SOUTH CENTRAL OHIO
INSURANCE CONSORTIUM
HEALTH BENEFIT PLAN
For Employees of
LOGAN-HOCKING LOCAL SCHOOLS
CERTIFIED/CLASSIFIED STAFF
NOTICE: If you or your family members are covered by more than one health
care plan, you may not be able to collect benefits from both plans. Each plan may
require you to follow its rules or use specific doctors and hospitals, and it may be
impossible to comply with both plans at the same time. Read all of the rules very
carefully, including the Coordination of Benefits section, and compare them with
the rules of any other plan that covers you or your family.
Effective: October 1, 2008
INTRODUCTION
This booklet is a Summary Plan Description (SPD). It is intended to explain the benefits provided by the South Central Ohio Insurance Consortium for LOGAN-HOCKING
LOCAL SCHOOLS . It does not constitute the Plan. Rights and benefits of Covered Persons
are determined in accordance with the provisions of the Plan, and coverage is effective only if a Covered Person is eligible for coverage and becomes and remains covered in accordance with the terms of this Plan.
The benefits described in this booklet replace similar types of benefits described in all booklets, amendments, certificates, or riders previously issued to Covered Persons by
LOGAN-HOCKING LOCAL SCHOOLS.
To avoid dual references throughout this booklet, masculine pronouns such as he, him and his will include the feminine gender as well for purpose of benefits and provisions of the plan.
Many of the provisions in this booklet are interrelated; therefore, reading just one or two sections may not give the Covered Person an accurate impression of his coverage. You are responsible for knowing the terms and conditions of this Plan.
Capitalization of the first letter of a word or phrase not normally capitalized according to the rules of standard punctuation (e.g., Surgery), with the exception of some job titles, company or agency names, certain types of coverage and references to specific sections of this Summary Plan Description, indicates a word or phrase that is defined in the “Definitions” section, or that refers to an item in the Schedule of Benefits.
Anyone who intentionally includes false or misleading information in any enrollment material, claims submission, or other written material pertaining to the Plan in an attempt to defraud or deceive is guilty of insurance fraud.
The Plan’s Claims Administrator is:
Employee Benefit Management Corp (EBMC) 4789 Rings Road
Dublin, Ohio 43017-1599
1-877-304-0761 - Toll-Free 614-932-6374 - In Columbus, Ohio
TABLE OF CONTENTS
Page
Managed Care Program ...4
Schedule of Benefits ...6
Eligibility and Effective Date of Coverage...12
Enrollment Requirements ...14
Late Enrollment ...14
Open Enrollment ...14
Special Enrollment Periods...14
Pre-Existing Conditions Limitation ...15
Employment Related Events Affecting Coverage ...16
Individual Termination of Coverage...17
COBRA Continuation Coverage...18
Pre-Tax Election ...21
COMPREHENSIVE MEDICAL BENEFITS ...25
Maximum Lifetime Benefit ...25
Calendar Year Deductible...25
Family Deductible...25
Deductible Carryover ...25
Co-insurance ...25
Per Visit Co-payment ...26
Out-of-Pocket Maximum ...26
Well Care Benefit ...26
Hospital Benefit ...28
Emergency Room Benefit...29
Urgent Care Facility Benefit ...30
Ambulance Benefit ...30
Skilled Nursing Facility Benefit ...30
Hospice Care Benefit ...30
Home Healthcare/Private-Duty Nursing Benefit ...31
Physician Expense Benefit...32
Medical Supplies, Durable Medical Equipment, and Appliances ...34
Therapy Services Expense Benefit ...35
TABLE OF CONTENTS (continued)
Page
Outpatient Mental Disorder Substance Abuse Treatment Benefit...36
TMJ (Temporomandibular Joint) Benefit...37
Independent Laboratory Benefit ...37
Organ and/or Tissue Transplant Benefit ...38
All Other Covered Medical Expenses...39
PRESCRIPTION DRUG PROGRAM ...42
GENERAL PROVISIONS General Limitations ...46
Coordination of Benefits with Group Plans and Medicare ...50
Payment of Benefits...52
Recovery Rights...53
Amendment, Modification or Termination...54
Plan Information ...54
Claim Procedures ...55
HIPAA Privacy and Security Compliance...58
MANAGED CARE PROGRAM
NETWORK PPO (PREFERRED PROVIDER ORGANIZATION)
The Plan has contracted with a Network of preferred provider Hospitals and Physicians to provide care at discounted rates. The Plan provides incentives for you to use in-network providers through benefit differential in the Calendar Year Deductible, Out-of-Pocket maximums and benefit percentages. The Network should be contacted to determine if a particular Hospital, Physician, or other health care provider participates in the Network.
The In-network level of benefits may be payable for the following covered services:
• Covered lab services performed by a Non-Network independent lab facility, anesthesia services, and radiology interpretations.
• Emergency care at a Non-Network Hospital for an Accidental Injury or a Medical Emergency. A Medical Emergency is an Illness that manifests itself by such acute symptoms of sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: the patient’s health, or in the case of a pregnancy, the health of the woman or her unborn child, would be placed in serious jeopardy; bodily function would be seriously impaired; or there would be serious dysfunction of a body organ or part. Examples of medical emergencies include heart attacks, loss of consciousness or respiration, and convulsions.
• For any Covered Person who cannot access Network Providers because he resides outside the Network service area, i.e. a student attending schools or a covered child living with a former spouse outside the Network service area. Persons residing outside the Network service area must be pre-approved and so designated by the Employer.
PRE-CERTIFICATION AND UTILIZATION REVIEW
The Plan uses the services of Alternative Care Management Systems, Inc. (ACMS) to provide the required pre-certification and utilization review services to the Plan.
The Patient Services Center is the operations center of ACMS. It is staffed by nurses and other support personnel who work closely with Covered Persons and their Physicians in the delivery of healthcare services.
The Covered Person, a friend, a relative or the Covered Person’s Physician may contact the ACMS Patient Services Center. ACMS will also certify the length of the Hospital stay, as each day of confinement must be medically necessary. ACMS certification, however, is not a benefit determination and questions regarding benefit payment should be directed to the Claims Administrator. The pre-certification and utilization requirements of the Plan do not apply to Covered Persons whose primary coverage is Medicare.
Hospital admissions (See the Benefit Section entitled Hospital Expense Benefits
for special rules for maternity admissions and the time frames for pre-certification;
Conversion of unused Inpatient Mental Health/Substance Abuse benefit days
to Outpatient visits;
NOTE: Because additional discounts may be available, ACMS notification is encouraged prior to rental or purchase of any durable medical equipment exceeding $750.
CASE MANAGEMENT
ACMS also performs Case Management services for the Plan. Case Management applies if the nature of a patient’s condition is, or is expected to become catastrophic or chronic, or when the cost of treatment is expected to be significant. Examples of conditions that might prompt case management intervention include organ transplants, amputations, multiple fractures, spinal cord injury, cerebral vascular accident, cancer, head trauma, AIDS, multiple sclerosis, severe burns, severe psychiatric disorder, or high risk pregnancy/high-risk infant. Additional information is available from ACMS.
Payments for expenses not covered under the Plan that are recommended by a medical case management service shall be reimbursable with the approval of the Plan Sponsor.
Office hours for ACMS are 8:00 a.m. to 5:00 p.m. (Eastern Time), Monday through Friday. An answering system will take messages during the hours when ACMS is closed. The toll-free telephone number for ACMS is:
614-932-6374 (In Columbus, Ohio)
SCHEDULE OF BENEFITS
Effective October 1, 2008COMPREHENSIVE MEDICAL BENEFITS
(Eligible Employees and Dependents)
All benefit considerations of the Plan are subject to the Usual, Customary, and Reasonable (UCR) Allowance and Necessary Medical Services provisions of the Plan.
Before any benefits are payable from the Plan, the Calendar Year Deductible has to be satisfied for covered services unless it is specifically waived in this Schedule of Benefits.
LIFETIME MAXIMUM BENEFIT ... $5,000,000 Network and Non-Network benefits are combined
Lifetime Maximum Benefit for Substance Abuse Treatment: ...Two Inpatient or Outpatient
Rehabilitation Programs
NON-NETWORK NETWORK
CALENDAR YEAR DEDUCTIBLE
Per Covered Person ... $250...$500 Per Covered Family ... $500... $1,000
Network and non-network deductibles do not accumulate toward each other. OUT OF POCKET LIMIT
Per Covered Person ... $1,250... $2,500 Per Covered Family ... $2,500... $5,000
NOTE: The Out-of-Pocket Limit includes Deductibles and Co-insurance incurred by the
Covered Person within the Calendar Year except for the following: • Prescription Drug benefits
• Non-network Human Organ and Tissue Transplant services • Co-Payments as required herein
Network and non-network out-of-pocket-limits do not accumulate toward each other.
NON-
COVERED SERVICES
NETWORK NETWORKPREVENTIVE CARE ... Deductible and Co-... Deductible and Co-
SCHEDULE OF BENEFITS (continued)
NON-
NETWORK
NETWORK
HOSPITAL BENEFIT Inpatient... 90%... 70%Calendar Year benefit maximums apply as follows: Mental Disorder or Network Only Substance Abuse
Treatment (Combined)1...30 days... 30 days –Non-Network Substance Abuse Treatment ... $550 combined in- or out patient
Biologically-Based Mental Illness (as defined herein) is covered the same as any other Illness
Outpatient
Surgical Facilities (includes alternative care facility)... 90%... 70% Diagnostic X-Ray and Lab (including their interpretations) ... 100%... 70%
(Deductible Waived for In-Network services only)
NOTE: Allergy testing, MRA, MRI, PET scan, CAT scan, nuclear cardiology
imaging studies and non-maternity related ultrasound services are covered under “All OTHER COVERED MEDICAL SERVICES” below
EMERGENCY ROOM (deductible is waived) ...$100 Co-Pay... Paid same
Facility and Physician Charges per visit, then 100% as Network Co-payment is waived if admitted
URGENT CARE CENTER...$15 Co-Pay...Paid same
as Network
AMBULANCE BENEFIT... 90%...Paid same
as Network
SKILLED NURSING FACILITY EXPENSE BENEFIT...90%...70%
Maximum Confinement per Calendar Year (Combined)1... 90 days... 90 days
HOSPICE CARE BENEFIT... 90%... Paid same
as Network
HOME HEALTH CARE ...90%... 70%
Maximum visits per Calendar Year (Combined)1...200...200 Maximum Private Duty Nursing Care rendered in the home (combined)1:
$50,000 per Calendar Year $100,000 per Lifetime
PHYSICIAN EXPENSE BENEFIT
SCHEDULE OF BENEFITS (continued)
NON-
NETWORK
NETWORK
Includes Primary Care Physician, Specialty Care Physician, or surgery performed in the office
Related covered charges not billed by the Physician will be paid at the appropriate benefit percentage as indicated by the place of service.
Allergy Injections... 90%... 70%
The Allergy Injection coinsurance applies when the injection is billed by itself. The office visit co-payment/co-insurance applies if an office visit is billed with an allergy injection. Allergy testing, services are covered under “All OTHER COVERED MEDICAL SERVICES” as described herein:
Mammogram (Routine or Diagnostic), Diabetes
Self-Management training, or Network Only Medical
Nutritional Therapy ... 100%... 70% Surgery and Assistant Surgeon ... 90%... 70% Anesthesia ... 90%...Paid Same
As Network
Hospital Inpatient Physician Visits ... 90%... 70% Other In-patient or Outpatient Professional Services ... 90%... 70%
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT,
APPLIANCES EXPENSE BENEFIT ... 90%... 70% Maximum per Calendar Year: (Combined)1
for all prosthetic devices received on an outpatient basis -$10,000 (not including surgical prosthetics)
for all Durable Medical Equipment and orthotics - $10,000
NOTE: Because additional discounts may be available, ACMS notification is encouraged prior to rental or purchase of any durable medical equipment exceeding $750.
THERAPY SERVICES ... 90%... 70% Maximum Visits per Calendar Year (Combined)1
for Physical Therapy ...20...20 for Occupational Therapy ...20...20 for Speech Therapy ...20...20
NOTES: The above limits apply when rendered as Physician Office visits or as outpatient services.
When rendered in the home, Home Health Care limits apply for the above services;
MANIPULATION THERAPY ...$15 Co-pay... 70%
SCHEDULE OF BENEFITS (continued)
NON-
NETWORK
NETWORK
RADIATION, RESPIRATORY THERAPIES, CHEMOTHERAPY, KIDNEY DIALYSIS AND
CARDIAC REHABILITATION EXPENSE BENEFIT... 90%... 70% OUTPATIENT MENTAL DISORDERS OR
SUBSTANCE ABUSE TREATMENT
Outpatient Services ... 90%... 70% Physician Home/Office Service...$15 Co-Payment... 70%
Maximum Visits Per Calendar Year
Mental Disorders or Network only substance abuse ...30...10 Non-Network Substance Abuse Treatment ...$550 combined in- or outpatient
Biologically-Based Mental Illness (as defined herein) is covered the same as any other Illness
TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJ) .... 90%... 70% INDEPENDENT LAB EXPENSE BENEFIT
(Calendar Year deductible is waived)
(Including their Interpretation) ... 100%... Paid same
as Network
NOTE: MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies and
non-maternity related ultrasound services are covered under “All OTHER COVERED MEDICAL SERVICES” below
ORGAN AND/OR TISSUE TRANSPLANTS
(Calendar Year Deductible is waived) ... 100%... 50% ALL OTHER COVERED MEDICAL SERVICES...90%...70%
1
For purpose of benefits described in this Schedule, the term “Combined” means that Network and Non-Network charges are combined for one Maximum Benefit allowance.
All expenses must be submitted within 12 months from the date such charges were incurred to be eligible for benefit payment under this Plan
PRESCRIPTION DRUG PROGRAM
(Eligible Employees and Dependents)
CO-PAYMENT
RETAIL RX PROGRAM (30-day supply) PER PRESCRIPTION
OR REFILL
SCHEDULE OF BENEFITS (continued)
MAIL-ORDER RX PROGRAM (90-day supply)
Generic Prescription...$25 Preferred Brand-Name ...$62 Non-Preferred Brand-Name...$112
SPECIALTY NETWORK DRUGS PROGRAM (30-day supply)
Generic Prescription...$10 Preferred Brand-Name ...$25 Non-Preferred Brand-Name...$45
If you obtain services from a non-Network pharmacy, The Pharmacy Benefit Manager (PBM) will provide 50% reimbursement after a co-payment of $45. You must pay the full amount of the bill for the Prescription Drug at the time of purchase. Then you must file a standard claim form which can be obtained from the PBM, and payment will be made directly to you. You may be responsible for any amount in excess of the Prescription Drug Covered Charges.
ELIGIBILITY AND EFFECTIVE
DATE OF COVERAGE
ELIGIBLE EMPLOYEE
Active, full-time Certified/Classified employees of the Employer who are regularly scheduled to work at least 20 hours per week or who were employed by the Logan Hocking Local Schools Board of Education before September 1, 1985, and elected Board of Education Members, are eligible to participate on the first day of the month following the date they become active employees or are elected.
Substitute teachers who have been assigned to one specific position for a period of 60 days or more shall be eligible to participate in the Plan. Coverage may begin the first day of the month following the month in which the substitute teacher met the eligibility requirements.
All Eligible Employees who are actively at work and enrolled on the Effective Date of the Plan will be covered on that date. New employees will be covered on the date they complete an Enrollment Form following completion of the Waiting Period and satisfaction of any other eligibility requirements, provided they are actively working on that date.
An employee who is not actively at work on his Effective Date of coverage will not be covered until the date he returns to active employment. However, an employee who is not actively at work because of medical disability or other health conditions on his Effective Date of coverage will not be subject to the active-at-work requirements.
ELIGIBLE DEPENDENT
Eligible Dependents include the Eligible Employee’s legal spouse as recognized by the state of residence (who is not also covered under the Plan as an employee), unless divorced or legally separated, and children to the end of the month in which they attain age 19 years of age provided the children have never been married and are dependent upon the Eligible Employee for support and maintenance. The term children includes:
• Natural children and legally adopted children
• Children for whom the Eligible Employee has retained the legal duty for total or partial support pending final adoption proceedings
NOTE: The Pre-existing Conditions Limitation is waived for any child in the process of adoption.
• Stepchildren living with the Eligible Employee
• Children for whom the Eligible Employee has legal guardianship who are living with the Eligible Employee in a regular parent-child relationship
In addition to the above, children will be considered as Eligible Dependents from age 19 through the end of the month in which they reach age 25 if they are Full-Time Students at an accredited college, university or institution offering high school or post-high school education. They must never have been married and be dependent upon the Eligible Employee for support and maintenance. Full-Time Student status will be determined based on the standards of the institution attended. A full time student is absent from school no more than one term per Calendar Year. Summer is considered a school term. If a student does not return to school at the onset of the term following a school break, coverage under this Plan will terminate retroactive to the end of the last term attended. Eligibility will cease at the end of the month in which the dependent graduates or is no longer a Full-Time Student.
If a child covered as an eligible dependent is between age 24 up through age 25, has gross income over the exemption amount set forth in Internal Revenue Code Section 151(d) or does not receive over one-half of his support for the year from the eligible employee, contributions attributable to this child’s coverage will be included in the employee’s gross income.
Newborn children are eligible for coverage under the Plan from birth if enrolled within 31 days after birth.
A child who is physically or mentally incapable of self-support upon attaining the age limit may be considered as an Eligible Dependent while remaining incapacitated and continuously covered as a dependent under this Plan or a previous employer-sponsored plan, and having never been married. This incapacity must have started before the age limit was reached and must be medically certified by a Physician. To continue a child under this provision, proof of incapacity must be submitted to the Claims Administrator at least 31 days prior to the child’s attainment of the age limit. If approved, proof of continuing incapacity may be required from time to time thereafter.
The Plan will recognize a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Notice (NMSN), as defined, for purposes of providing coverage to dependent children. The order must be sent to the Plan Administrator, who will notify the Eligible Employee named in the order and each Alternate Recipient (a child of an Eligible Employee who is recognized in the QMCSO or NMSN as having the right to enroll in the Plan) that a Medical Child Support Order (MCSO) has been received. The Plan Administrator must also advise the Eligible Employee of the Plan procedures for determining if it is a “qualified” MCSO. In addition, the Plan Administrator must notify each person specified in the MCSO as to his eligibility for coverage and must allow the Alternate Recipient to designate a representative to receive Plan communications.
EFFECTIVE DATE OF COVERAGE FOR DEPENDENTS
An Eligible Dependent who is enrolled after the Effective Date of this Plan will become covered on the same date as the Eligible Employee or the date such dependent is acquired, whichever is later.
ENROLLMENT REQUIREMENTS
Coverage does not become effective for an employee and/or his dependents who become eligible for coverage on or after the Effective Date of this Plan until the employee completes an Enrollment Form agreeing to any required contributions. If the Eligible Employee enrolls himself and his Eligible Dependents within 31 days after first becoming eligible, coverage for any additional dependents acquired later (e.g., a newborn or adopted child or a new spouse) will become effective on the date they qualify as Eligible Dependents. However, the employee must notify the Employer of any new dependents and complete a new Enrollment Form. Additional information verifying eligibility may be required. If the contribution level is affected, the employee must complete the Enrollment Form within 31 days.
If the employee authorizes required contributions for himself and/or his Eligible Dependents more than 31 days after first becoming eligible, the enrollment is considered a late enrollment. LATE ENROLLMENT
If the employee initially declines coverage for himself and/or his Eligible Dependents during the 31-day eligibility period following his date of hire, he will be considered a late enrollee. Late Enrollees may enroll only during the open enrollment period.
OPEN ENROLLMENT
In September of each year, an open enrollment period will allow all covered employees who failed to enroll in the Plan during their initial eligibility period to elect coverage under the Plan. The Effective Date of new coverage will be October 1, assuming the Enrollment Forms are submitted on a timely basis. No enrollment will be allowed at any other time during the year, except as provided under “Special Enrollment Periods” below.
SPECIAL ENROLLMENT PERIODS
An Eligible Employee who declined this coverage for himself or his dependents during the initial 31-day eligibility period may enroll for coverage later if the following conditions are met:
1) The Eligible Employee (and/or dependent) loses coverage under another Group Health Plan or other health insurance coverage, which was in force at the time this coverage was initially declined and was the reason for the declination.
a) Loss of eligibility for coverage is due to cessation of employer contributions, legal separation, divorce, or due to a spouse’s death, termination of employment or reduction in the number of hours employed. Loss of eligibility does not include any loss due to failure of the individual to pay premiums on a timely basis or termination for cause; or b) COBRA Continuation Coverage has been exhausted.
A Special Enrollment Period is also offered to any Eligible Employee who previously declined coverage for any reason and later acquires an Eligible Dependent (or additional Eligible Dependent) due to:
• Marriage • Birth of a child
• Adoption or placement for adoption
In the case of enrollment during a Special Enrollment Period, the employee must request coverage as outlined in this section within 31 days of the date
a) COBRA Continuation Coverage is exhausted;
b) The other coverage is terminated due to loss of eligibility; or c) Of acquiring an Eligible Dependent.
The Effective Date of coverage obtained under a Special Enrollment Period will be the date the completed request for enrollment is received by the Plan Administrator. However, in the case of marriage, birth, adoption or placement for adoption, the Effective Date will be the date of the event causing the Special Enrollment opportunity.
PRE-EXISTING CONDITIONS LIMITATION
Covered Persons will not be entitled to benefits for expenses incurred as the result of any Injury or Illness for which the Covered Person has consulted with a Physician, taken medication or received any medical care services during the three-month period immediately prior to becoming covered under the Plan, until the expiration of:
1) A period of 12 consecutive months from the Covered Person’s Enrollment Date in the Plan; or
2) A period of 12 consecutive months from the Covered Person’s Enrollment Date in the Plan, if enrollment is more than 31 days after the individual was first eligible as described under “Enrollment Requirements.”
Any period of time during which Creditable Coverage, as defined, was in effect will carry over to offset or reduce the Pre-Existing Conditions Limitation as long as no break in coverage of 63 days or more has occurred. Any Waiting Period for coverage is not considered a break in coverage. Certification of Creditable Coverage must be supplied indicating the exact time period such coverage was in effect. This certification is supplied by the employer, insurance company or other organization that provided the Creditable Coverage (see “Definitions” section, “Creditable Coverage”). The Pre-Existing Conditions Limitation is reduced by one day for each day of prior Creditable Coverage certified. The newly enrolled individual will be notified in writing of the number of days remaining, if any, in the Pre-Existing Conditions Limitation after prior Creditable Coverage has been deducted.
Eligible individuals have the right to appeal the decision relative to the application of Creditable Coverage and supply additional evidence of such prior coverage.
EMPLOYMENT RELATED EVENTS AFFECTING
COVERAGE
PAID ABSENCE
If the covered employee is absent from active work but continues to received regular payroll checks under a paid vacation, short term sick leave, bereavement, jury duty or other paid absence policy of the Employer, coverage under this Plan will continue for the duration of the approved, paid absence.
MILITARY LEAVE
If a covered employee is on a military leave of absence, coverage will continue for a maximum of 31 days from the date leave began, subject to payment of required employee contributions.
Additionally, under the Uniformed Services Employment and Re-employment Rights Act of 1994 (USERRA), as amended by the Veterans Benefit Improvement Act of 2004 (VBIA), an eligible employee may elect to continue coverage for himself and his enrolled dependents for a period up to a maximum of 24 months. During this extended leave, the covered employee may be required to pay up to 102% of the cost of the coverage.
Coverage will be reinstated effective on the date the employee returns to work.
The section entitled “COBRA Continuation Coverage” outlines alternative continuation coverage.
DEATH OF EMPLOYEE
FMLA LEAVE OF ABSENCE
Notwithstanding the policies stated above, the Plan shall at all times comply with the Family and Medical Leave Act of 1993 (“FMLA”), as amended, and as promulgated in regulations issued by the Department of Labor. During any leave taken under the FMLA (the “FMLA Leave”), coverage under the Plan shall be maintained on the same conditions as coverage would have been provided if the covered Employee had been continuously employed during the FMLA Leave.
If coverage under the Plan terminates during the FMLA Leave, coverage shall be reinstated for the Employee and his covered dependents if the Employee returns to work in accordance with the terms of the FMLA Leave. Coverage shall be reinstated only if the Employee and any covered dependents had coverage under the Plan when the FMLA Leave started, and shall be reinstated to the same extent that it was in force when that coverage terminated.
NON-FMLA LEAVE OF ABSENCE
During an approved non-FMLA leave of absence, coverage under this Plan may be continued in accordance with the appropriate bargaining agreement or School Board policy. The section entitled “COBRA Continuation Coverage” outlines additional continued coverage provisions.
INDIVIDUAL TERMINATION OF COVERAGE
The coverage of any Covered Person under the Plan will terminate on the earliest of the following dates:
• The date of termination of the Plan or the date certain benefits terminate.
• The date a Covered Person becomes a full-time member of the armed forces of any country, except as specifically outlined for Military Leave in the previous section, “Employment-Related Events Affecting Coverage.”
• The beginning of a period of coverage for which the Covered Person fails to make any required contribution.
• The date an active covered employee or his eligible covered dependent spouse elects Medicare as the primary plan of benefits.
• The date a covered employee’s employment terminates or the date he no longer meets eligibility requirements, except as provided in the previous section, “Employment Related Events Affecting Coverage” and as outlined in the following section, “COBRA Continuation Coverage.”
COBRA CONTINUATION COVERAGE
(Consolidated Omnibus Budget Reconciliation Act)
EMPLOYEE QUALIFYING EVENTS
A covered employee and/or any covered dependent may elect COBRA Continuation Coverage under the Plan at his own expense for up to 18 months if coverage is lost due to one of the following qualifying events:
1) Voluntary or involuntary termination of employment of the covered employee (other than for gross misconduct)
2) A reduction in work hours for the covered employee
DEPENDENT QUALIFYING EVENTS
A covered dependent may elect COBRA Continuation Coverage under the Plan at his own expense for up to a maximum of 36 months if coverage is lost due to one of the following qualifying events:
1) The death of the covered employee
2) Loss of eligibility as a covered dependent as defined in the Plan 3) Divorce or legal separation of the covered employee
4) The covered employee becoming entitled to primary Medicare benefits
5) A filing for reorganization under Chapter 11 of the Bankruptcy Code by the Company in the case of a surviving spouse and/or dependent child(ren) of a deceased retired employee
The covered employee or dependent is responsible for notifying the Company within 60 days of the events outlined in items 2) and 3) above. The notification must be in writing and include the name and address of the person affected as well as the date of the event. Failure to do so will result in the loss of the covered dependent’s right to elect COBRA Continuation Coverage.
MEDICARE’S EFFECT ON COBRA
If the employee is enrolled for Medicare benefits at the time coverage terminates due to an Employee Qualifying Event listed above, the period of continuation for covered dependents will be the longer of:
a. 18 months from the date coverage terminates due to the Qualifying Event; or b. 36 months from the date the Employee became enrolled for Medicare benefits.
MULTIPLE QUALIFYING EVENTS
COBRA RIGHTS AND OBLIGATIONS
COBRA Continuation Coverage must be elected within 60 days from the later of the date coverage terminates or the date written notice of the right to elect COBRA Continuation Coverage is sent. Failure to elect within this time frame will result in the loss of the Covered Person’s right of COBRA Continuation Coverage. Payment for the cost of COBRA Continuation Coverage is due by the first of the month for each month of coverage, and coverage will cease if the monthly payment is not received within 30 days of the date it was due. Payment for the full cost of COBRA Continuation Coverage for the period from when coverage was lost through the date of election must be made within 45 days after the election.
A Qualified Beneficiary may waive COBRA continuation coverage during the 60-day election period. This waiver of coverage may be revoked by the Covered Person at any time before the end of the election period. In this case, coverage will be effective on the date of the waiver revocation notice is received by the COBRA Administrator. Coverage will not be provided retroactively.
COBRA Continuation Coverage will be provided for each month as long as payment for that coverage period is made before the end of the grace period for that payment. However, if a monthly payment is paid later than the first day of the month, but before the end of the grace period for the coverage period, coverage under the Plan may be suspended and then retroactively reinstated (going back to the first day of the month) when the monthly payment is received. This means that any claims submitted while coverage is suspended may be denied and may have to be resubmitted once coverage is reinstated.
If the Company makes revisions in coverage after a Covered Person has elected COBRA, any revisions to active employees will also apply to COBRA-qualified beneficiaries.
Special rules apply to a loss of retiree health coverage resulting from a Company’s Chapter 11 bankruptcy proceedings that commence within one year before or after the date the proceedings begin.
A child who is born to or placed for adoption with the covered employee during a period of COBRA Continuation Coverage will be eligible to become covered as a dependent. In accordance with the terms of the Plan and federal law requirements, these new dependents may be added to COBRA Continuation Coverage upon proper notification to the Company of the birth or adoption.
TRADE ACT OF 2002
Special COBRA rights apply to employees who have been terminated or experience a reduction of hours as a result of import competition or shifts of production to other countries. These employees may qualify for a “trade readjustment allowance” or “alternative trade adjustment assistance” under a federal law called the Trade Act of 2002. These employees are entitled to a second opportunity to elect COBRA Continuation Coverage for themselves and certain family members (if they did not elect COBRA Continuation Coverage), but only within a limited period of 60 days (or less) and only during the six months immediately after their Group Health Plan coverage ended.
or receive advanced payment of 65% of premiums paid for qualified health insurance, including COBRA Continuation Coverage. Employees who qualify, or may qualify, for assistance under the Trade Act of 2002, should contact their COBRA Administrator for additional information. They must contact their COBRA Administrator promptly after qualifying for assistance under the Trade Act of 2002 or they will lose their special COBRA rights.
Any questions about the Trade Act of 2002 may be directed to the Health Care Tax Credit Customer Contact Center toll-free at 1-866-628-4282, or the website can be accessed at www.doleta.gov/tradeact.
COBRA DISABILITY CONTINUATION
Covered employees and dependents entitled to elect COBRA Continuation Coverage due to an employee’s termination of employment or reduction in hours may extend their coverage from 18 to 29 months. The covered employee or dependent must be disabled (as defined under Title II or Title XVI of the Social Security Act) at the time of termination or reduction in hours or within the first 60 days of COBRA Continuation Coverage. The covered employee or dependent must notify the Company (in writing) within 60 days of the Social Security disability determination (or, if later, within the first 60 days of COBRA Continuation Coverage) and before the end of the normal 18-month coverage period. Failure to provide notice within this time frame will result in the loss of the 11-month extension of COBRA Continuation Coverage. Beginning with the 19th month, the cost of the COBRA Continuation Coverage may increase up to 50%.
The covered employee or dependent is also responsible for notifying the Company within 30 days after a final determination has been made by Social Security that the Covered Person is no longer disabled. COBRA Continuation Coverage may be terminated on the first day of the month that is more than 30 days after the final determination that the Covered Person is no longer disabled or on the date the individual becomes entitled to Medicare benefits, if sooner.
TERMINATION OF COBRA COVERAGE
Any COBRA Continuation Coverage made available above will cease if:
• The Company no longer provides group health coverage to any of its employees.
• After payment has begun, a covered employee or dependent fails to make the full payment when due or within the 30-day grace period allowed by law.
• The covered employee or dependent becomes entitled to Medicare after COBRA Continuation Coverage has been elected.
• The covered employee or dependent becomes covered (as an employee or otherwise) under another Group Health Plan after COBRA Continuation Coverage has been elected, unless that plan contains any exclusion or limitation in regard to a Pre-Existing Condition that is not waived by reason of prior Creditable Coverage.
PLAN CONTACT INFORMATION
Contact the Company for additional details concerning COBRA Continuation Coverage. In order to protect a family’s rights, the covered person should keep the Company informed of any changes in the addresses of family members and/or any new dependents, and should retain a copy of any notices sent to the Company.
For more information about rights under COBRA, the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting Group Health Plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)
PRE-TAX ELECTION
Unless they elect otherwise, all covered employees will have their share of the cost of coverage paid on a pre-tax basis. This means the employee’s share of the cost will be deducted from his pay before his taxable wages are determined. Therefore, total wages remain the same, but the amount of wages that is taxed is a lower amount. The use of pre-tax dollars to pay for coverage will reduce federal and state income taxes and increase an employee’s spendable income.
No change in election is permitted prior to that time except in cases of significant cost or coverage changes to the employee, separation from service by the employee or certain change-in-status events. Change-change-in-status events include:
1) Marriage, divorce, legal separation or annulment of the employee’s marriage 2) Death of the employee’s spouse or a child
3) Birth, adoption or placement for adoption of a child of the employee, including the commencement or termination of an adoption proceeding
4) Commencement or termination of employment by the employee, the employee’s spouse or a dependent
5) A reduction or increase in hours by the employee, spouse or dependent, including a switch from full-time to part-time employment, a strike or lockout, or commencement or return from an unpaid leave of absence
6) Dependent satisfies (or ceases to satisfy) dependent eligibility requirements
7) A change in the place of residence or work of the employee, spouse or dependent that affects the employee’s eligibility for coverage
8) Significant change in the health coverage of the employee or spouse attributable to the spouse’s employment
10) The entitlement or loss of entitlement by the employee, spouse or dependent to Medicare or Medicaid
11) Increase or decrease during the Plan year in the cost of the healthcare program. The Plan will automatically make a corresponding change in the salary reduction amount. If the cost of the healthcare Plan reduces significantly, the employee is allowed to begin participation in the Pre-Tax Election option. If the cost of the healthcare Plan increases significantly, the employee is allowed to revoke his pre-tax election.
12) Significant curtailment without loss of employee, spouse or dependent’s coverage. “Significant curtailment” means a significant increase in the deductible, co-payments or out-of-pocket limit of the Group Health Plan. If there is a significant curtailment with loss of employee, spouse or dependent’s coverage, the employee may revoke his election. If the Plan adds a new coverage option or if an existing benefit package option is significantly improved, the Plan may permit a covered employee to revoke his election and, instead, make a pre-tax election on a prospective basis to fund for coverage under the new or improved benefit package option.
13) An election change that is due to, and corresponds with, a change made under another employer’s cafeteria plan. The other cafeteria plan must permit Participants to make an election change that would be permitted under special enrollment rights; change in status; judgment, decree or order; entitlement to Medicare or Medicaid; significant cost or coverage changes; or special requirements related to the Family and Medical Leave Act (FMLA).
14) Loss of coverage under any group health coverage sponsored by a government or educational institution
AN ELECTION CHANGE DUE TO A CHANGE IN STATUS MUST BE MADE WITHIN 30 DAYS OF THE DATE OF THE CHANGE IN STATUS. ACCORDING TO RULES ESTABLISHED BY THE INTERNAL REVENUE SERVICE, THE ELECTION CHANGE MUST BE CONSISTENT WITH THE CHANGE IN STATUS.
In the event of separation from service and subsequent re-employment during the same Pre-Tax Election Plan year, if the employee should be rehired within 30 days of his termination, he would be able to make a new election if the facts and circumstances justified the change. If the employee is rehired more than 30 days after termination, he may make a new election regardless of the circumstances.
The regulations also permit an employee to increase his pre-tax contributions for coverage under his current employer’s health plan if a qualifying event as defined under the Consolidated Omnibus Budget Reconciliation Act (COBRA) occurs with respect to the employee, the employee’s spouse or a dependent. As a result, the employee could increase pre-tax contributions in mid-year to pay his cost of COBRA Continuation Coverage. The right to increase pre-tax contributions does not apply to COBRA coverage under another employer’s plan.
COMPREHENSIVE MEDICAL BENEFITS
If a Covered Person incurs covered medical expenses for Necessary Medical Services due to a non-occupational Injury or Illness, the Plan will consider benefits up to the Usual, Customary, and Reasonable (UCR) Allowance and pay benefits after the Calendar Year Deductible is satisfied (unless specifically waived) and at the benefit percentages specified in the Schedule of Benefits for covered medical services received during any one Calendar Year. The benefits payable shall not exceed the Maximum Lifetime Benefit and are subject to all limitations and conditions of the Plan.
MAXIMUM LIFETIME BENEFIT
The Maximum Lifetime Benefit per Covered Person under this Plan is listed in the Schedule of Benefits. This maximum includes, but is not in addition to, any separate maximums shown for specific treatment. For purposes of determining benefits under this Plan, the term “Lifetime” means the period of a person’s life during which he is continuously covered under this Plan. Changing to another Plan Option offered by the Employer shall not create a new Lifetime Maximum benefit allowance.
CALENDAR YEAR DEDUCTIBLE
Covered medical expenses are subject to the Calendar Year Deductible amount shown in the Schedule of Benefits, except when specifically waived in the Schedule of Benefits. Covered medical expenses used to satisfy this deductible are not reimbursable by the Plan. The Calendar Year Deductible is satisfied when the Covered Person or covered Family has incurred covered medical expenses within a Calendar Year as outlined in the Schedule of Benefits.
Expenses applied to the In-Network Deductible shall not apply to the Out-of-Network Deductible and vice versa.
Family Deductible
If the total covered medical expenses applied to the individual deductibles of the family members exceed the family deductible amount shown in the Schedule of Benefits, no additional deductibles are required of the family members for the remainder of that Calendar Year.
Deductible Carryover
Covered medical expenses incurred during the last three months of any Calendar Year that are applied toward the individual and family Calendar Year Deductible for that year are also applied toward the individual and family Calendar Year Deductible for the next year.
CO-INSURANCE
PER VISIT CO-PAYMENT
The Plan may impose an initial per visit Co-payment each time a Covered Person incurs charges for certain types of medical services. The amount of this Co-payment is shown in the Schedule of Benefits when it is applicable. The per-visit-co-payment is not applied to the Calendar Year Deductible nor to the Out-of-Pocket limit.
OUT-OF-POCKET MAXIMUM
If the maximum out-of-pocket amount shown in the Schedule of Benefits is met during any one Calendar Year, the Plan will pay 100% of additional incurred covered expenses for the remainder of that Calendar Year. Deductibles and co-insurance can be used to satisfy the Out-of-Pocket Maximum except as specified below.
Network deductibles and co-insurance shall not apply to the Non-Network Out-of-Pocket Maximum amount and vice versa.
The following will not apply to the Out-of-Pocket Maximum: • Prescription Drug co-payments
• Non-network Human Organ and Tissue Transplant services • Per-visit co-payments as required herein
• Any charges not covered by the Plan.
WELL CARE EXPENSE BENEFIT
If a Covered Person incurs charges for the following well care, the Plan will pay benefits for Inpatient or Outpatient services, and Physician home and office services at the benefit level and up to the maximums shown in the Schedule of Benefits. The covered services may vary based on the age, sex, and personal history of the individual, and as determined appropriate by the Plan’s clinical coverage guidelines. Screenings and other services are generally covered as Well Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service. Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Well Care for that condition but instead benefits will be considered under the Diagnostic Service benefit.
The following are examples of covered Well Care services:
1. Routine or periodic exams, including school enrollment physical exams. (Physical exams and immunizations required for travel, enrollment in any insurance program, as a condition of employment, for licensing, sports programs, or for other purposed are not covered services.) Exams include but are not limited to:
Well-baby care and Well Child Care (as defined herein). Adult routine physical examinations.
Pelvic examinations.
Routine EKG, Chest x-ray, laboratory tests such as complete blood count, comprehensive metabolic panel, and urinalysis.
2. Immunizations (including those required for school), following the current Childhood and Adolescent Immunization Schedule as approved by the Advisory Committee on Immunization Practice (ACIP), the American Academy of Pediatrics (AAP), and the American Academy for Family Physicians (AAPP). For Adults, the Plan follows the Adult Immunization Schedule by age and medical condition as approved by the Advisory Committee on Immunization Practice (ACIP) and accepted by the American College of Gynecologists (ACOG) and the American Academy of Family Physician. These include but are not limited to
• Hepatitis A Vaccine. • Hepatitis B Vaccine.
• Hemophilus influenza b vaccine (Hib). • Influenza virus vaccine.
• Rabies vaccine.
• Diphtheria, Tetanus, Pertussis vaccine. • Mumps virus vaccine.
• Measles virus vaccine. • Rubella virus vaccine. • Poliovirus vaccine. 3. Screening examinations:
Routine vision screening for disease or abnormalities, including but not limited to diseased such as glaucoma, strabismus, amblyopic, cataracts. Routine hearing screening.
Routine cytologic screening for the presence of cervical cancer and Chlamydia screening including pap test).
Routine bone density testing for women. Routine prostate specific antigen testing
Routine colorectal cancer examination and related laboratory tests.
No benefits are payable for:
physical examinations required for enrollment in any insurance program, as a condition of employment, for licensing, or for other purposes;
self-help training and other forms of non-medical self-care except as otherwise provided herein;
HOSPITAL BENEFIT
INPATIENT HOSPITAL EXPENSES
All Inpatient Hospital admissions for Covered Persons require ACMS Patient Services Center notification according to the following timetables.
Elective Admission ...Seven days advance notice
Emergency Admission...Within 48 hours following admission Maternity Management...Notification is encouraged as soon as
possible after pregnancy is confirmed. No reduction in Hospital benefits will be made for Hospital stays of up to 48 hours after a vaginal delivery or 96 hours after a cesarean delivery.
If a Covered Person is in her second or third trimester of pregnancy on her effective date of coverage, both in-patient and outpatient obstetrical care may be continued .with the current provider through the end of the pregnancy and the immediate post-partum period upon ACMS approval and benefits will be provided at the Network level based on the place where service is rendered.
The toll-free telephone number for ACMS is: 1-877-304-0761
ACMS office hours are 8:00 a.m. to 5:00 p.m. (Eastern Time), Monday through Friday. An answering system will take messages when ACMS is closed.
When hospitalization of a Covered Person is authorized and recommended by a Physician for the necessary treatment of a non-occupational Injury or Illness, the Plan will consider medically necessary Hospital charges and pay benefits after the Calendar Year Deductible is met (if applicable) and at the percentage and terms shown in the Schedule of Benefits. Covered charges include charges for daily room and board, including routine nursery care of healthy newborns, and miscellaneous expenses. “Miscellaneous expenses” means necessary services, medicines and supplies for diagnosis and treatment, including anesthesia materials, radiology and pathology, but excluding charges of a private-duty nurse or Physician.
If a Covered Person is treated at a Hospital for dental care for accidental Injury to sound natural teeth, either Inpatient or Outpatient Hospital benefits may be payable as outlined herein. An Inpatient admission for dental care must be certified as medically necessary.
The Plan will recognize a birthing center as a covered facility for covered services of the Plan.
Newborns’ and Mothers’ Health Protection Act of 1996
The Plan will not restrict benefits or require authorization for any Hospital stay in connection with childbirth of 48 hours or less following a normal vaginal delivery, or of 96 hours or less following a cesarean section. This applies to Hospital Inpatient expenses for both the mother and the newborn child. The mother may leave the Hospital sooner than these periods if she and her attending Physician agree to an earlier release. For Maternity Management purposes, the Plan encourages all Participants to notify ACMS of their pregnancy as soon as possible after a pregnancy is confirmed or as soon as coverage becomes effective if a new Participant is pregnant on her Effective Date. This notification to ACMS will not affect reimbursement levels for the minimum length of Hospital stay.
OUTPATIENT HOSPITAL EXPENSES
The Plan will pay benefits at the benefit percentages shown in the Schedule of Benefits for Outpatient Hospital services in connection with:
1) Use of facilities and supplies when surgery is performed in the Outpatient department of a Hospital, or at a Free-Standing Surgical or Emergency Care Facility
2) The Calendar Year Deductible is waived for diagnostic x-ray and laboratory services when received from an in-network provider, including their interpretations. Medical tests such as MRA, MRI, PET scan, CAT scan, nuclear cardiology imaging studies, and non-maternity related ultra-sound services are subject to the provisions of “ALL OTHER COVERED MEDICAL SERVICES” as described herein.
EMERGENCY ROOM EXPENSE BENEFIT
(Calendar Year Deductible is waived)
URGENT CARE FACILITY EXPENSE BENEFIT
When a Covered Person uses the services of an Urgent Care Facility for treatment of an Illness or Injury, facility and Physician charges will be paid as shown in the Schedule of Benefits.
AMBULANCE BENEFIT
If a Covered Person incurs expenses for medically necessary professional ambulance (whether ground or air) service due to accidental Injury or Illness, the Plan will pay benefits at the benefit percentages specified in the Schedule of Benefits for transportation to the nearest Hospital qualified to provide care, as well as to a Skilled Nursing Facility from a Hospital when recommended by the attending Physician.
No benefits are payable hereunder for:
• Ambulette or wheelchair accessible van;
• Ambulance usage for the convenience of family or Physician; • Trips to a physician’s office or clinic;
• Trip to a morgue or funeral home.
SKILLED NURSING FACILITY BENEFIT
If a Covered Person is transferred to a Skilled Nursing Facility from a Hospital following a confinement and/or the attending Physician makes documented certification of medical necessity, the Plan will pay benefits for daily room and board and covered miscellaneous expenses. Benefits are payable at the benefit percentages up to the maximum confinement per Calendar Year shown in the Schedule of Benefits. Benefits are subject to the following conditions:
a. The confinement must be certified by the attending physician as Medically Necessary for recuperation from the same Injury or Illness that caused the prior Hospital confinement.
b. The attending Physician must continue to render treatment for that Injury or Illness throughout the confinement.
No benefits are payable under this Section of the Plan:
• Once a patient can no longer significantly improve from treatment for the current conditions unless it is deemed Medically Necessary;
• For Custodial Care, rest care or care which is only for someone’s convenience; or • For the treatment of mental illness, drug abuse or alcoholism.
HOSPICE CARE BENEFIT
shown in the Schedule of Benefits. Hospice treatment must be recommended by the attending Physician and is normally rendered within six months of the terminally ill Covered Person’s entry or re-entry (after a remission period) into the Hospice Care program.
Hospice services consist of:
• Inpatient charges at a Hospice if medically necessary • Periodic respite care
• Services of Physicians
• Part-time nursing care and home health aide services • Necessary medical supplies, drugs and medicines
• Laboratory services, radiotherapy, oxygen and oxygen equipment
• Emotional support services and bereavement counseling furnished within six months after the patient’s death
• Physical, occupational, speech, respiratory and chemical therapy No Hospice benefits are payable for:
• Services or supplies rendered during any period in which the Covered Person is not under the regular care of a Physician
• Services or supplies which might be considered as a covered expense under other sections of the Plan
• Charges incurred during a remission period when the Covered Person is discharged from the Hospice Care program
• Charges for services provided by the Covered Person, spouse, child, brother, sister or parent of the Covered Person or spouse
• Pre-death counseling and bereavement counseling not provided by or through the Hospice
HOME HEALTHCARE/PRIVATE-DUTY
NURSING BENEFIT
If a Covered Person incurs charges for services rendered by a Home Healthcare Agency or for private-duty nursing care for treatment due to an Injury or Illness, the Plan will pay benefits at the benefit percentages and for the maximum benefit amount as shown in the Schedule of Benefits. Home healthcare and private-duty nursing services must be established and approved in writing by the attending Physician and must be rendered following a Hospital confinement and/or after documented certification of medical necessity is made by the attending Physician. A visit occurs each time an employee of a Home Healthcare Agency visits the patient. Each four hours or less of home healthcare services will be considered one home healthcare visit.
Home healthcare/private-duty nursing services consist of:
• Part-time or intermittent home health aide services primarily for the care of the Covered Person as long as the Covered Person is receiving either skilled nursing care or physical, speech, respiratory or occupational therapy by the Home Health Care Agency
• Physical, speech, respiratory or occupational therapy provided in the Covered Person’s home (Manipulation therapy is not covered when provided in the home).
• Medical supplies, drugs and medicines prescribed by a Physician, and laboratory services No home healthcare/private-duty nursing benefits are payable for:
• Services performed by a member of the Covered Person’s family or a person residing in the Covered Person’s home
• Transportation services
• Services or supplies rendered during any period in which the Covered Person is not under the regular care of a Physician
• Food, housing, homemaker services and home delivered meals.
Upon ACMS approval, home infusion therapy may be covered. Benefits for home infusion therapy include a combination of nursing care, durable medical equipment and pharmaceutical services which are delivered and administered intravenously in the home. Home IV therapy includes but is not limited to:
o injections,(intra-muscular, subcutaneous, continuous subcutaneous, o Total Parenteral Nutrition (TPN);
o Enteral nutrition therapy; o Antibiotic therapy; o pain management; o chemotherapy.
PHYSICIAN EXPENSE BENEFIT
If a Covered Person incurs eligible expenses as the result of a non-occupational Injury or Illness for the medical services listed below, the Plan will pay benefits as shown in the Schedule of Benefits for the Physician’s charges, not to exceed the Usual, Customary and Reasonable Charge for such services. Certain In-Network services are subject to a per-visit co-payment (see the Schedule of Benefits for the specific amount).
Office or Home Visits
Physician expense benefits are payable for office/home visits, including any surgery, x-ray and laboratory tests performed in connection with the office visit and billed by the doctor’s office, as well as clinic facility charges related to the office visit. In-Network Physician charges are payable after the per-visit office co-payment shown in the Schedule of Benefits.
Urgent Care/After-Hours Clinic
Mammograms, Diabetes Self-Management Training,
Routine and Diagnostic mammograms and diabetes self management training are covered as shown in the Schedule of Benefits.
Diabetes Self Management Training is available for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition when:
Medically Necessary;
Ordered in writing by a physician or a podiatrist; and
Provided by a Health Care Professional who is licensed, registered, or certified under state law. For purposes of this provision, a Health Care Professional: means the Physician or podiatrist ordering the training or a Provider who has obtained certification in diabetes education by the American Diabetes Association.
Surgery
Surgical benefits are payable as shown in the Schedule of Benefits and include operative and cutting procedures when performed by a Physician acting within the scope of his license who is not an employee of the Hospital where the surgery is performed. Vasectomy and tubal ligation—but not reversals of sterilization—and certain oral surgical procedures will also be covered, including:
• Surgical removal of full bony impacted teeth
• Repair of Injury to teeth within 12 months from the Injury, or as reasonably soon thereafter as possible and includes all examinations and treatment to complete the repair. For a child requiring facial reconstruction due to dental related injury, there may be several years between the accident and the final repair.
• Excision of tumors and cysts of the mouth and oral cavity
Note: ACMS may recommend a Second Surgical Opinion during the pre-admission review process. Obtaining a Second Surgical Opinion is entirely voluntary on the part of the Covered Person.
With regard to services of an assistant surgeon, charges will be covered if provided by a Physician who is not a Hospital intern, resident or employee and they are certified by the operating surgeon as medically necessary.
Women’s Health and Cancer Rights Act of 1998
Medical and surgical services for mastectomy, as well as subsequent reconstruction in connection with a mastectomy, will be covered under the Plan as follows:
• Reconstruction of the breast on which the mastectomy has been performed
• Coverage for prostheses and physical complications of all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending Physician and the patient
Anesthesia
Anesthesia benefits are payable as shown in the Schedule of Benefits, including charges for administration of general anesthesia in connection with a covered surgical procedure.
Anesthesia services must be ordered by the Physician or surgeon and administered by a Physician or surgeon who is not the operating surgeon, his surgical assistant or the Physician performing an obstetrical delivery. A qualified registered nurse who is not an employee of the Hospital may also administer anesthesia. This registered nurse must be under the direction and immediate presence of a Physician or surgeon.
Physician Hospital Visits
Physician Hospital visits limited to one visit per day by any one physician, consultations which are a personal bedside examination by another Physician when requested by the attending Physician, and intensive medical care when medically necessary are payable as shown in the Schedule of Benefits and include the Physician’s charges for each day the Covered Person is hospitalized. These services must be rendered by a Physician other than the operating surgeon or his assistant and, in the case of a surgical admission, must be for a non-related medical condition.
Pathology and Radiology Interpretation
Pathology and radiology interpretation benefits are payable as shown in the Schedule of Benefits and include such Necessary Medical Services performed by a Physician who is not an employee of the Hospital.
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND
APPLIANCES
Note: Because additional discounts may be available, ACMS notification is encouraged prior to rental or purchase of any durable medical equipment exceeding $750.
If the Covered Person incurs expenses for medical supplies, rental of durable medical equipment (not to exceed purchase price or purchase at the Plan’s option), or prosthetics, the Plan will pay benefits as outlined herein at the benefit percentage and up to the maximum amounts shown in the Schedule of Benefits, subject to the following:
Medical and surgical supplies –Supplies and equipment for the management of Illness or Injury
are covered. Covered items include but are not limited to: syringes, needles, oxygen, surgical dressings, splints and other similar items which serve only a medical purpose.
Durable Medical Equipment – Rental, or at the Plan’s option, purchase, of durable medical
equipment prescribed by a Physician is covered. Examples of covered durable medical equipment include but are not limited to: wheelchairs, crutches, hospital beds. and oxygen equipment. Rental price may not exceed the purchase price.
Items for which no benefits are payable include, but are not limited to: translift chairs, air conditioning, exercise equipment, and tub chairs for use in the shower.
Prosthetic Devices – Prosthetic appliances such as artificial limbs and eyes, including repairs,
replacements and adjustments when medically necessary. The Plan will also pay for the first wig following cancer treatment, limited to one per Calendar Year.
Items for which no benefits are payable include but are not limited to: dental appliances artificial heart implants, non-rigid appliance such as support hose, and wigs except as specifically stated herein.
Orthotic devices: Covered orthotic devices may include but are not limited to: cervical collars,
special surgical corsets, splints slings and wristlets.
Non-covered items may include but are not limited to: orthopedic shoes, foot supports or elastic stockings.
THERAPY SERVICES EXPENSE BENEFIT
If a Covered Person incurs charges for physical, occupational, speech, or manipulation therapies which are medically necessary and recommended by the attending Physician due to Illness or Injury, the Plan will pay benefits as shown in the Schedule of Benefits. If different types of Therapy Services are performed during one Physician Office Service, or Outpatient Service, then each different type therapy Service performed will be considered a separate Therapy visit. Each Therapy visit will count against the applicable maximum visits listed in the Schedule of Benefits. For example, if both a Physical Therapy service and a manipulation therapy service are performed during one Office service or Outpatient service, they will count as both one Physical Therapy Visit and one Manipulation Visit.
Physical or Occupational Therapy
Physical or occupational therapy rendered by a licensed Physician, physical therapist (L.P.T.), occupational therapist (O.T.), registered physical therapist (R.P.T.) will be considered as shown in the Schedule of Benefits. Physical therapy must result in improvement of a bodily function.
Physical or occupational therapy are subject to periodic evaluation for continued medical necessity and should proceed according to a written referral or treatment plan submitted by the attending Physician and/or therapist indicating the projected number of treatments and the length of the treatment program.
Speech Therapy
