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HomeMy WebLinkAboutEmployee Health BenefitsEMPLOYEE HEALTH BENEFITS CITY OF JEFFERSONVILLE SUMMARY PLAN DESCRIPTION TABLE OF CONTENTS INTRODUCTION ScHEDuLE OF BENEFITS General plan Information General Health Care Coverage Information Prescription Drug Coverage Information ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE PRE-EXISTING CONDITION WAITING PERIOD THE PREFERRED PROVIDER ARRANGEMENT SPECIAL MANAGED CARE PROVISIONS Individualized Care Management (ICM) Pre-Admission Certification and Hospitalization Review Pre-Certification Concerning Certain Inpatient and Outpatient Services YOUR HEALTH CARE COVERED SERVICES Inpatient Hospital Services Inpatient Medical Services Surgical Services Outpatient Services Preventive Care Services Major Medical Expenses Psychiatric and Substance Abuse Services EXCLUSIONS OR LIMITATIONS FOR YOUR HEALTH CARE COVERAGE HUMAN ORGAN TRANSPLANTS YOUR PRESCRIPTION DRUG COVERAGE Prescription Drug Copayment What is Covered Exclusions or Limitations CLAIMS INFORMATION/PROCEDURE FOR CLAIMING BENEFITS MEDICARE TERMINATION OF COVERAGE CONTINUATION OF COVERAGE DEFINITIONS GENERAL PROVISIONS AND ADMINISTRATION OF THE PLAN BENEFIT PLAN INFORMATION PAGE 1 2 2 2 5 6 9 10 11 11 11 12 15 15 15 16 17 17 18 21 22 25 27 28 28 28 3O 35 36 37 4O 47 49 INTRODUCTION This Summary Plan Description (SPD) describes and establishes the important provisions of the plan of health care benefits (called the "Plan") provided to employees and retirees of City of Jeffersonville (the Employer) and their eligible Dependents. It is very important that you have a good understanding of the Covered Services available to you and of the things, which are excluded or limited by the Plan. It is also important that you know that certain words or phrases have a special meaning in this SPD. If a word or phrase starts with a capital letter, it has a special meaning. It is defined in the Definitions section or where used in the text. The titles that appear in this SPD although capitalized, are not necessarily "definitions." We strongly urge you to read this SPD in its entirety. SCHEDULE OF BENEFITS GENERAL PLAN INFORMATION BenefitPeHod january 1st through December 31st Dependent Age Limit 23rd birthday; or 25th birthday if full-time Student Lifetime Maximum (Medical & Behavioral Healthcare) $1,000,000 per insured GENERAL HEALTH CARE COVERAGE INFORMATION In.Network Out-of-Network, Calendar Year Deductible Inpatient Hospital Outpatient Surgery Outpatient Non-surgery Hospital Physician Services Other Medical Services Out of Pocket Maximum* No Deductible $500 per admission copay No Deductible $250 per admission copay No Deductible $100 per admission copay No Deductible $50 Individual/S100 Family $50 Individual/S100 Family $50 Individual/S100 Family : Hosp I~-" ita:~xpenSeS: $1000 $500 Individual $1,000 Family per person per calendar Physician & Other Medical Services: $500 Individual/ $1000 Family *Out of Pocket Maximum doeS not include deductible, office viSit and prescription copayments, and out-of-pocket expenses for treatment of psyChiatric diSOrders, alcoholism and drug dependency, or charges in excess of Usual & Customary. All Covered Services are Subject to the appropriate Copayments, Deductible and Coinsurance as set forth in this Schedule of Benefits. Your Plan pays as follows: HOSPITAL SERVICES Inpatient Hospital OUtPatient Surgical In-Network 100% 100% Out-of-Network 80% after applicable copay 80% after applicable copay Outpatient Non-Surgical Emergency Room Visit (when not admitted) PHYSICIAN SERVICES Inpatient Outpatient Physician Office Visits Emergency Room Visit Diagnostic testing, x-rays, laboratory tests and allergy testing preformed in the physicians office Chiropractic Treatment (20 visits per calendar yr.) Allergy Injections* In-Net~vork 100% 100% after $40 copay 100% 100% 100% after $10 copay 100% after $10 copay 100% after $10 copay 100% of usual & customary after $10 copay 100% after $3 copay/visit Allergy Serums are processed under the Allergy Injection benefit. Out-of-Network 80% after applicable copay 80% after $40 copay 80% after applicable deductible 80% after applicable deductible 80% after applicable deductible 80% after applicable deductible 80% after applicable deductible 100% of usual & customary after $10 cepay 80% after applicable deductible Wellness Benefit for Covered Persons over age 2* Routine Office Visit 100% after $10 copay 80% after applicable deductible 1. One detailed office visit per calendar year for clinical exam and health counseling, which includes a pap smear or PSA antigen test, colonoscopy, total blood cholesterol screening, and routine hearing test. 2. Immunizations given to insureds to prevent disease as recommended by the U.S. Preventive Service Task Force. Immunizations include pneumococcal, influenza, hepatitis B, tetanus, diphtheria, pertussis, hemophilus influenza, polio, measles, mumps, and rubella. Allergy shots or immunizations for work or travel are not covered. Immunizations* 100% after $3 per injection 80% after applicable deductible Mammography 100% 80% after applicable deductible Well Child Care for covered dependent child to two (2) years of a~ Physician Office Visit 100% after $10 copay 80% after applicable deductible Outpatient preventive well-child care means the charges made by a personal physician for routine pediatric exams and immunizations given to a child as recommended by the Amedcan Academy of Pediatrics for children to two (2) years of age. This will be limited to three (3) exams between a child's birth and the first twelve (12) months and two (2) exams between twelve (12) months and the child's second birthday. 3 OTHER MEDICAL SERVICES, In-NetwOrk Out-of-Network CAT Scans/MRI Procedures 80% after applicable PET' scans DeduCtible Home Health Care Services 80% after deductible, up to a maximum of 40 visits per calendar year Skilled Nursing Facility Services 80% uP to 60 days per calendar yr, after deductible Ambulance Services 80% Coinsurance after Deductible 60% after applicable deductible 60% after deductible, up to a maximum of 40 visits per Calendar year 60% up to 60 days per calendar yr, after deductible 80% Coinsurance after Deductible Durable Medical Equipment 80% coinsurance, after Deductible; not to exceed Purchase pdce 60% coinsurance after Deductible; not to exceed purchase price Hospice Care Services Inpatient Deductible, then $150 per day up to Maximum benefit of $3000, Deductible, then $150 per day up to Maximum benefit of $3000, Outpatient Physical Therapy, Speech Therapy and Hearing Deductible, then $50 per visit up to a Max benefit of $2000 80% coinsurance, after Deductible Deductible, then $50 per visit up to a Max benefit of $2000 80% coinsurance after Deductible Therapy Therapy Services must be pre-authorized. Number of visits will be based on medical necessity. All other Major Medical 80% coinsurance, after 80% Coinsurance Expenses including Deductible Deductible Services/supplies not Available at participating Providers PSYCHIATRIC SERVICES Inpatient Services Outpatient Services* Individual Therapy In-Network 80% up to max of 20 Days per calendar year 100% up to 20 visits annual maximum, after $20 copay per visit Out-of-Network Not Covered 100% Of UCR; uP to 20 visits annual max, after $20 copay per visit 4 Group Therapy 100% up to 20 visits annual maximum, after $10 copay per visit 100% of UCR; up to 20 visits annual max, after $10 copay per visit * The 20 visit annual maximum for Outpatient Psychiatric Services is combined with the 20 visit annual maximum for Outpatient Substance Abuse Services. SUBSTANCE ABUSE SERVICES Inpatient Rehabilitation Services 80% up to a max of 10 days per calendar year Not Covered Detoxification Services Outpatient Services* Individual Therapy 100% Benefit Not Covered 100% up to 20 visits annual maximum, after $20 copay per visit 100% of UCR; up to 20 visits annual maximum, after $20 copay per visit Group Therapy 100% up to 20 visits annual maximum, after $10 copay per visit 100% of UCR; up to 20 visits annual maximum, after $10 copay per visit * The 20 visit annual maximum for Outpatient Substance Abuse Services is combined with the 20 visit annual maximum for Outpatient Psychiatric Services. HUMAN ORGAN TRANSPLANT SERVICES Transplant Surgery Acquisition See Plan Description See Plan Description PRESCRIPTION DRUG COVERAGE INFORMATION ParticipatinR Pharmacy Coverage (30-day supply) Name Brand Drugs $10 Copayment Genedc $5 Copayment Mail Service Coverage (30 to 90-day supply) Name Brand Drugs Genedc Non-Participating 25% of billed charges, After $10 copayment 25% of billed charges After $10 copayment $10 Copayment per prescription $5 Copayment per prescription Accidental Injury Coverage 100% of the first $500 Coverage includes eligible facility, physician's office and physician charges up to a specified amount. Initial treatment must begin within 72 hours of the date of the accident. Includes follow-up treatment, related to the injury, received within 90 days of the date of the accidental injury. 5.5 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE ELIGIBLE EMPLOYEES Employees must meet the following eligibility requirement~ in order to be considered an Eligible Employee: 1. the employee must regularly work at least 30 hours per week; 2. or be an elected or appointed officials; 3. the employee cannot be a temporary or seasonal employee; and 4. if applicable, the employee must make the required contribution towards the Coverage. A person who joins the group on or after the date the Group Policy becomes effective is eligible for insurance on the first of the month following the date of hire. Elected or appointed officials are eligible for Coverage on the date the official takes office. ELIGIBLE DEPENDENTS The following persons are considered to be Eligible Dependents: The spouse of the Covered Participant; An unmarried child of the Covered Employee or spouse who has not reached the limiting age as shown in the Schedule of Benefits. A child is eligible under this paragraph only if legally dependent by IRS standards or by court order upon the Covered Employee or spouse. This includes children who have been adopted by the Covered Employee or spouse, or who are in the custody of the Covered Employee or spouse pursuant to an interlocutory order of adoption; and An unmarried child of the Covered Employee or spouse who is permanently disabled upon attainment of the limiting age. The child must be incapable of self-sustaining employment by reason of mental retardation or mental or physical handicap and primarily dependent upon the Covered Employee for suPport and maintenance. The Covered Employee must make application for continuation of Coverage to Stewart C. Miller & Company, Inc. (SCM) within 31 days after the child reaches the limiting age. Such application shall include proof satisfactory to SCM of the child's incapacity and dependence upon the Covered Employee. Upon SCM's request, the Covered Employee will provide proof of the continuance of such incapacity and dependence, but not more frequently than annually after the two year period following the child's attainment of the limiting age. ELIGIBLE RETIREES Retirees must meet all eligibility requirements as specified by state statute Or city ordinance in order to be considered an Eligible Retiree. The Employer and SCM have the dght to request information needed to determine the patient's eligibility when a claim is filed. APPLYING FOR COVERAGE AND EFFECTIVE DATES Timely Enrollment for Eligible Employees and their Eligible Dependents -Applications for Eligible Employees and their Eligible Dependents which are received by SCM's home office on or before the Plans Restatement Date will be made effective on the Plan's Restatement Date. Applications completed within 31 days and submitted to SCM's home office within 45 days folloWing the Eligible Employee's Eligibility Date will be made effective the first day of the month following the Eligible Employee's Eligibility Date. This enrollment period is considered to be an initial enrollment pedod. Applications for Eligible Dependents which are completed within 31 days and submitted to SCM's home office within 45 days following the date they become an Eligible Dependent (e.., date of marriage, date of birth, date of adoption or placement for adoption) shall be made effective on the date they become an Eligible Dependent. This enrollment period is considered to be a special enrollment period. Special Enrollment Period - If you (a) had other group health coverage at the time you were first eligible to enroll in the group policy, (b) did not elect (in writing, if required) to be covered under the Group Policy at that time; and (c) subsequently lost such other coverage, you and your dependents, if any, who were covered under the other group health coverage will not be considered Late Enrollees. You and your dependent(s) may enroll in the Group Policy if application is made within 31 days of losing such other coverage, provided the other coverage was either: COBRA coverage which was terminated; or Non-COBRA which was canceled as a result of.' 1) legal separation; 2) divorce; 3) death; 4) termination of employment 5) a reduction of hours worked; or 6) the employer ceased making contributions toward the Subscription Fee. This is a Special Enrollment Period. If you enroll, coverage for you and your dependent(s) will start on the first day following the date that your other group coverage terminated. Open Enrollment Period - Eligible Employees or Dependents of Employees who fail to submit a registration application dudng the initial enrollment period or during the special enrollment pedod, will be able to apply for Coverage during the months of February and March of each year. Coverage will be made effective April 1st of the same year. Eli.qible Employees or Dependents of Eli.qible Employees who enroll dudn.q the open enrollment period are considered late enrollees. Late Enrollee means and employee or dependent who requests enrollment in a health bepefit plan after the initial 31-day enrollment period. An individual will not be considered a late enrollee if: 1. The person enrolls during his/her initial enrollment period under the Group Policy, or 2. The persoh ~nrolls in the Group Policy during a special enrollment period; or 3. A court orders that coverage be provided for a minor child under a covered employee's health benefit plan, but only as long as the person requests enrollment for such dependent within 31 days after the court order is issued. EFFECTIVE DATE OF INSURANCE FOR GROUP MEMBERS If you are eligible for insurance, you may elect to be insured only by signing an enrollment form obtained from the City of Jeffersonville. The date your insurance begins depends on the date on which you enroll. Subject to making any required contribution, your coverage will start as described in the paragraphs which follow: 1. If you are eligible for coverag® on the effective date of the Group Policy, your coverage will start on the effective date of the Group Policy if you enrolled for coverage when you were first eligible for it, subject to completing any waiting period. 2. If you becOme eligible after the effectiVe date of the Group Policy and you enroll on or before the date you first become eligible, your coverage will start on the date yOu become eligible, subject to completing any waiting pedod. 3. If you become eligible after the effective date of the Group Policy and you enroll within 31 days after the date you first become eligible, your coverage will start on the date you signed the enrollment application, subject to completing any waiting period. If you do not enroll within 31 days after the date yOu firSt become eligible to do so, then you will be considered a late enrollee and your coverage Will start on the first day of the calendar month coinciding with or next following the date you enroll but you will be subject to a 15-month pre-existing condition EUGIBLE RETIREES AND ELIGIBLE DEPENDENTS OF RETIREES - Applications for Eligible Retirees and their eligible Dependents Which are received by SCM's home office on or before the Plan's Restatement Date will be made effective on the Plan's Restatement Date. For retirees who retire after the Plan's Restatement Date, applications completed within 90 days and submitted to SCM's home office within 105 days following the Eligible Retiree's retirement date will be made effective the first day of the month following the Eligible Retiree's retirement date. Eligible Dependents of the Covered Retiree are only eligible for Coverage if the Covered Retiree elects Coverage for the Dependent at the time the retiree initially elects Coverage, PRE-EXISTING CONDITION WAITING PERIOD PRE-EXISTING CONDITIONS LIMITATION PRE-EXISTING CONDITION means a physical or mental condition which: 1. is caused by an injury or sickness; and 2, required an insured person, dudng the 6 months pdor to his or her enrollment date to seek diagnosis or advice or receive medical care treatment. Health insurance benefits are excluded for a pre-existing condition until the earlier of the following dates: 1. the date the insured person has been free of treatment for the pre-existing condition for 6 consecutive months following the insured person's enrollment date; or 2. the date the insured person has been insured by the Group Policy for 12 consecutive months, 18 months for late enrollees. The exclusion does not apply to (a) pregnancy or (b) newborn children or children adopted before the age of 18 if they are covered under the Group Policy within 30 days of the date of birth or date of placement for adoption. Additionally, a genetic condition is not a pre-existing condition in the absence of a diagnosis of the condition related to the genetic information. The pedod of such pre-existing condition exclusion must be reduced by all pedods of creditable coverage, if any, applicable to the insured person as of his or her enrollment date that are not separated by a break in coverage of more than 90 days, not counting waiting pedods. YOUR HEALTH CARE COVERAGE SPECIALPROVISIONS OFYOURCOVERAGE THE PREFERRED PROVlDER ARRANGEMENT Your Plan provides Coverage under a Preferred Provider Arrangement which offers benefits for Covered Services rendered by both Preferred Providers and Non-Preferred Providers. Under the Preferred Provider Arrangement, the benefits payable will depend upon your election of Providers. If, for example, you choose a Preferred Provider instead of a Non-Preferred Provider, the Plan will pay a greater benefit level. You are not required to use a Preferrea Provider under the Preferred Provider Arrangement. However, if you choose a Non-Preferred Provider. a lesser benefit amount will be provided for Covered Services. except as listed below:. ]. If a service, treatment or procedure '~s not available from a Preferred Provider. and as a result, a Preferred Provider refers you to a Non-Preferred Provider, Coverage will be provided at the In-Network benefit level. This also includes specialty service categories not available within the contracted Provider Network. Such services categories include, but are not limited to. chiropractic, clinical psychologist, providers of mental health and substance abuse treatment who hold a Masters of Social Work degree, licensed clinical social workers and licensed family therapists. 2. If you receive a service, treatment or procedure at an In-Network facility, but the Professional Provider rendering the seance, treatment or procedure at the facility is a Non-Preferred Provider, Coverage will be provided at the In-Network benefit level. This also includes anesthesiologists, radiologists. pathologists, laboratories and emergency medicine physicians. 3. If you or a Dependent are confined in a Facility that is a Preferred Provider of services at a time when the Facility terminates its agreement with the Preferred Provider Organization, Coverage will be provided for the remainder of the period of confinement at the In-Network benefit level. It is important to vedfy that your Providers are PPO Providers each time you call for an appointment or at the time of service. Your Schedule of Benefits shows the benefit level available in connection with services rendered by Preferred and Non-Preferred Providers. Covered Services rendered by a Preferred Provider are considered to be rendered In-Network while Covered Services rendered by a Non-Preferred Provider are considered to be rendered Out-of-Network. SPECIAL MANAGED CARE PROVISIONS Individualized Care Management ¢CM) PRE-ADMISSION CERTIFICATION AND HOSPITALIZATION REVIEW Pre-admission Certification - Pro-admission Certification is a pro-admission determination by ICM on behalf of the Employer of the Medical Necessity of an Inpatient Hospital setting and the appropriate length of stay. pre-admission Certification is not a guarantee of benefit payment. All terms and conditions of your Plan apply in determining your Coverage for a Hospital admission. Pro-admission Certification must be obtained for every Hospital Admission, except Emergency Admissions, Urgent Care Admissions and Maternity Admissions. Refer to "Emergency and Urgent Cato Review" for details concerning emergency or urgent care admissions. These admissions are subject to separate notification requirements. It is the Covered Person's responsibility to obtain Pre-admission Certification and inform their Provider that they are a participant in a program, which has Pre-admission Certification requirements. In order to obtain Pro-admission Certification for all admissions other than Emergency Admissions and Urgent Care Admissions: 1. ICM must be provided with information necessary to make a decision on behalf of the Employer as to the Medical Necessity of the admission; and ICM must be informed no later than 48 hours prior to the admission to the Hospital. Notice can be given to ICM by: a) the Hospital; b) the admitting Physician; c) the Covered Person; or d) a family member of the Covered Person. Notice may be given to ICM by calling the ICM number shown on your identification card. When Pro-admission Certification is provided to the Covered Person, a certain number of Inpatient Hospital days for the stay will be assigned. If ICM is not informed of a Covered Person's admission, payment of benefits for Admitting Physician charges and Hospital expenses will be reduced by 50%, up to a maximum of $500 per occurrence (called perialty). This penalty will be applied prior to any applicable Copayment, Deductible or Coinsurance. Continued Stay Review - During a Covered Person's Hospital stay, a Continued Stay Review will be conducted. This review applies to ail Hospital admissions. The purpose of Continued Stay Review is to: 1. provide ICM with an update as to the Covered Person's condition and progress; and, if necessary, 2. to enable ICM to re-evaluate the Medical Necessity of a continued Hospital stay. Weekend Admission Review - All weekend (Friday and Saturday) Hospital admissions will be reviewed. Coverage is limited to Medically Necessary admissions. Emergency and Urgent Care Review - if a Covered Person is admitted to a Hospital for an Emergency or Urgent Cato Admission, notice of the admission must be provided to ICM no later than 48 hours after the admission. Notice may be given to ICM by: a) the Hospital; b) the admitting Physician; c) the Covered Person; or d) a family member of the Covered Person. Notice may be given to ICM by calling the ICM nUmber shOwn on your identification card. ICM will review the case within 1 working day of the date ICM is informed of the admission. The review will be performed with the Covered Person's Physician to determine if a continued Hospital stay is Medically Necessary. If ICM is not informed of a Covered Person's Emergency or Urgent Care Admission, payment for admitting Physician and Hospital Eligible Expenses will be reduced by 50%, up to a maximum of $500 per occurrence (called penalty). This penalty will be applied prior to any applicable Copayment, Deductible or Coinsurance. Discharge Planning - Review for Discharge Planning occurs dudng Hospitalization Review. The purpose is to: 1. identify patients requiring extended care following discharge; and 2. determine the most appropriate setting for continued care. PRE-CERTIFICATION CONCERNING CERTAIN INPATIENT AND OUTPATIENT SERVICES The program described below and on the following page(s) is a Special program which requires Pre- certification concerning certain types of Inpatient and Outpatient Services. This means that it is your responsibility to obtain Pre-certification for these Covered Services and inform your Provider that you are a participant in a program that has Pre-certificati°n [equirements- pre-certification is a determination by ICM on behalf of the Employer, of the Medical Necessity of a scheduled procedure, service, supply or charge, pre-certification is not a guarantee of benef'~ payment. All terms and conditions of your Plan apply in determining your COverage for the procedure, service, supPly or charge. In order to obtain Pre-certification: 1. ICM must be provided with information necessary to determine on behalf of the Employer as to the Medical Necessity of a scheduled procedure, service, supply or charge, and 2. ICM must be informed no later than 48 hours prior to the Covered Services being rendered. Notice can be given to ICM by the treating Physician, Covered Person, or a familY member of the Covered Person. Notice may be given to ICM by calling the ICM number shown on your identification card. If notice is n°{ given to ICM 48 hours prior to the Covered Service being rendered, Eligible ExPenses for such procedure, service, supply or charge will be reduced by 50%1 up to a maximum of $500 per occurrence (called penalty). This penalty will be applied prior to any applicable Copayment, Deductible or Coinsurance. Pre-certification must be obtained for the following Covered Services, subject to the terms and conditions set forth in this SPD: 1. Outpatient intravenous chemotherapy rendered by a Physician or other Professional in a Physician's office or by the Outpatient department of a Hospital or other Outpatient Facility that is organized and operated to provide such services; 2. Home health care services rendered by a Home Health Care Provider; 3. Hospice services rendered by a Hospice Provider; 4. Outpatient durable medical equipment that costs more than $100 per equipment; 5. Outpatient medical supplies which cost more than $200 per medical supply; 6. Covered prescription drugs which are dispensed for your Outpatient use and which cost more than $200 per prescription; 7. Outpatient surgery rendered by a Physician or other Professional in a Physician's office or by the Outpatient department of a Hospital or other Outpatient Facility that is organized and operated to provide Outpatient surgery, when the anticipated surgical charge is in excess of $1,000; 8. Outpatient intravenous infusions of a substance rendered by a Physician or other Professional in a Physician's office or by the Outpatient department of a Hospital or other Outpatient Facility that is organized and operated to provide such services; 9. Skilled Nursing Facility admissions; 10. Outpatient occupational, speech and Physical Therapy rendered by a Physician or other Professional in a Physician's office or by the Outpatient department of a Hospital or other Outpatient Facility that is organized and operated to provide such services; 11. Outpatient Covered Services to study, diagnose or treat sleep apnea which are rendered by a Physician or other Professional in a Physician's office or by the Outpatient department of a Hospital or other Outpatient Facility that is organized and operated to provide such services; and 12. Outpatient pain management programs conducted by a Physician or other Professional in a Physician's office or by the Outpatient department of a Hospital or other Outpatient Facility that is organized and operated to provide such services. Under this Plan, a "pain management program" is a program which is conducted under the supervision of your treating Physician and established for the purpose of training you to control and manage pain. Pre-certification is not required for any Unscheduled Covered Service. An Unscheduled Covered Service is a Covered Service which has not been scheduled and/or prescribed in advance due to the unexpected nature of the Sickness or Injury for which the Covered Service was rendered. In addition, you need not obtain a separate Pre-certification for any Covered Service rendered during a Confinement which has already been pre-certified under this Plan. INDIVIDUAL BENEFITS MANAGEMENT Individual Benefits Management is a voluntary program. It is designed to inform patients of more cost- effective settings for treatment. On an exception basis, subject to ICM's approval on behalf of the Employer, benefits may be provided for settings and/or procedures not expressly provided for, but not prohibited by law, rule or Federal policy. All requests for individual Benefits Management will be individually reviewed by ICM Under Individual Benefits Management, the Deductible or Coinsurance may be waived for certain services. ICM, on behalf of the Employer, has the right to deny an extension of benefits under Individual Benefits Management. ICM also has the right to administer benefits pursuant to the terms of the Plan, exclusive of this provision. In each instance, actual application of this provision must be approved by Covered Person. HOW pAYMENT IS DETERMINED FOR YOUR HEALTH CARE COVERAGE Payment of the Maximum Allowable Charge or the actual charge, whichever is less, will be provided for all Covered Services. All payments will be subject to any applicable Copayments, Deductible, Coinsurance, maximum benefits and other provisions and limitations in this SPD and th~ Schedule of Benefits. COPAYMENTS Some Covered Services are subject to a Copayment. This is the amount you must pay each time you receive the Covered Service. See the Schedule of Benefits for a list of services, which are subject to a Copayment. The Copayment amounts) are also shown in the Schedule of Benefits. Any expense applied to the Copayment will not be applied to the Deductible or Coinsurance. DEDUCTIBLE Your Deductible is applied to all Covered Services, unless specified othenNise in this SPD. Your Deductible amount is shown in the Schedule of Benefits. SCM's records must show that you have reached this Deductible, so submit copies of all your bills, even those that you must pay to meet the Deductible. End of Year Expenses - Deductible Carry-Over - Any Eligible Expenses incurred dudng the last 3 months of the benefit pedod and credited to your Deductible for that benefit period will be applied toward your Deductible for the next benefit period. Common Accident - If two or more family members are hurt in the same accident, they need to satisfy only one individual Deductible among them for expenses relating to the accident. This special feature applies to Eligible Expenses each benefit pedod for the same accident. COINSURANCE After the Covered Services exceed your Deductible. you begin to pay Coinsurance. Because the amount paid by this program may differ by the type of service that you receive, refer to the Schedule of Benefits to see what your Coinsurance is for each service. COINSURANCE LIMIT Your Coinsurance stops when you have paid the amount shown ~n the Schedule of Benefits. 100% of Eligible Expenses will be paid for the remainder of the benefit period or until you reach the maximum benefits as describea in this SPD. Your Deductible is not credited toward the Coinsurance Limit. MAXIMUM BENEFITS A maximum benefit amount is now much will be paid for a Covered Service. At the beginning of each benefit period, the Plan will automatically restore up to $1,000 of the lifetime maximum payment. In addition, your Coverage is subject to a lifetime maximum benefit for all Covered Services combined. Refer to the Schedule of Benefits for maximum benefit amounts. ORDER OF CLAIMS SUBMISSION AND EFFECT ON DEDUCTIBLE AND COINSURANCE Many times you submit claims for Covered Services that are not in the same order that you received the Covered Services. Regardless of the order claims were incurred, the Copayment(s), Deductible and Coinsurance will be applied to Covered Services in the sequence that claims are submitted and ready for payment. Any Deductible carryover, however, will be based on the date an Eligible Expense is recurred. 14 YOUR HEALTH CARE COVERED SERVICES Your health care services are listed below. In order for these services and supplies to be considered Covered Services, they must be: · authorized by a Physician; · rendered and billed by a Provider; and · Medically Necessary, except as specified. INPATIENT HOSPITAL SERVICES The following Hospital services are covered on an Inpatient basis: Room and board in a semi-private room, including meals, special diets and nursing services, other than private duty nursing services. Coverage includes a bed in a special care unit approved by SCM on behalf of the Employer. · Ancillary services, including, but not limited to: 1. Operating, delivery and treatment rooms and equipment; 2. Routine nursery cara for.a newborn child for up to a maximum of 10 days; 3. Prescribed drugs; 3. Anesthesia, anesthesia supplies and services given by an employee of the Facility; 4. Medical and surgical dressings, supplies, casts and splints; 5. Blood and blood services; 6. Diagnostic Services; 7. Radiation therapy, intravenous chemotherapy, kidney dialysis, inhalation therapy, Physical Therapy, Occupational Therapy and Speech Therapy. INPATIENT MEDICAL SERVICES The following Medical Services performed by a Physician are covered on an Inpatient basis: One Physician visit per day. 2. Constant care and treatment while you are confined in an intensive care unit. 3. Care by two or more Physicians during one Hospital stay when your condition requires the skills of separate Physicians. Consultation by another Physician when requested by your Physician. For each admission, Coverage is limited to one consultation per consultant per specialty. Staff consultations required by Hospital rules are excluded from Coverage. Maternity services including the first Inpatient visit to examine a newborn. A Physician other than the Physician who performed the obstetrical delivery must do the examination. Routine nursery care is considered part of the mother's hospital confinement. When the mother is discharged, Coverage for the newbom infant is provided only as a Covered Person under Family Coverage. · Coverage is provided for Hospital stays in connection with childbirth for at leaSt 48 hours following a normal vaginal delivery and 96 hours following cesarean section, unless the attending Physician, in consultation with the mother, agrees to a shorter length of stay. This provision applies to both the covered mother and the covered newborn. · Coverage for the treatment of a dependent daughter's pregnancy is limited to the treatment of a medical complication adsing from it. or for pregnancies which result from rape or incest. Dental services which are required as a result of Injury to the jaws sound natural teeth, mouth or face. Dental services are limited to the initial treatment for the injury. In order for the Injury to be coverec the Injury must have occurred on or after your Effective Date. SURGICAL SERVICES Surgery performed by a Physician is covered on an Inpatient or Outpatient basis. Surgical services also include: · Services of a Physician who helps your surgeon ~n performing covered major surgery when a house staff member, intern or resident cannot be present: · Administration of anesthesia by a Physician or other Professional who is not the surgeon or assistant at surgery; · Second Surgical Opinion to help determine the need for elective surgery recommended by another Physician~ Coverage ~s provided for the Physician's opinion and related diagnostic services. · VVhen more than one surgical procedure is performed through the same body opening during one operation, you are covered only for the most complex procedure, unless more than one body system ~s involved or the procedures are needed for the handling of multiple trauma. · When more than one surgical procedure is performed through more than one body opening during one operation, you are covered for the most complex procedure and for a portion of the benefit for the less complex procedure(s). Coverage is provided for the following special types of surgery: · Reconstructive Surgery - You are covered for surgery to restore bodily function or correct deformity. Coverage ~s limited to problems caused by disease, Injury, birth or growth defects, or previous treatments. · Elective Sterilization - You are covered for elective sterilization. Oral Surgery: Oral Surgery, including extraction of teeth, if hospitalization is Medical? .Necessary to safeguard the Covered Person's life or health due to a specific non-dental organic ~mpairment. 1. removal of full bony impactions; 2. mandibular staple implant when not done to prepare the mouth for dentures: 3. maxillary or mandibular frenectomy; 4. aiveoiectomy and alveoplasty related to tooth extraction: and 5. orthognathic surgery if severe handicapping malocclusion is present and proved. OUTPATIENT SERVICES Pre-admission testing for tests and studies required for a scheduled admission as an Inpatient. These services must be performed within 7 days of the planned Inpatient Hospital admission or Outpatient surgery. · Radiation therapy, intravenous chemotherapy, infusion therapy, kidney dialysis, inhalation therapy, Chiropractic Treatment, Physical Therapy, Occupational Therapy and Speech Therapy. · Diagnostic Services including laboratory services. Allergy testing is covered. · Blood and blood services, if provided and billed by a Hospital or other Facility. Dental services to treat an Injury to the jaws, sound natural teeth or face. Dental services are limited to the initial treatment of the Injury which is rendered within 72 hours of the Injury. In order for the Injury to be covered, the Injury must have occurred on or after your Effective Date. · Home and office visits to examine, diagnose or treat an Injury or Sickness. Allergy sera and are covered. · Outpatient surgical services and supplies and other Outpatient visits including allergy treatment and Emergency Care. Outpatient Covered Services to study, diagnose or treat sleep apnea which are rendered by a Physician or other Professional in a Physician's office or by the Outpatient department of a Hospital or other Outpatient Facility that is organized and operated to provide such services; Outpatient pain management programs conducted by a Physician or other Professional in a Physician's office or by the Outpatient department of a Hospital or other Outpatient Facility that is organized and operated to provide such services. Under this Plan, a "pain management program" is a program which is conducted under the supervision of your treating Physician and established for the purpose of training you to control and manage pain. PREVENTATIVE CARE SERVlCES Well-Child Care Services. Coverage will be provided for Outpatient preventive care for Dependent children. Coverage includes a medical history, routine examination, developmental assessment, anticipatory guidance and appropriate immunizations and lab tests. Services are limited to three exams from birth through 12 months and 2 exams from age 1 to age 2. Well Care Services. Coverage will be provided for Outpatient preventive care for the Covered Person over age 2. Coverage includes one routine examination, Pap smear or PSA test, blood cholesterol screening, colonoscopy, and routine headng exam per benefit pedod. Immunizations are limited to immunizations for pneumococcal, influenza, hepatitis 8, tetanus, diptheria, pertussis, hemophilus influenza, polio, measles, mumps and rubella. · Routine Mammography Services. Coverage for mammography services will be provided as follows: a. Women age 35-39, one baseline mammogram; b. Women age 40-49, one mammogram screening every two years or one screening every year if a licensed Physician has determined that the woman has dsk factors to breast cancer; c. Women overage 49, one mammogram every year. ]7 MAJOR MEDICAL EXPENSES HOME HEALTH CARE SERVICES Home Health Care Services may 13e provided to you on a part-time basis ~n your home as a Medically Necessary alternative to Inpatient care or must beg~n within 30 days of the Covered Person's discharge from a Hospital or Skilled Nursing Facility. A Home Health Care Provider must provide the services according to a Physician-prescribed course of treatment which has been previously approved by ICM on behalf of the Employer. Covered Services include the following: 1. nursing care by or under the supervision of an R.N. or L.V.N. 2. physical, occupational, respiratory or speech therapy, medical social work, nutrition services and ~ome health aide services: 3. medical appliances and equipment, laboratory services and special meals, if such services and supplies would have been covered by the Group Policy if the insured person had been in a hospital; 4. services of a home health aide including extension of therapy services, personal care, ambulation and exercise, householct services essential to health care, assistance with medications that are ordinarily self-administered, reporting changes in the insured person's condition and needs and completing appropriate records. HOSPICE SERVICES Hospice Services are the following services which are provided to a terminally ill patient with a life expectancy of 6 months or less. Hospice Services must be provided by a Hospice Provider according to a Physician-prescribed plan of care which has been previously approved by ICM on behalf of the Employer. · Nursing Care · Medical Social Services · Physical, Speech and Occupational Therapy · Inhalation Therapy · Home Health Aide Services · Dietary Counseling · Medical/Surgical Supplies · Medical Equipment · Lab Services · Bereavement Counseling (limited to two visits within 6 month's of the Covered Person's death) · 24 Hour Continuous Nursing Care (up to three intervals of continuous care, 5 days per interval) Hospice Services are most often provided in the home and must be agreed to by the Covered Person. SKILLED NURSING FACILITY SERVICES · Covered Services for an inpatient of a Skilled Nursing Facility are the same as those ShOwn in the sections called "Inpatient Hospital Services" and" npabent Mad cai Serv'ces'. Coverage is subject to the following requirements: YOU must be admitted to the Ski!led NurSing FacilitY within 14 days following a Medically Necessary Hospital stay; and · Services must be Medically Necessary as a continuation of treatment for the condition for which you were hospitalized. AMBULANCE SERVlCE Ambulance service is transportation by a vehicle designed, equipped and used only to transport the sick and injured: · from your home, scene of accident or medical emergency to a Hospital; · between Hospitals; · between Hospital and Skilled Nursing Facility; or · from a Hospital or Skilled Nursing Facility to your home. Surface trips must be to the closest local facility that can give Covered Services appropriate for your condition. If none, you are covered for trips to the closest such facility outside your local area. Air transportation is only covered when such transportation is Medically Necessary because of a life threatening Injury or Sickness. Air ambulance is air transportation by a vehicle designed, equipped and used only to transport the sick and injured to and from a Hospital for Inpatient care. MEDICAL SUPPLIES, EQUIPMENT AND APPLIANCES Durable Medical Equipment - The rental (or, at ICM's option, on behalf of the Employer, the purchase) of durable medical equipment prescribed by a Physician. Rental costs must not be more than purchase price. This equipment must serve only a medical purpose and be able to withstand repeated use. Prosthetic Appliances - Purchase, tiffing, needed adjustment, repairs, and replacements of prosthetic devices and supplies that: · replace all or part of a missing body part and its adjoining tissues; or · replace all or part of the function of a permanently useless or malfunctioning body organ. Orthotic Devices - A rigid or semi-rigid supportive device which limits or stops motion of a weak or diseased body part. Medical and Surgical Supplies - Syringes, needles, oxygen, surgical dressings, splints and other similar items which serve a medical purpose. Covered Services do not include items usually stocked in the home for general use like adhesive bandages, thermometers and petroleum jelly. THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT OF t996 Group plans offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section· However, the plan may pay for a shorter stay if the attending provider (e.g. your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. In addition, a plan may not require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain pre-certification. For information on pre-certification, contact your plan administrator. ]9 Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any eadier portion of the stay· COVERAGE FOR SERVICES RELATED TO INFANT EXAMINATIONS Effective JUly 1, 2001, the coverage for services related to infant examinations provisions in your contract will be changed as follows to comply with the new regulations as outlined in House Enrolled Act No. 1487. prOpOsed language and benefit changes aie subject t° DePartment of Insurance aPprOval. The following list of examinations under 1410 were effective July 1, 1999 covered under the requirements of the minimum maternity stay law. These need to be provided at the earliest feasible time for detection of the following disorders: Phenylketonuria; · Hypothyroidism; · Hemoglobinopathies, including sickle cell anemia; · Galactosemia; · Maple Syrup urine disease; · Homocystinuria; · Inborn errors of metabolism that result in mental retardation and that are designated by the state department of health; · PhysiolOgic hearing screening examination for the detection of hearing impairments. Requires plans to extend the coverage for infant examinations as follows: · Congenital adrenal hYperplasia; · Biotinidase deficiency; · Disorders detected by tandem mass spectrometry or other technologies with the same or greater detection capabilities as tandem mass spectrometry, if the state department determines that the technology is available for use by a designated laboratory. cOverag~ for infant examination§ is Subject to the requirements of the plan description regarding the use of participating providers. Upon Department of Insurance approval the contract language will reflect the new regulations as contained n House Enrolled Act 1487. THE WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 Group health plans are required to provide coverage forthe f~il°Wing ServiCes to an individual receiving benefits in connection with a covered mastectomy: · reconstruction of the breast on which the mastectomy has been performed; · surgery and reconstruction of the other breast to produce a symmetrical appearance; and · prostheses and physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes): Coverage described in this notice will be subject to all limitations (including but not limited to any applicable deductible, coinsurance or maximum benefit) under your benefit plan. COVERAGE FOR SERVICES RELATED TO PERVASIVE DEVELOPMENTAL DISORDER Effective July 1, 2001, the plan will cover services related to "PERVASIVE DEVELOPMENTAL DISORDER" INCLUDING Asperger's syndrome and autism. The Plan will be changed as followS to comply with the new regulations as outlined in House Enrolled Act No. 1122. Proposed language and benefit changes are subject to Department of Insurance apProval. The law requires plans must provide a covered individual with coverage for the treatment of a pervasive developmental disorder. Coverage provided under this section is limited to treatment that is prescribed by the covered individual's treating physician in accordance with a treatment plan. A "pervasive developmental disorder" means a neurological condition, including Asperger's syndrome and autism, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. The coverage and services required may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to a covered individual than the dollar limits, deductibles, copayments, or coinsurance provisions that apply to physical illness generally under the health insurance plan. Upon Department of Insurance approval the contract language will reflect the new regulations as contained in House Enrolled Act 1122. PSYCHIATRIC AND SUBSTANCE ABUSE SERVICES Psychiatric Services for the care and treatment of mental illness are covered on an Inpatient or Outpatient basis. Substance Abuse Services for the care and treatment of alcoholism and drug addiction are also covered on an Inpatient or Outpatient basis. Inpatient services include all Covered Services listed under Inpatient Hospital Services and Inpatient Medical Services. In addition, the following services are covered on an Inpatient or Outpatient basis: · Individual psychotherapy · Group psychotherapy · Psychological testing · Family counseling - Counseling with family members to assist in your diagnosis and treatment, except marriage counseling. · Convulsive therapy - Convulsive therapy treatment is limited to Inpatient care. It includes electroshock treatment or convulsive drug therapy. Psychiatric and Substance Abuse Services may be provided by a Physician, Hospital, Specialized Hospital, Alcoholism Treatment Facility or Community Mental Health Facility. 2[ EXCLUSIONS OR LIMITATIONS FOR YOUR HEALTH CARE COVERAGE Unless specifically stated otherwise, no benefits will be provided for or on account of the following items. 1. Injury or Sickness arising in the course of employment if whole or partial compensation is available under worker's compensation or any other laws of any governmental unit. This applies whether or not you claim such compensation or recover losses from a third party; 2. Sickness or injury for which the insured person is any way paid or entitled to payment or care and treatment by or through a government program, other than Medicaid. 3. Injury or Sickness that occurs as a result of any act of war, declared or undeclared; 4. Any service for which you have no legal obligation to pay in the absence of this or like coverage; 5. Dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust or similar persons or group; 6. Cosmetic/Plastic Surgery: No services will be provided for plastic, cosmetic or reconstructive surgery, unless a functional impairment is present. An objective functional impairment is defined as a direct measurable reduction of physical performance of an organ or body part or to correct deformity from disease, trauma birth or growth defects or prior therapeutic processes. The presence of a psychological condition will not entitle an Insured Person to coverage for plastic, cosmetic or reconstructive surgery unless all conditions are met. Coverage will be extended for breast reconstruction when the Insured Person has had a Medically Necessary mastectomy. 7. Treatment received from a member of your household or from an Immediate Family Member. For the purposes of this exclusion, Immediate Family Member means you or your spouse, or you or your spouse's child, brother, sister, or parent; 8. Incurred prior to your Effective Date or after the termination date except as specified in this SPD; 9. For personal hygiene and convenience items; 10. For telephone consultations, missed appointments, or completion of claim forms; 11. Any drug, biological product, device, medical treatment, or proCedure which is experimental or investigative that is defined in this Group Policy; any drug biological product, device, medical treatment or procedure which is not covered as experimental or investigational (or similar) by the HCFA Medicare Coverage Issues Manual; any drug, biological product or device which cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and which lacks such approval at the time of its use or proposed use; or, any drug or biological product categorized as a Treatment Investigational New Drug (IND) by the U.S. Food and Drug Administration or as a Group C Treatment Protocol drug by the U.S. National Cancer Institute at the time of its use or proposed use. Specifically excluded are ambulatory blood pressure monitor, refractive keratoplasty or radial keratotomy, transurethral balloon dilation of prostate, immunotherapy for recurrent abortion, chemonucleolysis, biliary lithotripsy, home utedne activity monitor, immunotherapy for food allergy, and percutaneous lumbar discectomy. 22 12. Services for custodial care or for services not needed to diagnose or treat an Injury or Sickness; 13. Screening examinations, including X-ray examinations made without film; 14. Foot care only to improve comfort or appearance such as care for fiat feet, subluxation, corns, bunions (except capsular or bone surgery), calluses, toenails, and the like; 15. In-vitro fertilization, artificial insemination, and reversal of elective sterilization; 16. Diagnosis and treatment of infertility; 17. Pregnancy of a child, except for medical complications arising from it, or for pregnancies which result from rape or incest; 18. Room, board and general nursing care for Hospital admissions mainly for Physical Therapy or diagnostic studies; 19. Incurred as a result of a Covered Person's (a) engaging in an illegal occupation; or (b) conviction of a felony. 204 Treatment of obesity, including any care which is primarily dieting or exercise for weight loss, except for surgical treatment of morbid obesity; 21. Weight loss or similar programs, including but not limited to, enrollment in a health or athletic club; 22. Purchase or rental of common household supplies, including but not limited to, exercise cycles; air or water purifiers, allergenic pillows or mattresses; or waterbeds. 23. Purchase or rental of motorized transportation equipment, escalators or elevators, saunas or swimming pools, professional medical equipment such as blood pressure kits, or supplies or attachments for any of these items; 24. Transsexual surgery or any treatment leading to or in connection with transsexual surgery; 25. Marital counseling or for hospitalization for environmental change; 26. Elective abortion, unless: a. the physician certifies in wdting that the pregnancy would endanger the life of the mother; or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to the abortion. 27. Homeopathic drugs 28. Acupuncture, unless: a. the treatment is medically necessary and appropriate and is provided within the scope of the acupuncturist's license; b. the insured person is referred to the acupuncturist's treatment by a licensed physician; and c. the acupuncture is performed in lieu of generally accepted anesthesia practices. 29. Care and treatment of methadone dependency; 23 30. Services that extend beyond the period necessary for the evaluation and diagnosis of learning and behavioral disabilities or for mental retardation; 31. Benefits are payable under Medicare Part A or would have been payable if a Covered Person had applied for Part A; and for wh ch benefits are payab e under Medicare Part B or would have been payable if a Covered Person had applied for Part B, exCept aS specified nthis SPD; 32~ Services or supplies pdmadly for educational, vocational or training purposes; 33. Treatment of a Pre-Existing Condition, during the pre-Existing Condition Waiting Period; 34. Contraceptive devices and Norplant insertions; 35. Court ordered care for psychiatric disorders, alcoholism and drug addiction; 36. Oral surgery, dentistry or dental processes, except as specified in this SPD; 37. Eye examinations for the purpose of prescribing or t-~ing of eye glasses or contact lenses, or for eye examinations for any occupational condition, ailment or injury arising out of or in the course of employment; 38. Eye examinations for the purpoSe Of prescribing or fitting of eye glasses or contact lenses, or for eye examinations for any occupational condition, ailment or Injury adsing out of or in the course of employment; 39. Vision analysis, testing or orthoptic training; 40. Headng aids, implantable hearing devices or examinations for prescribing or fitting them; except as routine hearing exam as covered under Wellness Benefit. 41.Treatment of Temporomandibular Joint Disorder (TM J) or dysfunction by surgery of the temporomandibular joint or mandible, intra-oral prosthetic devices, orthodontics, dental splints or extractions, or any other means, regardless of Medical Necessity; 42. Services which are not specified in your Health Care Coverage as Covered Services. HUMAN ORGAN TRANSPLANTS Contrary to any limitations on organ transplants contained in the Group Policy, we will pay benefits for covered organ transplant expenses, as defined below, incurred by an insured person for an organ transplant approved by us at a facility approved by ICM, subject to those conditions and limitations described below. TRANSPLANT means pre-transplant inclusive of any chemotherapy and associated services and post- discharged services, and treatment of complications after transplantation. We will pay benefits only for services, care, and treatment received for or in connection with the approved transplantation of the following human organs: 1. Heart; 2. Lung(s); 3. Heart-lung(s); 4. Liver, for the following diagnoses: Biliary Atresia, Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis, Postnecrotic Cirrhosis Hepatitis B Surface Antigen Negative, Alcoholic Cirrhosis (only if 6 months abstinence from alcohol is documented), Alpha-1 Antitrypsin Deficiency Disease, Wilson's Disease, Pdmary Hemochromatosis. Diagnoses not covered for liver transplantion include, but are not limited to, the following diagnoses: Primary or Metastatic Cancer of the Liver, Hepatitis B Surface Antigen Positive, Secondary Biliary Cirrhosis, Lupus Hepatitis or Autoimmune Hepatitis, Cytomegalovirus Hepatitis, Epstein-Barr Virus Hepatitis, Budd-Chiari Syndrome, Veno-Occlusive Disease, Liver damage caused by chemicals, toxins, or external agents, Alcoholic cirrhosis without 6 months abstinence from Alcohol; 5. Kidney; 6. Bone marrow (allogeneic, autologous and peripheral blood stem cells) but only for certain types of Leukemia, Neuroblastomas, Lymphomas, Ewing's Sarcoma, Aplastic Anemia, Wiskott-Aldrich Syndrome, Severe Combined Immuno-Deficiency Syndrome. We will not cover bone marrow transplants (allogeneic, autologous or peripheral blood stem cells) for treatment of cancers or diseases of the brain, breast, bone, large bowel, ovary, small bowel, testicle, esophagus, kidney, liver, lungs, pharynx, prostate, skin, connective tissue and uterus. We will not cover bone marrow transplants for any congenital, genetic or metabolic disorders affecting or originating in the blood-forming (hematopoietic) system except as stated above as covered. 7. Intestine; 8. Simultaneous pancreas/kidney; 9. Pancreas following kidney; or 10. Any organ not listed above required by state or federal law. Corneal transplants, which are tissues rather than organs, do not require prior approval. As used in this document, the term "bone marrow transplant" means human blood precursor cells which are administered to a patient following ablative or myelosuppressive therapy. Such cells may be derived from bone marrow, circulating blood, or a combination of bone marrow and circulating blood obtained from the patient in an autologous transplant or from a matched related or unrelated donor. In chemotherapy is an integral part of the treatment involving bone marrow transplantation, the term "bone marrow transplant" includes the harvesting, the transplantation and the chemotherapy components. For a transplant procedure to be considered approved for this Transplant Benefit, prior approval from ,1i Individualized Care Management (ICM) is required in advance of the procedure. You or your Physician must notify ICM in advance of your initial evaluation for the procedure in order to determine if the transplant ~- services will be covered. For approval of the transplant itself, ICM must be given the opportunity to :1~11 evaluate the clinical results of the evaluation. Approval will be based on written cdteda and procedures 25 established by ICM. If approval is not given, benefits will not be provided for the transplant procedure as defined above. EXCLUSIONS No benefit is payable for or in connection with a transplant if: 1 The organ or diagnosis involved is not listed in this section of the Group Policy. Transplants that are not covered include, but are not limited to, islet cells, panCreas, kidney-pancreas combination, bowel, stomach, thymus, and pituitary. Bone Marrow and ~liver transPlants are also excluded except as stated as covered in this Group Policy. 2. ICM is not contracted for authorization prior to referral for transplant evaluation of the procedure. 3. ICM does not approve coverage for the procedure, based on established criteria. 4. The transplant procedure is performed in a facility that has not been designated by IcM as an approved transplant facility. 5. Expenses are eligible to be paid under any private or public research fund, government program except Medicaid, or other funding program, whether or not such funding was applied for or received. 6. The expense related to the transplantation of any non-human organ or tissue. 7. The expense related to the donation or acquisition of an organ for a recipient who is not covered by us. 8. A denied transplant is performed; this includes the transplant procedure, follow uP care, immuno- suppressive drugs, and complications of such transplant. The following services/supplies/expenses are also not covered: ii Artifidiai heart devices used as a bridge t° transplant' 2. Drugs Used in connection with diagnosis or treatment leading to a transplant when such drugs have not received FDA approval for such use. Once the transplant procedure is approved, ICM will advise the Insured person's physician of those facilities that have been approved for the type of transplant procedure involved. Benefits are payable only if the pre-transplant services, the transplant procedure and post-discharged services are performed in an approved facility. COVERED EXPENSES For approved transplant procedures, and all related complications, we will cover only the following expenses: 1. Hospital expenses and physician's expenses will be paid under the Hospital Benefit and Physician's Benefit in this Group Policy in accordance with the same terms and conditions as we will pay benefits for care and treatment of any other covered injury or sickness. 2. Transportation costs for the insured person to and from the approved facility where the transplant is to be performed if the facility is more than 100 miles from the insUred person's home. 3. Direct, non-medical costs for one member of the insured person's immediate family (two members if the patient is under age 18 years) for (a) transportation to and from the approved facility where the transplant is performed, but no more than one round trip per person per transplant and (b) temporary lodging ant a prearranged location during the insured person's confinement in the approved transplant facility, not to exceed $75 per day. Direct, non-medical costs are only payabie if the insured person lives more than 100 miles from the approved transplant facility. There is a $5000 maximum for these direct, non-medical expense~. 4. Organ acquisition and donor costs. However, donor costs are not payable under the Group Policy if they are payable in whole or in part by anY other group plan, insurance company, organization or person other than the donor's family or estate. YOUR PRESCRIPTION DRUG COVERAGE DEFINITIONS BRAND NAME MEDICATION means a medication that is manufactured and distributed by only one pharmaceutical manufacturer. CO-PAYMENT means the portion of covered prescription drug expenses which must be paid by or on behalf of the insured incurring the expenses. GENERIC MEDICATION means a medication that is manufactured, diStributed and available from several pharmaceutical manufacturers and identified by the chemical name. FORMULARY means a list of drug products approved under the plan that are available for use by insureds. NON-PARTICIPATING PHARMACY means a pharmacy which agrees to provide services under terms set forth by the Pharmacy Network Provider. PARTICIPATING PHARMACY means a pharmacy which agrees to provide services under terms set Forth by the Pharmacy Network Provider. PHARMACIST means a person wh° is licensed to prepare, compound and dispense medication and who ~ is participating within the scope of his or her license. PHARMACY means a licensed establishment where prescription medications are dispensed by a ~ pharmacist. PHYSICIAN means a licensed medical practitioner who is practicing within the scope of his or her license and whose services are required to be covered by the laws of the jurisdiction where the treatment is given. PRESCRIPTION means a direct order for the preparation and use of a drug, medicine of medication. This order may be given by a physician to a pharmacist for the benefit of and use by an insured person. the drug, medicine or medication must be obtainable only by prescription. The prescription may be given to the pharmacist verbally or in wdting by the physician. The prescription must include: 1. the name and address of the insured person for whom the prescription is intended; 2. the type and quantity of the drug, medicine or medication prescribed, and the directions for its use; 3. the date the prescription was prescribed; and 4. the name, address and DEA number of the prescribing physician. BENEFIT DESCRIPTION Benefits are payable if covered prescription drugs are received by the insured person while he or she is insured for this benefit. The amount of the benefit provided, except for self-administered injectable drugs defined as any FDA approved medication which a person may administer to himself/herself by means of intermuscular, intravenous or subcutaneous injection, exCluding insulin, is as follows: For prescriptions filled at participating pharmacies-the sum of a, b, and c below, minus the insured person's co-payment: a. the ingredient cost, as determined for participating pharmacies; b. the professional dispensing fee, as determined for participating pharmacies; and c. any sales or provider tax. Your ID card must be presented to a participating pharmacy each time a prescription is filled or refilled. PRESCRIPTION DRUG COPAYMENT The prescription co-payment at a participating pharmacy is $5 for a generic drug and $10 for a brand name drug. For prescriptions purchased at a non-participating pharmacy, you must pay the full cost of the prescription and submit a prescription drug claim form. These claims forms can be obtained from you Employer. Payment will be made for prescriptions at 75% of the pharmacy's billed amount after the Proscription Drug Card Co-payment is applied. The preceding co-payments will apply to all covered medications except for self-administered injectable drugs. The insured is rosponsible for any amount that exceeds the benefit payable for self-administerod injectable drugs as stated in the Benefit Description section. Any expenses incurred under provisions of this benefit do not apply toward the insured person's maximum personal expense limit per calendar year. Coverod expenses will be applied toward the maximum individual benefit provisions of the Group Policy. WHAT IS COVERED Coverod proscription drugs arc: 1. drugs, medicines or medications that under federal or state law, may be dispensed only by proscription from a physician, and that arc on the formulary list: 2. limited to a maximum of a 30-day supply per prescnption or refill; 3. insulin; 4. hypodermic needles or sydnges on proscription for use with insulin or self-administerod injectable drugs; and 5. self-administerod injectable drugs approved under the Plan. Covered prescription drugs must: 1. be prescribed by a physician for the troatment of an injury or siCkne§s; 2. be dispensed by a pharmacist; and 3. be included in the formulary approved under the Plan. Contrary to any other provisions of the Group Policy, prescription drug expenses covered under this benefit are not covered under any other provision in the Group Policy. Any amount in excess of the maximum amount provided under this benefit, if any, is not covered under any other provision in the Group Policy. EXCLUSIONS OR LIMITATIONS No Prescription Drug benefits are provided for the following: 1. any oral drug, medicine or medication that is consumed or injected at the place where the prescription is given, or that is dispensed by a physician; 2. any portion of a proscription or refill that exceeds a 30-day supply; 3. proscription refills in excess of the number specified by the physician or dispensec more than one year from the date of the physician's original order; 28 4. the administration of covered medications; prescriptions that are to be taken by or administered to the insured person, in whole or in part, while he or she is a patient in a hospital, rest home, sanitarium, skilled nursing facility, convalescent hospital, inpatient hospice facility or other facility where drugs are ordinarily provided by the facility on an inpatient basis; 6. prescriptions that may be properly received without charge under local, state or federal programs, including Worker's Compensation; 7. any drug, medicine or medication labeled "Caution - Limited by Federal Law to Investigational Use" or any experimental drug, medicine or medication, even though a charge is made to the Insured person; 8. immunizing agents, biological serums or allergy serums; 9. any drug or medicine that is lawfully obtainable without a prescription; 10. any drug, medicine, or medication received by the insured person before becoming covered under this benefit or after the date the insured person's coverage under this benefit has ended; 11. therapeutic devices or appliances, including hypodermic needles, syringes, support garments, contraceptive devices, and other non-medical substances, regardless of intended use, except as otherwise states in this benefit; 12. any costs related to the mailing, sending or delivery of prescription drugs; 13. prescriptions filled at a non-participating pharmacy, except for prescriptions required dudng an emergency; 14. any service, supply, or therapy to eliminate or reduce a dependency on or addiction to tobacco, and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services, and medications; 15. mechanical pumps for the delivery of medications; 16. any fraudulent misuse of this benefit, including prescriptions purchased for consumption by someone other than yourself; 17. any drug prescribed for intended use other than for indications approved by the FDA; 18. more than one prescription for the same drug or therapeutic equivalent medication prescribed by one or more physicians and dispensed by one or more pharmacies until at least 75% of the previous prescription has been used by the insured person. (Based on the dosage schedule prescribed by the physician); or 19. drug delivery implants. CLAIMS INFORMATION PROCEDURE FOR CLAIMING BENEFITS HOW TO OBTAIN BENEFITS When you receive Covered Services. a claim must be filed for you to obtain benefits. In some cases, the Provider will file the claim for you. If you submit the claim yourseif, you should use a claim form. It is in your best interest te ask the Provider if the claim will be filed for you. Refer to the Prescription Drug benefits section for additional details concerning claiming benefits for Prescription Drugs. CLAIM FORMS Claim forms will usually be available from the Employer. If forms are not available, send a written request for claim forms to SCM. The forms will be sent to you. If you do not receive the forms within 15 days, written notice of services rendered may be submitted to SCM without the claim form. The same information that would be given on the claim form must be included in the written notice of claim. This includes: · Name of patient · Patient's relationship to the Covered Participant · Identification number · Date. type and place of service · Your signature and the Provider's signature NOTICE OF CLAIM Written notice that Coveree Services have been given to you must be prowded to SCM. The notice must be g~ven to SCM within 90 days of receiving Covered Services and must have the data needed to determine benefits. An expense ;s considered incurred on the date the service or supply is given. Failure to give SCM notice within 90 days will not reduce any benefit if you show that the notice was given as soon as reasonably possible..No notice can be submitted later than one year after the usual 90-day filing pedod ends. In the event of termination of the Administrative Agreement, all notices of claims for Covered Services rece;ved after the termination of the Administrative Agreement should be prowded to the Employer. PAYMENT OF BENEFITS You may request that payments be made directly to a Provider, however, SCM reserves the right to make payments to the Provider or directly to you. You cannot request that payment be directed to anyone else. Once a Provider gives a Covered Service. SCM will not honor your request te withhold payment of the claims submitted. If a benefit is owed when you are not able to handle your affairs, the benefit may be paid to a relative by blood or marriage. This would happen if the Covered Participant ~ad died or become mentally incompetent. SCM. on behalf of the Employer, would provide the benefit to a relative whom it judged to be entitled in fairness to the money. Any such payment would discharge any obligation to the extent of such payment. 30 REFUND OF OVERPAYMENT OF BENEFITS If the Plan pays benefits for expenses incurred by a Covered Person, the Covered Participant or any other person or organization that was paid must make a refund to SCM if: · All or some of the expenses did not legally have to be paid by the Plan; or · All or some of the payment made by SCM, on behalf of the Employer, exceeded the benefits under the Plan. The refund equals the amount SCM paid in excess of the amount it should have paid under the Plan. If the refund is due from another person or organization, the Covered Person agrees to assist CB N in obtaining the refund when requested. RECORDS By.accepting Coverage under the Plan, you and your Dependents agree that all information and records concerning diagnosis and treatment of any condition for which Coverage is provided will be available to the Employer and SCM as the claims administrator for purposes of determining liability or for statistical analysis. You also agree that the Employer or SCM may provide similar information if requested to anyone providing similar benefits to you or your Dependents. Finally, you and your Dependents agree that SCM may provide any medical or non-medical records in its possession to your Employer, or to any other party identified by the Employer, provided such records are essential to the administration of the benefit plan. The Covered Participant and/or Dependent will furnish a specific release of medical information as necessary for the purposes of determining liability under the Plan. PHYSICAL EXAMINATION AND AUTOPSY By accepting Coverage as described in this SPD you agree that you may be required to have one or more physical examinations. Performance of an autopsy may also be required in the case of death where it is not forbidden by law. These examinations and/or autopsy will help to determine what benefits will be payable, particularly when there are questions concerning services on a claim. LIMITS ON LEGAL ACTION No legal action may be taken to recover benefits within 60 days after Notice of Claim has been given. No -~ such action may be taken later than 3 years after the time limit for filing claims for the service. M YOUR RIGHTS TO AN ITEMIZED BILL You have the right to receive a copy of an itemized bill. This bill would identify the services and supplies rendered to you. To receive a copy of the bill, send a written request to the Provider from which you have received care. It is in your best interest to exercise this right so that you have a copy of the bill for your personal files. APPEAL PROCEDURE --" If a claim is wholly or partially denied, a wdtten notice will be sent to you containing the reason for denial. The notice will include a reference provision in the SPD that applies and a description of any additional -- information, which might be necessary for reconsideration of the claim· The notice will also describe your ~1~ right to appeal· You may appeal a denial of benefits by sending a wdtten appeal to SCM, along with any additional information or comments which you feel support your claim, within 90 days after the notice of __ denial. In preparing the appeal, you or a representative may review all documents related to the claim, ~ 3! and submit written comments and issues related to the denial. After the wdtten notice is filed and all relevant information is presented, the claim will be reviewed and a final decision sent to you within 60 days after receipt of the notice of appeal. Under special circumstances, SCM will grant an extension for further review, but not for longer than 60 additional days. If such an extension is necessary, you will be given notice of the extension before the first 60-day pedod expires. COORDINATION OF BENEFITS All benefits provided as described in this SPD are subject to Coordination of Benefits (COB). COB determines when a benefit plan is pdmary or secondary when a Covered Person is covered by more than one benefit plan. COB affects benefits in the following manner when you are covered by more than one benefit plan: If the total benefits for Covered Services to which you would be entitled under this Plan and under all Other Benefit Plans exceed the Covered Services you receive, then the benefits provided will be determined according to this provision. · When the Plan is primary, SCM will authorize the payment of benefits on behalf of the Employer without regard to any Other Benefit Plan. Which plan provides primary or secondary Coverage will be determined by using the first of the following rules that applies: When the Plan is secondary, the benefits SCM authorizes on behalf of the Employer may be m reduced and will not exceed the balance of charges remaining after payment by the Other Benef~ Plan. - - 1. If the Other Benefit Plan contains no COB provision, it will always be pdmary. 2. The benefit plan covedng you as an employee, member or subscriber (other than a Dependent is primary. 3. When a Dependent is covered by more than one plan of different parents who are not separated or divorced, the coverage of the parent whose birthday falls eadier in the calendar year (excluding year of birth) is pdmary. If both parents have the same birthday, the plan, which covered the parent longer, will be primary. If a Dependent is covered by two benefit plans and the Other Benefit Plan does not have this COB rule, the rule of the Other Benefit Plan will determine the primary and secondary contract. If the parents are separated or diVorced, the following rules apply: 4. If the parent with custody has not remarried, his or her coverage is primary; 5. If the parent with custody has remarried, his or her coverage is primary, the stepparent's is secondary and the coverage of the parent without custody pays last; 6. If a court decree specifies the parent who is financially responsible for the child's health care expenses, the coverage of that parent is primary. 7. When a plan covers you as an active employee or a Dependent of such employee and the Other Benefit Plan covers you as a laid-off or retired employee or as a Dependent of such person, the plan which covers you as an active employee or Dependent of such employee is pdmary. 8. When the rules above do not apply, the plan, which has covered you longer, is primary. RIGHTS OF RECOVERY The rights of recovery available under this Plan apply to situations where a Covered Person is injured and another party is responsible for payment of health care expenses the Covered Person incurs because of the Injury, illness or other loss. The other party may be an individual, insurance .company or some other public or private entity. If the Plan pays benefits for injury, illness or other loss, SCM, on behalf of the Employer, may seek reimbursement, recoupment, or subrogation against any person or entity (or responsible insurer) that caused, contributed to, or is responsible for said injury, illness or other loss. The Plan may also enforce its dghts of recovery which arise under a no fault, personal injury protection, financial responsibility, uninsured or underinsured insurance coverage. The Plan may also enforce its rights of recovery from any medical reimbursement insurance coverage, which is not purchased by the Covered Person. The Covered Person must cooperate fully with the Employer and SCM and must provide all information needed by the Employer or SCM to recover payments made under this Plan and to execute any papers necessary for such recovery. The Plan may sue the other party to recover the payments made for the Covered Person. The Covered Person must not do anything that will limit or prohibit the Plan's dghts to recover expenses equal to the claims paid on his or her behalf from the responsible party. For example, if the Covered Person submits claims to SCM and takes no action to recover payment from the responsible party, the Covered Person must not take any action or sign any statements that relieve the party of responsibility for health care expenses. If the Covered Person chooses to recover payment from the responsible party, the Covered Person must include the amount paid by the Plan in the requested settlement. If the Covered Person receives a settlement from the responsible party, the Covered Person must send the Plan an amount equal to the amount paid by the Plan. As used in this section, "Covered Person" includes the Covered Person's heirs, guardians; executors or other representatives. 34 MEDICARE Medicare is the secondary payer to some employer group health plans for services provided to the following individuals: 1. Employees or spouses of employees who are 65 or older; 2. Individuals with permanent kidney failure; 3. Certain disabled people. This is explained in detail below and on the following page(s). Employees or Spouses Age 65 or Older - When a Covered Employee age 65 years or older is Actively Working and is eligible for Medicare coverage, the Covered Employee must make a choice concerning coverage under the Plan. The employee must elect to either continue to have the Plan remain as the pdmary payer, or he/she may elect Medicare as the primary payer. If the employee chooses the Plan as pdmary, coverage will continue as described in this SPD. Medicare will be considered the secondary payer to the Plan. If the employee elects Medicare as the pdmary payer, any charges considered by Medicare to be allowable charges cannot be covered by the Plan. The Plan cannot (by law) coordinate benefits with Medicare or be the secondary payer for any charges that are allowable by Medicare. Therefore, in this eventl the employee will be cancelled from the Employer's Plan. The spouse of a Covered Employee subject to this section must also make the election between the Plan and Medicare as pdmary payer and will also be cancelled from the Employer's Plan in the event he or she elects Medicare as pdmary payer. People With Permanent Kidney Failure - Medicare is the secondary payer if the Covered Person has Medicare due to permanent kidney failure for a period of 18 months, beginning with the earlier of the following dates: 1. The month in which the Covered Person begins a regular course of renal dialysis; or, 2. The first month in which the Covered Person becomes entitled to Medicare, if he or she receives a kidney transplant within first beginning dialysis. After a pedod of up to 18 months following this date expires, Medicare will become the primary payer. Once Medicare becomes primary, the benefits of the Plan will be applied only to any unpaid balance after -- the Covered Person receives Medicare benefits. In this event, Medicare benefits available to the Covered Person will be subtracted whether or not a Medicare claim is filed. Certain Disabled Individuals - Medicare is the secondary payer for people under age 65 who have Medicare because of a disability (other than those with permanent kidney failure) and who are covered under a Large Group Health Plan as an employee, employer or Dependent of such person. To be eligible under this provision, the employee or employer must be Actively Working in spite of the disability. The Covered Employee or spouse should contact the Employer to determine whether or not Coverage is being provided under a Large Group Health Plan. All Other Medicare-Eligibles - Where specified by state statute or city ordinance, certain Participants who are eligible for Medicare may continue coverage under the Plan. Benefits for eligible Participants will be based on a carve-out approach. Under the carve-out approach, any benefits received under Medicare will not be considered Covered Services under the Plan. This means that the benefits will be applied only to any unpaid balance after Medicare benefits are received. If the Covered Person is eligible for Medicare, the Medicare benefits will be subtracted whether or not a Medicare claim is filed. 35 TERMINATION OF COVERAGE TERMINATION OF THE PLAN coverage under the Plan ends for ail covered persons on the dat® On which the Plan terminates or is not renewed by the Employer. The Employer reserves the right to terminate this Plan, in whole or in part, at any time. TERMINATION OF EMPLOYEE COVERAGE Coverage will terminate for the Covered Employee and his/her Covered Dependents at the end of the month when the following occurs: ·the employee ceases to be an Eligible Employee; · leaves employment; · or otherwise ceases to meet the eligibility requirements of the Plan. OF DEPENDENT COVERAGE TERMINATION coverage will terminate for the following Covered Persons) on the date the following events occur: · for the Covered Dependent, when the Covered EmplOyee ceases to be an Eligible EmPloyee, leaves employment or otherwise ceases to meet the eligibility requirements of the Plan; · for the COVered Dependent, when the Covered Employee or City of Jeffersonville fails to make the required contribution; ' for the SpouSe of the Covered PartiCipant, UPon the Covered Participant's and covered spouse's decree of divorce or dissolution; · for the CoVered Dependents upon the Covered Employee's death, unless continuation of coverage is requested by the Covered Dependents) in the manner outlined under the section of this SPD entitled "continuation of Coverage," or; · for a Dependent child, when the child no longer qualifies as a Dependent. TERMINATION OF COVERAGE FOR RETIREES AND DEPENDENTS OF RETIREES Unless otherwise specified by state statute or city ordinance, coverage will terminate for the Covered Retiree or the DePendent of a Covered Retiree on the date the following occurs: · the Covered Retiree or spouse becomes eligible for Medicare; or · the Covered Retiree fails to make the required contribution; or · for. a Dependent child, when the Child ndlOnger qualifies as a Dependent. HANDICAPPED CHILDREN If a dependent child who has reached the maximum age for a dependent meets all of the requirements shown below, dependent health insurance for that child for as long as you remain insured for dependent insurance. 1. The child must be incapable of self-sustaining employment because of mental or physical handicap. 2. The child must rely On you for financial support. CONTINUATION OF COVERAGE Your Plan has a number of Coverage continuation provisions. Once your benefits end under a particular provision you may have additional continued benefits under another provision. Read each section carefully to determine your eligibility under the provision. CONTINUED COVERAGE UNDER THE FAMILY AND MEDICAL LEAVE ACT (FMLA) This provision does not apply to retirees or the spouses of retirees. Under federal law, an employer who is subject to FMLA requirements must provide to the employee unpaid leave of absence for 12 weeks during each 12-month period without a lapse in the employee's existing health coverage when: a. the employee requests such leave of absence in order to care for a newborn or newly-adopted child; b. the employee requests such leave of absence in order to care for a sick child, spouse or parent; or ~ c. the employee requests such leave of absence because the employee has a serious health condition. In order for Health Coverage to be continued, wdtten proof of the employee's eligibility and election must be submitted to SCM's home office. In addition, all monthly payments must be received by SCM's home office by the due date. The Employer may require the Covered Employee to pay the full cost of the continued Coverage. Generally, an employer is subject to the FMLA if your employer has 50 or more full-time,employees on an average business day. This section is merely a general summary of the provisions of the FMLA. If you require additional details concerning how the FMLA affects you, contact the Employer. Once you have exhausted your 12 weeks of continued Coverage under this section, you may be eligible for additional continued Coverage under COBRA. COBRA (CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT) A federal law commonly referred to as COBRA, requires that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health Coverage (called Continuation Coverage) at group rates in certain instances where Coverage under the Plan would otherwise end. This notice is intended to inform you, in a summary fashion, of your rights and obligations under the Continuation Coverage provisions of the law. If you are an employee covered by the Plan, you have a dght to choose this Continuation Coverage if you lose your group health Coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part). If you are the spouse of an employee covered by the Plan, you have the right to choose Continuation Coverage for yourself if you lose group health Coverage under the Plan for any of the following four reasons: · The death of your spouse; · A termination of your spouse's employment (for reasons other than gross misconduct) or reduction in your spouse's hours of employment; --- · Divorce or legal separation from your spouse; or 37 · Your spouse becomes entitled to Medicare. In the case of a dependent Child of an employee covered by the Plan, he or She has the dght to Continuation Coverage if group health Coverage under the Plan is lost for any of the following five reasons: The death of a parent; The termination of a parent's employment (for reasons other than gross misconduct) Or reduction in a parent's hours of employment with the Plan; Parents' divorce or legal separation; · A parent becomes entitled to Medicare; or · The Dependent ceases tO be a "dependent Child" under the Plan. Rights similar to those described aboVe may apply to retirees and their spouses and Dependents if these individuals lose group health Coverage because a bankruptcy proceeding under Chapter 11 of the federal bankruptcy code with respect to the Plan is commenced. Under this law, the emPlOyee Or a family member has the responsibility to inform the Employer of a divorce, legal separation, or a child losing dependent status under the Plan. If such an event occurs and notice is not sent to the Plan within 60 days of the date the event occurs or, if later, the date CoVerage under the Plan would terminate as a resUlt of the event, the affected individuals will lose their dght to elect Continuation Coverage under the plan With respect to occurrence of the event. VVhen the Plan is notified that one of these events has happened, or if any other qualifying event occurs, the Plan will notify yOu and Your family of the right to Choose Continuation Coverage. Under this law, you have at least 60 days from the date you would lose Coverage because of one of the events described above to inform the Plan that you want Continuation Coverage. If you do not chooSe ContinuatiOn Coverage, your group health COverage Will end. If you chOose Continuati°n COverage, {~e Plan is required t° give you coVerage WhiCh, as of the time Coverage is being provided, is identical to the Coverage provided under the Plan to similarly situated employees or family members. The law requires that you be afforded the opportunity to maintain Continuation Coverage for three years (36 months) unless you lose group health Coverage because of a termination of employment or reduction in hours. In that case, the required Continuation Coverage period is 18 months. This 18-month period may be extended if another event (for example, divorce, legal separation, an employee's becoming entitled to Medicare or death) occurs during that 18-month period. Under no circumstances, however, will Coverage last beyond three years (36 months) from the date of the event that originally made you eligible to elect Coverage. If the event which resulted in your loss of group health Coverage under the Plan is the employee's termination or reduction in hoUrs of employment with the Plan and you are disabled (within the meaning of Title II or XVI of the Social Security Act) on the date of the employee's termination or reduction in hours of employment with the Plan, or if the disability exists at any time dudng the first 60 days of Continuation Coverage, then the Coverage period will be extended for up to 11 months. In order to receive this extension of Continuation Coverage, the disabled individual must notify the Plan of the determination of disability within the original Coverage period and within 60 days after this determination is made. However, this law also provides that your Continuation Coverage may be cut short for any of the following reasons: 1. The Plan no longer provides group health Coverage to any of its employees; 2. The premium for your Continuation Coverage is not paid on time; 3. You become covered under another group health plan which does not contain any exclusion or limitation with respect to any pre-existing condition; 4. You become entitled to Medicare; or In the event that you are receiving extended Continuation Coverage as a result of your being disabled under the Social Secudty Act, your extended Continuation Coverage may be terminated by the Plan on the first day of the month at least 31 days after a final determination that you are no longer disabled. You must notify the Plan within 30 days of the date of any final determination under the Social Security Act that you are no longer disabled. It is not necessary for you to show that you are insurable to choose Continuation Coverage. Under this law, you must pay all or part of the premium for your Continuation Coverage. The premium for an extended Continuation Coverage pedod due to a total disability may also be higher than the premium due for the first 18 months. This law also says that, at the end of the Continuation Coverage pedod, you must be allowed to enroll in any individual conversion health plan which is provided under the Plan If you have any questions about the law, please contact the Employer during normal business hours. Also, if you have changed marital status, or you and your spouse have changed address, please notify the Employer. CONTINUATION OF COVERAGE FOR SURVIVING SPOUSES AND ELIGIBLE DEPENDENTS Where specified by state statute or city ordinance, a surviving spouse or eligible Dependent of a Covered Participant may elect to continue Coverage under this Plan following the death of the Covered Participant. In order for Coverage under this Plan to continue for the surviving spouse or eligible Dependent, a wdtten request must be filed with the City of Jeffersonville within 90 days after the death of the Covered Participant. This provision for continuation of Coverage rights does not preclude additional coverage under COBRA. DEFINITIONS Actively Working/Actively At Work - Means the employee is performing his/her regular duties on behalf of, and in the regular business of, City of Jeffersonville, for the hours as listed in this section and is reasonably being compensated by City of Jeffersonville on a regular basis for such duties. Administrative Agreement - Means the contract between City of Jeffersonville and SCM pursuant to which SCM has been contracted to process claims on behalf of the Employer. Alcoholism Treatment Facility - Means a facility that is primarily engaged in the treatment of alcoholism. The facility must have in effect plans for utilization and peer review and programs for rehabilitation or rehabilitation and detoxification of alcoholism. The facility must also be approved by the Joint Commission on the Accreditation of Health Care organizations or certified by the Department of Health. · Ambulatory Health Facility - Means a facility which is organized and operated to provide medical care to Outpatients. The facility must provide preventive, diagnostic, therapeutic or rehabilitative services under the direction of a Physician. The facility must not be part of a Hospital. Ambulatory Surgical Facility - Means a facility, with an organized staff of Physicians, which: · has permanent facilities and equipment for the pdmary purpose of performing surgical procedures on an Outpatient basis: · provides treatment by or under the supervision of Physicians and nursing services whenever the patient is in the facility; · does not provide Inpatient accommodations; and · is not. other than incidentally, used as an office or clinic for the private practice of a Physlcia~ or other Professional. The facility must be accredited by the Joint Commission on the Accreditation of Health Care Organizations or by the American Osteopathic Association. Chiropractic Treatment - Means treatment by physical means including modalities such as whirlpool and diathermy; procedures such as massage, ultrasound and manipulation; and tests of measurements required to determine the need and progress of treatment. Such treatment must be given to relieve para. restore maximum function, and to prevent disability following disease, injury, or loss of body part. Treatment must be for acute conditions where rehabilitation potential exists and the skills of a Physician or other Professional are required. Coinsurance - Means a percentage of the Maximum Allowable Charge that a Covered Person pays for Covered Services. Coinsurance Limit - Means the maximum Coinsurance expense payable in a benefit ~3eriod. An Individual Coinsurance Limit is the maximum amount each person is required to pay in Coinsurance expense in a benefit period. A Family Coinsurance Limit is the maximum amount 2 or more family members covered under the same Coverage are required to pay ~n Coinsurance expense in a benef~ period. Coinsurance Limit is divided into two categories: Coinsurance Limit for Facility charges and Coinsurance Limit for Professional charges. Community Mental Health Facility - Means a facility that is primarily engaged in the treatment of mental illness including substance abuse. The facility must have in effect utilization and peer review plans. The facility must also be approved by the Joint Commission on Accreditation of Health Care Organizations or certified by the Department of Health. 4o Confinement - Means an Inpatient stay in a Hospital or other Facility. Two successive Confinements will be considered one Confinement if readmission is for the same or related condition for which you were previously confined and the readmission occurs within 90 days. Coverage - Means the payment for Covered Services as specified and limited by this Plan. Covered Employee - means an active employee who meets the eligibility criteria outlined in this SPD and who is Covered under this plan. Covered Participant - Means the person whose name appears on the identification card. Covered Retiree - means a retired employee who meets the eligibility criteria outlined in the Indiana statutes, town ordinances, and/or union contracts and who is Covered under this plan. Covered Persons - Means the Covered Employee and, under Family Coverage, the Covered Employee's spouse and any unmarried Dependent children who are eligible for Coverage. The term also means the Covered Retiree and the eligible Dependents of the Covered Retiree. Creditable Coverage - Means prior coverage by an insured person under any of the following: 1. A group health plan, including church and governmental plans; 2. Health insurance coverage; 3. Medicare or Medicaid; 4. The health plan for active military personnel, including CHAMPUS; 5. The Indiana Health Services or other tribal organization program; 6. A state health benefits risk pool; 7. The Federal Employees Health Benefits Program; 8. A non-federal, public health plan; 9. A health plan under section 5(e) of the Peace Corps Act. m Creditable coverage does not include any of the following: 1. Accident only coverage, disability income insurance, or any combination thereof; 2. Supplemental coverage to liability insurance; 3. Liability insurance, including general liability insurance and automobile liability insurance; 4. Worker's compensation or similar insurance; 5. Automobile medical payment insurance; 6. Credit-only insurance; 7. Coverage for on-site medical clinics; 8. Benefits if offered separately: a. limited scope dental and vision b. long-term care, nursing home care, home health care, community based care, or any combination thereof, and c. other similar, limited benefits. 9. Benefits if offered as independent, non-coordinated benefits: a. specified disease or illness coverage; and b. hospital indemnity or other fixed indemnity insurance. 10. Benefits offered as a separate policy: a. Medicare supplement insurance; b. Supplemental coverage to the health plan for active military personnel, including CHAMPUS, and 4! c. Similar supplemental coverage provided to group health plan coverage. DedUctible, Means the amount a Covered Person must p~y for Eligible Expenses incurred in a benefit pedod before benefits begin to be Paid for that person under the Plan. An ndividual Deductible is the amount that each Covered Person must pay during a benefit period before benefits begin t°be Paid for that pem0n. A Family Deductible is the maximum amount that 2 or more family members covered Under the same Family Coverage must pay in Deductible expense in a benefit period. Once the Family Deductible is reached, the Deductible will be considered satisfied for all family members under that Family Coverage during the remainder Of the benefit period. Dependent- Means a Covered Person other than the covered Participant as described in !his SPD. Diagnostic Services - Means tests and procedures performed when you have specific symptoms to detect or to monitor your disease or condition. Diagnostic Services include, but are not limited to, the following: X-ray and other radiology services; laboratory and pathology services; cardiographic, encephalographic and radioisotope tests. Effective Date - Means the date on which your Coverage begins. Eligibility Date - The date the employee is eligible for Coverage under the Plan. For elected or appointed officials, the Eligibility Date is the date the official takes office; for all other Eligible Employees, the Eligibility Date is 1st of the month following the date of hire. Eligible Expenses - Means expenses for Covered Services which are incurred by a Covered Person. Eligible Expenses do not include expenses in excess of the MaXimum Allowable Charge. Emergency Care - Means care and treatment provided in the Outpatient emergency department of a Hospital or other Facility within 72 hours of the onset of the Sickness or occurrence of the Injury. Enrollment Date- Is used in determining When the pre-existing Condition W~itih~l~eri0d begins and means the following: FOr Eligible Employees Who Complete and Submit a re i~tration applicati°n within 31 and 4,5 days '. g respectively, following the Eligible Employee's Eligibility Date, Enrollment Date means the Eligible Employee's date of hire for elected or appointed officials, and 30 days following the date of hire for ail other Eligible Employees. · For all other enrollees, Enrollment Date means the Effective Date of Coverage. EXperimental/investigative - Means any treatment, procedure, facility, equiPment, drug, device or supply which ICM does not recognize as accepted medical practice or which did not have required governmental approval when you received it. Family Coverage - Means Coverage for the Covered Participant and one or more Dependents. Family or Medical Leave of Absence ' Means an unpaid leave of absence to care for a newborn, newly adopted child, a sick child, spouse or parent, or an unpaid leave of absence due to a serious health condition pursuant to the Family and Medical Leave Act. Hearing Services - Means the services performed by licensed audiologists t° determine and measure heating function loss which occurred while the Covered Person is eligible for Coverage under the Plan. 42 Home Health Care Provider - Means a facility which provides skilled nursing and other services on a visiting basis in your home, and is responsible for supervising the delivery of such services under a plan prescribed and approved in writing by the attending Physician. A Home Health Care Provider must be certified by Medicare or accredited by the Join~t Commission on the Accreditation of Health Care Organizations. Hospice Provider - Means a facility which provides medical, social, psychological and spiritual care as palliative treatment for terminally ill patients in the home and/or as an Inpatient using an interdisciplinary team of professionals. A Hospice Provider must be approved by the Joint Commission on Accreditation of Health Care Organizations or certified by Medicare. Hospital - Means an institution licensed by the jurisdiction in which it is located; approved by the Joint Commission on the Accreditation of the Health Care Organizations or certified under Medicare. It must provide Inpatient medical care and treatment, a staff of physicians and nurses, facilities for diagnosis and major surgery, but cannot be mainly a place for the aged or for treatment of alcoholism or drug addiction. Human Organ - Means a human heart, lung, liver or pancreas. Human Organ Transplant - Means a human heart, heart-lung, liver or pancreas transplant. In-Network - Refers to Covered Services rendered by a Preferred Provider. Individual Coverage - Means Coverage for the Covered Participant only. Injury - Means an accidental bodily injury caused by external and violent means. Injury to the teeth as a result of biting and chewing is not considered an accidental bodily Injury. Inpatient - Means a Covered Person who is admitted to a Hospital or other Facility as a registered Inpatient and who remains in the Hospital or other Facility for 24 or more hours. Laboratory - Means a facility which is maintained to perform diagnostic tests and which is approved for Medicare reimbursement. Life-threatening Pregnancy - Means a condition distinct from pregnancy, but which is adversely affected by pregnancy. Such conditions include, but are not limited to: acute nephritis, nephrosis, cardiac decompensation, missed abortion, non-elective cesarean section, ectopic pregnancy, hyperemesis gravidarum, spontaneous abortion and miscarriage. A Life-threatening Pregnancy does not include conditions such as false labor, physician-prescribed rest during pregnancy, morning sickness, occasional spotting, pre-eclampsia or other conditions related to a difficult pregnancy. Maternity Admission - Means an admission to a Hospital expressly far giving birth. Maternity Services - Means services for normal pregnancy, complications of pregnancy~ miscarriage and therapeutic abortions. Maximum Allowable Charge - Means the maximum amount of reimbursement to be paid to a Professional and/or Facility. When a charge is submitted to SCM, payment will be made for the actual charge or the Maximum Allowable Charge, whichever is less, subject to any applicable Deductible, Coinsurance, Copayment or other limitation of your Plan. Medically Necessary (or Medical Necessity) - Means the criteria used by SCM on behalf of the Employer to determine the Medical Necessity of Health Care services under this Plan. To be Medically Necessary, Covered Services must: 43 · Be rendered in connection with an Injury or Sickness; · Be consistent with the diagnosis and treatment of your condition; · Be in accordance with the standards of good medical practice; · Not be considered Experimental or Investigative; and · Not be for your convenience or your Physician's convenience. To be Medically Necessary, Covered Services must also be Provided at the most appropriate level of care or in the. mo. st appropriate type of health care facility. Only your medical condition (not the financial status Or family situation, the distance from a Facility or any ether non-medical factor) is considered in determining which level of care or type of health care facility is appropriate. In order for Covered Services to be paid, the services must be Medically Necessary. Any service failing to meet the Medical NeCeSsity criteria may be the Covered Participant's liability. Medicare - Means the program of health care for the aged and disabled established by Title XVIII of the Social Secudty Act of 1965, as amended. Non-Preferred Provider - Means a Provider which is not participating in a PPO ~etwork which has a contract with the plan Administrator. : ~ ~: ~ Occupational Therapy - Means treatment rendered on an Inpatient or Outpatient basis as a part of a physical medicine and rehabilitatiOn program to improve functional impairments where the expectation exists that the therapy will result in practical improvement in the level of functioning within a reasonable period of time. No benefits are provided for diversional, recreational, and vocational therapies (such as hobbies, arts and crafts). Open Enrollment Period - Refers to an annual thirty (30) day Period, beginning 30 days prior to the anniversary date during which eligible persons can enroll under the Group Policy or terminate their coverage. Other Benefit Plan - Refers to COB and means any arrangement providing health care benefits or services, including but not limited to: group, blanket, or franchise insurance coverage; group or individual practice or other prepayment coverage; labor management trustee plans; union welfare plans; employer organization plans, or employee benefit organization plans; or any tax supported or governmental program. Out-of-Net~vork - Refers to Covered ServiCes rendered by a Non-Preferred Provider. Outpatient - Means. a Covered Person who receives medical care or treatment when he or she is not an Inpatient. Pharmacy - Means a facility which is a licensed establishment where prescription drugs are dispensed by a pharmacist under applicable state laws. Physical Therapy - Means treatment by physical means including modalities such as whirlpool and diathermy; procedures such as massage, ultrasound and manipulation; and tests of measurements required to determine the need and Progress of treatment. Such treatment must be given to relieve pain, restore maximum function, and to prevent disability following disease, injury, or loss of body part. Treatment must be for acute conditions where rehabilitation potential exists, the skills of a Physician or other Professional are required and are dUe to a trauma, stroke or surgical procedure while Covered Person was eligible for Coverage under the Plan. Physician - Means one of these professionals licensed under the applicable state laws: · Doctor of Medicine (M.D.) · Doctor of Osteopathy (D.O.) · Podiatrist (D.P.M.) or Surgical Chiropodist (D.S:C.) · Dental Surgeon or Dentist (D.D.S.) · Chiropractor (D. C.) · Doctor of Optometry (O.D.) · Psychiatrist · Psychologist Plan - Means a self funded health coverage program provided to you by City of Jeffersonville and administered by SCM, on behalf of City of Jeffersonville according to the terms of the Administrative Agreement. Plan Administrator - Means City of Jeffersonville or the person designated by City of JeffersonVille as the Plan Administrator. Pre-Existing Condition - Means a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, cato, or treatment was recommended or received within the 3 month period ending on the Covered Person's Enrollment Date. A pregnancy is not considered a Pro-Existing Condition. Pre-Existing Condition Waiting Period - Means the waiting period in connection with a Pre-Existing Condition as set forth in this Plan. Preferred Provider- Means a ProVider which is participating in a PPO network which has a contract with the parent company of SCM. Provider - Means for Health Care Coverage, the Facilities or Professionals listed below which are licensed and are operating within the scope of that liCense: Facility · Hospital · Ambulatory Health Facility · Ambulatory Surgical Facility · Home Health Care Provider · Hospice Provider · Skilled Nursing Facility · Community Mental Health Facility · Alcoholism Treatment Facility · Specialized Hospital Professional · Physician · Physical Therapist · Registered Nurse Anesthetist (C.R.N.A.) · Registered Nurse (R.N.) · Licensed Practical Nurse (L.P.N.) · Licensed OccupationaITherapist (O.T.) · Pharmacy · Certified Nurse Midwife (C.N.M.) · Laboratory (must be Medicare approved) · Professional AmbulanCe Service · Licensed Social Worker 45 ,- Schedule of Benefits - Means a separate schedule showing vital information with respect to your Coverage. The Schedule of Benefits, when issued with this SPD, becomes a part of the SPD. Sickness - Means any physical disease or mental illness. Pregnancy, premature birth, congenital anomalies and birth anomalies are considered to be sicknesses. Skilled Nursing Facility - Means a facility which mainly provides Inpatient skilled nursing and related r-- services to patients requiring convalescent and rehabilitative care. Such care is given by or under the / supervision of Physicians. A Skilled Nursing Facility is not, other than incid~entaiiy, a place that provides ' ' minimal custodial care, ambulatory or part time care or that provides treatment for mental illness, ~- alcoholism, drug abuse or tuberculosis. The Skilled Nursing Facility must be certified by the Medicare program. Specialized Hospital - Means a facility that is primarily engaged in providing diagnostic and therapeutic services for the Inpatient treatment of mental illness. Such services must be provided by or under the supervision of an organized staff of Physicians. Continuous nursing services must also be provided under the supervision of a registered nurse. Speech Therapy - Means active treatment for improvement of an organic medical condition causing a speech loss or impairment. Treatment must be either postoperative or for the convalescent stage of an active illness or disease. Summary Plan Description (SpD) Means this document. The SPD includes the identification card r-- currently in effect, the application, the Schedule of Benefits and any modification Or endorsement to the SPD. Urgent Care Admission - Means an unplanned admission or an admission scheduled less than 48 hours prior to the admission, for a condition requiring prompt medical attention. An Urgent Care Admission is not an admission through the emergency room. Weekend Non-Emergency Hospital Admission means an admission to a hospital on a Friday, Saturday, or Sunday at the convenience of the insured person or his or her physician when there is not cause for an emergency admission and the insured person receives no surgery or therapeutic treatment until the following Monday. 46 GENERAL PROVISIONS AND ADMINISTRATION OF THE PLAN ALTERATION OF APPLICATION A registration and change application may not be altered by anyone other than the applicant unless the ~ applicant has given his or her written consent allowing alterations. LIABILITY AND LIMITATION OF ACTION This Plan will not give you any claim, right, action or cause of action against any person or entity other than the Provider rendering Covered Services to you for acts or omissions of such Provider. The EmplOyer and SCM do not actually furnish health care services as described in this SPD. Rather, Coverage will be provided for the health care services covered under the Plan when rendered by a Provider to you. ALTERATION OF THE PLAN No person other than the Employer has the authority to change the Coverage under the Plan on behalf of ~i the EmplOyer. The Employer reserves the right, at any time or from time to time, to amend or change any or all provisions of the Plan without the consent of any other person or entity. ASSIGNMENT OF BENEFITS This Coverage may not be assigned. The Coverage will terminate without notice and all rights forfeited if the Covered Person attempts to assign it, or aids or attempts to aid any person not covered by the Plan to obtain any Covered Service. ADMINISTRATION OF THE PLAN The benefits provided under this Plan are paid for directly by City of Jeffersonville, For this reason, the Plan is considered to be self-funded. However, City of Jeffersonville has pumhased what is known as stop-loss insurance coverage which reimburses City of Jeffersonville for claims paid once they exceed certain predetermined dollar levels. This stop loss insurance is provided by the City of Jeffersonville's stop loss insurance carrier. City of Jeffersonville serves as Plan Administrator and business manager of the Plan. These responsibilities include maintaining all Plan records, filing tax returns and reports, authorizihg payments and resolving questions concerning the Plan. The Employer may also appoint a committee or hire outside professionals to assist with Plan Administration. The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies, interpretations, practices, and procedures. It is the express intent of this Plan that the Plan Administrator shall have maximum legal discretionary authority to construe and interpret the terms and provisions of the Plan, to make determinations regarding issues which relate to eligibility for benefits, to decide disputes which may arise relative to a Plan Participant's rights, and to decide questions of Plan interpretation and those of fact relating to the Plan. The decisions of the Plan Administrator will be final and binding on all interested parties. Under the Plan, Stewart C. Miller & Company, Inc. has agreed to provide certain administrative services on behalf of City of Jeffersonville according to the terms and limitations of the Plan. The responsibilities of SCM are spelled out in the Administrative Agreement. SCM does not furnish health care services and is not liable for the quality of health care services received by a Covered Person. SCM does not provide 47 all insurance coverage or benefits nor does SCM underwrite the liability of this Plan. SCM will not act nor assume the responsibility to act as the Plan Administrator on behalf of City of Jeffersonville. SCM is merely providing assistance with the administration of this Plan by adjudicating claims in accordance with the terms of the Plan. In the event the Administrative Agreement is terminated, SCM will cease to process claims as of the termination of the Administrative Agreement. If applicable, the Eligible Participant pays part of the cost of providing benefits under the Plan through applicable payroll withholdings and the Plan provides the balance. 48 10. 11. BENEFIT PLAN INFORMATION NAME OF THE PLAN Employee Benefits Plan of City of Jeffersonville NAME AND ADDRESS OF THE EMPLOYER City of Jeffersonville 501 East Court Avenue Jeffersonville, IN 47130 EMPLOYER IDENTIFICATION NUMBER 35-6001067 TYPE OF PLAN This is an employee/retiree benefit plan providing hospital and medical benefits as described in this SPD. TYPE OF ADMINISTRATION Third Party Administration NAME, BUSINESS ADDRESS & TELEPHONE NUMBER OF THE PLAN ADMINISTRATOR City of Jeffersonville Director of Personnel 501 East Court Avenue JeffersonviIle, IN 47130 812-285-6405 CONTRIBUTIONS The Employer contributes to this Plan together with employee and retiree contributions where applicable. The Employer determines the amount of contribution required. TYPE OF FUNDING Self-funded with Stop Loss Agreement PLAN YEAR (for fiscal record keeping) January 1 through December 31 CLAIMS ADMINISTRATOR Stewart C. Miller & Company; Inc. 3440 Kossuth St. P.O. Box 5769 Lafayette, IN 47903-5769 EFFECTIVE DATE OF THE PLAN The effective date of the Plan is April I, 2001 49