HomeMy WebLinkAboutHumana Plan Management Agreement
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ASOCOJ02
T ABLE OF CONTENTS
PLAN DESCRIPTION INFORMATION ..... ............. ................. ......................... ................. ............ ................ 1
SCHED ULE OF BENEFITS..............................,............................................................................................... 3
PRECER TIFI CA TI ON...................................;~............................................................................................... 3
COVERED AND NON-COVERED EXPENSES..... ...... ................... ........ ......... .......... ....... .................. .......5
UTILIZATION ICASE MANAGEMENT. ....... .:.. ......... ...... ................. ................... ...... ......................... ......... 10
PRECER TIFICA TION .. ......... ......... ...... ....... ............... ..................... ................... ........ ........... ................ ....... 10
SECOND SURGICAL OPINION ............... .... ............. ......... ........ ........................... :............ .......... ............. 10
PREDETERMINATION OF MEDICAL BENEFITS.....,......................................,...................................11
MEDICAL DEDUCTIBLE AND COINSURANCE INFORMATION .......................................................12
MED I CAL COVERED EXPENSES ........ .... ......... ..................... ................. ................... ..................... ............ 13
INPATIENT HOSPITAL ........ ............. ...... .....,... ...... ....... ........ ....... .......... ................... .... .... ............. ............ 13
OUTPATIENT HOSPiTAL.... ............. ............. ............. ........ ......... ........................... ........ ............. .............. 13
FREE-STAND IN G SURGICAL FACiLITy:............. ...... ................. ......... ............ ................... ............ ...... 13
URGENT CARE CENTER ........... ............. ....:........... ........ ......... ,..... ......... .......... .........,............. .......... ........13
QUALIFIED PRACTITIONER..................... .:..................................;........................................................... 14
RO UTINE CARE........................................... .:.............................................................................................. 15
SUPPLEMENTAL ACCIDENT RIDER.... ...... ................................ ...... ........... ........ .... ......................... ..... 15
CHIROPRACTIC CARE ... .... ......... .... ......... .... ............... ......................... ........... ........ ........................... ....... 15
AMBULANCE SERViCE..... ..... ................... .'. ............... ............... ................... ........ ....................... ............. 16
PREGNANCY BENEFITS.. ....... .... ............... ',' ....... .... ....... ........ ................... ........ ............. .......... .......... .... ... 16
NEWBORN BENEFITS.... ..... ...... ....... ...... ....L ........ ............. ................... ........ ........... .... ........ ..................... 16
B IR THING CENTERS .... ....... ........... ...... ............. ......... ...... ............... ..................... ...... ............................... 16
SKILLED NURSING FACILITY... ............. ..'............. .... ........... ......................... .......... ........... ...... ...... ........ 17
HOME HEALTH CARE................ ........ ....... ..'.. ......... ............. ........ ................... .......... ........... ............ .......... 18
HOSPICE CARE .. ............. ........... ............... ....'............... ......... ...... ........... ................................. .... .......... ...... 19
ORGAN TRANSPLANT BENEFIT ........ ......'......... ...... ..... ........ ......... .... ...... ........ ........... .......... ..................20
MENTAL DISORDER, CHEMICAL DEPE:N"DENCE OR ALCOHOLISM BENEFIT ........................23
OTHER COVERED EXPENSES.................. ,......... ..................................................................................... 24
LIMITATIONS AND EXCLUSIONS .......... ....~........ ................. ................... ...... ............. ........ .............. ......... 26
ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE......................................................................... 32
OPEN ENROLLMENT................................................................................................................................. 32
EMPLOYEE ELIGIBILITY... ......... ...... ..... ...1.... ............. ......... ...... ..................... ............ ......... .............. ......32
EMPLOYEE EFFECTIVE DATE OF COVERAGE.................................................................................. 32
EMPLOYEE DELAYED EFFECTIVE DATE ............................................................................................ 32
DEPENDENT ELI G IB ILITY ........................;.............................................................................................. 33
DEPDENDENT EFFECTIVE DATE OF COVERAGE ......................................................................,......33
MEDICAL CHILD SUPPORT ORDERS ............. ................. ......................... ......... ...... ........ ...... ............... 34
PRE-EXISTING COND ITION LIMITATION ..... ............. ................... ........ ......... ...... .... ........................... 34
SPECIAL PROVISIONS FOR NOT BEING IN ACTIVE STATUS ........................................................ 35
REINSTATEMENT OF COVERAGE FOLLOWING INACTIVE STATUS .........................................36
FAMILY AND MEDICAL LEAVE ACT (FMLA).................................................................................... 36
RETIREE COVERAGE.................................,.................................................................................... .......... 36
SPECIAL ENROLLMENT............................ ,.............................................................................................. 37
1.7 Plan Administrator (or Administrator) means the person named in the documents describing the Plan
as responsible for the operation and administration of the Plan. If no such person is identified., then
the person establishing or maintaining the Plan will be deemed to be the Plan Administrator.
1.8 Plan Manager means Humana Insurance Company and HumanaDental Insurance Company,
individually and collectively, acting in accordance with this Agreement.
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
ARTICLE II
Relationship Between the Parties
In performing its obligations under this Agreement, the Plan Manager operates within a framework of
Plan management policies and practices authorized or established by the Plan Administrator, in
accordance with the provisions of the Plan. In this context, the Plan Manager's normal operating
procedures, practices and rules will be followed unless they are inconsistent with these Plan
management policies or practices.
The Plan Manager does not have discretionary authority or responsibility in the administration ofthe
Plan. The Plan Manager will not exercise discretionary authority or control respecting the disposition
or management of assets of the Plan.
The Plan Administrator and not the Plan Manager is ultimately responsible for interpreting the
provisions of the Plan and determining'questions of eligibility for Plan participation.
Accordingly, the Plan Manager is not ~ trustee, sponsor, or fiduciary with respect to directing the
operation of the Plan or managing any assets of the Plan.
The Plan Manager may act as an agent of the Client authorized to perform specific actions or conduct
specified transactions only as provided in this Agreement.
Plan benefits shall be funded exclusively through the Plan. The Plan Manager is not responsible or
accountable for providing funds to pay plan benefits under any circumstances.
The Plan Manager is not responsible :for maintaining the Plan in compliance witJ ERISA or any
applicable laws and regulations governing or affecting the Plan. .
However, the Client and the Plan Manager may agree that the Plan Manager will serve in the limited
capacity of Plan fiduciary for fmal determination of claims if and only as provided in section 7.7 of
this Agreement.
Non-ERISNHIC, HOlC Fiduciary
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ARTICLE III
General Duties of Client
3.1 The Client will identify and describe the Plan as to type (e.g. single employer) on Exhibit "A" of this
Agreement. The Client warrants that the Plan is not a "multiple employer welfare arrangement", as
defmed in the Federal Employee Retirement Security Act of 1974, as amended ("ERISA").
3.2 The Client assures that sufficient funds will be available on a timely basis to honor all claims
reimbursements under the Plan. Suffici~nt funds for making claims payments must be made available,
in accordance with this Agreement, to enable services under this Agreement to continue without
interruption.
3.3 The Client promises that all methods employed to fund the Plan shall comply with all applicable laws
or regulations.
3.4 The Client agrees to furnish each Participant written notification of the source of funding for Plan
benefits. .
3.5 The Client promises that current copies ofthe documents describing the Plan will be provided to the
Plan Manager along with other appropriate materials governing the administration ofthe Plan. These
documents and materials may include employee booklets, summary descriptions, employee
communications significantly affecting the Plan, and any amendments or revisions.
3.6 The Client promises that timely written notice will be provided to the Plan Manager of Plan
management policies and practices, interpretations of the benefit provisions of the Plan, and changes
in the Plan provisions.
3.7 The Client shall provide accurate information to the Plan Manager as to the number and names of
persons covered by the Plan and any other information necessary to enable the Plan Manager to
provide the services required by this Agreement. This information shall be kept current on at least a
monthly basis.
3.8 The Client is responsible for selecting legal and/or tax counsel to provide advice to the Client about
the law and the Plan. The Client acknowledges that the Plan Manager cannot provide professional tax
or legal services to the Client. '
3.9 The Client is responsible for compliance with all applicable provisions oflaw addressing the Client's
duties respecting the Plan. This includes compliance with all legal reporting and disclosure
requirements, adoption and approval of all required documents respecting the Plan and compliance
with state escheat and unclaimed or abandoned property laws. Even though the Plan Manager may be
required to perform certain duties under this Agreement, such as preparing drafts of documents for
approval and adoption, the Client agrees that the Plan Manager does not undertake the responsibility
for legal compliance for any other person.
3.10 The Client must make full payment for services rendered under this Agreement when due. However,
if full payment is not made when due, payment in full must be made by the end of a grace period of
thirty (30) days to enable services under this Agreement to continue without interruption. The Plan
Manager may provide written notice by regular U.S. mail to the Client requesting payment of the
deficiency in full by the end of the thirty (30) day period.
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Non-ERISA/HlC, HDIC Fiduciary
3.11 The Client shall not direct the Plan Mapager to act or refrain from acting in any way which would
violate any applicable law or regulation. The Client shall not behave in any way which could
implicate or involve the Plan Manager in a violation of these laws.
3.12 In the event that the general obligations of this Article III may be construed in such a manner so as to
conflict with more specific provisions of this Agreement regarding a particular issue, the more specific
and comprehensive provisions shall be given effect.
ARTICLE IV
General D:uties of Plan Manager
4.1 The Plan Manager shall process claims and make payments in accordance with the provisions of the
Plan and related interpretations of the benefit provisions of the Plan which are made or approved by
the Plan Administrator on a timely basis and confirmed in writing.
4.2 The Plan Manager shall be entitled to rely and act based upon documents, letters, electronic
communications, or telephone commUIiications which are confirmed in writing and provided to it by
the Client or Plan Administrator. Reliance will continue until the time the Client or the Plan
Administrator notifies the Plan Manager in writing of any change or amendment to those
communications.
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4.3 The Plan Manager shall provide claimants who have had a claim wholly or partially denied with a
written explanation of the reason for the denial. The Plan Manager shall provide claimants with
information about what steps may be taken if the claimant wishes to submit the denied claim for
review. These obligations of the Plan Manager will be discharged in accordance with the provisions
of the Plan or authorization by the PI~ Administrator.
4.4 The Plan Manager shall not be responsible for any delay or lack of performance of services under this
Agreement attributable to the Client's failure to provide any information as required under this
Agreement.
4.5 The Plan Manager will perform its duties under this agreement using the same degree of ordinary care,
skill, prudence, and diligence that a reasonable provider of administrative services would use in
similar circumstances. This includes making a good faith effort to correct any mistake or clerical error
which may occur due to actions or inaction by the Plan Manager undertaken in good faith once the
error or mistake is discovered. .
4.6 With respect to its obligations under this Agreement, the Plan Manager will maintain professional
liability and errors and omissions insurance in amounts sufficient to protect against losses with respect
to occurrences arising out of failure to properly perform its obligations under this Agreement.
4.7 In the event that the general obligations of this Article N maybe construed in such a manner so as to
conflict with more specific provisions of this Agreement with respect to a particular issue, the more
specific and comprehensive provisions shall be given effect.
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Non-ERISNHIC, HOlC Fiduciary
ARTICLE V
Claims Administration
5.1 The Client hereby delegates to the Plan Manager authority to make determinations on behalf of the
Client or Plan Administrator with respect to benefit payments under the Plan and to pay such benefits,
as specified in this Article V.
5.2 The Plan Manager will accept claims for benefits under the Plan which are made in accordance with
procedures established in the Plan documents and submitted for payment during the term of this
Agreement.
5.3 The Plan Manager will process claims. in accordance with the provisions of the Plan which are in
effect and which have been communicated to the Plan Manager by the Client at the time the services
are provided.
5.4 Claims will be processed using the Plan Manager's normal claims processing procedures, practices and
rules unless they are (a) inconsistent with Plan management policies or practices authorized or
established by the Plan Administrator ill accordance with the provisions of the Plan, and (b) described
to the Plan Manager in writing as being inconsistent.
5.5 The Plan Manager will promptly approve or deny claims submitted for payment in accordance with an
initial determination by the Plan Manager or an appeal of a denied claim, except as provided in section
5.6.
5.6 However, if the Plan Administrator makes a determination to approve or deny a claim which is
different than the determination made by the Plan Manager, the Plan Manager will promptly issue an
approval or denial of the claim, provided the Plan Administrator's decision is fITst communicated to
the Plan Manager in writing.
5.7 In the event a claim is wholly or partililly denied in accordance with section 5.5, above, the Plan
Manager shall provide the Participant :With a written explanation of the reason for the denial, and
information as to what steps may be taken if the Participant wishes to appeal the claim denial.
However, if a claim is wholly or partially denied in accordance with section 5.6, above, the Plan
Manager may decide that it will provide this explanation and information only as directed in special
written instructions from the Plan Administrator which are acceptable to the Plan Manager.
5.8 Appeals of denied claims shall be processed in accordance with the applicable provisions of the Plan.
The Client acknowledges that the Plan Manager shall have the ultimate responsibility and authority to
make fmal determinations with respect to claims.
5.9 If adequate funds are not made available for the timely payment of claims, the Plan Manager may
notify Participants and payees who may be affected if the Client or Plan Administrator does not notify
Participants and payees within fourteen (14) business days after written request by the Plan Manager
to do so.
5.10 With respect to claims for which provider discounts are available ("Provider Discounts"), the Client
authorizes and directs the Plan Manager to process claims under this Agreement taking the Provider
Discounts into account.
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Non-ERISA/HIC, HDIC Fiduciary
ARTICLE VI
Reports and Records
6.1 The Plan Manager will provide standard reports to the Client or Plan Administrator only as mutually
agreed upon by the Plan Manager and the Client.
6.2 The Plan Manager agrees to provide a report of each claim with respect to which the Shared Savings
Program Provider Discounts described in Exhibit D-l are applied at reasonable intervals.
6.3 The Plan Manager will keep and maintain accounts and records pertaining to its activities under this
Agreement which are required by law or by mutual agreement of the parties.
6.4 The Plan Manager prepares and makes available records required to assist the Client or the Plan
Administrator regarding audits, legal action, or regulatory review and reporting, upon reasonable
request by the Client. Requests for audits are governed by the Plan Manager's policy regarding Client
audit requests. The Client agrees to reimburse the Plan Manager for its reasonable costs of these
services and the preparation, duplication, and transmission of these records. A report by the Plan
Manager's independent accountant on the controls over claims adjudication (known as a SAS 70
report) is provided at no cost upon request.
6.5 Claims records may be maintained in micro-photographic or electronic media format, in accordance
with the Plan Manager's internal policies, rather than original hard copy. If the Client desires that
original hard copy records be maintained, the Client must notify the Plan Manager in writing no later
than 45 days after the effective date of this Agreement. The Plan Manager will then ship the original
documents to a location specified by the Client, and the Client agrees to pay the cost for this service.
ARTICLE VII
Additional Administrative Services
7.1 Upon reasonable request by the Client or the Plan Administrator, the Plan Manager will provide
standard language concerning Plan benefits to assist the Plan Administrator in the preparation of the
summary description of the Plan. This service will be available at the commencement of this
Agreement and when language changes are made necessary by changes in Plan design or
governmental requirements.
7.2 The Plan Manager will retain a COBRA Service Provider to coordinate and provide certain
administrative services regarding COBRA continuation coverage provided under the Plan only as
specified in Exhibit "B". The Client or the Employer shall continue to have all liability for funding of
COBRA coverage benefits under the ~lan.
7.3 The Plan Manager will assist the Client or the Plan Administrator in arranging to provide Utilization
and/or Case Management services with respect to the Plan only as specified in Exhibit "C".
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Non-ERISA/HIC, HDIC Fiduciary
7.4 The Plan Manager will provide the following miscellaneous administrative services, following its
normal procedures:
(a) Production of basic Participant identification cards.
(b) Routine claims processing audit controls.
7.5 The Plan Manager will provide "Subrogation/Recovery" services (in addition to routine application of
the coordination of benefits provisions of the Plan) for identifying and obtaining recovery of claims
payments from all appropriate parties through operation of the subrogation or recovery provisions of
the Plan.
(a) Subrogation I Recovery services will be provided by the Plan Manager following its normal
procedures, and such services may be performed by subcontractors selected by the Plan
Manager (including local counsel).
(b) Subrogation I Recovery services include the following activities:
(I) Investigation of claims and obtaining additional information to determine if a person
or entity may be the appropriate party for payment;
(2) Presentation of appropriate claims and demands for payment to parties determined to
be liable; .
(3) Notification to Participants that recovery or subrogation rights will be exercise-Ai with
respect to a claim; .
(4) Filing and prosecution of legal proceedings against any appropriate party for
determination of liability and collection of any payments for which such appropriate
party may be liable;
(5) Pursuit of appropriate 'post judgment remedies; and
(6) Submittal of a quarterly report setting forth the status of the Plan Manager's
Subrogation I Recovery efforts.
(c) Subrogation I Recovery services will be provided for a period of two (2) years following
termination ofthis Agreement, unless such termination results from a material default in the
delivery of such subrogation services. Subrogation I Recovery services will be continued only
in respect to claims processed under this Agreement.
(d) The cost to the Client for providing services under this section 7.5 is presented within section
F3.1 (a) of Exhibit "F", in accordance with Article IX. However, there will be no cost to the
Client for recovery of claims payments made in error by the Plan Manager exclusive of any
other cause. Also in this context, the Plan Manager may not be obligated to file and prosecute
legal proceedings against persons for determination of liability and collection of any
payments.
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Non-ERlSA/HIC, HDIC Fiduciary
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7.6 The Plan Manager may retain or coordiriate with service providers, experts, or professional advisors to
assist the Plan Manager in providing services under this Agreement. The Client shall reimburse the
Plan Manager for these services if requested by or agreed to by the Client.
,
7.7 The Plan Manager, within the scope of its professional ability and its duties under this Agreement, will
serve in the limited capacity of Plan fiduciary for fmal determination of claims.
7.8 The Plan Manager may upon written request by the Client or the Employer provide assistance in
submitting claims against stop loss coverage. Any proceeds of the stop loss coverage delivered to the
Plan Manager will be handled as directed by the Client or the Employer. However, the Plan Manager
shall have no liability for providing this assistance within a particular time period or for collecting the
proceeds.
7.9 The Plan Manager will arrange access 'to one or more networks of health care providers which are
presently available through an arrangetpent with the Plan Manager only as specified in Exhibit "D".
7.10 The Plan Manager will arrange access. for the Client to certain Shared Savings Program Provider
Discounts established by the Plan Manager which may be available at the time services are rendered
only as specified in Exhibit "D-I ".
7 .11 In the event the number of Participants in the Plan decreases by 1 0% in connection with changes such
as:
(1) Employee benefit programs or"flan design made by the Client, including changes required by
applicable law or regulatory action;
I
(2) The Client's corporate structur~ or organization; or
(3) The level of Plan participation attributable to employee choice
The Plan Manager will continue processing Claims for the terminated employees, which are incurred
prior to the date of such change as provided in Article V of this Agreement.
Such claims will be processed as long as this Agreement is in force. The Client will be billed an
additional administrative fee per employee as provided under this section 7.11.
This section 7.11 will not apply in the event the Plan Administrator provides timely written
notification to the Plan Manager directing that services described in this section are not required.
7.12 The Plan Manager will provide prescription drug benefit management services, including access to
therapeutic value, drug interaction, and drug usage information at the point of sale, solely for the
purpose of implementing applicable Plan provisions and assisting in decision making which results in
the delivery of appropriate levels ofPlim benefits.
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Non-ERISA/HIC, HDIC Fiduciary
7.13 The Plan Manager will provide certificates of prior coverage ("COPC") required to be issued by the
Client under the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA")
requirement. The Client allocates responsibility for generating forms certifying prior coverage and
accompanying liability for noncompliance to the Plan Manager, to the extent of its obligations under
this Agreement.
(a) On a timely basis, the Plan Mmiager will issue a COPC form to persons whom the Client has
identified as having had covera.ge under the Plan which has ended ("Recipients").
(b) The Plan Manager will issue a 'COPC to the Recipients' last known addresses.
(c) The Client's administrative fees per month will be adjusted, based on the number of
Participants in the Plan, for the services provided under this section 7.13.
ARTICLE VIII
I
: Banking
8.1 The rights and obligations of the Client and the Plan Manager under this Article VIII shall be
regulated through a "Banking Arrangefuent" substantially in the form presented in Exhibit "E".
8.2 The Client promises that sufficient funds will be available on a timely basis to honor all claims
reimbursements under the Plan. Vpon notice from the Plan Manager that additional funds are
required, the Client promises that adequate funds will be immediately provided to fund claims
approved.
8.3 The Client agrees that funds provided to honor all claims reimbursements under the Plan will be
United States money, which may be trab.smitted by wire transfer, bank draft, or other medium agreed
to by the Plan Manager and the Client.
ARTICLE IX
Costs of Administrative Services
9.1 The Plan Manager shall be entitled to a fee for services provided under this Agreement described on
Exhibit "F" to this Agreement.
9.2 If payments for administrative services provided under this Agreement are not made on a timely basis,
a late charge of 1.25% per month (or the maximum amount allowed by applicable law, if less)
multiplied by the amount of the deficiency shall be paid by the Client no later than by the end. of the
next billing cycle. Payments made after the grace period allowed in the invoice or billing arrangement
are not "timely".
9.3 The Client and the Plan Manager understand and agree that the fees for services under this Agreement
may be renegotiated in the event that substantial changes to the Plan would significantly increase or
decrease the obligations or costs of providing administrative services with respect to the Plan.
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Non-ERISA/HIC, HDIC Fiduciary
ARTICLE X
Contract Period
10.1 The effective date of this Agreement is April 01, 2006 (the "Effective Date"). This Agreement shall
continue for an initial period of one (1) year from the Effective Date, unless terminated earlier as
provided in Article XI, below.
10.2 This Agreement shall automatically renew for successive additional one-year periods unless it is
terminated as provided in Article XI.
ARTICLE XI
Termination
11.1 This Agreement may be terminated by'the Client or by the Plan Manager at the end of any contract
period upon advance written notice of at least thirty (30) days.
11.2 The Plan Manager, in its discretion, may terminate this Agreement before the end of any contract
period upon thirty (30) days written notice, if the Client fails to cure anyone or more of the following
deficiencies before the end of the thirty (30) day notice period:
(a) Failure to pay all or part of the fees payable under Article IX of this Agreement when due.
(b) Failure to provide adequate funds to honor claims reimbursement payments on a timely basis.
(c) Direction is given by the Client or Plan Administrator requiring the Plan Manager to suspend
claims processing or payment for more than twenty (20) days; or
11.3 Either party may terminate this Agreement immediately upon written notice in the event of:
(a) The bankruptcy, insolvency or liquidation of the other party; or
(b) The commission by the other party of any material breach of this Agreement which is not
cured, or any act of fraud, misconduct or bad faith in connection with the performance of its
duties under this Agreement. However, a material breach of this Agreement may be cured
within thirty (30) days after written notice from the other party.
11.4 The Plan Manager, in its discretion, may terminate this Agreement upon written notice in the event of
repeated occurrences (two or more) of the conditions described in section 11.2 or two or more
instances where services are interrupted in accordance with section 3.10.
11.5 All obligations of the Plan Manager under this Agreement will end on the effective date of termination
of this Agreement, even though the clajm for benefits was incurred or submitted for payment prior to
termination of this Agreement, unless a supplemental Agreement is entered into prior to the
termination date.
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Non-ERISNHIC, HDIC Fiduciary
11.6 In the event of the termination of this Agreement, the Plan Manager will provide the Client or the Plan
Administrator with reasonable access to records or information concerning the Plan in its possession,
upon written request. The Plan Manager will within a reasonable time honor requests for copies of
records and information provided they are reasonable and the Client agrees to pay for the services. The
Plan Manager shall have the right to' retain copies of such property and records as reasonably
necessary or is otherwise required by law.
11.7 Upon termination of this Agreement, arty monetary obligation of the Client to the Plan Manager shall
become immediately due and payable.
11.8 Termination under any section of this Article XI shall not cause either party to waive any rights it may
have to exercise any remedies available to it under any other section of this Agreement or under any
applicable law.
ARTICLE XII
Confidentiality
12.1 For purposes of this Article XII:
(a) Covered Person means an individual with respect to whom benefits may be or become
payable under the provisions o'fthe Plan.
(b) Private Health Information mdms any of the following categories of information:
(1)
Patient Records includes, but is not limited to, all health records, physician and
provider notes and bills and claims with respect to a Covered Person.
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(2)
Patient Information includes Patient Records and all written and oral health
information received about a Covered Person.
(3)
Individually Identifiable Health Information means any other information, including
demographic information, collected from an individual that:
(A) Is created or \eceived by a health care provider, health plan, employer, or
health care clearinghouse; and
(B) Relates to the' past, present, or future payment for the provision of health
care to an individual and identifies the individual, or with respect to which
there is a reasonable basis to believe that the information can be used to
identify the in~vidua1.
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Non-ERISA/HIC, HDIC Fiduciary
12.2 The Client and the Plan Manager acknowledge and agree that in the course of performing their
respective duties under this Agreement, they may acquire or obtain access to or knowledge of Private
Health Information or other personal information regarding Covered Persons. This information is at all
times the property of the Plan or the Client, depending upon its nature and source, and not the Plan
Manager, even if it is received by the Plan Manager. Information ofthis nature that is received by the
Plan Manager will be deemed to be information received on behalf of the Plan. However, information
that is produced incidentally through application of the computer systems employed by the Plan
Manager in the course of providing services under this Agreement will not be considered property of
the Plan or the Client or any Covered Person, if it is not specific to the Plan or not material to Plan
administration.
12.3 The Client and the Plan Manager wilI safeguard Private Health Information and other personal
information to ensure that the information is not improperly disclosed. The Client, the Plan
Administrator, and the Plan Manager or any person appointed by or under their control, respectively,
will make sure that Plan functionaries and third party service providers having access to Private Health
Information and other personal information are trained in privacy policies directed at safeguarding
against improper disclosure, made familiar with the confidentiality obligations set forth in this
Agreement, and abide by those requirements as minimum safeguards against improper disclosure. The
Client and the Plan Manager acknow1edge with respect to Private Health Information, and other
personal information that:
(a)
(b)
(c)
(d)
(e)
(t)
Disclosure is improper if it is hot allowed by law or made for any purpose other than Plan
administration or benefits deli,,:ery. Disclosure to Plan functionaries or health care providers
may be proper, if the disclosure is allowed by law and made for Plan purposes.
The Employer or Plan sponsor may legally have access, on an as-needed basis, through the
Plan Administrator to limited health information for the purpose of determining Plan costs,
contributions, Plan design, and whether Pl<m modifications are warranted.
Federal regulators such as the Department of Health and Human Services and the Department
of Labor may legally require access to Protected Health Information in order to investigate
compliance with federal legal requirements concerning confidentiality of Private Health
Information.
The Plan Manager will not be responsible for determining the rights of Covered Persons to
acquire access to or modify Private Health Information and other personal information
concerning them (whether or not such information is at any time in the possession of the Plan
Manager).
In the event that the Plan Manager is directed by the Client or Plan Administrator to disclose
Private Health Information or other personal information concerning them for purposes other
than Plan operation or benefits delivery, the Plan Manager will not be responsible for
providing an accounting to Covered Persons of such disclosure(s) (whether or not such
information is at any time in the possession of the Plan Manager).
The Plan Manager will notify the Plan Administrator of any disclosure of Private Health
Information in its possession :or control that is not consistent with the provisions of this
Agreement of which the Plan Manager becomes aware.
Non-ERISA/HIC, HOlC Fiduciary
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(g) The Client, the Plan Administrator, and the Plan Manager acknowledge and agree that
improper disclosure of Private Health information or other personal information agreement
will amount to a material breach of this Agreement. In the event of improper disclosure, the
culpable party shall take reasonable steps to alleviate the effects of the improper disclosure;
but ifthose efforts to cure are not successful, the improper disclosure will constitute grounds
for immediate termination of this Agreement.
12.4 Accordingly, the Plan Manager will afford access to Private Health Information or other personal
information received by it to the Plan Administrator or the Client, as permitted under this Agreement
and by law. The Plan Manager will.afford access to this information to other persons only as
reasonably directed in writing by th~ Plan Administrator or the Client, with due regard for
confidentiality, and the Plan Manager shall have no further obligation with respect to that information.
The Plan Manager is directed to afford access to Private Health Information and other personal
information to the persons listed on Exhibit "G".
12.5 The Client represents and warrants that the Plan Administrator is and shall continue to be obligated to
safeguard Private Health Information in accordance with the provisions of this Agreement as
minimum standards. The Client furth,er represents and warrants that security controls, restrictive
processes, and other appropriate safeguards have been put in place between the Employer and the Plan
to protect Private Health Information from improper disclosure.
12.6 In connection with performing its obligations under this Agreement, it may become necessary for the
Plan Manager to disclose to the Plan Administrator or the Client, their designees or third parties under
contract with either of them ("Recipients", for purposes of this subsection) trade secret and/or
proprietary information of the Plan Manager or its affiliates (referred to in this subsection collectively
as "Humana"). The Client and the Plan Administrator agree to safeguard and ensure the confidentiality
of such trade secret and/or proprietary i.J;lformation, which shall include information relating to (i) the
business of Humana, its affiliates, their clients and representatives, (ii) third parties under contract
with Humana, (iii) medical service provider arrangements or contracts, (iv) medical service provider
network arrangements or contracts, and (v) documentation relating to the computer systems utilized by
Humana.
(a) Access to the trade secret and/6r proprietary information described above will be permitted for
Recipients only; it may be used by Recipients only in a manner necessary to accomplish the
purposes described above with respect to Private Health Information and other personal
information; and it may not be disclosed to any third parties, including their employees that do
not have a need to know, without authorization by Humana. Access to such records or
information does not constitute atransfer of ownership, permission to appropriate, or license
to use the same for any purpose not contemplated under this Agreement.
(b) The Client understands and agrees that the Client (or its designee) must recognize and abide
by restrictions upon disclosure of information and/or systems that are imposed by contracts
between Humana and third parties or by law, regulation, or order of a court or regulatory
agency.
13
Non-ERISA/HIC, HDlC Fiduciary
12.7 Upon termination of this Agreement, retords containing Private Health Information or other personal
information in the possession ofthe Plan Manager will be either delivered to the Plan Administrator or
destroyed when the Plan Manager's records retention obligations have been fulfilled. If such delivery
or destruction is not feasible, the protections of this Agreement will continue to apply to those records
and further uses and disclosures of the }>rivate Health Information or other personal information shall
be limited to those purposes that make the return or destruction of the information infeasible.
12.8 The Client and the Plan Manager agree that they will require other persons or entities that receive
Private Health Information or other personal information regarding Covered Persons and/or trade
secret or propriety information in connection with and as permitted by this Agreement to agree in
writing to observe the protections described herein as minimum safeguards against improper
disclosure of such information.
ARTICLE xm
Hold Harmless
13.1 The Client agrees to indemnify and hold the Plan Manager harmless against any and all loss, liability,
or damage (including payment of reasonable attorney's fees) which the Plan Manager may incur by
reason of failure of the Client or its employees, agents or representatives to abide by the provisions of
the Plans or this Agreement or to administer thePlans or assets and funds of the Plans in a prudent and
proper manner; failure of the Plans or documents describing the Plan prepared or adopted by the Plan
sponsor to comply with applicable laws; fraud, embezzlement, willful misconduct, or intentional
disregard on the part of the Client or its employees, agents or representatives; disputes concerning
denials of benefits or benefit payments made by or at the direction of the Client or the Plan
Administrator; or actions taken by the plan Manager at the direction of the Client or the Administrator.
13.2 The Plan Manager agrees to indemnify and hold the Client harmless against any and all loss, liability,
or damage (including payment of reasonable attorney's fees) which the Client may incur by reason of
the failure of the employees, agents or representatives of the Plan Manager to abide by this Agreement,
or fraud, embezzlement, willful misconduct or intentional disregard on the part of the Plan Manager
or its employees, agents, or representatives. The Plan Manager will not be liable on account of
actions or inaction undertaken by it in good faith and performed in accordance with the provisions of
this Agreement or for the cost of behefits under the Plan which are claimed or awarded to a
Participant.
13.3 The obligations under this Article XIII shall continue beyond the term of this Agreement as to any act
or omission which occurred during the term of this Agreement.
ARTICLE XIV
Taxes and Assessments
14.1 If a tax or other assessment, including a premium tax, with respect to the Plan (other than an income
tax with respect to the fees earned by the Plan Manager) is imposed upon the Plan Manager, the Plan
Manager will provide written notification to the Client together with a copy of the tax bill or
assessment within ten (10) business days of receipt.
14
Non-ERISA/HIC, HDIC Fiduciary
14.2 If the Plan Manager pays the tax or assessment, the Client shall reimburse the Plan Manager for any
amounts paid plus reasonable out-of-pocket expenses immediately upon notification by the Plan
Manager that the tax has been paid.
ARTICLE XV
Defense of Actions
15.1 The Client and the Plan Manager agree to cooperate with respect to (a) the determination, settlement
and defense of any and all claims for benefits undertaken by the Plan Manager pursuant to this
Agreement, and (b) the settlement of and conduct of a defense against any claim for benefits which
has been denied, which may include 'attending hearings and trials and assisting in securing the
attendance of witnesses and giving of evidence.
15.2 The payment of legal fees arising out of any transaction or activity under this Agreement shall be the
responsibility of the person incurring the expense, except as provided in Article XIII. However, legal
fees incurred by the Plan Manager and attributable to a request, direction, or demand by the Client, the
Plan Administrator, or Employer shall be the responsibility of the person making the request, direction
or demand. Legal fees incurred by the Plan Manager and attributable to the defense of claims
determinations made in accordance with this Agreement shall be the obligation of the Client.
ARTICLE XVI
Miscellaneous
16.1 Ancillary Agreements. The Client agrees to execute or cause to be executed all ancillary agreements
appropriate and necessary to enable the services described in this Agreement to be performed.
16.2 Entire Agreement. This Agreement (including the Exhibits and Plan documents as incorporated
herein by reference) constitutes the entire agreement between the parties with respect to the Plan, and
there are no agreements, representations or warranties regarding the subject matter of this Agreement
between the parties other than those set forth or provided for in this Agreement (including the Exhibits
and Plan documents as incorporated by reference).
16.3 Assignment. Neither the Plan Manager nor the Client may assign or otherwise transfer its rights and
obligations under this Agreement to any other person or entity without the prior written consent ofthe
other party. However, the functions to be performed by the Plan Manager may at any time be
transferred to an affiliate of the Plan Manager. Any other attempted assignment or delegation shall
render this Agreement voidable at the option of the non-assigning party.
15
Non-ERISA/HIC, HDIC Fiduciary
16.4 Notices. All notices to the Client under this Agreement shall be personally delivered or sent by a
method no less rapid than fIrst class mail, with postage prepaid, or facsimile, to the Client at the
following address:
Attn: Robert Waiz, Jr.
Mayor
501 East Court Avenue
City Attorney, Room 501
Jeffersonville, IN 471'30
Telephone: 812-285-6400
Fax: 812-285-6403
Email: rwaiz(W.citvofieff.net
,All notices to the Plan Manager under this Agreement shall be personally delivered or sent by a
method no less rapid than fIrst class mail, with postage prepaid, or facsimile, to the Plan Manager at
the following address:
Attn: Tim Batson ,
Humana Insurance Company
500 West Main Street
Louisville, Kentucky 40202
Telephone: 502-580-8508
Fax: 502-580-3639
Email: tbatson@hum~na.com
Attn.: Gerald L. Ganoni
HumanaDental Insurance Company
1100 Employers Boulevard
Green Bay, Wisconsin 54344
Telephone: 920-337-7602
Fax: 920-337-3183
Email: jganoni@humana.com
16.5 Severability. If any provision of this Agreement is determined to be unenforceable or invalid, such
determination will not affect the validity of the other provisions contained in this Agreement. Failure
to enforce any provision of this Agreement does not affect the rights of the parties to enforce such
provision in another circumstance. Neither does it affect the rights of the parties to enforce any other
provision of this Agreement at any time.
16.6 Applicable Law. This Agreement shall be governed by and construed in accordance with the internal
laws of the State of Wisconsin, to the extent not preempted by federal law.
16.7 Amendment. This Agreement may be amended by the Client and the Plan Manager at any time by a
writing duly executed by an appropriate officer of the Plan Manager and the Client.
16
Non-ERISA/HIC, HDIC Fiduciary
16.8 Effect ofPavrnent of Administration Charges. This Agreement shall be considered executed by the
Plan Manager and Client, upon signature of both Plan Manager and Client. Payment of fees prior to
completion and signing of this Agreement will constitute execution of a written temporary agreement,
pending completion and signing ofthis'Agreement.
IN WITNESS WHEREOF, the Client and the Plan Manager have executed this Agreement on
,20_.
Non-ERISA/HIC, HDIC Fiduciary
CIT'X OF JEFFERSONVILLE
Jeffersonville, Indiana
(By)
(signature)
Name:
Title: '
,
HuMANA INSURANCE COMPANY
DePete, Wisconsin
(By)
Khalid N azir
Vice President
HUMANADENTAL INSURANCE COMPANY
DePe:re, Wisconsin
(By) ,
Gerald L. Ganoni
President
17
Print Date:
10/17/06
015497549
269115
03
01
Market Office Name:
HHCP-LOUISVILLE
Additional Information:
J
ASOCOJOI
CITY OF JEFFERSONVILLE EMPLOYEE HEALTH PLAN
I
GROUP NUMBER
. N3830
PPO PLAN B (OUT OF AREA)
I
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EFFECTIVE MAY 1, 2006
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ASOCOJ02
TERMINATION OF COVERAGE ...... ........... ..;............ ............. ........~............ ................. ........................ .......39
IMPORTANT NOTICE FOR EMPLOYEES AND SPOUSES AGE 65 AND OVER ...............................40
CONTINUATION OF MEDICAL AND DENiAL BENEFITS ..................................................................41
THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994
(USERRA) ...........................................................;............................................................................................. 47
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COORDINATION OF BENEFITS... ....... ........ ..;........ ............... ................. ...... ........... ........ ..................... .......48
REIMBURSEMENT /SUBROGA TION.. ...... ....l........ ............... ................... .... ........... ........ ............................51
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GENERAL PRO VIS IONS ................................ .l............................................................................................. 53
I
CLAIM S PROCEDURES .................................. i............................................................................................. 57
i
DEFINITION S.....................................................1............................................................................................. 66
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PRESCRIPTION DRUG BENEFIT .... ...... ....... .t........... .... ...... ............... ................. ........ ......... ........ ...............75
D EFINITI ON S ................................................. i...........................................:................................................. 75
SCHEDULE OF PRESCRIPTION DRUG BENEFITS.............................................................................. 77
ADDITIONAL PRESCRIPTION DRUG BENBFIT INFORMATION .................................................... 78
PRIOR AUTHORIZATION.. ..... ........ ..... ...... ........... ...... ............... ................. ............... ........ ........... ............ 79
D ISPENSIN G L 1M ITS................................... .l................................................. ............................................ 79
RETAIL PHARMACy.... ......... ...... ....... ...... ...l... ...... ......... ...... ......... ........ ................. ........ ........... ...... ...... ....79
MAIL ORDER PHARMACY.. ........... ...........~. ...... ......... ...... ......... ........ ................. ................. .......... .... ......79
SPECIALTY OFFICE MEDICATIONS AND INJECTABLES ...............................................................79
I
PRESCRIPTION DRUG COST SHARING ................................................................................................ 80
PRESCRIPTION DRUG COVERAGE ....... ..l..... ....... ............. .......... ......... ...... .... ............... ...... ............... ...80
PRESCRIPTION DRUG LIMITATIONS .....l..... ..... ........ ........... .... ........... ........................... ........ ..............81
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ASOCOJ03
PLAN DESCRIPTION INFORMATION
1.
Proper Name of Plan:
City of Jeffersonville Employee Health Plan
2. Plan Sponsor and Employer.
City of Jeffersonville
501 East Court Avenue, Room 407
Jeffersonville, IN 47130
This Plan is maintained under a collective bargaining agreement. A copy of the agreement may
be obtained on written request and is available for examination.
3. Plan Administrator and Named Fiduciary:
City of Jeffersonville
501 East Court Avenue, Room 407
County Building
Jeffersonville, IN 47130
4. Employer Identification Number: 35-6001067
5. The Plan provides medical and prescription drug benefits for participating employees and their
enrolled dependents.
6. Plan benefits described in this booklet are effective 04/01/06.
7. The Plan year is April 1 through March 31 and the fiscal year January 1 through December 31 of
each year.
8. Service of legal process may be served upon the Plan Administrator as shown above or the
following agent for service oflegal process:
Leslie Merkley, City Attorney
City of Jeffersonville
501 East Court Avenue, Room 410
Jeffersonville, IN 47130
(812) 285-6491
9. The Plan Manager is responsible for perfornling certain delegated administrative duties,
including the processing of claims. The Plan Managerand Claim Fiduciary is:
Humana Insurance Company
500 West Main Street
Louisville, Kentucky 40202
Telephone: Refer to your ID card
HumanaDental Insurance Company
1100 Employers Boulevard
Green Bay, WI 54344
Telephone: (920) 336-1100
Toll Free: 1-800-233-4013
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ASOCOJ03
Plan Description Information Continued
10. This is a self-insured and self-administered health benefit plan. The cost of the Plan is paid with
contributions shared by the employer and employee. Benefits under the Plan are provided from
the general assets of the employer and are used to fund payment of covered claims under the Plan
plus administrative expenses. Please see your employer for the method of calculating
contributions and the funding mechanism used for the accumulation of assets through which
benefits are provided under this Plan.
11. Each employee of the employer who participates in the Plan receives a Summary Plan Description,
which is this booklet. This booklet will be provided to employees by the employer. It contains
information regarding eligibility requirements, termination provisions, and a description of the
benefits provided and other Plan information.
12. The Plan benefits and/or contributions may be modified or amended from time to time, or may be
terminated at any time by the Plan Sponsor. Significant changes to the Plan, including
termination, will be communicated to participants as required by applicable law.
13. Upon termination of the Plan, the rights of the participants to benefits are limited to claims
incurred and payable by the Plan up to the date of termination. Plan assets, if any, will be
allocated and disposed of for the exclusive benefit of the participating employees and their
dependents covered by the Plan, except that any taxes and administration expenses may be made
from the Plan assets.
14. The Plan does not constitute a contract between the employer and any covered person and will not
be considered as an inducement or condition of the employment of any employee. Nothing in the
Plan will give any employee the right to be retained in the service of the employe1; or for the
employer to discharge any employee at any time. It is provided, however, that the foregoing will
not modify the provisions of any collective bargaining agreement which may be made by the
employer with the bargaining representative of any employees. A copy of the collective
bargaining agreement will be made available by the employer for review, upon written request. .
15. This Plan is not in lieu of and does not affect any requirement for coverage by Workers'
Compensation insurance.
2
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ASOCOJ04
SCHEDULE OF BENEFITS
AN IMPORTANT MESSAGE ABOUT YOUR PLAN
Services are subject to all provisions of the Plan, including the limitations and exclusions.
Italicized terms within the text are defined in the Definitions section ofthis booklet.
PRECERTIFICATION
In most locations, the Plan Manager will be performing precertification. In those locations where the
Plan Managerwill be performing precertification, the following applies:
Medical Management is a Utilization/Case Management Program provided by the Plan Manager.
The Medical Management team will provide precertification as required by your Plan. Medical
Management recommends calling as soon as possible to receive proper precertification Refer to your ID
card for the phone number to call for precert(fication
The following benefits require precertification.
. PRECERTIFICA TION
BENEFIT REQUIREMENTS PENALTY
Inpatient Hospitalization, The Plan Manager must be If the admission is not precertified,
Inpatient Mental notified at least 7 days in advance. benefits for both the qualified
Disorder, Chemical If the admission IS on an practitioner and hospital or
Dependence and emergency basis, the Plan qualified treatment facility will be
Alcoholism Manager must be notified within subject to a $500 penalty per
48 hours or the first business day confinement. The penalty does not
following admission. apply to the deductible or out-of-
pocket maximums.
Outpatient Surgery The Plan Manager must be If the surgery is not precertified,
notified at least 7 days in advance. benefits for both the qualified
practitioner and hospital or
qualified treatment facility will be
subject to a $500 penalty per
occurrence. The penalty does not
apply to the deductible or out-of-
pocket maximums.
Outpatient Speech, The Plan Manager must be If therapy services are not
Physical and notified prior to services being precertified, benefits will be subject
Occupational Therapy rendered. to a $500 penalty per occurrence.
( Qualified practitioner The penalty does not apply to the
office or outpatient deductible or out-of-pocket
facility) maxImums.
Outpatient Sleep Apnea The Plan Manager must be If services are not precertified,
( Qualified practitioner notified prior to services being benefits will be subject to a $500
office or outpatient rendered. penalty per occurrence. The penalty
facility) does not apply to the deductible or
out-of-pocket maximums.
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ASOCOJ04
Schedule of Medical Benefits - Precertification Continued
PRECERTIFICA TION
BENEFIT REQUIREMENTS PENALTY
Outpatient Pain The Plan Manager must be If services are not precert({ied,
Management (Qual({ied notified prior to services being benefits will be subject to a $500
practitioner office or rendered. penalty per occurrence. The penalty
outpatient facility) does not apply to the deductible or
out-of-pocket maximums.
Home Health Care The Plan Manager must be If home health care services are not
notified prior to services being precert(fied, benefits will be subject
rendered. to a $500 penalty per occurrence.
The penalty does not apply to the
deductible or out-of-pocket
maximums.
Skilled Nursing Facility The Plan Manager must be If the skilled nursmg facility
notified pnor to services being c011{inement IS not precert(fied,
rendered. benefits will be subject to a $500
penalty per occurrence. The penalty
does not apply to the deductible or
out-of-pocket maximums.
Hospice Care The Plan Manager must be If hospice care is not precert(fied,
notified pnor to services being benefits will be subject to a $500
rendered. penalty per occurrence. The penalty
does not apply to the deductible or
out-of-pocket maximums.
Durable Medical The Plan Manager must be If the equipment is not precert(fied,
Equipment (over $750 notified prior to services being benefits will be subject to a $500
per equipment) rendered. penalty per occurrence. The penalty
does not apply to the deductible or
out-of-pocket maximums.
Organ Transplants The Plan Manager must be If organ transplant services are not
notified prior to organ transplant precert(fied, they are not covered.
services being rendered.
4
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ASOCOJ04
COVERED AND NON-COVERED EXPENSES
Benefits are payable only if services are considered to be a covered expense and are subject to the specific
conditions, limitations and applicable maximums of the Plan. The benefit payable for covered expenses
will not exceed the maximum allowable Jee(s).
A covered expense is deemed to be incurred on the date a covered service is received.
One copaymentwill be taken per visit per qualified practitioner.
If you incur non-covered expenses, you are responsible for making the full payment to the health care
provider. The fact that a qualified practitioner has performed or prescribed a medically appropriate
procedure, treatment, or supply, or the fact that it may be the only available treatment for a bodily injury or
sickness, does not mean that the procedure, treatment or supply is covered under the Plan.
Please refer to the "Schedule of Benefits" and the "Limitations and Exclusions" sections of this Summary
Plan Description for more information about covered expenses and non-covered expenses.
MEDICAL DEDUCTIBLE AND COINSURANCE
INFORMATION
Lifetime Maximum $2,000,000 per covered person.
BENEFIT
Deductible:
Inpatient Hospital . No deductible
Outpatient Surgery No deductible
Outpatient N on- Surgery No deductible
Hospital Physician Services No deductible
Other Medical Services $500 Individual/$I,OOO Familv
You must satisfy the deductible before the Plan will pay any benefits.
Out-of-Pocket Limit:
Individual $1,000
Family $2,500 .
When the amount of combined covered expenses paid by you and/or all your covered dependents
satisfy the separate deductible and out-of-pocket limits as shown above, the Plan will pay 100% of
covered expenses for the remainder of the calendar year, unless specifically indicated, subject to any
calendar vearmaximums and the lifetime maximum of the Plan.
5
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ASOCOJ04
MEDICAL COVERED EXPENSES
BENEFIT
Inpatient Hospital Payable at 80%.
Precert{fication is required. If precert{fication is not receiyed,
benefits are subject to the penalty described on the Schedule of
Benefits.
Ancillary Services
Inpatient Hospital Payable at 80%.
Outpatient Sur~ical/N on-sur~ical Payable at 100%.
Diagnostic X-ray & Lab
In an Office Setting Payable at 100%.
In an Outpatient Settin~ Subiect to a $100 cOlJavmen~ then payable at 100%.
CAT, PET & MRI
In an Office Setting Payable at 100%.
In an Outpatient Settin~ Subiect to the deductible, then payable at 80%.
Outpatient Surgical Facility Subject to a $100 co payment per procedure, then payable at
100%.
Outpatient Hospital Subject to a $100 copayment per procedure, then payable at
100%.
Emergency Room (Hospita~ Subject to a $1 00 copaymen~ then payable at 100%.
Covavmentwaived if admitted.
Urgent Care Facility Subiect to a $40 cOlJavmen~ then payable at 100%.
Free Standing Surgical Facility Subject to a $100 co payment per procedure, then payable at
100%.
Precert{fication is required. If precert{fication is not received,
benefits are subject to the penalty described on the Schedule of
Benefits.
Qual{fied Practitioner
(Office Visits/In Office Surgery
including Second Surgical Opinion)
PCP Subject to a $25 copaymen~ then payable at 100%.
Specialist Subiect to a $40 covavmenl.. then oayable at 100%.
Surgical services are subject to Precertificatio11. If
precert{fication is not received, benefits are subject to the
oenalty described on the Schedule of Benefits.
Qual{fied Practitioner
(Other than office visits)
Inpatient HospitalVisits Payable at 100%.
Emer~encv Room Visits Pavable at 100%.
6
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Injections
Vials & Testin
Routine Care - Up to age 16
Exam
Lab/X-ray
Immunizations & FlulPneumonia
Routine Care
(Age 16 and above)
ASOCOJ04
MEDICAL COVERED EXPENSES
Subject to a $3 copaymentper visit then payable at 100%.
Pa able at 100%.
Subject to the office visit copaymen~ then payable at 100%.
Payable at 100%.
Exam Subject to the office visit copaymen~ then payable at 100%.
Lab/X-ray Payable at 100%.
Immunizations & Flu/Pneumonia Subject to a $3 copaymentper injection, then payable at 100%.
Pap Smear Payable at 100%.
Prostate Antigen Testing
Pa able at 100%.
Routine physical exam limited to 1 per calendar year. Well
woman exams are not limited.
Pa able at 100%.
Payable at 100%.
Payable the same as any other sickness.
7
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ASOCOJ04
MEDICAL COVERED EXPENSES
BENEFIT
Chiropractic Care
(For treatment of a bodily injUlyor
sicA71ess)
. Exam Subject to a $40 copaymen~ then payable at 100%.
. Manipulations
. Therapy
Lab & X-ray Payable at 100%.
Routine Maintenance Care Not covered.
Covered services aggregate to a maXImum of 20 visits per
calendar yem:
Only 1 copayment applies regardless of the number of services
rendered.
Physical, Speech, Cognitive and Subject to the deductible, then payable at 80%.
Occupational Therapy Precertijication IS required for outpatient therapy. If
precert(fication is not received, benefits are subject to the
penalty described on the Schedule of Benefits.
Respiratory Therapy Subiect to the deductible, then payable at 80%.
Chemotherapy and Radiation Subject to the deductible, then payable at 80%.
Therapy
Cardiac Rehabilitation (Limited to Subject to the deductible, then payable at 80%.
Phases I &II)
Ambulance Service Subject to the deductible, then payable at 80%.
Prel!nancv Benefits Payable the same as any other sickness.
Newborn Benefits Payable at 80%.
Birthinl! Centers Payable at 80%.
Elective sterilizations Payable the same as any other sickness.
Reversal of Sterilization Not covered.
Skilled Nursing Facility Subiect to the deductible, then payable at 80%.
Covered services aggregate to a maximum of 60 days per
calendar year. Precert~fication is required. If precertification is
not received, benefits are subject to the penalty described on the
Schedule of Benefits.
Home Health Care Subject to the deductible then payable at 80%.
Covered expenses aggregate to a maximum of 40 visits per
calendar yem: Precertification is required. If precert~fication is
not received, benefits are subject to the penalty described on the
Schedule of Benefits.
Hospice Care Subject to the deductible, then payable at 80%.
Durable Medical Equipment Subject to the deductible, then payable at 80%.
Precert{fication is required. If precertification is not received,
benefits are subject to the penalty described on the Schedule of
Benefits.
8
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ASOCOJ04
MEDICAL COVERED EXPENSES
BENEFIT
Mental Disorder, Chemical Payable as shown in text.
Dependence and Alcoholism
Private Duty Nursing (inpatient Payable at 100%.
hospital only)
Other Covered Expenses Subject to the deductible, then payable at 80%.
MEDICAL COVERED EXPENSES
BENEFIT HUMANA NATIONAL OTHER THAN A HUMANA
TRANSPLANT NETWORK NATIONAL TRANSPLANT
FACILITY NETWORK FACILITY
Organ Transplants Payable same as any other Payable same as any other
sickness. sickness.
Covered expenses are limited to a
maximum benefit of $35,000 per
transDlant.
Covered expenses for organ transplants performed at a Humana National Transplant Network facility
aggregate toward the out-of-pocket limits described in the Schedule of Benefits. Covered expenses for
organ transplants performed at a facility other than a Humana National Transplant Network facility do
not aggregate toward the out-of-Docket limits described in the Schedule of Benefits.
9
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ASOCOJ05
UTILIZATION/CASE MANAGEMENT
Utilization management and case management are designed to assist covered persons in making informed
medical care decisions resulting in the delivery of appropriate levels of Plan benefits for each proposed
course of treatment. These decisions are based on the medical information provided by the patient and the
patient's physician. The patient and his or her physician determine the course of treatment. The assistance
provided through these services does not constitute the practice of medicine. Payment of Plan benefits is
not determined through these processes.
PRE CERTIFICATION
Utilization review includes precertification and concurrent review.
This provision will not provide benefits to cover a confinement or service which is not medically
necessmy or otherwise would not be covered under the Plan. Precertification is not a guarantee of
coverage.
If you or your covered dependent are to receive a service which requires precertification, you or your
qualified practitioner must contact the Plan Managerby telephone or in writing. Refer to the Schedule of
Benefits for time requirements.
After you or your qualified practitioner have provided the Plan Manager with your diagnosis and
treatment plan, the Plan Manager will:
1. Advise you in writing if the proposed treatment plan is medically necesswy,
2. Advise you in writing the number of days the corifinement is initially precertified, and
3. Conduct concurrent review as necessary.
If your qualified practitioner extends your corifinement beyond the number of days initially precertified,
the extension must be precertifiedthrough concurrent review.
If it is detennined at any time your proposed treatment plan, either partially or totally, is not a covered
expense under the terms and provisions of the Plan, benefits for services may be reduced or services may
not be covered.
PENAL TY FOR NOT OBTAINING PRECERTIFICA TION
If you do not obtain precertification for services being rendered, your benefits for both qualified
practitioner and hospital or qualified treatmentfacilitymay be reduced. Refer to the Schedule of Benefits
for the applicable penalty.
SECOND SURGICAL OPINION
A second surgical opinion may be required, as provided in the Plan, before the confinement will be
precertified Benefits for the second surgical opinion, including any medically necessmy x-ray and
laboratory tests performed by the second qualified practitioner, are payable as shown on the Schedule of
Benefits.
10
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ASOCOJ05
Utilization/Case Management Continued
If the two opinions disagree, you may obtain a third opinion. Benefits for the third opinion are payable the
same as for the second opinion.
The qualified practitioners providing the surgical opinions MUST NOT be in the same group practice or
clinic. The qualified practitioner providing the second or third surgical opinion may confirm the need for
surgery or present other treatment options. The decision whether or not to have the surgery is always
yours.
PREDETERMINATION OF MEDICAL BENEFITS
You or your qualified practitioner may submit a written request for a predetermination of benefits. The
written request should contain the treatment plan, specific diagnostic and procedure codes, as well as the
expected charges. The Plan Manager will provide a written response advising if the services are a
covered or non-covered expense under the Plan, what the applicable Plan benefits are and if the expected
charges are within the maximum allowable fee. The predetermination 9f benefits is not a guarantee of
benefits. Services will be subject to all terms and provisions of the Plan applicable at the time treatment is
provided.
If treatment is to commence more than 90 days after the date treatment is authorized, the Plan Manager
will require you to submit another treatment plan.
11
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ASOCOJ05
MEDICAL DEDUCTIBLE AND COINSURANCE INFORMATION
Covered e.:rpenses are payable, after satisfaction of the deductible, to a maximum allowable fee at the
coinsurance percentages and up to the maximum benefits shown on the Schedule of Benefits.
DEDUCTIBLE
The deductible applies to each covered person each calendar yew: Only charges which qualify as a
covered e.:rpense may be used to satisfy the deductible. The amount of the deductible is stated on the
Schedule of Benefits. Any covered expense incurred during the last three months of the calendar year that
is used to satisfy all or part of the deductible for that year, will be used to satisfy all or part of the
deductible for the following calendar yew:
You must satisfy the separate PAR or Non-PAR deductible before the Plan will pay any benefits.
MAXIMUM F AMIL Y DEDUCTIBLE
The total deductible applied to all covered persons in one family in a calendar year is subject to the
maximum shown on the Schedule of Benefits.
COINSURANCE
The tenn coinsurance means the shared financial responsibility for covered expenses between the covered
person and the self-insured plan.
Covered expenses are payable at the applicable percentage rate shown on the Schedule of Benefits after
the deductible is satisfied each calendar yew:
OUT-OF-POCKET LIMIT
When the amount of combined covered expenses paid by you and/or all your covered dependents satisfy
the deductible and out-of-pocket limits as shown on the Schedule of Benefits, the Plan will pay 100% of
covered e.:rpenses for the remainder of the calendar yew; unless specifically indicated, subject to any
calendar year maximums and the lifetime maximum of the Plan.
If you and/or all yow'covered dependents use a combination of PAR and Non-PAR providers, the out-of-
pocket amounts will track separately. Copayments, penalties, mental disorder, chemical dependence and
alcoholism expenses are not applied to the out-of-pocket limit.
Covered e.:rpenses are subject to any calendar year maximums or the lifetime maximum of the Plan.
LIFETIME MAXIMUM
Lifetime maximum means the maximum amount of benefits available while you are covered under the
Plan. Under no circumstances does lifetime mean during the lifetime of the covered person.
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ASOCOJ06
MEDICAL COVERED EXPENSES
INPATIENT HOSPITAL
Covered expenses are payable as shown on the Schedule of Benefits and include charges made by a:
1. Hospital for daily semi-private, ward, intensive care or coronary care room and board charges for
each day of confinement The maximum amount payable is shown on the Schedule of Benefits.
Benefits for a private or single-bed room are limited to the maximum allowable fee charged for a
semi-private room in the hospitalwhile a registered bed patient;
2. Hospitalfor services furnished for your treatment during confinement
OUTPATIENT HOSPITAL
Covered expenses are payable as shown on the Schedule of Benefits. Covered expenses include charges
made by a hospital for:
1. Treatment of a bodily injury, including the emergency room charge if rendered within 48 hours of
an accident;
2. Treatment of a sickness following an emergency, including the emergency room charge;
3. Preadmission testing,
4. A surgical procedure;
5. Regularly scheduled treatment such as chemotherapy, inhalation therapy, radiation therapy as
ordered by your attending physician.
FREE-STANDING SURGICAL FACILITY
Charges made by a free-standing surgical facility, for surgical procedures performed and for services
rendered in the facility are payable as shown on the Schedule of Benefits.
URGENT CARE CENTER
Facility charges made by an urgent care center are payable as shown on the Schedule of Benefits.
Outpatient surgery, diagnostic x-ray, laboratory tests and any additional services other than the facility
charge are not payable under this benefit. Please refer to the other provisions of this Plan for available
coverage.
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ASOCOJ06
QUALIFIED PRACTITIONER
Covered expenses are payable as shown on the Schedule of Benefits and include charges made by a
qualified practitioner when incurred for:
1. Office, home, emergency room physician or inpatient hospitalvisits;
2. Diagnostic x-ray or laboratory tests;
3. Professional services of a radiologist or pathologist for diagnostic x-ray examination or laboratory
tests, including x-ray, radon, radium and radioactive isotope therapy;
4. Other covered medical services received from or at the direction of a qualified practitionel;
5. Administration of anesthesia;
6. A surgical procedure, including pre-operative and post-operative care.
If multiple or bilateral surgical procedures are performed at one operative session, the amount
payable for these procedures will be limited to the maximum allowable fee for the primary
surgical procedure and;
a. 50% of the maximum allowable fee for the secondary procedure; and
b. 25% of the ma.:rimum allowable fee for the third and subsequent procedures.
No benefits will be payable for incidental procedures.
7. Assisting the surgeon;
8. Physician assistant;
9. Charges made by a qualified practitioner for services in performing certain oral surgical
operations due to bodily injUlJ10r sickness are covered as follows:
a. Excision of partially or completely lmempted impacted teeth;
b. Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth
when such conditions require pathological examination;
c. Surgical procedures required to correct accidental injuries of the jaws, cheeks, lips,
tongue, roof and floor of the mouth;
d. Mandibular staple implant when not done to prepare the mouth for dentures;
e. Removal of full bony impactions;
f. Frenectomy (the cutting of the tissue in the midline of the tongue);
g. Alveolectomy and alveoplasty related to tooth extraction; and
h: Orthognathic surgelY if severe handicapping malocclusion is present and proved.
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ASOCOJ06
ROUTINE CARE
The following expenses are payable for you or your covered dependen~ up to the amount shown on the
Schedule of Benefits, subject to all terms and provisions of the Plan, except the exclusion for services
which are not medically necessary, if you are not confined in a hospital or qualified treatment facility and
if such expenses are not incurred for diagnosis of a specific bodily injury or sickness.
Benefits include:
1. Routine exams and annual checkups;
2. Immunizations;
3. Pap smears;
4. Mammograms;
5. Routine x-ray and laboratory tests; and
6. Prostate antigen testing.
No benefits are payable under this benefit for:
1. Any dental examinations;
2. Hearing examinations;
3. Vision examinations; and
4. Medical examination for bodily injury or sickness.
SUPPLEMENTAL ACCIDENT BENEFIT
This provision provides benefits for you or your covered dependents in the event of a bodily injury. The
expense must be incurred within 3 days of the date of the accident. Eligible expenses are payable as
shown on the Schedule of Benefits and are not subject to the deductible and coinsurance. Dental x-rays
and dental surgical procedures are included as eligible expenses under this provision.
No benefits are payable under this provision for expenses incurred to treat a sickness.
CHIROPRACTIC CARE
Chiropractic care for treatment of a bodily injwy or sickness is payable as shown on the Schedule of
Benefits. Maintenance care is not covered.
15
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ASOCOJ06
AMBULANCE SERVICE
Local professional ambulance service to the nearest hospital equipped to provide the necessary treatment
is covered as shown on the Schedule of Benefits. Ambulance service must not be provided primarily for
the convenience of the patient or the qualified practitioner.
PREGNANCY BENEFITS
Pregnancy is a covered expense for any covered person payable as shown on the Schedule of Benefits.
Complications 0.( pregnancy are payable as any other covered sickness at the point the complication sets in
for any covered person.
Pregnancy benefits are subject to all terms and provisions of the Plan, with the exception of the pre-
e.xisting condition (medical) limitation.
Group health plans and health insurance issuers generally may not, under Federal law, 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 cesarean section. However, Federal
law generally does not prohibit the mother's or newborn's attending provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In
any case, plans may not, under Federal law, require that a provider obtain authorization from the Plan or
the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
NEWBORN BENEFITS
Covered expenses incurred during a newborn child's initial inpatient hospital corifinement include
hospital expenses for room and board and miscellaneous services; qual(fied practitioner's expenses for
circumcision; and qualified practitioner '."1 expenses for routine examination before release from the
hospital
BIRTHING CENTERS
A birthing center is a free standing facility, licensed by the state, which provides prenatal care, delivery
and immediate postpartum care, and care of the newborn child.
Expense incurred within 24 hours after corifinement in a birthing center for services and supplies
furnished for prenatal care and delivery of child(ren) are payable as shown on the Schedule of Benefits.
16
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ASOCOJ06
SKILLED NURSING FACILITY
Covered expenses for a skilled nursing facility corifinementare payable when the confinement,
1. Begins while you or an eligible dependent are covered under this Plan;
2. Begins after discharge from a hospital confinement or a prior covered skilled nursing facility
corifinement,
3. Is necessary for care or treatment of the same bodily injury or sickness which caused the prior
confinement, and
4. Occurs while you or an eligible dependent are under the regular care of the physician who
precertifiedthe required skilled nursing facility corifinement.
Skilled nursing facility means only an institution licensed as a skilled nursing facility and lawfully
operated in the jurisdiction where located. It must maintain and provide:
1. Permanent and full-time bed care facilities for resident patients;
2. A physician's services available at all times;
3. 24-hour-a-day skilled nursing services under the full-time supervision of a physician or registered
nurse (R.N.);
4. A daily record for each patient;
5. Continuous skilled nursing care for sick or injured persons during their convalescence from
sickness or bodily injury; and
6. A utilization review plan.
A skilled nursing facility is not except by incident, a rest home, a home for care of the aged, or engaged in
the care and treatment of mental disorders, chemical dependence or alcoholism.
BENEFITS PAYABLE
Expense incurred for daily room and board and general nursing services for each day of confinement in a
skilled nursing facility is payable as shown on the Schedule of Benefits. The daily rate will not exceed the
maximum daily rate established for licensed skilled nursing care facilities by the Department of Health
and Social Services.
17
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ASOCOJ06
HOME HEALTH CARE
Expense incurred for home health care as described below is payable as shown on the Schedule of
Benefits.
Each visit by a home health care provider for evaluating the need for, developing a plan, or providing
services under a home health care plan will be considered one home health care visit. Up to 4 consecutive
hours of service in a 24-hour period is considered one home health care visit. A visit by a home health
care provider of 4 hours or more is considered one visit for every 4 hours or part thereof.
Home health care provider means an agency licensed by the proper authority as a home health agency or
Medicare approved as a home health agency.
Home health care will not be reimbursed unless the Plan determines:
1. Hospitalization or confinement in a skilled nursing facility would otherwise be required if home
care were not provided;
2. Necessary care and treatment are not available from a fami{v member or other persons residing
with you; and
3. The home health care services will be provided or coordinated by a state-licensed or Medicare-
certified home health agency or certified rehabilitation agency.
The home health care plan must be reviewed and approved by the qual!fied practitioner under whose care
you are currently receiving treatment for the bodily injUlJ10r sickness which requires the home health care.
The home health care plan consists of:
1. Care by or under the supervision of a registered nurse (R.N.);
2. Physical, speech, occupational and respiratory therapy and home health aide services; and
3. Medical supplies and durable medical equipmen~ laboratory services and nutritional counseling,
if such services and supplies would have been covered if you were hospital confined.
LIMITATIONS ON HOME HEALTH CARE BENEFITS
Home health care benefits do not include:
1. Charges for mileage or travel time to and from the covered person's home;
2. Wage or shift differentials for home health care providers; or
3. Charges for supervision of home health care providers.
18
ASOCOJ06
HOSPICE CARE
Hospice services must be furnished in a hospice facility or in your home. A qualified practitioner must
certify you are terminally ill with a life expectancy of six months or less.
For hospice services only, your immediate family is considered to be your parent, spouse, and
your children or step-children.
Covered expenses are payable as shown on the Schedule of Benefits for the following hospice services:
1. Room and board and other services and supplies;
2. Part-time nursing care by or supervised by a R.N. for up to 8 hours per day;
3. Counseling services by a qualified practitioner for the hospice patient and the immediate family;
4. Medical social services provided to you or your immediate family under the direction of a
qualified practitioner, which include the following:
a. Assessment of social, emotional and medical needs, and the home and family situation,
b. Identification of the community resources available, and
c. Assistance in obtaining those resources;
5. Nutritional counseling;
6. Physical or occupational therapy;
7. Part-time home health aide service for up to 8 hours in anyone day; and
8. Medical supplies, drugs and medicines prescribed by a qualified practitioner.
LIMITATIONS ON HOSPICE CARE BENEFITS
Hospice care benefits do NOT include: (1) private duty nursing services when confined in a hospice
facility; (2) a confinement not required for pain control or other acute chronic symptom management; (3)
funeral arrangements; (4) financial or legal counseling, including estate planning or drafting of a will; (5)
homemaker or caretaker services, including a sitter or companion services; (6) housecleaning and
household maintenance; (7) services of a social worker other than a licensed clinical social worker; (8)
services by volunteers or persons who do not regularly charge for their services; or (9) services by a
licensed pastoral counselor to a member of his or her congregation when services are in the course of the
duties to which he or she is called as a pastor or minister.
Hospice care program means a written plan of hospice care, established and reviewed by the qualified
practitioner attending the patient and the hospice care agency, for providing palliative and supportive care
to hospice patients. It offers supportive care to the families of hospice patients, an assessment of the
hospice patient's medical and social needs, and a description of the care to meet those needs.
19
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ASOCOJ06
Hospice Care Continued
Hospice facility means a licensed facility or part of a facility which principally provides hospice care,
keeps medical records of each patient, has an ongoing quality assurance program and has a physician on
call at all times.
A hospice facility provides 24-hour-a-day nursing services under the direction of a R.N. and has a full-
time administrator.
Hospice care agency means an agency which has the primary purpose of providing hospice services to
hospice patients. It must be licensed and operated according to the laws of the state in which it is located
and meets all of these requirements: (1) has obtained any required certificate of need; (2) provides 24-
hours a day, 7 day-a-week service supervised by a qual{tled practitionel; (3) has a full-time coordinator;
(4) keeps written records of services provided to each patient; (5) has a nurse coordinator who is a R.N.,
who has four years of full-time clinical experience, of which at least two involved caring for terminally ill
patients; and, (6) has a licensed social service coordinator.
A hospice care agency will establish policies for the provision of hospice care, assess the patient's medical
and social needs and develop a program to meet those needs. It will provide an ongoing quality assurance
program, permit area medical personnel to use its services for their patients, and use volunteers trained in
care of and services for non-medical needs.
ORGAN TRANSPLANT BENEFIT
Precert{tication is required. If precert{tication is not received, organ transplant services will not be
covered.
The Plan will pay benefits for the expense of a transplant as defined below for a covered person when
approved in advance by the Plan Manager, subject to those terms, conditions and limitations described
below and contained in the Plan. Please contact the Plan Manager at our toll free number (866) 421-5663
when in need of these services.
COVERED ORGAN TRANSPLANT
Only the services, care and treatment received for, or in connection with, the pre-approved transplant of
the organs identified hereafter, which are determined by the Plan Manager to be medically necessary
services and which are not experimental, investigational or for research purposes will be covered by the
Plan. The transplant includes: pre-transplant services, transplant inclusive of any chemotherapy and
associated services, post-discharge services and treatment of complications after transplantation of the
following organs or procedures only:
1. Heart;
2. Lung(s);
3. Liver;
4. Kidney;
5. Bone Marrow*;
6. Intestine;
7. Pancreas;
8. Auto islet cell;
20
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ASOCOJ06
Organ Transplant Benefit Continued
9. Multivisceral;
10. Any combination of the above listed organs;
11. Any organ not listed above required by federal law.
*The term bone marrow refers to the transplant of human blood precursor cells which are administered to
a patient following high-dose, ablative or myelosuppresive chemotherapy. 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 or cord blood. If
chemotherapy is an integral part of the treatment involving a transplant of bone marrow, the term bone
marrow includes the harvesting, the transplantation and the chemotherapy components. Storage of cord
blood and stem cells will not be covered unless as an integral part of a transplant of bone marrow
approved by the Plan Manager.
Corneal transplants and porcine heart valve implants, which are tissues rather than organs, are considered
part of regular plan benefits and are subject to other applicable provisions ofthe Plan.
For a transplant to be considered fully approved, prior written approval from the Plan Manager is required
in advance of the transplant. You or your qualified practitioner must notify the Plan Manager in advance
of your need for an initial transplant evaluation in order for the Plan Manager to determine if the
transplant will be covered. For approval of the transplant itself, the Plan Manager must be given a
reasonable opportunity to review the clinical results ofthe evaluation before rendering a determination.
Once the transplant is approved, the Plan Manager will advise the covered person's qualified
practitioner. Benefits are payable only if the pre-transplant services, the transplant and post-discharge
services are approved by the Plan Manager.
EXCLUSIONS
No benefit is payable for, or in connection with, a transplant if:
1. It is experimental, investigational or for research purposes as defined in the Definitions section of
this booklet.
2. The Plan Manager is not contacted for authorization prior to referral for evaluation of the
transplant, unless such authorization is waived by the Plan Manager.
3. The Plan Managerdoes not approve coverage for the transplant, based on its established criteria.
4. Expenses are eligible to be paid under any private or public research fund, government program,
except Medicaid, or another funding program, whether or not such funding was applied for or
received.
5. The expense relates to the transplantation of any non-human organ or tissue, unless otherwise
stated in the Plan.
6. The expense relates to the donation or acquisition of an organ for a recipient who is not covered
by the Plan.
21
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ASOCOJ06
Organ Transplant Benefit Continued
7. A denied transplant is performed; this includes the pre-transplant evaluation, p~e-transplant
services, the transplant procedure, post-discharge services, immunosuppressive drugs and
complications of such transplant.
8. The covered person for whom a transplant is requested has not met pre-transplant criteria as
established by the Plan Manager.
COVERED SERVICES
For approved transplants, and all related complications, the Plan will cover only the following expenses:
1. Hospital and qualified practitioner benefits, payable as shown on the Schedule of Benefits. If
services are rendered at a Humana National Transplant Network (NTN) facility, covered expenses
are paid in accordance to the NTN contracted rates.
2. Organ acquisition and donor costs. Except for bone marrow transplants, donor costs are not
payable under the Plan 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. Coverage for bone
marrow transplants procedures will include costs associated with the donor-patient to the same
extent and limitations associated with the covered person.
3. Direct, non-medical costs* for the covered person, when the transplant is performed at a Humana
National Transplant Network facility, will be paid for: (a) transportation to and from the hospital
where the transplant is performed; and (b) temporary lodging at a prearranged location when
requested by the hospital and approved by the Plan Manage1: Transportation costs for the
covered per.<;on to and from the hospital where the transplant is performed will be payable as
shown on the Schedule of Benefits. These direct, non-medical costs are only available if the
covered person lives more than 100 miles from the transplant facility. * *
4. Direct, non-medical costs* for one member of the covered person's immediate family (two
members if the patient is under age 18 years), when the transplant is performed at a Humana
National Transplant Network facility, will be paid for: (a) transportation to and from the approved
facility where the transplant is perfoffiled; and (b) temporary lodging at a prearranged location
during the covered person's confinement in the hospital Transportation costs for the covered
person's immediate family member(s) to and from the hospital where the transplant is performed
will be payable as shown on the Schedule of Benefits. These direct, non-medical costs are only
available if the covered person's immediate famizy member(s) live more than 100 miles from the
transplant facility. * *
*Non-medical costs are not covered if a transplant is performed at a facility that is not a Humana National
Transplant Network facility.
** All direct, non-medical expenses for the covered person receiving the transplant and his/her family
member(s) are limited to a combined maximum ben~fit of $1 0,000 per transplant.
22
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ASOCOJ06
MENTAL DISORDER, CHEMICAL DEPENDENCE OR ALCOHOLISM BENEFIT
Expense incurred by you during a plan of treatment for mental disorder, chemical dependence or
alcoholism is payable for:
1. Charges made by a qualified practitioner,
2. Charges made by a hospital;
3. Charges made by a qualified treatment facility.
INPATIENT BENEFITS
Covered expenses while confined as a registered bed patient in a hospital or qualified treatment facility,
are payable as shown below:
Covered expenses for inpatient treatment do not aggregate toward the coinsurance and out-of-pocket
limits described on the Schedule of Benefits.
OUTPATIENT BENEFITS
Covered expenses for outpatient treatment received while not confined in a hospital or qualified treatment
facility are payable as shown below:
then a able at 100%.
Outpatient treatment of a mental disorder, chemical dependence or alcoholism aggregates to a
maximum of 20 visits er calendar ear.
Covered expenses for outpatient treatment do not aggregate toward the coinsurance and out-of-pocket
limits described on the Schedule of Benefits.
LIMITATIONS ON MENTAL DISORDER, CHEMICAL DEPENDENCE OR ALCOHOLISM
BENEFITS
No benefits are payable under this provision for marriage counseling, treatment of nicotine habit or
addiction, or for treatment of being obese or overweight.
No benefits are payable under this provision for services performed at a Residential Treatment Facility.
Treatment must be provided for the cause for which benefits are payable under this provision of the Plan.
23
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ASOCOJ06
OTHER COVERED EXPENSES
The following are other covered expenses payable as shown on the Schedule of Benefits (unless otherwise
specified):
1. Blood and blood plasma are payable as long as it is NOT replaced by donation, and administration
of blood and blood products including blood extracts or derivatives;
2. Oxygen and rental of equipment for its administration;
3. Drugs and medicines that are provided to or administered to you while you are confined in a
hospital or skilled nursing facility, or from a qualified practitioner during an office visit or from a
home health care provider;
4. Initial prosthetic devices or supplies, including but not limited to, limbs and eyes. Coverage will
be provided for prosthetic devices necessary to restore minimal basic function. Replacement is a
covered expense if due to pathological changes. Covered e'(pense includes repair of the prosthetic
device if not covered by the manufacturer;
5. Supplies, up to a 30-day supply, when prescribed by yow'attending physician;
6. Casts, trusses, crutches, orthotics, splints and braces. Orthotics must be custom made or custom
fitted, made of rigid or semi-rigid material. Fabric supports, replacement orthotics and braces,
oral splints and appliances and dental splints and dental braces are not a covered expense,
7. Initial contact lenses or eyeglasses following cataract surgely,
8. The rental, up to but not to exceed the purchase price, of a wheelchair, hospital bed, ventilator,
hospital type equipment or other durable medical equipment (DME). The Plan, at its option, may
authorize the purchase of DME in lieu of its rental, if the rental price is projected to exceed the
purchase price. Repair, maintenance or duplicate DMErental is not considered a covered expense.
Refer to the precertification requirements of this Plan if the rental or purchase price is expected to
be $750 or more;
9. Wigs for cancer patients due to hair loss resulting from chemotherapy or radiation therapy;
10. Services for the treatment of a dental injury to a sound natural tooth, including but not limited to
extraction and initial replacement. Service.s must begin within 90 days and be completed within
24 months after the date of the dental b?iUlY. Benefits will be paid only for expense incurred for
the least expensive service that will, in the Plan Manager's opinion, produce a professionally
adequate result;
11. Installation and use of an insulin infusion pump, diabetic self-management education programs
and other equipment or supplies in the treatment of diabetes, except as specifically described
within the Prescription Drug section;
12. Reconstructive surgery due to bodily i1?jwy, infection or other disease of the involved part or
congenital disease or anomaly of a covered dependent child which resulted in a functional defect;
24
ASOCOJ06
Other Covered Expenses Continued
13. Reconstructive services following a covered mastectomy, including but not limited to:
a. reconstruction of the breast on which the mastectomy was performed;
b. reconstruction of the other breast to achieve symmetry;
c. prosthesis; and
d. treatment of physical complications of all stages of the mastectomy, including
lymphedemas;
14. Speech, occupational and physical therapy;
15. Respiratory therapy;
16. Cardiac rehabilitation, limited to phases I and II;
17. Chemotherapy and radiation therapy; and
18. Private duty nursing (inpatient hospital only).
The following services are considered other covered expenses and are payable as shown on the Schedule
of Benefits, subject to all terms and provisions of the Plan, except the exclusion for services which are not
medically necessmy;
1. Elective sterilizations; and
2. Birth control devices, injections, implant systems and removal of contraceptive implants.
25
ASOCOJ07
LIMITATIONS AND EXCLUSIONS
The Plan does not provide benefits for:
1. Services:
a. Not furnished by a qual~fied practitioner or qual~fied treatment facility;
b. Not authorized or prescribed by a qual~ed practitioner;
c. Not covered by this Plan whether or not prescribed by a qual~fied practitionel;
d. Which are not provided;
e. For which no charge is made, or for which you would not be required to pay if you were
not covered under this Plan unless charges are received from and reimbursable to the
United States Government or any of its agencies as required by law; or
f. Furnished by or payable under any plan or law through any government or any political
subdivision (this does not include Medicare or Medicaid);
g. Furnished for a military service connected sickness or bodily injury by or tmder an
agreement with a department or agency of the United States Government, including the
Department of Veterans Affairs;
h. Perfornled in association with a service that is not covered tmder this Plan;
1. Performed as a result of a complication arising from a service that is not covered under
this Plan;
2. Routine vision examinations or testing; services to correct eye refractive disorders; radial
keratotomy, refractive keratoplasty or any other surgel)Jto correct myopia, hyperopia or stigmatic
error; or, the purchase, fitting or repair of eyeglass frames and lenses or contact lenses, unless
specifically provided under this Plan;
3. Vision therapy (eye exercises to strengthen the muscles of the eye);
4. Routine hearing examinations;
5. Hearing aids, the fitting or repair of hearing aids or advice on their care; implantable hearing
devices;
6. Routine physical examinations and related services for occupation, employment, school, sports,
camp, travel, purchase of insurance or premarital tests or examinations, unless specifically
provided under this Plan;
7. Immunizations required for foreign travel;
8. Elective medical or surgical abortion unless:
a. The pregnancy would endanger the life of the mother; or
b. The pregnancy is a result ofrape or incest; or
c. The fetus has been diagnosed with a lethal or otherwise significant abnormality;
26
ASOCOJ07
Limitations and Exclusions Continued
9. All fertility testing or services performed to achieve pregnancy or ovulation by artificial means,
including but not limited to, artificial insemination, in vitro fertilization, spermatogenesis, gamete
intra fallopian transfer (GIFT), zygote intm fallopian tmnsfer (ZIFT), tubal ovum transfer, embryo
freezing or transfer and sperm banking;
10. Services related to gender change;
11. Services for a reversal of sterilization;
12. Cosmetic surgery and cosmetic services or devices, unless for reconstructive surgery.
a. Resulting from a bodily injury, infection or other disease of the involved part, when
functional impairment is present; or
b. Resulting from a congenital disease or anomaly of a covered dependent child which
resulted in a functional impairment.
c. A functional impairment is defined as a direct measumble reduction of physical
performance of an organ or body part. Expense incurred for reconstructive surgery
performed due to the presence of a psychological condition are not covered, unless the
condition(s) described above are also met;
13. Hair prosthesis, hair tmnsplants or hair implants;
14. Dental services or appliances for the treatment of the teeth, gums, jaws or alveolar processes,
including but not limited to, implants and related procedures, routine dental extmctions and
orthodontic procedures, unless specifically provided under this Plan;
15. Dental osteotomies;
16. Surgical or non-surgical treatment including but not limited to, appliances and thempy, for any
jaw joint problem including any temporomandibular joint disorder, craniomaxillary,
craniomandibular disorder or other conditions of the joint linking the jaw bone and skull.
Surgical or non-surgical treatment of the facial muscles used in expression and mastication
functions, for symptoms including but not limited to, headaches;
17. Services which are:
a. Rendered in connection with a mental disorder not classified in the International
Classification of Diseases of the U.S. Department of Health and Human Services;
b. Extended beyond the period necessary for evaluation and diagnosis of learning and
behavioral disabilities or for mental retardation;
Specifically excluded are marriage counseling and services for autism;
18. Court ordered mental disordel~ chemical dependence or alcoholism services;
19. Education or tmining, except for diabetes self-management tmining;
20. Educational or vocational therapy, testing, services or schools, including thempeutic boarding
schools and other therapeutic environments. Educational or vocational videos, tapes, books and
similar materials are also excluded;
27
tI, '~,
ASOCOJ07
Limitations and Exclusions Continued
21. Expenses for services that are primarily and customarily used for environmental control or
enhancement (whether or not prescribed by a qualified practitionelJ and certain medical devices
including, but not limited to:
a. Common household items including air conditioners, air purifiers, water purifiers,
vacuum cleaners, waterbeds, hypoallergenic mattresses or pillows or exercise equipment;
b. Motorized transportation equipment (e.g. scooters), escalators, elevators, ramps or
modifications or additions to living/working quarters or transportation vehicles;
c. Personal hygiene equipment including bath/shower chairs, transfer equipment or supplies
or bed side commodes;
d. Personal comfort items including cervical pillows, gravity lumbar reduction chairs,
swimming pools, whirlpools, spas or saunas;
e. Medical equipment including blood pressure monitoring devices, breast pumps, PUV A
lights and stethoscopes;
f. Communication system, telephone, television or computer systems and related equipment
or similar items or equipment;
g. Communication devices, except after surgical removal of the larynx or a diagnosis of
permanent lack of function of the larynx;
22. Any medical treatment, procedure, drug, biological product or device which is experimental,
investigational or for research pUlposes, unless otherwise specified in the Plan;
23. Pre-existing conditions to the extent specified in the Definitions section;
24. Services not medically necessary for diagnosis and treatment of a bodily injury or sickness;
25. Charges in excess of the maximum allowable fee for the service,
26. Services provided by a person who ordinarily resides in your home or who is afami{v member,
27. Any expense incurred prior to your effective date lUlder the Plan or after the date your coverage
under the Plan terminates, except as specifically described in this Plan;
28. Expenses incurred for which you are entitled to receive benefits under your previous dental or
medical plan;
29. Any expense due to the covered person's:
a. Engaging in an illegal occupation; or
b. Commission of or an attempt to commit a criminal act;
31. Any loss caused by or contributed to:
a. War or any act of war, whether declared or not;
b. Insurrection; or
c. Any act of armed conflict, or any conflict involving armed forces of any authority;
32. Any expense incurred for services received outside of the United States while you are residing
outside of the United States for more than six months in a year except as required by law for
emergency care services;
28
ASOCOJ07
Limitations and Exclusions Continued
33. Birth control pills;
34. Treatment of nicotine habit or addiction, including, but not limited to hypnosis, smoking
cessation products, classes or tapes;
35. Vitamins, dietary supplements and dietary formulas (except enteral formulas for the treatment of
genetic metabolic diseases, e.g. phenylketonuria (PKU);
36. Over the counter, non-prescription medications;
37. Medication, drugs or hormones to stimulate growth unless there IS a laboratory confirmed
diagnosis of growth hormone deficiency, as determined by the Plan;
38. Therapy and testing for treatment of allergies including, but not limited to, services related to
clinical ecology, environmental allergy and allergic immune system dysregulation and sublingual
antigen(s), extracts, neutralization test and/or treatment UNLESS such therapy or testing is
approved by: .
a. The American Academy of Allergy and Immunology, or
b. The Department of Health and Human Services or any of its offices or agencies;
39. Professional pathology or radiology charges, including but not limited to, blood counts, multi-
channel testing, and other clinical chemistry tests, when:
a. The services do not require a professional interpretation, or
b. The qualified practitioner did not provide a specific professional interpretation of the test
results of the covered person;
40. Services related to the treatment and/or diagnosis of sexual dysfunction/impotence;
41. Any treatment, including but not limited to, surgical procedures:
a. For obesity, including morbid obesity
b. For obesity including morbid obesity for the purpose of treating a sickness or bodily
injury caused by, complicated by, or exacerbated by the obesity;
42. Expenses for health clubs or health spas, aerobic and strength conditioning, work-hardening
programs or weight loss or similar programs, and all related material and product for these
programs;
43. Alternative medicine,
44. Acupuncture, unless:
a. The treatment is medically necessary and appropriate and is provided within the scope of
the acupuncturist's license;
b. You are directed to the acupuncturist for treatment by a licensed physician; and
c. The acupuncture is performed in lieu of generally accepted anesthesia practices;
45. Services rendered in a premenstrual syndrome clinic or holistic medicine clinic;
46. Services of a midwife, unless provided by a Certified Nurse Midwife;
29
.. ..
ASOCOJ07
Limitations and Exclusions Continued
47. The following types of care of the feet:
a. Shock wave therapy of the feet;
b. The treatment of weak, strained, flat, unstable or unbalanced feet;
c. Hygienic care, and the treatment of superficial lesions of the feet, such as corns, calluses
or hyperkeratosis;
d. The treatment of tarsalgia, metatarsalgia, or bunion, except surgically;
e. The cutting of toenails, except the removal of the nail matrix;
f. The provision of heel wedges, lifts or shoe inserts; and
g. The provision of arch supports or orthopedic shoes, unless medically necessary because
of diabetes or hammertoe;
48. Custodial care and maintenance cart;
49 . Weekend non-emergency hospital admissions, specifically admissions to a hospital on a Friday or
Saturday at the convenience of the covered person or his or her qualified practitioner when there
is no cause for an emergency admission and the covered person receives no surgelyor therapeutic
treatment until the following Monday;
50. Hospital inpatient services when you are in observation status;
51. Services rendered by a standby physician, surgical assistant, assistant surgeon, physician assistant,
registered nurse or certified operating room technician unless medicanv necesswy,
52. Private duty nursing; other than in an inpatient hospital;
53. Ambulance services for routine transportation to, from or between medical facilities and/or a
qualified practitioner's office;
54. Preadmission/procedural testing duplicated during a hospital confinement,
55. Lodging accommodations or transportation, unless specifically provided under this Plan;
56. Communications or travel time;
57. No benefits will be provided for:
a. Immunotherapy for recurrent abortion;
b. Chemonucleolysis;
c. Biliary lithotripsy;
d. Home uterine activity monitoring;
e. Sleep therapy;
f. Light treatments for Seasonal Affective Disorder (S.A.D.);
g. Immunotherapy for food allergy;
h. Prolotherapy;
1. Cranial banding;
J. Hyperhydroosis surge1y,
k. Lactation therapy; or
1. Sensory integration therapy;
30
ASOCOJ07
Limitations and Exclusions Continued
58. Sickness or bodily injury for which medical payments/personal injury protection (PIP) coverage
exists under any automobile, homeowner, marine, aviation, premise, or any other similar
coverage, whether such coverage is in effect on a primary, secondary, or excess basis. This
exclusion applies up to the available limit under the other coverage regardless of whether a claim
is filed with the medical payments/PIP carrier. Whether medical payment or expense coverage is
payable under another coverage is to be determined as if the coverages under this Plan did not
exist;
59. Any covered expenses to the extent of any amount received from others for the bodily injuries or
losses which necessitate such benefits. "Amounts received from others" specifically includes,
without limitation, liability insurance, worker's compensation, uninsured motorists, underinsured
motorists, "no-fault" and automobile med-pay payments;
60. Any bodily injury or sickness arising from or sustained in the course of any occupation or
employment for compensation, profit or gain for which:
a. Benefits are provided or payable under any Workers' Compensation or Occupational
Disease Act or Law, or
b. Coverage was available tmder any Workers' Compensation or Occupational Disease Act
or Law regardless of whether such coverage was actually purchased.
NOTE: These limitations and exclusions apply even if a qualified practitioner has performed or
prescribed a medically necessary procedure, treatment or supply. This does not prevent your qualified
practitioner from providing or performing the procedure, treatment or supply, however, the procedure,
treatment or supply will not be a covered expense.
31
-f
ASOCOJ08
ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE
OPEN ENROLLMENT
Once annually you will have a choice of enrolling yourse(( and your eligible dependents in this Plan. You
will be notified in advance when the open enrollment period is to begin and how long it will last. If you
decline coverage for yourself or your dependents at the time you are initially eligible for coverage, you
will be able to enroll yourself and/or eligible dependents during the Open Enrollment Period. Your
coverage will be subject to the pre-e.:tisting condition limitation.
EMPLOYEE ELIGIBILITY
You are eligible for coverage if the following conditions are met:
1. You are an eligible employee as defined in the Personnel Policy Manual or City Ordinance.
Temporary, seasonal, or part-time employees are not eligible for health benefits; or
2. You are an elected or appointed official; and
3. You are in active status.
Your eligibility date is yourdate of hire.
EMPLOYEE EFFECTIVE DATE OF COVERAGE
You must enroll in a manner acceptable to the Plan Manager.
1. If your completed enrollment is received by the Plan Manager before your eligibility date or
within 31 days after your eligibility date, your coverage is effective on your eligibility date.
2. If your completed enrollment is received by the Plan Manager more than 31 days after your
eligibility date, you are a late applicant and your coverage will be subject to the pre-e.:tisting
condition (medical) limitation as defined within the Definitions section of this booklet. Coverage
will be effective immediately following receipt of yourcompleted enrollment.
EMPLOYEE DELAYED EFFECTIVE DATE
If the employee is not in active status on the effective date of coverage, coverage will be effective the day
the employee returns to active status. The employer must notify the Plan Manager in writing of the
employee'sreturn to active status.
32
ASOCOJ08
Eligibility and Effective Date of Coverage Continued
DEPENDENT ELIGIBILITY
Each dependentis eligible for coverage on:
1. The date the employee is eligible for coverage, if he or she has dependents who may be covered on
that date; or
2. The date of the employee'smarriage for any dependent acquired on that date; or
3. The date of birth of the employee's natural-born child; or
4. The date a child is placed for adoption under the employee's legal guardianship, or the date which
the employee incurs a legal obligation for total or partial support in anticipation of adoption; or
5. The date a covered employee 'schild is determined to be eligible as an alternate recipient under the
terms of a medical child support order.
The covered employee may cover dependents only if the employee is also covered. Check with your
employer immediately on how to enroll for dependent coverage. Late enrollment will result in your
dependents' coverage being subject to the pre-existing condition (medical) limitation as defined within the
Definitions section of this booklet.
No person may be simultaneously covered as both an employee and a dependent. If both parents are
eligible for coverage, only one may enroll for dependent coverage.
DEPENDENT EFFECTIVE DATE OF COVERAGE
If the employee wishes to add a newborn dependent to the Plan and a change in the employee's level of
coverage is not required, enrollment must be completed and submitted to the Plan Manager.
The newborn dependentwill be covered on the date he or she is eligible.
If the employee wishes to add a dependent (other than a newborn) to the Plan, the dependent's effective
date of coverage is deternlined as follows:
1. If the completed enrollment is received by the Plan Manager before the dependent's eligibility
date or within 31 days after the dependent's eligibility date, that dependentis covered on the date
he or she is eligible.
2. If the completed enrollment is received by the Plan Manager more than 31 days after the
dependent's eligibility date, the dependent is a late applicant. The dependent's coverage will be
subject to the pre-existing condition (medical) limitation as defined within the Definitions section
of this booklet. Coverage will be effective the first of the month following receipt of the
dependent's completed enrollment.
No dependent's effective date will be prior to the covered employee's effective date of coverage. A
dependent child who becomes eligible for other group coverage through any employment is no longer
eligible for coverage under this Plan. If your dependent child becomes an eligible employee of the
employer, he or she is no longer eligible as your dependent and must make application as an eligible
employee.
33
4_ ,.
ASOCOJ08
Eligibility and Effective Date of Coverage Continued
MEDICAL CHILD SUPPORT ORDERS
An individual who is a child of a covered employee shall be enrolled for coverage under the Plan in
accordance with the direction of a Qualified Medical Child Support Order (QMCSO) or a National
Medical Support Notice (NMSN).
A QMCSO is a state court order or judgment, including approval of a settlement agreement that: (a)
provides for support of a covered employee's child; (b) provides for health care coverage for that child; (c)
is made under state domestic relations law (including a community property law); (d) relates to benefits
under the Plan; and (e) is "qualified" in that it meets the technical requirements of ERISA or applicable
state law. QMCSO also means a state court order or judgment that enforces a state Medicaid law
regarding medical child support required by Social Security Act ~ 1908 (as added by Omnibus Budget
Reconciliation Act of 1993).
An NMSN is a notice issued by an appropriate agency of a state or local government that is similar to a
QMCSO that requires coverage under the Plan for the dependent child of a non-custodial parent who is (or
will become) a covered person by a domestic relations order that provides for health care coverage.
Procedures for determining the qualified status of medical child support orders are available at no cost
upon request from the Plan Administrator.
PRE-EXISTING CONDITION LIMITATION
Benefits for pre-existing conditions are limited under the Plan. Pre-existing condition is defined in the
Definitions section of this booklet.
Once you or your dependents obtain health plan coverage, you are entitled to use evidence of that coverage
to reduce or eliminate any pre-existing condition limitation period that might otherwise be imposed when
you become covered under a subsequent health plan. Evidence may include a certificate of prior
creditable coverage The length of any pre-existing condition limitation period under the subsequent
health plan must be reduced by the number of days of creditable coverage
Prior to imposing a pre-e.:'(isting condition limitation, the Plan Manager will:
1. Notify you in writing of the existence and ternlS of any pre-e"lCisting condition limitation;
2. Notify you of yow'right to request a certificate of creditable coverage from any applicable prior
plans;
3. Notify you of your right to submit evidence of creditable coverageto the Plan Managerto reduce
the length of any pre-e"lCisting condition limitation; and
4. Offer to request a certificate of prior creditable coverage on yourbehalf.
34
'"
ASOCOJ08
Eligibility and Effective Date of Coverage Continued
If, after receiving evidence of creditable coverage, the Plan Manager determines the creditable coverage
is not sufficient to completely offset the Plan's pre-existing condition limitation period, the Plan Manager
will:
1. Notify you in writing of its determination;
2. Notify you ofthe source and substance of any information on which it relied; and
3. Provide an explanation of appeal procedures and allow a reasonable opportunity to submit
additional evidence of creditable coverage
The Plan Manager may modify an initial determination of creditable coverage if it determines the
individual did not have the claimed creditable coverage, provided the Plan Manager.
1. Notifies you of such reconsideration in writing disclosing its determination;
2. Notifies you with the source and substance of any information on which it relied; and
3. Provides an explanation of appeal procedures and allows a reasonable opportunity to submit
additional evidence of creditable coverage
Alternate means of providing evidence of creditable coverage may include an explanation of benefits,
correspondence from a plan, pay stubs showing a payroll deduction of premium for health plan coverage,
third party statements verifying period(s) of coverage, information obtained by telephone, and any other
relevant document providing evidence ofperiod(s) of health coverage.
SPECIAL PROVISIONS FOR NOT BEING IN ACTIVE STATUS
If your employer continues to pay required contributions and does not ternlinate the Plan, your coverage
will remain in force for:
1. No longer than the end of the calendar month during part-time status;
2. No longer than the end of the calendar month during an approved leave of absence;
3. No longer than the end of 18 months or the duration of an approved military leave of absence,
whichever is shorter;
4. No longer than the end of the calendar month of a layoff;
5. No longer than the end of the calendar month during a period of total disability.
35
i ..
ASOCOJ08
Eligibility and Effective Date of Coverage Continued
REINSTATEMENT OF COVERAGE FOLLOWING INACTIVE STATUS
If your coverage tmder the Plan was terminated after a period oflayoff, total disability, approved leave of
absence, approved military leave of absence (other than USERRA) or during part-time status, and you are
now returning to work, your coverage is effective immediately on the day you return to work, subject to
any pre-e.;'(isting condition limitation. The eligibility period requirement and will be waived with respect
to the reinstatement of your coverage.
If your coverage under the Plan was terminated due to a period of service in the uniformed services
covered under the Unifonned Services Employment and Reemployment Rights Act of 1994, your
coverage is effective immediately on the day you return to work. Eligibility waiting periods and pre-
e.x:isting condition limitations will be imposed only to the extent they were applicable prior to the period of
service in the uniformed services.
F AMIL Y AND MEDICAL LEAVE ACT (FMLA)
If you are granted a leave of absence (Leave) by the employer as required by the Federal Family and
Medical Leave Act, you may continue to be covered under the Plan for the duration of the Leave under the
same conditions as other employees who are in active status and covered by the Plan. If you choose to
terminate coverage during the Leave, or if coverage terminates as a result of nonpayment of any required
contribution, coverage may be reinstated on the date you return to active status immediately following the
end of the Leave. Charges incurred after the date of reinstatement will be paid as if you had been
continuously covered.
RETIREE COVERAGE
If you are an early retiree under age 65 with at least 20 years of continuous service, you may continue
coverage under the Plan with retiree benefits for you and any of your eligible dependents until you turn
age 65, provided such coverage was effective at the time of your retirement. Please see your employer for
more details.
SURVIVORSHIP COVERAGE
If the employee dies while covered under the Plan, the surviving spouse and any eligible dependents may
continue coverage under the Plan as per federal, state stature, or city ordinance. Any dependents acquired
through the remarriage of the employee's surviving spouse will not be eligible for coverage under the
Plan.
36
..
ASOCOJ08
Eligibility and Effective Date of Coverage Continued
SPECIAL ENROLLMENT
If you previously declined coverage under this Plan for yourse(f or any eligible dependents, due to the
existence of other health coverage (including COBRA), and that coverage is now lost, this Plan permits
you, your dependent spouse, and any eligible dependents to be enrolled for medical and dental benefits
under this Plan due to any ofthe following qualifying events:
1. Loss of eligibility for the coverage due to any of the following:
a. Legal separation;
b. Divorce;
c. Cessation of dependent status (such as attaining the limiting age);
d. Death;
e. Termination of employment;
f. Reduction in the number of hours of employment;
g. Any loss of eligibility after a period that is measured by reference to any of the foregoing.
h. Meeting or exceeding a lifetime limit on all benefits;
1. Plan no longer offering benefits to a class of similarly situated individuals, which includes
the employee.
However, loss of eligibility does not include a loss due to failure of the individual or the
participant to pay premiums on a timely basis or termination of coverage for cause (such as
making a fraudulent claim or an intentional misrepresentation of a material fact in connection
with the plan).
2. Employer contributions towards the other coverage have been terminated. Employer
contributions include contributions by any current or former employer (of the individual or
another person) that was contributing to coverage for the individual.
3. COBRA coverage under the other plan has since been exhausted.
The previously listed qualifying events apply only if you stated in writing at the previous enrollment the
other health coverage was the reason for declining enrollment, but only if your employer requires a written
waiver of coverage which includes a warning of the penalties imposed on late enrollees.
If you are a covered employee or an otherwise eligible employe~ who either did not enroll or did not enroll
dependents when eligible, you now have the opportunity to enroll yourselfand/or any previously eligible
dependents or any newly acquired dependents when due to any of the following family status changes:
1. Marriage;
2. Birth; or
3. Adoption or placement for adoption.
37
i 'f,'
ASOCOJ08
Eligibility and Effective Date of Coverage Continued
You may elect coverage under this Plan provided enrollment is within 31 days from the qualifying event.
You MUST provide proof that the qualifying event has occurred due to one of the reasons listed before
coverage under this Plan will be effective. Coverage under this Plan will be effective the date
immediately following the date of the qualifying event, unless otherwise specified in this section.
In the case ofa dependent'sbirth, enrollment is effective on the date of such birth.
In the case of a dependent's adoption or placement for adoption, enrollment is effective on the date of such
adoption or placement for adoption.
If you become eligible for coverage under this Plan through the special enrollment provision, benefits
under the Plan will be subject to the pre-existing condition limitation as defined within the Definitions
section of this booklet.
If you apply more than 31 days after a qualifying event, you are considered a late applicant and coverage
will be subject to the pre-e.xisting condition limitation as defined within the Definitions section of this
booklet.
Please see your employer for more details.
38
e: ,
ASOCOJ09
TERMINATION OF COVERAGE
Coverage tenninates on the earliest of the following:
1. The date the Plan tenninates;
2. The end of the period for which any required contribution was due and not paid;
3. The date you enter full-time military, naval or air service, except coverage may continue during an
approved military leave of absence as indicated in the Special Provisions For Not Being in Active
Status provision;
4. The date you fail to be in an eligible class of persons according to the eligibility requirements of
the employer,
5. For all employees, immediately following tennination of employment with your employer,
6. For all employees, immediately following your retirement;
7. For any benefit, the date the benefit is removed from the Plan;
8. For your dependents, the date your coverage terminates;
9. For a dependen~ the date the dependent enters full-time military, naval or air service;
10. For a dependen~ the date such covered person no longer meets the definition of dependent, or
11. The date you request termination of coverage to be effective for yourself and! or your dependents.
IF YOU OR ANY OF YOUR COVERED DEPENDENTS NO LONGER MEET THE ELIGIBILITY
REQUIREMENTS, YOU AND YOUR EMPLOYER ARE RESPONSIBLE FOR NOTIFYING THE PLAN
MANAGER OF THE CHANGE IN STATUS. COVERAGE WILL NOT CONTINUE BEYOND THE
LAST DATE OF ELIGIBILITY EVEN IF NOTICE HAS NOT BEEN GIVEN TO THE PLAN
MANAGER
39
_ t
ASOCOJ 11
IMPORTANT NOTICE FOR EMPLOYEES AND SPOUSES AGE 65 AND
OVER
Federal law may affect your coverage under this Plan. The Medicare as Secondary Payer rules were
enacted by an amendment to the Social Security Act. Also, additional rules which specifically affect how
a large group health plan provides coverage to employees (or their spouses) over age 65 were added to the
Social Security Act and to the Internal Revenue Code.
Generally, the health care plan of an employer that has at least 20 employees must operate in compliance
with these ndes in providing plan coverage to plan participants who have "current employment status" and
are Medicare beneficiaries, age 65 and over.
Persons who have "cunent employment status" with an employer are generally employees who are
actively working and also persons who are NOT actively working as follows:
· Individuals receiving disability benefits from an employer for up to 6 months, or
· Individuals who retain employment rights and have not been terminated by the employer and for
whom the employer continues to provide coverage under this Plan. (For example, employees who are
on an approved leave of absence.)
If you are a person having "current employment status" who is age 65 and over (or the dependent spouse
age 65 and over of an employee of any age), your coverage under this Plan will be provided on the same
terms and conditions as are applicable to employees (or dependent spouses) who are under the age of 65.
Your rights under this Plan do not change because you (or your dependent spouse) are eligible for
Medicare coverage on the basis of age, as long as you have "current employment status" with your
employel:
You have the option to reject plan coverage offered by your employer, as does any eligible employee. If
you reject coverage under your employer's Plan, coverage is terminated and your employer is not
permitted to offer you coverage that supplements Medicarecovered services.
If you (or your dependent spouse) obtain Medicare coverage on the basis of age, and not due to disability
or end-stage renal disease, this Plan will consider its coverage to be primary to Medicare when you have
elected coverage under this Plan and have "current employment status".
If you have any questions about how coverage under this Plan relates to Medicarecoverage, please contact
your employer.
40
~, ~
ASOC0J12
CONTINUATION OF MEDICAL AND DENTAL BENEFITS
THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1986 (COBRA)
CONTINUATION OF BENEFITS
On April 7, 1986, the Consolidated Omnibus Budget Reconciliation Act (COBRA) was signed into law.
This federal law applies to employers with 20 or more employees. The law requires that employers offer
employees and/or their dependents continuation of medical and dental coverage at group rates in certain
instances where there is a loss of group insurance coverage.
ELIGIBILITY
A qualified beneficiary under COBRA law means an employee, employee's spouse or dependent child
covered by the Plan on the day before a qualifying event. A qualified beneficiary under COBRA law also
includes a child born to the employee during the coverage period or a child placed for adoption with the
employee during the coverage period.
EMPLOYEE: An employee covered by the employer's Plan has the right to elect continuation coverage
if coverage is lost due to one of the following qualifying events:
. Termination (for reasons other than gross misconduct, as defined by your employer) of the employee's
employment or reduction in the hours of employee 's employment; or
. Termination of retiree coverage when the former employer discontinues retiree coverage within one
year before or one year after filing for Chapter 11 bankruptcy.
SPOUSE: A spouse covered by the employer's Plan has the right to elect continuation coverage if the
group coverage is lost due to one of the following qualifying events:
. The death of the employee,
. Termination of the employee's employment (for reasons other than gross misconduct, as defined by
your employer) or reduction ofthe employee's hours of employment with the employer,
. Divorce or legal separation from the employee,
. The employee becomes entitled to Medicarebenefits; or
. Termination of a retiree spouse's coverage when the former employer discontinues retiree coverage
within one year before or one year after filing for Chapter 11 bankruptcy.
DEPENDENT CHILD: A dependent child covered by the employer's Plan has the right to continuation
coverage if group coverage is lost due to one of the following qualifying events:
. The death of the employee parent;
. The ternlination of the employee parent's employment (for reasons other than gross misconduct, as
defined by your employer) or reduction in the employee parent's hours of employment with the
employer,
. The employeeparent's divorce or legal separation;
. Ceasing to be a " dependent child" under the Plan;
. The employee parent becomes entitled to Medicarebenefits; or
. Termination of the retiree parent's coverage when the former employer discontinues retiree coverage
within one year before or one year after filing for Chapter 11 bankruptcy.
41
-i ~
ASOC0J12
COBRA Continued
LOSS OF COVERAGE
Coverage is lost in connection with the foregoing qualified events, when a covered employee, spouse or
dependent child ceases to be covered under the same Plan terms and conditions as in effect immediately
before the qualifying event (such as an increase in the premium or contribution that must be paid for
employee, spouse or dependent child coverage).
If coverage is reduced or eliminated in anticipation of an event (for example, an employer eliminating an
employee's coverage in anticipation of the termination of th-e employee's employment, or an employee
eliminating the coverage of the employee's spouse in anticipation of a divorce or legal separation), the
reduction or elimination is disregarded in determining whether the event causes a loss of coverage.
A loss of coverage need not occur immediately after the event, so long as it occurs before the end of the
Maximum Coverage Period.
NOTICES AND ELECTION
The Plan provides that coverage terminates, for a spouse due to legal separation or divorce or for a child
when that child loses dependent status. Under the law, the employee or qualified beneficiary has the
responsibility to inform the Plan Administrator (see Plan Description Information) if one of the above
events has occurred. The qualified beneficiary must give this notice within 60 days after the event occurs.
(For example, an ex-spouse should make sure that the Plan Administrator is notified of his or her divorce,
whether or not his or her coverage was reduced or eliminated in anticipation of the event). When the Plan
Administrator is notified that one of these events has happened, it is the Plan Administrator's
responsibility to notify the Plan Manager who has contracted with a COBRA Service Provider who will in
turn notify the qualified beneficiary of the right to elect continuation coverage.
For a qualified beneficiary who is determined under the Social Security Act to be disabled at any time
during the first 60 days of COBRA coverage, the continuation coverage period may be extended 11
additional months. The disability that extends the I8-month coverage period must be determined under
Title II (Old Age, Survivors, and Disability Insurance) or Title XVI (Supplemental Security Income) of
the Social Security Act. To be entitled to the extended coverage period, the disabled qualified beneficiary
must provide notice to the COBRA Service Provider within the initial 18 month coverage period and
within 60 days after the date of the determination of disability under the Social Security Act. Failure to
provide this notice will result in the loss of the right to extend the COBRA continuation period.
For termination of employment, reduction in work hours, the death of the employee, the employee
becoming covered by Medicare or loss of retiree benefits due to bankruptcy, it is the Plan Administrator's
responsibility to notify the Plan Managerwho has contracted with a COBRA Service Provider who will in
turn notify the qualified beneficiary of the right to elect continuation coverage.
Under the law, continuation coverage must be elected within 60 days after Plan coverage ends, or if later,
60 days after the date of the notice of the right to elect continuation coverage. If continuation coverage is
not elected within the 60 day period, the right to elect coverage under the Plan will end.
A covered employee or the spouse of the covered employee may elect continuation coverage for all
covered dependents, even if the covered employee or spouse of the covered emplo,vee or all covered
dependents are covered under another group health plan (as an employee or otherwise) prior to the
election. The covered employee, his or her spouse and dependent child, however, each have an
independent right to elect continuation coverage. Thus a spouse or dependent child may elect
continuation coverage even if the covered employee does not elect it.
42
\o:!'.'
..
ASOC0J12
COBRA Continued
Coverage will not be provided during the election period. However, if the individual makes a timely
election, covemge will be provided from the date that coverage would otherwise have been lost. If
covemge is waived before the end of the 60 day election period and the waiver revoked before the end of
the 60 day election period, covemge will be effective on the date the election of coverage is sent to the
COBRA Service Provider.
On August 6, 2002, The Tmde Act of2002 (TAA), was signed in to law. Workers whose employment is
adversely affected by international tmde (increased import or shift in production to another country) may
become eligible to receive TAA. TAA provides a second 60-day COBRA election period for those who
become eligible for assistance under T AA. Pursuant to the Tmde Act of 1974, an individual who is either
an eligible TAA recipient or an eligible alternative TAA recipient and who did not elect continuation
covemge during the 60-day COBRA election period that was a direct consequence of the TAA-related loss
of coverage, may elect continuation covemge during a 60-day period that begins on the first day of the
month in which he or she is determined to be TAA-eligible individual, provided such election is made not
later than 6 months after the date of the T AA-related loss of covemge. Any continuation coverage elected
during the second election period will begin with the first day of the second election period and not on the
date on which coverage originally lapsed.
T AA created a new tax credit for certain individuals who became eligible for tmde adjustment assistance
(eligible individuals). Under the new tax provisions, eligible individuals can either take a tax credit or get
advance payment of 65% of premiums paid for qualified health insurance, including continuation
coverage. If you have questions about these new tax provisions, you may call the Health Care Tax Credit
Customer Contact Center toll-free at 1-866-628-4282. TTDtTTY callers may call toll-free at
1-866-626-4282.
The Plan Administmtor shall require documentation evidencing eligibility of T AA benefits. The Plan
need not require every available document to establish evidence ofTAA. The burden for evidencing TAA
eligibility is that of the individual applying for covemge under the Plan.
MAXIMUM COVERAGE PERIOD
Coverage may continue up to:
. 18 months for an employee and! or dependent whose group coverage ended due to termination of the
employee'semployment or reduction in hours of employment;
. 36 months for a spouse whose coverage ended due to the death of the employee or retiree, divorce, or
the employee becoming entitled to Medicareat the time of the initial qualifying event;
. 36 months for a dependent child whose covemge ended due to the divorce of the employee parent, the
employee becoming entitled to Medicare at the time of the initial qualifying event, the death of the
employee, or the child ceasing to be a dependent under the Plan;
. For the retiree, until the date of death of the retiree who is on continuation. due to loss of coverage
within one year before or one year after the employer filed Chapter 11 bankruptcy.
43
'"
~
ASOC0J12
COBRA Continued
DISABILITY
An II-month extension of coverage may be available if any of the qualified beneficiaries are detemlined
by the Social Security Administration (SSA) to be disabled. The disability has to have started at some
time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-
month period of continuation coverage. The qualified beneficiary must provide notice of such
determination prior to the end of the initial 18-month continuation period to be entitled to the additional
11 months of coverage. Each qualified beneficiary who has elected continuation coverage will be entitled
to the II-month disability extension if one of them qualifies. If a qualified beneficiary is determined by
SSA to no longer be disabled, you must notify the Plan of that fact within 30 days after SSA's
determination.
SECOND QUALIFYING EVENT
An 18-month extension of coverage will be available to spouses and dependent children who elect
continuation coverage if a second qualifying event occurs during the first 18 months of continuation
coverage. The maximum amount of continuation coverage available when a second qualifying event
occurs is 36 months. Such second qualifying event may include the death of a covered employee, divorce
or separation from the covered employee, the covered employee's becoming entitled to Medicare benefits
(under Part A, Part B, or both), or a dependent child's ceasing to be eligible for coverage as a dependent
under the Plan. These events can be a second qualifying event only if they would have caused the
qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. You
must notify the Plan within 60 days after the second qualifying event occurs if you want to extend your
continuation coverage.
TERMINATION BEFORE THE END OF MAXIMUM COVERAGE PERIOD
Continuation coverage will terminate before the end of the maximum coverage period for any of the
following reasons:
· The employerno longer provides group health coverage to any of its employees;
· The premium for continuation is not paid timely;
· The individual on continuation becomes covered under another group health plan (as an employee or
otherwise); however, if the new plan coverage contains any exclusion or limitation with respect to any
pre-existing condition, then continuation coverage will end for this reason only after the exclusion or
limitation no longer applies or prior creditable coverage satisfies the exclusion or limitation;
NOTE: the federal Health Insurance Portability and Accountability Act of 1996 requires portability of
health care coverage effective for plan years beginning after June 30, 1997, an exclusion or limitation
under the other group health plan may not apply at all to the qualified beneficiary, depending on the
length of his or her prior creditable coverage. Portability means once you obtain health insurance, you
will be able to use evidence of that insurance to reduce or eliminate any pre-existing medical
condition limitation period (under certain circumstances) when you move from one health plan to
another.
44
ASOC0J12
COBRA Continued
. The individual on continuation becomes entitled to Medicare benefits;
. If there is a final determination under Title II or XVI of the Social Security Act that an individual is no
longer disabled; however, continuation coverage will not end until the month that begins more than 30
days after the determination;
· The occurrence of any event (e.g. submission of a fraudulent claim) permitting termination of
coverage for cause under the Plan.
TYPE OF COVERAGE; PREMIUM PAYMENT
If continuation coverage is elected, the coverage must be identical to the coverage provided under the
employer's Plan to similarly situated non-COBRA beneficiaries. This means that if the coverage for
similarly situated non-COBRA beneficiaries is modified, coverage for the individual on continuation will
be modified.
The initial premium payment for continuation coverage is due by the 45th day after coverage is elected.
The initial premium includes charges back to the date the continuation coverage began. All other
premiums are due on the first of the month for which the premium is paid, subject to a 31 day grace
period. The COBRA Service Provider must provide the individual with a quote of the total monthly
premmm.
Premium for continuation coverage may be increased, however, the premium may not be increased more
than once in any determination period. The determination period is a 12 month period which is
established by the Plan.
The monthly premium payment to the Plan for continuing coverage must be submitted directly to the
COBRA Service Provider. This monthly premium may include the employee's share and any portion
previously paid by the emploYe!: The monthly premium must be a reasonable estimate of the cost of
providing coverage under the Plan for similarly situated non-COBRA beneficiaries. The premium for
COBRA continuation coverage may include a 2% administration charge. However, for qualified
beneficiaries who are receiving up to 11 months additional coverage (beyond the first 18 months) due to
disability extension (and not a second qualifying event), the premium for COBRA continuation coverage
may be up to 150% of the applicable premium for the additional months. Qualified beneficiaries who do
not take the additional 11 months of special coverage will pay up to 102% of the premium cost.
OTHER INFORMATION
Additional information regarding rights and obligations under the Plan and under federal law may be
obtained by contacting the COBRA Service Provider or the Plan Manager.
It is important for the covered person or qualified beneficiary to keep the Plan Administrator, COBRA
Service Provider and Plan Manger informed of any changes in marital status, or a change of address.
45
COBRA Continued
PLAN CONTACT INFORMATION
Ceridian COBRA Continuation Services
3201 34th Street South
St. Petersburg, FL 33711-3828
1-800-488-8757
Humana Insurance Company
Billing/Enrollment Department
101 E. Main Street
Louisville, KY 40201
Toll Free: 1-800-872-7207
HumanaDental Insurance Company
P.O. Box 14209
Lexington, KY 40512-4209
1-800-232-2006
46
~
ASOCOJ 12
"
ASOC0J12
THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT
RIGHTS ACT OF 1994 (USERRA)
CONTINUATION OF BENEFITS
Effective October 13, 1994 federal law requires that health plans must offer to continue coverage for
employees who are absent due to service in the uniformed services and! or their dependents. Coverage may
continue for up to 18 or 24 months after the date the employee is first absent due to uniformed service.
ELIGIBILITY
An employee is eligible for continuation under USERRA if absent from employment because of voluntary
or involuntary performance of duty in the Armed Forces, Army National Guard, Air National Guard, or
the commissioned corps of the Public Health Service, or any other category of persons designated by the
President of the United States of America in a time of war or national emergency. Duty includes absence
for active duty, active duty for training, initial active duty for training, inactive duty training, full-time
National Guard duty, and for the purpose of an examination to determine fitness for duty.
An employee's dependents who have coverage under the Plan immediately prior to the date of the
employee'scovered absence are eligible to elect continuation under USERRA.
PREMIUM PAYMENT
If continuation of Plan coverage is elected under USERRA, the employee or dependent is responsible for
payment of the applicable cost of coverage. If the employee is absent for less than 31 days, the cost will
be the amount the employee would otherwise pay for coverage. For absences longer than 30 days, the cost
may be up to 102% of the cost of coverage under the Plan. This includes the employee's share and any
portion previously paid by the employer.
DURA TION OF COVERAGE
Elected continuation coverage under USERRA will continue until the earlier of:
. 18 months beginning the first day of absence from employment due to service in the uniformed
services for elections made prior to 12/10104; or
. 24 months beginning the first day of absence from employment due to service in the uniformed
services for elections beginning on or after 12/10104; or
. The day after the employee fails to apply for or return to employment as required by USERRA, after
completion of a period of service.
Under federal law, the period of coverage available under USERRA shall run concurrently with the
COBRA period available to an employeeandlor eligible dependents.
OTHER INFORMATION
Employees should contact their employer with any questions regarding coverage normally available
during a military leave of absence or continuation coverage and notify the employer of any changes in
marital status, or a change of address.
47
jC
ASOC0J13
COORDINATION OF BENEFITS
BENEFITS SUBJECT TO THIS PROVISION
Benefits described in this Plan are coordinated with benefits provided by other plans under which you are
also covered. (Note: The Prescription Drug benefit is not subject to these coordination provisions). This
is to prevent duplication of coverage and a resulting increase in the cost of medical or dental coverage.
For this purpose, a plan is one which covers medical or dental expenses and provides benefits or services
by group, franchise or blanket insurance coverage. This includes group-type contracts not available to the
general public, obtained and maintained only because of the covered person's membership in or
connection with a particular organization or group, whether or not designated as franchise, blanket, or in
some other fashion. Plan also includes any coverage provided through the following:
1. Employer, trustee, union, employee benefit, or other association; or
2. Governmental programs, programs mandated by state statute, or sponsored or provided by an
educational institution.
This Coordination of Benefits provision does not apply to any individual policies or Blanket Student
Accident Insurance provided by or through an educational institution. Allowable expense means any
eligible expense, a portion of which is covered under one of the plans covering the person for whom claim
is made. Each plan will determine what is an allowable expense according to the provisions of the
respective plan. When a plan provides benefits in the fornl of services rather than cash payments, the
reasonable cash value of each service rendered will be deemed to be both an allowable expense and a
benefit paid.
EFFECT ON BENEFITS
One of the plans involved will pay benefits first. This is called the primary plan. All other plans are called
secondary plans.
When this Plan is the secondary plan, the sum of the benefit payable will not exceed 100% of the total
allowable expenses incurred under the Plan and any other plans included under this provision.
ORDER OF BENEFIT DETERMINATION
In order to pay claims, it must be determined which plan is primary and which planes) are secondary. A
plan will pay benefits first ifit meets one of the following conditions:
1. The plan has no coordination of benefits provision;
2. The plan covers the person as an employee;
3. For a child who is covered under both parents' plans, the plan covering the parent whose birthday
(month and day) occurs first in the calendar yeai'pays before the plan covering the other parent.
If the birthdates of both parents are the same, the Plan which has covered the person for the longer
period oftime will be determined the primary plan;
If a plan other than this Plan does not include provision 3, then the gender rule will be followed to
determine which plan is primary.
48
,i
ASOC0J13
Coordination of Benefits Continued
4. In the case of dependent children covered under the plans of divorced or separated parents, the
following rules apply:
a. The plan of a parent who has custody will pay the benefits first;
b. The plan of a step-parent who has custody will pay benefits next;
c. The plan of a parent who does not have custody will pay benefits next;
d. The plan of a step-parent who does not have custody will pay benefits next.
There may be a court decree which gives one parent financial responsibility for the medical or dental
expenses of the dependent children. If there is a court decree, the rules stated above will not apply if they
conflict with the court decree. Instead, the plan of the parent with financial responsibility will pay benefits
first.
5. If a person is laid off or is retired or is a dependent of such person, that plan covers after the plan
covering such person as an active employee or dependent of such employee. If the other plan does
not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule will
be ignored.
If the above rules do not apply or cannot be determined, then the plan that covered the person for the
longest period of time will pay first.
COORDINATION OF BENEFITS WITH MEDICARE
When an employer employs 100 or more persons, the benefits of the Plan will be payable first for a
covered person who is under age 65 and eligible for Medicare. The benefits of Medicare will be payable
second.
MEDICARE PART A means the Social Security program that provides hospital insurance benefits.
MEDICARE PART B means the Social Security program that provides medical insurance benefits.
For the purposes of determining benefits payable for any covered person who is eligible to enroll for
Medicare Part B, but does not, the Plan Manager assumes the amount payable under Medicare Part B to
be the amount the covered person would have received if he or she enrolled for it. A covered person is
considered to be eligible for Medicare on the earliest date coverage under Medicare could become
effective for him or her.
OPTIONS
Federal Law allows the Plan's actively working covered employees age 65 or older and their covered
spouses who are eligible for Medicareto choose one ofthe following options:
OPTION 1 - The benefits of the Plan will be payable first and the benefits of Medicare will be payable
second.
49
t:( /!l
ASOCOJl4
Reimbursement/Subrogation Continued
DUTY TO COOPERATE IN GOOD FAITH
You are obliged to cooperate with the Plan Manager in order to protect the Plan's recovery rights.
Cooperation includes promptly notifying the Plan Managerthat you may have a claim, providing the Plan
Manager relevant information, and signing and delivering such documents as the Plan Manager
reasonably request to secure the Plan's recovery rights. You agree to obtain the Plan's consent before
releasing any party from liability for payment of medical or dental expenses. You agree to provide the
Plan Manager with a copy of any summons, complaint or any other process serviced in any lawsuit in
which you seek to recover compensation for your bodily injury or sickness and its treatment.
You will do whatever is necessary to enable the Plan Manager to enforce the Plan's recovery rights and
will do nothing after loss to prejudice the Plan's recovery rights.
You agree that you will not attempt to avoid the Plan's recovery rights by designating all (or any
disproportionate part) of any recovery as exclusively for pain and suffering.
Failure of the covered person to provide the Plan Manager such notice or cooperation, or any action by
the covered person resulting in prejudice to the Plan's rights will be a material breach of this Plan and will
result in the covered person being personally responsible to make repayment. In such an event, the Plan
may deduct from any pending or subsequent claim made under this Plan any amotmts the covered person
owes the Plan until such time as cooperation is provided and the prejudice ceases.
52
'!'; .;..,
ASOC0J70
GENERAL PROVISIONS
The following provisions are to protect your legal rights and the legal rights of the Plan.
INCONTESTABILITY
After you are covered under this Plan without interruption for two years, the Plan cannot contest the
validity of your coverage except for:
1. Nonpayment of premium;
2. Your ineligibility under the' Plan;
3. Any Plan provision;
4. Any fraudulent misrepresentation made by yoU; or
5. Any defenses the Plan may have by law.
An independent incontestability period begins for each type of change in coverage or when the Plan
requires a new employee enrollment form.
This provision only limits the Plan's rights to void your coverage after you have been covered without
interruption for two years.
RIGHT TO REQUEST OVERPAYMENTS
The Plan reserves the right to recover any payments made by the Plan that were:
1. Made in error; or
2. Made to you or any party on your behalf where the Plan determines the payment to you or any
party is greater than the amount payable under this Plan.
The Plan has the right to recover against you if the Plan has paid you or any other party on your behalf.
WORKERS' COMPENSATION NOT AFFECTED
The Plan is not issued in lieu of, nor does it affect any requirement for coverage by any Workers'
Compensation or Occupational Disease Act or Law.
53
... ,~
Asocono
General Provisions Continued
WORKERS' COMPENSATION
Ifbenefits are paid by the Plan and the Plan determines you received Workers' Compensation for the same
incident, the Plan has the right to recover as described under the Reimbursement/Subrogation provision.
The Plan will exercise its right to recover against you even though:
1. The Workers' Compensation benefits are in dispute or are made by means of settlement or
compromise;
2. No final determination is made that bodi(v injwyor sickness was sustained in the course of or
resulted from your employment;
3. The amount of Workers' Compensation due to medical or health care is not agreed upon or
defined by you or the Workers' Compensation carrier;
4. The medical or health care benefits are specifically excluded from the Workers' Compensation
settlement or compromise.
You hereby agree that, in consideration for the coverage provided by the Plan, you will notify the Plan
Manager of any Workers' Compensation claim you make, and that you agree to reimburse the Plan as
described above.
MEDICAID
This Plan will not take into account the fact that an employee or dependent is eligible for medical
assistance or Medicaid under state law with respect to enrollment, determining eligibility for benefits, or
paying claims.
If payment for Medicaid benefits has been made under a state Medicaid plan for which payment would
otherwise be due under this Plan, payment of benefits under this Plan will be made in accordance with a
state law which provides that the state has acquired the rights with respect to a covered employee to the
benefits payment.
CONSTRUCTION OF PLAN TERMS
The Plan Manager has the sole right to construe and prescribe the meaning, scope and application of each
and all of the terms of the Plan, including, without limitation, the benefits provided thereunder, the
obligations of the beneficiary and the recovery rights of the Plan; such construction and prescription by
the Plan Manager shall be final and uncontestable.
PRIVACY OF PROTECTED HEAL TH INFORMATION
The Plan is required by law to maintain the privacy of your protected health iJiformation in all forms
including written, oral and electronically maintained, stored and transmitted information and to provide
individuals with notice of the Plan's legal duties and privacy practices with respect to protected health
information.
54
" ,'"
ASOC0J70
General Provisions Continued
The Plan has policies and procedures specifically designed to protect your health information when it is in
electronic format. This includes administrative, physical and technical safeguards to ensure that your
health information cannot be inappropriately accessed while it is stored and transmitted to the Plan
Managerand others that support the Plan.
In order for the Plan to operate, it may be necessary from time to time for health care professionals, the
Plan Administrator, individuals who perform Plan-related functions under the auspices of the Plan
Administrator, the Plan Managerand other service providers that have been engaged to assist the Plan in
discharging its obligations with respect to delivery of benefits, to have access to what is referred to as
protected health information.
A covered person will be deemed to have consented to use of protected health information about him or
her by virtue of enrollment in the Plan. Any individual who may not have intended to provide this
consent and who does not so consent must contact the Plan Administrator prior to filing any claim for
Plan benefits, as coverage under the Plan is contingent upon consent.
Individually identifiable health information will only be used or disclosed for purposes of Plan operation
or benefits delivery. In that regard, only the minimum necessary disclosure will be allowed. The Plan
Administrator, Plan Manager, and other entities given access to protected health information, as
permitted by applicable law, will safeguard protected health information to ensure that the information is
not improperly disclosed.
Disclosure of protected health information is improper if it is not allowed by law or if it is made for any
purpose other than Plan operation or benefits delivery. Disclosure for Plan purposes to persons authorized
to receive protected health information may be proper, so long as the disclosure is allowed by law and
appropriate under the circumstances. Improper disclosure includes disclosure to the employer for
employment purposes, employee representatives, consultants, attorneys, relatives, etc. who have not
executed appropriate agreements effective to authorize such disclosure.
The Plan Manager will afford access to protected health information in its possession only as necessary
to discharge its obligations as a service provider, within the restrictions noted above. However, Plan
records that include protected health information are the property of the Plan. Information received by the
Plan Manager is information received on behalf ofthe Plan.
The Plan Managerwill afford access to protected health information as reasonably directed in writing by
the Plan Administrator, which shall only be made with due regard for confidentiality. In that regard, the
Plan Manager has been directed that disclosure of protected health information may be made to the
person(s) designated by the Plan Administrator.
Individuals who have access to protected health information in connection with their performance of
Plan-related functions under the auspices of the Plan Administrator will be trained in these privacy
policies and relevant procedures prior to being granted any access to protected health information. The
Plan Managerand other Plan service providers will be required to safeguard protected health information
against improper disclosure through contractual arrangements.
55
~@"" ~
ASOC0J70
General Provisions Continued
In addition, you should know that the employer I Plan Sponsor may legally have access, on an as-needed
basis, to limited health information for the purpose of determining Plan costs, contributions, Plan design,
and whether Plan modifications are warranted. In addition, federal regulators such as the Department of
Health and Human Services and the Department of Labor may legally require access to protected health
inforrnationto police federal legal requirements about privacy.
Covered persons may have access to protected health information about them that is in the possession of
the Plan, and they may make changes to correct errors. Covered persons are also entitled to an accounting
of all disclosures that may be made by any person who acquires access to protected health information
conceming them and uses it other than for Plan operation or benefits delivery. In this regard, please
contact the Plan Administrator.
Covered persons are urged to contact the originating health care professional with respect to medical or
dental information that may have been acquired from them, as those items of information are relevant to
medical care and treatment. And finally, covered persons may consent to disclosure of protected health
information, as they please.
56
.~ '--:f
ASOC0J71
CLAIMS PROCEDURES
SUBMITTING A CLAIM
This section describes what a covered person (or his or her authorized representative) must do to file a
claim for Plan benefits.
. A claim must be filed with the Plan Manager in writing and delivered to the Plan Manager, by mail,
postage prepaid. However, a submission to obtain pre-authorization may also be filed with the Plan
Manager by telephone (this applies to dental Plans only with respect to urgent care claims).
. Claims must be submitted to the Plan Manager at the address indicated in the documents describing
the Plan or claimant's identification card. Claims will not be deemed submitted for purposes ofthese
procedures unless and until received at the correct address.
. Also, claims submissions must be in a format acceptable to the Plan Managerand compliant with any
applicable legal requirements. Claims that are not submitted in accordance with the requirements of
applicable federal law respecting privacy of protected health or dental information and/or electronic
claims standards will not be accepted by the Plan.
. Claims submissions must be timely. Claims must be filed as soon as reasonably possible after they
are incurred, and in no event later than 6 months after the date of loss, except if you were legally
incapacitated. Plan benefits are only available for claims that are incurred by a covered person during
the period that he or she is covered under the Plan.
. Claims submissions must be complete. They must contain, at a minimum:
a. The name ofthe covered person who incurred the covered expense,
b. The name and address of the health or dental care provider;
c. The diagnosis of the condition;
d. The procedure or nature of the treatment;
e. The date of and place where the procedure or treatment has been or will be provided;
f. The amount billed and the amount of the covered expense not paid through coverage other
than Plan coverage, as appropriate;
g. Evidence that substantiates the nature, amount, and timeliness of each covered expense in a
format that is acceptable according to industry standards and in compliance with applicable
law.
Presentation of a prescription to a pharmacy does not constitute a claim. If a covered person is required to
pay the cost of a covered prescription drug, however, he or she may submit a claim based on that amount
to the Plan Manager.
A general request for an interpretation of Plan provisions will not be considered to be a claim. Requests of
this type, such as a request for an interpretation of the eligibility provisions of the Plan, should be directed
to the Plan Administrator.
57
.-' I-
ASOC0J71
Claims Procedures Continued
Medical claims, correspondence should be mailed to:
Humana Claims Office
P.O. Box 14610
Lexington, KY 40512-4610
DENTAL
Dental claims and correspondence should be mailed to:
HumanaDental Claims Office
P.O. Box 14611
Lexington, Kentucky 40512-4611
MISCELLANEOUS MEDICAL CHARGES
If you accumulate bills for medical items you purchase or rent yourself, send them to the Plan Manager at
least once every three months during the year (quarterly). The receipts must include the patient name,
name of item, date item purchased or rented and name of the provider of service.
PROCEDURAL DEFECTS
If a pre-service claim submission is not made in accordance with the Plan's procedural requirements, the
Plan ManagerwiII notify the claimant of the procedural deficiency and how it may be cured no later than
within five (5) days (or within 24 hours, in the case of an urgent care claim) following the failure. A post-
service claim that is not submitted in accordance with these claims procedures will be returned to the
submitter.
ASSIGNMENTS AND REPRESENTATIVES
A covered person may assign his or her right to receive Plan benefits to a health or dental care provider
only with the consent of the Plan Manager, in its sole discretion, except as may be required by applicable
law. Assignments must be in writing. If a doclIDlent is not sufficient to constitute an assignment, as
determined by the Plan Manager, then the Plan will not consider an assignment to have been made. An
assignment is not binding on the Plan until the Plan Manager receives and acknowledges in writing the
original or copy of the assignment before payment of the benefit.
If benefits are assigned in accordance with the foregoing paragraph and a health or dental care provider
submits claims on behalf of a covered pen5011, benefits will be paid to that health or dental care provider.
58
"'<e-
ASOC0J71
Claims Procedures Continued
In addition, a covered person may designate an authorized representative to act on his or her behalf in
pursuing a benefit claim or appeal. The designation must be explicitly stated in writing and it must
authorize disclosure of Protected Health Information with respect to the claim by the Plan, the Plan
Manager and the authorized representative to one another. If a document is not sufficient to constitute a
designation of an authorized representative, as determined by the Plan Manager, then the Plan will not
consider a designation to have been made. An assignment of benefits does not constitute designation of
an authorized representative.
. Any document designating an authorized representative must be submitted to the Plan Manager in
advance, or at the time an authorized representative commences a course of action on behalf of a
claimant At the same time, the authorized representative should also provide notice of
commencement of the action on behalf ofthe claimant to the claiman~ which the Plan Manager may
verify with the claimant prior to recognizing the authorized representative status.
· In any event, a health or dental care provider with knowledge of a claimant's medical or dental
condition acting in connection with an urgent care claim will be recognized by the Plan as the
claimant's authorized representative.
Covered persons should carefully consider whether to designate an authorized representative. An
authorized representative may make decisions independent of the covered person, such as whether and
how to appeal a claim denial.
CLAIMS DECISIONS
After submission of a claim by a claiman~ the Plan Managerwill notify the claimant within a reasonable
time, as follows:
PRE-SERVICE CLAIMS
The Plan Manager will notify the claimant of a favorable or adverse determination within a reasonable
time appropriate to the medical or dental circumstances, but no later than 15 days after receipt of the claim
by the Plan.
However, this period may be extended by an additional 15 days, ifthe Plan Manager determines that the
extension is necessary due to matters beyond the control of the Plan. The Plan Manager will notify the
affected claimant of the extension before the end of the initial 15-day period, the circumstances requiring
the extension, and the date by which the Plan expects to make a decision.
If the reason for the extension is because of the claimant's failure to submit information necessary to
decide the claim, the notice of extension will describe the required information. The claimantwill have at
least 45 days from the date the notice is received to provide the specified information.
59
.' f:
ASOC0J71
Claims Procedures Continued
URGENT CARE CLAIMS
The Plan Manager will detennine whether a claim is an urgent care claim This determination will be
made on the basis of information furnished by or on behalf of a claimant In making this determination,
the Plan Manager will exercise its judgment, with deference to the judgment of a physician with
knowledge of the claimant'scondition. Accordingly, the Plan Managermay require a claimant to clarify
the medical or dental urgency and circumstances that support the urgent care claim for expedited
decision-making.
The Plan Manager will notify the claimant of a favorable or adverse determination as soon as possible,
taking into account the medical or dental exigencies particular to the claimant's situation, but not later
than 72 hours after receipt of the urgent care claim by the Plan.
However, if a claim is submitted that does not provide sufficient information to deternline whether, or to
what extent, expenses are covered or payable under the Plan, notice will be provided by the Plan Manager
as soon as possible, but not more than 24 hours after receipt of the urgent care claim by the Plan. The
notice will describe the specific infonnation necessary to complete the claim.
· The claimant will have a reasonable amount of time, taking into account his or her circumstances, to
provide the necessary information but not less than 48 hours.
· The Plan 1l1anagerwill notify the claimant of the Plan's urgent care claim determination as soon as
possible, but in no event more than 48 hours after the earlier of:
a. The Plan's receipt of the specified infonnation; or
b. The end of the period afforded the claimant to provide the specified additional infornlation.
CONCURRENT CARE DECISIONS
The Plan Manager will notify a claimant of a concurrent care decision that involves a reduction in or
termination of benefits that have been pre-authorized. The Plan Manager will provide the notice
sufficiently in advance of the reduction or tennination to allow the claimant to appeal and obtain a
deternlination on review of the adverse determination before the benefit is reduced or terminated.
A request by a claimant to extend a course of treatment beyond the period of time or number of treatments
that is a claim involving urgent care will be decided by the Plan Manageras soon as possible, taking into
account the medical or dental exigencies. The Plan Manager will notify a claimant of the benefit
determination, whether adverse or not within 24 hours after receipt of the claim by the Plan, provided that
the claim is submitted to the Plan at least 24 hours prior to the expiration of the prescribed period of time
or mmlber of treatments.
POST-SERVICE CLAIMS
The Plan Manager will notify the claimant of a favorable or adverse determination within a reasonable
time, but not later than 30 days after receipt of the claim by the Plan.
60
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ASOC0J71
Claims Procedures Continued
However, this period may be extended by an additional 15 days, if the Plan Manager determines that the
extension is necessary due to matters beyond the control of the Plan. The Plan Manager will notify the
affected claimant of the extension before the end of the initial 30-day period, the circumstances requiring
the extension, and the date by which the Plan expects to make a decision.
If the reason for the extension is because of the claimant's failure to submit information necessary to
decide the claim, the notice of extension will describe the required information. The claimantwill have at
least 45 days from the date the notice is received to provide the specified information. The Plan Manager
will make a decision no later than 15 days after the earlier of the date on which the information provided
by the claimant is received by the Plan or the expiration of the time allowed for submission of the
additional information.
TIMES FOR DECISIONS
The periods of time for claims decisions presented above begin when a claim is received by the Plan, in
accordance with these claims procedures.
PAYMENT OF CLAIMS
Many health care providers will request an assignment of benefits as a matter of convenience to both
provider and patient. Also as a matter of convenience, the Plan Manager will, in its sole discretion,
assume that an assignment of benefits has been made to certain Network Providers. In those instances, the
Plan Manager will make direct payment to the hospita~ clinic, dentist, or physician's office, unless the
Plan Manager is advised in writing that you have already paid the bill. If you have paid the bill, please
indicate on the original statement, "paid by employee," and send it directly to the Plan Manager. You will
receive a written explanation of the benefit determination. The Plan Managerreserves the right to request
any information required to determine benefits or process a claim. You or the provider of services will be
contacted if additional information is needed to process your claim.
When an employee's child is subject to a medical child support order, the Plan Manager will make
reimbursement of eligible expenses paid by you, the child, the child's non-employee custodial parent, or
legal guardian, to that child or the child's custodial parent, or legal guardian, or as provided in the medical
child support order.
Payment of benefits under this Plan will be made in accordance with an assignment of rights for you and
your dependents as required under state Medicaid law.
Benefits payable on behalf of you or your covered dependent after death will be paid, at the Plan's option,
to any family member(s) or your estate. The Plan Manager will rely upon an affidavit to determine
benefit payment, unless it receives written notice of valid claim before payment is made. The affidavit
will release the Plan from further liability.
Any payment made by the Plan Manager in good faith will fully discharge it to the extent of such
payment.
Payments due under the Plan will be paid upon receipt of written proof of loss.
61
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ASOC0J71
Claims Procedures Continued
INITIAL DENIAL NOTICES
Notice of a claim denial (including a partial denial) will be provided to claimants by mail, postage
prepaid, or bye-mail, as appropriate, within the time frames noted above.
However, notices of adverse decisions involving urgent care claims may be provided to a claimant orally
within the time frames noted above for expedited urgent care claim decisions. If oral notice is given,
written notification will be provided to the claimant no later than 3 days after the oral notification.
A claims denial notice will state the specific reason or reasons for the adverse determination, the specific
Plan provisions on which the determination is based, and a description of the Plan's review procedures
and associated timeline. The notice will also include a description of any additional material or
information necessary for the claimant to perfect the claim and an explanation of why such material or
information is necessary.
The notice will describe the Plan's review procedures and the time limits applicable to such procedures,
including a statement of the claimant's right to bring a civil action under ERISA Section 502(a) following
an adverse benefit determination on review.
The notice will also disclose any internal Plan rule, protocol or similar criterion that was relied on to deny
the claim. A copy of the rule, protocol or similar criterion relied upon will be provided to a claimant free
of charge upon request.
If the adverse determination is based on medical necessity, dental necessity, experimental, investigational
or for research purposes, or similar exclusion or limit, the notice will provide either an explanation of the
scientific or clinical judgment for the determination, applying the ternlS of the Plan to the claimant's
medical or dental circumstances, or a statement that such explanation will be provided free of charge upon
request.
In the case of an adverse decision of an urgent care claim, the notice will provide a description of the
Plan's expedited review procedures applicable to such claims.
APPEALS OF ADVERSE DETERMINATIONS
A claimant must appeal an adverse determination within 180 days after receiving written notice of the
denial (or partial denial). With the exception of urgent care claims and concurrent care decisions, the
Plan uses a two level appeals process for all adverse deternlinations. The Plan Manager will make the
determination on the first level of appeal. If the claimant is dissatisfied with the decision on this first level
of appeal, or if the Plan Manager fails to make a decision within the time frame indicated below, the
claimant may appeal again to the Plan Manage!: Urgent care claims and concurrent care decisions are
subject to a single level appeal process only, with the Plan Manager making the detennination.
62
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ASOC0J71
Claims Procedures Continued
A first level appeal must be made by a claimant by means of written application, in person, or by mail
(postage prepaid), addressed to:
For Medical Claims:
Humana G&A
P.O. Box 14610
Lexington, KY 40512-4610
For Dental Claims:
HumanaDental Claims Office
P.O. Box 14611
Lexington, KY 40512-4611
A second level appeal must be made by a claimant by means of written application, in person, or by mail
(postage prepaid), addressed to:
For Medical Claims:
Humana G&A
P.O. Box 14610
Lexington, KY 40512-4610
For Dental Claims:
HumanaDental Claims Office
P.O. Box 14611
Lexington, K Y 40512-4611
Appeals of denied claims will be conducted promptly, will not deferto the initial determination, and will
not be made by the person who made the initial adverse claim determination or a subordinate of that
person. The determination will take into account all comments, documents, records, and other information
submitted by the claimant relating to the claim.
A claimant may review relevant documents and may submit issues and comments in writing. A claimant
on appeal may, upon request, discover the identity of medical or vocational experts whose advice was
obtained on behalf of the Plan in connection with the adverse determination being appealed, as permitted
under applicable law.
If the claims denial being appealed is based in whole, or in part, upon a medical or dental judgment,
including determinations with regard to whether a particular treatment, drug, or other item is
experimental, investigational, or for research purposes, or not medically necessary or appropriate, the
person deciding the appeal will consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical or dental judgment. The consulting health care
professional will not be the same person who decided the initial appeal or a subordinate ofthat person.
Time Periods for Decisions on Appeal -- First Level
Appeals of claims denials will be decided and notice of the decision provided as follows:
Concurrent Care Decisions
As soon as possible, but not later than 72 hours after the Plan
Manager receives the appeal request. (If oral notification is given,
written notification will follow in hard copy or electronic format
within the next 3 da s .
Within a reasonable period, but not later than 15 days after the Plan
Mana erreceives the a eal re uest.
Within a reasonable period but no later than 30 days after the Plan
Mana erreceives the a eal re uest.
Within the time periods specified above, depending upon the type of
claim involved.
Urgent Care Claims
Pre-Service Claims
Post-Service Claims
63
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ASOC0J71
Claims Procedures Continued
Time Periods for Decisions on Appeal -- Second Level
Appeals of claims denials will be decided and notice of the decision provided as follows:
Pre-Service Claims
Within a reasonable period, but not later than 15 days after the Plan
Mana erreceives the a eal re uest.
Within a reasonable period but no later than 30 days after the Plan
Mana erreceives the a eal re uest.
Post-Service Claims
APPEAL DENIAL NOTICES
Notice of a benefit determination on appeal will be provided to claimants by mail, postage prepaid, or by
e-mail, as appropriate, within the time frames noted above.
A notice that a claim appeal has been denied will convey the specific reason or reasons for the adverse
detemlination and the specific plan provisions on which the detennination is based.
The notice will also disclose any intemal Plan rule, protocol or similar criterion that was relied on to deny
the claim. A copy of the rule, protocol or similar criterion relied upon will be provided to a claimant free
of charge upon request.
If the adverse detennination is based on a medical or dental necessity or experimental, investigational, or
for research pwposes or similar exclusion or limit, the notice will provide either an explanation of the
scientific or clinical judgment for the detemlination, applying the terms of the Plan to the claimant's
medical circumstances, or a statement that such explanation will be provided free of charge upon request.
In the event of a denial of an appealed claim, the claimant on appeal will be entitled to receive, upon
request and without charge, reasonable access to and copies of any document, record or other information:
1. Relied on in making the detennination.
2. Submitted, considered or generated in the course of making the benefit determination.
3. That demonstrates compliance with the administrative processes and safeguards required with
respect to such determinations.
4. That constitutes a statement of policy or guidance with respect to the Plan concerning the denied
treatment, without regard to whether the statement was relied on.
RIGHT TO REQUIRE MEDICAL EXAMINATIONS
(Applies only to medical Plans)
The Plan has the right to require that a medical examination be performed on any claimant for whom a
claim is pending as often as may be reasonably required. If the Plan requires a medical examination, it
will be performed at the Plan's expense. The Plan also has a right to request an autopsy in the case of
death, if state law so allows.
64
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ASOC0J71
Claims Procedures Continued
EXHAUSTION
Upon completion of the appeals process under this section, a claimant will have exhausted his or her
administrative remedies under the Plan. If the Plan Manager fails to complete a claim determination or
appeal within the time limits set forth above, the claimant may treat the claim or appeal as having been
denied, and the claimant may proceed to the next level in the review process. After exhaustion, a claimant
may pursue any other legal remedies available to him or her which may include bringing a civil action.
Additional information may be available from a local U.S. Department of Labor Office.
LEGAL,ACTIONS AND LIMITATIONS
No action at law or inequity may be brought with respect to Plan benefits until all remedies under the Plan
have been exhausted and then prior to the expiration of the applicable limitations period under applicable
law.
65
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ASOCOJ72
DEFINITIONS
Active status means performing on a regular, full-time basis all customary occupational duties, for: 30
hours per week, at the employer's business locations or when required to travel for the employer's
business purposes. Each day of a regular paid vacation and any regular non-working holiday will be
deemed active status if you were in an active status on your last regular working day prior to the vacation
or holiday.
Alternative medicine means an approach to medical diagnosis, treatment or therapy that has been
developed or practiced NOT using the generally accepted scientific methods in the United States of
America. For purposes of this definition, alternative medicine shall include, but is not limited to:
acupressure, acupuncture, aroma therapy, ayurveda, biofeedback, faith healing, guided mental imagery,
herbal medicine, holistic medicine, homeopathy, hypnosis, macrobiotics, naturopathy, ozone therapy,
reflexotherapy, relaxation response, rolfing, shiatsu and yoga.
Beneficiary means you and your covered dependent(s), or legal representative of either, and anyone to
whom the rights of you or your covered dependent(s} may pass.
Bodily injury means injury due directly to an accident and independent of all other causes. Muscle strain
due to athletic or physical activity is considered a sickness.
Calendar year means a period of time beginning on January 1 and ending on December 31.
Case management means the process of assessing whether an alternative plan of care would more
effectively provide medically necessary health care services in an appropriate setting.
Claimant means a covered person (or authorized representative) who files a claim.
COBRA Service Provider means a provider of COBRA administrative services retained by the Plan
Managerto provide specific COBRA administrative services.
Complications of pregnancy means:
1. Conditions whose diagnoses are distinct from pregnancy but adversely affected by pregnancy or
caused by pregnancy. Such conditions include: acute nephritis, nephrosis, cardiac
decompensation, hyperemesis gravidarum, puerperal infection, toxemia, eclampsia and missed
abortion;
2. A nonelective cesarean section surgical procedure;
3. Terminated ectopic pregnancy; or
4. Spontaneous termination of pregnancy which occurs during a period of gestation in which a viable
birth is not possible.
66
1<
ASOC0J72
Definitions Continued
Complications of pregnancy does not mean:
1. False labor;
2. Occasional spotting;
3. Prescribed rest during the period of pregnancy;
4. Conditions associated with the management of a difficult pregnancy but which do not constitute
distinct complications of pregnancy; or
5. An elective cesarean section.
Concurrent care decision means a decision by the Plan to reduce or terminate benefits otherwise payable
for a course of treatment that has been approved by the Plan (other than by Plan amendment or
termination) or a decision with respect to a request by a claimant to extend a course of treatment beyond
the period of time or number of treatments that has been approved by the Plan.
Concurrent review means the process of assessing the continuing medical necessity, appropriateness, or
utility of additional days of hospital confinemen~ outpatient care, and other health care services.
Confinement means being a resident patient in a hospital or a qualified treatment facility for at least 15
consecutive hours per day. Successive confinements are considered one confinement if:
1. Due to the same bodily injury or sickness, and
2. Separated by fewer than 30 consecutive days when you are not confined.
Copaymentmeans the amount to be paid by you for each applicable medical service.
Cosmetic surgery means surgery performed to reshape structures of the body in order to change your
appearance or improve self-esteem.
Covered expense means services incurred by you or your covered dependents due to bodily injwy or
sickness for which benefits may be available under the Plan. Covered expenses are subject to all
provisions of the Plan, including the limitations and exclusions.
Covered person means the employee or any of the employee's covered dependents.
Creditable coverage means the total time of prior continuous health plan coverage periods used to reduce
the length of any pre-existing condition limitation period applicable to you or your dependents under this
Plan where these prior continuous health coverage(s) existed with no more than a 63-consecutive day
lapse in coverage.
Custodial care means services provided to assist in the activities of daily living which are not likely to
improve your condition. Examples include, but are not limited to, assistance with dressing, bathing,
toileting, transferring, eating, walking and taking medication. These services are considered custodial
care regardless if a qualified practitioner or provider has prescribed, recommended or performed the
services.
67
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~
ASOC0J72
Definitions Continued
Dental injury is an injury caused by a sudden, violent, and external force that could not be predicted in
advance and could not be avoided. Dental injwy does not include chewing injuries.
Dependentmeans a covered employee's:
1. Legally recognized spouse;
2. Unmarried natural blood related child, step-child, legally adopted child or child placed with the
employee for adoption, or child for which the employee has legal guardianship whose age is less
than the limiting age. Each child must legally qualify as a dependent as defined by the United
States Internal Revenue Service and be declared on and legally qualify as a dependent on the
employee 's federal personal income tax retum filed for each year of coverage.
The limiting age for each dependentchild is:
to the end of the month of his/her 23rd birthday; or
to the end of the month of his/her 25th birthday, if such child is in regular full-time
attendance at an accredited secondary school, college or university. The dependent child
must be enrolled for sufficient course credits to maintain full-time status as defined by
that school. A dependent child continues to be eligible for coverage for up to four months
following the close of a school term only if enrolled as a full-time student for the
following school term.
a.
b.
Adopted children and children placed for adoption are subject to all terms and provisions of the
Plan, with the exception of the pre-existing condition (medical) limitation.
3. A covered employee's child whose age is less than the limiting age and is entitled to coverage
under the provisions of this Plan because of a medical child support order;
You must furnish satisfactory proof to the Plan Manager upon request that the above conditions
continuously exist. If satisfactory proof is not submitted to the Plan Manager, the child's coverage will
not continue beyond the last date of eligibility.
A covered dependent child who attains the limiting age while covered under the Plan will remain eligible
for benefits if all of the following exist at the same time:
I. Mentally retarded or permanently physically handicapped;
2. Incapable of self-sustaining employment;
3. The child meets all of the qualifications of a dependent as determined by the United States
Internal Revenue Service;
4. Declared on and legally qualify as a dependent on the employee's federal personal income tax
return filed for each year of coverage; and
5. Unmarried.
68
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ASOC0J72
Definition Dependent Continued
You must furnish satisfactory proof to the Plan Managerthat the above conditions continuously exist on
and after the date the limiting age is reached. The Plan Manager may not request such proof more often
than annually after two years from the date the first proof was furnished. If satisfactory proof is not
submitted to the Plan Manager, the child's coverage will not continue beyond the last date of eligibility.
Durable medical equipment (DME) means equipment that is medically necessary and able to withstand
repeated use. It must also be primarily and customarily used to serve a medical purpose and not be
generally useful to a person except for the treatment of a bodily injury or sickness.
Emergency means an acute, sudden onset of a sickness or bodily injury which is life threatening or will
significantly worsen without immediate medical or surgical treatment.
Employee means you, as an employee, when you are permanently employed and paid a salary or earnings
and are in an active status at your employer's place of business .
Employermeans the sponsor of the Group Plan or any subsidiary(s).
Expense incurred means the fee charged for services provided to you. The date a service is provided is
the expense incurred date.
Experimental, investigational or for research purposes:
A service is experimental, investigational or for research purposes if the Plan Manager determines;
1. The service cannot be lawfully marketed without approval of the U.S. Food and Drug
Administration and approval for marketing has not been given at the time the service is furnished;
or
2. The service or your informed consent document utilized with the service was reviewed and
approved by the treating facility's Institutional Review Board or other body serving a similar
function, or if federal law requires such review and approval; or .
3. Reliable evidence shows that the service is the subject of on-going phase I or phase II clinical
trials; is the research, experimental, study or investigational arm of ongoing phase III clinical
trials; or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety,
its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis; or
4. Reliable evidence shows that the prevailing opinion among experts regarding the service is that
further studies or clinical trials are necessary to determine its maximum tolerated dose, its
toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or
diagnosis.
5. Reliable evidence will mean only published reports and articles in the authoritative medical and
scientific literature; the written protocol or protocols used by the treating facility or the protocol(s)
of another facility studying substantially the same service, or the written informed consent used
by the treating facility or by another facility studying substantially the same service.
Family member means you or your spouse, or you or your spouse's child, brother, sister, parent,
grandchild or grandparent.
69
;!~. l'
ASOC0J72
Definitions Continued
Free-standing surgical facility means a public or private establishment licensed to perform surgery and
which has permanent facilities that are equipped and operated primarily for the purpose of performing
surgery. It does not provide services or accommodations for patients to stay overnight.
Hospitalmeans an institution which:
1. Maintains permanent full-time facilities for bed care of resident patients;
2. Has a physician and surgeon in regular attendance;
3. Provides continuous 24 hour a day nursing services;
4. Is primarily engaged in providing diagnostic and therapeutic facilities for medical or surgical care
of sick or injured persons;
5. Is legally operated in the jurisdiction where located; and
6. Has surgical facilities on its premises or has a contractual agreement for surgical services with an
institution having a valid license to provide such surgical services; or
7. Is a lawfully operated qualified treatment facility certified by the First Church of Christ Scientist,
Boston, Massachusetts.
Hospital does not include an institution which is principally a rest home, skilled nursing facility,
convalescent home or home for the aged. Hospital does not include a place principally for the treatment of
alcoholism, chemical dependence or mental disorders.
Late applicant means an employee and/or an employee's eligible dependent who applies for medical and
dental coverage more than 31 days after the eligibility date.
Maintenance care means any service or activity which seeks to prevent bodi(v injury or sickness, prolong
life, promote health or prevent deterioration of a covered person who has reached the maximum level of
improvement or whose condition is resolved or stable.
Maximum allowablefeefor a service means the lesser of:
1. The fee most often charged in the geographical area where the service was perfornled;
2. The fee most often charged by the provider;
3. The fee which is recognized as reasonable by a prudent person;
4. The fee determined by comparing charges for similar services to a national data base adjusted to
the geographical area where the services or procedures were performed; or
70
!) ~
ASOC0J72
Definitions Continued
5. The fee determined by using a national relative value scale. Relative value scale means a
methodology that values medical procedures and services relative to each other that includes, but is not
limited to, a scale in terms of difficulty, work, risk, as well as the material and outside costs of providing
the service., as adjusted to the geographic area where the services or procedures were performed.
Maximum bel1efitmeans the maximum amount that may be payable for each covered person, for expense
incurred The applicable maximum benefit is shown on the Schedule of Benefits. No further benefits are
payable once the maximum benefit is reached.
Medically necessary or medical necessity means the extent of services required to diagnose or treat a
bodily injury or sickness which is known to be safe and effective by the majority of qualified practitioners
who are licensed to diagnose or treat that bodily injury or sickness. Such services must be:
1. Performed in the least costly setting required by your condition;
2. Not provided primarily for the convenience ofthe patient or the qualified practitioner,
3. Appropriate for and consistent with your symptoms or diagnosis of the sickness or bodily injury
under treatment;
4. Furnished for an appropriate duration and frequency in accordance with accepted medical
practices, and which are appropriate for your symptoms, diagnosis, sickness or bodily injury, and
5. Substantiated by the records and documentation maintained by the provider of service.
Medicaremeans Title XVIII, Parts A and B of the Social Security Act, as enacted or amended.
Mental disorder means a mental, nervous, or emotional disease or disorder of any type as classified in the
Diagnostic and Statistical Manual of Mental Disorders, regardless of the cause or causes of the disease or
disorder.
Morbid obesity means a body mass index (BMI) of 40 kilograms per mass squared or 100 pounds or more
over your ideal weight as determined by the Metropolitan Life Height and Weight Tables for Men and
Women, as of the date of service.
Orthotic means a custom-fitted or custom-made braces, splints, casts, supports and other devices used to
support, align, prevent, or correct deformities or to improve the function of movable parts of the body
when prescribed by a qualified practitioner.
71
;I'" r
ASOCOJ72
Definitions Continued
Partial h08pitalization means those services offered by a program:
1. Must be medically necessary, and
2. Not custodial care, and
3. Not day-care; and
4. Accredited by the Joint Commission on the Accreditation of Hospitals or in compliance with
equivalent standards.
Licensed dmg abuse rehabilitation programs and alcohol rehabilitation programs accredited by the Joint
Commission on the Accreditation of Health Care Organizations or approved by the appropriate state
agency are also considered to be partial hospitalization services.
Plan Manager means Humana Insurance Company (HIC) and HumanaDental Insurance Company
(HDIC). The Plan Manager provides services to the Plan Administrator, as defined under the Plan
Management Agreement. The Plan Manageris not the Plan Administrator or the Plan Sponsor.
Plan year means a period of time beginning on the Plan anniversary date of any year and ending on the
day before the same date of the succeeding year.
P08t-8erl'ice claim means any claim for a benefit under a group health or dental plan that is not a pre-
service claim
Preadmission testing means only those outpatient x-ray and laboratory tests made within seven days
before admission as a registered bed patient in a hospital The tests must be for the same bodily i11juryor
sickness causing the patient to be hospital confined. The tests must be accepted by the hospital in lieu of
like tests made during confinement Preadmission testing does not mean tests for a routine physical
check-up.
Precertification means the process of assessing the medical necessity, appropriateness, or utility of
proposed non-emergency hospital admissions, surgical procedures, outpatient care, and other health care
services.
Predetermination of benefits means a review by the Plan Manager of a qual~fied practitioner's treatment
plan, specific diagnostic and procedure codes and expected charges prior to the rendering of services.
Pre-exi8ting condition (dental) applies to orthodontic services only. There will be no coverage available
for orthodontic services if bands were placed prior to your effective date of coverage.
Pre-exi8ting condition (medical) means a physical or mental condition for which you have received
medical attention (medical attention includes, but is not limited to: services or care) during the six month
period immediately prior to the enrollment date of your medical coverage under the Plan. Pre-e.xisting
conditions are covered after the end of a period of twelve months after the enrollment date (first day of
coverage or, if there is a waiting period, the first day of the waiting period).
Pre-existing condition limitations will be waived or reduced for pre-existing conditions that were satisfied
under previous creditable coverage
72
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~~
ASOC0J72
Definitions Continued
Pre-sen1ice claim means a claim with respect to which the terms of the Plan condition receipt of a Plan
benefit, in whole or in part, on approval of the benefit by the Plan Manager in advance of obtaining
medical or dental care.
Protected health information means individually identifiable health information about a covered person,
including: (a) patient records, which includes but is not limited to all health records, dentis~ physician and
provider notes and bills and claims with respect to a covered person; (b) patient information, which
includes patient records and all written and oral information received about a covered person; and (c) any
other individually identifiable health information about covered persons.
Qualified practitioner means a practitioner, professionally licensed by the appropriate state agency to
diagnose or treat a bodily injury or sicA:ness, and who provides services within the scope of that license.
Qualified treatmeltt facility means only a facility, institution or clinic duly licensed by the appropriate
state agency, and is primarily established and operating within the scope of its license.
Services mean procedures, surgeries, examinations, consultations, advice, diagnosis, referrals, treatment,
tests, supplies, drugs, devices or technologies.
Sickness means a disturbance in function or structure of your body which causes physical signs or
symptoms and which, if left untreated, will result in a deterioration of the health state of the structure or
system(s) of yourbody.
Sound natural tooth means a tooth that:
1. Is organic and formed by the natural development ofthe body (not manufactured);
2. Has not been extensively restored;
3. Has not become extensively decayed or involved in periodontal disease; and
4. Is not more susceptible to injury than a whole natural tooth.
Surgery means excision or incision of the skin or mucosal tissues, or insertion for exploratory purposes
into a natural body opening. This includes insertion of instruments into any body opening, natural or
otherwise, done for diagnostic or other therapeutic purposes.
Timely applicant means an employee and/or an employee's eligible dependent who applies for medical
and dental coverage within 31 days of the eligibility date.
73
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f
ASOC0J72
Definitions Continued
Total disability or totally disabled means:
1. During the first twelve months of disability you or your employed covered spouse are at all times
prevented by bodily injwy or siclmess from performing each and every material duty of your
respective job or occupation;
2. After the first twelve months, total disability or totally disabled means that you or your employed
covered spouse are at all times prevented by bodily injury or sickness from engaging in any job or
occupation for wage or profit for which you or your employed covered spouse are reasonably
qualified by education, training or experience;
3. For a non-employed spouse or a child, total disability or totally disabled means the inability to
perform the normal activities of a person of similar age and gender.
A total~v disabledperson also may not engage in any job or occupation for wage or profit.
Urgent care claim means a claim for medical or dental care or treatment with respect to which the
application of the time periods for making non-urgent care detemlinations:
1. Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain
maximum function; or
2. In the opinion of a physician or dentist with knowledge of the claimant's medical or dental
condition, would subject the claimant to severe pain that cannot be adequately managed without
the care or treatment that is the subject of the claim.
3. Generally, whether a claim is a claim involving urgent care will be detennined by the Plan
Manage1: However, any claim that a physician with know ledge of a claimant's medical or dental
condition determines is a "claim involving urgent care" will be treated as a "claim involving
urgent care."
Utilization review means the process of assessing the medical necessity, appropriateness, or utility of
hospital admissions, surgical procedures, outpatient care, and other health care services. Utilization
review includes precertification and concurrent review.
You andyourmeans you as the employee and any of yourcovered dependents, unless otherwise indicated.
74
~ '.--11;
ASOC0J74
PRESCRIPTION DRUG BENEFIT
DEFINITIONS
Copayment (prescription drug) means the amount to be paid by you toward the cost of each separate
prescription or refill of a covered prescription drug when dispensed by a pharmacy.
Dispensing limit means the monthly drug dosage limit and/or the number of months the drug usage is
needed to treat a particular condition.
Drug List means a list of prescription drugs, medicines, medications and supplies, specified by the Plan
Manager. This list identifies drugs as Levell, Level 2, Level 3 and Level 4 and indicates applicable
dispensing limits and/or any prior authorization requirements. This list is subject to change.
Legend drug means any medicinal substance the label of which, under the Federal Food, Drug and
Cosmetic Act, is required to bear the legend: Caution: Federal Law Prohibits dispensing without
prescription
Level 1 drugs means a category of prescription drugs, medicines or medications within the Plan
Manager's drug list that are designated by the Plan Manager as Levell drugs.
Level 2 drugs means a category of prescription drugs, medicines or medications within the Plan
Manager's drug list that are designated by the Plan Manageras Level 2 drugs.
Level 3 drugs means a category of prescription drugs, medicines or medications within the Plan
Manager's drug listthat are designated by the Plan Manageras Level 3 drugs.
Level 4 drugs means a category of prescription drugs, medicines or medications within the Plan
Manager's drug listthat are designated by the Plan Manageras Level 4 drugs.
Mail order pharmacy means a pharmaceutical vendor designated by the Plan Manager who is properly
licensed to dispense and deliver covered prescriptions through the mail.
Non-participating pharmacy means a pharmacy, which has not entered into an agreement with the Plan
Manager or has not been designated by the Plan Managerto provide services to covered persons.
Orphan drug means a drug or biological used for the diagnosis, treatment, or prevention of rare diseases
or conditions, which:
1. Affects less than 200,000 persons in the United States; or
2. Affects more than 200,000 persons in the United States, however, there is no reasonable
expectation that the cost of developing the drug and making it available in the United States will
be recovered from the sales of that drug in the United States.
Participating pharmacy means a pharmacy which has entered into an agreement with or has been
designated by the Plan Managerto provide servicesto covered persons.
75
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ASOC0J74
Prescription Drug Benefit Continued
Pharmacist means a person who is licensed to prepare, compound and dispense medication and who is
practicing within the scope of his or her license.
Pharmacy means a licensed establishment where prescription medications are dispensed by a pharmacist.
Prescription means a direct order for the preparation and use of a drug, medicine or medication. The
dmg, medicine or medication must be obtainable only by prescription. The prescription must be given
verbally, electronically or in writing by a qualified practitioner to a pharmacist for the benefit of and use
by a covered person. The prescription must include:
I. The name and address of the covered person for whom the prescription is intended;
2. The type and quantity of the dmg, 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 quai(fied practitionel:
Prior authorization means the required prior approval from the Plan Manager for the coverage of
prescription dmgs, medicines, medications, including the dosage, quantity and duration, as appropriate for
the covered person's age and sex.
Self-administered injectable drug means an FDA approved medication which a person may administer to
himself/herself by means of intramuscular, intravenous, or subcutaneous injection, and intended for use by
you.
76
);" .-s
ASOC0J74
Prescription Drug Benefit Continued
SCHEDULE OF PRESCRIPTION DRUG BENEFITS
NOTE: Additional drug informatiorI can be obtained by accessing the Plan Manager'swebsite at
www.humana.com.
You are required to pay the applicable copaymentper prescription as follows:
RETAIL PHARMACY
P ARTICIP A TING PHARMACY
Levell Drugs $10 copaymentper prescription.
Level 2 Drugs $20 copaymentper prescription.
Level 3 Drugs $30 copaymentper prescription.
Level 4 Drugs 25% copayment per prescription, up to the
prescription drug out-of-pocket maximum of $2,500
per covered person per calendar year. Level 4 Drugs
will be payable at 100% for the remainder of the
calendar year once the prescription drug out-of-
pocket maximum of$2,500 has been met.
For a 90-day maxImum supply of a Two (2) times the applicable copayment as outlined
maintenance medication received from a retail under the Retail Pharmacy Copayment Structure
pharmacy above.
77
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ASOC0J74
Prescription Drug Benefit Continued
MAIL ORDER PHARMACY
For up to a 90-day supply of a medication received Two (2) times the applicable copayment as
from a mail order pharmacy outlined under the Retail Pharmacy Copayment
Stmcture above.
Mail Order Pharmacy Dmg Maximum Supply 90 days
SPECIAL TY OFFICE MEDICATION AND INJECT ABLE DRUGS PER PRESCRIPTION*
I For up to a 30 day supply I $0 copayment
*Specialty office medication and injectable drugs do not include self-administered injectable drugs.
ADDITIONAL PRESCRIPTION DRUG BENEFIT INFORMATION
If an employee'eligible dependent purchases a brand name medication, and an equivalent generic
medication is available, the employee'eligible dependent must pay the difference between the brand name
medication and the generic medication plus any applicable generic medication copayment. If the
physician indicates on the prescription "dispense as written", the dmg will be dispensed as such, the
employee'eligible dependentwill only be responsible for the brand name medication copayment
Participatin~ Pharmacy
When a participating pharmacy is used and you do not present your I.D. card at the time of purchase, you
must pay the pharmacy the full retail price and submit the pharmacy receipt to Humana at the address
listed below. You will be reimbursed at 100% of billed charges after the charge has been reduced by the
applicable copaymentand 20%.
Non-participating Pharmacy
Prescription Drug Benefit Continued
When a non-participating pharmacy is used, you must pay the pharmacy the full price of the drug and
submit the pharmacy receipt to Humana at the address listed below. You will be responsible for 25% of
the actual charge made by the dispensing pharmacy after this charge has been reduced by the applicable
copayment
Mail pharmacy receipts to:
Humana Claims Office
Attention: Pharmacy Department
P.O. Box 14610
Lexington, KY 40512-4610
78
t""~
ASOC0J74
Prescription Drug Benefit Continued
PRIOR AUTHORIZATION
Some prescription drugs may be subject to prior authorization. To verify if a prescription drug requires
prior authorization, call the toll free customer service phone number on the back of your ID card or visit
the Plan Manager 's website at www.humana.com.
DISPENSING LIMITS
Some prescription drugs may be subject to dispensing limits. To verify if a prescription drug has
dispensing limits, call the toll free customer service phone number on the back of your ID card or visit the
Plan Manager'swebsite at www.humana.com.
RETAIL PHARMACY
Your Plan provisions include a retail prescription drug benefit. You will receive an identification (ID)
card, which includes your name, group number and your effective date.
Present your ID card at a participating pharmacy when purchasing a prescription. Prescriptions dispensed
at a retail pharmacy are limited to a 30 day supply per prescription or refill.
MAIL ORDER PHARMACY
Your prescription drug coverage also includes mail order pharmacy benefits, allowing participants an
easy and convenient way to obtain prescription drugs.
Mail order pharmacy prescriptions will only be filled with the quantity prescribed by your physician and
are limited to a maximum of a:
. 90 day supply per prescription or refill for a drug received from a mail order pharmacy, or
· 30 day supply per prescription or refill for self-administered injectable medications or specialty
office medications and injectables.
Additional mail order pharmacy information can be obtained through your Human Resources Department
or by calling the toll free customer service phone number on the back of your ID card or visit the Plan
Manager 's website at www.humana.com.
SPECIALTY OFFICE MEDICATIONS AND INJECTABLES
Your qualified practitioner has access to specialty office medications and injectables used to treat chronic
conditions. These medications can be ordered specifically for you for administration in his/her office
setting. This allows your physician a cost effective and convenient way to obtain high cost, high tech
specialty medications and injectables. Additional information can be obtained through your Human
Resources Department or by calling the toll-free customer service phone number on the back of your ID
card.
79
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ASOC0J74
Prescription Drug Benefit Continued
PRESCRIPTION DRUG COST SHARING
Prescription drug benefits are payable for covered prescription expenses incurred by you and your
covered dependents. Benefits for expenses made by a pharmacy are payable as shown on the Schedule of
Prescription Drug Benefits.
You are responsible for payment of:
· The drug deductible, if any;
· The copayment;
· The cost of medication not covered under the prescription drug benefit;
· The cost of any quantity of medication dispensed in excess of the day supply noted on the
Schedule of Prescription Drug Benefits.
If the dispensing pharmacy's charge is less than the copaymen~ you will be responsible for the lesser
amount. The amount paid by the Plan Managerto the dispensing pharmacy may not reflect the ultimate
cost to the Plan Manager for the drug. Your copayment is made on a per prescription or refill basis and
will not be adjusted if the Plan Manager or your employerreceives any retrospective volume discounts or
prescription drug rebates.
PRESCRIPTION DRUG COVERAGE
Because Humana's drug /istis continually updated with prescription drugs approved or not approved for
coverage, you must call the toll free customer service phone number on the back of your ID card or visit
the Plan Manager's website at www.humana.com to verify whether a prescription drug is covered or not
covered under the Plan.
Please follow the directions below when accessing the Plan Manager'swebsite:
1. Go to Humana's website (www.humana.com) and log-in as a Registered Member;
2. Click on "Pharmacy Tools, Drug Coverage Search";
3. Type in the name of the drug under step 1 to obtain results from the drug /is~ or
4. Search alphabetically for the drug under step 2; or
5. Search by therapeutic class under step 3; or
6. Search most commonly referenced drugs under step 4.
Covered prescription drugs, medicines or medications must:
1. Be prescribed by a qualified practitioner for the treatment of a sickness or bodily injUly, and
2. Be dispensed by a pharmacist.
80
" ....
ASOC0J74
Prescription Drug Benefit Continued
Prescription drug expenses covered under the Prescription Drug Benefit are not covered under any other
provisions of the Plan. Any amount in excess of the maximum amount provided under the Prescription
Drug Benefit is not covered under any other provision of the Plan.
Any expenses incurred under provisions of the Prescription Drug Benefit section do not apply toward
your medical deductible, out-of-pocket limits or lifetime maximum. Any expenses incurred under the
medical benefits do not apply toward your prescription drug deductible or out-of-pocket limits.
The Plan Managermay decline coverage of a specific medication until the conclusion of a review period
not to exceed six (6) months following FDA approval for the use and release of the drug, medicine or
medication into the market.
PRESCRIPTION DRUG LIMIT A TIONS
Expense incurred will not be payable for the following:
1. Any drug, medicine, medication or supply not approved for coverage under the Plan (call the toll
free customer service phone number on the back of your ID card or visit the Plan Manager's
website at www.humana.com to verify whether a prescription drug is covered or not covered
under the Plan);
2. Legend drugs which are not recommended and not deemed necessary by a qualified practitionel;
3. More than two fills for the same drug or therapeutic equivalent medication prescribed by one or
more qualified practitioners and dispensed by one or more retail pharmacies;
4. Charges for the administration or injection of any drug;
5. Drug delivery implants;
6. Any drug, medicine or medication labeled "Caution-Limited by Federal Law to Investigational
Use," or experimental drug, medicine or medication, even though a charge is made to yoU;
7. Any drug, medicine or medication that is consumed or injected at the place where the prescription
is given, or dispensed by the qualified practitioner,
8. Prescriptions that are to be taken by or administered to the covered person, in whole or in part,
while he or she is a patient in a facility where drugs are ordinarily provided by the facility on an
inpatient basis. Inpatient facilities include, but are not limited to:
a. Hospital;
b. Skilled nursing facility; or
c. Hospice facility;
9. Any drug prescribed for intended use other than for:
a. Indications approved by the FDA; or
b. Recognized off-label indications through peer-reviewed medical literature;
81
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~ !.' ~
ASOC0J74
Prescription Drug Benefit Continued
10. Prescription refills:
a. In excess of the number specified by the qualified practitionel; or
b. Dispensed more than one year from the date of the original order;
11. Any drug for which a charge is customarily not made;
12. Therapeutic devices or appliances, including: hypodermic needles and syringes (except needles
and syringes for use with insulin, and covered self-administered injectable drugs); support
garments; test reagents; mechanical pumps for delivery of medication; and other non-medical
substances, unless otherwise specified by the Plan;
13. Dietary supplements, nutritional products, fluoride supplements, minerals, herbs and vitamins
(except pre-natal vitamins, including greater than one milligram of folic acid, and pediatric multi-
vitamins with fluoride), unless otherwise specified by the Plan;
14. Injectable drugs, including but not limited to: immunizing agents; biological sera; blood; blood
plasma; or self-administered injectable drugs not covered under the Plan;
15. Any drug prescribed for a sickness or bodi(v injwynot covered under this Plan;
16. Any portion of a prescription or refill that exceeds a 30-day supply (or a 90-day supply for a
prescription or refill that is received from a mail order pharmacy);
17. Any portion of a prescription refill that exceeds the drug specific dispensing limi~ is dispensed to
a covered person whose age is outside the drug specific age limits, or exceeds the duration-
specific dispensing limi~ if applicable;
18. Any drug, medicine or medication received by the covered perS01T.
a. Before becoming covered under the Plan; or
b. After the date the covered person's coverage under the Plan has ended;
19. Any costs related to the mailing, sending, or delivery of prescription drugs;
20. Any fraudulent misuse of this benefit including prescriptions purchased for consumption by
someone other than the covered penson;
21. Prescription or refill for drugs, medicines, or medications that are lost, stolen, spilled, spoiled, or
damaged;
22. Repackaged drugs;
23. Any drug or medicine that is:
a. Lawfully obtainable without a prescription (over the counter drugs), except insulin; or
b. Available in prescription strength without a prescription;
24. Any drug or biological that has received an It olphan drug' designation, unless approved by the
Plan Administrator;
82
.$0. J' "'"
ASOC0J74
Prescription Drug Benefit Continued
25. Any amount you paid for a prescription that has been filled, regardless of whether the prescription
is revoked or changed due to adverse reaction or change in dosage or prescripti01T,
26. More than one prescription within a 23-day period for the same drug or therapeutic equivalent
medication prescribed by one or more qualified practitioners and dispensed by one or more
pharmacies, unless received from a mail order pharmacy. For drugs received from a mail order
pharmacy, more than one prescription within a 20-day period for a 1-30 day supply; or a 60-day
period for a 61-90 day supply. (Based on the dosage schedule prescribed by the qualified
practitioner).
83
EXHIBIT A
Identification of the Plan
City of Jeffersonville Employee Health Plan
(Medical, Prescription and Dental Coverage)
(Non-Federal Governmental Entity)
EXlDBIT B
COBRA Administration Services
DEFINITIONS
B 1.1 "COBRA" means the Federal Consolidated Omnibus Budget Reconciliation Act of 1986, as amended,
which requires health care continuation coverage through amendments to the Employee Retirement
mcome Security Act of 1974, the mternal Revenue Code of 1986, and the Public Health Services Act
of 1944.
B 1.2 "Qualified Beneficiary" means a current or former employee of an Employer who is entitled to
continued coverage under the Plan through COBRA and a spouse or dependent of a current or former
employee who is entitled to continued coverage under the Plan through COBRA. A Qualified
Beneficiary under COBRA law also includes a child born to the current or former employee during the
coverage period or a child placed for adoption with the current or former employee during the
coverage period. At the time COBRA election is made, these individuals are also referred to as a
"COBRA Continuee".
B 1.3 "COBRA Service Provider" means a provider of COBRA administrative services retained by the Plan
Manager to provide specific COBRA administrative services as described in this Exhibit B.
DUTIES OF THE PLAN MANAGER
B2.1 The Plan Manager will provide claims processing and other administrative services as described in this
Agreement with respect to COBRA Continuees as Covered Persons under the Plan.
B2.2 The Plan Manager will not determine questions of eligibility for COBRA continuation under the Plan.
B2.3 The Plan Manager will retain a COBRA Service Provider who is responsible for providing all notices
required by COBRA to Qualified Beneficiaries.
B2.4 The COBRA Service Provider will notify the Plan Manager and Employer of an individual's election
of COBRA continuation coverage.
B2.5 The COBRA Service Provider will, in accordance with its regular practices, bill COBRA Continuees
for the costs payable by them for COBRA continuation coverage under the Plan on a monthly basis.
B2.6 The COBRA Service Provider will, in accordance with its regular practices, collect the amounts billed
in accordance with section B2.5 on a monthly basis from COBRA Continuees. A 31-day grace period
will be allowed for payment of the amount due.
The COBRA Service Provider will deposit the amounts collected under section B2.6 in a general
account for COBRA payments, and remit the balance in the account to the Employer or Plan
Administrator on a monthly basis less any amount which may be directed by the Employer or Plan
Administrator to be offset against the costs of services due under this Agreement.
B2.7 Where the costs of COBRA continuation coverage are billed and collected by the COBRA Service
Provider, the COBRA Service Provider will furnish the Client, the Employer, or the Plan
Administrator with monthly information of the aggregate COBRA continuation coverage costs billed
in accordance with section B2.5 and the aggregate coverage costs collected in accordance with section
B2.6.
B2.8 The Plan Manager will record a termination date for each COBRA Continuee as designated to the Plan
Manager by the Employer or Plan Administrator (the "Termination Date"). After the Termination
Date such individual will no longer be considered to be a COBRA Continuee and a Covered Person.
The Plan Manager will not provide services under this Agreement with respect to any COBRA
Continuee insofar as those services may pertain to time periods occurring after the Termination Date.
DUTIES OF THE CLIENT OR EMPLOYER
B3.1 The Client and the Employer understand and agree that the Employer is solely responsible for
compliance with COBRA and for deciding all questions, including matters of clerical error, arising out
of COBRA Continuees' eligibility for COBRA continuation coverage.
B3.2 The Client and the Employer understand and agree that the Plan Manager is in no way responsible and
does not assume responsibility for compliance with any obligations of the Employer under COBRA.
Performance of services under this Agreement shall not be construed by the Client or Employer that
the Plan Manager endorses, warrants, or represents that the COBRA continuation coverage provided
by the Employer is in compliance with any legal obligation of the Employer.
B3.3 Notification to the Plan Manager and COBRA Service Provider by the Employer, or Plan
Administrator of the termination date, qualifying event and eligibility of an individual to receive
COBRA continuation coverage
B3.4 Notification to the Plan Manager and COBRA Service Provider by the Employer or Plan
Administrator of the appropriate amounts due for coverage under the Plan.
B3.5 The Client and the Employer understand and agree that the Client shall inform each affected entity
(e.g. HMO) of the existence of this Agreement and, by separate written agreement or otherwise, secure
each entity's acceptance of its pertinent provisions.
NOTICES
B4.1 The Plan Manager shall be entitled to rely and act based upon documents, letters, electronic
communications, or telephone communications which are confirmed in writing and provided to it by
the Client or Employer. Reliance will continue until the time the Client or the Employer notifies the
Plan Manager in writing of any change or amendment to those communications.
B4.2 Notices provided by the Client regarding these COBRA Administration Services to the Plan Manager
shall be personally delivered or sent by a method no less rapid than fIrst class mail, with postage
prepaid, or facsimile, to the Plan Manager at the following address:
Attn: Tim Batson
Humana Insurance Company
500 West Main Street
Louisville, Kentucky 40202
Telephone: 502-580-8508
Fax: 502-580-3639
Email: tbatson@humana.com
Attn: Gerald L. Ganoni
HumanaDental Insurance Company
1100 Employers Boulevard
Green Bay, Wisconsin 54344
Telephone: 920-337-7602
Fax: 920-337-3183
Email: iganoni@humana.com
EXHIBIT C
Utilization / Case Management Services
These Utilization / Case Management services are performed by the Plan Manager in connection with
Plan provisions aimed at monitoring quality, containing costs, and promoting efficient delivery of Covered
Services ( see below) in appropriate settings.
In all circumstances, the Client understands and agrees that these services are performed solely for the
purpose of implementing Plan provisions and assisting in utilization management decision making which
results in the delivery of appropriate levels of Plan benefits. The assistance provided through these services
does not constitute the practice of medicine.
None of the Utilization / Case Management services performed by the Plan Manager under this
Agreement constitute a claims review determination or a guarantee of coverage or benefits eligibility. Benefits
eligibility will be determined in the normal course of claims processing.
DEFINITIONS
C 1.1 "Covered Services" means health care services or supplies to which a health care coverage provision
of the Plan might apply.
C 1.2 "Emergency" care means Covered Services received by a Participant related to a sudden and
unexpected change in the Participant's physical or mental condition which is severe enough to require
immediate hospital level care.
C 1.3 "Health Care Provider" means any physician, practitioner, hospital, facility, laboratory, or any other
provider of health care services or supplies which are Covered Services under the terms ofthe Plan.
C 1.4 Utilization / Case Management services are performed employing processes generally described as
follows. These concepts may be described similarly by the terms of the Plan, differing only with
respect to terminology.
(a) "Utilization Review" means the process of assessing the appropriateness, utility, or necessity
of hospital admissions, surgical procedures, outpatient care, and other health care services as
required under the provisions of the Plan. Utilization Review includes:
(1) "Precertification", which is the process of assessing the appropriateness, utility, or
necessity of proposed non-emergency hospital admissions, surgical procedures,
outpatient care, and other health care services.
(2) "Concurrent Review", which is the process of assessing the continuing
appropriateness, utility, or necessity of additional days of hospital confmement,
outpatient care, and other health care services.
(b) "Retrospective Review" means the process of assessing after the fact the appropriateness,
utility, or necessity of hospital admissions, additional days of hospital confmement, surgical
procedures, outpatient care, and other health care services, as required under the provisions of
the Plan.
(c) "Case Management" means the process of assessing whether an alternative plan of care would
more effectively provide necessary health care services in an appropriate setting, as required
under the provisions of the Plan.
UTILIZATION MANAGEMENT AND CASE MANAGEMENT SERVICES
C2.1 Precertification, Concurrent Review, and Retrospective Review will be performed by the Plan
Manager, or a consulting health care professional engaged by the Plan Manager, which may use
criteria and protocols developed with input from health care experts.
C2.2 The Plan Manager will provide or arrange for the provision of Precertification services, under
applicable Plan provisions.
(a) In the event that a proposed treatment cannot be Precertified:
(1) The Plan Manager, the person requesting Precertification, and the attending Health
Care Provider may, if sufficient information is provided, discuss possible treatment
alternatives available under the Plan which might be Precertified.
(2) In the event that the attending Health Care Provider chooses not to select possible
treatment alternatives which might be Precertified or otherwise wishes to pursue
Precertification of the proposed treatment as originally proposed, the Precertification
process will proceed to resolution on the basis of available information.
(b) Precertification will be completed within the time periods prescribed in the Plan, or if there
are none, within a reasonable time after a request is made.
C2.3 During the Precertification and Concurrent Review processes, each hospital admission is evaluated for
discharge planning needs, home health care, and Case Management potential, as appropriate.
C2.4 The Plan Manager will provide or arrange for the provision of Concurrent Review services, under
applicable Plan provisions.
C2.5 The Plan Manager will provide or arrange for the provision of Retrospective Review services, under
applicable Plan provisions.
(a) For emergency inpatient admissions, Retrospective Review services will not be performed
unless they are requested within the earlier of:
(1) The period of time following admission specified in the Plan; or
(2) If no time is specified in the Plan, 48 hours following admission.
(b) When required notification is not provided so that Precertification is not performed,
Retrospective Review services will be performed only if specifically required by the Plan.
C2.6 Notices of the results of the Precertification, Concurrent Review, and Retrospective Review processes,
provided in accordance with the provisions of the Plan, will include information about the Plan
Manager's standard procedures for having those results reconsidered. Results of these processes do
not constitute claims determinations, and reconsideration of these results does not constitute an appeal
of a disputed claim.
C2.7 The Plan Manager will provide or arrange for the provision of Case Management services, under
applicable Plan provisions.
C2.8 The Plan Manager will provide or arrange for the provision of the following additional services, under
applicable Plan provisions.
(a) "Personal Nurse" services which provides members with a specially trained nurse and
provides information and tools that can help members understand their health care options,
take control of their health needs and get the most from their plan benefits. Participation is
voluntary and members can choose to opt out at anytime. Members are identified as potential
candidates who meet all of the following criteria:
(1) Humana is the third party administrator;
(2) Active enrollment status;
(3) Expected/actual hospital admission.
HEALTH CARE PROVIDERS
C3.1 The Client agrees that the Plan Manager shall not be held responsible for the actions of Health Care
Providers acting as licensed professionals within the scope of their professional practice, and that in no
event shall the hold harmless and indemnity provisions of the Agreement apply against the Plan
Manager with respect to any expense caused by the acts or omissions of Health Care Providers.
REPORTS
C4.1 Special reports may be provided by the Plan Manager, if requested by the Client and the contents,
composition, and cost is mutually agreed upon.
MISCELLANEOUS
C5.1 The Plan Manager will provide these Utilization I Case Management services in accordance with the
provisions of the Plan which are in effect and which have been communicated to the Plan Manager by
the Client at the time the services are provided.
C5.2 If the Plan Administrator directs the Plan Manager to make a Utilization I Case Management services
determination which is different than the determination which would otherwise be made by the Plan
Manager, the Plan Manager will follow the determination of the Plan Administrator, provided the Plan
Administrator's determination is ftrst communicated to the Plan Manager in writing.
However, the Plan Manager may decide that it will communicate this determination only as directed in
special written instructions from the Plan Administrator which are acceptable to the Plan Manager.
C5.3 The Plan Manager is an independent contractor with respect to the services provided under section 7.3
and Exhibit "C" of this Agreement, section 2.5 of this Agreement notwithstanding.
C5.4 The obligations of the Plan Manager under section 7.3 and Exhibit "C" of this Agreement shall
terminate upon the expiration of this Agreement.
EXHIBIT D
Networks
DEFINITIONS
D 1.1 "Health Care Provider" means any physician, practitioner, hospital, facility, laboratory, or any other
provider of health care services or supplies which are Covered Services under the terms of the Plan.
Dl.2 "Network" means a network of Preferred Providers which is available to provide services with respect
to Participants in connection with this Agreement.
D1.3 "Preferred Provider" means a Health Care Provider that is available by virtue of this Agreement to
furnish services or supplies with respect to Participants under applicable utilization management or
case management provisions of the Plan.
D1.4 "Preferred Provider Services" means Covered Services provided by a Preferred Provider or for
emergency care.
D 1.5 "Service Area" means the Zip Code Areas in which each Network provides health care services in
accordance with the terms of this Agreement and the Plan.
D 1.6 "Zip Code Area" means the geographical area described by any five-digit zip code established by the
United States Post Office.
NETWORKS
D2.l The Plan Manager will engage one or more Networks to provide Covered Services under the Preferred
Provider Services provisions of the Plan, within each Service Area served by the Networks. The Plan
Manager will provide a listing of Network locations and Preferred Provider locations within each
Service Area.
PROVIDERS
D3.l The Client agrees that the Plan Manager shall not be held responsible for the actions of Health Care
Providers, including providing health care services, and that in no event shall the hold harmless and
indemnity provisions of the Agreement apply against the Plan Manager with respect to any expense
caused by the acts or omissions of Health Care Providers.
D3.2 The Plan Manager represents that provider agreements entered into by it in connection with its
obligations under this Agreement comply with all of the requirements of applicable law. With respect
to its obligations under this Agreement, the Plan Manager will exercise due diligence in selecting
Health Care Providers.
D3.3 The Plan Manager acknowledges that providers of professional health care services under contract
with a Network maintained by the Plan Manager or by companies under common control with it
comply with credentialing standards no less stringent than those prevailing in the industry.
EXHffiIT D-l
Shared Savings Program Provider Discounts
In accordance with section 7.9, the Plan Manager will arrange access for the Client to certain provider
discounts established by the Plan Manager that may be available at the time when services are rendered and/or
provider fee negotiations occur. The Shared Savings Program does not extend to services by providers that the
Client has already contracted for by selecting a network through the Plan Manager or through contracting
directly with a network or provider.
D-I.I The "savings" are the expenses charged by the provider above the discounted provider fee.
D-I.2 The Client realizes that the Shared Savings Program provider discounts and/or fee negotiations are
only available with respect to hospital or facility services that are part ofthe current program structure
but that the program structure may change over time.
D-1.3 The Shared Savings Program does not include discounts with respect to (a) providers that the Client
has already contracted for by selecting a network through the Plan Manager, or (b) networks or
providers with which the Client has directly contracted.
D-l.4 After application of the Shared Savings Program, Plan benefits will be determined as if the services
were provided in an out-of-network setting, unless it is appropriate that they be considered as in-
network due to the application of the urgent/emergency benefits provision of the Plan.
D-l.5 The Client agrees to pay a fee for access to and application of the Shared Savings Program as specified
in Exhibit "F".
D-l.6 The Client agrees to hold the Plan Manager and its affiliates harmless and indemnify them for any and
all loss, liability, or damage (including payment of reasonable attorney's fees) which they may incur by
virtue of the Client's authorization and direction to apply the Shared Savings Program provider
discounts to claims submitted under the Client's health care Plan.
EXHIBIT E
INSERT SIGNED BANKING FORM
Appendix A, Banking Arrangement, is made a part of this document.
EXIllBIT F
Schedule of Fees
Fl.I The monthly fees presented in this Exhibit F are valid for the period of time beginning on the
Effective Date of this Agreement and ending on March 31, 2007, except as otherwise stated.
F2.1 General:
Line of Covera2e
Composite
Medical and Prescription
Dental
$31.99
$3.94
F3.1 Specific:
(a) Under ~7.5 of the Agreement, the administrative fee for providing Subrogation I Recovery
Services is 30% of all amounts recovered under that section. The administrative fee will be
applied towards the net recovery, exclusive of any legal fees.
(b) With respect to access to provider networks in accordance with ~7.9 of this Agreement or
other similar provider arrangements arranged through the Plan Manager, the Client
understands that a special access fee may be payable, depending upon the network or
arrangement. The Client and the Plan Manager agree that the Client will be obligated to pay
any special fee under this ~F3.1 (b) only upon advance written notice to and written consent
by the Client.
(c) With respect to access to and application of the Shared Savings Program in accordance with
section 7.10 and Exhibit D-I, the Client agrees to pay a fee equal to 30% ofthe "savings" on
medical services realized by virtue of application of the Shared Savings Program Provider
Discounts.
(d) The fee payable for run-out claims processing under section 7.11 of the Agreement will be
based upon the enrollment levels in effect the month prior to the date of such change. Fees
will be equal to three (3) months of administrative fees that are in effect for the service period
during which the run-out claims processing services are provided.
(e) With respect to rebates which may be available with respect to pharmacy benefits provided
under the Plan, the Client agrees that the Plan Manager will retain amounts attributable to
rebates as reasonable compensation for services under this Agreement, including arranging
pharmacy discount programs.
F4.1 Payment:
(a) Fees set forth in sections F2.l are payable to the Plan Manager by check once per month.
(b) Any special access fees payable under ~F3.l (b) shall be paid by the Client to Plan Manager as
billed.
r.\
. I
EXHIBIT G
Persons Authorized to Receive
Private Health Information
Name:
Title:
Address:
Name:
Title:
Company:
Address:
Telephone:
Fax:
Email:
Name:
Title:
Company:
Address:
Telephone:
Fax:
Email:
Name:
Company:
Address:
Telephone:
Email:
(1\
Leslie Merkley
City Attorney/City of Jeffersonville
501 East Court Avenue
Jeffersonville, IN 47130
Robert Waiz, Jr.
Mayor
City of Jeffersonville
501 East Court Avenue
City Attorney, Room 501
Jeffersonville, IN 47130
812-285-6400
812-285-6403
rwaiz@cityofieff.net
Kim Calabro
Human Resources Director
City of Jeffersonville
501 East Court Avenue, Room 407
City County Building
Jeffersonville, IN 47130
812-285-6405
812-285-6490
kcalabro@cityofieff.net
Larry Lynn
City of Jeffersonville
501 East Court Avenue, Room 421
City County Building
Jeffersonville, IN 47130
812-285-6400
llvnn@citvofieff.net
16.8 Effect of Payment of Administration Charges. This Agreement shall be considered executed by the
Plan Manager and Client, upon signature of both Plan Manager and Client. Payment of fees prior to
completion and signing of this Agreement will constitute execution ofa written temporary agreement,
pending completion and signing of this Agreement.
IN WITNESS WHEREOF, the Client and the Plan Manager have executed this Agreement on
~,20~
(By)
Name:
L. vV&'1; 2- -;:rr.
tfl III '{ (j y-
(
HUMANA INSURANCE COMPANY
DePere, Wisconsin
\ ~h..~ :...r
(By)
Khalid N azir
Vice President
Title:
.
N6F
HUMANADENTAL INSURANCE COMPANY
DePere, Wiscon .'~ ". , . Or, .
I . -~, "" -""", ...."'.. '"''''''t'.,\
'~'., :,"~::.,~
17
Non-ERISA/HIC, HDIC Fiduciary