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Schedule of Benefits. mharvardpilgrim. V Health Care. for The Harvard Pilgrim HMO

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Schedule

of Benefits

for The Harvard Pilgrim HMO

m

HarvardPilgrim

(2)

I

DISCLOSURE OF MINIMUM CREDITABLE COVERAGE STANDARDS

As of January 1,2009, Massachusetts Health Care Reform requires that Massachusetts residents age 18 and older have health coverage that meets the Minimum Creditable

Coverage (MCC) standards set by the Commonwealth Health Insurance Connector, unless waived from the health insurance requirement based on affordability or individual

hardship.

This notice is to inform you that this health insurance plan complies with the requirements ofthe Massachusetts Health Care Reform Law and meets the Minimum Creditable Coverage standards that are in effect January 1,2009 ..

By purchasing coverage under this plan,you and any dependents enrolled under your plan will have satisfied the statutory requirement that you have health insurance meeting these standards. There is no action needed by you.

This disclosure is for minimum creditable coverage standards that are effective January 1,2009. Because these standards may change, review your health plan material each year to determine whether your plan meets the latest standards.

Ifyou have any questions about this notice, please call our Member Services department at (888) 333-4742.For TTY service, please call (800) 637-8257. Our representatives are available

weekdays between 8:00 a.m. and 5:30 p.m., and unti17:30 p.m.on Monday and Wednesday evenings.

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G7, 10/08

Schedule

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Service

Inpatient Acute Hospital Services (including Day Surgery)

Allcovered services including thefollowing: • Coronary care

• Hospital services • Intensive care

• Semi-private room and board

• Physicians' and surgeons' services including consultations

Covered infull.

Hospital Outpatient Department Services

All covered services including thefollowing:

• Anesthesia services • Chemotherapy

• Endoscopic procedures • Laboratory tests andx-rays • Radiation therapy

• Physicians' andsurgeons' services

Covered infull.

Emergency Services

• Youare always covered for care in a Medical Emergency. A referral from your PCP isnot needed. In a Medical Emergency, you should go to the nearest emergency facility or call 911 or other local emergency number. Ifyou are hospitalized, you mustcallyour PCP within 48hours or assoon as you can. Please notethat thisrequirement ismet if your attending physician hasalready given notice to yourPCP.

$50 Copayment pervisit in anemergency room.This Copayment iswaived if admitted directlytothe hospital from the emergency room. See "Physician's Services" for coverage of emergency services by a physician inany other location.

The Harvard Pilgrim HMO Massachusetts

Form#113

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.----Physician Services (including covered services by podiatrists) All covered services including thefollowing:

• Administration of injections • Allergy tests and treatments

• Changes and removals of casts,dressings orsutures • Chemotherapy

• Consultations concerning contraception and hormone replacement therapy

• Diabetes self-management, including education and training

• Diagnostic screening and tests,including but not limited to mammograms, blood tests,leadscreenings andscreenings mandated by state law

• Family planning services

• Infertility services

• Health education, including nutritional counseling

• Medical treatment of temporomandibular joint dysfunction (TMD)

• Preventive care, including routinephysical examinations, immunizations, routine annual eye examinations, school, camp, sports and premarital examinations

• Sickand well office visits,including psychopharmacological services

• Vision and hearing screening

$10 Copayment pervisit.

(Please note:diagnostic tests, mammograms, x-rays and immunizations will be covered infullifbilled without an office visitand no other services areprovided.)

• Administration ofallergy injections $5 Copayment pervisit.

Maternity Services

• Prenatal and postpartum care

• All hospital services for mother and routine nursery charges for newborn care

The Harvard Pilgrim HMO Massachusetts

Form#113

Covered in full. Covered in full.

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r

Mental Health and Drug and Alcohol Rehabilitation Services

Please notethat no dayorvisit limitsapplyto inpatient or outpatient mental health treatment for biologically-based mental disorders, rape-related mental oremotional disorders, and non-biologically-based mental, behavioral oremotional disorders for children and adolescents. No day or visit limits apply to inpatient or outpatient drugand alcohol

rehabilitation services that are authorized bya Plan mental health clinician in conjunction with treatment ofmental disorders. (please see your Benefit Handbook for details.)

• Inpatient mental health services inalicensedgeneral hospital - unlimited • Inpatient mental health services inapsychiatric hospital - up to 60 daysper

calendar year I

• Inpatient drug and alcohol rehabilitation services - up to 30 daysper calendar year I

Covered in full.

• Inpatient detoxification

• Outpatient mental healthservices - up to 24 visits per calendar year for individual therapy and up to25visitsper calendar year forgroup therapy, not to exceed a combined maximum of25 individual and group therapy visitsper calendar year Group therapy

Individual therapy

• Outpatient drug andalcohol rehabilitation services - up to 20visitsor$500 in benefit valuepercalendaryear,whichever is greater

Group therapy

Individual therapy visits 1-8 Individual therapy after visit 8

• Outpatient drug and alcohol rehabilitation services in conjunction with the treatment ofmental disorders

Group therapy Individual therapy • Outpatient detoxification • Psychological testing

$10 Copayment pervisit. $10 Copayment pervisit.

$10 Copayment per visit. $10Copayment pervisit. $25Copayment pervisit.

$10Copayment pervisit. $10Copayment pervisit. $10 Copayment pervisit. $10 Copayment per visit.

Home Health Care Services

• Home careservices

Covered in full. • Intermittent skilled nursing care

No costsharing or benefit limit applies to durable medical equipment, physical therapy or occupational therapy received as part of authorized home health care.

IPartial hospitalization services are available up toamaximum of 120 days per calendar year in place ofinpatient

mental health services. Partial hospitalization services are available up to a maximum of 60 days per calendar year in place ofinpatient drug and alcohol rehabilitation services.

The Harvard Pilgrim HMO

Massachusetts

Form # 113

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Dental Services

• Preventive care for children through the age of 12.Two visitsperMember per

calendar year, including examination, cleaning, x-rays, andfluoride treatment. Covered infull.

• Extraction ofunerupted teeth impacted in bone

• Initialemergency treatment (within 72hours of injury)

$10Copayment per visit.If inpatient services are required, please see "Inpatient AcuteHospital Services" forcostsharing.

Skilled Nursing Facility Care Services

• Covered up to100 daysper calendar year Covered infull.

Inpatient Rehabilitation Services

• Covered up to 60 daysper calendar year Covered infull.

Diabetes Equipment and Supplies

• Therapeutic molded shoes and inserts, dosage gauges, injectors, lancet devices, voice synthesizers andvisual magnifying aids

• Blood glucose monitors, insulin pumps andsupplies and infusion devices

• Insulin, insulin syringes, insulin pens with insulin, lancets,oral agents for

controlling blood sugar,blood teststrips,and glucose, ketone and urinetest strips

Subject to the applicable cost

sharing, if any,under the durable medical and prosthetic equipment benefit. Covered infull. Subject tothe applicable prescription drug Copayment listed onyour ID card,ifyour Plan includes prescription drug coverage. Ifprescription drug coverage isnot

available, thenyou will pay a $5 Copayment forTier 1 items,$10 Copayment for Tier 2 items and a$25 Copayment for Tier 3 items.

Durable Medical Equipment including Prosthetics

Durable medical equipment (DME) including prosthetics - up to a maximum of

$2,500 per calendar year forall covered equipment. Coverage includes, but isnot limited to:

• Durable medical equipment

• Prosthetic devices (theDME benefit limit doesnot apply to artificial arms and legs)

• Ostomy supplies

• Breast prostheses, including replacements and mastectomy bras (the DME benefit limit does not apply)

• Oxygen and respiratory equipment (the DME benefit limit orcost sharing,ifany,

doesnot apply)

• Wigs - up to a limit of$350 per calendar year when needed asa result of anyform ofcancer or leukemia, alopecia areata, alopecia totalis or permanent hair lossdue

to injury

The Harvard Pilgrim HMO

Massachusetts

Form#113

Covered infull.

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Hypodermic Syringes and Needles

• Hypodermic syringes and needles to theextent Medically Necessary, asrequired

by Massachusetts law

Subject tothe applicable

prescription drug Copayment

listedonyour IDcard, if your

Plan includes prescription

drug coverage. Ifprescription

drug coverage isnot

available, thenyouwillpay

thelower ofthepharmacy's

retail priceora $5

Copayment for Tier 1items,

$10Copayment for Tier 2

items anda $25Copayment for Tier 3 items.

Other Health Services • Cardiac rehabilitation

• Dialysis

• Physical and occupational therapies - up to 60 consecutive days per condition • Speech-language and hearing services, including therapy

• Early intervention services up toamaximum of$3,200 per Member per calendar

year and alifetime maximum of $9,600

• Second opinion

$10Copayment pervisit.

• House calls $15Copayment pervisit.

• Ambulance services

• Low protein foods ($5,000 per Member per calendar year) • Statemandated formulas

Covered in full.

• Hospice services Covered in full.If inpatient

services are required, please

see "Inpatient Acute Hospital Services" for cost sharing. • Vision hardware for special conditions

The Harvard Pilgrim HMO Massachusetts

Form#113

Covered in full up to the applicable benefit limits as

described in the Benefit

Handbook.

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Special Enrollment Rights

For Subscribers enrolled through anEmployer Group:

If the Subscriber declines enrollment for himself orherself and Dependents (including spouse) because of other health insurance coverage, the Subscriber maybe ableto enroll inthis plan in the future along with theDependents,

provided that enrollment is requested within 30days after other coverage ends. In addition, if the Subscriber hasa new Dependent as a result ofmarriage, birth,adoption orplacement for adoption, the Subscriber may beableto

enroll along with the newDependents, provided that enrollment is requested within30 days after the marriage,

birth, adoption or placement for adoption.

Membership Requirements

There are a few important requirements thatyou must meet inorder tobe covered by thePlan. (please see your

Benefit Handbook fora complete description) .

• Members must live intheHPHC's Enrollment Area forat least ninemonths ofthe year.Anexception is

made for full-time student dependents and dependents enrolled under aQualified Medical Support Order.

• Allyourmedical and health care needs must beprovided orarranged by your Primary CarePhysician (PCP),

except ina Medical Emergency, whenyou aretemporarily outside theHPHC Service Area orwhen you

needone ofthe special services which donot require areferral. TheHPHC Service Area isthe state in which

you live.

The Harvard Pilgrim HMO Massachusetts

Form#113

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Exdusions

• Services notapproved, arranged or provided by your PCP except: (1) inaMedical Emergency; (2) when youare outside oftheService Area; or

(3)the special services that donot require a referral listed inyour Benefit Handbook

• Cosmetic procedures, except asdescribed inyour Benefit Handbook

Commercial diet plans or weight lossprograms andany services in connection with such plansor programs

• Transsexual surgery, including related drugs or procedures

• Drugs, devices, treatments or procedures which

are Experimental or Unproven

• Refractive eye surgery, including laser surgery

and orthokeratology, for correction ofmyopia,

hyperopia andastigmatism

• Transportation other than byambulance

• Costs forany services forwhichyou areentitled totreatment atgovemment expense, including military serviceconnected disabilities

• Costs forservices covered byworkers'

compensation, third party liability,other

insurance coverage oranemployer under state or federal law

• Hair removal or restoration, including, but not limited to, electrolysis, laser treatment,

transplantation or drugtherapy

• Routine foot care, biofeedback, pain management programs, massage therapy,

including myotherapy, and sports medicine

clinics

• Any treatment with crystals

• Blood and blood products

• Educational services (including problems of

school performance) or testing for developmental, educational or behavioral problems, except services covered under Early Intervention

• Mental healthservices that are(1) provided to Members who are confined or committed to a jail, house ofcorrection, prison or custodial

facilityof the Department ofY outh Services or

(2)provided bythe Department of Mental Health

• Sensory integrative praxis tests

• Physical examinations for insurance, licensing or

employment

• Vocational rehabilitation orvocational

evaluations on job adaptability, job placement or therapy to restore function for a specific

occupation

• Rest orcustodial care

• Personal comfort or convenience items (including telephone and television charges), exercise equipment, wigs (except as required by statelaw andspecificallycovered in this

Schedule of Benefits),derotation knee braces,

and repair or replacement ofdurable medical

equipment or prosthetic devices as aresult of

loss,negligence, willful damage ortheft

• Non-durable medical equipment, unless used as

part of thetreatment atamedical facility or as

part of approved homehealthcare services

• Reversal of voluntary sterilization (including

procedures necessary for conception as aresult of

voluntary sterilization)

• Any form of surrogacy

• Infertility treatment for Members who arenot medically infertile

• Routine matemity (prenatal and postpartum) care

when you are traveling outsidethe Service Area

• Delivery outside theServiceAreaafter the 37th week of pregnancy or after you have been told that you are at risk forearlydelivery

• Planned home births

• Devices or special equipment needed forsports

or occupational purposes

• Care outside the scopeof standard chiropractic practice, including,but not limited to, surgery,

prescription or dispensing of drugs or

medications, internal examinations, obstetrical practice, or treatment of infections and diagnostic testing for chiropractic care other than an initial x-ray

• Services for which no charge would be made in the absence of insurance

• Charges for any products or services, including,

but notlimited to,professional fees,medical equipment, drugsand hospital or other facility

charges that are related to any carethat isnota

covered service under thisHandbook

• Services for non-Members

• Services after termination of membership Services orsuppliesgiven toyou by: (I) anyone related to you by blood,marriage or adoption or (2) anyone who ordinarily liveswith you

• Charges for missed appointments

• Services that are not Medically Necessary

• Services for which no coverage isprovided in the

The Harvard Pilgrim HMO Massachusetts

Form#113

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Exclusions

Benefit Handbook, Schedule ofBenefits or

Prescription DrugBrochure (if yourPlan

includesprescription drug coverage)

• Any home adaptations, including, but not limited to,home improvements and home adaptation equipment

• All charges over the semi-private room rate,

except when a private room is Medically Necessary

Hospital charges after thedate of discharge

• Follow-up careto anemergency room visit

unless provided or arranged by yourPCP • Servicesforanewborn whohas not been

enrolledas aMember, other than nursery charges for routine services provided to ahealthy

newborn

• If yourPlan does not include coverage for

outpatient prescription drugs, there isno

coverage for birthcontrol drugs, implants, injections and devices

• Acupuncture, aromatherapy andalternative medicine

• Dentures

• Dental services,except the specific dental

services listedinyour Benefit Handbook and this Schedule ofBenefits. Restorative, periodontal,

orthodontic, endodontic, prosthodontic and

dental services for temporomandibular joint

dysfunction (TMD) arenotcovered. Removal of impacted teeth toprepare fororsupport

orthodontic, prosthodontic, or periodontal procedures and dental fillings, crowns, gum care,

including gum surgery, braces, root canals,

bridges and bonding.

• Chiropractic services, including osteopathic manipulation

• Eyeglasses, contact lenses and fittings,except as

listed in yourBenefit Handbook and this Schedule ofBenefits

• Hearing aids

• Foot orthotics, except for thetreatment of severe

diabetic footdisease

• Methadone maintenance

Private dutynursing

• If a service islisted asrequiring that it be provided at a Center of Excellence, no coverage will beprovided under your Benefit Handbook

andthisSchedule ofBenefits ifthatservice is received fromaprovider thathas not been

designated as a Center of Excellence byHPHC.

.

.

-The Harvard Pilgrim HMO Massachusetts

Form#113

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