to the provider of the Health Services at the time of service.The total Copayment Charges
paid by any Covered Person in any Contract Year may not exceed 200%of the total annual Health Services Fees paid to
PLAN during the same period on behalf of the Covered Person through the Enrolling Unit. In those cases where the
Enrollee has enrolled his or her Family Dependents with PLAN,the total Copayment Charges paid in any Contract Year
by all Covered Persons in the family unit shall not exceed 200%of the total annual Health Services Fees paid to PLAN
during the same period through the Enrolling Unit. The Enrollee is responsible for the recovery of excess Copayment
Charges. (See Section III.)
"Cosmetic Procedures" means those procedures which improve physical appearance, but which do not correct or
materially improve a physiological function, and are not Medically Necessary.
"Coverage"means the entitlement by a Covered Person to Health Services provided under the Contract, subject to the
terms, limitations, and exclusions of the Contract, and the following conditions: (a) Health Services must be provided
when the Contract is in effect; (b) Health Services must be provided prior to the date that any of termination conditions
two(2)through ten(10)of Section VI occur,and(c)Health Services must be provided only when the recipient is a Covered
Person, and meets all eligibility requirements as described in Section II.
"Covered Person"means either the Enrollee or an Enrolled Family Dependent,but applies only while Coverage of such
person under the Contract is in effect.
"Crisis Intervention" means short-term care for a condition which is determined by the Mental Health Provider to be
psychological in nature,and which has a sudden onset and inhibits the normal daily functioning of the individual.Crisis
Intervention services include evaluation and assistance to the individual in developing immediate coping skills.
"Custodial Care"means 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 to cure,
is provided in any setting,and may be provided between periods of acute or intercurrent health care needs.Custodial Care
is provided to an individual whose Health Service's requirements are stabilized and whose current medical condition is
not expected to significantly and objectively improve or progress over a specified period of time. The absence of such
improvement and progress will be based upon predictable medical outcome or objectively documented through periodic
assessment by licensed health professionals and Plan. 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 and 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.
"Dental Surgery,Treatment or Care"means all services provided by or under the direction of a Dentist,including but not
limited to any surgical procedure which involves the hand or soft tissues of the mouth.
"Dentist"means any doctor of dental surgery, "D.D.S.",who is duly licensed and qualified to provide Dental Surgery,
Treatment or Care under the law of jurisdiction in which treatment is received.
"Designated Organ Transplant Facility"means a Hospital named as such by PLAN,which has entered into an agreement
with or on behalf of PLAN to render Health Services for organ transplants which are not Experimental or Unproven and
which are covered under the Contract.
"Durable Medical Equipment"means medical equipment which can withstand repeated use and is not disposable,is used
to serve a medical purpose, is generally not useful to a person in the absence of a Sickness or Injury,and is appropriate
for use in the home.
"Eligible Expenses"are the fees established specific to the service area for Health Services covered under this Contract.
"Eligible Person" means an employee of the Enrolling Unit or other person who meets the eligibility requirements
specified in the application and the Contract, and who resides within the Service Area unless PLAN approves other ar-
rangements.Part-time employees(i.e.those employees who work or are scheduled to work less than 20 hours per week)
are not eligible unless prior approved in writing by the PLAN.Enrolled Eligible Persons who temporarily reside outside
of the Service Area shall be covered only for Health Services rendered by Participating Providers in the Service Area,
except in the event of an Emergency, or upon prior written approval by PLAN.
3 3ri3
"Emergency"means a serious medical condition resulting from Injury,Sickness,or Mental Illness which arises suddenly
and requires immediate care and treatment to avoid jeopardy to the life or health of a Covered Person.
"Emergency Health Services" means those Health Services and supplies necessary for the treatment of an Emergency,
which are generally provided no later than twenty-four (24) hours after the onset of an Emergency, subject to the
conditions and Copayment Charges as described in the Contract.
"Enrolled Family Dependent"means a Family Dependent who is enrolled for Coverage under the Contract.
"Enrollee"means an Eligible Person who is enrolled for Coverage under the Contract.
"Enrolling Unit" means the employer or other entity with whom the Contract is made.
"Experimental or Unproven Procedures" means medical, surgical or psychiatric procedures, treatments, devices and
pharmacological regimes(including investigational drugs and drug therapies)as determined by the medical community
at large, including but not limited to the Food and Drug Administration. PLAN reserves the right to change,from time
to time,the procedures considered to be Experimental or Unproven.Contact PLAN to determine if a particular procedure,
treatment, device, or pharmacological regime is considered to be Experimental or Unproven.
"Family Dependent"means a person who is(1)the Enrollee's legal spouse or(2)an unmarried dependent child(including
a stepchild,legally adopted child,or a child for whom the Enrollee has court-appointed guardianship and for whom the
Enrollee has legal or permanent parental responsibility and control)of either the Enrollee or the Enrollee's spouse,and
(3)whose principal place of residence is with the Enrollee unless PLAN approves other arrangements.Enrolled Family
Dependents who temporarily reside outside of the Service Area shall be covered only for Health Services rendered by
Participating Providers in the Service Area,except in the event of an Emergency,or upon prior written approval by PLAN.
The definition of"Family Dependent" is subject to the following conditions and limitations:
1. The term"Family Dependent" shall not include any unmarried dependent child 19 years of age or older,
2. The term"Family Dependent"shall not include any unmarried dependent child 19 years of age or older but less
than 23 years of age unless:
a. The child is not regularly employed on a full-time basis; and
b. The child is a Full-time Student and evidence satisfactory to PLAN is furnished upon request; and
c. The child is primarily dependent upon the Enrollee for support and maintenance and evidence satisfactory
to PLAN is furnished upon request; and
3. The Enrollee shall be responsible for any Health Services provided to the child at a time when the child did not
satisfy these conditions.The Enrolling Unit agrees to assist PLAN in obtaining reimbursement from the Enrollee
for such Health Services.
"Full-time Student"means a person who is enrolled and attending full-time in a recognized course of study or training
at:
1. an accredited high school or vocational school;
2. an accredited college or university; or
3. a licensed technical school,beautician school, automotive school, or similar training school.
A person ceases to be a Full-time Student at the end of the Contract Month during which the person graduates or
otherwise ceases to be enrolled and in attendance at the institution on a full-time basis. A person continues to be a
Full-time Student during periods of vacation established by the institution,unless the person does not continue as a
Full-time Student immediately following the period of vacation.
"Health Services"means the health care services and supplies covered under the Contract,except to the extent that such
health care services and supplies are limited or excluded under the Contract.
-4 - r e.270
"Health Services Fee" means the monthly fee required for each Enrollee and each Enrolled Family Dependent in
accordance with the terms of the Contract.
"Hospital means an institution 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 facili-
ties(including a surgical facility which has a bona fide arrangement,by contract 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, and is accredited as a Hospital by the Joint Commission on Accreditation of Healthcare
Organizations. 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.
"Initial Eligibility Period"means the period of time determined by PLAN and the Enrolling Unit during which Eligible
Persons may enroll themselves and Family Dependents under the Contract.
"Injury"means bodily damage other than Sickness(excluding medical malpractice),including all related conditions and
=current symptoms, not otherwise excluded under the Contract.
"Medical Director"means the Physician so named by PLAN as the Medical Director, or his or her designee.
"Medically Necessary"services means those Health Services which are determined by PLAN to be necessary to meet the
basic health needs of an individual. Determination of Medical Necessity is done on a case-by-case basis.The fact that a
Physician has performed or prescribed a procedure or treatment does not mean that it is Medically Necessary.In addition,
the service must(1) be consistent with the diagnosis of, and prescribed course of treatment for the patient's condition,
(2)be required for reasons other than the convenience of the patient or his or her Physician,or not be required solely for
custodial,comfort or maintenance reasons,and(3)be performed in the most cost efficient type of setting appropriate for
the condition.
"Medicare"means Part A and Part B of the insurance program established by Title XVIII,United States Social Security
Act, as later amended, 42 U.S.C. Sections 1394, et seq.
"Mental Health Provider"means the organization, entity or individual who has entered into a service agreement with
PLAN to arrange or provide the Mental Health Services and Chemical Dependency Services covered under the Contract.
"Mental Health Services"means those services and supplies covered under the Contract for the diagnosis and treatment
of Mental Illnesses which are classified in the International Classification of Diseases of the U.S. Department of Health
and Human Services.
"Mental Illness"means a physical or mental condition having an emotional or psychological origin or effect,including
alcoholism and chemical or drug dependency.
"Open Enrollment Period"means an annual period thirty-one(31) days in duration,subsequent to the Initial Eligibility
Period,determined by PLAN and the Enrolling Unit,during which Eligible Persons may enroll themselves and Family
Dependents under the Contract.
"Participating Alternate Facility"means a non-Hospital health care facility, or adjunct facility designated as such by a
Hospital which(1)provides one or more of the following services on an outpatient basis:prescheduled surgical services,
Emergency Health Services,urgent care services,or prescheduled rehabilitative,laboratory,or diagnostic services,and
(2) has entered into a service agreement with PLAN to provide Health Services to Covered Persons.
"Participating Home Health Agency"means a program which is(1)engaged in providing home health care services and
is authorized pursuant to the law of jurisdiction in which treatment is received,and(2)has entered into a service agreement
with PLAN to provide Health Services to Covered Persons.
"Participating Hospital" means a Hospital which has entered into a service agreement with PLAN to provide Health
Services to Covered Persons.
"Participating Physician"means any Physician who has entered into a service agreement with PLAN to provide Health
Services to Covered Persons.
e
"participating Primary Care Physician"means any Physician whose practice predominately includes pediatrics,internal
medicine, obstetrics/gynecology, or family or general medicine, and who has entered into a Primary Care Physician
service agreement with PLAN to provide Health Services to Covered Persons.
"Participating Provider"means a Participating Hospital,Participating Physician, and any other Health Service provider
who/which has entered into a service agreement with PLAN to provide Health Services to Covered Persons.
"Participating Skilled Nursing Facility"means a Hospital or nursing home facility which is(1)licensed and operated in
accordance with the law of jurisdiction in which treatment is received,(2)is Medicare approved,and(3)has entered into
a service agreement with PLAN to provide Health Services to Covered Persons.
"Physician"means any doctor of medicine,"M.D.",or doctor of osteopathy,"D.O.",who is duly licensed and qualified
under the law of jurisdiction in which treatment is received.
"Reasonable and Customary Charges"means fees for covered Health Services and supplies which do not exceed the fees
that the provider would charge any other payor for the same services.
"Reconstructive Surgery"means any Medically Necessary surgery which is incidental to an Injury,Sickness,or Congeni-
tal Anomaly and whose purpose is to restore normal physiological functioning to the involved part of the body.
"Semi-private Accommodations"means a room with two or more beds in a Hospital or Participating Skilled Nursing
Facility.
"Service Area" means the geographic area served by PLAN, as approved by regulatory agencies. Contact PLAN to
determine the precise geographic area served by PLAN.
"Sickness"means physical illness or disease, or pregnancy,but does not include Mental Illness.
Section II
ENROLLMENT AND Et rECTIVE DATE OF INDIVIDUAL COVERAGE
A. Enrollment
Eligible Persons may enroll themselves and their Family Dependents in PLAN during the Initial Eligibility Period
or during an Open Enrollment Period specified by LNHP by submitting application on a form provided or approved
by LNHP.In addition,new Eligible Persons may be enrolled in PLAN within 31 days of the date on which they first
become Eligible Persons,and new Family Dependents may be enrolled in PLAN within 31 days of the date on which
they first become Family Dependents,except that Family Dependents who are newborn children are covered at the
moment of birth. Except during the time periods set forth in this paragraph, Eligible Persons and/or Family
Dependents may not enroll in PLAN without the express written authorization of LNHP and evidence of insurability.
The Plan Sponsor shall notify PLAN in writing within sixty(60)days of the effective date of enrollments,terminations
or other changes;provided,however,that the Plan Sponsor shall notify LNHP in writing each month of any changes
in the Coverage classification of any Enrollee.
B. Effective Date of Coverage
Coverage for an Eligible Person and his or her Family Dependents,if any,is effective on the date specified by Plan
Sponsor and LNHP,provided that LNHP receives a properly completed individual enrollment application that was
submitted to LNHP according to the enrollment provisions of Section ILA of this booklet; and provided,however,
that:
1. No Coverage shall be effective until the PLAN takes effect;
2. No Family Dependent shall be covered under the PLAN until the Eligible Person is covered.
- 6 - ran., ^'a!
tifrfi1...A1 O ti
3. If an Enrollee acquires a new Family Dependent by reason of adoption or marriage,then Coverage for that Family
Dependent shall take effect on the date that the new Family Dependent is adopted or married,if LNHP and Plan
Sponsor is notified by the Enrollee of the adoption or marriage within thirty-one(31)days of occurrence;and any
necessary adjustments to Health Services Fees have been made.
4. If anEnrollee acquires anew Family Dependent who is a newborn child,then Coverage for that Family Dependent
shall take effect at the moment of birth and remain in effect for thirty-one(31)days beyond the date of birth.To
continue Coverage for that Family Dependent,the Enrollee shall notify LNHP and Plan Sponsor of the newborn
child's birth and the name; and make any necessary changes in the Coverage classification and Health Services
Fees.
5. Health Services for medical conditions arising prior to the effective date of Coverage and resulting in
Confinement are covered as of the effective date only if the Covered Person notifies LNHP of Confinement within
forty-eight(48)hours of the effective date,or as soon thereafter as is reasonably possible,and if Health Services
are received in accordance with the terms,conditions, exclusions and limitations of the PLAN.
Section III
PROCEDURES FOR REIMBURSEMENT OF ELIGIBLE EXPENSES
Reimbursement of Eligible Expenses
Plan Sponsor shall reimburse for Eligible Expenses incurred with non-participating providers only for MEDICALLY
NECESSARY EMERGENCY SERVICES OR SERVICES AUTHORIZED OR APPROVED BY LNHP in accordance
with the terms of the PLAN.
Participating Providers are responsible for submitting written proof of loss for Eligible Expenses directly to LNHP on the
Covered Person's behalf. In the event a Covered Person is billed by a Participating Provider for Eligible Expenses, the
Covered Person should contact LNHP.
Written proof of loss for services rendered by non-participating providers, satisfactory to LNHP, shall be furnished at
PLAN's office within ninety(90)days after the date of such loss.Failure to furnish proof within the time required shall
invalidate or reduce Coverage unless it was not reasonably possible to have given proof within ninety(90)days or,in the
absence of legal capacity of the Covered Person,later than one(1)year from the time in which proof is otherwise required.
All Eligible Expenses shall be paid within sixty(60)days of receipt by LNHP of proof of loss.Where applicable,Eligible
Expenses shall be paid to the Enrollee. Subject to written authorization from an Enrollee,all or a portion of any Eligible
Expenses due may be paid directly to the provider of the Health Services.
Copayment Reimbursement
The Plan Sponsor shall reimburse for amounts of Copayment Charges paid by any Enrollee in any Contract Year that
exceed 200%of the total annual Health Services Fees paid during the same period on behalf of the Enrollee.In those cases
where the Enrollee has enrolled his or her Family Dependents with LNHP,the Plan Sponsor shall reimburse for amounts
of Copayment Charges paid by all Covered Persons in the family unit in any Contract Year that exceed 200%of the total
annual Health Services Fees paid during the same period.
Written notice that excess amounts of Copayment Charges have been paid by the Enrollee or by all Covered Persons in
the same family unit must be sent to LNHP. Such notice must(1)include proof satisfactory to LNHP of the payment of
Copayment Charges,and(2)be provided to LNHP not later than ninety(90)days after the end of the Contract Year.The
amount of any excess Copayment Charges will be paid within sixty(60)days of receipt of written notice by Plan Sponsor
that excess Copayment Charges have been paid by Covered Persons.
Limitation of Actions
No action at law or in equity shall be brought to recover on the Contract by a Covered Person prior to the expiration of
sixty(60)days after proof of loss has been filed in accordance with the requirements of the Contract,nor shall such action
be brought at all unless brought within three (3) years after the time written proof of loss is required by the Contract
Section IV
COORDINATION OF BENEFITS AND SUBROGATION
Coordination of Benefits
A. Applicability
1. This coordination of benefits("COB")provision applies to This Plan when an Enrollee or the Enrollee's Enrolled
Family Dependents have health care coverage under more than one coverage plan. "Coverage plan"and"This
Plan" are defined below.
2. If this COB provision applies,the order of benefit determination rules should be looked at first.Those rules de-
termine whether the benefits of This Plan are determined before or after those of another coverage plan. The
benefits of This Plan:
(a) Shall not be reduced when,under the order of benefit determination rules,This Plan determines its benefits
before another coverage plan; but
(b) May be reduced when,under the order of benefits determination rules,another coverage plan determines its
benefits first. The above reduction is described in subsection D"Effect on the Benefits of This Plan."
B. Definitions
1. "Coverage plan"is any of these which provides benefits or services for,or because of,medical or dental cam or
treatment:
(a) Group insurance or group-type coverage, whether insured or uninsured. This includes prepayment, group
practice or individual practice coverage.It also includes coverage other than school accident-type coverage.
(b) Coverage under a governmental plan,or coverage required or provided by law.This does not include a state
plan under Medicaid (Tide XIX, Grants to States for Medical Assistance Programs, of the United States
Social Security act, as amended from time to time).
Each contract or other arrangement for coverage under(a) or(b) is a separate coverage 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 coverage
plan.
2. 'This Plan"is the part of this group Contract that provides benefits for health care expenses.
3. "Primary Plan/Secondary Plan": The order of benefit determination rules state whether This Plan is a Primary
Plan or Secondary Plan as to another coverage plan covering the person.
When This Plan is a Primary Plan,its benefits are determined before those of the othercoverage plan and without
considering the other coverage plan's benefits.
When This Plan is a Secondary Plan,its benefits are determined after those of the other coverage plan and may
be reduced because of the other coverage plan's benefits.
When there are more than two coverage plans covering the person,This Plan may be a Primary Plan as to one
or more other coverage plans, and may be a Secondary Plan as to a different coverage plan or plans.
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 coverage plans covering the person for whom the claim
is made.
The difference between the cost of private accommodations in a Hospital and the cost of Semi-private Accom-
modations in a Hospital 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
_ g n1 ^i
as specifically defined in the coverage plan.
When a coverage plan provides benefits in the form of services,the reasonable cash value of each service ren-
dered will be considered both an Allowable Expense and a benefit paid.
5. "Claim Determination Period"means a Calendar Year. However, it does not include any part of a year during
which a person has no Coverage under This Plan, or any part of a year before the date this COB provision or a
similar provision takes effect.
C. Order of Benefit Determination Rules
1. General. When there is a basis for a claim under This Plan and another coverage plan,This Plan is a Secondary
Plan which has its benefits determined after those of the other coverage plan, unless;
(a) The other coverage plan has rules coordinating its benefits with those of This Plan; and
(b) Both those rules and This Plan's rules,in subsection 2 below,require that This Plan's benefits be determined
before those of the other coverage plan.
2. Rules. This Plan determines its order of benefits using the first of the following rules which applies:
(a) Non-Dependent/Dependent. The benefits of the coverage plan which covers the person as an employee,
member or subscriber(that is,other than as a dependent) are determined before those of the coverage plan
which covers the person as a dependent.
(b) Dependent Child/Parents not Separated or Divorced.Except as stated in Paragraph(2)(c)below,when This
Plan and another coverage plan cover the same child as a dependent of different persons, called"parents":
(i) The benefits of the coverage plan of the parent whose birthday falls earlier in a year are determined before
those of the coverage plan of the parent whose birthday falls later in that year; but
(ii) If both parents have the same birthday,the benefits of the coverage plan which covered one parent longer
are determined before those of the coverage plan which covered the other parent for a shorter period of
time.
However,if the other coverage plan does not have the rule described in(i)immediately above,but instead
has a rule based upon the gender of the parent,and if,as a result,the coverage plans do not agree on the
order of benefits, the rule in the other coverage plan will determine the order of benefits.
(c) Dependent Child/Separated or Divorced.If two or more coverage plans cover a person as a dependent child
of divorced or separated parents, benefits for the child are determined in this order.
(i) First, the coverage plan of the parent with custody of the child;
(ii) Then, the coverage plan of the spouse of the parent with the custody of the child; and
(iii)Finally, the coverage 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 coverage plan are determined first. The coverage plan of the
other parent shall 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.
(d) Active/Inactive Employee. The benefits of a coverage 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 coverage plan
which covers that person as a laid off or retired employee(or as that employee's dependent).If the other cov-
erage plan does not have this rule,and if,as a result,the coverage plans do not agree on the order of benefits,
this rule (d) is ignored.
(e) Longer/Shorter Length of Coverage.If none of the above rules determines the order of benefits,the benefits
of the coverage plan which covered an employee,member or subscriber longer are determined before those
of the coverage plan which covered that person for the shorter term.
(f) No-Fault Automobile Insurance. Your benefits under this PLAN will be coordinated with minimum
coverages required under the Colorado Auto Accident Reparations Act (No-Fault).
WHAT IF YOU FAIL TO PURCHASE THE REQUIRED NO-FAULT COVERAGE ON YOUR AUTO-
MOBILE
The benefits of this PLAN will not be available to you to the extent of minimum benefits required by the"No-
Fault"Law for injuries suffered by you while operating or riding in a motor vehicle owned by you if said
vehicle is in operation on the public highways of this State and such vehicle is not covered by No-Fault
Automobile Insurance as required by Law.This denial of benefits does not apply to any other person injured
in a motor vehicle accident if the injured person is a non-owner operator,passenger or a pedestrian and such
other person is not covered by No-Fault Automobile Insurance.
D. Effect on the Benefits of This Plan
1. When This Subsection Applies. This subsection D applies when, in accordance with subsection C "Order of
Benefit Detennination Rules,"This Plan is a Secondary Plan as to one or more other coverage plans.In that event
the benefits of This Plan may be reduced under this subsection. Such other coverage plan or plans are referred
to as "the other coverage plans" in subsection 2 immediately below.
2. Reduction in This Plan's Benefits. The benefits of This Plan will be reduced when the sum of:
(a) The benefits that would be payable for the Allowable Expense under This Plan in the absence of this COB
provision; and
(b) The benefits that would be payable for the Allowable Expenses under the other coverage plans,in the absence
of provisions with a purpose like that of this COB provision, whether or not 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 coverage plans do not total more than those Allowable
Expenses.
When the benefits of This Plan are reduced as described above,each benefit is reduced in proportion. It is then
charged against any applicable benefit limit of This Plan.
E. Right to Receive and Release Needed Information
Certain facts are needed to apply these COB rules.PLAN has the right to decide which facts it needs. It may get needed
facts from or give them to any other organization or person.PLAN need not tell,or get the consent of,any person to do
this. Each person claiming benefits under This Plan must give PLAN any facts it needs to pay the claim.
F. Payments Made
A payment made under another coverage plan may include an amount which should have been paid under This Plan. If
it does,PLAN 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.PLAN 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.
G. Right of Recovery
If the amount of the payment made by PLAN is more than it should have been paid under this COB provision, it may
recover the excess from one or more of:
- 10-
32:_07:3
(b) The benefits that would be payable for the Allowable Expenses under the other coverage plans.in the absence
of provisions with a purpose like that of this COB provision, whether or not 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 coverage plans do not total more than those Allowable
Expenses.
When the benefits of This Plan are reduced as described above,each benefit is reduced in proportion. It is then
charged against any applicable benefit limit of This Plan.
E. Right to Receive and Release Needed Information
Certain facts are needed to apply these COB rules.PLAN has the right to decide which facts it needs.It may get needed
facts from or give them to any other organization or person.PLAN need not tell,or get the consent of,any person to do
this. Each person claiming benefits under This Plan must give PLAN any facts it needs to pay the claim.
F. Payments Made
A payment made under another coverage plan may include an amount which should have been paid under This Plan. If
it does, PLAN 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.PLAN 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.
G. Right of Recovery
If the amount of the payment made by PLAN is more than it should have been paid under this COB provision,it may re-
cover the excess front one or more of:
1. The persons it has paid or for whom it has paid:
2. Insurance companies: or
3. Other organizations.
The"amount of the payments made"includes the reasonable cash value of any benefits provided in the form of services.
Subrogation
PLAN shall be subrogated to,and shall succeed to all rights of recovery of any Covered Person from a third party,includ-
ing his or her employer,for the reasonable value of services provided under this Contract PLAN may require assignment
of the rights of recovery from the Covered Person,to the extent of the reasonable value of services and benefits provided
by it plus reasonable costs of collection.
The Covered Person shall cooperate with PLAN in protecting the PLAN's legal rights under these subrogation provisions
and acknowledges that PLAN's subrogation rights shall be considered as the first priority claim against any third parry,
to be paid before any other claims which may exist are paid,including claims for general damages by the Covered Person.
The Covered Person shall do nothing to prejudice PLAN's rights under this provision,either before or after the need for
services or benefits under this Contract.PLAN may, at its option. take necessary and appropriate action to preserve its
rights under these subrogation provisions,including the right to bring suit in the name of the Covered Person.PLAN may
collect, at its option, amounts from the proceeds of any settlement or judgment that may be recovered by the Covered
Person or his or her legal representative, regardless of whether or not the Covered Person has been fully compensated.
Any proceeds of settlement or judgment shall be held in trust by the Covered Person for the benefit of PLAN under these
subrogation provisions,and PLAN shall be entitled to recover reasonable attorney fees from the Covered Person incurred
in collecting proceeds held by the Covered Person.
a W, .d
Section V
COMPLAINT AND GRIEVANCE PROCESSES
the provision of Health Services or benefits under this Contract.a written If complaint concerning P the affected Coveted Person's legal guardian,or a verbal co Person mayhas a the affected Covered Person or by
complaint be made by
PLAN's Member Services Department. and attempt to resolve the verbal complaint
ant shall contact the complainant taint erbaltom
the complainant of the resolution of the verbal comp 1�,thirty-owhe or
The PLAN's Member Services Deparim with the resolution of the wed au��h infor-
mation informal discussions.itrce and shall Person is not satisfied m resew the t complaint ofth
she days equewing its writing,
the Member Services Department P
she may request. in PLAN's consideration
to the Member Relations Committee for further
are researched and reviewed by the Member Relations Commir-
the complainant f he resolution mmit-
tainand unresolved m to shall l complaints ipninant ofiheed the resolutn
ion
Written compreview this information and notify through the PLAN's siCommit-
tee.The Member Relations aetwritten
Committee laintwas first received.lf a C to overed
levels of appeal
by tt ems)days of rRel dotethewritten�eecomplainanthastheright
the Member Relations Committer.
formal grievance process.
Section VI
TERMINATION OF INDIVIDUAL COVERAGE
Termination Conditions including Coverage of the Covered Person under this Contract. Coverage for any Health Services rendered after the date
eons arising prior to the date of termination shall automatically terminate on the earliest
of termination.formedicalcoPdi
of the following dates:
1. The date this Contract is terminated• been paid.
2. The last day of the last Contact Month that the required Health Services Fee
has required Copayme°t Charge for Health Services rendered.the
pay a notice to the a for Healing th Such notice be
3. date the casespecified a Covered or feronmi °ho an Cto erage in written
provided byPLAN PLAN one(31) days in advance of such termination.
by at least thirty
notice to the Enrollee that all Coverage under this
wi terminate
4. The date the
Enrollee by PLAN in knowingly provided
rovi�PLAN with false.material information ngnt t not limited to,
because the aoherp Pt° eligibility for Coverage or status as aFamily Depew
person's eligi rY Family Dependent.
al
informationrrelai n to another Enrollee's
or that of any
information relating the Enrollee's health status
g• The date specified by PLAN or used
in written notice to the Enrollee that all Coverage under this Contract will terminate
Enrollee's identification card by any unauthorized person,
because the Enrollee permitted the use of the
another person's card. a The Enrolling Unit or Enrollee
longer in the PLAN Service Are • under this
6. The date a pon ible for f residence PLA is a provided PLAN
of a Covered Person's move from the Service Area.Coverage
shall ra responsible terminate notify g e or the
Contract will on the date of such move, even if such notice is not
termination of Coverage,7. The date the Enrolling Unit receives written notice from the Enrollee requesting
date requested by the Enrollee in such notice,if later. classification is specified for retired o.
•
8. The date the Enrollee is retired or pensioned,unless[o this specific
fiContracr-erage
pensioned individuals in the application attached notice to the Fsiioller that all Coverage uncle
cifiedby PLAN,aftezthitty-0er(31)dayspn°rwritten T^
this Contraa will terminate due to the failure of the Enrollee to establish and maintain a satisfactory provider-
paw=relationship with any Participating Provider.Termination of Coverage under this condition shall not occur
prior to the date that the Enrollee exercises his or her rights through the Complaint and Grievance Processes.
should the Enrollee choose to do so.
10. The last day of the Contract Month in which the Covered Person ceases to be eligible as an Enrollee or Enrolled
Family Dependent Under certain circumstances, Covered Persons who cease to be eligible for Coverage under
this Contract am entitled to continue Coverage under this Contract. as described below in "Continuation
Coverage."
Continuation Coverage
A Covered Person whose Coverage ends under this Contract is entitled to elect continuation of Coverage in accordance
with either Part I (Federal continuation)or Pan II (State continuation)of this subsection.The Covered Person should
contact the Enrolling Unit to determine whether Part I or Pan II is applicable.
Pant I: Continuation of Coverage Under Federal Law
A. Qualifying Events
The Covered Person's Coverage must have terminated due to one of the following Qualifying Events:
1. Termination of the Enrollee from employment with the Enrolling Unit.or reduction of bows,for any reason
other than gross misconduct
2. Death of the Enrollee;
3. Divorce or legal separation from the Enrollee:
4. Loss of eligibility by an Enrolled Family Dependent who is a child:
5. Entitlement of an Enrollee to Medicare benefits
6. The Enrolling Unit filing for bankruptcy.underTitle XI.United States Code.on or after July 1,1986.but only
for a retired Enrollee and his or her Enrolled Family Dependents.
A Covered Person who is totally disabled may extend continuation coverage it
a. it has been determined that the Covered Person is totally disabled for Social Security purposes; and
b. the Covered Person notifies the PLAN within 60 days of the date the determination is made by the Social
Security Administration.
The Covered Person must elect continuation during the election period,and payment of the Health Service Fees
is required. If the Covered Person elects continuation of Health Services,it must be the same Coverage that the
Covered Person had at the ante of the Qualifying Event
B. Notification Requirements and Election Period
The Covered Person must notify the Enrolling Unit's designated plan administrator within sixty(60)days when
divorce, legal separation, or loss of eligibility as an Enrolled Family Dependent would end Coverage. NOTE:
PLAN is not the Enrolling Unit's designated plan administrator.The Covered Person should consult his or her
Enrolling Unit.
In the case of an Enrollee's reduction of hours,termination of employment,death,or entitlement to Medicare.
the Enrolling Unit will notify its designated plan adtmmstator.
Within fourteen(14)days upon receiving such notification,the Enrolling Unit's designated plan administrator
will notify the eligible Covered Persons) of the right to elect continuation. and of the Health Service Fees re-
quired.
Continuation must be elected by the later of:
1. Sixty (60) days after the Covered Person's Coverage ends; or
2. Sixty(60)days after the Covered Person receives notice of the continuation right from the Enrolling Unit's
designated plan administrator. the initial Health Service
A Covered Person whose Coverage was terminated due to a Qualifying Event must pay
Fees due within forty-five (45) days after electing continuation.All other Health Service Fees after the initial
payment are due within the applicable grace period.
C. Terminating Events dates:
Continuation under this Contract will end on the earliest of the following a Covered Person whose Coverage ended because of
1. Eighteen(18)months from the date continuation began
for
Qualifying Event 1. whose coverage was extended2. Twenty-nine(29)months from the date continuation began
for Covered Persons
due to total disability. lied Family Dependent whose Coverage
3. Thirty-six (36) months from the date continuation began for an Enrolled
ended because of Qualifying Events 2.3.4 and 5.
4. The date Coverage terminates under the Contract for failure to make timely payment of the Health Services
n with a pre-existing is obtainedunnderanyothergrouphealthp»•Ex�t ,a C vered SPerso plan may LLg
5. The date coverage other employer sponsored condition which is limited or excluded under any
coverage• (except that this shall not apply in the event Covered care.6. The tin's the Coverage ag wasd teonin d because of Qualifntitled to ying Eve ).
Person's was terminated
7. The date the Contract ends.
If a second qualifying event occurs.the following rules apply
of continuation.and a second qualifying event occurs
may contind ti to. a maximum of (36) occurs
1. Ifduring a Covered Person is Covered dd ato eighteen Co e a)monthsup
that time.the Person's Coverage
from the date of Qualifying Event 1. dies during
tali eer thirty-six the
2. If a Covered Person is entitled to continuation due to Qualifying Event 6.and the retired Enrollee the
36)
continuation period.the Enrolled Family Dependents shall be entitled to continue Coverage
months from the date of death.Terminating Events 2 - 6 shall apply during the extended continuation period.
Part II: Continuation of Coverage Under State Law
under state law
iremtrac of may be entitled
lo to an alternative continuation COBRA when bow ale lat
An Enrollee whose Coverage ends under this Contract be entitled elect Coverage
if the Enrolling Unit is not subject to the requirements
and COBRA apply. The Enrollee shall not be entitled to cot
The Enrollee's Coverage must have ended due to tennination of employment
Urination Coverage under state law if:
7
a. Health Services Fees for Coverage up to the termination date have not been paid by or on behalf of the Enrollee:
or
b. the Enrollee has not been continuously covered under this Contract or under any coverage plan providing similar
coverage which this Contract replaced.for at least six(6)months immediately pnor to termination from employ-
ment: or
c. the Enrollee is covered by Medicate or Medicaid: or
d. the entire Contract is discontinued.
The Enrollee must elect continuation Coverage and pay Health Services Fees due within twenty(20)days from the date
of termination from employment
Coverage may be continued for enrollees working 40 hours or more when the working hours are reduced to less than 30
hours because of economic conditions.Coverage may also be continued for such enrollees enrolled family dependents.
Coverage may be continued provided:
1. the enrollee has been continuously covered under the Contract or under any coverage plan providing similar
coverage which the Contract replaced.for at least six(6)months immediately prior to the reduction in working
hours:
2. the enrolling unit has imposed the reduction in hours due to economic conditions:
3. the enrolling unit intends to restore the enrollee to a full 40 hour work schedule as soon as economic conditions
improve; and
4. the applicable Health services Fees are paid.
Continuation of Coverage under state law will aid after a period of ninety(90)days after the date Coverage would have
ended,or until the Enrollee is reemployed.whichever occurs first.At the end of the ninety(90))c aye continuationeun
under state law,the Enrollee or the Enrolled Family Dependents are entitled to conversion privileges
Conversion
A Covered Person who ceases to be eligible for PLAN Coverage for the reasons stated n r termination
oondit rosy or 10
above, or upon termination of continuation Coverage, and who continues evidence of insurability.ServiArema make
application to PLAN for coverage under a conversion contract without furnishing evidence
s after e e of Coverage
and payment of the initial Health Services Fees must be made within thirty
under this Contract.A conversion contract shall be issued in accordance with the terms and conditions in effect at the time
of application.
Out of Area Conversion
PLAN may designate a carrier to provide conversion membership to any Covered Person who ceases to be eligible for
PLAN Coverage for the reasons stated in termination conditions 6or10 above,and who nolonlgier resides
►within c
Service Area.Application to convert membership effective on the date
of
termina) tion,
aft wr ithout
furnishing
of shCoverage evidence of
insurability,must be made to the PLAN designated carrier within thirty
this Contract.A conversion contact may be issued in accordance with the terms and conditions the designated carrier may
have in effect at the time of application.
Section VII
CONTRACT CHARGES
Computation of Contract Charges
Each monthly Contract Charge shall be calculated on the basis of PLAN's record as to the number of Enrollees in each
Coverage classification at the time of calculation.
at Addenda.S
e. Fees then in effect The initial Health Services
and/ r any Fees are shown in the Master Group Application.
Adjustments to Contract Charges s in classifi-
cation or terminations of EnrolleesanPd�Howe Coverage e etclassiv-
ca Retroactive reflected
i adjustments P may S recordsbe made for any a is calculated Y
credtnotrbegrantd oranyc angecaurt rine nmotheConranCharg
credicshallbegantedforanychangeoccun'�gmorethansixty(60)days prior to the date PLAN was notified of the change
by the Enrolling Unit.
th Services Fees(1)on the due dateafteamend t Contract
PLAN reserves the right tod change the saher.or(2)on any datethat the provisions of thus Contract are nor d. tori the
monthl due date shall be • llin Unit at least thirty-one(31)days p
n
Year or on any monthly given by PLAN to the Enrolling notice of any such change in rates shall be
effective date of the change.
Payment of Contract Charges
All Contract Charges are payable monthly in advance by the Enrolling Unit to PLAN at its offices or at an address specified
by PLAN. Contract Charges are due
The first Contract Charge is due and payable on the effective date of this Contract.Subsequent� nffact
and payable no later than the first day of each.Contract Month thereafter shon Contract is in h Service Fee is due
and often re He thno Health Service Feefor
ir
I a month.
If
a Person's ed o is effective the 1st through the th 15th of the the month,
that month If a Covered Person's coverage is effective the 16th through
due until the following month He the
Covered Person:If a Covered Person's coverage terminates the 1st through u are of the the 15th of the month no month HeHe the
Service Fee is due for that month. If a Covered Person's coverage terminates the 16th through
gh
entire Health Service Fee is due for that month.
Grace Period during which time this Contract
A grace period of ten(10)days will be granted for the payment of any Contract Charga
shall continue in force. In no event shall any grace period extend beyond the date this Contract terminates.
Contract Termination- follow-
ing date of Coverage at 12:01 a.m.on the
i paid date of Charge. Should such day This the grace gr shall if the Enrolling oy terminateretroactivefails once i to the quiwithin PLAN'd su h Contract o toCharge
reinstate the
e
e y the period PL if the afterhc Unit period to remit the above.it will be totally
received by PLAN the grace outlined nittand terminate the group.
coverage or return the Contract Charge to the Enrolling
PLAN or Enrolling Unit may terminate this Contract for other than non-payment of Contract charge by giving the other
party written notice of termination thirty-one(31) days prior to the effective date of termination•revised in Section III
Termination of this Contract shall be without prejudice to any written proof of loss furnished as p
for Eligible Expenses for Health Services rendered prior to the effective date of termination.
Upon termination of this Contras. the Enrolling Unit shall be liable to PLAN for the payment of any and all Health
Services Fees which are accrued and unpaid at the time of termination.
1—
4-
Section VIII
GENERAL PROVISIONS
Entire Contract
The Master Group Contract. the application of the Enrolling Unit, any individual Enrollee applications.Addenda and
amendments shall constitute the entire Contract of Coverage between parties.All statements made by the Enrolling Unit
or by an Enrollee shall.in the absence of fraud, be deemed representations and not warranties.No such statement shall
void or reduce Coverage under this Contract or be used in defense of a legal action unless it is contained in a written
application.
Limitation of Actions
No action in law or equity may be brought against PLAN,or any officer,director,or employee of PLAN,by any Covered
Person with respect m any matter arising under this Contract or the relationship between that Covered Pelson and PLAN
without full and complete compliance with the complaint procedure set forth in Section V of this Contract nor shall such
action be brought at all unless brought within one(1)year from the date when the cause of action first arose.Written proofs
of loss furnished under Section III of this Contract are subject to the provisions regarding limitation of actions set forth
in that Section.
Time Limit on Certain Defenses
No statement,except a fraudulent statement.made by the Enrolling Unit shall ire used to void this Contact after it has
been in forte for a period of two(2) years.
Alterations
No alteration of this Contract and no waiver of any of its provisions shall be valid unless evidenced by an Addendum or
an amendment attached to this Contract which is signed by an executive officer of PLAN.No agent has authority w change
this Contact or to waive any of its provisions.
Minimum Number of Enrollees
For initial coverage.the minimum number of Eligible Persons selecting Health Services
the mpsticatihe number
at PLAN's
on the Application.The Enrolling Unit must maintain at least the number specified will A plbe caowed or te the individua.
N'
option this Contact may be terminated and conversion to an individual direct-pay plan
meets the conversion requirements outlined in this Contract and under applicable state law.
Relationships Between Panics
The relationships between PLAN and Participating Providers(except for the position of Medical Director),and betwee
PLAN and Enrolling Units are contractual relationships between independent contractors. Participating Providers an
Enrolling Units are not agents or employees of PLAN nor is PLAN or any employee of PLAN an agent or employee c
Participating Providers or Enrolling Units.
The relationship between a Participating Provider and any Covered Person is that of provider and patient.Tin
Panic
ic
paring Physician is solely responsible for the medical services provided to any Covered Person.The Participating l '"P
is solely responsible for the Hospital services provided to any Covered Person.
The relationship between any Enrolling Unit and any Covered Person is that of employer and employee,Family Depen
ent,or other Coverage classification as defined in this Contract.
The Enrolling Unit is solely responsible for providing written notice to PLAN of the enrollment and Coverage changr
including termination of a Covered Person's Coverage through PLAN, and the timely payment of Contract Charges
PLAN.
n.,._7
Assossissmanisw
Records documentation PLAN
The Enrolling Unit shall furnish PLAN with all information.authorization,and supporting nhed to the which PL Enrolling
may reasonably require with regard to any matters pertaining to this Contract.All documents furor
Unit by an individual in connection with the Coverage, and the Enrolling Unit's payroll and any other records pertinent
to the Coverage under this Contract shall be open for inspection by PLAN at any reasonable time.
Each Covered Person authorizes and directs any person or institution that has attended.examined or treated the Covered
Person,to furnish PLAN at any reasonable time.upon its request.any and all information and records or copies of records
relating to attendance.examination or treatment rendered to the Covered Person.PLAN agrees that such information and
records will be considered confidential.PLAN shall have the right to submit any and all records concerning episodes of
health care for Covered Persons to appropriate medical or other review bodies or individuals and/or Physicians.
Examination of Covered Persons payment for such services under this In rvices or C nther event f a may or dispute y require
equir that e a Coverion of Health ed Person be examined.at L 's expense.by a Participating
Contract.PLAN may also reasonably require
Physician acceptable to PLAN.
Clerical Error on of the date it is scheduled to terminate according to the terms of this Contract.
Clerical error shall not deprive any individual of Coverage under this Contract Failure to report the termination
Cov-
erage shall not discovery continue such Coverage beyond adjustment in Health Services Fees shall be made.However,no such
Upon s mnt in Health a Services ericcl Fees e•an appropriate by PLAN to the Enrolling Unit for more than sixty(60)
adjustment in or Coverage shall be granted
days of Coverage prior to the date PLAN was notified of such clerical error.
Notice notice to allaffected
e of the Enrolling Unit shall be deemed termination f this
Notice given PLAN to an authorized rev stration of this Contract. irritating
Enrollees and their Enrolled Family Dependents in the admini
Contract or the termination of individual Coverage.
Covered Benefits with this Contract except
In no event shall any Covered Person be responsible to pay for benefits received in accordance
as otherwise provided in this Contract.
Workers' Compensation Not Affected ants for coverage by Wolters'ct any ho provided under e. B Contract is not in lieu of s will not be denied toand does not a member hose employer has not complied with law and
Compensation goveminance• that such member has sought and received services
regulations governing-Workers Compensation Insurance,provided
under the provisions of this Contract.
Conformity with Statutes
Any provision of this Contract which,on its effective date.is in conflict with the statutes of the jurisdiction in which it
is delivered is hereby amended to conform to the minimum requirements of such statutes.
Non Discrimination
In compliance with federal and state law, PLAN shall not discriminate on the basis of age, sex, color, race, disability.
marital status, sexual preference. religious affiliation or public assistance status.
Section IX
PROCEDURES FOR OBTAINING HEALTH SERVICES
A. HEALTH SERVICES RENDERED BY PARTICIPATING PROVIDERS
Subject to the terms.conditions.exclusions.and limitations of this Contract.a Covered Person is entitled to age
described in Section X if such services (1) are authorized and determined to be Medically Necessary by
LAN a
(2) are provided by or referred by the Participating Primary Care Physician.
Each Covered Person shall select a Participating Primary Care Physician who shall be responsible for the coordination
of all Health Services rendered to the Covered Person and for ensuring continuity of care.Covered Persons who have
not selected a Participating Primary Care Physician within 31 days of enrollment may be assigned one by the PLAN.
The Participating Primary Care Physician shall refer the Covered Person only to Participating Providers.except as
provided in Section IX.B. All Health Services rendered to the Covered Person must be provided or referred by the
Participating Primary Care Physician. Health Services obtained by the Covered Person without referral by the
Participating Primary Care Physician are not covered.The fact that a Physician may prescribe.order. recommend.
approve or provide a service or supply does not,in and of itself.make the service or supply a covered Health Service.
Each Covered Person is responsible for verifying the participation status of the provider prior to receiving HealrequirHe forth
Services.These Health Services are subject to(1)payment by the Enrollee of the Health Services Fees for
under this Contract and(2) payment by the Covered Person of the Copayment Charge specified any
service.
LIMITATION ON SELECTION OF PROVIDER
In the case of a medical condition which significantly endangers either a Covered Person's health or the public health
the Covered Person may be required to receive all covered Health Services through a single PLAN Participatirr
Physician or network of Participating Providers designated by PLAN.
B. REFERRAL HEALTH SERVICES RENDERED BY NON-PARTICIPATING PROVIDERS
In the event that specific Health Services cannot be provided by or through a Participating Provider,a Covered Perso
shall be entitled to Coverage for Eligible Expenses for Medically Necessary Health Services obtained through nor.
participating providers. All such Health Services. including but not limited to Miscellaneous Health Service
identified in this Contract.must be authorized in writing in advance by PLAN. and are subject to all of the term,:
conditions.exclusions. and limitations of this Contract
IT IS THE COVERED PERSON'S RESPONSIBILITY TO VERIFY THAT THE REQUIRED WRTCTE-
APPROVAL FROM PLAN HAS BEEN GRANTED. PRIOR TO RECEIVING SERVICES FROM NO?
PARTICIPATING PROVIDER SHOULD THE COVERED PERSON RECEIVE CARE FROM A NON-PAT
TICIPATING PROVIDER,INCLUDING HOSPITALIZATION, WITHOUT THE REQUIRED APPROVAL B
PLAN, THE COVERED PERSON WILL BE RESPONSIBLE FOR ALL COSTS ASSOCIATED WITH THA
CARE. FAILURE OF PARTICIPATING PRIMARY CARE PHYSICIAN TO OBTAIN NECESSARY PRI(
APPROVAL FROM PLAN DOES NOT EXCUSE THE COVERED PERSON'S NSIBILITY TO VERT'
APPROVAL FROM PLAN BEFORE RECEIVING SERVICES FROM OR THROUGH NON-PARTICIPATE
PROVIDERS.
C. EMERGENCY HEALTH SERVICES
Covered Persons are directed to telephone their Participating Primary Care Physician whenever possible prior
p r.
receiving Emergency Health Services.PLAN will payEligible Expenses for Medically Necessary Emergency He
Services rendered to a Covered Person.subject to the terms,conditions,exclusions,and limitations of this achMeieontr
Emergency Health Services rendered by Participating Providers are subject to a Copayment Charge for
In order for Emergency Health Services rendered by non-participating providers to be covered under this Contr
the required Emergency Health Services must be(1)of such immediate nature that the Covered Person's life or he:
would be jeopardized if taken to a facility where the services of a Participating Physician would be available,or(2)
provided under circumstances in which the Covered Person is unable,due to unconsciousness
n ss r e inability
ould be available. Inthis
to be
rational.to request treatment at a location where the services of a Participating Necessary Emergency Health
case, Coverage is subject to a Copayment Chargefor each incident of Medically
Services rendered by a non-participating Pro
r.
The above Copayment Charges for Emergency Health Services rendered by either Participating Providers or by non-
participating providers are in addition to any other Copayment Charges which may apply to the Health Service. If,
however, a Covered Person is confined. the above Copayment Charge is waived, but the Copayment Charges
described in Section X.B.1. and X.E.2. shall apply.
The Covered Person must notify PLAN within forty-eight(48) hours after Emergency Health Services are initially
provided,or as soon thereafter as is reasonably possible.Full details of the Emergency Health Services received shall
be made available by the Covered Person at the request and PLAN.e pnor Continuation
written an�o care the of after shy require
coordination by the Participating PrimaryC Physician ng If the Covered Person is hospitalized,the PLAN may elect to transfer the Covered
Emergency t Health a Sepaatii ng Hospred
ospital
as soon as it is medically appropriate in the opinion of the attending Physician.
remain in non-participating o paz pating facility after P providers or in LAN has notified the ating facilities Co Covered Person of the intent to transfnot covered if the Covered feerthe Covered
Person to a Participating Provider facility.
ELIGIBLE EXPENSES FOR EMERGENCY HEALTH SERVICES
Eligible Expenses for Emergency Health Services are the Reasonable and Customary Charges for the Health Services
described in Section X of this Contract,provided during b course medical case of the Emergency,and
d when ica Medically NCCessary
y
for stabilization y r The n
of lSment until smustbepro dedbyorunderthedirearonofaPhysicianandaresubject
to Primary he Care Physician.n The Health ovisi Services of n a Services rendered on an Emergency basis are not
to the d i f,in pi other n PLAN. of this islater Contract.
Health to be non-emergency.This determination shall
covered if.in the opinion of PLAN.the situation is later determined
be based on generally accepted medical criteria.
D. SECOND OPINION POLICY econd Participating
Coverage of certain Health Services requires that the Covered Person obtain a cotn>lt�ith �e Co eied Persog
Physician prior to the scheduling of the Health Service.The Participating Physician
PLAN policy.ofThe Covered Person
that second opinions are implemented at the PLAN's discretion in accordance vines who authorizedon r render is then responsible for contacting PLAN to obtain a list of Participating are i with PLAN
second opinion and verify that the procedure or treatment referred for a second opinion with the AN
policy.The Enrollee will arrange a consultation with the second Participating Physician.not affiliated
first
Participating Physician.The consultation for the second opinion must occur within thirty-one(31)days of the first
opinion, or as soon thereafter as is reasonably possible. In the event that the second opinion differs from the first
opinion, the Covered Person may arrange for a third opinion.
Coverage is provided for second and third opinions if arranged through PLAN as described above.
Failure to comply with this procedure for obtaining a second opinion shall result in a total Copayment Charge of 40%
of Eligible Expenses.
E. COPAYMENT CHARGES
In the event that two (2) or more Copayment Charges apply to a single Health Service, all applicable Copayment
Charges shall apply,provided,however,that the total of all applicable Copayment Charges shall not exceed 40%of
Eligible Expenses for the single Health Service. (PLAN Enrollees who wish to ascertain the total dollar amount of
combined Copayment Charges may obtain such information from PLAN.)
n= • �. $
.7:t...:0t .
Section X
SCHEDULE OF BENEFITS
The amount paid by the Enrollee for Coverage under this Contract exclusive of Copayment Charges or charges for non-
covered services, is described in the Appendix.
A. PHYSICIAN SERVICES (except for those identified in Sections X.C and X.D of this Contract). when provided or
referred by the Participating Primary Care Physician. authorized by PLAN, and rendered through a Participating
Providerunless alternative arrangements have been authorized in advance by PLAN,or in the event of an Emergency:
1. Services and supplies provided in a Physician's office, including diagnostic ueatmem and preventive medical
care such as x-rays, electrocardiograms, electroencephalograms, and other clinical laboratory tests.well-baby
cart. physical examinations. voluntary family planning, application and removal of casts and dressings.
immunizations, and Medically Necessary therapeutic injections.
COPAYMENT CHARGE: $10.00 per visit during scheduled office hours or$25.00 after scheduled office
hours except for Copayment Charges required for specific services and supplies set forth below.
2. Eye exams,excluding refraction,provided in the Physician's office. (No limitation applies to Covered Persons
through the age of seventeen(17).)
COPAYMENT CHARGE: $10.00 per visit
Eye exams for refraction provided in a Participating Provider's office,limited to one(1)exam per Covered Person
per Calendar Year.
COPAYMENT CHARGE: $10.00 per visit
3. Physician surgical services and other medical care. including anesthesia. consultation with and treatment by
specialists, and services by surgical assistants only when authorized in advance by PLAN,when provided in a
Participating Physician's office.
COPAYMENT CHARGE:$10.00 per visit except for Copayment Charges for specific services and supplies
set forth in this contract
4. Allergy Testing and Treatment Services. No Coverage is provided for RAST testing,except when skin testing
is medically impossible.
COPAYMENT CHARGE: $10.00 per visit
5. Dermatology Services.
COPAYMENT CHARGE: $10.00 per visit
B. HOSPITAL AND RELATED SERVICES,when provided or referred by the Participating Primary Care Physician,
and authorized by PLAN:
1. Inpatient Services
Some Health Services rendered while confined are subject to separate benefit limitations, restrictions and/or
Copayment Charges, as described elsewhere in this Contract.
a. Room and Board
Unlimited Confinement.when Medically Necessary and approved by PLAN prior to admission in a Partici-
pating Hospital on a Semi-Private Accommodations basis.The difference in cost between Semi-private and
private mom accommodations will not be considered an Eligible Expense unless private accommodations
are Medically Ner nary, or unless Semi-private Accommodations are not available.
- 20- .52....ir `.3
Sar
COPAYMENT CHARGE: $100 per admission for non-surgical or surgical Health Services. Copay-
menu are limited to two(2)admissions per person per Calendar year.except copayments for transplant
services. In addition to the Copayment Charges listed elsewhere in this Contract, the following shall
apply when Health Services are rendered for organ transplants provided, however, that the total of all
applicable Copayment Charges shall not exceed 40%of Eligible Expenses for the Health Service.
5%of Eligible Expenses for kidney and corneal transplants in children and adults.liver transplants in chil-
dren with biliary atresia or children with other end stage liver disease.bone marrow transplants in chil-
dren and adults for the following diseases:
• Aplastic anemia
• Leukemia
• Severe combined immunodeficiency disease
and
• Wiskott-Aldrich syndrome
and any other transplants required by Federal or State Statutes and Regulations when Health Services are
rendered in a Designated Transplant Facility.
b. Other Inpatient Services and Supplies
Services and supplies provided while confined in a Participating Hospital as described in Section X.B.1.a of
this Contract. Services and supplies include nursing care.Medically Nei-nary meals and special diets.use
of operating morn and related facilities. use of intensive care unit and services,x-ray,laboratory and other
diagnostic tests, thugs, medications, biologicals. anesthesia and oxygen services. internal prosthetics.
Medically Necessary special duty nursing,radiation therapy,inhalation therapy,and administration of blood
and blood plasma,except that such services are subject to the terms,conditions,exclusions,and limitations
of this Contract
COPAYMENT CHARGE: $100 per admission for non-surgical or surgical Health Services. Copay-
mans are limited to two(2)adm1Csions per person per Calendar year.except copayments for transplant
services.In addition to the Copayment charges listed elsewhere in this Contract.the following shall apply
when Health Services are rendered for organ transplants provided.however,that the total of all applicable
Copayment Charges shall not exceed 40%of Eligible Expenses for the Health Service.
5%of Eligible Expenses for kidney and comeal transplants in children and adults,liver transplants in chil-
dren with biliary anesia or children with other end stage liver disease,bone marrow transplants in chil-
dren and adults for the following diseases:
• Aplastic anemia
• Leukemia
• Severe combined immunodeficiency disease
and
• Wiskott-Aldrich syndrome
and any other transplants required by Federal or State Statutes and Regulations when Health Services arc
rendered in a Designated Transplant Facility.
2. Outpatient Services and Supplies, at either Participating Hospital or Participating Alternate Facility and when
provided or referred by the Participating Primary Care Physician and authorized by PLAN.except in the event
of an Emergency. Emergency Health Services provided at or by nonparticipating facilities or providers are
covered subject to the terms, conditions. exclusions and limitations of this Contract. and when PLAN later
determines these Emergency Health Services to be Medically Necessary:
a. Emergency Services
1) Services and supplies for stabilization or initiation of treatment of Emergency conditions•rendered on
an outpatient basis in an emergency mom of a HospitaL
- 21 - 3 21J7
COPAYMENT CHARGE:$50.00 per visit except the the Copayment Charge described in Section
X.B.1.a or X.E.2 will apply when the Emergency condition directly results in Confinement.
2) Services and supplies for stabilization or initiation of treatment of Emergency conditions, rendered on
an outpatient basis in a physician's office or urgent care facility.
COPAYMENT CHARGE: $25.00 per visit, except the Copayment Charge described in Section
X.A.1 will apply when services are rendered by a Primary Care Physician during regularly scheduled
office hours.
b. Non-Emergency Services
1) Physician surgical services,supplies and other medical can:,including anesthesia,consultation with and
treatment by specialists,and services by surgical assistants only when authorized in advance by PLAN,
for prescheduled outpatient surgery provided at a Participating Hospital or Participating Alternate
Facility.
COPAYMENT CHARGE: $50.00 per outpatient surgery
2) Prescheduled diagnostic and therapeutic services,including x-ray,radiation therapy and laboratory tests
and services, provided at a Participating Hospital or Participating Alternate Facility.
COPAYMENT CHARGE: $10.00 per visit
C. MATERNITY, FAMILY PLANNING AND INFERTILITY SERVICES
For the purposes of this subsection, maternity and obstetrical care shall mean pre- and post-partum care during
pregnancy, childbirth.early termination of pregnancy, or any associated complications.
1. Services,equipment and supplies provided on an inpatient or outpatient basis for obstetrical care of the mother
before and during delivery and during the post-parwm period. including Physician services. operations and
special procedures such as Caesarean sections,Hospital services,including use of the delivery room.x-ray and
laboratory, injectable substances and anesthesia. Unless authorized in writing and in advance, obstetrical and
neonatal care provided outside of the Service Area will not be covered if such care is rendered during the normal
delivery period.The normal delivery period is the three to five week period prior to the expected delivery date.
COPAYMENT CHARGE: $10.00 per outpatient visit,and inpatient services- same as X.B.1.
2. Services and supplies provided on an inpatient or outpatient basis for family planning counseling and treatment.
including infertility evaluation,birth control counseling and treatment,certain intrauterine devices,measurement
for contraceptive diaphragms,voluntary male or female surgical sterilization,and up to two(2)elective abortions
per lifetime if performed within ten(10)weeks of conception.(Donor semen for artificial insemination,in vitro
fertilization,embryo transport procedures,surrogate parenting,and outpatient injectable substances and supplies
related to infertility are not covered.)
COPAYMENT CHARGE: $10.00 per outpatient visit, and inpatient services same as X.B.1.
D. MENTAL HEALTH SERVICES AND CHEMICAL DEPENDENCY SERVICES
The following Health Services are covered only when provided or referred by PLAN's Mental Health Provider.
1. Inpatient and outpatient Health Services for detoxification of chemical dependency, without limitation. Health
Services otherwise covered under this Contract for the treatment of medical complications of chemical
dependency are described in Sections X.A. and X.B. of this Contract.
2. Inpatient Mental Health. Coverage,up to a maximum of forty-five(45)full days or ninety(90)partial days per
Calendar Year,for inpatient Semi-private Accommodations,or private when Medically Necessary, for Mental
Health Services when provided by the Mental Health Provider in a Participating Hospital or Participating
- 22 - 5v_.✓-I ;3
Alternate Facility."Partial Days"means neamtem for at least three(3)hours but not mote than twelve(12)hours
in a 24-hour period.
COPAYMENT CHARGE:The first day's Copayment Charge is the same as specified in Section X.B.l.a plus
S25.00 per day thereafter.
3. Inpatient Chemical Dependency. Coverage for Semi-private accommodations, or private when Medically
Necessary, for a maximum of twenty-one (21) days per Calendar Year and two (2) Confinements per lifetime,
for treatment of alcoholism or chemical dependency when authorized in writing in advance by the Mental Health
Provider, and provided in an inpatient treatment facility designated by PLAN. Covered Person must complete
prescribed and approved course of treatment of PLAN to be responsible for payment.
COPAYMENT CHARGE:The first day's Copayment Charge is the same as specified in Section X.B.1.aplus
$25.00 per day thereafter.
4. Outpatient Mental Health and Chemical Dependency Services are provided when furnished by the Mental Health
Provider.
COPAYMENT CHARGE: No charge per visit. The full Reasonable and Customary Charge for each
appointment broken less than twenty-four(24) hours prior to the time of scheduled visit.
E. MISCELLANEOUS HEALTH SERVICES
THE FOLLOWING HEALTH SERVICES ARE COVERED PROVIDED THAT SUCH HEALTH SERVICES
(EXCEPT EMERGENCY SURFACE AMBULANCE SERVICE) ARE (A) ORDERED, PROVIDED, OR AR-
RANGED BY OR UNDER THE DIRECTION OF THE PARTICIPATING PRIMARY CARE PHYSICIAN AND
(B) APPROVED IN WRITING IN ADVANCE BY PLAN AND (C) OBTAINED THROUGH A VENDOR OR
PROVIDER SELECau BY PLAN MANAGEMENT.
I. Home Health Agency and Private Duty Nursing Services
Intermittent Health Services of a Participating Home Health Agency,and private duty nursing care,by,or under
the supervision of, a registered nurse, in a Covered Person's home, required for care and treatment which
otherwise would require Confinement in a Participating Hospital or Participating Skilled Nursing Facility.
Covered Health Services include diagnostic and therapeutic nursing services and Physician home visits within
the Service Area.
COPAYMENT CHARGE: No charge per visit
2. Skilled Nursing Facility
Up to sixty-two(62)days of Medically Necessary Confinement(Semi-Private Accommodations unless private
accommodations are Medically Necessary)and medical services and supplies and equipment ordinarily provided
in a Participating Skilled Nursing Facility for the care and treatment of an acute Injury or Sickness,and which
otherwise would require Confinement in a Participating Hospital.Some Health Services rendered while confined
are subject to separate benefit limitations,restrictions and/or Copayment Charges,as described elsewhere in this
Contract.
COPAYMENT CHARGE: No charge per confinement
3. Ambulance Services
Medically Necessary ambulance transportation is covered if approved in advance by PLAN or when PLAN
determines after the transportation is provided that the transportation was Medically Necessary. Ambulance
transportation provided due to the absence of other medically appropriate forms of transportation is not covered.
a. Emergency surface ambulance transportation by a licensed ambulance service to the nearest Hospital where
Emergency care and treatment can be rendered.
-23 - 3 '.' :':`"n
COPAYMENT CHARGE: $30.00 per trip
b. Non-emergency surface ambulance transportation when referred by the Participating Primary Cam Physician
and approved in writing in advance by PLAN.
COPAYMENT CHARGE: $30.00 per trip
c. Air ambulance transportation only when medically appropriate surface ambulance transportation is not
available.
COPAYMENT CHARGE: $30.00 per trip
4. Rehabilitation Services
Short term inpatient or outpatient, whichever is Medically Necessary,rehabilitative services(physical therapy,
occupational therapy,and speech therapy)performed at a Participating Hospital or Participating Skilled Nursing
Facility, or through Participating Home Health Agency,or other Participating Provider. Rehabilitation services
are limited to services which, in the judgment of the Participating Primary Cam Physician and PLAN, are
Medically Necessary and will result in significant improvement of a Covered Person's condition through short
term therapy. (Short term means that significant improvement is anticipated within two (2) months of start of
treatment)All combined rehabilitation services are limited to a sixty-two(62)day period per Sickness episode,
beginning with the first day of treatment.
COPAYMENT CHARGE: $10.00 per outpatient visit and No Charge per Confinement
5. Blood and Blood Products
The administration of prescribed blood transfusions,including supplies and equipment used in the administration
of blood,and blood products and derivatives if such products and derivatives am replaced in accordance with the
blood bank's requirements.Coverage is provided for the drawing and storing of the Covered Person's blood for
use by the Covered Person only for blood units used as replacement therapy for Medically Necessary treatment
of conditions while the Covered Person is covered under this Contract
COPAYMENT CHARGE: No Charge
6. Tempommandibular Joint Syndrome
Treatment of temporomardibular joint syndrome as a result of trauma: fracture of the jaw or laceration of the
mouth,tongue,or gums is covered. Health Services and supplies provided for the treatment of temporomandi-
bular joint syndrome are covered only when performed by a PLAN-designated Physician or oral surgeon.
COPAYMENT CHARGE: 40% of Eligible Expenses
7. Hemodialysis
Services and supplies, subject to approval by PLAN and a determination that the Covered Person meets PLAN
medical criteria,when provided in a Participating Hospital or Participating Alternate Facility,for dialysis for end
stage renal disease (ESRD), and services and supplies for renal conditions.
COPAYMENT CHARGE: $10.00 per hemodialysis treatment
'1 4
GENERAL EXCLUSIONS
The following are not covered:
1. Dental Surgery, Treatment or Care (including such for overbite or underbite, maxillary and mandibulary
osteotomies. and orthognathic conditions, whether or not related to temporomandibular joint dysfunction), or
dental x-rays,supplies and appliances(including occlusal splints)and all associated expenses arising out of such
Dental Surgery,Treatment or Care including hospitalizations. Hospital and Physician services and supplies and
anesthesiology services referred by the Participating Primary Care Physician and approved in writing in advance
by PLAN, for the correction of cleft lip or cleft palate which has been diagnosed as a Congenital Anomaly in
newborn children,or as are necessary to safeguard the health of a Covered Person because of a specific non-dental
physiological impairment are covered. Dental Services required due to trauma are limited to functional
restoration of structures other than teeth.Treatment of trauma resulting in fracture of the jaw or laceration of the
mouth, tongue, or gums is covered.
2. Health Services and associated expenses for temporomandibular joint syndrome.except as described in X.E.6.
3. Custodial Care, domiciliary care, respite care or rest cures.
4. Health Services and associated expenses for Cosmetic Procedures including,but not limited to.pharmaceutical
regimes, nutritional procedures or treatments. plastic surgery, including reduction mammoplasty, and recon-
structive mammoplasty,except when the original mastectomy was performed while the person was covered under
this Contract. (Medically Necessary reconstructive surgery is not excluded.)
5. Health Services and associated expenses for Experimental or Unproven Procedures.treatments,devices or phar-
macological regimes.
6. Health Services and associated expenses for organ transplants, except for those transplants stated as covered
under Section X,B,1.,a.and b.unless covered through an addendum to this Contract.Liver transplants in adults
are NOT covered. Bone marrow transplants are NOT covered for conditions other than those listed in Section
X,B,I. a. and b.
7. Health Services and associated expenses for in vitro fertilization, embryo transport. Gamete Intra-Fallopian
Transfer, surrogate parenting, donor semen,outpatient injectable substances and supplies related to infertility,
elective abortions when performed beyond the tenth week of pregnancy,or elective abortions in excess of two
(2) per lifetime, home childbirth, and non-Medically N- ecsary amniocentesis.
8. Health Services not authorized by PLAN or not Medically Necessary, or not provided or referred by the
Participating Primary Care Physician,except in Emergency situations (described in Section IX.C.)
9. Hearing aids,cochlear implant devices and implant procedures.eye glasses,contact lenses and the fitting thereof.
unless covered through an Addendum to this contract.
10. Personal comfort and convenience items or services obtained or rendered in or out of the Hospital or any facility,
such as television,telephone,barber or beauty service,guest service and similar incidental services and supplies
which are not Medically Necessary.
11. Mental Health Services, which are (a) rendered in connection with Mental Illnesses not classified in the
International Classification of Diseases of the U.S.Department of Health and Human Services,or(b)for any of
the following: learning, behavioral or developmental disabilities, mental retardation or autism. marriage
counseling, counseling or therapy for weight reduction, behavioral training, personal growth, lifestyle or
vocational counseling, biofeedback,pain control,hypnosis, sexual dysfunction or inadequacy, transsexualism,
early infant stimulation,or psychotherapy credited toward earning a degree or required for educational purposes.
12. Services rendered by a provider with the same legal residence as a Covered Person, or who is a member of a
Covered Person's family, including spouse. brother,sister, parent, or child.
- 25 -
13. Physical.psychiatric,or psychological examinations or testing,or vaccinations.immunizations,or treatments not
otherwise covered under this Contract,when such services are for purposes of obtaining,maintaining orothetwise
relating to employment or insurance,marriage or adoption,or relating to judicial or administrative proceedings
or orders,or which are conducted for purposes of medical research,or to obtain or maintain a license of any type.
14. Travel or transportation expenses (except ambulance service as specifically provided in this Contract) even
though prescribed by a Physician.
15. Health Services and associated expenses for outpatient Hospital and Hospital emergency room or Participating
Alternative Facility services obtained during normal Physician office hours (unless necessary because of an
Emergency),except as specified in Section X.B.2.b,or when authorized in advance in writing by the Participating
Primary Care Physician or PLAN.
16. Prosthetic devices.Durable Medical Equipment,and appliances,and personal comfort items.including air con-
ditioners,even though prescribed by a Physician,unless covered through an Addendum to this Contract or when
such devices,equipment or appliances are medically necessary for outpatient care in lieu of hospitalization or an
integral part of a case management plan.
17. Health Services and associated expenses for surgical procedures and associated Health Services intended
primarily for the treatment of morbid obesity, including gastric bypasses, gastric balloons, stomach stapling,
wiring of the jaw,jejunal bypasses. and Health Services of a similar nature. unless Medically Necessary.
18. Health Services and associated expenses for sex transformation operations and for reversal of voluntary
sterilization.
19. Health Services otherwise covered under this Connact related to a specific condition or treatment when a Covered
Person has terminated the specific scheduled service or treatment against the advice of a Physician,or has left
a Hospital or inpatient facility against medical advice.
20. Health Services for military service connected disabilities for which the Covered Person is legally entitled to
services and for which facilities are reasonably available to the Covered Person.
21. Health Services and associated expenses for megavitamin therapy,psychosurgery,radial keratotomy,nutritional
based therapy for alcoholism or other chemical dependency. salabrasion, chemosurgery or other such skin
abrasion procedures associated with the removal of scars,tattoos.actinic changes and/or which are performed
as a treatment for acne,RAST testing,except with skin testing is medically impossible.acupuncture,services or
treatment for sleep apnea,or chelation therapy,unless Medically Necessary for the treatment of metal poisoning.
22. Health Services provided by a chemical dependency neatment or rehabilitation ro 'except as described in
Section X.D.,or unless covered through an Addendum to this Contract. p
23. Prescription Medications for outpatient treatment.unless covered through an Addendum, to this.Contract.
24. Health Services otherwise covered under this Contract,but rendered after the date individual Coverage under this
Contract terminates, including Health Services for medical conditions arising prior to the date individual
Coverage under this Contract terminates.
25. Medical supplies,oxygen,blood, blood derivatives and fees for blood replacement,and penile implant devices
and procedures,except as described in Section X.E.5.,or unless covered through an Addendum to this Contract.
26. Outpatient nutritional and dietary services in the absence of a physiological disease condition.
- 26- 3n'070
1. The persons it has paid or for whom it has paid;
2. Insurance companies; or
3. Other organizations.
The"amount of the payments made"includes the reasonable cash value of any benefits provided in the form of services.
Subrogation
PLAN shall be subrogated to,and shall succeed to all rights of recovery of any Covered Person from a third party,including
his or her employer, for the reasonable value of services provided under the Contract. PLAN may require assignment of
the rights of recovery from the Covered Person, to the extent of the reasonable value of services and benefits provided
by it plus reasonable costs of collection.
The Covered Person shall cooperate with PLAN in protecting the PLAN's legal rights under these subrogation provisions
and acknowledges that PLAN's subrogation rights shall be considered as the first priority claim against any third party,
to be paid before any other claims which may exist are paid,including claims for general damages by the Covered Person.
The Covered Person shall do nothing to prejudice PLAN's rights under this provision,either before or after the need for
services or benefits under the Contract. PLAN may, at its option,take necessary and appropriate action to preserve its
rights under these subrogation provisions,including the right to bring suit in the name of the Covered Person.PLAN may
collect, at its option, amounts from the proceeds of any settlement or judgment that may be recovered by the Covered
Person or his or her legal representative, regardless of whether or not the Covered Person has been fully compensated.
Any proceeds of settlement or judgment shall be held in trust by the Covered Person for the benefit of PLAN under these
subrogation provisions,and PLAN shall be entitled to recover reasonable attorney fees from the Covered Person incurred
in collecting proceeds held by the Covered Person.
Section V
COMPLAINT AND GRIEVANCE PROCESSES
If a Covered Person has a complaint concerning the provision of Health Services or benefits under the Contract,a written
or verbal complaint may be made by the affected Covered Person or by the affected Covered Person's legal guardian,to
PLAN's Member Services Department.
The PLAN's Member Services Department shall contact the complainant and attempt to resolve the verbal complaint
through informal discussions,and shall notify the complainant of the resolution of the verbal complaint within thirty-one
(31) days following its receipt. If the Covered Person is not satisfied with the resolution of the verbal complaint, he or
she may request, in writing,the PLAN's Member Services Department to present the complaint and all research infor-
mation to the Member Relations Committee for further consideration.
Written complaints and unresolved verbal complaints are researched and reviewed by the Member Relations Committee.
The Member Relations Committee shall review this information and notify the complainant of the resolution within sixty
(60) days of the date the written complaint was first received. If the Covered Person is not satisfied with the resolution
by the Member Relations Committee, the complainant has the right to successive levels of appeal through the PLAN's
formal grievance process.
2'1
Section VI
TERMINATION OF INDIVIDUAL COVERAGE
Termination Conditions
Coverage of the Covered Person under the Contract,including Coverage for any Health Services rendered after the date
of termination,for medical conditions arising prior to the date of termination,shall automatically terminate on the earliest
of the following dates:
. The date the Contract is terminated.
2. The last day of the last Contract Month that the required Health Services Fee has been paid.
3. In the case of a Covered Person who fails to pay a required Copayment Charge for Health Services rendered,the
date specified by PLAN for termination of Coverage in written notice to the Enrolling Unit.Such notice shall be
provided by PLAN at least thirty-one (31) days in advance of such termination.
4. The date specified by PLAN in written notice to the Enrollee that all Coverage under the Contract will terminate
because the Enrollee knowingly provided PLAN with false,material information,including,but not limited to,
information relating to another person's eligibility for Coverage or status as a Family Dependent;or false,ma-
terial information relating to the Enrollee's health status or that of any Family Dependent.
5. The date specified by PLAN in written notice to the Enrollee that all Coverage under the Contract will terminate
because the Enrollee permitted the use of the Enrollee's identification card by any unauthorized person,or used
another person's card.
6. The date a Covered Person's residence is no longer in the PLAN Service Area.The Enrolling Unit or Enrollee
snail be responsible for notifying PLAN of a Covered Person's move from the Service Area.Coverage under the
Contract will terminate on the date of such move, even if such notice is not provided to PLAN.
7. The date the Enrolling Unit receives written notice from the Enrollee requesting termination of Coverage,or the
date requested by the Enrollee in such notice, if later.
8. The date the Enrollee is retired or pensioned,unless a specific Coverage classification is specified for retired or
pensioned individuals in the application attached to the Contract.
9. The date specified by PLAN,after thirty-one(31)days prior written notice to the Enrollee,that all Coverage under
the Contract will terminate due to the failure of the Enrollee to establish and maintain a satisfactory provider-
patient relationship with any Participating Provider.Termination of Coverage under this condition shall not occur
prior to the date that the Enrollee exercises his or her rights through the Complaint and Grievance Processes,
should the Enrollee choose to do so.
10. The last day of the Contract Month in which the Covered Person ceases to be eligible as an Enrollee or Enrolled
Family Dependent. Under certain circumstances, Covered Persons who cease to be eligible for Coverage under
the Contract are entitled to continue Coverage under the Contract, as described below in "Continuation
Coverage."
Continuation Coverage
A Covered Person whose Coverage ends under the Contract is entitled to elect continuation of Coverage in accordance
with either Part I (Federal continuation) or Part II (State continuation) of this subsection. The Covered Person should
contact the Enrolling Unit to determine whether Part I or Part II is applicable.
Part I: Continuation of Coverage Under Federal Law
A. Qualifying Events
The Covered Person's Coverage must have terminated due to one of the following Qualifying Events:
,n `van
- 12 - '•i
1. Termination of the Enrollee from employment with the Enrolling Unit,or reduction of hours,for any mason
other than gross misconduct;
2. Death of the Enrollee;
3. Divorce or legal separation from the Enrollee;
4. Loss of eligibility by an Enrolled Family Dependent who is a child;
5. Entitlement of an Enrollee to Medicare benefits;
6. The Enrolling Unit filing for bankruptcy, under Tide XI, United States Code,on or after July 1, 1986, but
only for a retired Enrollee and his or her Enrolled Family Dependents.
A Covered Person who is totally disabled may extend continuation coverage if:
a. it has been determined that the Covered Person is totally disabled for Social Security purposes; and
b. the Covered Person notifies the PLAN within 60 days of the date the determination is made by the Social
Security Administration.
The Covered Person must elect continuation during the election period,and payment of the Health Service Fees
is required. If the Covered Person elects continuation of Health Services,it must be the same Coverage that the
Covered Person had at the time of the Qualifying Event.
B. Notification Requirements and Election Period
The Covered Person must notify the Enrolling Unit's designated plan administrator within sixty(60)days when
divorce, legal separation,or loss of eligibility as an Enrolled Family Dependent would end Coverage. NOTE:
PLAN is not the Enrolling Unit's designated plan administrator.The Covered Person should consult his or her
Enrolling Unit.
In the case of an Enrollee's reduction of hours,termination of employment,death,or entitlement to Medicare,
the Enrolling Unit will notify its designated plan administrator.
Within fourteen(14)days upon receiving such notification, the Enrolling Unit's designated plan administrator
will notify the eligible Covered Person(s) of the right to elect continuation, and of the Health Service Fees
required.
Continuation must be elected by the later of:
1. Sixty (60) days after the Covered Person's Coverage ends; or
2. Sixty (60) days after the Covered Person receives notice of the continuation right from the Enrolling
Unit's designated plan administrator.
A Covered Person whose Coverage was terminated due to a Qualifying Event must pay the initial Health Service
Fees due within forty-five(45) days after electing continuation. All other Health Service Fees after the initial
payment am due within the applicable grace period.
C. Terminating Events
Continuation under the Contract will end on the earliest of the following dates:
1. Eighteen(18)months from the date continuation began for a Covered Person whose Coverage ended because
of Qualifying Event 1.
2. Twenty-nine (29) months from the date continuation began for Covered Persons whose coverage was
extended due to total disability.
13 - Jr, Ai
I
3. Thirty-six(36)months from the date continuation began for an Enrolled Family Dependent whose Coverage
ended because of Qualifying Events 2, 3,4 and 5.
4. The date Coverage terminates under the Contract for failure to make timely payment of the Health Services
Fee.
5. The date coverage is obtained under any other group health plan. Except that,a Covered Person with a pre-
existing condition which is limited or excluded under any other employer sponsored group health plan may
continue coverage.
6. The date the Covered Person becomes entitled to Medicare, (except that this shall not apply in the event
Covered Person's Coverage was terminated because of Qualifying Event 6).
7. The date the Contract ends.
If a second qualifying event occurs, the following rules apply:
1. If a Covered Person is entitled to eighteen(18)months of continuation,and a second qualifying event occurs
during that time,the Covered Person's Coverage may be extended up to a maximum of thirty-six(36)months
from the date of Qualifying Event 1.
2. If a Covered Person is entitled to continuation due to Qualifying Event 6,and the retired Enrollee dies during
the continuation period, the Enrolled Family Dependents shall be entitled to continue Coverage for thirty-
six (36)months from the date of death.
Terminating Events 2 - 6 shall apply during the extended continuation period.
Part II: Continuation of Coverage Under State Law
An Enrollee whose Coverage ends under the Contract may be entitled to elect continuation Coverage under state law,if
the Enrolling Unit is not subject to the requirements of COBRA,or as an alternative to COBRA when both state law and
COBRA apply.
The Enrollee's Coverage must have ended due to termination of employment. The Enrollee shall not be entitled to
continuation Coverage under state law if:
a. Health Services Fees for Coverage up to the termination date have not been paid by or on behalf of the Enrollee;
or
b. the Enrollee has not been continuously covered under the Contract,or under any coverage plan providing similar
coverage which the Contract replaced,for at least six(6)months immediately prior to termination from employ-
ment; or
c. the Enrollee is covered by Medicare or Medicaid; or
d. the entire Contract is discontinued.
The Enrollee must elect continuation Coverage and pay Health Services Fees due within twenty(20)days from the date
of termination from employment.
Coverage may be continued for enrollees working 40 hours or more when the working hours are reduced to less than 30
hours because of economic conditions. Coverage may also be continued for such enrollees enrolled family dependents.
Coverage may be continued provided:
1. the enrollee has been continuously covered under the Contract, or under any coverage plan providing similar
coverage which the Contract replaced, for at least six(6)months immediately prior to the reduction in working
hours;
- 14 - ate-_ 3i.
2. the enrolling unit has imposed the reduction in hours due to economic conditions;
3. the enrolling unit intends to restore the enrollee to a full 40 hour work schedule as soon as economic conditions
improve; and
4. the applicable Health services Fees are paid.
Continuation of Coverage under state law will end after a period of ninety(90)days after the date Coverage would have
ended,or until the Enrollee is reemployed,whichever occurs first. At the end of the ninety(90)day continuation period
under state law,the Enrollee or the Enrolled Family Dependents are entitled to conversion privileges as described below.
Conversion
A Covered Person who ceases to be eligible for PLAN Coverage for the reasons stated in termination conditions 8 or 10
above, or upon termination of continuation Coverage, and who continues to reside in the Service Area, may make
application to PLAN for coverage under a conversion contract without furnishing evidence of insurability. Application
and payment of the initial Health Services Fees must be made within thirty-one(31)days after termination of Coverage
under the Contract.A conversion contract shall be issued in accordance with the terms and conditions in effect at the time
of application.
Out of Area Conversion
PLAN may designate a carrier to provide conversion membership to any Covered Person who ceases to be eligible for
PLAN Coverage for the reasons stated in termination conditions 6 or 10 above,and who no longer resides within the PLAN
Service Area. Application to convert membership effective on the date of termination, without furnishing evidence of
insurability,must be made to the PLAN designated carrier within thirty-one(31)days after termination of Coverage under
the Contract.A conversion contract may be issued in accordance with the terms and conditions the designated carrier may
have in effect at the time of application.
Section VII
CONTRACT CHARGES
Your employer is responsible for making all monthly payments due under the Contract.For other than copayments,you
should speak with your employer regarding any amount due for payment for health services under this Contract.
If your employer fails to make the required payment within ten(10)days of when it is due,coverage terminates effective
on the last day for which payment was made.Please consult your employer and review the Contract if you have further
questions regarding Contract payments.
Section VIII
GENERAL PROVISIONS
Entire Contract
The Master Group Contract, the application of the Enrolling Unit, any individual Enrollee applications, Addenda and
amendments shall constitute the entire Contract of Coverage between parties.All statements made by the Enrolling Unit
or by an Enrollee shall,in the absence of fraud,be deemed representations and not warranties. No such statement shall
void or reduce Coverage under the Contract or be used in defense of a legal action unless it is contained in a written
application.
Limitation of Actions
No action in law or equity may be brought against PLAN,or any officer,director,or employee of PLAN,by any Covered
Person with respect to any matter arising under the Contract or the relationship between that Covered Person and PLAN
without full and complete compliance with the complaint procedure set forth in Section V of the Contract,nor shall such
- 15 - 9 W.373
action be brought at all unless brought within one(I)year from the date when the cause of action first arose.Written proofs
of loss furnished under Section III of the Contract are subject to the provisions regarding limitation of actions set forth
in that Section.
Time Limit on Certain Defenses
No statement,except a fraudulent statement,made by the Enrolling Unit shall be used to void the Contract after it has been
in force for a period of two (2) years.
Alterations
No alteration of the Contract and no waiver of any of its provisions shall be valid unless evidenced by an Addendum or
an amendment attached to the Contract which is signed by an executive officer of PLAN.No agent has authority to change
the Contract or to waive any of its provisions.
Relationships Between Parties
The relationships between PLAN and Participating Providers(except for the position of Medical Director),and between
PLAN and Enrolling Units are contractual relationships between independent contractors. Participating Providers and
Enrolling Units are not agents or employees of PLAN nor is PLAN or any employee of PLAN an agent or employee of
Participating Providers or Enrolling Units.
The relationship between a Participating Provider and any Covered Person is that of provider and patient. The
Participating Physician is solely responsible for the medical services provided to any Covered Person.The Participating
Hospital is solely responsible for the Hospital services provided to any Covered Person.
The relationship between any Enrolling Unit and any Covered Person is that of employer and employee, Family
Dependent, or other Coverage classification as defined in the Contract.
The Enrolling Unit is solely responsible for providing written notice to PLAN of the enrollment and Coverage changes,
including termination of a Covered Person's Coverage through PLAN, and the timely payment of Contract Charges to
PLAN.
Records
The Enrolling Unit shall furnish PLAN with all information,authorization,and supporting documentation which PLAN
may reasonably require with regard to any matters pertaining to the Contract.All documents furnished to the Enrolling
Unit by an individual in connection with the Coverage,and the Enrolling Unit's payroll and any other records pertinent
to the Coverage under the Contract shall be open for inspection by PLAN at any reasonable time.
Each Covered Person authorizes and directs any person or institution that has attended,examined or treated the Covered
Person,to furnish PLAN at any reasonable time,upon its request,any and all information and records or copies of records
relating to attendance,examination or treatment rendered to the Covered Person.PLAN agrees that such information and
records will be considered confidential.PLAN shall have the right to submit any and all records concerning episodes of
health care for Covered Persons to appropriate medical or other review bodies or individuals and/or Physicians.
Examination of Covered Persons
In the event of a question or dispute concerning the provision of Health Services or payment for such services under the
Contract,PLAN may also reasonably require that a Covered Person be examined,at PLAN's expense,by a Participating
Physician acceptable to PLAN.
Clerical Error
Clerical error shall not deprive any individual of Coverage under the Contract. 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 the
Contract. Upon discovery of a clerical error,an appropriate adjustment in Health Services Fees shall be made.However,
no such adjustment in Health Services Fees or Coverage shall be granted by PLAN to the Enrolling Unit for more than
sixty (60)days of Coverage prior to the date PLAN was notified of such clerical error.
- 16 - ' )014
Notice
Notice given by PLAN to an authorized representative of the Enrolling Unit shall be deemed notice to all affected
Enrollees and their Enrolled Family Dependents in the administration of the Contract, including termination of the
Contract or the termination of individual Coverage.
Covered Benefits
In no event shall any Covered Person be responsible to pay for benefits received in accordance with the Contract except
as otherwise provided in the Contract.
Workers' Compensation Not Affected
The Coverage provided under the Contract is not in lieu of and does not affect any requirements for coverage by Workers'
Compensation Insurance. Benefits will not be denied to a member whose employer has not complied with law and
regulations governing Workers' Compensation Insurance,provided that such member has sought and received services
under the provisions of this Contract.
Conformity with Statutes
Any provision of the Contract which,on its effective date,is in conflict with the statutes of the jurisdiction in which it
is delivered is hereby amended to conform to the minimum requirements of such statutes.
Non Discrimination
In compliance with federal and state law, PLAN shall not discriminate on the basis of age, sex, color, race, disability,
marital status, sexual preference, religious affiliation or public assistance status.
Section IX
PROCEDURES FOR OBTAINING HEALTH SERVICES
A. HEALTH SERVICES RENDERED BY PARTICIPATING PROVIDERS
Subject to the terms,conditions,exclusions,and limitations of this Contract,a Covered Person is entitled to Coverage
described in Section X if such services(1)are authorized and determined to be Medically Necessary by PLAN and
(2) are provided by or referred by the Participating Primary Care Physician.
Each Covered Person shall select a Participating Primary Care Physician who shall be responsible for the coordination
of all Health Services rendered to the Covered Person and for ensuring continuity of care.Covered Persons who have
not selected a Participating Primary Care Physician within 31 days of enrollment may be assigned one by the PLAN.
The Participating Primary Care Physician shall refer the Covered Person only to Participating Providers,except as
provided in Section IX.B. All Health Services rendered to the Covered Person must be provided or referred by the
Participating Primary Care Physician. Health Services obtained by the Covered Person without referral by the
Participating Primary Care Physician are not covered.The fact that a Physician may prescribe,order, recommend,
approve or provide a service or supply does not,in and of itself,make the service or supply a covered Health Service.
Each Covered Person is responsible for verifying the participation status of the provider prior to receiving Health
Services.These Health Services are subject to (1)payment by the Enrollee of the Health Services Fees required for
Coverage under this Contract and (2)payment by the Covered Person of the Copayment Charge specified for any
service.
LIMITATION ON SELECTION OF PROVIDER
In the case of a medical condition which significantly endangers either a Covered Person's health or the public health,
the Covered Person may be required to receive all covered Health Services through a single PLAN Participating
Physician or network of Participating Providers designated by PLAN.
17 rt...rns
J Gay....OJ 1
B. REFERRAL HEALTH SERVICES RENDERED BY NON-PARTICIPATING PROVIDERS
In the event that specific Health Services cannot be provided by or through a Participating Provider,a Covered Person
shall be entitled to Coverage for Eligible Expenses for Medically Necessary Health Services obtained through non-
participating providers. All such Health Services, including but not limited to Miscellaneous Health Services
identified in this Contract, must be authorized in writing in advance by PLAN, and are subject to all of the terms,
conditions, exclusions, and limitations of this Contract.
IT IS THE COVERED PERSON'S RESPONSIBILITY TO VERIFY THAT THE REQUIRED WRI11"hN
APPROVAL FROM PLAN HAS BEEN GRANTED, PRIOR TO RECEIVING SERVICES FROM NON-
PARTICIPATING PROVIDER. SHOULD THE COVERED PERSON RECEIVE CARE FROM A NONPAR-
TICIPATING PROVIDER, INCLUDING HOSPITALIZATION, WITHOUT THE REQUIRED APPROVAL BY
PLAN, THE COVERED PERSON WILL BE RESPONSIBLE FOR ALL COSTS ASSOCIATED WITH THAT
CARE. FAILURE OF PARTICIPATING PRIMARY CARE PHYSICIAN TO OBTAIN NECESSARY PRIOR
APPROVAL FROM PLAN DOES NOT EXCUSE THE COVERED PERSON'S RESPONSIBILITY TO VERIFY
APPROVAL FROM PLAN BEFORE RECEIVING SERVICES FROM OR THROUGH NON-PARTICIPATING
PROVIDERS.
C. EMERGENCY HEALTH SERVICES
Covered Persons are directed to telephone their Participating Primary Care Physician whenever possible prior to
receiving Emergency Health Services.PLAN will pay Eligible Expenses for Medically Necessary Emergency Health
Services rendered to a Covered Person,subject to the terms,conditions,exclusions,and limitations of this Contract.
Emergency Health Services rendered by Participating Providers are subject to a Copayment Charge for each incident.
In order for Emergency Health Services rendered by non-participating providers to be covered under this Contract,
the required Emergency Health Services must be(1)of such immediate nature that the Covered Person's life or health
would be jeopardized if taken to a facility where the services of a Participating Physician would be available,or(2)
provided under circumstances in which the Covered Person is unable,due to unconsciousness or the inability to be
rational,to request treatment at a location where the services of a Participating Physician would be available.In this
case, Coverage is subject to a Copayment Charge for each incident of Medically Necessary Emergency Health
Services rendered by a non-participating provider.
The above Copayment Charges for Emergency Health Services rendered by either Participating Providers or by non-
participating providers are in addition to any other Copayment Charges which may apply to the Health Service. If,
however, a Covered Person is confined, the above Copayment Charge is waived, but the Copayment Charges
described in Section X.B.I. and X.E.2. shall apply.
The Covered Person must notify PLAN within forty-eight(48)hours after Emergency Health Services are initially
provided,or as soon thereafter as is reasonably possible.Full details of the Emergency Health Services received shall
be made available by the Covered Person at the request of PLAN. Continuation of care thereafter shall require
coordination by the Participating Primary Care Physician and the prior written authorization of PLAN.
If the Covered Person is hospitalized,the PLAN may elect to transfer the Covered Person to a Participating Hospital
as soon as it is medically appropriate in the opinion of the attending Physician.Emergency Health Services rendered
by non-participating providers or in non-participating facilities are not covered if the Covered Person chooses to
remain in a non-participating facility after PLAN has notified the Covered Person of the intent to transfer the Covered
Person to a Participating Provider facility.
ELIGIBLE EXPENSES FOR EMERGENCY HEALTH SERVICES
Eligible Expenses for Emergency Health Services are the Reasonable and Customary Charges for the Health Services
described in Section X of this Contract,provided during the course of the Emergency,and when Medically Necessary
for stabilization and initiation of treatment until responsibility for medical care can be assumed by the Participating
Primary Care Physician.The Health Services must be provided by or under the direction of a Physician and are subject
to the exclusions and other provisions of this Contract. Health Services rendered on an Emergency basis are not
covered if,in the opinion of PLAN, the situation is later determined to be non-emergency.This determination shall
be based on generally accepted medical criteria.
18 :I u e�:�
D. SECOND OPINION POLICY
Coverage of certain Health Services requires that the Covered Person obtain a consultation with a second Participating
Physician prior to the scheduling of the Health Service.The Participating Physician shall notify the Covered Person
that second opinions are implemented at the PLAN's discretion in accordance with PLAN policy.The Covered Person
is then responsible for contacting PLAN to obtain a list of Participating Physicians who are authorized to render a
second opinion and verify that the procedure or treatment referred for a second opinion is consistent with PLAN
policy.The Enrollee will arrange a consultation with the second Participating Physician,not affiliated with the first
Participating Physician. The consultation for the second opinion must occur within thirty-one(31) days of the first
opinion, or as soon thereafter as is reasonably possible. In the event that the second opinion differs from the first
opinion, the Covered Person may arrange for a third opinion.
Coverage is provided for second and third opinions if arranged through PLAN as described above.
Failure to comply with this procedure for obtaining a second opinion shall result in a total Copayment Charge of 40%
of Eligible Expenses.
E. COPAYMENT CHARGES
In the event that two (2) or more Copayment Charges apply to a single Health Service, all applicable Copayment
Charges shall apply,provided,however,that the total of all applicable Copayment Charges shall not exceed 40%of
Eligible Expenses for the single Health Service. (PLAN Enrollees who wish to ascertain the total dollar amount of
combined Copayment Charges may obtain such information from PLAN.)
Section X
SCHEDULE OF BENEFITS
The amount paid by the Enrollee for Coverage under this Contract,exclusive of Copayment Charges or charges for non-
covered services, is described in the Appendix.
A. PHYSICIAN SERVICES (except for those identified in Sections X.C and X.D of this Contract), when provided or
referred by the Participating Primary Care Physician, authorized by PLAN, and rendered through a Participating
Provider unless alternative arrangements have been authorized in advance by PLAN,or in the event of an Emergency:
1. Services and supplies provided in a Physician's office, including diagnostic treatment and preventive medical
care such as x-rays, electrocardiograms, electroencephalograms, and other clinical laboratory tests, well-baby
care, physical examinations, voluntary family planning, application and removal of casts and dressings,
immunizations, and Medically Necessary therapeutic injections.
COPAYMENT CHARGE: $10.00 per visit during scheduled office hours or$25.00 after scheduled office
hours except for Copayment Charges required for specific services and supplies set forth below.
2. Eye exams,excluding refraction,provided in the Physician's office. (No limitation applies to Covered Persons
through the age of seventeen(17).)
COPAYMENT CHARGE: $10.00 per visit
Eye exams for refraction provided in a Participating Provider's office,limited to one(1)exam per Covered Person
per Calendar Year.
COPAYMENT CHARGE: $10.00 per visit
3. Physician surgical services and other medical care, including anesthesia, consultation with and treatment by
specialists, and services by surgical assistants only when authorized in advance by PLAN, when provided in a
Participating Physician's office.
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srt�
COPAYMENT CHARGE:$10.00 per visit,except for Copayment Charges for specific services and supplies
set forth in this contract.
4. Allergy Testing and Treatment Services. No Coverage is provided for RAST testing, except when skin testing
is medically impossible.
COPAYMENT CHARGE: $10.00 per visit
5. Dermatology Services.
COPAYMENT CHARGE: $10.00 per visit
B. HOSPITAL AND RELATED SERVICES,when provided or referred by the Participating Primary Cate Physician,
and authorized by PLAN:
1. Inpatient Services
Some Health Services rendered while confined are subject to separate benefit limitations, restrictions and/or
Copayment Charges, as described elsewhere in this Contract.
a. Room and Board
Unlimited Confinement,when Medically Necessary and approved by PLAN prior to admission in a Partici-
pating Hospital on a Semi-Private Accommodations basis.The difference in cost between Semi-private and
private mom accommodations will not be considered an Eligible Expense unless private accommodations
are Medically Necessary, or unless Semi-private Accommodations are not available.
COPAYMENT CHARGE: $100 per admission for non-surgical or surgical Health Services. Copay-
ments are limited to two(2)admissions per person per Calendar year,except copayments for transplant
services. In addition to the Copayment Charges listed elsewhere in this Contract, the following shall
apply when Health Services are rendered for organ transplants provided, however, that the total of all
applicable Copayment Charges shall not exceed 40% of Eligible Expenses for the Health Service.
5%of Eligible Expenses for kidney and corneal transplants inch children and adults,liver transplants in chil-
dren with biliary atresia or children with other end stage liver disease,bone marrow transplants in chil-
dren and adults for the following diseases:
• Aplastic anemia
• Leukemia
• Severe combined immunodeficiency disease
and
• Wiskott-Aldrich syndrome
and any other transplants required by Federal or State Statutes and Regulations when Health Services are
rendered in a Designated Transplant Facility.
b. Other Inpatient Services and Supplies
Services and supplies provided while confined in a Participating Hospital as described in Section X.B.l.a of
this Contract. Services and supplies include nursing care,Medically Necessary meals and special diets,use
of operating room and related facilities, use of intensive care unit and services,x-ray,laboratory and other
diagnostic tests, drugs, medications, biologicals, anesthesia and oxygen services, internal prosthetics,
Medically Necessary special duty nursing,radiation therapy,inhalation therapy,and administration of blood
and blood plasma,except that such services are subject to the terms,conditions,exclusions, and limitations
of this Contract.
COPAYMENT CHARGE: $100 per admission for non-surgical or surgical Health Services. Copay-
ments are limited to two(2)admissions per person per Calendar year,except copayments for transplant
services.In addition to the Copayment charges listed elsewhere in this Contract,the following shall apply
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W ,
when Health Services are rendered for organ transplants provided,however,that the total of all applicable
Copayment Charges shall not exceed 40% of Eligible Expenses for the Health Service.
5%of Eligible Expenses for kidney and corneal transplants in children and adults,liver transplants inchil-
dren with biliary atresia or children with other end stage liver disease,bone marrow transplants in chil-
dren and adults for the following diseases:
• Aplastic anemia
• Leukemia
• Severe combined immunodeficiency disease
and
- Wiskott-Aldrich syndrome
and any other transplants required by Federal or State Statutes and Regulations when Health Services are
rendered in a Designated Transplant Facility.
2. Outpatient Services and Supplies, at either Participating Hospital or Participating Alternate Facility and when
provided or referred by the Participating Primary Care Physician and authorized by PLAN,except in the event
of an Emergency. Emergency Health Services provided at or by nonparticipating facilities or providers are
covered subject to the terms, conditions, exclusions and limitations of this Contract, and when PLAN later
determines these Emergency Health Services to be Medically Necessary:
a. Emergency Services
1) Services and supplies for stabilization or initiation of treatment of Emergency conditions, rendered on
an outpatient basis in an emergency room of a Hospital.
COPAYMENT CHARGE: $50.00 per visit except the the Copayment Charge described in Section
X.B.1.a or X.E.2 will apply when the Emergency condition directly results in Confinement.
2) Services and supplies for stabilization or initiation of treatment of Emergency conditions,rendered on
an outpatient basis in a physician's office or urgent care facility.
COPAYMENT CHARGE: $25.00 per visit, except the Copayment Charge described in Section
X.A.1 will apply when services are rendered by a Primary Care Physician during regularly scheduled
office hours.
b. Non-Emergency Services
1) Physician surgical services,supplies and other medical care,including anesthesia,consultation with and
treatment by specialists,and services by surgical assistants only when authorized in advance by PLAN,
for prescheduled outpatient surgery provided at a Participating Hospital or Participating Alternate
Facility.
COPAYMENT CHARGE: $50.00 per outpatient surgery
2) Prescheduled diagnostic and therapeutic services,including x-ray,radiation therapy and laboratory tests
and services,provided at a Participating Hospital or Participating Alternate Facility.
COPAYMENT CHARGE: $10.00 per visit
C. MATERNITY, FAMILY PLANNING AND INFERTILITY SERVICES
For the purposes of this subsection, maternity and obstetrical care shall mean pre- and post-partum care during
pregnancy, childbirth, early termination of pregnancy, or any associated complications.
1. Services,equipment and supplies provided on an inpatient or outpatient basis for obstetrical care of the mother
before and during delivery and during the post-partum period, including Physician services, operations and
special procedures such as Caesarean sections,Hospital services,including use of the delivery room,x-ray and
laboratory, injectable substances and anesthesia. Unless authorized in writing and in advance, obstetrical and
neonatal care provided outside of the Service Area will not be covered if such care is rendered during the normal
delivery period. The normal delivery period is the three to five week period prior to the expected delivery date.
COPAYMENT CHARGE: $10.00 per outpatient visit, and inpatient services - same as X.B.1.
2. Services and supplies provided on an inpatient or outpatient basis for family planning counseling and treatment,
including infertility evaluation,birth control counseling and treatment,certain intrauterine devices,measurement
for contraceptive diaphragms,voluntary male or female surgical sterilization,and up to two(2)elective abortions
per lifetime if performed within ten(10)weeks of conception.(Donor semen for artificial insemination,in vitro
fertilization,embryo transport procedures,surrogate parenting,and outpatient injectable substances and supplies
related to infertility are not covered.)
COPAYMENT CHARGE: $10.00 per outpatient visit, and inpatient services same as X.B.1.
D. MENTAL HEALTH SERVICES AND CHEMICAL DEPENDENCY SERVICES
The following Health Services are covered only when provided or referred by PLAN's Mental Health Provider.
1. Inpatient and outpatient Health Services for detoxification of chemical dependency, without limitation. Health
Services otherwise covered under this Contract for the treatment of medical complications of chemical
dependency are described in Sections X.A. and X.B. of this Contract.
2. Inpatient Mental Health. Coverage,up to a maximum of forty-five(45)full days or ninety(90)partial days per
Calendar Year,for inpatient Semi-private Accommodations, or private when Medically Necessary, for Mental
Health Services when provided by the Mental Health Provider in a Participating Hospital or Participating
Alternate Facility."Partial Days"means treatment for at least three(3)hours but not more than twelve(12)hours
in a 24-hour period.
COPAYMENT CHARGE:The first day's Copayment Charge is the same as specified in Section X.B.1.aplus
$25.00 per day thereafter.
3. Inpatient Chemical Dependency. Coverage for Semi-private accommodations, or private when Medically
Necessary, for a maximum of twenty-one(21)days per Calendar Year and two (2) Confinements per lifetime,
for treatment of alcoholism or chemical dependency when authorized in writing in advance by the Mental Health
Provider, and provided in an inpatient treatment facility designated by PLAN. Covered Person must complete
prescribed and approved course of treatment of PLAN to be responsible for payment.
COPAYMENT CHARGE:The first day's Copayment Charge is the same as specified in Section X.B.l.a plus
$25.00 per day thereafter.
4. Outpatient Mental Health and Chemical Dependency Services are provided when furnished by the Mental Health
Provider.
COPAYMENT CHARGE: No charge per visit. The full Reasonable and Customary Charge for each
appointment broken less than twenty-four(24) hours prior to the time of scheduled visit.
E. MISCELLANEOUS HEALTH SERVICES
THE FOLLOWING HEALTH SERVICES ARE COVERED PROVIDED THAT SUCH HEALTH SERVICES
(EXCEPT EMERGENCY SURFACE AMBULANCE SERVICE) ARE (A) ORDERED, PROVIDED, OR AR-
RANGED BY OR UNDER THE DIRECTION OF THE PARTICIPATING PRIMARY CARE PHYSICIAN AND
(B) APPROVED IN WRITING IN ADVANCE BY PLAN AND (C) OBTAINED THROUGH A VENDOR OR
PROVIDER SELECTED BY PLAN MANAGEMENT.
1. Home Health Agency and Private Duty Nursing Services
Intermittent Health Services of a Participating Home Health Agency,and private duty nursing care,by,-or under
the supervision of, a registered nurse, in a Covered Person's home, required for care and treatment which
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•
otherwise would require Confinement in a Participating Hospital or Participating Skilled Nursing Facility.
Covered Health Services include diagnostic and therapeutic nursing services and Physician home visits within
the Service Area.
COPAYMENT CHARGE: No charge per visit
2. Skilled Nursing Facility
Up to sixty-two(62)days of Medically Necessary Confinement(Semi-Private Accommodations unless private
accommodations are Medically Necessary)and medical services and supplies and equipment ordinarily provided
in a Participating Skilled Nursing Facility for the care and treatment of an acute Injury or Sickness, and which
otherwise would require Confinement in a Participating Hospital.Some Health Services rendered while confined
are subject to separate benefit limitations,restrictions and/or Copayment Charges,as described elsewhere in this
Contract.
COPAYMENT CHARGE: No charge per confinement
3. Ambulance Services
Medically Necessary ambulance transportation is covered if approved in advance by PLAN or when PLAN
determines after the transportation is provided that the transportation was Medically Necessary. Ambulance
transportation provided due to the absence of other medically appropriate forms of transportation is not covered.
a. Emergency surface ambulance transportation by a licensed ambulance service to the nearest Hospital where
Emergency care and treatment can be rendered.
COPAYMENT CHARGE: $30.00 per trip
b. Non-emergency surface ambulance transportation when referred by the Participating Primary Care Physician
and approved in writing in advance by PLAN.
COPAYMENT CHARGE: $30.00 per trip
c. Air ambulance transportation only when medically appropriate surface ambulance transportation is not
available.
COPAYMENT CHARGE: $30.00 per trip
4. Rehabilitation Services
Short term inpatient or outpatient,whichever is Medically Necessary,rehabilitative services(physical therapy,
occupational therapy,and speech therapy)performed at a Participating Hospital or Participating Skilled Nursing
Facility,or through Participating Home Health Agency,or other Participating Provider.Rehabilitation services
are limited to services which, in the judgment of the Participating Primary Care Physician and PLAN, are
Medically Necessary and will result in significant improvement of a Covered Person's condition through short
term therapy. (Short term means that significant improvement is anticipated within two (2)months of start of
treatment.)All combined rehabilitation services are limited to a sixty-two(62)day period per Sickness episode,
beginning with the first day of treatment.
COPAYMENT CHARGE: $10.00 per outpatient visit, and No Charge per Confinement
5. Blood and Blood Products
The administration of prescribed blood transfusions,including supplies and equipment used in the administration
of blood,and blood products and derivatives if such products and derivatives are replaced in accordance with the
blood bank's requirements.Coverage is provided for the drawing and storing of the Covered Person's blood for
use by the Covered Person only for blood units used as replacement therapy for Medically Necessary treatment
of conditions while the Covered Person is covered under this Contract.
-23 - 3st'�,.t70
COPAYMENT CHARGE: No Charge
6. Temporomandibular Joint Syndrome
Treatment of temporomandibular joint syndrome as a result of trauma: fracture of the jaw or laceration of the
mouth, tongue,or gums is covered. Health Services and supplies provided for the treatment of temporomandi-
bular joint syndrome are covered only when performed by a PLAN-designated Physician or oral surgeon.
COPAYMENT CHARGE: 40% of Eligible Expenses
7. Hemodialysis
Services and supplies, subject to approval by PLAN and a determination that the Covered Person meets PLAN
medical criteria,when provided in a Participating Hospital or Participating Alternate Facility,for dialysis for end
stage renal disease (ESRD), and services and supplies for renal conditions.
COPAYMENT CHARGE: $10.00 per hemodialysis treatment
GENERAL EXCLUSIONS
The following are not covered:
1. Dental Surgery, Treatment or Care (including such for overbite or underbite, maxillary and mandibulary
osteotomies, and orthognathic conditions, whether or not related to temporomandibular joint dysfunction), or
dental x-rays,supplies and appliances(including occlusal splints)and all associated expenses arising out of such
Dental Surgery,Treatment or Care including hospitalizations. Hospital and Physician services and supplies and
anesthesiology services referred by the Participating Primary Care Physician and approved in writing in advance
by PLAN, for the correction of cleft lip or cleft palate which has been diagnosed as a Congenital Anomaly in
newborn children,or as are necessary to safeguard the health of a Covered Person because of a specific non-dental
physiological impairment are covered. Dental Services required due to trauma are limited to functional
restoration of structures other than teeth.Treatment ofsrauma resulting in fracture of the jaw or laceration of the
mouth, tongue,or gums is covered.
2. Health Services and associated expenses for temporomandibular joint syndrome, except as described in X.E.6.
3. Custodial Care, domiciliary care, respite care or rest cures.
4. Health Services and associated expenses for Cosmetic Procedures including,but not limited to,pharmaceutical
regimes, nutritional procedures or treatments, plastic surgery, including reduction mammoplasty, and recon-
structive mammoplasty,except when the original mastectomy was performed while the person was covered under
this Contract. (Medically Necessary reconstructive surgery is not excluded.)
5. Health Services and associated expenses for Experimental or Unproven Procedures,treatments,devices or phar-
macological regimes.
6. Health Services and associated expenses for organ transplants, except for those transplants stated as covered
under Section X,B,1.,a. and b.unless covered through an addendum to this Contract.Liver transplants in adults
are NOT covered. Bone marrow transplants are NOT covered for conditions other than those listed in Section
X,B,I. a. and b.
7. Health Services and associated expenses for in vitro fertilization, embryo transport, Gamete Intra-Fallopian
Transfer, surrogate parenting, donor semen, outpatient injectable substances and supplies related to infertility,
elective abortions when performed beyond the tenth week of pregnancy, or elective abortions in excess of two
(2)per lifetime, home childbirth, and non-Medically Necessary amniocentesis.
8. Health Services not authorized by PLAN or not Medically Necessary, or not provided or referred by the
Participating Primary Care Physician, except in Emergency situations (described in Section IX.C.)
- 24 -
9. Hearing aids,cochlear implant devices and implant procedures,eye glasses,contact lenses and the fitting thereof,
unless covered through an Addendum to this contract.
10. Personal comfort and convenience items or services obtained or rendered in or out of the Hospital or any facility,
such as television,telephone,barber or beauty service,guest service and similar incidental services and supplies
which are not Medically Necessary.
11. Mental Health Services, which are (a) rendered in connection with Mental Illnesses not classified in the
International Classification of Diseases of the U.S. Department of Health and Human Services,or(b)for any of
the following: learning, behavioral or developmental disabilities, mental retardation or autism, marriage
counseling, counseling or therapy for weight reduction, behavioral training, personal growth, lifestyle or
vocational counseling,biofeedback,pain control,hypnosis, sexual dysfunction or inadequacy, transsexualism,
early infant stimulation,or psychotherapy credited toward earning a degree or required for educational purposes.
12. Services rendered by a provider with the same legal residence as a Covered Person, or who is a member of a
Covered Person's family, including spouse, brother, sister, parent, or child.
13. Physical,psychiatric,orpsychological examinations or testing,orvaccinations,immunizations,or treatments not
otherwise covered under this Contract,when such services are for purposes of obtaining,maintaining or otherwise
relating to employment or insurance,marriage or adoption,or relating to judicial or administrative proceedings
or orders,or which are conducted for purposes of medical research,or to obtain or maintain a license of any type.
14. Travel or transportation expenses (except ambulance service as specifically provided in this Contract) even
though prescribed by a Physician.
15. Health Services and associated expenses for outpatient Hospital and Hospital emergency room or Participating
Alternative Facility services obtained during normal Physician office hours (unless necessary because of an
Emergency),except as specified in Section X.B.2.b,or when authorized in advance in writing by the Participating
Primary Care Physician or PLAN.
16. Prosthetic devices,Durable Medical Equipment,and appliances,and personal comfort items,including air con-
ditioners,even though prescribed by a Physician,unless covered through an Addendum to this Contract or when
such devices,equipment or appliances are medically necessary for outpatient care in lieu of hospitalization or an
integral part of a case management plan.
17. Health Services and associated expenses for surgical procedures and associated Health Services intended
primarily for the treatment of morbid obesity, including gastric bypasses, gastric balloons, stomach stapling,
wiring of the jaw,jejunal bypasses, and Health Services of a similar nature, unless Medically Necessary.
18. Health Services and associated expenses for sex transformation operations and for reversal of voluntary
sterilization.
19. Health Services otherwise covered under this Contract related to a specific condition or treatment when a Covered
Person has terminated the specific scheduled service or treatment against the advice of a Physician, or has left
a Hospital or inpatient facility against medical advice.
20. Health Services for military service connected disabilities for which the Covered Person is legally entitled to
services and for which facilities are reasonably available to the Covered Person.
21. Health Services and associated expenses for megavitamin therapy,psychosurgery,radial keratotomy,nutritional
based therapy for alcoholism or other chemical dependency, salabrasion, chemosurgery or other such skin
abrasion procedures associated with the removal of scan,tattoos, actinic changes and/or which are performed
as a treatment for acne,RAST testing,except with skin testing is medically impossible,acupuncture,services or
treatment for sleep apnea,or chelation therapy,unless Medically Necessary for the treatment of metal poisoning.
22. Health Services provided by a chemical dependency treatment or rehabilitation program,except as described in
Section X.D., or unless covered through an Addendum to this Contract.
- 25 _
23. Prescription Medications tut outpatient treatment, unless covered through an Addendum, to this Contract.
24. Health Services otherwise covered under this Contract,but rendered after the date individual Coverage under this
Contract terminates, including Health Services for medical conditions arising prior to the date individual
Coverage under this Contract terminates.
25. Medical supplies,oxygen, blood, blood derivatives and fees for blood replacement, and penile implant devices
and procedures,except as described in Section X.E.5.,or unless covered through an Addendum to this Contract.
26. Outpatient nutritional and dietary services in the absence of a physiological disease condition.
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I
i
INDEX
How to use this index:
The Definitions are found in Section I.Specific topics are cross Rendered by Non-Participating Providers Section IX
referenced for your convenience. Please refer to Section I, Rendered by Participating Providers Section IX
Definitions (DEF) for specific information as related to the Skilled Nursing Facility Section X E.
topic. (Example: Adoption; See Section I,Definition-Family Temporomandibular Joint Syndrome Section X E.
Dependent.)
Adoption Section II Indentification Card E.O.C.
Def:Family Dependent
• Limitation on Selection Provider Section IX
Benefit Determination Rules Section IV
Marriage Section II
Clerical Error Section VIII Def:Family Dependent
Complaint Process Section V Newborn Coverage , Section II
Def:Family Dependent
Conformity with Statutes Section VIII
No Fault Coverage Section IV
Continuation of Individual Coverage Section VI
Non Discrimination Section VIII
Contract Alterations Section VIII
Notice to
Contract Charges Section VII Enrolling Unit Section VIII
Enrollees Section VIII
Conversion Section VI
Records Section VII
Coordination of Benefits Section IV
Reimbursement of
Copayment Def:Copyament Eligible Expenses Section II
Section II Copayment Section II
Section III
Section IX Relationship Between Parties Section VIII
Section X-See Specific
Health Services Right of Recovery Section IV
Effective Date of Coverage Section II Second Opinion Policy Section IX
Eligible Expenses Section II-Def.
Subrogation Section IV
Emergency Health Services Section IX
Termination of
Enrollment Section II Individual Coverage Section VI
Contract Section VII
Examination of Covered Person Section VIII
Verbal Complaint Section V
Grievance Section V
Worker's Compensation Section VIII
Health Services
Ambulance Services Section X E. Written Complaint Section V
Blood&Blood Products Section X E.
Family Planning Section X C.
Hemodialysis Section X E.
Home Health Services Section X E.
Hospital Services Section X B.
Infertility Planning Section X C.
Maternity Services Section X C.
Mental Health Services Section X D.
Obtaining Services Section IX
Physician Services Section X A.
Private Duty Nursing Section X E.
Rehabilitation Services Section X E.
- 27 - era", -),,
As of August 1, 1992 the name of our health
Lincoln National Health Plan of Color plan has changed to TakeCare of Colorado,
Evidence of Coverage Inc., from Lincoln National Health Plan.
Amendment I (Effective 01/01/92)
Design I - 6729(10/91) Design III - 6910(10/91) Design IV - 6928(12/91)
Design Va - 6752(10/91) Design VIa - 6753(10/91) Design IXa - 6754(10/91)
Design X - 6730(10/91)
This amendment replaces Sections II and III entirely and Section VI,Continuation Coverage,Part H: Continuation of Coverage
Under State Law.
Section II
ENROLLMENT AND EFFECTIVE DATE OF INDIVIDUAL COVERAGE
A. Enrollment
Eligible Persons may enroll themselves and their Family Dependents in PLAN during the Initial Eligibility
Period or during an Open Enrollment Period specified by PLAN by submitting application on a form
provided or approved by PLAN. In addition, new Eligible Persons may be enrolled in PLAN within 31 days
of the date on which they first become Eligible Persons, and new Family Dependents may be enrolled in
PLAN within 31 days of the date on which they first become Family Dependents, except that Family
Dependents who are newborn children are covered at the moment of birth. Except during the time periods
set forth in this paragraph, Eligible Persons and/or Family Dependents may not enroll in PLAN without the
express written authorization of PLAN and evidence of insurability.
The Enrolling Unit shall notify PLAN in writing within sixty (60) days of the effective date of enrollments,
terminations or other changes; provided, however,that the Enrolling Unit shall notify PLAN in writing each
month of any changes in the Coverage classification of any Enrollee.
B. Effective Date of Coverage
Coverage for an Eligible Person and his or her Family Dependents, if any, is effective on the date specified
by Enrolling Unit and PLAN, provided that PLAN receives a properly completed individual enrollment
application that was submitted to PLAN according to the enrollment provisions of Section HA of the
Contract; and provided, however, that:
1. No Coverage shall be effective until the Contract takes effect;
2. No Family Dependent shall be covered under the Contract until the Eligible Person is
covered.
3. If an Enrollee acquires a new Family Dependent by reason of adoption or marriage, then
Coverage for that Family Dependent shall take effect on the date that the new Family
Dependent is adopted or married, if PLAN and Enrolling Unit is notified by the Enrollee
of the adoption or marriage within thirty-one (31) days of occurrence; and any necessary
adjustments to Health Services Fees have been made.
4. If an Enrollee acquires a new Family Dependent who is a newborn child,then Coverage for
that Family Dependent shall take effect at the moment of birth and remain in effect for
thirty-one (31) days beyond the date of birth. To continue Coverage for that Family
Dependent,the Enrollee shall notify PLAN and Enrolling Unit of the newborn child's birth
and the name; and make any necessary changes in the Coverage classification and Health
Services Fees.
5. Health Services for medical conditions arising prior to the effective date of Coverage and
resulting in Confinement are covered as of the effective date only if the Covered Person
notifies PLAN of Confinement within forty-eight(48)hours of the effective date,or as soon
thereafter as is reasonably possible, and if Health Services are received in accordance with
the terms, conditions, exclusions and limitations of the Contract.
in; -u, as
Section III
PROCEDURES FOR REIMBURSEMENT OF ELIGIBLE EXPENSES
Reimbursement of Eligible Expenses
PLAN shall reimburse for Eligible Expenses incurred with non-participating providers only for MEDICALLY NECESSARY
EMERGENCY SERVICES OR SERVICES AUTHORIZED OR APPROVED BY PLAN in accordance with the terms of
the Contract.
Participating Providers are responsible for submitting written proof of loss for Eligible Expenses directly to PLAN on the
Covered Person's behalf. In the event a Covered Person is billed by a Participating Provider for Eligible Expenses, the
Covered Person should contact PLAN.
Written proof of loss for services rendered by non-participating providers,satisfactory to PLAN,shall be furnished at PLAN's
office within ninety(90) days after the date of such loss. Failure to furnish proof within the time required shall invalidate or
reduce Coverage unless it was not reasonably possible to have given proof within ninety (90) days or, in the absence of legal
capacity of the Covered Person, later than one (1) year from the time in which proof is otherwise required.
All Eligible Expenses shall be paid within sixty (60) days of receipt by PLAN of proof of loss. Where applicable, Eligible
Expenses shall be paid to the Enrollee. Subject to written authorization from an Enrollee, all or a portion of any Eligible
Expenses due may be paid directly to the provider of the Health Services.
Copayment Reimbursement
PLAN shall reimburse for amounts of Copayment Charges paid by an Enrollee in any Contract Year that erread 200%of the
total annual Health Services Fees paid to PLAN during the same period on behalf of the Enrollee through the Enrolling Unit.
In those cases where the Enrollee has enrolled his or her Family Dependents with PLAN,PLAN shall reimburse for amounts
of Copayment Charges paid by all Covered Persons in the family unit in any Contract Year that exceed 200% of the total
annual Health Services Fees paid to PLAN through the Enrolling Unit during the same period.
Written notice that excess amounts of Copayment Charges have been paid by the Enrollee or by all Covered Persons in the
same family unit must be sent to PLAN. Such notice must (1) include proof satisfactory to PLAN of the payment of
Copayment Charges, and (2) be provided to PLAN not later than ninety (90) days after the end of the Contract Year. The
amount of any excess Copayment Charges will be paid within sixty(60) days of receipt of written notice by PLAN that excess
Copayment Charges have been paid by Covered Persons.
Limitation of Actions
No action at law or in equity shall be brought to recover on the Contract by a Covered Person prior to the expiration of sixty
(60) days after proof of loss has been filed in accordance with the requirements of the Contract, nor shall such action be
brought at all unless brought within three (3) years after the time written proof of loss is required by the Contract.
Section VI
Part II: Continuation of Coverage Under State Law
An Enrollee whose Coverage ends under the Contract may be entitled to elect continuation Coverage under state law, if the
Enrolling Unit is not subject to the requirements of COBRA, or as an alternative to COBRA when both state law and
COBRA apply.
The Enrollee's Coverage must have ended due to termination of employment. The Enrollee shall not be entitled to
continuation Coverage under state law if:
a. Health Services Fees for Coverage up to the termination date have not been paid by or on
behalf of the Enrollee; or
b. the Enrollee has not been continuously covered under the Contract, or under any coverage
plan providing similar coverage which the contract replaced, for at least six (6) months
immediately prior to termination from employment; or
c. the Enrollee is covered by Medicare of Medicaid; or
d. the entire Contract is discontinued.
The Enrollee must elect continuation Coverage and pay Health Services Fees due within twenty (20) days from the date of
termination from employment.
Continuation of Coverage under state law will end after a period of ninety(90)days after the date Coverage would have ended,
or until the Enrollee is reemployed,whichever occurs first. At the end of the ninety(90) day continuation period under state
law, the Enrollee or the Enrolled Family Dependents are entitled to conversion privileges as described below.
Coverage may be continued for enrollees working 40 hours or more when the working hours are reduced to less than 30 hours
because of economic conditions. Coverage may also be continued for such enrollees enrolled family dependents.
Coverage may be continued provided:
1. the enrollee has been continuously covered under the Contract,or under any coverage plan
providing similar coverage which the Contract replaced, for at least six (6) months
immediately prior to the reduction in working hours;
2. the enrolling unit has imposed the reduction in hours due to economic conditions;
3. the enrolling unit intends to restore the enrollee to a full 40 hour work schedule as soon as
economic conditions improve; and
4. the applicable Health services Fees are paid.
INDEX
How to use this index:
The Definitions are found in Section I.Specific topics are cross Rendered by Non-Participating Providers Section IX
referenced for your convenience. Please refer to Section I. Rendered by Participating Providers Section IX
Definitions (DEF) for specific information as related to the Skilled Nursing Facility Section X E.
topic. (Example: Adoption:See Section I,Definition-Family Temporomardibular Joint Syndrome Section X E.
Dependent)
Adoption Section II Indentification Card E.O.C.
Dee Family Dependent
Limitation on Selection Provider Section IX
Benefit Determination Rules Section IV
Marriage Section II
Clerical Error Section VIII Del:Family Dependent
Complaint Process Section V Newborn Coverage Section II
Deft Family Dependent
Conformity with Statutes Section VIII
No Fault Coverage Section IV
Continuation of Individual Coverage Section VI
Non Discrimination Section VIII
Contract Alterations Section VIII
Notice to
Contract Charges Section VII Enrolling Unit Section VIII
Enrollees Section VIII
Conversion Section VI Section ection
Coordination of Benefits Section IV
Reimbursement of Section II
Copayment Oct Copyament figible Espana Section
II
Section II ��t
Section III Section VIII
Section IX Relationship Between Parties
Section X-See Specific Section IV
Health Services Right of Recovery
Effective Date of Coverage Section II Second Opinion Policy Section DC
Eligible Expenses Section II-Def. Section IV
Subrogation
Emergency Health Services Section DC
Termination of Section VI
Enrollment Section II Individual Coverage Section VII
Contract
Examination of Covered-Person Section VIII
Verbal Complaint Section V
Grievance Section V Section VIII
Worker's Compensation
Health Services
Ambulance Services Section X E. Written Complaint Section V
Blood&Blood Products Section X E.
Family Planning Section X C.
Hemodialysis Section X E.
Home Health Services Section X E.
Hospital Services Section X B.
Infertility Planning Section X C.
Maternity Services Section X C.
Mental Health Services Section X D.
Obtaining Services Section IX
Physician Services Sedan X A.
Private Duty Nursing Section X E.
Rehabilitation Services Section X E. Sil, ,
-27 -
is of August 1, 1992 the name of our healt
plan has changed to TakeCare of Colorado,
Inc., from Lincoln National Health Plan.
Lincoin iNattonal health Plan of Colorado
Master Group Contract
Amendment I (Effective 01/01/92)
Design I - 6729(10/91) Design III - 6910(10/91) Design IV - 6928(12/91)
Design Va - 6752(10/91) Design VIa - 6753(10/91) Design IXa - 6754(10/91)
Design X - 6730(10/91)
This amendment replaces Section VI, Continuation Coverage, Part II: Continuation of Coverage Under State Law.
Part II: Continuation of Coverage Under State Law
An Enrollee whose Coverage ends under the Contract may be entitled to elect continuation Coverage under state law, if the
Enrolling Unit is not subject to the requirements of COBRA, or as an alternative to COBRA when both state law and
COBRA apply.
The Enrollee's Coverage must have ended due to termination of employment. The Enrollee shall not be entitled to
continuation Coverage under state law if:
a. Health Services Fees for Coverage up to the termination date have not been paid by or on
behalf of the Enrollee; or
b. the Enrollee has not been continuously covered under the Contract, or under any coverage
plan providing similar coverage which the contract replaced, for at least six (6) months
immediately prior to termination from employment; or
c. the Enrollee is covered by Medicare of Medicaid; or
d. the entire Contract is discontinued.
The Enrollee must elect continuation Coverage and pay Health Services Fees due within twenty (20) days from the date of
termination from employment.
Continuation of Coverage under state law will end after a period of ninety(90)days after the date Coverage would have ended,
or until the Enrollee is reemployed,whichever occurs first. At the end of the ninety(90) day continuation period under state
law, the Enrollee or the Enrolled Family Dependents are entitled to conversion privileges as described below.
Coverage may be continued for enrollees working 40 hours or more when the working hours are reduced to less than 30 hours
because of economic conditions. Coverage may also be continued for such enrollees enrolled family dependents.
Coverage may be continued provided:
1. the enrollee has been continuously covered under the Contract,or under any coverage plan
providing similar coverage which the Contract replaced, for at least six (6) months
immediately prior to the reduction in working hours;
2. the enrolling unit has imposed the reduction in hours due to economic conditions;
3. the enrolling unit intends to restore the enrollee to a full 40 hour work schedule as soon as
economic conditions improve; and
4. the applicable Health services Fees are paid.
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