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RESOURCE BANCSHARES MORTGAGE GROUP, INC.
Preferred Provider Organization Plan (PPO)
for Retired Executives
May 1, 1998
UNITEDhealthcare(R)
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Table of Contents
Certification........................................................ 3
Schedule of Benefits ................................................ 4
Effective Date of this Plan ................................... 4
Medical Benefits .............................................. 4
Mental Health Benefits ........................................ 5
Pregnancy Benefits ............................................ 5
Preventive Health Care Benefits ............................... 5
Family Planning Benefits ...................................... 6
Prescription Drug Benefits .................................... 6
Transplant Benefit Management Program ......................... 6
Coverage under the Former Plan ................................ 6
Eligibility ......................................................... 7
Eligible Employees ............................................ 7
Eligible Dependents ........................................... 7
Cost of Coverage .............................................. 7
Enrollment Requirements ....................................... 7
Enrollment Periods ............................................ 8
Effective Date of Employee Coverage ........................... 9
Effective Date of Dependent Coverage .......................... 9
Qualified Medical Child Support Order ......................... 9
Special Provision for Newborn Children ........................ 9
Utilization Review .................................................. 10
Notification .................................................. 10
Mental Disorder Treatment ..................................... 12
Preferred Provider Plan ............................................. 13
Network Benefits .............................................. 14
Non-Network Benefits .......................................... 14
Medical Benefits .................................................... 15
Copayments and Deductibles .................................... 15
Out-of-Pocket Feature ......................................... 16
Maximum Benefit ............................................... 17
Covered Services and Supplies ................................. 17
Mental Health Benefits .............................................. 24
Additional Covered Services and Supplies ...................... 24
Pregnancy Benefits .................................................. 25
Additional Covered Services and Supplies ...................... 25
Family Planning Benefits ............................................ 26
Covered Services and Supplies ................................. 26
Preventive Health Care Benefits ..................................... 26
Covered Services and Supplies ................................. 27
Prescription Drug Benefits .......................................... 27
Copayments .................................................... 27
Network Pharmacy .............................................. 27
Non-Network Pharmacy .......................................... 28
Mail Service Network Pharmacy ................................. 28
Supply Limits ................................................. 28
Glossary ...................................................... 29
Not Covered ................................................... 30
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Transplant Benefit Management Program ............................... 30
General Exclusions and Limitations .................................. 32
Claims Information .................................................. 35
How to File a Claim ........................................... 35
When Claims Must be Filed ..................................... 35
How and When Claims Are Paid .................................. 36
Legal Actions ................................................. 36
Incontestability of Coverage .................................. 36
Review Procedure for Denied Claims ............................ 36
Coordination of Benefits ............................................ 37
Definitions ................................................... 37
How Coordination Works ........................................ 37
Which Plan Pays First ......................................... 38
Right to Exchange Information ................................. 39
Facility of Payment ........................................... 39
Right of Recovery ............................................. 39
Recovery Provisions ................................................. 39
Refund of Overpayments ........................................ 39
Subrogation ................................................... 40
Effect of Medicare and Government Plans ............................. 40
Medicare ...................................................... 40
Government Plans (other than Medicare and Medicaid) ........... 42
Termination of Coverage ............................................. 42
Employee Coverage ............................................. 42
Dependent Coverage ............................................ 42
Extended Benefits ................................................... 43
Conversion Coverage ................................................. 43
Conditions for Conversion ..................................... 44
How to Apply .................................................. 45
Limitations ................................................... 45
Conversion Coverage for Medicare Eligibles .................... 46
Glossary ............................................................ 46
Continuation of Health Coverage (COBRA) ............................. 56
Summary Plan Description ............................................ 59
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Certification
CERTIFICATE OF INSURANCE
for Employees of
Resource Bancshares Mortgage Group,
Inc.
(called the Employer)
insured by
UNITED HEALTHCARE INSURANCE COMPANY
Hartford, Connecticut
(called the Company)
United HealthCare Insurance Company has issued Group Policy No. GA-187129G.
It covers certain Employees of the Employer.
This Certificate of Insurance describes the benefits and provisions of the
policy. Additional benefits and provisions may apply based on the
requirements of
-- The state where the policy is issued.
-- The state where the Employee lives.
These state benefits and provisions are described in separate Amendments.
See the Employer for details.
This is a Covered Person's Certificate of Insurance only while that person
is insured under the policy. Dependent benefits apply only if the Employee
is insured under the Employer's Plan for Dependent Benefits.
This Certificate describes the Plan in effect as of May 1, 1998 for Retired
Executives enrolled in the Preferred Provider Organization Plan. It is void
if issued to any other Employee.
This Certificate replaces any and all Certificates previously issued for
Employees under the plan.
UNITED HEALTHCARE INSURANCE COMPANY
/s/ Ben B. Cuy
President and CEO
C-CE1, C-SB2, C-EL1SC, C-EL6, C-RE1, C-PP1, C-MB1, C-MH1, C-PB1, C-FP1,
C-PH1, C-PD5, C-TB1, C-GE1SC, C-CI1, C-CB1SC, C-RP1SC, C-EM1, C-TE1, C-EB1,
C-CR1, C-GL1,
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Schedule of Benefits
Effective Date of this Plan
May 1, 1998
Medical Benefits
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MAXIMUM BENEFITS
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Lifetime Maximum Benefit $2,000,000
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Durable Medical Equipment - Calendar Year Maximum $ 50,000
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Nursing Services - Lifetime Maximum $ 50,000
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DEDUCTIBLES AND OUT-OF-POCKET MAXIMUMS
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Non-Network Individual Deductible $ 250
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Non-Network Family Deductible $ 750
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Non-Notification Deductible
(Applicable only if Medical Management is not
notified as required. It does not count toward
the Out-of-Pocket Feature.) $ 500
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Network Individual Out-of-Pocket Maximum $ 1,000
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Network Family Out-of-Pocket Maximum $ 3,000
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Non-Network Individual Out-of-Pocket Maximum $ 2,000
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Non-Network Family Out-of-Pocket Maximum $ 6,000
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COPAYMENTS
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Office Visit Copayment $ 10
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Emergency Room Copayment $ 50
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PERCENTAGE OF COVERED EXPENSES PAYABLE BEFORE DEDUCTIBLES ARE SATISFIED
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Independent Labs, X-Rays and MRI Facilities 100%
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Durable Medical Equipment 100%
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Home Health Care*
*The care must be recommended by Medical
Management 100%
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PERCENTAGE OF COVERED EXPENSES PAYABLE FOR PREVENTIVE HEALTH CARE
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Services received from a Network Physician
(The Office Visit Copayment applies.) 100%
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PERCENTAGE OF COVERED EXPENSES PAYABLE AFTER
DEDUCTIBLES/COPAYMENTS ARE SATISFIED
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Network Non-Network
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Office Visits 100% 70%
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Physician's Services 90% 70%
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Hospital Services 90% 70%
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Ambulatory Surgical Center Services 90% 70%
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Home Health Care Provider Services
(including home IV therapy) 90% 70%
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Hospice Care Provider Services 90% 70%
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Physical Therapist Services 90% 70%
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Rehabilitation Facility Services 90% 70%
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Skilled Nursing Facility Confinement Services 90% 70%
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All Other Covered Expenses for Medical
Benefits 90% 70%
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Mental Health Benefits
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MAXIMUM BENEFITS EACH CALENDAR YEAR
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Inpatient 30 days
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Outpatient 30 visits
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Mental Health Benefits are subject to the same Cash Deductibles and
Percentages as Medical Benefits. There is no Out-of-Pocket Maximum
applicable to Mental Health Benefits.
Pregnancy Benefits
Pregnancy Benefits are payable in the same manner as Medical Benefits.
Preventive Health Care Benefits
Preventive Health Care Benefits are payable in the same manner as Medical
Benefits.
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Family Planning Benefits
Family Planning Benefits are payable in the same manner as Medical Benefits.
Prescription Drug Benefits
Prescription Drug Benefits are payable as described in the section
Prescription Drug Benefits.
Transplant Benefit Management Program
Benefits for Qualified Procedures performed at a Designated Transplant
Facility are payable at 100% of Covered Expenses without application of
deductibles.
Coverage under the Former Plan
This section applies only to persons covered under this Employer's prior
group plan (called the Former Plan) in effect on the day before the
Effective Date of this Plan. The coverage described in this Certificate
replaces the coverage under the Former Plan.
Coverage and benefits paid under the Former Plan will be considered as
coverage and benefits paid under this Plan for figuring the following under
any benefits of this Plan:
-- Benefit limits and maximum amounts. Any Covered Expenses applied toward
the benefit limits or maximum amounts under the Former Plan are applied
to those same benefit limits or maximum amounts under this Plan.
-- Coinsurance percentage.
A person may have satisfied or partially satisfied an out-of-pocket maximum
or a deductible requirement under the Former Plan. Expenses counted toward
either of them under the Former Plan will be counted toward them under this
Plan. They will be counted under this Plan the same way they were counted
under the Former Plan.
Certain children will be included as Eligible Dependents under this Plan
regardless of age. The child must have been covered under the Former Plan.
The child must meet the following conditions:
-- The child is mentally or physically incapacitated.
-- The child is not capable of self-support.
-- The child depends mainly on the Employee for support.
The Employee must give the Company proof that the child meets these
conditions when requested.
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Eligibility
Eligible Employees
All Retired Executive Employees* of the Employer enrolled in the Preferred
Provider Organization (PPO) Plan.
* Whenever the term "Employee(s) is used in this certificate, it means a
Retired Employee as defined in the Glossary.
Employees must reside in the United States.
Eligible Dependents
Dependents are:
-- A wife or husband of an eligible Employee.
-- Any unmarried child from birth until the end of the month following the
19th birthday of the child of an eligible Employee.
-- An unmarried child until the end of the month following the 25th
birthday of the child of an eligible Employee, if the child is a
registered student in regular full-time attendance at school. The child
must be mainly dependent on the Employee for care and support. The child
cannot be employed on a regular full-time basis by one or more employers
for a total of 30 or more hours per week.
-- Child includes the following:
-- A stepchild who resides in the eligible Employee's home.
-- A legally adopted child. (A child is considered legally adopted on
the earlier of the date of placement or the date the legal adoption
proceedings have been started.)
-- Any other child related to an eligible Employee, mainly dependent on
the eligible Employee for care and support and residing in the
eligible Employee's home.
Dependents must reside in the United States.
Cost of Coverage
The coverage under this Plan is contributory. This means that Employees must
make contributions toward the cost of coverage.
Enrollment Requirements
The date the person is enrolled under this Plan.
Employee Coverage
An Employee enrolls for Employee coverage by:
-- completing an enrollment form, and
-- giving the form to the Employer.
An Employee's enrollment is either timely or late.
An Employee is considered a timely enrollee if he or she enrolls during
either the Initial Eligibility Period or a Special Enrollment Period.
An Employee is considered a late enrollee when he or she enrolls during the
Annual Enrollment Period.
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Dependent Coverage
An Employee must enroll for coverage as an Employee in order to enroll his
or her Dependents. If a husband and wife are both eligible Employees, only
one may enroll Dependents for coverage.
No person can be covered both as an Employee and as a Dependent.
Initial Dependents are those family members who are eligible Dependents on
the date the Employee first becomes eligible for Employee coverage.
Subsequent Dependents are any family members who become Eligible Dependents
after the date the Employee first becomes eligible under this Plan.
Subsequent Dependents may be added during a Special Enrollment Period.
A Dependent's enrollment is either timely or late.
A Dependent is considered a timely enrollee when he or she is enrolled for
coverage during either the Initial Eligibility Period or a Special
Enrollment Period.
A Dependent is considered a late enrollee when he or she enrolls during the
Annual Enrollment Period.
Enrollment Periods
The Initial Eligibility Period is the 31-day period which begins on the date
the person is first eligible under this Plan.
Employees and/or Dependents who are not enrolled during the Initial
Eligibility Period or a Special Enrollment Period must wait until the next
Annual Enrollment Period to enroll for coverage.
The Annual Enrollment Period is designated by the Employer each year. It is
held before the start of each Plan Year. During this period, all eligible
Employees and Dependents can enroll for coverage.
Special Enrollment Periods are available to certain persons who have lost
other coverage and to certain dependents.
A Special Enrollment Period is available to a person who meets each of the
following conditions:
-- The Employee or Dependent was covered under a group health plan or had
health insurance coverage at the time coverage under this Plan was
previously offered to the Employee or Dependent.
-- The Employee stated in writing, at the time coverage was previously
offered, that the other coverage was the reason for declining enrollment
under this Plan. The Employer must have requested the statement at that
time. The Employer must have provided the Employee with notice of this
requirement (and its consequences) at that time.
-- The Employee's or Dependent's prior coverage was one of the following:
-- COBRA continuation which was exhausted.
-- Non-COBRA coverage which was terminated either as a result of loss
of eligibility for the coverage (including as a result of legal
separation, divorce, death, termination of employment, or reduction
in the number of hours of employment) or employer contributions
towards such coverage were terminated.
-- The Employee requests enrollment under this Plan not later than 31 days
after the date of the end of the COBRA continuation, termination of
coverage, or termination of Employer contribution.
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A Special Enrollment Period is available to Subsequent Dependents. The
Dependent Special Enrollment Period is the 31-day period which begins with
the date the person becomes a Dependent.
If a Subsequent Dependent is enrolled, the Employee must enroll at the same
time if not already covered. In addition, any of the Employee's other
Dependents may be enrolled at the same time, if not already covered, subject
to the same enrollment requirements.
Late Enrollees
A late enrollee can enroll only during an Annual Enrollment Period.
Effective Date of Employee Coverage
Employee coverage is effective on the first day of the month coincident with
or next following the latest of.
-- The Effective Date shown in Schedule of Benefits.
-- The date the Employee enrolls for coverage.
-- The date the Employee becomes a Retired Employee.
Effective Date of Dependent Coverage
Coverage for an Initial Dependent(s) is effective on the later of the
following dates:
-- The date the Employee becomes covered.
-- The date the Employee enrolls the Dependents.
Coverage for a Subsequent Dependent is effective as follows:
-- For a spouse, the first day of the month coincident or next following
the later of the date the spouse is enrolled and the date of marriage.
-- For a newborn child, the date of birth.
-- For an adopted child, the date of adoption or placement for adoption.
-- For any other child, the date the child becomes a Dependent.
Qualified Medical Child Support Order
If an Employee is required by a qualified medical child support order, as
defined in the Omnibus Budget Reconciliation Act of 1993 (OBRA 93), to
provide coverage for his/her children, these children can be enrolled as
timely enrollees as required by OBRA 93.
If the Employee is not already enrolled, the Employee may also enroll as a
timely enrollee at the same time.
Special Provision for Newborn Children
Plan Benefits are payable for a newborn child for 31 days after the child's
birth, even if the Employee has not enrolled the child.
If additional contributions are required from the Employee for the coverage
of that child, the Employee must enroll the child during the 31-day Special
Enrollment Period in order for the child to be a timely enrollee.
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Utilization Review
Covered Services and Supplies under this Plan are subject to a Utilization
Review (UR).
Medical Management determines the Medical Necessity of the services. No
benefits are payable unless Medical Management determines the Covered
Services and Supplies are Medically Necessary.
The ultimate decisions on medical care must be made by the Covered Person
and his or her Physician. Medical Management only determines the Medical
Necessity of a listed service or supply according to the Plan benefits and
provisions.
Approval by Medical Management does not guarantee that benefits are payable
under this Plan. Benefits are based on:
-- The Covered Services and Supplies actually performed or given.
-- The Covered Person's eligibility under this Plan on the date the Covered
Services and Supplies are performed or given.
-- Copayments, deductibles, coinsurance, maximum limits and all other terms
of this Plan.
Notification
Medical Management must be notified for any of the services shown below:
Inpatient
-- Hospital confinement.
-- Skilled Nursing Facility confinement.
Outpatient
-- Back surgery.
-- Ear, nose and throat surgery.
-- Female pelvic surgery.
-- Foot surgery.
-- Gall bladder surgery.
-- Hand/wrist surgery.
-- Heart surgery.
-- Knee surgery.
-- Rectal Surgery.
-- Home Health Care.
-- Private duty nursing.
Organ/Tissue Transplants
How To Notify Medical Management
Medical Management is notified by calling the toll-free number shown on the
ID card.
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When to Notify Medical Management
-- For inpatient confinement, the Covered Person must notify Medical
Management of the scheduled admission date at least 5 working days
before the start of the confinement. An admission date may not have been
set when the confinement was planned. The Covered Person must call
Medical Management again as soon as the admission date is set.
-- Pregnancy is subject to the following notification time periods:
-- Prenatal Programs - Medical Management should be notified during the
first trimester (12 weeks) of pregnancy. This early notification
makes it possible for the mother to participate in the prenatal
programs.
-- Inpatient Confinement for Delivery of Child -- Medical Management
must be notified only if the inpatient care for the mother or child
is expected to continue beyond:
-- 48 hours following a normal vaginal delivery, or
-- 96 hours following a cesarean section.
For inpatient care (for either the mother or child) which continues
beyond the 48/96 hour limits stated above, Medical Management must
be notified before the end of these time periods.
-- Non-Emergency Inpatient Confinement Without Delivery of Child--
Confinement during pregnancy but before the admission for delivery,
which is not Emergency Care, requires notification as a scheduled
confinement. Medical Management must be notified prior to the
scheduled admission.
-- For outpatient services which require notification, the Covered Person
must notify Medical Management at least five working days before the
service is given.
-- Organ/Tissue Transplants
A Covered Person must notify Medical Management at least seven working
days before the scheduled date of any of the following or as soon as
reasonably possible:
-- The evaluation.
-- The donor search.
-- The organ procurement/tissue harvest.
-- The transplant.
Medical Management will then complete the Utilization Review. The Covered
Person, the Physician and the facility will be sent a letter confirming the
results of the Review.
Benefits Reduced if Medical Management Not Called
Benefits are reduced if the Covered Person does not call Medical Management
as required. This reduction is called a Non-Notification Deductible. A
Non-Notification Deductible applies to each confinement, surgical procedure,
or treatment plan.
The amount of the Non-Notification Deductible is shown in the Schedule of
Benefits. The amount of the Non-Notification Deductible will never be more
than the amount of the Covered Expenses.
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A Covered Person can appeal a Utilization Review by calling Medical
Management.
If the Covered Person or the Physician does not agree with Medical
Management's decision, it can be appealed.
-- The Covered Person or the Physician can request Medical Management to
reconsider the decision by writing or telephoning within 60 days of the
decision.
-- If the Covered Person, the Physician and Medical Management still cannot
find an acceptable solution, this decision can be reappealed. Another
Physician will review the facts of the case -- taking into account the
Covered Person's and the attending Physician's point of view -- and make
a final decision.
Emergency Care
When Emergency Care is required and results in a confinement, the Covered
Person (or that person's representative or Physician) must call Medical
Management. Medical Management must be called within one working day of the
date the confinement begins.
A working day is a business day of the Company. It does not include
Saturday, Sunday or a State or Federal holiday. If it is not reasonably
possible to call Medical Management within one working day, Medical
Management must be notified as soon as reasonably possible.
When the Emergency Care has ended, however, Medical Management must be
called before any additional services are received.
Benefits are subject to the Non-Notification Deductible if Medical
Management is not called as shown above. The Non-Notification Deductible
applies to each confinement.
The amount of the Non-Notification Deductible is shown in the Schedule of
Benefits. The amount of the Non-Notification Deductible will never be more
than the amount of the Covered Expenses.
Mental Disorder Treatment
Notification Requirement
The Covered Person must call Behavioral Health Care Management (BHCM) before
Covered Services and Supplies are given for Mental Disorder Treatment. This
call starts the Utilization Review process.
BHCM can be contacted by calling the toll-free number in the directory of
providers, or by calling Customer Service at the toll-free number shown on
the ID card.
Benefits under this Plan are subject to the Non-Notification Deductible if
BHCM is not called before services are received.
The amount of the Non-Notification Deductible is shown in the Schedule of
Benefits. The amount of the Non-Notification Deductible will never be more
than the amount of the Covered Expenses.
BHCM performs a Utilization Review to determine the Medical Necessity of
Covered Services and Supplies. No benefits are payable unless BHCM
determines the Covered Services and Supplies are Medically Necessary.
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Emergency Care
When Emergency Care is required for Mental Disorder Treatment, the Covered
Person (or representative or Physician) must call BHCM within one day after
the Emergency Care is given. BHCM is ready to take calls 7 days a week, 24
hours a day. If it is not reasonably possible to make this call within one
calendar day, the call must be made as soon as reasonably possible.
When the Emergency Care has ended, BHCM must be called before any additional
services are received.
Benefits are subject to the Non-Notification Deductible if BHCM is not
called as required above.
The amount of the Non-Notification Deductible is shown in the Schedule of
Benefits. The amount of the Non-Notification Deductible will never be more
than the amount of the Covered Expenses.
Appeal
The Covered Person can appeal a Utilization Review. Call BHCM for further
information.
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Preferred Provider Plan
This Plan pays for Covered Services and Supplies received from either
Network or Non-Network Providers.
If Network Providers are used, this Plan pays a greater portion of Covered
Expenses. This is called the Network level.
If Non-Network Providers are used, this Plan pays a lesser portion of
Covered Expenses. This is called the Non-Network level.
A directory of the Network Providers is available from the Employer.
There are many types of providers who participate in the Network. The
following types of providers participate in the Network:
-- Ambulatory Surgical Centers.
-- Chiropractors.
-- Durable Medical Equipment Providers.
-- Home Health Care Providers.
-- Home IV Providers.
-- Hospices.
-- Hospitals.
-- Physical Therapists.
-- Physicians.
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-- Podiatrists.
-- Rehabilitation Facilities.
-- Skilled Nursing Facilities.
This Plan also covers Specialized Providers and Specialized Facilities.
These are types of providers which are not represented in the Network. These
providers and facilities are not subject to the Network/Non-Network level of
coverage. Instead these types of providers are covered at 80%.
Network Benefits
This Plan pays the Network percentage for Network Provider services as shown
in the Schedule of Benefits. See Medical Benefits for a complete description
of any deductibles or copayments that may apply under this Plan.
Non-Network Providers Paid At Network Level
-- Radiology, anesthesiology, and pathology services are paid at the
Network level. Services must be given in one of the settings shown
below:
-- Inpatient Hospital.
-- Outpatient facility which is part of a Hospital.
-- Ambulatory Surgical Center.
-- Emergency Care.
Emergency Care is payable at the Network level, even if services are
received from a Non-Network Provider.
Network Provider Charges Not Covered
A Network Provider has contracted with the Company to participate in the
Network. Under this contract a Network Provider may not charge the Covered
Person or the Company for certain expenses, except as stated below. A
Network Provider cannot charge the Covered Person or the Company for any
services or supplies which are not Medically Necessary.
The Covered Person may agree with the Network Provider to pay any charges
for services and supplies which are not Medically Necessary. In this case,
the Network Provider may make charges to the Covered Person. However, these
charges are not Covered Expenses under this Plan and are not payable by the
Company.
Non-Network Benefits
This Plan pays the Non-Network percentage of Covered Expenses as shown in
the Schedule of Benefits for Non-Network Provider services.
See Medical Benefits for a complete description of the deductibles that
apply under this Plan.
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Medical Benefits
Medical Benefits are payable for Covered Expenses incurred by the Covered
Person while covered under this Plan.
Covered Expenses are the actual cost to the Covered Person of the Reasonable
Charge for Covered Services and Supplies listed in this Benefit. The
Company, in its discretion, will calculate Covered Expenses following
evaluation and validation of all provider billings in accordance with:
-- The methodologies in the most recent edition of the Current Procedural
Terminology.
-- The methodologies as reported by generally recognized professionals or
publications.
The Covered Expenses must be incurred for the care of an accidental injury
or Sickness. A Covered Expense is incurred on the date that the Covered
Service or Supply is performed or given.
Each Covered Person must satisfy certain Copayments and/or Deductibles
before any payment is made for certain Covered Services and Supplies. Then
the Medical Benefits pays the percentage of Covered Expenses shown in the
Schedule of Benefits.
There is a Lifetime Maximum shown in Schedule of Benefits.
After coverage under this Plan stops, Medical Benefits are payable as shown
in Extended Benefits.
Covered Services and Supplies for pregnancy are shown in Pregnancy Benefits.
Covered Services and Supplies for Mental Disorder Treatment are shown in
Mental Health Benefits.
Copayments and Deductibles
Before Medical Benefits are payable, each Covered Person must satisfy
certain Copayments and/or Deductibles.
A Copayment is the amount of Covered Expenses the Covered Person must pay to
a Network Provider at the time services are given. Copayments are not
counted toward any Deductible or Out-of-Pocket Feature. Covered Services and
Supplies which require a Copayment are not subject to a Deductible.
A Deductible is the amount of Covered Expenses the Covered Person must pay
before Medical Benefits are payable. After the Deductible has been met,
Covered Expenses are payable at the percentage shown in the Schedule of
Benefits.
The amount of each Copayment/Deductible is shown in the Schedule of
Benefits. A Covered Expense can only be used to satisfy one copayment or
deductible.
Office Visit Copayment
The Office Visit Copayment applies to Network Physician's Services. It also
applies to Network physical therapist's services if the physical therapist
bills for his/her services separately from any other charges. It applies to
all Covered Services and Supplies given in connection with each office
visit.
The Office Visit Copayment does not apply to the prenatal and postnatal
office visits to the Network obstetrician/gynecologist who is primarily
responsible for maternity care.
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Emergency Room Copayment
The Emergency Room Copayment applies to Hospital emergency room services. It
applies to each emergency room visit. Emergency room services are payable
only if it is determined that the services are Medically Necessary and there
is not a less intensive or more appropriate place of service, diagnostic or
treatment alternative that could have been used in lieu of emergency room
services. (See definition of Emergency Care.)
The Emergency Room Copayment does not apply if the Covered Person is
admitted as a Hospital inpatient.
Non-Network Individual Deductible
The Non-Network Individual Deductible applies to Covered Expenses charged by
a Non-Network Provider. It applies each Calendar Year.
Non-Network Family Deductible
The most a family will have to pay for Non-Network Individual Deductibles in
any Calendar Year, no matter how large a family may be, is the amount of the
Non-Network Family Deductible. Only Covered Expenses which count toward the
Covered Person's Non-Network Individual Deductible count toward this
Deductible.
Non-Notification Deductible
The Non-Notification Deductible applies to Covered Expenses if Medical
Management is not notified as required.
Out-of-Pocket Feature
Covered Expenses are payable at the percentage shown in the Schedule of
Benefits until any Out-of-Pocket Maximum shown in the Schedule of Benefits
has been reached during a Calendar Year. Then, Covered Expenses are payable
at 100% for the rest of that year as shown below.
All Covered Expenses that the Covered Person pays, other than those shown
below, count toward the Out-of-Pocket Maximums.
Covered Expenses used to satisfy the following Copayments and/or Deductibles
do not count toward any of the Out-of-Pocket Maximums. These Copayments and
Deductibles still apply even after the applicable Out-of-Pocket Maximum has
been reached:
-- Office Visit Copayment.
-- Emergency Room Copayment.
-- Non-Notification Deductible.
Network Individual Out-of-Pocket Maximum
When the Network Individual Out-of-Pocket Maximum is reached for any one
Covered Person in a Calendar Year, Network Covered Expenses, other than
those shown in the Out-of-Pocket Feature, are payable at 100% for that same
person for the rest of that year.
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Network Family Out-of-Pocket Maximum
When the Network Family Out-of-Pocket Maximum is reached for all Covered
Family Members in a Calendar Year, Network Covered Expenses, except those
shown in the Out-of-Pocket Feature, are payable at 100% for all Covered
Family Members for the rest of that year.
Non-Network Individual Out-of-Pocket Maximum
When the Non-Network Individual Out-of-Pocket Maximum is reached for any one
Covered Person in a Calendar Year, Non-Network Covered Expenses, other than
those shown in the Out-of-Pocket Feature, are payable at 100% for that
person for the rest of that year.
Non-Network Family Out-of-Pocket Maximum
When the Non-Network Family Out-of-Pocket Maximum is reached for all Covered
Family Members in a Calendar Year, Non-Network Covered Expenses other than
those shown in the Out-of-Pocket Feature, are payable at 100% for all
Covered Family Members for the rest of that year.
Maximum Benefit
The Maximum Benefit payable for each Covered Person is shown in the Schedule
of Benefits. This maximum applies to each Covered Person's lifetime.
Covered Services and Supplies
Covered Services and Supplies must be Medically Necessary and given for the
diagnosis or treatment of an accidental injury or Sickness.
A Covered Person and his or her Physician decide which services and supplies
are given, but this Plan only pays for the following Covered Services and
Supplies which are Medically Necessary as determined by the Company.
Covered Services and Supplies also include services and supplies that are
part of an Alternate Care Proposal (ACP). An ACP is a course of treatment
developed by the Company and authorized by the Employer as an alternative to
the services and supplies that would otherwise have been considered Covered
Services and Supplies.
Unless the ACP specifies otherwise, the provisions of the Plan related to
benefit amounts, maximum amounts, copayments and deductibles will apply to
these services.
Ambulatory Surgical Center Services
A Center's services given within 72 hours before or after a surgical
procedure. The services must be given in connection with the procedure.
Anesthetics
Chemotherapy
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Durable Medical Equipment
Durable Medical Equipment means equipment which meets all of the following:
-- It is for repeated use and is not a consumable or disposable item.
-- It is used primarily for a medical purpose.
-- It is appropriate for use in the home.
Some examples of Durable Medical Equipment are:
-- Appliances which replace a lost body organ or part or help an impaired
one to work.
-- Orthotic devices such as arm, leg, neck and back braces.
-- Hospital-type beds.
-- Equipment needed to increase mobility, such as a wheelchair.
-- Respirators or other equipment for the use of oxygen.
-- Monitoring devices.
The Company decides whether to cover the purchase or rental of the
equipment.
Payment for all Durable Medical Equipment and artificial aids is subject to
Calendar Year Maximum of $50,000 for each Covered Person.
Foot Care
Care and treatment of the feet, if needed due to severe systemic disease.
Routine care such as removal of warts, corns, or calluses, the cutting and
trimming of toenails, foot care for flat feet, fallen arches, and chronic
foot strain is a Covered Service only if needed due to severe systemic
disease.
Health Care Provider Services
Services of a licensed or certified Health Care Provider, other than a
Physician, when required by state law. Services given by a Health Care
Provider acting within the scope of that license or certification are
payable on the same basis as Covered Services given by a Physician.
Home Health Care
The following Covered Services must be given by a Home Health Care Agency:
-- Temporary or part-time nursing care by or supervised by a registered
graduate nurse (R.N.).
-- Temporary or part-time care by a home health aide.
-- Physical therapy.
-- Occupational therapy.
-- Speech Therapy.
Covered Services are limited to 40 visits each Calendar Year. Each period of
home health aide care of up to four hours given in the same day counts as
one visit. Each visit by any other member of the home health team will count
as one visit.
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Hospice Care
-- Room and Board.
-- Other Services and Supplies.
-- Part-time nursing care by or supervised by a registered graduate nurse
(R.N.).
-- Home Health Care Services as shown under Home Health Care. The limit on
the number of visits shown under Home Health Care does not apply to
Hospice patients.
-- Counseling for the patent and Covered Family Members.
-- Bereavement counseling for Covered Family Members. Services must be
given within six months after the patient's death. Covered Services are
limited to a total of 15 visits for each family.
Counseling must be given by a Licensed Counselor.
Services for the patient must be given in an inpatient Hospice facility or
in the patient's home.
The Physician must certify that the patient is terminally ill with six
months or less to live.
Any counseling services given in connection with a terminal illness will not
be considered as Mental Disorder Treatment.
Hospital Services
-- Room and Board.
Covered Expenses for a private room are limited to the regular daily
charge made by the Hospital for a semi-private room.
-- Other Services and Supplies.
-- Emergency Room.
Emergency room services are Covered Services only if it is determined
that the services are Medically Necessary and there is not a less
intensive or more appropriate place of service, diagnostic or treatment
alternative that could have been used in lieu of emergency room
services. If the Company, at its discretion, determines that a less
intensive or more appropriate treatment could have been given then no
benefits are payable.
Infertility Treatment
Diagnosis and treatment of infertility, including surgery and drug therapy.
Laboratory Tests and X-rays
X-rays or tests for diagnosis or treatment.
Medical Supplies
-- Surgical supplies (such as bandages and dressings). Supplies given
during surgery or a diagnostic procedure are included in the overall
cost for that surgery or diagnostic procedure. Covered expenses for a
surgical tray, which is a covered supply separate from the surgery, are
limited to $150.
-- Blood or blood derivatives only if not donated or replaced.
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Medical Transportation Services
Transportation by professional ambulance, other than air ambulance, to and
from a medical facility.
Transportation by regularly-scheduled airline, railroad or air ambulance, to
the nearest medical facility qualified to give the required treatment.
These services must be given within the United States, Puerto Rico or
Canada.
Nurse-Practitioner Services
Services of a licensed or certified Nurse-Practitioner acting within the
scope of that license or certification.
Oral Surgery and Dental Services
-- Oral surgery if needed as a necessary, but incidental, part of a larger
service in treatment of an underlying medical condition.
-- The following services and supplies are covered only if needed because
of accidental injury to natural teeth which happened to the Covered
Person while covered under this Plan:
-- Oral surgery.
-- Full or partial dentures.
-- Fixed bridge work.
-- Prompt repair to natural teeth.
-- Crowns.
Organ/Tissue Transplants
Services and supplies for Medically Necessary organ or tissue transplants
are payable under this Plan. Certain transplants (called Qualified
Procedures) are only payable if they are performed at a Designated
Transplant Facility. See Transplant Benefit Management Program for
information on how Qualified Procedures are paid.
Orthoptic Training (Eye Muscle Exercise)
Training by a licensed optometrist or an orthoptic technician. Covered
Services are limited to a lifetime maximum of 20 visits for each Employee or
Dependent spouse. Covered Services are limited to a lifetime maximum of 30
visits for each Dependent child.
Outpatient Occupational Therapy
Services of a licensed occupational therapist, provided the following
conditions are met:
-- The therapy must be ordered and monitored by a Physician.
-- The therapy must be given in accordance with a written treatment plan
approved by a Physician. The therapist must submit progress reports at
the intervals stated in the treatment plan.
Covered Services are limited to 20 visits each Calendar Year.
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Outpatient Physical Therapy
Services of a licensed physical therapist, provided the following conditions
are met:
-- The therapy must be ordered and monitored by a Physician.
-- The therapy must be given in accordance with a written treatment plan
approved by a Physician. The therapist must submit progress reports at
the intervals stated in the treatment plan.
Covered Services are limited to 20 visits each Calendar Year. Covered
Services are limited to three types of treatment to each body part during
each visit.
Physician Services
Medical Care and Treatment
-- Hospital, office and home visits.
-- Emergency room services.
Surgery
Services for surgical procedures.
Reconstructive Surgery
-- Reconstructive surgery to improve the function of a body part when the
malfunction is the direct result of one of the following:
-- Birth defect.
-- Sickness.
-- Surgery to treat a Sickness or accidental injury.
-- Accidental injury which happens while the person is covered under
this Plan.
-- Reconstructive breast surgery following a Medically Necessary
mastectomy.
-- Reconstructive surgery to remove scar tissue on the neck, face, or head
if the scar tissue is due to Sickness or accidental injury which happens
while the person is covered under this Plan.
Assistant Surgeon Services
Covered Expenses for assistant surgeon services are limited to 1/5 of the
amount of Covered Expenses for the surgeon's charge for the surgery. An
assistant surgeon must be a Physician. Surgical assistant's services are not
covered.
Multiple Surgical Procedures
Multiple surgical procedures means more than one surgical procedure
performed during the same operative session. Covered Expenses for multiple
surgical procedures are limited as follows:
-- Covered Expenses for a secondary procedure are limited to 50% of the
Covered Expenses that would otherwise be considered for the secondary
procedure had it been performed during a separate operative session.
-- Covered Expenses for any subsequent procedure are limited to 25% of the
Covered Expenses that would otherwise be considered for the subsequent
procedure had it been performed during a separate operative session.
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Prescribed Drugs and Medicines
-- Prescribed drugs and medicines for inpatient services.
-- Outpatient Prescription Drugs filled at a Non-Network Pharmacy.
(Outpatient Prescription Drugs filled at a Network Pharmacy are covered
under Prescription Drug Benefits unless the drugs are specifically
excluded under that benefit.)
Private Duty Nursing Care
Private duty nursing care given on an outpatient basis by a licensed nurse
(R.N., L.P.N., or L.V.N.).
Payment for outpatient private duty nursing care is subject to a Lifetime
Maximum of $50,000 for each Covered Person.
Psychologist Services
Radiation Therapy
Rehabilitation Therapy
Inpatient
-- Services of a Hospital or Rehabilitation Facility for room, board, care
and treatment during a confinement.
-- Inpatient rehabilitative therapy is a Covered Service only if intensive
and multidisciplinary rehabilitation care is necessary to improve the
patient's ability to function independently.
Covered Services are limited to a combined total of 120 days of confinement
in a Hospital, Skilled Nursing Facility and/or Rehabilitation Facility each
Calendar Year.
Outpatient
-- Services of a Hospital or Comprehensive Outpatient Rehabilitative
Facility (CORF).
-- Covered Services are limited to 20 days of therapy each Calendar Year. A
day of therapy includes all services given by or visits to the Hospital
or CORF in any one day.
-- Covered Services for each day of therapy reduces the number of visits
under Covered Services for Outpatient Physical Therapy, Outpatient
Occupational Therapy or Speech Therapy. This reduction only applies to
days of therapy during which the therapy includes services given by a
physical therapist, occupational therapist or speech therapist.
Skilled Nursing Facility Services
-- Room and Board.
Covered Expenses for Room and Board are limited to the facility's
regular daily charge for a semi-private room.
-- Other Services and Supplies.
Covered Services are limited to the first 120 days of confinement each
Calendar Year.
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Speech Therapy
Services of a licensed speech therapist.
These services must be given to restore speech lost or impaired due to one
of the following:
-- Surgery, radiation therapy or other treatment which affects the vocal
chords.
-- Cerebral thrombosis (cerebral vascular accident).
-- Brain damage due to accidental injury or organic brain lesion (aphasia).
-- Accidental injury which happens while a person is covered under this
Plan.
Covered Services are limited to 20 visits each Calendar Year.
Speech Therapy for Children Under Age 3
Services of a licensed speech therapist for treatment given to a child under
age 3 whose speech is impaired due to one of the following conditions:
-- Infantile autism.
-- Developmental delay or cerebral palsy.
-- Hearing impairment.
-- Major congenital anomalies that affect speech such as, but not limited
to, cleft lip and cleft palate.
Covered Services are limited to 20 visits each Calendar Year.
Spinal Manipulations
Services of a Physician given for the detection or correction (manipulation)
by manual or mechanical means of structural imbalance or distortion in the
spine.
Covered Services are limited to 20 visits each Calendar Year.
Exclusions and limitations that apply to this benefit are in General
Exclusions and Limitations.
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- - --------------------------------------------------------------------------------
Mental Health Benefits
Benefits are payable for Covered Services and Supplies for Mental Disorder
Treatment given to the Covered Person while covered under this Plan. These
Covered Services and Supplies are listed in Medical Benefits.
These Mental Health Benefits are subject to the same copayments, deductibles
and percentage of Covered Expenses payable as benefits that are paid due to
Sickness, except as shown below.
Mental Health Benefits include, but are not limited to:
-- Assessment.
-- Diagnosis.
-- Treatment planning.
-- Medication management.
-- Individual, family and group psychotherapy.
-- Psychological education.
-- Psychological testing.
After coverage under this Plan stops, extended benefits for Mental Health
Benefits are the same as for Sickness.
Covered Services and Supplies for Mental Disorder Treatment are subject to
the following limitations:
============================================================================
Maximum Benefits each Calendar Year
----------------------------------------------------------------------------
Inpatient 30 days
----------------------------------------------------------------------------
Outpatient 30 visits
============================================================================
The Out-of-Pocket Feature shown in Medical Benefits does not apply to Mental
Health Benefits. Covered Expenses incurred for Mental Disorder Treatment do
not count toward the Out-of-Pocket Maximums. After the Out-of-Pocket
Maximums are reached, benefits for Mental Disorder Treatment are not payable
at 100%.
Additional Covered Services and Supplies specific to Mental Disorder
Treatment are listed below. These Additional Covered Services and Supplies
are subject to the same requirements as Covered Services and Supplies listed
in Medical Benefits.
Additional Covered Services and Supplies
Licensed Counselor Services
Services of a Licensed Counselor for Mental Disorder Treatment.
Treatment Center Services
-- Room and Board.
-- Other Services and Supplies.
Exclusions and limitations that apply to this benefit are in General
Exclusions and Limitations.
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- - --------------------------------------------------------------------------------
Pregnancy Benefits
Benefits are payable for Covered Services and Supplies for pregnancy given
to the Covered Person while covered under this Plan. These Covered Services
and Supplies are listed in Medical Benefits.
Benefits for pregnancy are paid in the same way as benefits are paid for
Sickness.
Benefits are payable for at least:
-- 48 hours of inpatient care for the mother and newborn child following a
normal vaginal delivery.
-- 96 hours of inpatient care for the mother and newborn child following a
cesarean section.
The hospital or other provider is not required to get authorization from the
Company for the time periods stated above. Authorizations are required for
longer lengths of stay.
After coverage under this Plan stops, extended benefits for pregnancy are
the same as for Sickness.
The Office Visit Copayment does not apply to prenatal and postnatal office
visits (after the initial diagnosis) by the Network
obstetrician/gynecologist who is primarily responsible for the patient's
maternity care.
Additional Covered Services and Supplies specific to pregnancy are listed
below. These Additional Covered Services and Supplies are subject to the
same requirements as Covered Services and Supplies listed in Medical
Benefits.
Additional Covered Services and Supplies
Birth Center Services
-- Room and Board.
-- Other Services and Supplies.
-- Anesthetics.
Nurse-Midwife's Services
Services of a licensed or certified Nurse-Midwife.
Routine Well Baby Care
The following services and supplies given during a newborn child's initial
Hospital confinement:
-- Hospital services for nursery care.
-- Other Services and Supplies given by the Hospital.
-- Services of a surgeon for circumcision.
-- Physician Services.
Exclusions and limitations that apply to these benefits are in General
Exclusions and Limitations.
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- - --------------------------------------------------------------------------------
Family Planning Benefits
Benefits are payable for Covered Expenses for Family Planning Benefits
incurred by the Covered Person while covered under this Plan.
Covered Expenses are the actual cost to the Covered Person of the Reasonable
Charge for the Covered Services and Supplies listed in this Benefit. A
Covered Expense is incurred on the date that the Covered Service or Supply
is performed or given.
These Family Planning Benefits are subject to the same copayments,
deductibles and percentage of Covered Expenses payable as benefits that are
paid due to Sickness under Medical Benefits.
After coverage under this Plan stops, there are no extended benefits.
Covered Services and Supplies
Contraceptive Drugs, Services and Devices
Contraceptive drugs, services and devices, including but not limited to:
-- Intrauterine device and related Physician services.
-- Physician services related to a diaphragm fitting.
-- Voluntary sterilization by either vasectomy or tubal ligation.
-- Surgical implants for contraception, such as Norplant.
Charges for the diaphragm and oral contraceptives are covered under
Prescription Drug Benefits.
Exclusions and limitations that apply to these benefits are in General
Exclusions and Limitations.
- - --------------------------------------------------------------------------------
Preventive Health Care Benefits
Benefits are payable for Covered Services and Supplies for Preventive Health
Care Benefits given to a Covered Person by a Network Physician while the
person is covered under this Plan.
The Office Visit Copayment shown in the Schedule of Benefits applies to the
Covered Services and Supplies on the same basis as it applies to Sickness
under the Medical Benefits.
Benefits are payable at 100% of Covered Expenses after the Copayment has
been paid.
After coverage under this Plan stops, there are no extended benefits.
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Covered Services and Supplies
-- Routine physical exam for covered Employees and Dependent spouses,
including diagnostic tests and immunizations.
-- Child preventive care services given in connection with routine
pediatric care, including PKU tests and immunizations.
-- Routine well-woman exams. A well-woman exam includes the following:
-- Breast examination and/or mammogram.
-- Pelvic examination.
-- Pap smear.
-- Chromosome testing.
Exclusions and limitations that apply to these benefits are in General
Exclusions and Limitations.
- - --------------------------------------------------------------------------------
Prescription Drug Benefits
Benefits are payable for outpatient Prescription Drugs. The Prescription
Drugs must be prescribed for:
-- Medically Necessary treatment of an accidental injury, sickness, or
pregnancy.
-- Prevention of pregnancy.
Certain Prescription Drugs require Prior Authorization by a pharmacist or
physician from the Company or its designee.
The Covered Person must be covered under this Prescription Drug Benefit when
the prescription is filled.
Copayments
============================================================================
Retail Pharmacy
----------------------------------------------------------------------------
Generic Drug $10
----------------------------------------------------------------------------
Brand Name Drug $15
============================================================================
Mail Service Pharmacy
----------------------------------------------------------------------------
Generic Drug $15
----------------------------------------------------------------------------
Brand Name Drug $15
============================================================================
Network Pharmacy
When a Network Pharmacy is used, the Covered Person pays the Copayment.
Copayment amounts are shown above.
If the Prescription Drug Cost is less than the Copayment, the Copayment does
not apply and the Covered Person pays the Prescription Drug Cost.
Network Pharmacies dispense Generic Drugs whenever possible.
For Generic Drugs, a Covered Person pays the Generic Drug Copayment.
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29
A Covered Person pays the Brand Name Drug Copayment for Brand Name Drugs
dispensed under either of the following conditions:
-- There is no equivalent Generic Drug for substitution.
-- The Physician orders a Brand Name Drug. This is usually done by writing
"Dispense as written" on the prescription.
For all other Brand Name Drugs, a Covered Person pays:
-- The Brand Name Drug Copayment.
-- The difference in cost between the Generic Drug and the Brand Name Drug
dispensed. The difference is not counted as a Covered Expense under
Medical Benefits.
Non-Network Pharmacy
When a Non-Network Pharmacy is used, the Covered Person must pay for the
entire cost of each prescription at the time it is filled. Then the Covered
Person must submit a claim. Benefits are payable at the Non-Network level
under Medical Benefits.
Mail Service Network Pharmacy
A mail service pharmacy option has been provided for convenience. If the
mail service pharmacy is used, the Covered Person must pay the Copayment.
See your Employer for the necessary information about how to use the mail
service option.
There is no coverage for Prescription Drugs dispensed by a Non-Network Mail
Service Pharmacy.
Mail service pharmacies dispense Generic Drugs whenever possible.
For Generic Drugs, a Covered Person pays the Mail Service Generic Drug
Copayment.
A Covered Person pays the Mail Service Brand Name Drug Copayment for Brand
Name Drugs dispensed under either of the following conditions:
-- There is no equivalent Generic Drug for substitution.
-- The Physician orders a Brand Name Drug. This is usually done by writing
"Dispense as written" on the prescription.
For all other Brand Name Drugs, a Covered Person must pay:
-- The Mail Service Brand Name Drug Copayment.
-- The difference in cost between the Generic Drug and the Brand Name Drug.
The difference is not counted as a Covered Expense under Medical
Benefits.
Supply Limits
Retail Pharmacy
If the Prescription Drug is dispensed by a retail Pharmacy, the following
limits apply:
-- Up to a 31 day supply of a Prescription Drug, unless adjusted based on
the drug manufacturer's packaging size. Some products may be subject to
additional supply limits adopted by the Company. A list of current
additional supply limits may be obtained from the Company.
-- A one cycle supply of an oral contraceptive. Up to three cycles can be
purchased at one time if a Copayment is paid for each cycle supplied.
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30
Mail Service Pharmacy
If the Prescription Drug is dispensed by a mail service pharmacy, the supply
limit is up to a 90 day supply of a Prescription Drug, unless adjusted based
on the drug manufacturer's packaging size or any additional supply limits
adopted by the Company. A list of current supply limits may be obtained from
the Company.
Identification Card
If a Covered Person does not show the identification card at the time
Prescription Drugs are obtained, the Covered Person will be required to pay
the full cost of the Prescription Drug and get payment from the Company. In
that case, benefits are calculated at the predominant contract reimbursement
rate for a Network Pharmacy (including any sales tax), less the applicable
Copayment.
Glossary
Brand Name Drug
A Prescription Drug which is (1) manufactured and marketed under a trademark
or name by a specific drug manufacturer, and (2) identified as a Brand Name
Drug by the Company.
Generic Drug
A Prescription Drug which is: (1) chemically equivalent to a Brand Name Drug
whose patent has expired; and (2) identified as a Generic Drug by the
Company.
Network Pharmacy
A pharmacy which has (1) entered into an agreement with the Company or its
designee to provide Prescription Drugs to Covered Persons; (2) has agreed to
accept specified reimbursement rates for dispensing Prescription Drugs and
(3) has been designated by the Company as a Network Pharmacy. A Network
Pharmacy can be either a retail or a mail service pharmacy.
Prescription Drugs
A medication, product or device which has been approved by the Food and Drug
Administration and which can, under federal or state law, be dispensed only
pursuant to a Prescription Order or Refill. For the purpose of coverage
under the Plan, this definition includes insulin and the following diabetic
supplies: insulin syringes with needles; blood testing strips - glucose;
urine testing strips - glucose; ketone testing strips and tablets; lancets
and lancet devices.
Prescription Drug Cost
The Company's contracted reimbursement rate, including any sales tax, with
the Network Pharmacy where a Prescription Drug is dispensed. The
Prescription Drug Cost does not include any manufacturer's refunds or
incentive payments which may be received by and will be retained by the
Company.
Prescription Order or Refill
The directive to dispense a Prescription Drug issued by a duly licensed
health care provider whose scope of practice permits issuing such a
directive.
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Prior Authorization
The process of obtaining approval for certain Prescription Drugs, prior to
dispensing, using guidelines approved by the Company. This approval is to be
obtained from the Company by the prescribing physician or the pharmacist.
The list of Prescription Drugs requiring Prior Authorization is subject to
periodic review and modification by the Company.
Not Covered
-- Drugs for tobacco dependency or smoking cessation.
-- Drugs for infertility treatment.
-- Drugs given while confined in a Hospital, nursing home or similar place
that has its own drug dispensary.
-- Therapeutic devices or appliances, including colostomy supplies and
support garments, regardless of intended use. (This exclusion does not
apply to insulin syringes with needles, blood testing strips - glucose,
urine testing strips - glucose, ketone testing strips and tablets,
lancets and lancet devices which are covered.)
-- Injectable drugs. (This exclusion does not apply to insulin or
self-administered injectables which can be injected subcutaneously which
are covered.)
-- Progesterone suppositories.
-- Appetite suppressants and other weight loss products.
-- General and injectable vitamins. (This exclusion does not apply to
prenatal vitamins, vitamins with fluoride and B-12 injections which are
covered.)
-- Drugs dispensed in any amount which exceed the supply limits.
-- Replacement drugs resulting from a lost, stolen, broken or destroyed
Prescription Order or Refill.
-- Unit dose packaging of drugs.
-- Drugs available over-the-counter that do not require a Prescription
Order or Refill by federal or state law before being dispensed and any
drug that is therapeutically equivalent to an over-the-counter drug.
Other exclusions that apply to this benefit are in General Exclusions and
Limitations.
- - --------------------------------------------------------------------------------
Transplant Benefit Management Program
Services and supplies for Medically Necessary organ or tissue transplant
procedures listed below are payable under this Plan provided the procedures
are performed at a Designated Transplant Facility.
See "Organ/Tissue Transplants" under Medical Benefits for other transplants
that are payable under this Plan.
Medical Management must be notified at least seven working days before the
scheduled date of any of the following or as soon as reasonably possible:
-- The evaluation.
-- The donor search.
-- The organ procurement/tissue harvest.
-- The transplant procedure.
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32
Qualified Procedures
-- Heart transplants.
-- Lung transplants.
-- Heart/Lung transplants.
-- Kidney transplants.
-- Liver transplants.
-- Pancreas transplants.
-- Kidney/Pancreas transplants.
-- Bone Marrow/Stem Cell transplants.
Donor Charges for Organ/Tissue Transplants
-- In the case of an organ or tissue transplant, donor charges are
considered Covered Expenses ONLY if the recipient is a Covered Person
under this Plan. If the recipient is not a Covered Person, no benefits
are payable for donor charges.
-- The search for bone marrow/stem cell from a donor who is not
biologically related to the patient is not considered a Covered Service
UNLESS the search is made in connection with a transplant procedure
arranged by a Designated Transplant Facility.
Medical Care and Treatment
The Covered Expenses for services provided in connection with the transplant
procedure include:
-- Pre-transplant evaluation for one of the procedures listed above.
-- Organ acquisition and procurement.
-- Hospital and physician fees.
-- Transplant procedures.
-- Follow-up care for a period up to one year after the transplant.
-- Search for bone marrow/stem cell from a donor who is not biologically
related to the patient. If a separate charge is made for bone
marrow/stem cell search, a Maximum Benefit of $25,000 is payable for all
charges made in connection with the search.
Transportation and Lodging
Medical Management will assist the patient and family with travel and
lodging arrangements. Expenses for travel, lodging and meals for the
transplant recipient and a companion are available under this Plan as
follows:
-- Transportation of the patient and one companion who is traveling on the
same day(s) to and/or from the site of the transplant for the purposes
of an evaluation, the transplant procedure or necessary post-discharge
follow-up.
-- Reasonable and necessary expenses for lodging and meals for the patient
(while not confined) and one companion. Benefits are paid at a per diem
rate of $50 for one person or $100 for two people.
-- Travel and lodging expenses are only available if the transplant
recipient resides more than 50 miles from the Designated Transplant
Facility.
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-- If the patient is a covered dependent minor child, the transportation
expenses of two companions will be covered and lodging and meal expenses
will be reimbursed at the $100 per diem rate.
-- There is a combined overall lifetime maximum of $10,000 per Covered
Person for all transportation, lodging and meal expenses incurred by the
transplant recipient and companion(s) and reimbursed under this Plan in
connection with all transplant procedures.
Not Covered
No benefits are payable for services or supplies received in connection with
a Qualified Procedure which is not performed at a Designated Transplant
Facility.
Other exclusions and limitations that apply are in General Exclusions and
Limitations.
- - --------------------------------------------------------------------------------
General Exclusions and Limitations
This Plan does not cover any expenses incurred for services, supplies,
medical care or treatment relating to, arising out of, or given in
connection with, the following:
-- Services or supplies received before an Employee or his or her Dependent
becomes covered under this Plan.
-- Expenses incurred by a Dependent if the Dependent is covered as an
Employee for the same services under this Plan.
-- Abdominoplastys.
-- Breast reduction surgery.
-- Chelation therapy, except to treat heavy metal poisoning.
-- Completion of claim forms, or missed appointments.
-- Cosmetic or reconstructive surgery or treatment. (This is surgery or
treatment primarily to change appearance.) It does not matter whether or
not it is for psychological or emotional reasons. See Medical Benefits
for limited coverage of reconstructive surgery.
-- Custodial Care. This is care made up of services and supplies that meets
one of the following conditions:
-- Care furnished mainly to train or assist in personal hygiene or
other activities of daily living, rather than to provide medical
treatment.
-- Care that can safely and adequately be provided by persons who do
not have the technical skills of a covered health care professional.
Care that meets one of these conditions is custodial care regardless of
any of the following:
-- Who recommends, provides or directs the care.
-- Where the care is provided.
-- Whether or not the patient or another caregiver can be or is
being trained to care for himself or herself.
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34
-- Ecological or environmental medicine, diagnosis and/or treatment.
-- Education, training and bed and board while confined in an institution
which is mainly a school or other institution for training, a place of
rest, a place for the aged or a nursing home.
-- Eye glasses, contact lenses, eye refractions, hearing aids and cochlear
implants, unless required due to an accidental injury which happens
while covered under this Plan.
-- Herbal medicine, holistic or homeopathic care, including drugs.
-- Services, supplies, medical care or treatment given by one of the
following members of the Employee's immediate family:
-- The Employee's spouse.
-- The child, brother, sister, parent or grandparent of either the
Employee or the Employee's spouse.
-- Charges for procedures which facilitate a pregnancy but do not treat the
cause of infertility, such as in vitro fertilization, artificial
insemination, embryo transfer, gamete intrafallopian transfer, zygote
intrafallopian transfer and tubal ovum transfer.
-- Expenses and associated expenses incurred for services and supplies for
Experimental, Investigational or Unproven Services, treatments, devices
and pharmacological regimens, except for services which are otherwise
Experimental, Investigational, or Unproven that are deemed to be, in the
Company's judgment, covered transplant services. The fact that an
Experimental, Investigational or Unproven Service, treatment, device and
pharmacological regimen, is the only available treatment for a
particular condition will not result in coverage if the procedure is
considered to be Experimental, Investigational or Unproven in the
treatment of that particular condition.
-- Services and supplies which the Covered Person is not legally required
to pay.
-- Liposuction.
-- Surgical correction or other treatment of malocclusion.
-- Services or supplies which are not Medically Necessary, including any
confinement or treatment given in connection with a service or supply
which is not Medically Necessary.
-- Membership costs for health clubs, weight loss clinics and similar
programs.
-- Nutritional counseling.
For persons for whom coverage under a workers' compensation act or
similar law is optional because they could elect it, or could have it
elected for them, occupational injury or Sickness includes any injury or
Sickness that would have been covered under the workers' compensation
act or similar law had that coverage been elected.
-- Occupational injury or Sickness. An occupational injury or Sickness for
which workers' compensation is paid.
-- Examinations or treatment ordered by a court in connection with legal
proceedings unless such examinations or treatment otherwise qualify as
Covered Services.
-- Services given by a pastoral counselor.
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-- Personal convenience or comfort items including, but not limited to,
such items as TVs, telephones, first aid kits, exercise equipment, air
conditioners, humidifiers, saunas and hot tubs.
-- Private duty nursing services while confined in a facility.
-- Services for a surgical procedure to correct refraction errors of the
eye, including any confinement, treatment, services, or supplies given
in connection with or related to the surgery.
-- Services for, or related to, the removal of an organ or tissue from a
person for transplantation into another person, unless the transplant
recipient is a Covered Person under this Plan and is undergoing a
covered transplant.
-- Reversal of sterilization.
-- Sensitivity training, educational training therapy or treatment for an
education requirement.
-- Sex-change surgery.
-- Charges made by a Hospital for confinement in a special area of the
Hospital which provides non-acute care, by whatever name called,
including but not limited to the type of care given by the facilities
listed below.
If that type of facility is otherwise covered under this Plan, then
benefits for that covered facility which is part of a Hospital, as
defined, are payable at the coverage level for that facility, not at the
coverage level for a Hospital.
-- Adult or child day care center.
-- Ambulatory Surgical Center.
-- Birth Center.
-- Half-way house.
-- Hospice.
-- Skilled Nursing Facility.
-- Treatment Center.
-- Vocational rehabilitation center.
-- Any other area of a Hospital which renders services on an inpatient
basis for other than acute care of sick, injured or pregnant
persons.
-- Stand-by services required by a Physician.
-- Care of or treatment to the teeth, gums or supporting structures such
as, but not limited to, periodontal treatment, endodontic services,
extractions, implants or any treatment to improve the ability to chew or
speak. See Medical Benefits for limited coverage of oral surgery and
dental services.
-- Telephone consultations.
-- Tobacco dependency.
-- Services or supplies received as a result of war declared or undeclared,
or international armed conflict
-- Weight reduction or control (unless there is a diagnosis of morbid
obesity).
-- Special foods, food supplements, liquid diets, diet plans or any related
products.
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-- Wigs or toupees (except for loss of hair resulting from treatment of a
malignancy or permanent loss of hair from an accidental injury), hair
transplants, hair weaving or any drug if such drug is used in connection
with baldness.
-- Services given by volunteers or persons who do not normally charge for
their services.
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Claims Information
How to File a Claim
A claim form does not need to be filed when a Network Provider is used.
The following steps should be completed when submitting bills for payment:
-- Get a claim form from the Employer, the Plan Administrator or the
Company.
-- Complete the Employee portion of the form.
-- Have the provider complete the provider portion of the form.
-- Send the form and bills to the address shown on the form.
Make sure the bills and the form include the following information:
-- The Employee's name and social security number.
-- The Employees name and contract number (187129G).
-- The patient's name.
-- The diagnosis.
-- The date the services or supplies were incurred.
-- The specific services or supplies provided.
A bill or cash receipt for Prescription Drugs must also show the
prescription number and the name of the Physician who issued the
prescription.
If the covered Employee asks for a claim form but does not receive it within
15 days, the covered Employee can file a claim without it by sending the
bills with a letter, including all of the information listed above.
When Claims Must be Filed
The covered Employee must give the Company written proof of loss within 15
months after the date the expenses are incurred.
The Company will determine if enough information has been submitted to
enable proper consideration of the claim. If not, more information may be
requested.
No benefits are payable for claims submitted after the 15-month period,
unless it can be shown that:
-- It was not reasonably possible to submit the claim during the 15-month
period.
-- Written proof of loss was given to the Company as soon as was reasonably
possible.
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How and When Claims Are Paid
All payments will be paid to the covered Employee as soon as the Company
receives satisfactory proof of loss, except in the following cases:
-- If the covered Employee has financial responsibility under a court order
for a dependent's medical care, the Company will make payments directly
to the provider of care.
-- If the Company pays benefits directly to Network Providers.
-- If the covered Employee requests in writing that payments be made
directly to a provider. A covered Employee does this when completing the
claim form.
These payments will satisfy the Company's obligation to the extent of the
payment.
The Company will send an Explanation of Benefits (EOB) to the covered
Employee. The EOB will explain how the Company considered each of the
charges submitted for payment. If any claims are denied or denied in part,
the covered Employee will receive a written explanation.
Any benefits continued for Dependents after a covered Employee's death will
be paid to one of the following.
-- The surviving spouse.
-- A Dependent child who is not a minor, if there is no surviving spouse.
-- A provider of care who makes charges to the covered Employee's
Dependents for Covered Services and Supplies.
-- The legal guardian of the covered Employee's Dependent.
Legal Actions
The covered Employee may not sue on a claim before 60 days after proof of
loss has been given to the Company. The covered Employee may not sue after
three years from the time proof of loss is required, unless the law in the
area where the covered Employee lives allows for a longer period of time.
Incontestability of Coverage
This Plan cannot be declared invalid after it has been in force for two
years. It can be declared invalid due to nonpayment of premium.
No statement used by any person to get coverage can be used to declare
coverage invalid if the person has been covered under this Plan for two
years. In order to use a statement to deny coverage before the end of two
years, it must have been signed by the person. A copy of the signed
statement must be given to the person.
Review Procedure for Denied Claims
In cases where a claim for benefits payment is denied in whole or in part,
the claimant may appeal the denial. A request for review must be directed to
the Company within 90 days after the claim payment date or the date of the
notification of denial of benefits. When requesting a review, the claimant
should state the reason he or she believes the claim was improperly paid or
denied and submit any data or comments to support the claim.
A review of the denial will be made and the Company will provide the
claimant with a written response within 60 days of the date the Company
receives the claimant's request for review. If, because of extenuating
circumstances, the Company is unable to complete the review process within
60 days, the Company will notify the claimant of the delay within the 60 day
period and will provide a final written response to the request for review
within 120 days of the date the Company received the claimant's written
request for review.
If the denial is upheld, the Company's written response to the claimant will
cite the specific Plan provision(s) upon which the denial is based.
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Coordination of Benefits
(This provision does not apply to Prescription Drug Benefits.)
Coordination of benefits applies when a covered Employee or a covered
Dependent have health coverage under this Plan and one or more Other Plans.
One of the plans involved will pay the benefits first: that plan is Primary.
Other Plans will pay benefits next: those plans are Secondary. The rules
shown in this provision determine which plan is Primary and which plan is
Secondary.
Whenever there is more than one plan, the total amount of benefits paid in a
Calendar Year under all plans cannot be more than the Allowable Expenses
charged for that Calendar Year.
Definitions
"Other Plans" are any of the following types of plans which provide health
benefits or services for medical care or treatment:
-- Group insurance and group subscriber contracts.
-- Uninsured arrangements of group coverage.
-- Group coverage through HMOs and other prepayment, group practice and
individual practice plans.
-- The amount by which group Hospital indemnity benefits exceed $100 per
day.
-- The medical benefits coverage in a group and individual automobile "no
fault" and traditional automobile "fault" type contract.
-- Medicare and other governmental benefits, except as a state plan under
Medicaid and except as mandated by federal law.
"Primary Plan": A plan that is Primary will pay benefits first. Benefits
under that plan will not be reduced due to benefits payable under Other
Plans.
"Secondary Plan": Benefits under a plan that is Secondary may be reduced due
to benefits payable under Other Plans that are Primary.
"Allowable Expenses" means the necessary, reasonable and customary expense
for health care when the expense is covered in whole or in part under at
least one of the plans.
The difference between the cost of a private Hospital room and the cost of a
semi-private Hospital room is not considered an Allowable Expense unless the
patient's stay in a private Hospital room is Medically Necessary either in
terms of generally accepted medical practice, or as defined in the plan.
When a plan provides benefits in the form of services, instead of a cash
payment, the reasonable cash value of each service rendered will be
considered both an Allowable Expense and a benefit paid.
How Coordination Works
When this Plan is Primary, it pays its benefits as if the Secondary Plan or
Plans did not exist.
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When this Plan is a Secondary Plan, its benefits are reduced so that the
total benefits paid or provided by all plans during a Calendar Year are not
more than total Allowable Expenses. The amount by which this Plan's benefits
have been reduced shall be used by this Plan to pay Allowable Expenses not
otherwise paid, which were incurred during the Calendar Year by the person
for whom the claim is made. As each claim is submitted, this Plan determines
its obligation to pay for Allowable Expenses based on all claims which were
submitted up to that point in time during the Calendar Year.
The benefits of this Plan will only be reduced when the sum of the benefits
that would be payable for the Allowable Expenses under the Other Plans, in
the absence of provisions with a purpose like that of this Coordination of
Benefits provision, whether or not claim is made, exceeds those Allowable
Expenses in a Calendar Year.
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.
Which Plan Pays First
When two or more plans provide benefits for the same Covered Person, the
benefit payment will follow the following rules in this order
-- A plan with no coordination provision will pay its benefits before a
plan that has a coordination provision.
-- The benefits of the plan which covers the person other than as a
dependent are determined before those of the plan which covers the
person as a dependent.
-- The benefits of the plan covering the person as a dependent are
determined before those of the plan covering that person as other than a
dependent, if the person is also a Medicare beneficiary and both of the
following are true:
-- Medicare is secondary to the plan covering the person as a
dependent.
-- Medicare is primary to the plan covering the person as other than a
dependent (example, a retired employee).
-- When this Plan and another plan cover the same child as a dependent of
parents who are not separated or divorced, the benefits of the plan of
the parent whose birthday falls earlier in a year are determined before
those of the plan of the parent whose birthday falls later in that year.
This is called the "Birthday Rule." The year of birth is ignored.
If both parents have the same birthday, the benefits of the plan which
covered one parent longer are determined before those of the plan which
covered the other parent for a shorter period of time.
If the other plan does not have a birthday rule, but instead has a rule
based on the gender of the parent, and if, as a result, the plans do not
agree on the order of benefits, the rule in the other plan will
determine the order of benefits.
-- If two or more plans cover a person as a dependent child of divorced or
separated parents, benefits for the child are determined in this order:
-- First, the plan of the parent with custody for the child.
-- Second, the plan of the spouse of the parent with the custody of the
child.
-- Finally, the plan of the parent not having custody of the child.
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However, if the specific terms of a court decree state that one of
the parents is responsible for the health care expense of the child,
and the entity obligated to pay or provide the benefits of the plan
of that parent has actual knowledge of those terms, the benefits of
that plan are determined first. The plan of the other parent shall
be the Secondary Plan. This rule does not apply with respect to any
claim for which any benefits are actually paid or provided before
the entity has that actual knowledge.
-- If the specific terms of a court decree state that the parents shall
share joint custody, without stating that one of the parents is
responsible for the health care expenses of the child, the plans
covering the child shall follow the order of benefit determination
rules that apply to dependents of parents who are not separated or
divorced.
If none of the above rules determines the order of benefits, the benefits of
the plan which covered an employee, member or subscriber for the longer
period are determined before those of the plan which covered that person for
the shorter period.
Right to Exchange Information
In order to coordinate benefit payments, the Company needs certain
information. It may get needed facts from or give them to any other
organization or person. The Company need not tell, or get the consent of,
any person to do this.
A Covered Person must give the Company the information it asks for about
other plans. If the Covered Person cannot furnish all the information the
Company needs, the Company has the right to get this information from any
source. If any other organization or person needs information to apply its
coordination provision, the Company has the right to give that organization
or person such information. Information can be given or obtained without the
consent of any person to do this.
Facility of Payment
It is possible for benefits to be paid first under the wrong plan. The
Company may pay the plan or organization or person for the amount of
benefits that the Company determines it should have paid. That amount will
be treated as if it was paid under this Plan. The Company will not have to
pay that amount again.
Right of Recovery
The Company may pay benefits that should be paid by another plan or
organization or person. The Company may recover the amount paid from the
other plan or organization or person.
The Company may pay benefits that are in excess of what it should have paid.
The Company has the right to recover the excess payment.
- - --------------------------------------------------------------------------------
Recovery Provisions
Refund of Overpayments
If the Company pays benefits for expenses incurred on account of a Covered
Person, that Covered Person or any other person or organization that was
paid must make a refund to the Company if:
-- All or some of the expenses were not paid by the Covered Person or did
not legally have to be paid by the Covered Person.
-- All or some of the payment made by the Company exceeded the benefit
under this Plan.
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The refund equals the amount the Company paid in excess of the amount it
should have paid under this Plan.
If the refund is due from another person or organization, the Covered Person
agrees to help the Company get the refund when requested.
If the Covered Person, or any other person or organization that was paid,
does not promptly refund the full amount, the Company may reduce the amount
of any future benefits that are payable under this Plan. The Company may
also reduce future benefits under any other group benefits plan administered
by the Company for the Employer. The reductions will equal the amount of the
required refund. The Company may have other rights in addition to the right
to reduce future benefits.
Subrogation
In the event a Covered Person suffers an injury as a result of a negligent
or wrongful act or omission of a liable third party, the Company has the
right to pursue subrogation where permitted by law.
The Company will be subrogated and succeed to the Covered Person's right
against a liable third party. The Company may use this right to the extent
of the benefits paid under this Plan.
The Covered Person agrees to help the Company use this right when requested.
If the Director or his designee, upon being petitioned by the Employee,
determines that the exercise of subrogation by the Company is inequitable
and commits an injustice to the Employee, subrogation is not allowed.
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Effect of Medicare and Government Plans
Medicare
When a Covered Person becomes eligible for Medicare, this Plan pays its
benefits in accordance with the Medicare Secondary Payer requirements of
federal law. If the Employer is subject to the Medicare Secondary Payer
requirements, this Plan will pay primary.
When This Plan Pays Primary to Medicare
This Plan pays primary to Medicare for Covered Persons who are Medicare
eligible if:
-- Eligibility for Medicare is due to age 65 and the employee has "current
employment status" with the employer as defined by federal law and
determined by the employer.
-- Eligibility for Medicare is due to disability and the employee has
"current employment status" with the employer as defined by federal law
and determined by the employer.
-- Eligibility for Medicare is due to end stage renal disease (ESRD) under
the conditions and for the time periods specified by federal law.
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When Medicare Pays Primary to this Plan
Medicare pays primary to this Plan for Covered Persons who are Medicare
eligible if:
-- The employee is a Retired Employee.
-- Eligibility is due to disability and the Employee does NOT have "current
employment status" with the employer as defined by federal law and
determined by the employer.
-- Eligibility for Medicare is due to end stage renal disease (ESRD), but
only after the conditions and/or time periods specified in federal law
cause Medicare to become primary.
See How this Plan Pays When Medicare is Primary.
Important! - Medicare Enrollment Requirements
When this Plan pays benefits first, without regard to Medicare, and the
Covered Person wants Medicare to pay after this Plan, the Covered Person
must enroll for Medicare Parts A and B. If the Covered Person does not
enroll for Medicare when he or she is first eligible, the Covered Person
must enroll during the special enrollment period which applies to that
person when the person stops being eligible under this Plan.
When Medicare pays benefits first, benefits available under Medicare are
deducted from the amounts payable under this Plan, whether or not the person
has enrolled for Medicare. If Medicare pays first, the Covered Person should
enroll for both Parts A and B of Medicare when that Covered Person is first
eligible; otherwise, the expenses may not be covered by the Plan or
Medicare.
How This Plan Pays When Medicare Is Primary
If Medicare pays benefits first, this Plan pays benefits as described below.
This method of payment only applies to Medicare eligibles. It does not apply
to any Covered Person unless that Covered Person becomes eligible under
Medicare.
If the provider has agreed to limit charges for services and supplies to the
charges allowed by Medicare (participating Physicians), this Plan determines
the amount of Covered Expenses based on the amount of charges allowed by
Medicare.
If the provider has not agreed to limit charges for services and supplies to
the charges allowed by Medicare (non-participating Physicians), this Plan
determines the amount of Covered Expenses based on the lesser of the
following:
-- The Reasonable Charges.
-- The amount of the Limiting Charge as defined by Medicare.
The amount of charges for Covered Expenses under this Plan is determined
first. Then the amount payable under Medicare for the same expenses is
subtracted from the amount of Covered Expenses. This Plan pays the
difference between the two amounts.
The amount payable under Medicare which is subtracted from this Plan's
benefits is determined as the amount that would have been payable to a
Medicare eligible covered under Medicare even if:
-- The person is not enrolled for Medicare Parts A and B. Benefits are
determined as if the person were covered under Medicare Parts A and B.
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-- The expenses are paid under another employer's group health plan which
is primary to Medicare. Benefits are determined as if benefits under
that other employer's plan did not exist.
-- The person is enrolled in a Health Maintenance Organization (HMO) or
Competitive Medical Plan (CMP) to receive Medicare benefits, and
receives unauthorized services (out-of-plan services not covered by the
HMO/CMP). Benefits are determined as if the services were authorized and
covered by the HMO/CMP.
Government Plans (other than Medicare and Medicaid)
If the Covered Person is also covered under a Government Plan, this Plan
does not cover any services or supplies to the extent that those services or
supplies, or benefits for them, are available to that Covered Person under
the Government Plan.
This provision does not apply to any Government Plan which by law requires
this Plan to pay primary.
A Government Plan is any plan, program, or coverage -- other than Medicare
or Medicaid -- which is established under the laws or regulations of any
government, or in which any government participates other than as an
employer.
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Termination of Coverage
Employee Coverage
Employee coverage ends on the earliest of the following:
-- The day this Plan ends.
-- The last day of the month in which the person stops being an eligible
Employee.
-- The last day of a period for which contributions for the cost of
coverage have been made, if the contributions for the next period are
not made when due.
Disability
The Employer has the right to continue a person's employment and coverage
under this Plan during a period in which the person is away from work due to
disability. The period of continuation is determined by the Employer based
on the Employer's general practice for an Employee in the person's job
class.
Coverage ends on the date the Employer notifies the Company that the
person's employment has stopped and coverage is to be ended.
Dependent Coverage
Coverage for all of an Employee's Dependents ends on the earlier of the
following:
-- The day the Employee's coverage ends.
-- The last day of a period for which contributions for the cost of
Dependent coverage have been made, if the contributions for the next
period are not made when due.
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Coverage for an individual Dependent ends on the earlier of:
-- The day the Dependent becomes covered as an Employee under this Plan.
-- The last day of the month in which the Dependent stops being an eligible
Dependent.
Continuation of Coverage for Incapacitated Children
A mentally or physically incapacitated child's coverage will not end due to
age. It will continue as long as Dependents coverage under this Plan
continues and the child continues to meet the following conditions:
-- The child is incapacitated.
-- The child is not capable of self-support.
-- The child depends mainly on the Employee for support.
The Employee must give the Company proof that the child meets these
conditions when requested. The Company will not ask for proof more than once
a year.
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Extended Benefits
There are extended benefits under Medical Benefits, Mental Health Benefits
and Pregnancy Benefits.
Extended benefits are payable for a Totally Disabled Covered Person for up
to 12 months. Extended benefits are only payable for Covered Services and
Supplies given during the 12-month period after the person's coverage ends.
The person must be continuously Totally Disabled due to the same cause from
the date coverage ends until the date Covered Services or Supplies are
given.
Extended benefits are only payable for Covered Services and Supplies given
for the accidental injury, Sickness, or pregnancy causing Total Disability.
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Conversion Coverage
If the covered Employee's group health coverage stops under this Plan, the
covered Employee may buy individual health insurance (called "Conversion
Coverage").
Proof of insurability will not have to be given. However, if the benefits
under Conversion Coverage are greater than those under this Plan, the
covered Employee and his or her covered Dependents will be asked to give
proof of insurability for the greater benefits.
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If the covered Employee has Dependents coverage when the group coverage
stops, the Conversion Coverage will be for the covered Employee and all
Covered Family Members on the day such coverage stops. The covered Employee
must apply for Conversion Coverage on the same basis as the coverage he or
she has under this Plan. The covered Employee cannot apply for single
Conversion Coverage unless he or she is enrolled for Employee Only coverage
under this Plan. A Dependent child over age 19 will be issued single
Conversion Coverage because only Dependent children under 19 are covered as
family members under Conversion Coverage.
An individual policy will be issued if the person converting is eligible and
lives in one of the following states:
Georgia Oregon
Maine Puerto Rico
Minnesota South Dakota
New Hampshire Vermont
New Mexico Virginia
New York
If the person converting lives in a state or jurisdiction of the United
States not listed above and is eligible, Conversion Coverage will be
provided through The Group Conversion Trust. The person will receive a
Certificate of Insurance instead of an individual policy.
See Conversion Coverage for Medicare Eligibles at the end of this provision
if the covered Employee or a covered Dependent is Medicare Eligible.
Conditions for Conversion
For Covered Employees
This Plan must be in force and the coverage has to stop for either of the
following reasons:
-- The person's employment ends.
-- The person is no longer an eligible Employee.
If a covered Employee's group health coverage stops because this Plan ends,
the covered Employee will not have the right to buy Conversion Coverage.
The person's Employer may continue coverage under this Plan when the person
becomes a Retired Employee. In this case, the person cannot buy Conversion
Coverage until the continued coverage stops.
For Covered Dependents
If the covered Employee dies, the covered Employee's wife or husband or any
guardian of the covered Employee's Dependent children may buy Conversion
Coverage for the covered Dependents.
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If the covered Employee's marriage is dissolved, the covered Employee's
former spouse may buy Conversion Coverage. This can happen at either of the
following times:
-- When the marriage is dissolved.
-- At the end of any period of continuation of coverage under this Plan,
but only if this Plan is in force on that date.
Any of a covered Employee's covered Dependents may buy Conversion Coverage
if one of the following is true:
-- The Dependent stops being eligible.
-- The Dependent is 19 or older when the covered Employee buys Conversion
Coverage. (Only Dependent children under 19 are covered under a covered
Employee's new family coverage.)
How to Apply
Application must be made within 31 days after the group coverage stops.
Get an application from the Company or the Employer.
The first premium must be paid before Conversion Coverage can be put in
force.
Conversion Coverage will be effective on the date that the group coverage
stops. In some cases a covered Employee can choose to continue group
coverage after employment ends. In some cases a covered Employee's
Dependents can choose to continue their group coverage after the covered
Employee's death. In these cases Conversion Coverage will go into effect
when the continued coverage stops but only if this Plan is in force on that
date.
If the covered Employee dies within the 31-day conversion period, the
covered Employee's wife or husband or any guardian of the covered Employee's
Dependents may apply for Conversion Coverage for those covered Dependents.
Limitations
Conversion Coverage may have greatly reduced benefits at a much higher cost.
In most cases, the benefits will be limited to Hospital and surgical
benefits only.
The benefit amounts for Conversion Coverage will be governed by the
following:
-- The rules of the Company.
-- The laws of the state or jurisdiction where the person lives when he or
she applies.
A copy of the individual policy or Certificate of Insurance is on file with
the state insurance authority, where required. A copy may also be obtained
from the Company.
The Company might limit the benefits of, or refuse to issue, Conversion
Coverage because the covered Employee or a Dependent has other health
coverage. Each person will be told the rules when they apply.
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Conversion Coverage for Medicare Eligibles
A Medicare Eligible who lives in one of the following states is not eligible
for Conversion Coverage:
Georgia Oregon
Maine Puerto Rico
Minnesota South Dakota
New Hampshire Vermont
New Mexico Virginia
New York
Conversion Coverage of a Medicare Eligible who lives in any other state or
jurisdiction of the United States (except Michigan) will be provided through
The Group Conversion Trust. Michigan residents will be covered under an
individual policy.
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Glossary
(These definitions apply when the following terms are used.)
Ambulatory Surgical Center
A specialized facility which is established, equipped, operated, and staffed
primarily for the purpose of performing surgical procedures and which fully
meets one of the following two tests:
-- It is licensed as an Ambulatory Surgical Center by the regulatory
authority having responsibility for the licensing under the laws of the
jurisdiction in which it is located.
-- Where licensing is not required, it meets all of the following
requirements:
-- It is operated under the supervision of a licensed doctor of
medicine (M.D.) or doctor of osteopathy (D.O.) who is devoting full
time to supervision and permits a surgical procedure to be performed
only by a duly qualified Physician who, at the time the procedure is
performed, is privileged to perform the procedure in at least one
Hospital in the area.
-- It requires in all cases, except those requiring only local
infiltration anesthetics, that a licensed anesthesiologist
administer the anesthetic or supervise an anesthetist who is
administering the anesthetic and that the anesthesiologist or
anesthetist remain present throughout the surgical procedure.
-- It provides at least one operating room and at least one
post-anesthesia recovery room.
-- It is equipped to perform diagnostic X-ray and laboratory
examinations or has an arrangement to obtain these services.
-- It has trained personnel and necessary equipment to handle emergency
situations.
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-- It has immediate access to a blood bank or blood supplies.
-- It provides the full-time services of one or more registered
graduate nurses (R.N.) for patient care in the operating rooms and
in the post-anesthesia recovery room.
-- It maintains an adequate medical record for each patient, the record
to contain an admitting diagnosis including, for all patients except
those undergoing a procedure under local anesthesia, a preoperative
examination report, medical history and laboratory tests and/or
X-rays, an operative report and a discharge summary.
An Ambulatory Surgical Center which is part of a Hospital, as defined
herein, will be considered an Ambulatory Surgical Center for the purposes of
this Plan.
Birth Center
A specialized facility which is primarily a place for delivery of children
following a normal uncomplicated pregnancy and which fully meets one of the
following two tests:
-- It is licensed by the regulatory authority having responsibility for the
licensing under the laws of the jurisdiction in which it is located.
-- It meets all of the following requirements:
-- It is operated and equipped in accordance with any applicable state
law.
-- It is equipped to perform routine diagnostic and laboratory
examinations such as hematocrit and urinalysis for glucose, protein,
bacteria and specific gravity.
-- It has available to handle foreseeable emergencies, trained
personnel and necessary equipment, including but not limited to
oxygen, positive pressure mask, suction, intravenous equipment,
equipment for maintaining infant temperature and ventilation, and
blood expanders.
-- It is operated under the full-time supervision of a licensed doctor
of medicine (M.D.), doctor of osteopathy (D.O.) or registered
graduate nurse (R.N.).
-- It maintains a written agreement with at least one Hospital in the
area for immediate acceptance of patients who develop complications.
-- It maintains an adequate medical record for each patient, the record
to contain prenatal history, prenatal examination, any laboratory or
diagnostic tests and a postpartum summary.
-- It is expected to discharge or transfer patients within 24 hours
following delivery.
A Birth Center which is part of a Hospital, as defined herein, will be
considered a Birth Center for the purposes of this Plan.
Calendar Year
A period of one year beginning with a January 1.
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Comprehensive Outpatient Rehabilitation Facility
A facility which is primarily engaged in providing diagnostic, therapeutic
and restorative services to outpatients for the rehabilitation of injured or
sick persons and which fully meets one of the following two tests:
-- It is approved by Medicare as a Comprehensive Outpatient Rehabilitation
Facility.
-- It meets all of the following tests:
-- It provides at least the following comprehensive outpatient
rehabilitation services:
-- Services of Physicians who are available at the facility on a
full or part-time basis.
-- Physical therapy.
-- Social or psychological services.
-- It has policies established by a group of professional personnel
(associated with the facility) including one or more Physicians to
govern the comprehensive outpatient rehabilitation services it
furnishes, and provides for the carrying out of such policies by a
full or part-time Physician.
-- It has a requirement that every patient must be under the care of a
Physician.
-- It is established and operated in accordance with the applicable
licensing and other laws.
Covered Family Members or Covered Person
The Employee and the Employee's wife or husband and/or Dependent children
who are covered under this Plan.
Designated Transplant Facility
A facility designated by the Company to render Medically Necessary Covered
Services and Supplies for Qualified Procedures under this Plan.
Emergency Care
Medical care and treatment provided after the sudden onset of a medical
condition manifesting itself by acute symptoms, including severe pain, which
are severe enough that the lack of immediate medical attention could
reasonably be expected to result in any of the following:
-- The patient's health would be placed in serious jeopardy.
-- Bodily function would be seriously impaired.
-- There would be serious dysfunction of a bodily organ or part.
In addition, Emergency Care includes immediate Mental Disorder Treatment
when the lack of the treatment could reasonably be expected to result in the
patient harming himself or herself and/or other persons.
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Employee (Retired)
Retired Employee means an Employee who meets all of the following:
-- The Employee is an Executive who is a Senior Vice President or higher
and who is retired by the Employer.
-- The Employee receives retirement income either from the Employer or as a
result of service with the Employer.
-- The Employee was covered under this Plan or the Former Plan on the day
before the date of retirement.
-- The Employee must be at least 50 years of age with a minimum of seven
years of service with the Employer.
Experimental, Investigational or Unproven Services
Medical, surgical, diagnostic, psychiatric, substance abuse or other health
care services, technologies, supplies, treatments, procedures, drug
therapies or devices that, at the time the Company makes a determination
regarding coverage in a particular case are determined to be:
-- not approved by the U.S. Food and Drug Administration ("FDA") to be
lawfully marketed for the proposed use and not identified in the
American Hospital Formulary Service, or the United States Pharmacopoeia
Dispensing Information, as appropriate for the proposed use; or
-- subject to review and approval by any institutional review board for the
proposed use; or
-- the subject of an ongoing clinical trial that meets the definition of a
Phase 1, 2 or 3 clinical trial set forth in the FDA regulations,
regardless of whether the trial is actually subject to FDA oversight; or
-- not demonstrated through prevailing peer-reviewed medical literature to
be safe and effective for treating or diagnosing the condition or
illness for which its use is proposed.
The Company, in its judgment, may deem an Experimental, Investigational or
Unproven Service covered under this Plan for treating a life threatening
Sickness or condition if it is determined by the Company that the
Experimental, Investigational or Unproven Service at the time of the
determination:
-- is proved to be safe with promising efficacy; and
-- is provided in a clinically controlled research setting, and
-- uses a specific research protocol that meets standards equivalent to
those defined by the National Institutes of Health.
(For the purpose of this definition, the term "life threatening" is used to
describe Sicknesses or conditions which are more likely than not to cause
death within one year of the date of the request for treatment.)
Health Care Provider
A licensed or certified provider other than a Physician whose services the
Company must cover due to a state law requiring payment of services given
within the scope of that provider's license or certification.
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Home Health Care Agency
An agency or organization which provides a program of home health care and
which meets one of the following three tests:
-- It is approved under Medicare.
-- It is established and operated in accordance with the applicable
licensing and other laws.
-- It meets all of the following tests:
-- It has the primary purpose of providing a home health care delivery
system bringing supportive services to the home.
-- It has a full-time administrator.
-- It maintains written records of services provided to the patient.
-- Its staff includes at least one registered graduate nurse (R.N.) or
it has nursing care by a registered graduate nurse (R.N.) available.
-- Its employees are bonded and it maintains malpractice insurance.
Hospice
An agency that provides counseling and incidental medical services for a
terminally ill individual. Room and Board may be provided. The agency must
meet one of the following three tests:
-- It is approved by Medicare as a Hospice.
-- It is licensed in accordance with any applicable state laws.
-- It meets the following criteria:
-- It provides 24 hour-a-day, 7 day-a-week service.
-- It is under the direct supervision of a duly qualified Physician.
-- It has a nurse coordinator who is a registered graduate nurse with
four years of full-time clinical experience. Two of these years must
involve caring for terminally ill patients.
-- The main purpose of the agency is to provide Hospice services.
-- It has a full-time administrator.
-- It maintains written records of services given to the patient.
-- It maintains malpractice insurance coverage.
A Hospice which is part of a Hospital will be considered a Hospice for the
purposes of this Plan.
Hospital
An institution which is engaged primarily in providing medical care and
treatment of sick and injured persons on an inpatient basis at the patient's
expense and which fully meets one of the following three tests:
-- It is accredited as a Hospital by the Joint Commission on Accreditation
of Healthcare Organizations.
-- It is approved by Medicare as a Hospital.
-- It meets all of the following tests:
-- It maintains on the premises diagnostic and therapeutic facilities
for surgical and medical diagnosis and treatment of sick and injured
persons by or under the supervision of a staff of duly qualified
Physicians.
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-- It continuously provides on the premises 24-hour-a-day nursing
service by or under the supervision of registered graduate nurses.
-- It is operated continuously with organized facilities for operative
surgery on the premises.
Licensed Counselor
A person who specializes in Mental Disorder Treatment and is licensed as a
Licensed Professional Counselor (LPC) or Licensed Clinical Social Worker
(LCSW) by the appropriate authority.
Medical Management
A program which performs a Utilization Review for the Company.
Medically Necessary or Medical Necessity
Health care services and supplies which are determined by the Company to be
medically appropriate, and
(1) necessary to meet the basic health needs of the Covered Person; and
(2) rendered in the most cost-efficient manner and type of setting
appropriate for the delivery of the service or supply; and
(3) consistent in type, frequency and duration of treatment with
scientifically based guidelines of national medical, research, or health
care coverage organizations or governmental agencies that are accepted
by the Company; and
(4) consistent with the diagnosis of the condition; and
(5) required for reasons other than the convenience of the Covered Person or
his or her Physician; and
(6) demonstrated through prevailing peer-reviewed medical literature to be
either:
(a) safe and effective for treating or diagnosing the condition or
Sickness for which their use is proposed, or,
(b) safe with promising efficacy
(i) for treating a life threatening Sickness or condition, and
(ii) in a clinically controlled research setting; and
(iii) using a specific research protocol that meets standards
equivalent to those defined by the National Institutes of
Health.
(For the purpose of this definition, the term "life threatening" is used
to describe Sicknesses or conditions which are more likely than not to
cause death within one year of the date of the request for treatment.)
The fact that a Physician has performed or prescribed a procedure or
treatment or the fact that it may be the only treatment for a particular
injury, Sickness or pregnancy does not mean that it is a Medically
Necessary service or supply as defined above. The definition of
Medically Necessary used in this certificate relates only to coverage
and differs from the way in which a Physician engaged in the practice of
medicine may define medically necessary.
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Medicare
The Health Insurance For The Aged and Disabled program under Title XVIII of
the Social Security Act.
Mental Disorder Treatment
Mental Disorder Treatment is treatment for both of the following:
-- Any Sickness which is identified in the current edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM), including a
psychological and/or physiological dependence or addiction to alcohol
or psychoactive drugs or medications, regardless of any underlying
physical or organic cause, and
-- Any Sickness where the treatment is primarily the use of psychotherapy
or other psychotherapeutic methods.
All inpatient services, including Room and Board, given by a mental health
facility or area of a Hospital which provides mental health or substance
abuse treatment for a Sickness identified in the DSM, are considered Mental
Disorder Treatment, except in the case of multiple diagnoses.
If there are multiple diagnoses, only the treatment for the Sickness which
is identified in the DSM is considered Mental Disorder Treatment.
Detoxification services given prior to and independent of a course of
psychotherapy or substance abuse treatment is not considered Mental Disorder
Treatment.
Prescription Drugs are not considered Mental Disorder Treatment.
Network Provider
A provider which participates in the network.
Non-Network Hospital
A Hospital (as defined) which does not participate in the network.
Non-Network Provider
A provider which does not participate in the network.
Nurse-Midwife
A person who is licensed or certified to practice as a Nurse-Midwife and
fulfills both of these requirements:
-- A person licensed by a board of nursing as a registered nurse.
-- A person who has completed a program approved by the state for the
preparation of Nurse-Midwives.
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Nurse-Practitioner
A person who is licensed or certified to practice as a Nurse-Practitioner
and fulfills both of these requirements:
-- A person licensed by a board of nursing as a registered nurse.
-- A person who has completed a program approved by the state for the
preparation of Nurse-Practitioners.
Other Services and Supplies
Services and supplies furnished to the individual and required for
treatment, other than the professional services of any Physician and any
private duty or special nursing services (including intensive nursing care
by whatever name called).
Physician
A legally qualified:
-- Doctor of Medicine (M.D.).
-- Doctor of Chiropody (D.P.M.; D.S.C.).
-- Doctor of Chiropractic (D.C.).
-- Doctor of Dental Surgery (D.D.S.).
-- Doctor of Medical Dentistry (D.M.D.).
-- Doctor of Osteopathy (D.O.).
-- Doctor of Podiatry (D.P.M.).
Plan
The group policy or policies issued by the Company which provide the
benefits described in this Certificate of Insurance.
Psychologist
A person who specializes in clinical psychology and fulfills one of these
requirements:
-- A person licensed or certified as a psychologist.
-- A Member or Fellow of the American Psychological Association, if there
is no government licensure or certification required.
Reasonable Charge
As to charges for services rendered by or on behalf of a Network Physician,
an amount not to exceed the amount determined by the Company in accordance
with the applicable fee schedule.
As to all other charges, an amount measured and determined by the Company by
comparing the actual charge for the service or supply with the prevailing
charges made for it. The Company determines the prevailing charge. It takes
into account all pertinent factors including:
-- The complexity of the service.
-- The range of services provided.
-- The prevailing charge level in the geographic area where the provider is
located and other geographic areas having similar medical cost
experience.
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Rehabilitation Facility
A facility accredited as a rehabilitation facility by the Commission on
Accreditation of Rehabilitation Facilities.
Room and Board
Room, board, general duty nursing, intensive nursing care by whatever name
called, and any other services regularly furnished by the Hospital as a
condition of occupancy of the class of accommodations occupied, but not
including professional services of Physicians nor special nursing services
rendered outside of an intensive care unit by whatever name called.
Sickness
The term "Sickness" used in connection with newborn children will include
congenital defects and birth abnormalities, including premature births.
Skilled Nursing Facility
If the facility is approved by Medicare as a Skilled Nursing Facility then
it is covered by this Plan.
If not approved by Medicare, the facility may be covered if it meets the
following tests:
-- It is operated under the applicable licensing and other laws.
-- It is under the supervision of a licensed Physician or registered
graduate nurse (R.N.) who is devoting full time to supervision.
-- It is regularly engaged in providing Room and Board and continuously
provides 24-hour-a-day skilled nursing care of sick and injured persons
at the patient's expense during the convalescent stage of an injury or
Sickness.
-- It maintains a daily medical record of each patient who is under the
care of a licensed Physician.
-- It is authorized to administer medication to patients on the order of a
licensed Physician.
-- It is not, other than incidentally, a home for the aged, the blind or
the deaf, a hotel, a domiciliary care home, a maternity home, or a home
for alcoholics or drug addicts or the mentally ill.
A Skilled Nursing Facility which is part of a Hospital will be considered a
Skilled Nursing Facility for the purposes of this Plan.
Specialized Facility
A facility which is a Non-Network facility and which holds a license that is
not the same type held by any Network Provider.
Specialized Provider
A provider who is a Non-Network Provider but who also holds a health care
professional license that is not the same type held by any Network Provider
in the service area in which the services are rendered.
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Total Disability or Totally Disabled
A Retired Employee's inability due to accidental injury or Sickness to
perform the normal activities of a person in good health and of like age and
sex.
Treatment Center
A facility which provides a program of effective Mental Disorder
Treatment and meets all of the following requirements:
-- It is established and operated in accordance with any applicable state
law.
-- It provides a program of treatment approved by a Physician and the
Company.
-- It has or maintains a written, specific and detailed regimen
requiring full-time residence and full-time participation by the
patient.
-- It provides at least the following basic services:
-- Room and Board (if this Plan provides inpatient benefits at a
Treatment Center).
-- Evaluation and diagnosis.
-- Counseling.
-- Referral and orientation to specialized community resources.
A Treatment Center which qualifies as a Hospital is covered as a
Hospital and not as a Treatment Center.
Utilization Review
A review and determination as to the Medical Necessity of services and
supplies.
End of Certificate
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Continuation of Health Coverage (COBRA)
This optional continuation only applies to Employees and their Dependents if
it has been made available by the Employer. The Employer is required to
offer this continuation in certain cases as a result of Public Law 99-272
(COBRA). This provision is intended to comply with the law and any pertinent
regulations, and its interpretation is governed by them. See the Employer to
find out if and how this continuation applies to Employees and their
Dependents.
In no event will the Company be obligated to provide continuation to a
Covered Person if the Employer or its designated Plan Administrator fails to
perform its responsibilities under federal law. These responsibilities
include but are not limited to notifying the Covered Person in a timely
manner of the right to elect continuation and notifying the Company in a
timely manner of the Covered Person's election of continuation.
The Company is not the Employer's designated Plan Administrator and does not
assume any responsibilities of a Plan Administrator pursuant to federal law.
If coverage under this Plan would have stopped due to a Qualifying Event, a
Qualified Beneficiary may elect to continue coverage subject to the
provisions below.
The Qualified Beneficiary may continue only the coverage in force
immediately before the Qualifying Event.
The coverage being continued will be the same as the coverage provided to
similarly situated individuals to whom a Qualifying Event has not occurred.
Coverage will continue until the earliest of the following dates:
-- 18 months from the date the Qualified Beneficiary's health coverage
would have stopped due to a Qualifying Event based on employment
stopping or work hours being reduced.
-- If a Qualified Beneficiary is determined to be disabled under the Social
Security Act at any time during the first 60 days of continued coverage
due to the employee's employment stopping or work hours being reduced,
that Qualified Beneficiary may elect an additional 11 months of coverage
under this Plan, subject to the following conditions:
-- The Qualified Beneficiary must provide the Employer with the Social
Security Administration's determination of disability within 60 days
of the time the determination is made and within the initial
18-month continuation period.
-- The Qualified Beneficiary must agree to pay any increase in the
required payment necessary to continue the coverage for the
additional 11 months.
-- If the Qualified Beneficiary entitled to the additional 11 months of
coverage has nondisabled family members who are entitled to
continuation coverage, those nondisabled family members are also
entitled to the additional 11 months of continuation coverage.
-- 36 months from the date the health coverage would have stopped due to
the Qualifying Event other than those described above.
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