El Paso Children’s Hospital - Preferred Admin Plan Document 2013-2014.pdfUnder a Federal law known as Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public

Si usted requiere este manual en Español,por favor comuníquese con PreferredAdministrators al 915-532-3778 o gratisal 1-877-532-3778 si llama fuera de El Pasode 7 am a 5 pm de Lunes a Viernes.

10/2013 E�ective October 2013

El Paso Children’s HospitalEmployee Health Benefit Fund Plan

PLAN DOCUMENT

TABLE OF CONTENTS

PLAN PARTICIPANTS RIGHTS AND RESPONSIBILITIES ....................................................................................... 1

NOTICE TO PARTICIPANTS ................................................................................................................................... 2

ARTICLE I ESTABLISHMENT OF THE PLAN; ADOPTION OF THE PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION .................................................. 5

1.01 EFFECTIVE DATE ........................................................................................................................................... 51.02 ADOPTION OF THE PLAN DOCUMENT ........................................................................................................ 5

ARTICLE II INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION ..................................................................................................... 6

2.01 INTRODUCTION AND PURPOSE ................................................................................................................... 62.02 GENERAL PLAN INFORMATION ................................................................................................................... 6

ARTICLE III SCHEDULE OF BENEFITS ................................................................................................................. 8

3.01 PPO PROVIDERS AND PREFERRED PROVIDERS ........................................................................................... 83.02 WRAP NETWORK FOR OUT-OF-AREA ......................................................................................................... 83.03 UTILIZATION REVIEW ................................................................................................................................... 113.04 BENEFIT PERCENTAGE, DEDUCTIBLES AND LIMITATIONS .......................................................................... 143.05 CLAIMS BILL REVIEW .................................................................................................................................... 153.06 ALPHABETICAL SCHEDULE OF PLAN BENEFITS ........................................................................................... 16 UNITED STATES PREVENTIVE SERVICES TASK FORCE (USPSTF) A & B RECOMMENDATIONS ................................................................................... 23 NEW WOMEN’S PREVENTIVE SERVICES ...................................................................................................... 26

ARTICLE IV DEFINITIONS ..................................................................................................................................... 27

4.01 ACCIDENTAL INjURy .................................................................................................................................... 274.02 ACTIVELy AT WORK ..................................................................................................................................... 274.03 ADA ............................................................................................................................................................ 274.04 ADMINISTRATIVE APPEAL ............................................................................................................................ 274.05 ADMINISTRATIVE DENIAL ............................................................................................................................ 274.06 ADVERSE BENEFIT DETERMINATION ........................................................................................................... 274.07 ADVERSE DETERMINATION APPEAL ........................................................................................................... 274.08 AFFILIATES .................................................................................................................................................... 284.09 AHA ............................................................................................................................................................ 284.10 ALLOWABLE ExPENSE .................................................................................................................................. 284.11 AMBULATORy SURGICAL FACILITy ............................................................................................................. 284.12 ANCILLARy SERVICES ................................................................................................................................... 284.13 APPEAL .......................................................................................................................................................... 284.14 ASSIGNMENT OF BENEFITS .......................................................................................................................... 28 4.15 BALANCE BILLING ......................................................................................................................................... 284.16 BENEFIT PERCENTAGE .................................................................................................................................. 284.17 BENEFIT MANAGEMENT ADVISORS ............................................................................................................ 284.18 BIRTHING CENTER ........................................................................................................................................ 28

PLAN DOCUMENT • i

LAST UPDATE OCTOBER 2013

4.19 CENTERS OF ExCELLENCE ............................................................................................................................ 294.20 CHANGE IN FAMILy STATUS......................................................................................................................... 294.21 CHANGE IN STATUS OR COVERAGE ............................................................................................................ 294.22 CHILD ............................................................................................................................................................ 304.23 CHIP ............................................................................................................................................................ 304.24 CHIPRA .......................................................................................................................................................... 304.25 CLEAN CLAIM ............................................................................................................................................... 304.26 COBRA ........................................................................................................................................................... 304.27 COMPLAINT .................................................................................................................................................. 314.28 COMPLETE CLAIM ........................................................................................................................................ 314.29 COORDINATION OF BENEFITS (COB) ........................................................................................................... 314.30 COSMETIC SURGERy OR PROCEDURES ....................................................................................................... 314.31 COVERAGE DATE .......................................................................................................................................... 314.32 COVERED ExPENSES ..................................................................................................................................... 314.33 COVERED PARTICIPANT................................................................................................................................ 314.34 CREDITABLE COVERAGE .............................................................................................................................. 314.35 CUSTODIAL CARE ......................................................................................................................................... 324.36 DEDUCTIBLE .................................................................................................................................................. 324.37 DENTIST ......................................................................................................................................................... 324.38 DEPENDENT .................................................................................................................................................. 324.39 DOMESTIC PARTNER .................................................................................................................................... 334.40 DURABLE MEDICAL EqUIPMENT ................................................................................................................. 334.41 EFFECTIVE DATE ........................................................................................................................................... 334.42 ELIGIBLE ExPENSE ........................................................................................................................................ 334.43 EMERGENCy MEDICAL CONDITION ............................................................................................................ 334.44 EMERGENCy SERVICES ................................................................................................................................. 344.45 EMPLOyEE .................................................................................................................................................... 34 4.46 EMPLOyER .................................................................................................................................................... 344.47 ERISA ............................................................................................................................................................ 344.48 ESSENTIAL HEALTH BENEFITS ...................................................................................................................... 344.49 ExPERIMENTAL AND/OR INVESTIGATIONAL (“ExPERIMENTAL”) ............................................................. 344.50 FMLA ............................................................................................................................................................ 354.51 FAMILy DEDUCTIBLE LIMIT .......................................................................................................................... 354.52 GINA ............................................................................................................................................................ 354.53 GLOBAL MATERNITy .................................................................................................................................... 354.54 HEALTH CARE SPENDING ACCOUNT ........................................................................................................... 354.55 HEALTH RISK ASSESSMENT (HRA) ............................................................................................................... 354.56 HIPAA ............................................................................................................................................................ 354.57 HOME HEALTH CARE AGENCy .................................................................................................................... 364.58 HOSPICE CARE .............................................................................................................................................. 364.59 HOSPICE CARE PROGRAM ........................................................................................................................... 364.60 HOSPITAL ...................................................................................................................................................... 364.61 HOSPITAL ExPENSES ..................................................................................................................................... 364.62 ILLNESS .......................................................................................................................................................... 364.63 IMMEDIATE FAMILy ..................................................................................................................................... 364.64 INCOMPLETE CLAIM ..................................................................................................................................... 364.65 INCURRED ..................................................................................................................................................... 374.66 INDEPENDENT REVIEW ORGANIZATION (IRO) ........................................................................................... 374.67 INjURy .......................................................................................................................................................... 374.68 IN-NETWORK ................................................................................................................................................ 374.69 INPATIENT BEHAVIORAL SERVICES .............................................................................................................. 374.70 INPATIENT SUBSTANCE ABUSE SERVICES .................................................................................................... 374.71 INTENSIVE CARE UNIT .................................................................................................................................. 374.72 INTENSIVE OUTPATIENT PROGRAM ............................................................................................................ 374.73 INTERLINK TRANSPLANT NETWORK ........................................................................................................... 374.74 LATE ENTRANT ............................................................................................................................................. 374.75 LIFETIME ........................................................................................................................................................ 374.76 MAxIMUM AMOUNT AND/OR MAxIMUM ALLOWABLE CHARGE ........................................................... 38

PLAN DOCUMENT • ii

PLAN DOCUMENT • iii

4.77 MAxIMUM BENEFIT PER PLAN yEAR .......................................................................................................... 384.78 MEDICAL EMERGENCy ................................................................................................................................. 384.79 MEDICALLy NECESSARy, MEDICAL CARE NECESSITy, MEDICAL NECESSITy ............................................. 384.80 MEDICALLy NECESSARy LEAVE OF ABSENCE ............................................................................................. 394.81 MEDICAL RECORD REVIEW .......................................................................................................................... 394.82 MEDICARE ..................................................................................................................................................... 394.83 NON-PREFERRED PROVIDER ........................................................................................................................ 394.84 ORGAN TRANSPLANT SERVICES .................................................................................................................. 394.85 ORTHOTIC DEVICE ........................................................................................................................................ 394.86 OTHER PLAN ................................................................................................................................................. 394.87 OUT-OF-AREA ............................................................................................................................................... 394.88 OUT-OF-POCKET OR MAxIMUM OUT-OF-POCKET ..................................................................................... 394.89 OUTPATIENT BEHAVIORAL HEALTH SERVICES ............................................................................................ 404.90 PHARMACy ................................................................................................................................................... 40 4.91 PHySICIAN .................................................................................................................................................... 404.92 PLAN ............................................................................................................................................................ 404.93 PLAN ADMINISTRATOR ................................................................................................................................ 404.94 PLAN SPONSOR ............................................................................................................................................. 404.95 PLAN yEAR ................................................................................................................................................... 404.96 PREFERRED PROVIDER ................................................................................................................................. 404.97 PREVENTIVE CARE ........................................................................................................................................ 404.98 PRIOR TO EFFECTIVE DATE OR AFTER TERMINATION DATE ...................................................................... 404.99 PROTECTED HEALTH INFORMATION OR SENSITIVE PERSONAL INFORMATION ....................................... 404.100 PROVIDER ..................................................................................................................................................... 414.101 PSyCHIATRIC DAy TREATMENT FACILITy ................................................................................................... 414.102 qUALIFIED DEPENDENT ............................................................................................................................... 414.103 qUALIFyING EVENT ..................................................................................................................................... 414.104 qUALIFIED MEDICAL DEPENDENT CHILD SUPPORT (qMCSO) .................................................................. 414.105 REASONABLE AND/OR REASONABLENESS ................................................................................................. 414.106 REHABILITATION (PHySICAL) FACILITy ....................................................................................................... 424.107 SKILLED NURSING FACILITy ......................................................................................................................... 424.108 SPECIALTy MEDICATIONS ............................................................................................................................ 424.109 SPOUSE .......................................................................................................................................................... 424.110 SUBROGATION .............................................................................................................................................. 424.111 SUBSTANCE ABUSE ....................................................................................................................................... 434.112 SCHEDULE OF MEDICAL BENEFITS .............................................................................................................. 434.113 TEMPOROMANDIBULAR jOINT DySFUNCTION (TMj) ............................................................................... 434.114 THIRD PARTy (CLAIM) ADMINISTRATOR .................................................................................................... 434.115 TOTALLy DISABLED ...................................................................................................................................... 434.116 USERRA ......................................................................................................................................................... 434.117 USUAL AND CUSTOMARy (U&C) ................................................................................................................. 444.118 WRAP NETWORK .......................................................................................................................................... 44

ARTICLE V ELIGIBILITY AND PARTICIPATION REQUIREMENTS ..................................................................... 45

5.01 ELIGIBILITy .................................................................................................................................................... 455.02 FAILURE TO ELECT MEDICAL COVERAGE DURING OPEN ENROLLMENT .................................................. 475.03 ENROLLMENT ............................................................................................................................................... 475.04 COVERAGE DURING A LEAVE OF ABSENCE ................................................................................................ 485.05 CONTINUATION OF COVERAGE UNDER COBRA ......................................................................................... 495.06 TERMINATION OF COVERAGE ..................................................................................................................... 545.07 REHIRED OR TRANSFERRED EMPLOyEES .................................................................................................... 555.08 PARTICIPANT CONTRIBUTIONS .................................................................................................................... 55

ARTICLE VI MEDICAL BENEFITS .......................................................................................................................... 56

6.01 BENEFITS PROVIDED ..................................................................................................................................... 566.02 DEDUCTIBLES AND CO-PAyS ....................................................................................................................... 566.03 COVERED MEDICAL ExPENSES .................................................................................................................... 566.04 ExPENSE LIMITATIONS ................................................................................................................................. 67

PLAN DOCUMENT • iv

ARTICLE VII EXCLUSIONS .................................................................................................................................... 68

7.01 CLAIMS SUBMITTED AFTER ONE yEAR ....................................................................................................... 687.02 MISCELLANEOUS RESTRICTIONS ON BENEFITS ........................................................................................... 687.03 ExCLUSIONS .................................................................................................................................................. 68

ARTICLE VIII CLAIMS PROCEDURES ................................................................................................................... 74

8.01 CLAIMS .......................................................................................................................................................... 748.02 REPORTING OF CLAIMS FROM ASSOCIATES ............................................................................................... 748.03 RECEIPT OF A COMPLETE CLAIM ................................................................................................................. 748.04 RECEIPT OF AN INCOMPLETE CLAIM ........................................................................................................... 748.05 UNCLAIMED BENEFITS ................................................................................................................................. 758.06 COVERED PARTICIPANT’S RESPONSIBILITIES TO UPDATE RECORDS .......................................................... 75

ARTICLE IX STANDARD COMPLAINT APPEALS PROCESS ............................................................................... 76

9.01 STANDARD COMPLAINT PROCESS ............................................................................................................... 769.02 APPEALS PROCESS ........................................................................................................................................ 769.03 ADVERSE DETERMINATION APPEAL ........................................................................................................... 779.04 APPEAL PROCESS FOR SPECIAL EPCH/UMC/TT BENEFIT COVERAGE ......................................................... 81

ARTICLE X MISCELLANEOUS ............................................................................................................................... 82

10.01 PLAN INTERPRETATION ................................................................................................................................ 8210.02 ExCLUSIVE BENEFIT ...................................................................................................................................... 8210.03 NON-ALIENATION OF BENEFITS ................................................................................................................... 8210.04 LIMITATION OF RIGHTS ................................................................................................................................ 8210.05 GOVERNING LAWS ....................................................................................................................................... 8210.06 SEVERABILITy ............................................................................................................................................... 8210.07 CAPTIONS ...................................................................................................................................................... 8210.08 CONSTRUCTION ............................................................................................................................................ 8210.09 ExPENSES ...................................................................................................................................................... 8310.10 CLAIM DETERMINATION PERIOD ................................................................................................................ 8310.11 RIGHT TO RECEIVE AND RELEASE NECESSARy INFORMATION ................................................................. 8310.12 FACILITy OF PAyMENT ................................................................................................................................. 8310.13 RIGHT TO RECOVERy ................................................................................................................................... 83

ARTICLE XI SUBROGATION, REIMBURSEMENT, AND THIRD PARTY RECOVERY PROVISION .................................................................................. 84

11.01 PAyMENT CONDITION ................................................................................................................................. 8411.02 SUBROGATION .............................................................................................................................................. 8411.03 RIGHT OF REIMBURSEMENT ........................................................................................................................ 8511.04 ExCESS INSURANCE ...................................................................................................................................... 8611.05 SEPARATION OF FUNDS ............................................................................................................................... 8611.06 WRONGFUL DEATH ...................................................................................................................................... 8611.07 OBLIGATIONS ................................................................................................................................................ 8611.08 OFFSET .......................................................................................................................................................... 8711.09 MINOR STATUS ............................................................................................................................................. 8711.10 LANGUAGE INTERPRETATION ...................................................................................................................... 8711.11 SEVERABILITy ............................................................................................................................................... 87

ARTICLE XII COORDINATION OF BENEFITS ....................................................................................................... 88

12.01 BENEFITS SUBjECT TO THIS PROVISION ...................................................................................................... 8812.02 ExCESS INSURANCE ...................................................................................................................................... 8812.03 VEHICLE LIMITATION .................................................................................................................................... 8812.04 ALLOWABLE ExPENSES ................................................................................................................................ 8812.05 CLAIM DETERMINATION PERIOD ................................................................................................................ 8812.06 EFFECT ON BENEFITS .................................................................................................................................... 8812.07 RIGHT TO RECEIVE AND RELEASE NECESSARy INFORMATION ................................................................. 8912.08 FACILITy OF PAyMENT ................................................................................................................................. 9012.09 RIGHT OF RECOVERy ................................................................................................................................... 9012.10 COORDINATION WITH MEDICARE .............................................................................................................. 90

PLAN DOCUMENT • v

ARTICLE XIII AMENDMENT AND TERMINATION ............................................................................................. 91

13.01 AMENDMENT ............................................................................................................................................... 9113.02 TERMINATION ............................................................................................................................................... 9113.03 EFFECT ON OTHER BENEFITS ....................................................................................................................... 91

ARTICLE XIV HIPAA PRIVACY RULE .................................................................................................................... 92

14.01 PLAN’S DESIGNATION OF PERSON/ENTITy TO ACT ON ITS BEHALF .......................................................... 9214.02 THE PLAN’S DISCLOSURE OF PHI/SPI TO THE PLAN SPONSOR/ REqUIRED CERTIFICATION OF COMPLIANCE By PLAN SPONSOR ............................................................. 9214.03 PERMITTED DISCLOSURE OF INDIVIDUALS’ /SPI TO THE PLAN SPONSOR ................................................. 9214.04 DISCLOSURE OF INDIVIDUALS’ /SPI/DISCLOSURE By THE PLAN SPONSOR ............................................... 9314.05 DISCLOSURES OF SUMMARy HEALTH INFORMATION AND ENROLLMENT AND DISENROLLMENT INFORMATION TO THE PLAN SPONSOR ............................................................... 9414.06 REqUIRED SEPARATION BETWEEN THE PLAN AND THE PLAN SPONSOR ................................................. 94

ARTICLE XV HIPAA SECURITY STANDARDS ..................................................................................................... 95

15.01 DEFINITIONS ................................................................................................................................................. 9515.02 PLAN SPONSOR OBLIGATIONS ..................................................................................................................... 95

EL PASO CHILDREN’S HOSPITALEMPLOYEES HEALTH BENEFIT PLAN

PLAN PARTICIPANT RIGHTS AND RESPONSIBILITIES

As an El Paso Children’s Hospital Employees Health Benefit Plan Participant you have certain rights and responsibilities, as outlined below.

YOU HAVE THE RIGHT TO: • Receivemedicaltreatmentthatisavailablewhenyouneeditandishandledinawaythat

respects your privacy and dignity.

• Gettheinformationyouneedaboutyourhealthcareplan,includinginformationaboutservices that are covered, and services that are not covered.

• HaveaccesstoacurrentlistofprovidersinthecontractedPreferredAdministratorsNetworkandhaveaccesstoinformationaboutaparticularprovider’seducation,trainingand practice.

• HaveyourmedicalinformationkeptconfidentialbythecontractedPreferredAdministra- tors Employees and your health care provider.

• Learnaboutanycareyoureceive.Youshouldbeaskedforyourconsentforallcare,unlessthereisanemergencyandyourlifeandhealthareinseriousdanger.

• Beheard.Ourcomplaint-handlingprocessisdesignedtohearandactonyourcomplaintorconcernaboutthecontractedPreferredAdministratorsand/orthequalityofserviceyou receive.

YOU HAVE THE RESPONSIBILITY TO: • ReviewandunderstandtheinformationyoureceiveabouttheElPasoChildren’sHospital

AssociateHealthBenefitPlanandtheadministrativeservicesprovidedbyPreferredAdministrators.PleasecallourCustomerServiceHelplinewhenyouhavequestionsorconcerns at 915-532-3778. Customer Service representatives are available to assist you from7:00amto5:00pm.

• ShowyourElPasoChildren’sHospitalEmployeeHealthBenefitPlanIDCardwiththePreferredAdministratorsinformationbeforeyoureceivecare.

• Establishacomfortablerelationshipwithyourpractitionerorprovider;askquestionsaboutthingsyoudon’tunderstand;andprovidehonest,completeinformationtotheproviderscaringforyou.

• Knowwhatmedicineyoutake,whyandhowtotakeit.

• Payallco-payments,deductiblesandcoinsuranceforwhichyouareresponsible,atthetime service is rendered.

• Beforeyourreceiveservices,youshouldalwaysverifythatyourproviderisstillin-networkwithPreferredAdministratorsbycalling915-532-3778from7:00amto5:00pm.

• Voiceyouropinions,concernsorcomplaintstoPreferredAdministrators.

• NotifyyouremployerElPasoChildren’sHospitalHumanResourcesDepartmentat915-242-8620aboutanychangesinfamilysize,address,phonenumberormembershipstatus.

PLAN DOCUMENT • PAGE 1

NOTICE TO PARTICIPANTS

NOTICE TO PARTICIPANTS OF THEEL PASO CHILDREN’S HOSPITAL

EMPLOYEE HEALTH BENEFIT PLAN

UnderaFederallawknownasHealthInsurancePortabilityandAccountabilityActof1996(HIPAA),PublicLaw104-191,asamended,grouphealthplansmustgenerallycomplywiththerequirementslistedbelow:

1. Specialenrollmentperiodsforindividuals(andDependents)losingothercoverage(146.117).

2. Prohibitions against discriminating against individual participants and beneficiaries based on health status (146.121).

3. Standardsrelatingtobenefitsformothersandnewborns (section2704ofPHSAct).

4. Parityintheapplicationofcertainlimitstomentalhealthbenefits (section2705ofPHSAct).

5. Requiredcoverageforreconstructivesurgeryfollowingmastectomies (section2706ofPHSAct).

COBRA NOTIFICATION PROCEDURES

ItisthePlanparticipant’sresponsibilitytoprovidethefollowingnoticesastheyrelatetoCOBRAContinuationCoverage:

Notice on COBRA Continuation Coverage Election – Thisnoticecontainsimportantinforma-tionaboutyourrighttocontinueyourhealthcarecoverageinthePreferredAdministratorsBenefit Plan, as well as other health coverage alternatives that may be available to you throughtheHealthInsuranceMarketplace.Theremaybeothercoverageoptionsforyouandyourfamily.Whenkeypartsofthehealthcarelawtakeeffect,you’llbeabletobuycoverage through the Health Insurance Marketplace. In the Marketplace, you could be eligibleforanewkindoftaxcreditthatlowersyourmonthlypremiumsrightaway,andyoucanseewhatyourpremium,deductibles,andout-of-pocketcostswillbebeforeyoumakeadecisiontoenroll.BeingeligibleforCOBRAdoesnotlimityoureligibilityforcoverageforataxcreditthroughtheMarketplace.Additionally,youmayqualifyforaspecialenrollmentopportunityforanothergrouphealthplanforwhichyouareeligible(suchasaspouse’splan),eveniftheplangenerallydoesnotacceptlateenrollees,ifyourequestenrollmentwithin 30 days.

Notice of Divorce or Legal Separation –NoticeoftheoccurrenceofaQualifyingEventthatisadivorceorlegalseparationofacoveredEmployeefromhisorherspouse.

Notice of Child’s Loss of Dependent Status –NoticeofaQualifyingEventthatisachild’slossofDependentstatusunderthePlan(e.g.,aDependentchildreachingthemaximumagelimit).

Notice of Second Qualifying Event – NoticeoftheoccurrenceofasecondQualifyingEventafteraQualifiedBeneficiaryhasbecomeentitledtoCOBRAContinuationCoveragewithamaximumdurationof18(or29)months.

Notice Regarding Disability –Noticethat:(a)aQualifiedBeneficiaryentitledtoreceiveCOBRAContinuationCoveragewithamaximumdurationof18monthshasbeendeterminedbytheSocialSecurityAdministrationtobedisabledatanytimeduringthefirst60daysofcontinuationcoverage,or(b)aQualifiedBeneficiaryasdescribedin“(a)”hassubsequentlybeen determined by the Social Security Administration to no longer be disabled.


Notice Regarding Address Changes – It is important that the Plan Administrator be kept informedofthecurrentaddressesofallPlanparticipantsorbeneficiarieswhoareormaybecome qualified Beneficiaries.

Notificationmustbemadeinaccordancewiththefollowingprocedures.AnyindividualwhoiseitherthecoveredAssociate,aQualifiedBeneficiarywithrespecttotheQualifyingEvent,oranyrepresentativeactingonbehalfofthecoveredAssociateorQualifiedBeneficiarymayprovidetheNotice.NoticebyoneindividualshallsatisfyanyresponsibilitytoprovideNoticeonbehalfofallrelatedQualifiedBeneficiarieswithrespecttotheQualifyingEvent.

Form of Notification and Delivery –NotificationoftheQualifyingEventmustbemadeonaspecificform.Theformcanbeobtained,freeofcharge,bycontactingtheCOBRAServiceProvider.ThecompletedformmustbedeliveredtotheCOBRAServiceProviderorthePlanSponsor’sHumanResourcesOffice.

Content –NotificationmustincludeevidenceregardingtheQualifyingEventorothereventextendingcoveragesuchas:copyofdivorcedecree,copyofchild’sbirthcertificate,copyofthe Social Security Administration’s disability determination letter.

Time Requirements for Notification –Inthecaseofadivorce,legalseparationorachildlosingdependentstatus,Noticemustbedeliveredwithin60daysfromthelaterof:(1)thedateoftheQualifyingEvent,(2)thedatehealthplancoverageislostduetotheevent,or(3)thedatetheQualifiedBeneficiaryisnotifiedoftheobligationtoprovideNotice through the Summary Plan Description or the Plan Sponsor’s General COBRA Notice.

IfanEmployeeorQualifiedBeneficiaryisdeterminedtobedisabledundertheSocialSecurityAct,Noticemustbedeliveredwithin60daysfromthelaterof:(1)thedateofthedetermination,(2)thedateoftheQualifyingEvent,(3)thedatecoverageislostasaresultoftheQualifyingEvent,or(4)thedatethecoveredEmployeeorQualifiedBeneficiaryisadvisedoftheNoticeobligationthroughthe SPD or the Plan Sponsor’s General COBRA Notice. Notice must be provided within the 18-month COBRAcoverageperiod.AnysuchQualifiedBeneficiarymustalsoprovideNoticewithin30daysofthedateheissubsequentlydeterminedbytheSocialSecurityAdministrationtonolongerbedisabled.

The Plan will not reject an incomplete Notice as long as the Notice identifies, the Plan, the covered EmployeeandQualifiedBeneficiary(ies),theQualifyingEvent/disabilitydeterminationandthedateonwhichitoccurred.However,thePlanisnotpreventedfromrejectinganincompleteNoticeiftheQualifiedBeneficiarydoesnotcomplywitharequestbythePlanformorecompleteinformationwithinareasonableperiodoftimefollowingtherequest.

IMPORTANT INFORMATION

WHO TO CONTACT FOR ADDITIONAL INFORMATIONAPlanparticipantcanobtainadditionalinformationaboutthecoverageofaspecificdrug,treat-ment,procedure,preventiveservice,etc.fromtheofficethathandlesclaimsonbehalfofthePlan(the“PlanAdministrator”).Thename,addressandphonenumberofthePlanAdministratoris:

El Paso Children’s HospitalHuman Resources Department

4845 Alameda AvenueEl Paso, Tx 79905

(915) 242-8620


THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACTGroup health plans and health insurance issuers generally may not, under Federal law, restrict bene-fits,foranyhospitallengthofstayinconnectionwithchildbirthforthemotherornewbornchildtolessthan48hoursfollowingavaginaldelivery,orlessthan96hoursfollowingacesareandelivery.However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, afterconsultingwiththemother,fromdischargingthemotherorhernewbornearlierthan48hours(or96hoursasapplicable).Inanycase,plansandissuersmaynot,underFederallaw,requirethataproviderobtainauthorizationfromtheplanortheissuerforprescribingalengthofstaynotinexcessof48hours(or96hours).

DEFINITIONSSomeofthetermsusedinthisdocumentbeginwithacapitalletter.Thesetermshavespecialmean-ingsandareincludedintheDefinitionssection.Whenreadingthisdocument,itwillbehelpfultorefertothissection.Becomingfamiliarwiththetermsdefinedwillprovideabetterunderstandingofthebenefitsandprovisions.

NOTICE OR RIGHT TO RECEIVE A CERTIFICATE OF CREDITABLE COVERAGEUndertheHealthInsurancePortabilityandAccountabilityActof1996(commonlyknownasHIPAA),anIndividualhastherighttoreceiveacertificateofpriorhealthcoverage,calleda“certificateofcreditablecoverage”or“certificateofgrouphealthplancoverage,”fromthePlanSponsororitsdelegate.IfPlancoverageorCOBRAcontinuationcoverageterminates,thePlanSponsorwillauto-maticallyprovideacertificateofcreditablecoverage.Thecertificateisprovidedatnochargeandwillbemailedtothepersonatthemostcurrentaddressonfile.Acertificateofcreditablecoveragewillalsobeprovided,onrequest,inaccordancewiththelaw(i.e.,arequestcanbemadeatanytimewhilecoverageisineffectandwithintwenty-four(24)monthsafterterminationofcoverage).WrittenproceduresforrequestingandreceivingcertificatesofcreditablecoverageareavailablefromthePlanSponsor.

TheAffordableCareActrequiresmostpeopletohavehealthcarecoveragethatqualifiesas“minimum essential coverage.” This plan or policy does provide minimum essential coverage.

TheAffordableCareActestablishesaminimumvaluestandardofbenefitsofahealthplan.Theminimum value standard is 83% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.


[signature]

LAWRENCE G. DUNCAN

CEO

October 1, 2013

ARTICLE I

ESTABLISHMENT OF THE PLAN;ADOPTION OF THE PLAN DOCUMENTAND SUMMARY PLAN DESCRIPTION

THIS PLAN DOCUMENT AND SUMMARy PLAN DESCRIPTION, made by the El Paso Children’s Hospital (the“Company”orthe“PlanSponsor”)asofOctober1,2013.

1.01 Effective Date

ThePlanDocumentiseffectiveasofthedatefirstsetforthabove,andeachamendmentiseffectiveasofthedatesetforththerein.

1.02 Adoption of the Plan Document

ThePlanSponsor,asthesettlerofthePlan,hasadoptedthisPlanDocumentasthewrittendescrip-tionofthePlan.ThisPlanDocumentrepresentsboththePlanDocumentandtheSummaryPlanDescription.ThisPlanDocumentamendsandreplacesanypriorstatementofthehealthcarecoverage contained in the Plan or any predecessor to the Plan.

INWITNESSWHEREOF,thePlanSponsorhascausedthisPlanDocumenttobeexecuted.

El Paso Children’s Hospital

By: _________________________________________

Name: ______________________________________

Date:________________________________________ Title: ________________________________________


ARTICLE II

INTRODUCTION AND PURPOSE;GENERAL PLAN INFORMATION

2.01 Introduction and Purpose

ThepurposeofthePlanistoprovideeligibleandenrolledEmployeesbenefitcoverageaccordingtoaScheduleofBenefits,forMedicallyNecessaryandAppropriatetreatmentadministeredbylicensedmedical providers.

This Plan has been designed to provide eligible Employees with coverage options that provide benefits basedonpointofservicedecisionsmadebytheAssociates.WhenEmployeesselectprovidersandreceive medical services, benefit coverage amounts will be determined based on the contracted status oftheprovider.Asthecontractstatusofprovidersisimproved,benefitcoverageamountsareincreas-edfortheAssociates.Becauseofthecostofmedicalcare,CoveredEmployeesareencouragedtobeselectiveconsumersofhealthcareandtobeawareoftheincreasesinbenefitcoverageamountsthathave been made available to Employees when they select El Paso Children’s Hospital or University MedicalCenterofElPasoandotherpreferredprovidersfortheirmedicalservices.

WeexpectandencourageyoutoreviewthisbookletwhichdescribesthebenefitsprovidedbythisPlan.Employees are mandated to participate in the Health Risk Assessment Program which is provided throughElPasoChildren’sHospitalWellnessProgramandtobeactiveparticipantsofhealthylifestylesandpreventivehealthpractices.

2.02 General Plan Information

NAME OF PLAN: El Paso Children’s Hospital Employees Health Benefit Plan

PLAN SPONSOR: El Paso Children’s Hospital 4845 Alameda Avenue El Paso, Tx 79905

PLAN ADMINISTRATOR: El Paso Children’s Hospital(Named Fiduciary) 4845 Alameda Avenue El Paso, Tx 79905

PLAN SPONSOR ID NO. (EIN): 26-3075429

SOURCE OF FUNDING: PartiallySelf-FundedwithMedicalStopLoss

APPLICABLE LAW: ERISA

PLAN YEAR: October 1 through September 30

PLAN NUMBER: 501

PLAN TYPE: Medical Prescription Drug

THIRD PARTY ADMINISTRATOR: PreferredAdministrators P.O.Box971100 El Paso, Tx 79997 Phone:(915)532-3778or(877)532-3778 Fax:(915)532-2877

PARTICIPATING EMPLOYER(S): None


AGENT FOR SERVICE OF PROCESS: Lawrence Duncan 4845 Alameda Avenue El Paso, Tx 79905

Legal Entity; Service of Process

The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the Plan’s agent,LawrenceDuncan,ChiefExecutiveOfficer.

Not a Contract

ThisPlanDocumentandanyamendmentsconstitutethetermsandprovisionsofcoverageunderthisPlan.ThePlanDocumentshallnotbedeemedtoconstituteacontractofanytypebetweentheCompanyandanyParticipantortobeconsiderationfor,oraninducementorconditionof,theemploymentofanyAssociate.NothinginthisPlanDocumentshallbedeemedtogiveanyAssociatetherighttoberetainedintheserviceoftheCompanyortointerferewiththerightoftheCompanytodischargeanyAssociateatanytime;provided,however,thattheforegoingshallnotbedeemedtomodifytheprovisionsofanycollectivebargainingagreementswhichmaybeenteredintobytheCompanywiththebargainingrepresentativesofanyEmployees.

Applicable Law

The Plan is governed by the Employee Retirement Income and Security Act (ERISA) as amended. InnoeventshalltheEmployerguaranteethefavorabletaxtreatmentsoughtbythisPlan.

Discretionary Authority

ThePlanAdministratorshallhavesole,fullandfinaldiscretionaryauthoritytointerpretallPlanprovisions, including the right to remedy possible ambiguities, inconsistencies and/or omissions in thePlanandrelateddocuments;tomakedeterminationsinregardstoissuesrelatingtoeligibilityforbenefits;todecidedisputesthatmayariserelativetoaPlanParticipants’rights;andtodetermineallquestionsoffactandlawarisingunderthePlan.

This Plan is not a “Grandfathered Health Plan” Under the Patient Protection and Affordable Care Act.

Thisgrouphealthplanbelievesthiscoverageisnota“GrandfatheredHealthPlan”underthePatientProtectionandAffordableCareAct(theAffordableCareAct).ThisisanewPlan.TheeffectivedateforthisPlanisaftertheeffectivedateofthePPACA.QuestionsregardingwhichprotectionsapplyandwhichprotectionsdonotapplytoaGrandfatheredHealthPlanandwhatmightcauseaplantochangefromgrandfatheredhealthplanstatuscanbedirectedtotheplanadministrator at 915-532-3778. questions regarding which protections apply and which protections donotapplytoaGrandfatheredHealthPlanandwhatmightcauseaplantochangefromGrand-fatheredPlanstatuscanbedirectedtothePlanAdministratoratthefollowingaddress:

Preferred Administrators1145 Westmoreland

El Paso, Tx 79925915-532-3778

Forindividualmarketpoliciesandnon-federalgovernmentalplans:YoumayalsocontactEmployeeBenefitsSecurityAdministration,U.S.DepartmentofLaborat1-866-444-3272 www.dol.gov/ebsa/healthreformortheU.S.DepartmentofHealthandHumanServicesatwww.healthreform.gov. ThiswebsitehasatablesummarizingwhichprotectionsdoanddonotapplytoGrandfatheredHealth Plans.


ARTICLE III

SCHEDULE OF BENEFITS

3.01 PPO Providers and Preferred Providers

AcurrentlistofPPOProvidersisavailable,withoutcharge,throughPreferredAdministratorswebsite at www.preferredadmin.net.

ThisPlanprovidesoptionsforEmployeestoreceivemedicalservicesfromproviderswhohavecontracted with the provider networks contracted by the Plan. This Plan rewards Employees with increased benefit coverage amounts based on the providers selected as described in the ScheduleofBenefits.ThegreatestbenefitamountsareprovidedwhenEmployeesuseElPasoChildren’sHospital,UniversityMedicalCenterofElPaso,andTexasTechfacilitiesandservices.BenefitcoverageamountsarebasedonatraditionalbenefitplandesignusingPreferredProviderNetworks.ForthisPlanthepreferredprovidersare:

(1) ElPasoChildren’sHospitalandUniversityMedicalCenterofElPasoandTexasTechPhysicians

Note:IfyourmedicalcareisnotavailableatElPasoChildren’sHospital,UniversityMedicalCenterofElPasoorTexasTech,butitisofferedwithaPPOprovider,yourbenefitwillbeappliedatPPOexceptfortheserviceslistedunder#4oftheSchedule

ofBenefitsforWrapNetworkProviders.

(2) PreferredAdministratorsNetworkinElPasoandotherproviderscontractedbyPreferredAdministratorsNetworkonbehalfofthisPlan.

Note:IfyourmedicalcareisnotavailablewithinaPPONetworkandyoureceiveservicesfromanOut-of-Networkprovider,yourbenefitwillbePPO,butadditionalcharges(BalanceBilling)maybeincurredwhenreceivingservicesfromanon-contracted provider.

Note: PreferredAdministratorsNetworkphysicians,whoprovideservicesatUMCorEPCH,willhaveprofessionalservicespaidatthecontractedrate.Member’sresponsibilitieswillbeUMC/EPCH/TexasTechbenefitcoveragelevel.

3.02 Wrap Network for Out-of-Area

Ifyoureceiveservicesout-of-area(outsideElPasoCountyandtheimmediatesurroundingareaswhereactiveEmployeesreside),youwillreceivePPOBenefitsaslongasyoumeetthefollowingcriteria and as long as the provider is contracted provider with our Wrap Network. Please note the

(1) TheCoveredemployeeorCoveredDependentresidesorisenrolledinschoolfulltimeoutside El Paso County and the provider is located in the City or County where the employee or Covered Dependent resides or attends school, or

(2) TheWrapNetworkforOut-of-Area/Non-ContractedProvidersCoveredEmployeeorCoveredDependentistravelingonvacationandrequiresurgentoremergencymedicalcarewhileoutsideofElPasoCounty,or

(3) ThemedicalservicerequiredhasbeenconfirmedbytheMedicalUtilizationReviewpro- gramasnotbeingprovided/performedbyaproviderinElPasoCounty.Ifamember electivelychoosestoreceiveservicesfromanout-of-networkprovider;thememberwill

beresponsibleforout-of-networkbenefitsasexplainedinthisPlanDocument.


***** Please Note the following: Services rendered by an Out-of-Network Provider *****

— Prior Authorization must be obtained. Failure to obtain an authorization will result in a loss of coverage for the service or procedure.

— Youwillberequiredtosatisfyahigherdeductibleandco-insurance.

— YoumayberequiredtopaythedifferencebetweentheamountsthehealthcareproviderchargesandthesumthePPOplanclaimstobe“reasonablecharge”forthegiven medical service.

SCHEDULE OF BENEFITS FOR WRAP NETWORk PROVIDERS

1. Wrap Network Providers for covered Employees and dependents,residingoutsideoftheState/Area to include

— BenefitsformedicalservicesprovidedformembersresidingoutsideofElPasoCountywillbebasedonthe“PPONetwork”ScheduleofBenefits,whentheemployeereceivesservicesfromacontractedproviderwithinourWrapNetwork(Multiplan/PHCS).

— MemberswillberesponsibletoupdatetheirOutofState/OutofareaaddresswithPreferredAdministratorsandverifyiftheproviderisacontractedproviderwith(Multiplan/PHCS)at1-800-922-4362andoryoucanverifyonlineatMultiplan.com. This will determine how the employee’s benefits will be applied.

Prior-AuthorizationwillberequestedforserviceslistedundertheUtilizationReviewsectioninthefollowingpages.PriorAuthorizationisnotaguaranteeofpayment.Allbenefitdeter-

minationsaresubjecttoeligibilityenrollment,andthetermsofcoveragedefinedinthisPlan.

2. Wrap Network Providers for Out-of-Area. Employeestravelingoronvacation,requiringanemergency medical care

— PPOBenefitswillbeappliedwhenusinganOut-Of-AreaProviderwhenthetreatmentis forasuddenacutemedicalillnessorinjurythatpresentsanurgentoremergencysituation.

Iftheproviderisacontractedprovider,theBenefitPercentagewillbeappliedtothecon- tractedallowableamounts.IftheproviderisnotacontractedproviderwithourWrap

Network, the PPO Benefit will be applied but additional charges (Balance Billing) may be incurredwhenreceivingservicesfromaNonContractedProvider.

— PPOBenefitswillbeappliedwhenusingOut-Of-AreaProviderwhenthetreatmentisforanemergencyroomphysicianwhostaffsanemergencyroomforOut-of-Area/Non-ContractedProviders.IftheproviderisnotacontractedproviderwithourWrapNetwork,thePPOBenefit will be applied but additional charges (Balance Billing) may be incurred when receivingservicesfromaNonContractedProvider.

AllEmergencyAdmissionsmustbeauthorizedwithin24hoursofadmission.PriorAuthori- zationisnotaguaranteeofpayment.Allbenefitdeterminationsaresubjecttoeligibility

enrollment,andthetermsofcoveragedefinedinthisPlan.

3. Wrap Network Providersformedicalservicesnotbeingprovided/performedbyaproviderin ElPasoCountyandconfirmedbytheMedicalUtilizationReviewProgram

— When services are not available within El Paso County but the services are available with oneofourWrapNetworkProviders(Multiplan/PHCS),thebenefitswillbeappliedatPPOBenefits. If the member electively chooses a provider that is not contracted with our Wrap Network, the benefit will be Out-of-Network Benefits at 60/40 when services are not offered in El Paso County and confirmed by our Medical Utilization Review Program.

Priorauthorizationmustbeobtained.Failuretoobtainpriorauthorizationwillresultinalossofcoveragefortheserviceorprocedure.PriorAuthorizationisnotaguaranteeofpayment.Allbenefitdeterminationsaresubjecttoeligibilityenrollment,andthetermsofcoverage defined in this Plan.


4. When the following services are not available at EPCH, UMC, or Texas Tech, benefit coverage throughaPPOorOut-of-NetworkproviderwillbepaidatthescheduleofbenefitlevelofEPCH,UMCandTexasTech:

1. Radiation Therapy (Adult and Children) 2. PET Scans 3. Electrophysiology Lab 4. Adult Allergy/Immunology – limited to patient management (physicians visit), treat- mentanddiagnosticsinthephysiciansoffice. 5. Cystic Fibrosis Treatments – limited to patient management (physicians visit), treatment

anddiagnosticsinthephysiciansoffice. 6. OphthalmologyServices–limitedtothemedicaldiagnosisforthetreatmentofaneye

disorder and outpatient surgery. 7. Pain Management – limited to patient management (physicians visit), treatment and

diagnosticsinthephysiciansoffice. 8. Urology – limited to patient management (physicians visit), treatment and diagnostics

inthephysiciansoffice.

Any service not mentioned above will be covered at the appropriate benefit level per the Schedule of Benefits.

TheservicesreferencedabovearecurrentlynotavailableatEPCH,UMCorTexasTech.Iftheservicesaredeemedtobemedicallynecessarybasedonpre-authorization,whichisrequired,andareconsideredastandardofmedicalcarefortheconditionbeingtreated,thentheservicesshallbesubjecttothebenefitcoveragelevelofEPCH,UMCorTexasTech.Thisbenefitonlyapplies to members residing in the El Paso Service Area.

Note: El Paso Service Area is comprised of El Paso County and its immediate surrounding areas that include in Texas: Anthony, Canutillo, Clint, Fabens, Fort Hancock, Horizon, San Elizario, Socorro, Tornillo; and in New Mexico: Chaparral, Santa Teresa and Sunland Park.

Theofficevisitwillbecoveredonthelesserofthetwoco-pays,whichisUMCandEPCH.

Theseserviceswillbecoveredundertheappealprocessafterservicesareprovidedandpaidatthecurrentbenefitlevel.Ifpriorauthorizationisnotobtained,theEPCH/UMCandTexasTechlevelofcoveragewillnotbeapplied.IftheservicebecomesavailableatEPCH,UMCorTexasTech,servicesmustbeprovidedtheretoattainthehigherlevelofreimbursement.

PleasecontactPreferredAdministratorsifthereisapotentialfortheabove-mentionedservicesto be rendered at 915-532-3778.

APPEAL PROCESS FOR SPECIAL EPCH/UMC/TT BENEFIT COVERAGE: • Membershaveuptosixty(60)calendardaystofileanappealforeachbilledservicefrom

thedateonthefirstExplanationofBenefits(EOB)Form.

• AllappealswillbereviewedbyPreferredAdministratorstoensuretheymeettheapplicablecriteria (i.e. filed on a timely basis, pre-authorization received).

• PreferredAdministratorswillnotifythememberthattheappealhasbeenreceived.

• PreferredAdministratorsprovidesallrelevantinformationrelativetotheappeal(Prior Authorization obtained, medical necessity confirmed) toEPCHforfinalapproval.

• OnceafinaldeterminationismadebyEPCH,PreferredAdministratorsnotifiesthememberinwritingwithinfive(5)daysofthedetermination.

• IftheoutcomeallowstheEPCH/UMC/TTlevelofbenefit,PreferredAdministratorswillreview the amounts and accumulators and process any changes accordingly.


FINDING PROVIDERS:(1)ForElPasoAreaNetworkProviders:www.preferredadmin.net or call 915-532-3778.

(2)ForProvidersoutsideoutoftheElPasoServiceArea:Logontowww.multiplan.com or call 1-800-678-7427 or to locate a PHCS provider, please call 1-800-922-4362.

(3)Ifyouhaveanyquestions,youcanreachourCustomerServiceDepartmentat915-532-3778 or 1-877-532-3778ifoutsideofthecallingarea.Our Customer Service Department is available Monday through Friday from 7 a.m. to 5 p.m., Mountain Time.

3.03 Utilization Review:

The Plan requires prior authorization through Preferred Administrators for all scheduled inpatient admissions and specified outpatient procedures and diagnostic tests. Failure to obtain prior authori-zation for a scheduled inpatient and outpatient procedure will result in a denial of eligible benefit.

NOTE: A Preauthorization does not guarantee payment of benefits nor verify eligibility. Payment of benefits is subject to all terms conditions, limitations and exclusions of the member’s Benefit Plan, regardless of a determination, medical, decisions regarding a course of treatment are solely between the physician and the patient.

UTILIZATION MANAGEMENT AND PRIOR AUTHORIZATION

Utilization Review:

PreferredAdministratorsrequirespriorauthorizationforallscheduledinpatientadmissionsandspecifiedoutpatientproceduresanddiagnostictests.Failuretoobtainpriorauthorizationforascheduledinpatientandoutpatientprocedurewillresultinalossofcoveragefortheserviceorprocedure.PleasecontactTPAAdministrationtoverifypayment,eligibilityandbenefits.

PRIOR AUTHORIZATION:ThePlanrequiresthataProviderobtainsapriorauthorizationforthefollowingCoveredServicesorprocedures:

All out-of-network services provided by non-participating facility, provider, lab, or vendor require pre-authorization.

Inpatient Admissions

• AcuteHospital• Surgical• Non-Surgical• Rehab• Hospice• MaternityandNewborn• BehavioralHealth• ElectiveAdmissions/Surgery

Outpatient Therapy

• PhysicalTherapy(Noauthorizationisrequiredfortheinitialevaluation)• SpeechTherapy(Noauthorizationisrequiredfortheinitialevaluation)• OccupationalTherapy(Noauthorizationisrequiredfortheinitialevaluation)• Chiropractic(Noauthorizationisrequiredfortheinitialevaluation)• BehavioralHealth(Noauthorizationisrequiredfortheinitialevaluation)• RadiationTherapy• Chemotherapy• InfusionTherapy• Dialysis• HomeHealth(Noauthorizationisrequiredfortheinitialevaluation)


Radiology/Diagnostic Imaging

• PETScans• ObstetricalUltrasounds(Memberisallowedfourultrasoundswithoutobtainingpre-

authorization)NO Authorization required for MRI, MRA, CT scans, EKG’s, or X-Rays

Outpatient Procedures

• AmbulatorySurgicalCenter• EndoscopyCenter• CardiacCatheterCenter• WoundClinic• OutpatientHospital

Pharmacy Medical

• GrowthHormones• Synagis• OralInjectableorIVDrugAdministrationover$500 NoTE: This includes oral, injectable, or IV provided in a Physician’s office

• SpecialtyMedicines NoTE: Please go to www.preferredadmin.net for complete list of specialty medicines

Other Services

• AllergyImmunotherapy• LaserSurgeries• OralSurgery• OrthoticsandProsthetics($200andoverforAdultandChildren)• Podiatry Except for debridement of nails, avulsion of nail plate, excision of nail and wedge excision of skin of nail

• Transplants(ToincludeevaluationservicesbyTransplantFacility)• Transportation(AirTransportandNon-Emergent Ambulance)

INPATIENT ADMISSIONS:Allelective(non-emergency)admissionsrequirepriorauthorization.Thepriorauthorizationprocesswillreviewthemedicalnecessityandappropriatenessfortherequestedadmission.Priorauthoriza-tionwillalsoidentifyappropriatealternativefacilityprovidersorsettingsfortherequestedadmission,suchasanalternativeuseofanoutpatientfacilitywhentherequestedservicecanbesafelyandeffectivelydoneinanoutpatientratherthananinpatientsetting.

Allemergencyadmissions(thosethroughanEmergencyRoomoradirectadmitfromaphysician’soffice)requirenotificationwithintwentyfour(24)hoursorthenextbusinessdayfollowingtheemergencyadmission.FailuretonotifyPreferredAdministratorsofanemergencyadmissionwillre-sultindenialofaclaim.Whenemergencyadmissionsoccurandthepatientwillbeconfinedbeyondtwentyfour(24)hours,transfertoUMCwillbeofferedwhenthepatient’sconditioncanappropri-ately be treated at UMC and the patient is medically stable and able to be transported to UMC.

AlthoughitistheProvider’sresponsibilitytorequestauthorizationforthehealthcareservicestobedelivered,itisultimatelytheAssociate’sresponsibilitytoensurethattherequestedserviceshavebeenpreauthorizedtoavoiddelayinservicesorunpaidclaims.WeencourageyoutoalwayscallPreferredAdministratorsat915-532-3778toverifyiftheproviderrequestedanauthorizationbeforeyourendertheservices.


INPATIENT MATERNITY:All Inpatient Maternity Admissionsrequirenotificationfromyourproviderwithintwentyfour(24)hoursorthenextbusinessdayfollowingthedelivery.FailuretonotifyPreferredAdministratorsofanemergencyadmissionwillresultindenialofaclaim.

NOTE: A Preauthorization does not guarantee payment of benefits nor verify eligibility. Payment of benefits is subject to all terms conditions, limitations and exclusions of the member’s Benefit Plan, regardless of a determination, medical, decisions regarding a course of treatment are solely between the physician and the patient.

CONCURRENT REVIEW AND DISCHARGE PLANNING: Allinpatientadmissionsaremonitoredforcompliancewiththecertifiedlengthofstay.Admissionswhicharecontinuedbeyondtheexpectedlengthofstay,arereviewedtodeterminethemedicalnecessityforthecontinuedstay,andtoidentifytheexpecteddischargedateofthepatient.

ThePreferredAdministratorsCaseManagerwillworkcollaborativelywiththefacilitywhenapatientcanappropriatelybetransferredtoanalternativecaresetting;orwhenapatientisdis-chargedfromanacutecaresettingtoanalternativecaresettingsuchashomehealthcare.

PRIOR AUTHORIZATION FOR OUTPATIENT BEHAVIORAL HEALTH ADMISSIONS AND OUTPATIENT THERAPY:Allelective(non-emergency)BehavioralHealthadmissionsforMental&NervousDisordersorSubstanceAbuserequirepriorauthorization.Thepriorauthorizationprocesswillreviewthemedi-calnecessityandappropriatenessfortherequestedadmission.Priorauthorizationwillalsoidentifyappropriatealternativefacilityprovidersorsettingsfortherequestedadmission,suchasanalterna-tiveuseofanoutpatientfacilitywhentherequestedservicecanbesafelyandeffectivelydoneinan outpatient rather than an inpatient setting.

Outpatient therapy by a Psychiatrist M.D. or a Psychologist Ph.D. or counseling by a licensed professionalbasedonawrittenreferralfortherapyorcounselingrequirespriorauthorization.AninitialevaluationbyanM.D.orPh.D.doesnotrequirepriorauthorization.Subsequenttherapysessionsorreferraltoalicensedprofessionalfortherapyorcounselingrequirespriorauthorization.

CASE MANAGEMENT:AsanElPasoChildren’sHospitalPlanParticipantyouqualifyforcertainCaseManagementbenefitsdetermined to be necessary and appropriate at no charge to the Associate. Case Management services areprovidedthroughPreferredAdministratorsandwillrequirefullparticipationbytheAssociate.

TheHealthServiceDepartmentstaffwhichincludesMedicalDirector,RegisteredNurses,LicensedVocational Nurses, Case Managers and Social Workers are available to assist Employees when situationsemergeinvolvingpotentiallyhighcostmedicalservices,complexmedicalcareneeds,catastrophicmedicalillnessorinjury,oroutofareamedicalservices.CaseManagerswillconsultwiththetreatingphysiciansandfacilityrepresentativesregardingmedicalserviceneedsandpotentialalternativetreatmentplans.ThefocusofCaseManagementistoassisttheAssociatebymonitoringthesituation,identifyingavailableclinicalresources,makingsuggestionsregardingtreatment plan options, helping the Associate understand a disease process, a treatment plan or medicalterminology,whichmayincludethefollowing:

• personalsupporttotheemployeeandfamily; • monitoringhospitalstaysandsub-acutefacilities; • identifyingappropriatealternativecareoptions; • assistinginobtaininganynecessaryequipmentorsupplies; • coordinatingthecareplanamongphysician(s)andotherhealthcareprofessionals.

ParticipationinCaseManagementisrequiredwhenitisdeterminedtobeanappropriateresource.Accepting Medical Case Management recommendations is voluntary and there will be no reduction ofbenefitsiftheAssociatechoosesnottoacceptrecommendationspresentedbytheCaseManager.


3.04 Benefit Percentage, Deductibles and Limitations

BENEFIT PERCENTAGE, DEDUCTIBLES AND LIMITATIONS Preferred EPCH & UMC, Administrators El Paso Children’s Network/ Hospital & University Texas Tech Wrap Network/ Non-Contracted Benefit Description Medical Center of El Paso Provider PPO Benefit Providers

BENEFIT PERCENTAGE or COINSURANCE PERCENTAGE (payable by the Plan)

InpatientHospitalAdmissions $150co-pay N/A $600co-pay $2,000co-pay(per admission) and 100% and 75% and 60% coverage coverage coverage once once once deductible deductible deductible is met is met is met

OtherOutpatientSurgery $60co-pay N/A $200co-pay $1,000co-payincluding Birthing Centers and 100% and 75% and 60% (unless specified otherwise) coverage coverage coverage once once once deductible deductible deductible is met is met is met

FailuretoobtainPriorAuthorizationortocomplywiththedeterminationoftheMedicalReviewprocessmayresultinthedenialofaclaimforbenefits.SeetheprecedingprovisionforMedicalManagementandPriorAuthorizationrequirements.

The Benefit Percentage will be applied to the contracted allowable amounts for the ParticipatingContractedProvidersandOut-of-NetworkbenefitswillbeappliedtoNon-ContractedProviders.

PPObenefitswillalsobeappliedwhenusingOut-of-AreaProvidersfor:

•Treatmentforasuddenacutemedicalillnessorinjurythatpresentsanurgentoremergencysitua- tionprovidedbyNon-Network/Non-ContractedProviders;•TreatmentbyOut-of-Area/Non-Contractedemergencyroomphysicianswhostaffanemergency

roomofanOut-of-Area/Non-Contractedhospital.

• SPECIAL NOTICE: Additional charges (Balance Billing) may be incurred when receiving services from Non-Contracted Providers.

DEDUCTIBLE PER FISCAL YEAR$100 $2,500 $3,000Per Covered Participant

MaximumFamilyDeductibleLimit $300 $5,000 $6,000 After the deductible is met, the Plan pays the Benefit Percentage (co-insurance percentage) ofCoveredExpensesincurredinthebalanceoftheFiscalYearforeachindividualuptotheOut-of-Pocketmaximum.


Preferred EPCH & UMC, Administrators El Paso Children’s Network/ Hospital & University Texas Tech Wrap Network/ Non-Contracted Benefit Description Medical Center of El Paso Provider PPO Benefit Providers

OUT-OF-POCKET MAXIMUM PER FISCAL YEARPerCoveredParticipant N/A $6,000 Unlimited

FamilyOut-of-Pocket N/A $12,000 Unlimited

TheOut-of-Pocketmaximumincludesanyapplicabledeductiblesandco-pays,butnotanynon-compliancepenalties,andamountsinexcessofallowableamountsoranynon-CoveredExpenses.AftertheOut-of-Pocketmaximumhasbeenreached,thePlanpays100%ofCoveredExpensesincurredfortheindividualinthebalanceoftheFiscalYear(excludingdeductibles,co-pays,non-compliancepenalties,andNon-CoveredExpenses).

WhentheOut-of-Pocketlimitisreached,thereimbursementpercentagerateisincreasedto100%forthebalanceoftheFiscalYearforcoveredmedicalchargesaslimitedbyanymaximumbenefitamounts.

TheOut-of-PocketMaximumdoesnotapply toPrescriptionDrugdeductiblesandco-pays,DurableMedicalEquipment,OrthoticDevices,EmergencyRoomCo-pays,andBereavementBenefits.Out-of-Area services will not apply.

ANNUAL LIMIT No annual limit.(Per Covered Participant)

3.05 Claims Bill Review

In addition to the Plan’s Medical Record Review process, the Plan Administrator may use its discretionary authoritytoutilizeanindependentbillreviewand/orclaimauditprogramorserviceforacompleteclaimreview While every claim may not be subject to a bill review or audit, the Plan Administrator has the sole discretionaryauthorityforselectionofclaimssubjecttorevieworaudit.

Theanalysiswillbeemployedtoidentifychargesbilledinerrorand/orchargesthatarenotandUsualandCustomaryandReasonableand/orMedicallyNecessaryand/orAppropriate,ifany,andmayincludeapatientmedicalbillingrecordsreviewand/orauditofthepatient’smedicalchartsandrecords.

Uponcompletionofananalysis,areportwillbesubmittedtothePlanAdministratororitsagenttoidentifythechargesdeemedinappropriateorineligibleorinexcessoftheUsualandCustomaryandReasonable amounts or other applicable provisions, as outlined in this Plan Document.

Despitetheexistenceofanyagreementtothecontrary,thePlanAdministratorhasthediscretionaryauthority to reduce any charge to a Usual and Customary and Reasonable charge, in accordance with thetermsofthisPlanDocument.



3.06 Alphabetical Schedule of Plan Benefits

PaymentforanyoftheexpenseslistedbelowissubjecttoallPlanexclusions,limitationsandprovisions.

ALPHABETICAL SCHEDULE OF PLAN BENEFITS

ALLERGY TESTING AND INJECTIONS

AllergyTestingandInjections 100%after 100%after 75%after 60%after deductible deductible deductible deductible

AllergySerumVials 100%after 100%after 75%after 60%afterDispensedinaPhysician’sOffice deductible deductible deductible deductible

Allergy Serum Vials Covered as a Prescription DrugDispensed by a Pharmacist

AMBULANCE (AIR AND GROUND)

Ambulance N/A N/A 75% 75%

Emergencyairandgroundambulancetransportationcoveredtothenearestappropriatefacility.Non-emergencygroundambulancetransportationthatismedicallynecessaryforlocalareatransferbetweeninpatient facilities (acute, subacute or hospice) when appropriate. Non-emergency air or groundtransportationforanyotherreasonrequiresPriorAuthorizationreview.BenefitamountsbasedontheUsualandCustomaryrateortheprovider’scontractedrateifapplicable.

DIAGNOSTIC X-RAY, PATHOLOGY AND LABORATORY SERVICES

Radiology, Pathology, and inpatient or inpatient or inpatient or inpatient orLaboratory Benefits outpatient outpatient outpatient outpatient 100%after 100%after 75%after 60%after deductible deductible deductible deductible

NOTE:Ifawomenyoungerthan40yearsofagereceivesamammogram,itwillbeconsideredDiagnosticand your deductibles or PPO co-insurance will apply.

DURABLE MEDICAL EQUIPMENT

HospitalInpatient/Outpatientor N/A 100%after 75%after 60%afterOther Medical / DME Provider deductible deductible deductible

EMERGENCY CARE BENEFITS UMC of El Paso Wrap Network PPO Non-Contracted Providers No Balance Billing “Warning” “Warning” (You will be Balanced Billed from the (You will be Balanced Billed from Emergency Care Provider that treated Providers Not Contracted by you in the Emergency Department) Preferred Administrators)

Facility Professional Facility Professional Facility Professional

100%of 100%of 100%of 100%ofUsual 100%ofUsual 100%ofUsual Contracted Contracted Contracted and Customary and Customary and Customary Amount Amount Amount Charges Charges Charges afterco-pay afterco-pay afterco-pay of$50 of$50 of$50

NOTE: Deductible/Coinsurance does not apply when obtaining emergency services. If you receive services at a PPo Hospital/out-of-Network Hospital you will be balanced billed from the Professional ER Providers that are not contracted by Preferred Administrators. Additional Charges (Balance Billing) will be incurred when receiving services from a Non-Contracted Provider. El Paso Children’s Hospital honors the same levels than UMC.



HOME HEALTH CARE

Benefit N/A N/A 75%after 60%after deductible deductible

MaximumBenefits N/A N/A 120visitsper 60visitsper Fiscal year Fiscal year (Includes (Includes Skilled Skilled Nursing) Nursing)

HOSPICE CARE

Benefit 100% 100% 75% 60%after deductible

MaximumvisitsperFiscalYear 180

InpatientHospiceCare N/A N/A $600co-pay $2,000co-pay 75%after 60%after deductible deductible

HOSPITAL SERVICES

HospitalCharges–InpatientAdmissions $150co-pay N/A $600co-pay $2,000co-pay(MedicalandSurgical) 100% 75%after 60%after inpatient deductible deductible after deductible

HospitalCharges–OutpatientServices $60co-pay N/A $200co-pay $1,000co-pay(MedicalandSurgical) 100%after 75%after 60%after deductible deductible deductible

HOSPITAL ROOM AND BOARD CHARGES

RoomandBoardCharges N/A 75%after 60%after(Including Medically Necessary deductible deductible Private Room Isolation)

IntensiveCare N/A 75%after 60%after(Allowable Room Rate) deductible deductible

PrivateRoomChargesforHospitals N/A 75%after 60%afterwith Private Rooms Only deductible deductible



BEHAVIORAL HEALTHMENTAL AND SUBSTANCE ABUSE Crisis Hotline – 866-804-8873PreferredAdministratorsprovidesacrisishotlinethatoffersimmediatesupportforEmployeeswhoareexperiencingemotionalandbehavioraldistress.

OutpatientOfficeVisit N/A $20co-pay $35co-pay 60%after deductible

IntensiveOutpatientVisit N/A N/A $35co-pay 60%after deductible

PsychiatricDayTreatment N/A N/A $35co-pay 60%after deductible

PartialHospitalization N/A N/A 75%after 60%after deductible deductible

InpatientBehavioralAdmission N/A N/A $600co-pay $2,000co-pay 75%after 60%after deductible deductible

InpatientSubstanceAbuseAdmission N/A N/A $600co-pay $2,000co-pay 75%after 60%after deductible deductible

CO-PAYPROVIDESFORTHEOFFICEVISIT/CONSULTATIONONLY.AllotherCoveredExpensesprovidedduringanofficevisitarecoveredatthe100%,75%or60%BenefitPercentageaccordingtothenetworkcontractedstatusoftheserviceprovider.

CoveredExpensesDuringOfficeVisit 100%after 100%after 75%after 60%after(Lab, x-Ray) deductible deductible deductible deductible

The Employee Assistance Program (EAP) offers 8 free counseling sessions for therapy and counseling by providers within the EAP Program. If you require more than 8 professional services a Prior Authorization will be required. You can call the EAP program at 915-351-4680 to make your appointment.

Prior Authorization for professional services is required through the Health Service Department ofPreferredAdministrators.IfPriorAuthorizationisnotobtainedyourbenefitswillbedenied.

NUTRITIONAL COUNSELING by A Registered Dietitian or Nutritionist

Youwillbecoveredat100%ifyoumeet 100% 100% 100% NotCoveredspecific guidelines according to the United States Preventive Services Task Force (USPSTF) A & B Recommendations List, page 23.

OCCUPATIONAL THERAPY – Non-Workers’ Compensation

Outpatient 100%after 100%after 75%after 60%after deductible deductible deductible deductible

MaximumBenefitperFiscalYear (30visitstobecombinedwithSpeechTherapyand Physical Therapy)



OFFICE VISITS

Physician,NursePractitioner, $10co-pay $20co-pay $35co-pay 60%afterorCertifiedNurseMidwife deductible

CoveredExpensesDuringOfficeVisit 100%after 100%after 75%after 60%after(Lab, x-Ray) deductible deductible deductible deductible

Co-payprovidesfortheofficevisit/consultationonly.AllotherCoveredExpensesprovidedduringanofficevisitarecoveredata100%,75%or60%BenefitPercentageaccordingtothenetwork/Out-of-Area/contractedstatusoftheserviceprovider.

ORGAN TRANSPLANTS

OrganTransplantservicesareprovidedthroughthetransplantnetworkorcontractedtransplantfacilityapproved by the Plan Administrator and stop loss carrier.

ORTHOTICS

Benefits 100%after 100%after 75%after None deductible deductible deductible

Onedevice/pairoforthopedic shoes,orthotics,andother supportivedevices for thefeet foradults.Limitedtooneorthoticdevice/pairperfiscalyear.Orthoticdevicesfordependentchildrenwillbecoveredasneededformedicalnecessity.

PHYSICAL THERAPY

Outpatienttherapyperformedby 100%after 100%after 75%after 60%aftera licensed therapist or Physician deductible deductible deductible deductible

MaximumBenefitperFiscalYear (30visitstobecombinedwithOccupationalTherapyand Speech Therapy)

PREGNANCY EXPENSES

CoveredEmployeesandSpouses GlobalBillingforallconfirmedpregnanciesstarting October 1, 2012

CoveredDependentDaughters (Inpatient/Non-EmergentwillrequirePriorAuthorization ifdependentresidesinoroutsideofElPasoCounty. ServiceswillbecoveredatPPOBenefitifPriorAuthoriza- tionisobtained.Serviceswillbedeniedifnoauthorization isobtained).GlobalBillingforallconfirmedpregnancies starting October 1, 2012.

PRESCRIPTION DRUGS

Co-Payments University Medical Center of El Paso Pharmacies All Network Pharmacies $5Generic $25Generic $25Brand $45Brand $50Non-Formulary $70Non-Formulary

PrescriptionDrugDeductible Separate$50FiscalYearDeductiblepermember. Prescription Drug Deductible does not apply to Medical PlanDeductibleortheOut-of-PocketMaximum. continued on next page



PRESCRIPTION DRUGS – continued

Maintenance Medication University Medical Center of El Paso Pharmacies Only A90daysupply(afterprescriptiondeductible) $5Generic $25Brand $50Non-Formulary

Specialty Drug Medication University Medical Center of El Paso Pharmacies Only or mail order $50Co-payandwillbedispensedat30daysupply.

Please go to www.preferredadmin.netforacomplete listofspecialtymedicines.

Prescriptionsover$500 Co-payapplies. AllNetworkPharmacies*AuthorizationRequired 60%afterprescription drug deductible.

Examples of Covered Drugs •Adderall,Dexedrine,andDextrostat •Drugsrequiringaprescriptionundertheapplicablestatelaw •Federallegendprescriptiondrugs •Injectableinsulin,insulinsyringes,chemstrips,andbloodlancets •Injectables(otherthaninsulin) •I.V.medicationsprescribedbyalicensedphysiciananddispensedbyalicensedpharmacist •Non-insulinneedles/syringes •Oralandinjectablecontraceptives •Prescriptionpre-natalvitamins

Examples of Excluded Drugs •Anabolicsteroids •Anorectics(anydrugusedforthepurposeofweightloss) •Anorexiants(exceptforAdderall,Dexedrine,andDextrostat) •Cosmetics •Fertilitymedications •Fluoridesupplements • Investigationalorexperimentaldrugsincludingcompoundedmedicationsfornon-FDA approved use •Outdateddrugsormedicines(dispensedmorethanayearafterthedateofthePrescription) •Medicaldevicesandothersupplies(exampleDiabetesbloodlevelmonitoriscoveredunder the Plan) •Non-legenddrugsotherthaninsulin •Nocharge prescription under Workers’ Compensation, or other governmental program •Rogaine •Viagraandsimilardrugs •Vitaminsotherthanprescriptionpre-natalvitamins

REHABILITATION (PHYSICAL) FACILITIES

In/OutpatientServices 100%afterdeductible 75%after 60%after deductible deductible

CoveredExpensesDuringRehabStay 100%after 100%after 75%after 60%after(Lab, x-Ray) deductible deductible deductible deductible



SKILLED NURSING FACILITIES

Benefit N/A N/A 75%after 60%after deductible deductible

MaximumDaysperFiscalYear 60

Confinementmustbeginwithin7daysoftheHospitalstayforthesameorrelatedconditionsunlesstheadmissioniscertifiedbymedicalreviewasanalternativetoanadmissiontoanacutecarefacility.

SPEECH THERAPY

Benefit 100%after 100%after 75%after 60%after deductible deductible deductible deductible

MaximumBenefitperFiscalYear (30visitstobecombinedwithOccupationalTherapyand Physical Therapy) Subject to certain other limitations

SPINAL ADJUSTMENT/CHIROPRACTIC ADJUSTMENT

OfficeVisit N/A $20co-pay $35co-pay 60%after deductible

CoveredExpensesDuringOfficeVisit N/A 100%after 75%after 60%after(Lab, x-Ray) deductible deductible deductible

MaximumBenefitperFiscalYear $2,500

Co-payprovidesfortheofficevisit/consultationonly.AllotherCoveredExpensesprovidedduringanofficevisitarecoveredata100%,75%or60%BenefitPercentageaccordingtothenetwork/Out-of-Area/contractedstatusoftheserviceprovider.

SURGICAL EXPENSES

Anesthesiology inpatient or inpatient or inpatient or inpatient or outpatient outpatient outpatient outpatient 100%after 100%after 75%after 60%after deductible deductible deductible deductible

Primary Surgeon inpatient or inpatient or inpatient or inpatient or outpatient outpatient outpatient outpatient 100%after 100%after 75%after 60%after deductible deductible deductible deductible

Pathology and Radiology inpatient or inpatient or inpatient or inpatient or outpatient outpatient outpatient outpatient 100%after 100%after 75%after 60%after deductible deductible deductible deductible

URGENT CARE/WALK-IN CLINICS

UrgentCareServices–afterhoursand $10co-pay $20co-pay $35co-pay 60%afterweekendmedicalservicesfornon- deductibleemergency illnesses and minor injuries.



WELLNESS BENEFITS

OfficeVisitsforAnnualPhysicalExams 100% 100% 100% NotCovered(PCP).OneperFiscalYearforMale/Female.

OfficeVisitsforAnnualWellWomen’s 100% 100% 100% NotCovered(OB/GyN). One per Fiscal year.

Well Adult routine immunizations recommended by the Centers for Disease Control and Prevention (CDC) will be covered over the age of 18. These services come with specific age guidelines.

Covered Preventive Screenings – 100% 100% 100% Not CoveredYouwillbecoveredat100%ifyoumeetspecific guidelines according to the United States Preventive Services Task Force (USPSTF) A & B Recommendations and Women’s Preventive Care, listed on pages 23-26

NOTE: These services come with specificGuidelines(e.g.,frequency).

Mammogram– 100% 100% 100%after NotCoveredCoveredat100%forwomenages deductible40 and older. One per Fiscal year.

NOTE:Ifawomenyoungerthan40yearsofagereceivesamammogram,itwillbeconsidered diagnostic and your deductibles or PPO co-insurance will apply

Flu Shots 100% 100% 100% Not Covered Covered

HPV – Age 9 up to 26. 100% 100% 100% Not Covered(Series must be completedbeforememberreachesage26.)

Meningococcal Vaccine 100% 100% 100% Not Covered

Zostavax–Age60andover. 100% 100% 100% NotCovered(Shingles)

WellAdultroutineimmunizationsrecommendedbytheCentersforDiseaseControlandPrevention(CDC)willbecoveredovertheageof18.Theseservicescomewithspecificageguidelines.

Well Baby and Well Child Preventative 100% 100% 100% Not CoveredCarePhysicalexamsand routineimmunizationsforcoveredparticipantsunder18yearsofage.

All Immunizations required by the Centers for Disease Control and Prevention (CDC) are covered.

Routine Immunizations include:Diphtheria,HepatitisB,Rotavirus,HaemophilusInfluenzaeTypeB(Hib),Pneumococcal,Pediarix,Measles, Mumps, Rubella (MMR), Pertussis, Polio, Tetanus, and Varicella.

Tetanus–Afterage11andboostersnomorethanevery10yearsorunlessmedicallynecessary.


UNITED STATES PREVENTIVE SERVICESTASk FORCE (USPSTF) A & B RECOMMENDATIONS

Abdominal aortic aneurysm screening: men —Recommendsone-timescreeningforabdominalaorticaneurysm by ultrasonography in men aged 65 to 75 who have ever smoked.

Alcohol misuse counseling — Recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.

Anemia screening: pregnant women — Recommendsroutinescreeningforirondeficiencyanemiainasymptomatic pregnant women.

Aspirin to prevent CVD: men —Recommendstheuseofaspirinformenage45to79yearswhenthepotentialbenefitduetoareductioninmyocardialinfarctionsoutweighsthepotentialharmduetoanincrease in gastrointestinal hemorrhage.

Aspirin to prevent CVD: women —Recommendstheuseofaspirinforwomenage55to79yearswhenthepotentialbenefitofareductioninischemicstrokesoutweighsthepotentialharmofanincrease in gastrointestinal hemorrhage.

Bacteriuria screening: pregnant women —Recommendsscreeningforasymptomaticbacteriuriawithurinecultureforpregnantwomenat12to16weeksgestationoratthefirstprenatalvisit,iflater.

Blood pressure screening —Recommendsscreeningforhighbloodpressureinadultsaged18andolder.

BRCA screening, counseling —RecommendsthatwomenwhosefamilyhistoryisemployeedwithanincreasedriskfordeleteriousmutationsinBRCA1orBRCA2genesbereferredforgeneticcounselingandevaluationforBRCAtesting.

Breast cancer preventive medication — Recommends that clinicians discuss chemoprevention with womenathighriskforbreastcancerandatlowriskforadverseeffectsofchemoprevention.Cliniciansshouldinformpatientsofthepotentialbenefitsandharmsofchemoprevention.

Breast cancer screening —Recommendsscreeningmammographyforwomen,withorwithoutclinicalbreastexamination,every1-2yearsforwomenaged40andolder.

Breastfeeding counseling —Recommendsinterventionsduringpregnancyandafterbirthtopromoteandsupportbreastfeeding.

Cervical cancer screening —Stronglyrecommendsscreeningforcervicalcancerinwomenwhohavebeensexuallyactiveandhaveacervix.

Chlamydia infection screening: non-pregnant women —RecommendsscreeningforChlamydiainfectionforallsexuallyactivenon-pregnantyoungwomenaged24andyoungerandforoldernon-pregnant women who are at increased risk.

Chlamydia infection screening: pregnant women —RecommendsscreeningforChlamydiainfectionforallsexuallyactivenon-pregnantyoungwomenaged24andyoungerandforoldernon-pregnantwomen who are at increased risk.

Cholesterol abnormalities screening: men 35 and older — The USPSTF strongly recommends screening menaged35andolderforlipiddisorders.

Cholesterol abnormalities screening: men younger than 35 — Recommends screening men aged 20 to 35forlipiddisordersiftheyareatincreasedriskforcoronaryheartdisease.

Cholesterol abnormalities screening: women 45 and older — Strongly recommends screening women aged45andolderforlipiddisordersiftheyareatincreasedriskforcoronaryheartdisease.

Cholesterol abnormalities screening: women younger than 45 — Recommends screening women aged 20to45forlipiddisordersiftheyareatincreasedriskforcoronaryheartdisease.

Colorectal cancer screening —Recommendsscreeningforcolorectalcancerusingfecaloccultbloodtesting, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75years.Therisksandbenefitsofthesescreeningmethodsvary.


Dental caries chemoprevention: preschool children — Recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than6monthsofagewhoseprimarywatersourceisdeficientinfluoride.

Depression screening: adolescents —Recommendsscreeningofadolescents(12-18yearsofage)formajor depressive disorder when systems are in place to assure accurate diagnosis, psychotherapy (cognitive-behavioralorinterpersonal),andfollow-up.

Depression screening: adults —Recommendsscreeningadultsfordepressionwhenstaff-assisteddepressioncaresupportsareinplacetoassureaccuratediagnosis,effectivetreatment,andfollow-up.

Diabetes screening —Recommendsscreeningfortype2diabetesinasymptomaticadultswithsustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.

Folic acid supplementation —Recommendsthatallwomenplanningorcapableofpregnancytakeadailysupplementcontaining0.4to0.8mg(400to800µg)offolicacid.

Gonorrhea prophylactic medication: newborns — Strongly recommends prophylactic ocular topical medicationforallnewbornsagainstgonococcalophthalmianeonatorum.

Gonorrhea screening: women —Recommendsthatcliniciansscreenallsexuallyactivewomen,includingthosewhoarepregnant,forgonorrheainfectioniftheyareatincreasedriskforinfection(thatis,iftheyareyoungorhaveotherindividualorpopulationriskfactors).

Healthy diet counseling —Recommendsintensivebehavioraldietarycounselingforadultpatientswithhyperlipidemiaandotherknownriskfactorsforcardiovascularanddiet-relatedchronicdisease.Intensivecounselingcanbedeliveredbyprimarycarecliniciansorbyreferraltootherspecialists,suchas nutritionists or dietitians.

Hearing loss screening: newborns —Recommendsscreeningforhearinglossinallnewborninfants.

Hemoglobinopathies screening: newborns —Recommendsscreeningforsicklecelldiseaseinnewborns.

Hepatitis B screening: pregnant women —TheUSPSTFstronglyrecommendsscreeningforhepatitisBvirusinfectioninpregnantwomenattheirfirstprenatalvisit.

HIV screening —Stronglyrecommendsthatcliniciansscreenforhumanimmunodeficiencyvirus(HIV)alladolescentsandadultsatincreasedriskforHIVinfection.

Hypothyroidism screening: newborns —Recommendsscreeningforcongenitalhypothyroidisminnewborns.

Iron Supplementation in children —Recommendsroutineironsupplementationforasymptomaticchildrenaged6to12monthswhoareatincreasedriskforirondeficiencyanemia.

Obesity screening and counseling: adults —Recommendsthatcliniciansscreenalladultpatientsforobesityandofferintensivecounselingandbehavioralinterventionstopromotesustainedweightlossforobeseadults.

Obesity screening and counseling: children — Recommends that clinicians screen children aged 6 yearsandolderandofferthemorreferthemtocomprehensive,intensivebehavioralinterventionstopromote improvement in weight status.

Osteoporosis screening: women — Recommends that women aged 65 and older be screened routinely forosteoporosis.Recommendsthatroutinescreeningbeginatage60forwomenatincreasedriskforosteoporoticfractures.

PKU screening: newborns —Recommendsscreeningforphenylketonuria(PKU)innewborns.

Rh incompatibility screening: first pregnancy visit — Strongly recommends Rd (D) blood typing and antibodytestingforallpregnantwomenduringtheirfirstvisitforpregnancy-relatedcare.

Rh incompatibility screening: 24-28 weeks gestation — Recommends repeated Rh (D) antibody testing forallunsensitizedRh(D)-negativewomenat24-28weeksgestation,unlessthebiologicalfatherisknown to be Rh (D)-negative.


STIs counseling —Recommendshigh-intensitybehavioralcounselingtopreventsexuallytransmittedinfections(STIs)forallsexuallyactiveadolescentsandforadultsatincreasedriskforSTIs.

Syphilis screening: non-pregnant persons — Strongly recommends that clinicians screen persons at increasedriskforsyphilisinfection.

Syphilis screening: pregnant women —Recommendsthatcliniciansscreenallpregnantwomenforsyphilisinfection.

Tobacco use counseling: non-pregnant adults — Recommends that clinicians ask all adults about tobaccouseandprovidetobaccocessationinterventionsforthosewhousetobaccoproducts.

Tobacco use counseling: pregnant women — Recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling to those who smoke.

Visual acuity screening in children — Recommends screening to detect amblyopia, strabismus, and defectsinvisualacuityinchildrenyoungerthanage5years.


NEW WOMEN’S PREVENTIVE SERVICES

Well-woman visits —Well-womanpreventivecarevisitannuallyforadultwomentoobtainthe recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care.

Breastfeeding support, supplies, and counseling ** (see note) — Recommends comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period,andcostsforrentingbreastfeedingequipment.

**NOTE: Breastfeeding Support/SuppliesThe purchase of a portable double electric pump (non-hospital grade)A purchase will be covered once every five years following the date of the birth. If a portable double electric pump was purchased within the previous period, the purchase of a portable double electric pump will not be covered until a five year period has elapsed from the last purchase of an electric pump.

The purchase of an manual breast pumpA purchase will be covered once every five years following the date of the birth. If a manual pump was purchased within the previous period, the purchase of a manual pump will not be covered until a five year period has elapsed from the last purchase of this type of pump.

Breast Pump SuppliesCoverage is limited to only one per pregnancy in a year where a covered female would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment for the same or similar purpose, and the accessories and supplies needed to operate the item.

The covered Employee or dependent is responsible for the entire cost of any additional same or similar equipment that is purchased or rented for personal convenience or mobility.

Contraceptive methods and counseling ** (see note) — All Food and Drug Administration approved contraceptivemethods,sterilizationprocedures,andpatienteducationandcounselingforallwomenwith reproductive capacity.

**NOTE: Contraceptive Methods and Sterilization: Coverage includes counseling services on contra-ceptive methods provided by a physician, obstetrician or Gynecologist. The following would be Covered Expenses: Voluntary Sterilization and Covered Contraceptives to include Female Generic Prescription Drugs.

Counseling for sexually transmitted infections —Recommendsannualcounselingonsexuallytrans-mittedinfectionsforallsexuallyactivewomen.

Counseling and screening for human immune-deficiency virus — Recommends annual Counseling and screeningforhumanimmune-deficiencyvirusinfectionforallsexuallyactivewomen.

Gestational diabetes screening —Recommendsthatallpregnantwomenbetween24and28weeksofgestationandatthefirstprenatalvisitforpregnantwomenidentifiedtobeathighriskfordiabetes.

Human papillomavirus testing — Recommends High-risk human papillomavirus DNA testing in women withnormalcytologyresults.Screeningshouldbeginat30yearsofageandshouldoccurnomorefrequentlythanevery3years.

Screening and counseling for interpersonal and domestic violence — Recommends annual counseling forinterpersonalanddomesticviolence.


ARTICLE IV

DEFINITIONS

4.01 Accidental InjurymeansaccidentalbodilyInjurycausedbyunexpectedexternalmeans,resulting,directlyandindependentlyofallothercauses,innecessarycarerenderedby

a Physician.

4.02 Actively at WorkmeanstheactiveexpenditureoftimeandenergyintheserviceoftheEmployer,exceptthatanEmployeeisdeemedActivelyatWorkoneachdayofaregularpaid vacation or on a regular non-working day, provided he was Actively at Work on the

last preceding regular working day.

4.03 ADA shall mean the American Dental Association.

4.04 Administrative AppealTheformalprocessbywhichaProviderrequestsareviewoftheanyofthebelowactionsthatdonotrequireamedicalreview:

(1) ThefailureofElPasoFirsttoactwithinthedescribedtimeframes (2) Thedenialinwholeorinpartofpaymentforservicenotrelatedtomedicalnecessity (3) Disputeofaclaimdenialforanon-coveredbenefit (4) Reimbursement dispute (5) Claims Coding dispute

Appealsinvolvingbenefitsexclusionssuchasexperimental,investigationalornon-coveredbenefitsarenoteligibleforreview.

4.05 Administrative DenialAdeterminationthatisissuedduetobenefitexclusions,benefitexhaustions,andincludes,butisnotlimitedtodeterminationsforfailuretofollowhealthplannotificationtimelinesandpriorauthorizationprocedures.

4.06 Adverse Benefit Determinationmeansanyofthefollowing:adenial,reduction,ortermi- nationof,orafailuretoprovideormakepayment(inwholeorinpart)for,abenefit,

includinganysuchdenial,reduction,termination,orfailuretoprovideormakepaymentthatisbasedonadeterminationofaparticipant’sorbeneficiary’seligibilitytoparticipateina plan, and including, with respect to group health plans, a denial, reduction, or termination of,orafailuretoprovideormakepayment(inwholeorinpart)for,abenefitresultingfromtheapplicationofanyutilizationreview,aswellasafailuretocoveranitemorserviceforwhichbenefitsareotherwiseprovidedbecauseitisdeterminedtobenotmedicallynecessary or appropriate.

PreferredAdministratorshasasplitprocessforhandlingAdverseBenefitDeterminationdecisions. Please refer to Administrative Denial and Adverse Determination definitions in this section.


4.07 Adverse Determination Appeal –theformalprocessbywhichaProvider,aMemberortheirlegalrepresentativerequestsareviewofanyofactionsrequiringmedicalinterpretationsuchas:

(1) Thedenialorlimitedauthorizationofarequestedservice,includingthetype orlevelofservice (2) Thereduction,suspension,orterminationofapreviouslyauthorizedservice (3) Denialofarequesttoobtainservicesoutsideofthenetwork (4) Adeterminationthataserviceisnotmedicallynecessary,experimental,or investigational in nature



4.08 AffiliatesmeansElPasoChildren’sHospital,andanyotherqualifyingoreligibleemployerauthorizedtoadoptthePlanbytheEmployerandwhohasadoptedthePlanbyitsdulyauthorizedboard.

4.09 AHA shall mean the American Hospital Association.

4.10 Allowable Expense All medically necessary, customary, and reasonable health care services that are to be provided pursuant to this Benefit Plan “Covered Services”.

4.11 Ambulatory Surgical Facilitymeansanypublicorprivatespecializedfacility(statelicensed andapprovedwheneverrequiredbylaw)withanorganizedmedicalstaffofPhysicians,that:

(a) haspermanentfacilitiesequippedandoperatedprimarilyforthepurposeof performingsurgicalproceduresonanoutpatientbasis;and (b) hascontinuousPhysicianservicesandregisteredprofessionalnursingservicewhenever

apatientisinthefacility;and (c) doesnotprovideaccommodationsforpatientstostayovernight.

4.12 Ancillary Services means services rendered in connection with inpatient or outpatient care in aHospitalorinconnectionwithaMedicalEmergencyincludingthefollowing:ambulance,

anesthesiology, assistant surgeon, pathology, and radiology. This term also includes services oftheattendingPhysicianorprimarysurgeonintheeventofaMedicalEmergency.

4.13 AppealmeansarequestbyaCoveredParticipantforre-considerationofanAdverseBenefitDeterminationofahealthservicerequestorbenefitthattheCoveredParticipantbelievesthey are entitled to receive.

4.14 Assignment of Benefits shall mean an arrangement whereby the Plan Participant assigns theirrighttoseekandreceivepaymentofeligiblePlanbenefits,instrictaccordancewiththetermsofthisPlanDocument,toaProvider.Ifaprovideracceptssaidarrangement,Providers’rightstoreceivePlanbenefitsareequaltothoseofaPlanParticipant,andarelimitedbythetermsofthisPlanDocument.AProviderthatacceptsthisarrangementindicatesacceptanceofan“AssignmentofBenefits”asconsiderationinfullforservices,supplies, and/or treatment rendered.

4.15 Balance Billingoccurswhenphysiciansorothermedicalprovidersandhospitalsorfacilities whoarenotcontractedwithinthepreferredproviderbenefitplanbillyouforthediffer- ence between the amount the health plan pays them and the amount the provider or

facilityhasbilled.

4.16 Benefit PercentagemeanstheportionofeligibleexpensespayablebythePlaninaccord- ance with the coverage provisions as stated in the Plan.

4.17 Benefit Management Advisors The team established by the Plan Sponsor to oversee the operationsofthePlanincludingthedevelopmentofrecommendationsregardingcoverageandplanprovisions,establishingthebudgetforthePlan,andmakingfinaldeterminationsregardingcomplaintsandappeals.TheadvisoryteamiscomprisedoftheChiefNursingOfficer,ChiefFinancialOfficerandtheHumanResourcesManager.

4.18 Birthing Centermeansafreestandingfacilitythat:

(a) islicensedtoprovideasettingforpre-natalcare,deliveryandimmediatepostpartum care;and (b) hasanorganizedstaffofPhysicians;and (c) haspermanentfacilitiesthatareequippedandoperatedprimarilyforDependent Childbirth;and


(d) hasacontractwithatleastonenearbyHospitalforimmediateacceptanceofpatients whorequireHospitalcare;and (e) doesnotprovideaccommodationsforpatientstostayovernight;and (f) providescontinuousservicesofPhysicians,registerednurses,orcertifiednursemidwife practitionerswhenapatientisinthefacility.

4.19 Centers of Excellence means transplant centers with proven credentials and outcome statistics.

4.20 Change in Family Status means

(a) themarriageordivorceoftheCoveredParticipant; (b) thedeathoftheCoveredParticipant’sSpouseorDependent; (c) thebirth,adoption,orplacementforadoptionofachildoftheCoveredParticipant; (d) aDependentceasestosatisfytherequirementsofDependentcoveragedueto attainmentofage,oranysimilarcircumstanceasprovidedinaBenefitProgram; (e) theterminationofemployment(orcommencementofemployment)ofhisSpouse; (f) thestrikeorlockoutoftheCoveredParticipant,orhisSpouseorDependent; (g) theswitchingfrompart-timetofull-timeemploymentstatusorfromfull-timetopart- timestatusbytheCoveredParticipantorhisSpouse; (h) thetakingofanunpaidleaveofabsencebytheCoveredParticipantorhisSpouse; (i) asignificantchangeinthehealthcoverageoftheCoveredParticipantorSpouse attributabletotheSpouse’semployment;or (j) any other event determined by the Plan Administrator to be a Change in Family Status consistent with Code Section 125.

4.21 Change in Status or Coverage means

(a) themarriageordivorceoftheCoveredParticipant; (b) thedeathofhisSpouseorDependent; (c) thebirth,adoption,orplacementforadoptionofaDependentChild; (d) aDependentceasestosatisfytherequirementsofDependentcoverageduetoattain- mentofage,oranysimilarcircumstanceasprovidedinaBenefitProgram; (e) theterminationofemployment(orcommencementofemployment)oftheCovered Participant’sSpouse; (f) thestrikeorlockoutoftheCoveredParticipant,ortheSpouseorDependentChild; (g) thechangeinresidenceorworksiteoftheCoveredParticipant,ortheSpouseor Dependent; (h) theswitchingfrompart-timetofull-timeemploymentstatusorfromfull-timetopart-

timestatusbytheCoveredParticipantorhisSpouse; (i) thetakingofanunpaidleaveofabsencebytheCoveredParticipantorhisSpouse; (j) asignificantchangeinthehealthcoverageoftheCoveredParticipantorhisSpouse

attributabletotheSpouse’semployment; (k) thechangeinemploymentstatusoftheCoveredParticipant,SpouseorDependent

ChildthataffectseligibilityforaBenefitProgramoraplanoftheemployerofhisSpouseorDependentChild;

(l) theadditionofaBenefitProgram,orofanoptionforcoverageunderaBenefit Programprovidingaccidentorhealthbenefits; (m)thesignificantimprovementofcoverageunderaBenefitProgramorBenefitProgram

optionprovidingaccidentorhealthbenefits;


(n) acoveragechangemadeundertheplanoftheemployerofaCoveredParticipant’sSpouse or Dependent, including an election change made during the open enrollment ofaCoveredParticipant’sSpouse;

(o) the change in a Covered Participant’s, or a Covered Participant’s Spouse’s or Dependent’s,entitlementforMedicareorMedicaid;

(p) an HMO or other arrangement in the individual market that does not provide benefits to individuals who no longer reside, live, or work in a service area (whether or not withinthechoiceoftheindividual);or

(q) anHMOorotherarrangementinthegroupmarketthatdoesnotprovidebenefitsto individuals who no longer reside, live or work in a service area (whether or not withinthechoiceoftheindividual),andnootherbenefitpackageisavailabletotheindividual;or

(r) anHMOceasingoperations;or (s) aplannolongerofferinganybenefitstoaclassofsimilarlysituatedindividuals;or (t) cessationofemployercontributionsfortheotherhealthcoverage;or (u) theexhaustingofCOBRAcontinuationcoverage;or (v) any other event determined by the Plan Administrator to be a Change in Status or

Coverage consistent with Code Section 125.

4.22 Childshallmean,inadditiontotheEmployee’sownblooddescendantofthefirstdegreeorlawfullyadoptedChild,aChildplacedwithacoveredEmployeeinanticipationofadoption,a covered Employee’s Child who is an alternate recipient under a qualified Medical Child SupportOrderasrequiredbytheFederalOmnibusBudgetReconciliationActof1993,anystepchild,an“eligiblefosterchild,”whichisdefinedasanindividualplacedwiththeEmployeebyanauthorizedplacementagencyorbyjudgment,decreeorotherorderofacourtofcompetentjurisdictionoranyotherChildforwhomtheEmployeehasobtainedlegal guardianship

4.23 CHIPreferstotheChildren’sHealthInsuranceProgramoranyprovisionorsectionthereof,whichishereinspecificallyreferredto,assuchact,provisionorsectionmaybeamendedfromtimetotime.

4.24 CHIPRAreferstotheChildren’sHealthInsuranceProgramReauthorizationActof2009oranyprovisionorsectionthereof,whichishereinspecificallyreferredto,assuchact.

4.25 Clean ClaimAclaimthatmaybeprocessedwithoutobtainingadditionalinformationfrom theproviderofserviceorfromathirdparty,butdoesnotincludeaclaimunderinvestigation forfraudorabuseorunderreviewformedicalnecessityormedicalappropriatenessfor

electronicclaims,acleanclaimmustmeetallrequirementsforaccurateandcompletedataasdefinedintheappropriate837-(claimtype)encounterguidesasfollows:

•837ProfessionalCombinedImplementationGuide •837InstitutionalCombinedImplementationGuide •837ProfessionalCompanionGuide •837InstitutionalCompanionGuide

PreferredAdministratorsmayrequireProvidertosubmitdocumentationthatconflictswiththerequirementsofTexasAdministrativeCode,Title28,Part1,Chapter21,Subchapters

C and T.

4.26 COBRAmeanstheConsolidatedOmnibusBudgetReconciliationActof1985,asamended.


4.27 ComplaintAnydissatisfaction,expressedbyacomplainant,orallyorinwritingtoPreferredAdministratorswithanyaspectofPreferredAdministratorsoperation,including,butnotlimitedto,dissatisfactionwithplanadministration,thedenial,reduction,orterminationofaserviceforreasonsnotrelatedtomedicalnecessity;thewayaserviceisprovided;ordisenrollmentdecisions.Thetermdoesnotincludemisinformationthatisresolvedpromptlybysupplyingtheappropriateinformationorclearingupthemisunderstandingtothesatis-

factionofthecomplainant.

4.28 Complete Claim – shall mean a claim submitted by an Associate or a Provider that complies withSubchapterJ,Chapter843oftheTexasInsuranceCode,asupdatedoramended,and

suppliesalltheinformationrequiredbyTexasAdmin.Code§21.2803,asupdatedoramended.

4.29 Coordination of Benefits (COB)meansthetechniqueusedtodeterminetheamountofbenefitspaidonaclaimwhentheCoveredParticipanthasmorethanonesourceofmedicalbenefit coverage.

4.30 Cosmetic Surgery or Procedures shall mean any Surgery, service, Drug or supply designed toimprovetheappearanceofanindividualbyalterationofaphysicalcharacteristicwhichiswithinthebroadrangeofnormalbutwhichmaybeconsideredunpleasingorunsightly,exceptwhennecessitatedbyanInjury.

4.31 Coverage DatemeansthedateanAssociateorDependenthasmetalloftheeligibilityrequirementsforcoverage.

4.32 Covered ExpensesmeansaUsualandCustomaryfeeforaReasonable,MedicallyNecessaryand Medically Appropriate service, treatment or supply, meant to improve a condition or participant’shealth,whichiseligibleforcoverageinthisPlan.CoveredExpenseswillbedetermined based upon all other Plan provisions. When more than one treatment option isavailable,andoneoptionisnomoreeffectivethananother,theCoveredExpenseistheleastcostlyoptionthatisnolesseffectivethananyotheroption.

AlltreatmentissubjecttobenefitpaymentmaximumsshownintheSummary of Benefits and as determined elsewhere in this document.

4.33 Covered Participant means any Associate and/or Dependent covered under this Plan.

4.34 Creditable Coverage means prior continuous health coverage and includes prior coverage under:

(a) anothergrouphealthplan; (b) group or individual health insurance coverage issued by a state regulated insurer oranHMO; (c) COBRA; (d) Medicaid; (e) Medicare; (f) StateChildren’sHealthInsuranceProgram(SCHIP); (g) theActiveMilitaryHealthProgram; (h) Tricare/CHAMPUS; (i) AmericanIndianHealthCarePrograms; (j) aStatehealthbenefitsriskpool; (k) theFederalEmployeesHealthPlan; (l) thePeaceCorpHealthProgram;or (m) a public health plan, including plans established or maintained by a state, the United

Statesgovernment,aforeigncountry,oranypoliticalsubdivisionofastate,theUnitedStatesgovernment,oraforeigncountrythatprovideshealthcoveragetoindividuals

whoareenrolledintheplan(forexample,coveragethroughtheUnitedStatesVeterans Administrationandcoveragefromastateorfederalpenitentiary).


4.35 Custodial Care means care including room and board needed to provide that care that is givenprincipallyforpersonalhygieneorforassistanceindailyactivitiesandcan(accordingtogenerallyacceptedmedicalstandards)beperformedbyindividualswhohavenomedicaltraining.Examplesofcustodialcareincludehelpinwalkingandgettingoutofbed;assist-

anceinbathing,dressing,andfeeding;orsupervisionovermedication,whichcouldnormally beself-administered.

4.36 DeductiblemeanstheamountofcoveredmedicalexpenseswhichmustbepaidbyaCovered ParticipanteachFiscalYearbeforebenefitsarepayableunderthisPlan.Aseparatedeductible appliestoacoveredAssociateandeachoftheAssociate’sDependents,subjecttothefamily

deductible limit. As applied to dental benefits under this Plan, this term means the amount ofcovereddentalexpenseswhichmustbepaidbyaCoveredParticipanteachFiscalYearbeforebenefitsarepayableunderthisPlan.AseparatedeductibleappliestoacoveredAssociateandeachoftheAssociate’sDependents,subjecttothefamilydeductiblelimit.

4.37 DentistmeansacurrentlylicenseddentistpracticingwithinthescopeofthelicenseoranyotherPhysicianfurnishingdentalserviceswhichthePhysicianislicensedtoperform.

4.38 Dependentshallmeanoneormoreofthefollowingperson(s):

1. ACoveredParticipant’slawfullymarriedspousepossessingamarriagelicensewhoisnotdivorcedfromtheEmployee.Forpurposesofthissection,“marriageormarried”meansalegalunionbetweenonemanandonewomanashusbandandwife;

2. ACoveredParticipant’sGrandchild,formedicalcoverageonly,whenthegrandchildisalegalDependentoftheEmployeeforfederalincometaxpurposes.ThecoveredgrandchildwillnotloseeligibilitystatusifatalaterdatetheDependentChildand/orthecoveredgrandchildcannolongerbeclaimedasaDependentforfederalincometaxpurposes.AgrandchildwillbeeligibleasaDependentprovidedthegrandchildis:

(a) undertheageof26,orovertheageof26ifTotallyDisableduponreachingtheageof26,proofofTotalDisabilityprovidedtothePlanAdministratorwithin31daysofage26andmayberequiredfromtimetotimebutnotmorefrequentlythanannually,TotalDisabilityiscontinuous,andthegrandchildiscontinuouslycoveredbythePlan;

3. AnAssociate’sDependentChildorChildren,forcoverageunderthemedicalplanonly, theAssociate’snaturalchildren,legallyadoptedchildren(includingchildrenplacedfor adoptionforwhomlegaladoptionproceedingshavebeenstarted),step-children,children theCoveredParticipanthasobtainedlegalguardianshipfor;andchildrenrequiredtobe covered under a qualified Medical Child Support Order (qMCSO). A Dependent Child

doesnotincludefosterchildren.ADependentChildmustalsomeetthefollowingrequirements:

(a)undertheageof26,orovertheageof26ifTotallyDisableduponreachingtheageof26,proofofTotalDisabilityisprovidedtothePlanAdministratorwithin31daysofage26andmayberequiredfromtimetotimebutnotmorefrequentlythanannually, Total Disability is continuous, and the Dependent Child is continuously coveredbythePlan;

(b)Youngadultlivingornotlivingatparentshome; (c) Doesnotrequiretobeonparent’staxreturn; (d)Doesnotrequirethatyoungadultbeastudent.Thisappliestobothmarriedand

unmarriedchildrenalthoughtheirownspousesandchildrendonotqualify; (e) CoverageforYoungAdultsallowschildrenuntilage26tocontinuetheircoverage

undertheirparent’sinsuranceeveniftheywereeligibleforotheremployer-sponsored coverage.


4.39 Domestic Partnerisapersonofthesameoroppositesex(gender)whohasthesameprincipalplaceofresidenceastheemployeeandboththeemployeeanddomesticpartnermeetthefollowingrequirements:

(a) Bothareatleast18yearsofage;and (b) Havelivedwitheachothercontinuouslyforatleastone(1)yearandwillcontinueto

livetogetherthroughouttheentireperiodofbenefitcoverage;and (c) Haveaserious,committed,andexclusiverelationshipwitheachotherandintendfor

therelationshiptobepermanent;and (d) Neitherislegallymarriedtoanyotherindividualsandifpreviouslymarried,alegal

divorceorannulmenthasbeenobtainedortheformerspouseisdeceasedandneitherisconsideredthedomesticpartnerofanyoneelse;and

(e) Arenotrelatedtoeachotherinanywaythatwouldbarmarriageunderstatelawifabletosatisfytheotherapplicablemarriagerequirements;and

(f) Arebothmentallycompetenttoenterintoacontractaccordingtostatelaw;and (g) Arenotintherelationshipsolelyforthepurposeofobtainingbenefits;and (h) Arejointlyfinanciallyresponsiblefor“basic”livingexpensesdefinedasthecostof

food,shelter,andotherexpensesofadomesticpartnerbecauseofthedomesticpartnership.

4.40 Durable Medical EquipmentmeansequipmentprescribedbytheattendingPhysicianwhich:isMedicallyNecessary;isnotprimarilyorcustomarilyusedfornon-medicalpurposes;

isdesignedforprolongeduse;andservesaspecifictherapeuticpurposeinthetreatmentofanAccidentalInjuryorIllness.DurableMedicalEquipmentincludessurgicalequipmentandaccessoriesneededtooperatetheequipment.

4.41 Effective DatemeansOctober1,2013andthedatesofsubsequentamendmentsandrestatements.

4.42 Eligible ExpensemeanstheUsualandCustomarychargesincurredforthediagnosis,cure, mitigation,treatment,orpreventionofdisease,orforthepurposeofaffectinganystructure orfunctionofthebodyortheexpensethatisagreeduponasahealthservicesfeeforhealth servicesandsuppliescoveredunderahealthplan.Thereasonablechargeisthelesserof:

(a) thecontractedratewiththePPOproviderPreferredAdministratorsnetwork;or (b) thelesserofthecontractedrateforaproviderwhoiscontractedwiththewrap;or (c) networkforNon-Contracted/Out-of-AreaservicesortheMedicareallowableamount;or (d) theUsualandCustomaryallowableamountforNon-Contractedproviders;or (e) the actual charge issued by the provider.

In the event the actual charge is less than a contracted charge, the lesser amount will be consideredtheEligibleAmountunlessprohibitedbythetermsoftheapplicablecontract.

4.43 Emergency Medical Conditionshallmeanamedicalconditionmanifestingitselfbyacutesymptomsofsufficientseverity(includingseverepain)sothataprudentlayperson,whopossessesanaverageknowledgeofhealthandmedicine,couldreasonablyexpecttheabsenceofimmediatemedicalattentiontoresultinaconditiondescribedinclause(i),(ii),or(iii)ofsection1867(e)(1)(A)oftheSocialSecurityAct(42U.S.C.1395dd(e)(1)(A)).InthatprovisionoftheSocialSecurityAct,clause(i)referstoplacingthehealthoftheindividual(or,withrespecttoapregnantwoman,thehealthofthewomanorherunbornchild)inseriousjeopardy;clause(ii)referstoseriousimpairmenttobodilyfunctions;andclause(iii)referstoseriousdysfunctionofanybodilyorganorpart.


4.44 Emergency Services shallmean,withrespecttoanEmergencyMedicalCondition:

1. Amedicalscreeningexamination(asrequiredundersection1867oftheSocialSecurityAct,42U.S.C.1395dd)thatiswithinthecapabilityoftheemergencydepartmentofaHospital, including ancillary services routinely available to the emergency department toevaluatesuchEmergencyMedicalCondition;and

2. Suchfurthermedicalexaminationandtreatment,totheextenttheyarewithinthecapabilitiesofthestaffandfacilitiesavailableattheHospital,asarerequiredundersection1867oftheSocialSecurityAct(42U.S.C.1395dd)tostabilizethepatient.

4.45 Employeemeansapersonwhoisdirectlyemployedonafull-timebasis(whoisregularlyscheduledtoworkaminimumof36hoursperweek),oronapart-timebasis(whoisregu-

larlyscheduledtoworkaminimumof20hoursperweek),andwhoisperforminghis/hercustomarydutiesattheEmployer’sfacilityorotherlocationdesignatedbytheEmployer.Employeedoesnotinclude:

(a) anyindividualwhoisclassifiedasanindependentcontractorforpurposesoffederal incometaxreportingandwithholding; (b) anyindividualwhoperformsservicesasaleasedemployeewithinthemeaningof CodeSection414(n),orwhootherwiseperformsservicesthroughanagreementwith aleasingorganizationoroutsourcingprovider; (c) reliefpersonnel; (d) temporaryemployees;or (e) PRNs.

4.46 Employer means El Paso Children’s Hospital.

4.47 ERISAshallmeantheEmployeeRetirementIncomeSecurityActof1974,asamended.

4.48 Essential Health Benefitsshallmean,undersection1302(b)ofthePatientProtectionandAffordableCareAct,thosehealthbenefitstoincludeatleastthefollowinggeneralcategoriesandtheitemsandservicescoveredwithinthecategories:ambulatorypatientservices;EmergencyServices;hospitalization;maternityandnewborncare;mentalhealthandsubstanceabusedisorderservices,includingbehavioralhealthtreatment;prescriptiondrugs;rehabilitativeandrehabilitativeservicesanddevices;laboratoryservices;preventiveandwellnessservicesandchronicdiseasemanagement;andpediatricservices,includingoraland vision care.

4.49 Experimental and/or Investigational (“Experimental”) shall mean services or treatments that are not widely used or accepted by most practitioners or lack credible evidence to supportpositiveshortorlong-termoutcomesfromthoseservicesortreatments;theseservices are not included under or as Medicare reimbursable procedures, and include services,supplies,care,procedures,treatmentsorcoursesoftreatmentwhich:

(1) Donotconstituteacceptedmedicalpracticeunderthestandardsofthecaseandbythestandardsofareasonablesegmentofthemedicalcommunityorgovernmentoversightagenciesatthetimerendered;or

(2) Are rendered on a research basis as determined by the United States Food and Drug Administration and the AMA’s Council on Medical Specialty Societies.

AllphasesofclinicaltrialsshallbeconsideredExperimental.


Adrug,device,ormedicaltreatmentorprocedureisExperimental:

(1) IfthedrugordevicecannotbelawfullymarketedwithoutapprovaloftheU.S.FoodandDrugAdministrationandapprovalformarketinghasnotbeengivenatthetimethedrugordeviceisfurnished;

(2) Ifreliableevidenceshowsthatthedrug,deviceormedicaltreatmentorprocedureisthesubjectofongoingPhaseI,clinicaltrialorunderstudytodetermineits:

(a) maximumtolerateddose; (b)toxicity; (c) safety; (d)efficacy;and (e)efficacyascomparedwiththestandardmeansoftreatmentordiagnosis;or (3) Ifreliableevidenceshowsthattheconsensusamongexpertsregardingthedrug,

device,ormedicaltreatmentorprocedureisthatfurtherstudiesorclinicaltrialsarenecessarytodetermineits:

(a)maximumtolerateddose; (b)toxicity; (c) safety; (d)efficacy;and (e)efficacyascomparedwiththestandardmeansoftreatmentordiagnosis.

Reliableevidenceshallmean:

(1) Only published reports and articles in the authoritative medical and scientific literature. (2) Thewrittenprotocolorprotocolsusedbythetreatingfacilityortheprotocol(s)of

anotherfacilitystudyingsubstantiallythesamedrug,device,ormedicaltreatmentorprocedure;or

(3) Thewritteninformedconsentusedbythetreatingfacilityorbyanotherfacilitystudying substantially the same drug, device, or medical treatment or procedure.

ThePlanAdministratorretainsmaximumlegalauthorityanddiscretiontodeterminewhat isExperimental.

4.50 FMLAmeanstheFamilyandMedicalLeaveActof1993,asamended.

4.51 Family Deductible LimitmeansthatoncethecombinedindividualdeductiblesofallCoveredParticipantsinthesamefamilyreachthecombineddeductiblelimit,nofurtherindividualdeductiblesapplyduringtheremainderoftheFiscalYear.

4.52 GINAshallmeantheGeneticInformationNondiscriminationActof2008(PublicLawNo.110-233),whichprohibitsgrouphealthplans,issuersofindividualhealthcarepolicies,andemployersfromdiscriminatingonthebasisofgeneticinformation.

4.53 Global Maternity Global maternity care includes routine antepartum care, delivery and postpartum care.

4.54 Health Care Spending Account means the Health Care Spending Account under the El Paso Children’sHospitalSection125CafeteriaPlan,oranysubsequentcafeteriaplanmaintainedby the Employer.

4.55 Health Risk Assessment (HRA) means the El Paso Children’s Hospital annual program which evaluatesanEmployee’soverallhealthconditionthroughaseriesofquestionnaires,labwork, fitness testing, etc.

4.56 HIPAAmeanstheHealthInsurancePortabilityandAccountabilityActof1996,asamended.


4.57 Home Health Care Agencymeansanagencyororganizationthat:

(a) is licensed and primarily engaged in providing skilled nursing care and other thera- peuticservices;and (b) haspoliciesestablishedbyaprofessionalgroupemployeedwiththeagencyororgani- zationthatincludesatleastonePhysicianandoneregisterednurse(R.N.)whoprovide

full-timesupervisionofsuchservices;and (c) maintainscompletemedicalrecordsoneachindividualandhasafull-timeadministrator.

4.58 Hospice Caremeansacoordinatedtreatmentplanofhomeandinpatientcare,whichtreatstheterminallyillpatientandfamilyasaunit.ThistreatmentplanprovidescaretomeetthespecialneedsofthefamilyunitduringthefinalstagesofaterminalIllnessandduringbereavement.Ateammadeupoftrainedmedicalpersonnelandcounselorsprovidescare.Theteamactsunderanindependenthospiceadministratortohelpthefamilyunitcopewith physical, psychological, spiritual, social and economic stresses.

4.59 Hospice Care ProgrammeansaformalprogramdirectedbyaPhysiciantohelpcarefora personwithalifeexpectancyofsixmonthsorless.Itmustmeetthestandardssetbythe NationalHospiceOrganization.IfsuchProgramisrequiredbyastatetobelicensed,certified, orregistered,itmustalsomeetthatrequirementtobeconsideredaHospiceCareProgram.

4.60 Hospitalmeansaninstitutionthat:

(a) islicensedtoprovideandisengagedprimarilyinprovidingonaninpatientbasis,forcompensationfromitspatients,diagnosticandtherapeuticfacilitiesforthesurgical,medicaldiagnosis,treatmentandcareofillandinjuredpersons;

(b) operates24hoursadayeverydayundercontinuoussupervisionofastaffofdoctors(MD,DO);

(c) continuouslyprovidesonthepremisesofthefacility24hoursadayskillednursingservicesbylicensednursesunderthedirectionofafull-timeregisterednurse(R.N.);

(d) provides,orhasawrittenagreementwithanotherHospitalintheareafortheprovision of,generallyaccepteddiagnosticortherapeuticservicesthatmayberequiredduring aconfinement;and (e) isnot,otherthanincidentally,aplaceforrest,aplacefortheaged,anursinghome, a residential treatment center, or a convalescent Hospital.

4.61 Hospital ExpensesmeanschargesbyaHospitalforroomandboardand/orforcareinanintensivecareunit,providedthatitschargesforsuchcarearefurnishedatthedirectionofaPhysician.Hospitalexpensesforprivateroomaccommodations,whichareinexcessoftheaveragechargeforsemi-privateaccommodationsinthefacility,shallnotbeconsideredunderthisPlanforanypurpose(exceptasspecifiedintheSchedule of Benefits).

4.62 Illnessmeansabodilydisorder,disease,physicalormentalsickness,functionalnervousdisorder,pregnancyorcomplicationofpregnancy.ThetermIllnesswhenusedinconnectionwithanewbornDependentChildincludes,butisnotlimitedto,congenitaldefectsandbirth abnormalities, including premature birth.

4.63 Immediate Family means an individual who is related to a Covered Participant, either by blood or created by law, including a Spouse, parent, Dependent Child, brother, or sister.

4.64 Incomplete Claim –shallmeanaclaimwhich,ifproperlycorrectedtocompletion,maybecompensableforthecoveredprocedure,butlacksimportantormaterialelementswhichpreventpaymentoftheclaim.IncompleteClaimsshallbedeniedifnotcuredwithin30daysofnoticeofthelackofcompleteness.IncompleteClaimsshallberequiredtobecompletedwithinoneyearofthedateofservicebeingbilled.


4.65 IncurredshallmeanthatacoveredexpenseisIncurredonthedatetheserviceisrenderedorthesupplyisobtained.Withrespecttoacourseoftreatmentorprocedurewhichincludesseveralstepsorphasesoftreatment,coveredexpensesareIncurredforthevariousstepsor phases as the services related to each step are rendered and not when services relating totheinitialsteporphasearerendered.Morespecifically,coveredexpensesfortheentireprocedureorcourseoftreatmentarenotIncurreduponcommencementofthefirststageoftheprocedureorcourseoftreatment.

4.66 Independent Review Organization (IRO) means independent third parties who conduct externalreviewofaservicedeniedbyahealthplan.PreferredAdministratorswilluseIROsaccreditedbytheUtilizationReviewAccreditationCommission(URAC)orbyasimilarnationally-recognizedaccreditingorganizationtoconducttheexternalreview.

4.67 Injury A condition caused by accidental means that result in damage to the Covered Person’s bodyfromanexternalforce.

4.68 In-NetworkmeansElPasoChildren’sHospital,UniversityMedicalCenterofElPaso,TexasTechproviders,andthemedicalproviderscontractedbyPreferredAdministratorsNetwork/PPO and Wrap Network.

4.69 Inpatient Behavioral Services means an acute inpatient program designed to provide medically necessary, intensive assessment, psychiatric treatment and support to individuals withasevereand/orpersistentmentalillnessand/orco-occurringdisorderexperiencinganacuteexacerbationofapsychiatriccondition.Theacuteinpatientsettingisequippedtoservepatientsathighriskofharmtoselforothersandinneedofasafe,secure,lockedsetting.Thepurposeoftheservicesprovidedwithinanacuteinpatientsettingistostabilizethepatient’sacutepsychiatriccondition.Medicalnecessitydrivesthenumberofdaysapatientisabletostayatthislevelofcare.

4.70 Inpatient Substance Abuse Servicesmeansanacuteprogramforpatientswithalcoholand otheraddictivedisordersthatprovidesinpatientdetoxificationand/orrecovery.Patients

workwithateamofprofessionalsincludingphysicians,nurses,andtherapiststoaddresstriggers to alcohol or drug use and relapse and are taught coping skill. Treatment is structured,short-termandintensive.Thelengthofstayisbasedonclinicalneed.

4.71 Intensive Care UnitmeansanaccommodationinaHospitalwhichisreservedforcriticallyandseriouslyillpatientsrequiringconstantaudio-visualobservationasprescribedbythe

attending Physician, and which provides room and board, nursing care by registered nurses whosedutiesareconfinedtocareofpatientsintheintensivecareunit,andspecialequip- mentorsuppliesimmediatelyavailableonastandbybasissegregatedfromtherestofthe

Hospital’sfacilities.

4.72 Intensive Outpatient Programmeansanintermediatelevelofmentalhealthcarewhereindividualsareseeninagroupsetting2to5timesaweekfor2to3hoursatatime(dependingonthestructureoftheindividualprogram).Theclinicalworkisprimarilydoneinagroupsetting,withindividualsessionsscheduledasneededoutsideofgrouphours.Medicalnecessitydrivesthenumberofdaysapatientisabletostayatthislevelofcare.

4.73 Interlink Transplant Network means a national network and an established leader in the transplantnetworkindustry,oftenreferredtoasbeingoneofthemostusedandrespectedtransplant networks in the United States.

4.74 Late Entrant means an individual who enrolls other than during the initial enrollment period or a special enrollment period as provided under Article III.

4.75 LifetimemeanswhileapersoniscoveredunderthisPlan.LifetimedoesnotmeanduringthelifetimeoftheCoveredParticipant.


4.76 Maximum Amount and/or Maximum Allowable Chargeshallmeanthebenefitpayablefor aspecificcoverageitemorbenefitunderthePlan.MaximumAllowableCharge(s)willbe

thelesserof:

(a) The Usual and Customary amount, (b) TheallowablechargespecifiedunderthetermsofthePlan, (c) The negotiated rate established in a contractual arrangement with a Provider, or (d) Theactualbilledchargesforthecoveredservices.

ThePlanwillreimbursetheactualchargebilledifitislessthantheUsualandCustomaryamount.ThePlanhasthediscretionaryauthoritytodecideifachargeisUsualandCustomaryandforaMedicallyNecessary,MedicallyAppropriateandReasonableservice.

TheMaximumAllowableChargewillnotincludeanyidentifiablebillingmistakesincluding,butnotlimitedto,up-coding,duplicatecharges,andchargesforservicesnotperformed.

4.77 Maximum Benefit per Plan YearmeansthemaximumbenefitpayableforcertainexpensesduringthePlanYear,whichcommencesOctober1ofeachyear.

4.78 Medical Emergency means a sudden acute medical Illness or Injury which occurs suddenly andunexpectedly,requiringimmediatemedicalcareanduseofthemostaccessibleHospital equippedtofurnishcaretopreventthedeathorseriousimpairmentoftheCoveredPartici- pant.Suchconditionsincludebutarenotlimitedtosuspectedheartattack,lossofconscious- ness,actualorsuspectedpoisoning,acuteappendicitis,heatexhaustion,convulsions,emer- gencymedicalcarerenderedinthecaseofAccidentalInjurycasesandotheracuteconditions. ForpurposesofbenefitspayableunderthisPlan,theClaimAdministratorwilldeterminethe

existenceofaMedicalEmergency.

4.79 Medically Necessary, Medical Care Necessity, Medical NecessityandsimilarlanguagereferstohealthcareservicesorderedbyaPhysicianexercisingprudentclinicaljudgmentprovidedtoaCoveredParticipantforthepurposesofevaluation,diagnosisortreatmentofthatCovered Participant’s Illness or Injury. Such services, to be considered Medically Necessary, mustbeclinicallyappropriateintermsoftype,frequency,extent,siteanddurationforthediagnosisortreatmentoftheCoveredParticipant’sIllnessorInjury.TheMedicallyNecessarysettingandlevelofserviceisthatsettingandlevelofservicewhich,consideringtheCovered

Participant’s medical symptoms and conditions, cannot be provided in a less intensive medical setting. Such services, to be considered Medically Necessary, must be no more costly than alternativeinterventions,includingnointerventionandareatleastaslikelytoproduceequiv- alenttherapeuticordiagnosticresultsastothediagnosisortreatmentoftheCoveredPartici- pant’sIllnessorInjurywithoutadverselyaffectingtheCoveredParticipant’smedicalcondition.

(a) It must not be maintenance therapy or maintenance treatment. (b) Its purpose must be to restore health. (c) It must not be primarily custodial in nature. (d) ItmustnotbealisteditemortreatmentnotallowedforreimbursementbyCMS(Medicare). (e) ThePlanreservestherighttoincorporateCMS(Medicare)guidelinesineffectonthe

dateoftreatmentasadditionalcriteriafordeterminationofMedicalNecessityand/oranAllowableExpense.

For Hospital stays, this means that acute care as an Inpatient is necessary due to the kind ofservicestheParticipantisreceivingortheseverityoftheParticipant’sconditionandthatsafeandadequatecarecannotbereceivedasanoutpatientorinalessintensifiedmedicalsetting.Themerefactthattheserviceisfurnished,prescribedorapprovedbyaPhysiciandoesnotmeanthatitis“MedicallyNecessary.”Inaddition,thefactthatcertainservicesareexcludedfromcoverageunderthisPlanbecausetheyarenot“MedicallyNecessary”doesnot mean that any other services are deemed to be “Medically Necessary.”


TobeMedicallyNecessaryallofthesecriteriamustbemet.MerelybecauseaPhysicianorDentist recommends, approves, or orders certain care does not mean that it is Medically

Necessary.Thedeterminationofwhetheraservice,supply,ortreatmentisorisnotMedically NecessarymayincludefindingsoftheAmericanMedicalAssociationandthePlanAdministra- tor’s own medical advisors. The Plan Administrator has the discretionary authority to decide

whether care or treatment is Medically Necessary.

4.80 Medically Necessary Leave of Absence shallmeanaLeaveofAbsencebyafull-timestudentDependentatapost-secondaryeducationalinstitutionthat:

(a) CommenceswhilesuchDependentissufferingfromaseriousIllnessorInjury; (b) IsMedicallyNecessary;and (c) CausessuchDependenttolosestudentstatusforpurposesofcoverageundertheterms

ofthePlan.

4.81 Medical Record Review is the process by which the Plan, based upon a medical record reviewandaudit,determinesthatadifferenttreatmentordifferentquantityofadrugorsupply was provided which is not supported in the billing, then the Plan Administrator may determinetheMaximumAllowableChargeaccordingtothemedicalrecordreviewandaudit results.

4.82 MedicaremeanstheprogramofmedicalcarebenefitsprovidedunderTitleXVIIIoftheSocialSecurityActof1965,asamended.

4.83 Non-Preferred Provider means a legally licensed health care Provider who has not entered intoacontractwithPreferredAdministrators.

4.84 Organ Transplant ServicesmeanstheservicesofacontractednetworkorcontractedfacilityforthetransplantationofhumanorgansasdescribedunderMedicalBenefits.

4.85 Orthotic Devicemeansanapparatususedtosupport,align,prevent,orcorrectdeformities,ortoimprovethefunctionofmovablepartsofthebody.

4.86 Other Planshallinclude,butisnotlimitedto:

1. AnyprimarypayerbesidesthePlan; 2. Anyothergrouphealthplan; 3. AnyothercoverageorpolicycoveringtheParticipant; 4. Any first party insurance through medical payment coverage, personal injury protection, no-faultcoverage,uninsuredorunderinsuredmotoristcoverage; 5. Anypolicyofinsurancefromanyinsurancecompanyorguarantorofaresponsibleparty; 6. Anypolicyofinsurancefromanyinsurancecompanyorguarantorofathirdparty; 7. Worker’scompensationorotherliabilityinsurancecompany;or 8. Anyothersource,includingbutnotlimitedtocrimevictimrestitutionfunds,any

medical, disability or other benefit payments, and school insurance coverage.

4.87 Out-of-AreameansoutsideofElPasoCountyandtheimmediatesurroundingareas(includingDoñaAnaCountyinsouthernNewMexico)whereactiveEmployeesresideandmay receive routine or other medical services.

4.88 Out-of-Pocket or Maximum Out-of-PocketmeanstheamountsforwhichtheCoveredParticipantisfinanciallyresponsibleforeligibleservicesinoneFiscalYear.TheOut-of-Pocketamount include deductibles and co-pays but not any non-compliance penalty amounts, any chargesforanyservicesnotdefinedasaCoveredCharge,chargesthatexceedmaximumamounts specified in the Schedule of Benefits,andchargesthatareinexcessoftheallow-

ableamountforanyservice.


4.89 Outpatient Behavioral Health Servicesmeansofficevisitstoalicensedbehavioralhealthpractitioner that occur in a community location on a regular basis. Treatment at this level can include psychotherapy and/or medication management. These services can be delivered inanindividual,familyorgroupsetting.

4.90 Pharmacy means a licensed establishment where prescription drugs are filled and dispensed byapharmacistlicensedunderthelawsofthestatewherethepharmacistpractices.

4.91 Physicianmeansadulylicenseddoctorofmedicine(M.D.),adoctorofosteopathy(D.O.),alicensedpodiatrist(D.P.M.),adoctorofoptometry(O.D.),Chiropractor(D.C.)orothersimilarlylicensedhealthcareprofessionalwhoisactingwithinthescopeofthelicense.

4.92 Plan means the El Paso Children’s Hospital Associate Health Benefit Plan Associate as it may beamendedfromtimetotime.

4.93 Plan Administrator means the Plan Sponsor.

4.94 Plan Sponsor means El Paso Children’s Hospital.

4.95 Plan Year means the 12-month period starting on October 1 and ending September 30. For theinceptionandeffectivedateofthePlan,thefirstPlanYearshallbethe8monthperiodofFebruary1,2012toSeptember30,2012.

4.96 Preferred ProvidermeansElPasoChildren’sHospital,UniversityMedicalCenterofElPaso,TexasTechProviders,andProviderscontractedbyElPasoFirstHealthPlans,d.b.a.PreferredAdministrators.

4.97 Preventive CareChargesforpreventivecareservices;

Benefits mandated through the PPACA legislation include preventive care such as immunizations,screenings,andotherservicesthatarelistedasrecommendedbytheUnitedStates Preventive Services Task Force (USPSTF), the Health Resources Services Administration (HRSA), andtheFederalCentersforDiseaseControl(CDC).

See http://www.healthcare.gov/law/provisions/preventive/index.html or www.preferred admin.netformoredetails.IMPORTANT NOTE: The preventive care services identified

through this link are recommended services, not mandated services. It is up to the provider ofcaretodeterminewhichservicestoprovide.

4.98 Prior to Effective Date or After Termination DatearedatesoccurringbeforeaParticipantgainseligibilityfromthePlan,ordatesoccurringafteraParticipantloseseligibilityfromthePlan,aswellaschargesincurredpriortotheeffectivedateofcoverageunderthePlanoraftercoverageisterminated,unlessExtensionofBenefitsapplies.

4.99 Protected Health Information or Sensitive Personal Informationmeanshealthinformationmaintainedinanymediumandcollectedfromanindividualthatiscreatedorreceivedbya health care provider, health plan, employer, or health care clearinghouse and that relates topast,present,orfuturephysicalormentalhealthorconditionoftheindividual;totheprovisionofhealthcaretoanindividual;ortothepast,present,orfuturepaymentfortheprovisionofhealthcaretoanindividualandthatidentifiesanindividualorwithrespecttowhichthereisareasonablebasistobelievetheinformationcouldbeusedtoidentifyanindividual.SensitivePersonalInformation(SPI)isanindividual’sfirstnameorfirstinitialandlastnameincombinationwithanyoneormoreofthefollowingitems,ifthenameanditemsarenotencrypted:socialsecuritynumber,driver’slicensenumberofgovernment-issued identification number, account number or credit or debit card number in combination withanyrequiredcode,orpasswordthatwouldpermitaccesstotheaccount,oridentifyinginformationthatrelatestothephysicalormentalhealthconditionoftheindividual,theprovisionofhealthcaretotheindividual,orthepaymentfortheprovisionofhealthcaretothe individual.


4.100 ProvidermeansaBirthingCenter,CertifiedNurseMidwife,HomeHealthCareAgency,Hospice, Hospital, Licensed Dietician, Pharmacy, Physician, Psychiatric Day Treatment Facility, Psychologist, Rehabilitation Facility, or Skilled Nursing Facility, and any other licensed practi-

tionerwhoisrequiredtoberecognizedforhealthinsurancebylaworregulationandisactingwithinthescopeofthelicense,asthecontextmayindicate.

4.101 Psychiatric Day Treatment Facilitymeansaninstitutionthat:

(a) isamentalhealthfacilitywhichprovidestreatmentforindividualssufferingfromacutemental,nervousoremotionaldisorders,inastructuredpsychiatricprogramutilizingindividualizedtreatmentplanswithspecificattainablegoalsandobjectivesappropriatebothtothepatientandthetreatmentmodalityoftheprogram,andisclinicallysuper-

visedbyadoctorofmedicinewhoiscertifiedinpsychiatrybytheAmericanBoardofPsychiatryandNeurology;and

(b) isaccreditedbytheProgramforPsychiatricFacilitiesoritssuccessor,ortheJointCommissiononAccreditationofHospitals;and

(c) treatsitspatientsfornotmorethan8hoursinany24-hourperiod.

4.102 Qualified DependentmeansaDependentwholosescoverageunderaWelfareProgramduetoaQualifyingEvent.

4.103 Qualifying Eventmeansanyofthefollowingeventsthat,butforCOBRAcontinuationcoverage,wouldresultinaCoveredParticipant’soreligibleDependent’slossofcoverage:

(a) deathofaCoveredParticipant; (b) terminationofemploymentofaCoveredParticipant; (c) reductioninhoursofaCoveredParticipant; (d) divorceorlegalseparationoftheCoveredParticipant; (e) theCoveredParticipant’sentitlementtoMedicarebenefits;or (f) DependentChildceasingtoqualifyasaDependentunderaWelfareProgram.

4.104 Qualified Medical Dependent Child Support (QMCSO) means a qualified Medical Dependent ChildSupportOrderinaccordancewiththeOmnibusBudgetReconciliationActof1993

(OBRA), as amended.

4.105 Reasonable and/or Reasonableness shall mean in the administrator’s discretion, services orsupplies,orfeesforservicesorsupplieswhicharenecessaryforthecareandtreatmentofillnessorinjurynotcausedbythetreatingProvider.Determinationthatfee(s)orservicesare reasonable will be made by the Plan Administrator, taking into consideration unusual circumstancesorcomplicationsrequiringadditionaltime,skillandexperienceinconnectionwithaparticularserviceorsupply;industrystandardsandpracticesastheyrelatetosimilarscenarios;andthecauseofinjuryorillnessnecessitatingtheservice(s)and/orcharge(s).

Thisdeterminationwillconsider,butwillnotbelimitedto,thefindingsandassessmentsofthefollowingentities:(a)TheNationalMedicalAssociations,Societies,andorganizations;and(b)TheFoodandDrugAdministration.TobeReasonable,service(s)and/orfee(s)mustbeincompliancewithgenerallyacceptedbillingpracticesforunbundlingormultiplepro-

cedures.Services,supplies,careand/ortreatmentthatresultsfromerrorsinmedicalcarethatareclearlyidentifiable,preventable,andseriousintheirconsequenceforpatients,are not Reasonable. The Plan Administrator retains discretionary authority to determine whetherservice(s)and/orfee(s)areReasonablebaseduponinformationpresentedtothePlanAdministrator.AfindingofProvidernegligenceand/ormalpracticeisnotrequiredforservice(s)and/orfee(s)tobeconsiderednotReasonable.


Charge(s) and/or services are not considered to be Reasonable, and as such are not eligible forpayment(exceedtheMaximumAllowableCharge),whentheyresultfromProvider

error(s)and/orfacility-acquiredconditionsdeemed“reasonablypreventable”throughthe useofevidence-basedguidelines,takingintoconsiderationbutnotlimitedtoCMSguidelines.

ThePlanreservesforitselfandpartiesactingonitsbehalftherighttoreviewchargespro- cessedand/orpaidbythePlan,toidentifycharge(s)and/orservice(s)thatarenotReasonable andthereforenoteligibleforpaymentbythePlan.

4.106 Rehabilitation (Physical) Facilitymeansafacilitythatprovidesservicesofnon-acuterehabili- tation.Allservicesareprovidedunderthedirectionofaphysiatrist,amedicaldoctorwitha specialtyinrehabilitationandphysicalmedicine.Registerednursesstaffthefacilityaround theclockanditdoesnotprovideservicesofacustodialnature.ThefacilitymustbeMedicare certified,licensedbytheStateDepartmentofHealthasaspecialHospitalandaccredited

bytheJointCommissiononAccreditationofHealthcareOrganizations.TheCommissiononAccreditationofRehabilitationFacilitiesalsoaccreditsit.

4.107 Skilled Nursing Facility(thistermalsoappliestoafacilitywhichreferstoitselfasanextend- edcarefacilityorconvalescentfacility)meansafacilitythatmeetsallofthefollowing:

(a) islicensedtoprovideprofessionalnursingservicesonaninpatientbasistopatientsconvalescingfromInjuryorIllnesstohelprestorepatientstoself-careinessentialdailylivingactivities;

(b) providescontinuousnursingservicesbylicensednursesfor24hoursofeveryday,underthedirectionofafull-timeregisterednurse(R.N.);

(c) providesservicesforcompensationandunderthefull-timesupervisionofaPhysician; (d) maintainsacompletemedicalrecordoneachpatient; (e) hasaneffectiveutilizationreviewplan;and (f) isnot,otherthanincidentally,aclinic,aplaceforrest,aplacedevotedtocareofthe

aged,aplacefortreatmentofmentaldisordersormentalretardation,oraplaceforcustodial care.

4.108 Specialty Medicationsmeanhigh-costoralorinjectablemedicationsusedtotreatcomplexacuteand/orchronicconditions.Thesearehighlycomplexmedications,typicallybiology-based,thatstructurallymimiccompoundsfoundwithinthebody.High-touchpatientcaremanagementisusuallyrequiredtocontrolsideeffectsandensurecompliance.Specializedhandlinganddistributionarealsonecessarytoensureappropriatemedicationadministration.

4.109 SpousemeansthepersonrecognizedunderTexaslawasthecoveredEmployee’shusbandorwifeunlessdivorcedorlegallyseparatedunderthelawsoftheState.Documentationprovingalegalmaritalrelationshipmayberequired.ThisPlanwillrecognizeCommonLawMarriageinTexasiftheEmployeeprovidesdocumentationrequiredbytheStatetosubstantiateCommonLawMarriageincluding:(1)anagreementtobemarried;(2)holdingyourselfouttoathirdparryasbeingmarriedand(3)livingtogether.RequiresCommonLawMarriageCertificatefromtheCountyClerk’sOffice.

4.110 Subrogation means the benefits provided by the Plan are secondary when a Covered Participantisentitledtoreceivemoneyfromanyothersource,includingbutnotlimitedtoany party’s liability insurance or uninsured/underinsured motorist proceeds.


4.111 Substance Abuse means the condition caused by physical and/or emotional dependence on drugs, narcotics, alcohol, or other addictive substances resulting in a chronic disorder, whichaffectsphysicalhealth,and/orpersonalorsocialfunctioning.Thisdoesnotincludedependenceontobaccoorordinarycaffeine-containingbeverages.

SubstanceAbuseshallmeananyuseofalcohol,anyDrug(whetherobtainedlegallyorillegally), any narcotic, or any hallucinogenic or other illegal substance, which produces a patternofpathologicaluse,causingimpairmentinsocialoroccupationalfunctioning,orwhich produces physiological dependency evidenced by physical tolerance or withdrawal. Itistheexcessiveuseofasubstance,especiallyalcoholoradrug.TheDSM-IVdefinitionisappliedasfollows:

(a) Amaladaptivepatternofsubstanceuseleadingtoclinicallysignificantimpairmentordistress,asmanifestedbyone(ormore)ofthefollowing,occurringwithina12-monthperiod:

1. Recurrentsubstanceuseresultinginafailuretofulfillmajorroleobligationsatwork,schoolorhome(e.g.,repeatedabsencesorpoorworkperformancerelatedtosubstanceuse;substance-relatedabsences,suspensionsorexpulsionsfromschool;neglectofchildrenorhousehold)

2. Recurrentsubstanceuseinsituationsinwhichitisphysicallyhazardous(e.g.,driving an automobile or operating a machine when impaired by substance use)

3. Recurrentsubstance-relatedlegalproblems(e.g.,arrestsforsubstance-relateddisorderly conduct)

4. Continued substance use despite having persistent or recurrent social or interpersonalproblemscausedorexacerbatedbytheeffectsofthesubstance

(e.g.,argumentswithspouseaboutconsequencesofintoxication,physicalfights)

(b) ThesymptomshavenevermetthecriteriaforSubstanceDependenceforthisclassofsubstance.

4.112 Schedule of Medical BenefitsmeansthelistingofMedicalBenefitsanddescriptionofthebenefit levels provided in the Introduction.

4.113 Temporomandibular Joint Dysfunction (TMJ) means jaw joint disorders including conditions ofstructureslinkingthejawboneandskullandthecomplexmuscles,nervesandothertissues related to the temporomandibular joint.

4.114 Third Party (Claim) AdministratormeansPreferredAdministratorstowhomthePlanAdmin- istratorhasdelegatedthedutytoprocessand/orreviewclaimsforbenefitsunderthePlan.

4.115 Totally DisabledmeansthecompleteinabilityofanEmployeetosubstantiallyperformtheimportantdailydutiesoftheEmployee’sownoccupation,forwhichtheEmployeeisreasonablysuitedbyeducation,trainingorexperience.ADependentwhoisTotallyDisabledmeansthattheDependentispreventedsolelybecauseofanon-occupationalInjuryornon-occupationalIllnessfromengaginginallofthenormalactivitiesofapersonoflikeageandsexandingoodhealth.ADependentChildorgrandchildwillbeconsideredTotallyDisablediftheyareincapableofself-supportbecauseofdevelopmentaldisabilityorphysicalhandicap.TheThirdPartyAdministratormayrequireproofofcontinuingTotalDisabilityfromtimetotime.

4.116 USERRAmeanstheUniformedServicesEmploymentandReemploymentRightsActof1994,as amended.


4.117 Usual and Customary (U&C) Usual Customary and Reasonable charges (UCR charges) refertothebaseamountthatistreatedasthestandardormostcommonchargeforaparticular medical service when rendered in a particular geographic area. Third-party payers including insurance carriers and employers use UCR charges to determine the amount to bepaidonbehalfofanenrollee,forservicesthatarereimbursedunderahealthinsurancepolicyorhealthplan.UCRchargesshouldnotexceedtheamountordinarilychargedbymostprovidersforcomparableservicesandsuppliesinthelocalitywheretheservicesorsupplies are received. The term “Usual and Customary” does not necessarily mean the actualchargemadenorthespecificserviceorsupplyfurnishedtoaPlanParticipantbyaProviderofservicesorsupplies,suchasaphysician,therapist,nurse,hospital,orpharmacist.ThePlanAdministratorwilldeterminewhattheUsualandCustomarychargeis,foranyprocedure, service, or supply, and whether a specific procedure, service or supply is Usual and Customary. Usual and Customary charges may, at the Plan Administrator’s discretion, alternatively be determined and established by the Plan using normative data such as, butnotlimitedto,Medicarecosttochargeratios,averagewholesaleprice(AWP)forprescriptionsand/ormanufacturer’sretailpricing(MRP)forsuppliesanddevices.

4.118 Wrap NetworkAgroupofdoctors,hospitalsandotherhealthcareproviderscontractedbyMultiplanandPHCStoprovideservicestoinsurancecompaniescustomersforlessthantheirusualfees.Providernetworkscancoveralargegeographicmarketorawiderangeofhealth care services.

All other defined terms in this Plan Document shall have the meaningsspecified in the Plan Document where they appear.


ARTICLE V

ELIGIBILITY AND PARTICIPATIONREQUIREMENTS

5.01 Eligibility

(a) Employee Eligibility.

Allfull-timeregularEmployees(normallyscheduledtoworkaminimumof36hoursper week) and part-time regular Employees (normally scheduled to work a minimum of20hoursperweek)areeligibletoparticipateinthePlanonthefirstofthemonthfollowing30daysofregularfull-timeorpart-timeemployment.AnEmployeewhoisnotActivelyatWorkforanyreasonotherthanmedicaldisabilitywillbecomeeligibleforcoverageuponhis/herreturntowork.

EmployeeswhowerespecificallyhiredtoworkforEPCHpriortotheopeningdate,February5,2012andsignedanEPCHoffer/commitmentlettersshallcontinuebenefitcoveragewithnobreakincoverageandserviceandareeligiblefordeductiblecredits.

CoverageunderthePlanElPasoChildren’sHospitalFlexibleBenefitsPlan.Thebenefitselectedmustbefora12-monthperiodasdescribedundertheFlexibleBenefitsPlanunlesstheCoveredParticipantexperiencesaChangeinFamilyStatusoraChangeinStatus or Coverage.

Eligibleexpensesforregisteredsame-sexdomesticpartnersandtheirchildrenmaybecoveredundertheflexiblespendinghealthcareanddependentdaycareaccountsiftheymeetthedefinitionofdependentsunderIRSSection152.

IfanindividualbecomesanEmployeeduetotheacquisitionofanAffiliate,hiscontinu- ousservicewiththeAffiliateshallcounttowardthewaitingperiod.ThePlanAdminis- trator may waive the waiting period with respect to all similarly situated Employees

whowerecoveredundertheotheremployer’sgrouphealthplanatthetimeoftheacquisitionand/orhonortheprioremployer’sgrouphealthplanwaitingperiod.

Any Employee covered as a participant may not also be covered as a Dependent under thisPlan.IfanEmployee’sSpouseiscoveredunderthisPlanastheEmployee’sDepend- ent,theSpousecannotalsobecoveredasanEmployee.IfbothparentsareEmployees,

DependentChildrencanbecoveredasDependentsofoneparentonly.

(b) Dependent Eligibility.

(i) Dependents are eligible to participate at the same time as the Employee, or on the firstdayofthemonthaftertheybecomeDependents,iflater.Newbornandadopted Dependent Children participate in the Plan immediately upon birth or adoption,

providedthattheEmployeeenrollsthechildwithin30daysofbirthoradoption.

(ii)DependentcoveragemaycontinueunderthisPlanfollowinganEmployee’selection ofMedicareasprimary.TheDependentwillbetreatedinthesamemannerasifthe Employee had remained on the Plan, as long as the Employee continues to meet the eligibilityrequirementsandcompletesallnecessaryagreementsonatimelybasis.

(iii) A Dependent may be added to the Plan pursuant to a qualified Medical Dependent ChildSupportOrder(QMCSO)issuedbyacourtofcompetentjurisdictionoradmin-

istrativebodythatrequiresthePlantoprovidemedicalcoveragetotheDependentChildofanEmployee.AstepchildnotlivingwiththeEmployeeisnotconsidereda

DependentChildforpurposesoftheQMCSOrules.ThePlanAdministratorwillestab- lishreasonableproceduresfordeterminingwhetheracourtorderoradministrative


decreerequiringmedicalcoverageforaDependentChildmeetstherequirementsforaQMCSO.ThePlanAdministratorshallhavetheauthoritytoenrollboththeEmployeeandDependentChild,iftheEmployeeisnotacurrentparticipantatthetimetheQMCSOisreceived.Thecostofcoverageoranyadditionalcostofsuchcoverage,ifany,isbornebytheEmployee.

(iv)DocumentationmayberequiredtoconfirmthataDependentmeetsthePlan’sDependenteligibilityrequirements.

(c) Domestic Partner Eligibility.

TheDomesticPartnerofanEligibleEmployeeiseligibletoparticipateinthePlanifhe/shemeetsthedefinitionofDomesticPartnerandproducesdocumentation*ofatleasttwoofthefollowingasevidenceofourjointresponsibilitiesandcommitmenttotheDomesticPartnership(oneofthetwoitemsmustbefromListA).

LIST A LIST B

joint Obligation on a loan (including Designated as the beneficiary under theanaffidavitbyacreditorona otherslifeinsurancepolicy,retirementpersonalloan) benefitsaccountorwillorexecutorof each other’s will

Jointownershipofsharedresidence Jointbankaccount

Jointresponsibilityforachild Jointcreditcardaccounts(eg. guardianship )

Jointownershiporholdingof Statusasauthorizedsignerontheinvestments partners bank account, credit card or debit or charge card

Jointownershiporleaseofa Otherproofoffinancialmotor vehicle interdependence

Both listed as tenants on the lease ofaresidence

Mutually granted authority to make health care decisions (healthcare powerofattorney)

Mutually granted durable power ofattorney

* All documents must be pre-dated by at least one year

1. Anydependentchild(ren)ofthecoveredemployee’sDomesticPartnerwillnotbeeligibleforanycoverageunlessthechild(ren)arealsoaneligibledependentchild(ren)oftheemployee;

2. NoemployeewhoiseligiblefortheElPasoChildren’sHospitalHealthBenefitPlancanbecoveredasaDomesticPartnerofanotheremployeewhoisalsoeligibleforbenefits;

3. DomesticPartnerbenefitsmayhavefederalandpossiblystatetaxconsequences;

4. IftheDomesticPartnershipnolongermeetsallofthecriteriaattestedtointhisAffidavit,aNoticeofTerminationofDomesticPartnershipmustbefiledwithinthirty-one(31)daysofsuchchange,withtheHumanResourcesdepartment.


5.02 Failure to Elect Medical Coverage During Open Enrollment

PursuanttotheprovisionsoftheFlexPlan,ifaCoveredParticipantfailstotimelycomplete andsubmitaBenefitsEnrollment/Changeagreementorenrollon-lineforthePlanYearcom- mencing October 1, he shall be deemed to have elected Employee Only Medical Coverage.

EffectiveforPlanYearsonandafterOctober1,2012,ifaCoveredParticipantfailstotimelycomplete and submit a Benefits Enrollment/Change agreement or enroll on-line he shall bedeemedtohavemadethesameMedicalelectionsaswasineffectonthelastdayofthepriorCoveragePeriod.Newlyhired/eligibleEmployeeswilldefaulttoEmployeeOnlyMedical Coverage.

5.03 Enrollment

(a) EffectiveDate.EachEmployeeontheEffectiveDateshallbeeligibletoparticipateinthisPlanasofsuchdate.AnynewEmployeeshallparticipateeffectiveasofthedatecoincidingwithhiseligibilityfortheBenefitProgramsandbepermittedtoenrollinthePlanduringthefirst31daysofemployment.AnyreclassifiedEmployeewillbepermittedtoenrollinthePlanorchangehisenrollmentinthePlanthe1stofmonthfollowing31daysofserviceofthestatusreclassification.

(b) Late Enrollment.Ifenrollmentisnotrequestedwithin31consecutivedaysaftersatisfyingthewaitingperiodandbecomingeligibletoenrollinthePlan,thentheEmployeemayonlyrequestenrollmentforhimselfand/orhiseligibleDependent(s)as

a Late Enrollee.

(c) LossofOtherCoverage–SpecialEnrollment. An Employee or Late Enrollee is eligible duringaspecialenrollmentperiodforanemployeewhoeitherinitiallydeclinedcoverageforhimselfand/orhiseligibledependent(s)becauseofexistingotherhealth

coverage,orwhopreviouslydeclinedcoverageforhimselfand/orhiseligibledependent(s)atasubsequentopportunitytoenrollunderaspecialenrollmentperiodoras

alateentrantbecauseofexistingotherhealthcoverage(suchnoticeprovidedtothePlanAdministratorinwriting),iftheemployeerequestsenrollmentforhimselfand/orsuchdependentsnotlaterthan31daysafterlossoftheotherhealthcoverageprovidedthattheothercoveragewasterminateddueto:

(i) lossofeligibilityasaresultoflegalseparation,divorce,cessationofdependentstatus(suchasattainingthelimitingageforadependentchild),death,terminationofemployment,orreductioninhours;or

(ii) an HMO or other arrangement in the individual market that does not provide benefits to individuals who no longer reside, live, or work in a service area (whetherornotwithinthechoiceoftheindividual);or

(iii) an HMO or other arrangement in the group market that does not provide benefits to individuals who no longer reside, live or work in a service area (whether or not withinthechoiceoftheindividual),andnootherbenefitpackageisavailabletotheindividual;or

(iv) anHMOceasingoperations;or

(v) aplannolongerofferinganybenefitstoaclassofsimilarlysituatedindividuals;or

(vi) cessationofemployercontributionsfortheotherhealthcoverage;or

(vii)theexhaustingofCOBRAcontinuationcoverage.

Ifcoverageisrequestedwithin31daysofthelossofotherhealthcoverageasdescribedabove,coverageunderthisPlanwillbecomeeffectiveonthefirstdayofthemonthimmediatelyfollowingnotificationinwritingtothePlanAdministratorofthechange-in-statusevent.(However,ifanemployeeordependentlostothercoverageasaresultoftheindividual’sfailuretopaypremiumsorforcause,suchasmakingafraudulentclaim, that individual does not have a special enrollment right.)


(d) New Dependent – Special Enrollment.IfanEmployeehasanewDependentduetomarriage,birth,adoption,orPlacementforAdoption,theEmployeemayenrollhimself,hisSpouse,andhisnewDependentinthePlan.TheEmployeemustsubmitawrittenrequestforenrollmentwithin31daysafterthemarriage,birth,adoption,orPlacementforAdoption.CoveragefortheDependentChildwillbeeffectivetothedateofmarriage,birth,adoptionorPlacementforAdoption.

(e) Change in Family Status Change.TheEmployeemustrequestenrollmentforhimselfand/orsuchDependent(s)withina31-dayperiod,whichbeginsonthedateoftheChangeinStatusevent.Coveragewillbeeffectiveonthefirstofthemonthfollowingnotification.

(f) Court Ordered Coverage.CoverageforaDependentChildpursuanttoaQMCSOwillbeeffectiveasofthedateofthedecreeprovidedtheEmployeerequestsenrollmentfortheDependentChildwithin31daysoftheQMCSO.

(g) Significant Change in Cost.EnrollmentmaycommenceasofthefirstdayofthenextpayrollperiodiftheEmployeehasexperiencedasignificantchange(increaseincostorsignificantcurtailmentofcoverage)providedthattheEmployeerequestsenrollmentforhimselfand/orsuchDependent(s)withina31-dayperiodwhichbeginsonthedatethatthesignificantincreaseincostorsignificantcurtailmentofcoverageoccurs.

(h) Significant Change in Coverage.EnrollmentmaycommenceasofthefirstdayofthenextpayrollperiodfollowingnotificationduetoasignificantchangeinhealthcoverageattributabletoaSpouse’semploymentprovidedthattherequestforenrollment is necessary or appropriate due to the significant change. The Employee mustrequestenrollmentforhimselfand/orhisDependent(s)withina31-dayperiodbeginning on the date that the significant change in health coverage occurs.

5.04 Coverage During a Leave of Absence

(a) TotalDisabilityLeaveofAbsence.IfaCoveredPersonisTotallyDisabledonthedatetheirLeaveofAbsencecommencesunderthePlan,coveragefortheInjuryorIllnesswhich caused the, the Employee may elect COBRA at the COBRA premium rates.

(b) PersonalLeaveofAbsence.IfanEmployeereceivesauthorizationforaneducational orpersonalLeaveofAbsencecoveragewhile:

(i) paidleavewillcontinueattheEmployeeratethroughtheendofthepaidleave.CoverageforperiodsthereafterwillbethroughCOBRA.

(ii) unpaidleavewillcontinuethroughtheendofthemonthattheregularEmployeecontributionrate(paidthrougheitherpayrolldeductionoronanafter-taxbasis).CoverageforperiodsthereafterwillbethroughCOBRA.

(iii)temporarylayoffwillcontinueforuptoa3-monthperiodattheregularEmployeecontributionrate(paidthrougheitherpayrolldeductionoronanafter-taxbasis).

Inlieuofthiscoverage,theEmployeemayelectCOBRAattheCOBRApremiumrates.

(c) FamilyorMedicalLeaveOfAbsence. During any period during which a Covered ParticipantisonafamilyormedicalleaveasdefinedintheFamilyorMedicalLeaveAct,anybenefitelectionsinforcefortheCoveredParticipantshallremainineffect.While the Covered Participant is on paid leave, contributions shall continue.

Prior to commencing an unpaid leave, the Covered Participant may elect to prepay all oraportionofrequiredcontributionsonapre-taxbasis.Alternatively,theCovered

Participantmayelecttomakesuchpaymentsonanafter-taxbasismonthlyinaccord- ancewithanarrangementthatthePlanAdministratorshallprovide.Ifcoverageis

notcontinuedduringtheentireperiodofthefamilyormedicalleavebecausetheCovered Participant declines to pay the premium, the coverage will be reinstated upon reemploymentwithnoexclusionsorwaitingperiods.


Benefitswillbecancelledifpaymentismorethan30dayslate.UponreturnfromFMLA or upon notification that the Covered Participant will not be returning to work, theCoveredParticipantmustpaythefullcostofanyhealthcarecoveragethatwascontinuedonhisbehalfduringtheleave.TheserulesapplytotheCOBRAEligibleWelfareProgramsandHealthCareSpendingAccounts.

(d) MilitaryLeave.PursuanttotheprovisionsoftheUniformedServicesEmploymentandReemploymentRightsActof1994,anEmployeeonmilitaryleavewillbeconsideredto

beonaleaveofabsenceandwillbeentitledduringtheleavetothehealthandwelfare benefitsthatwouldbemadeavailabletoothersimilarlysituatedEmployeesiftheywere onaleaveofabsence.ThisentitlementendsiftheEmployeeprovideswrittennoticeof intentnottoreturntoworkfollowingthecompletionofthemilitaryleave.TheEmployee shallhavetherighttocontinuehiscoverage,includinganyDependentcoverage,for

thelesserofthelengthoftheleaveor18months(24monthsforelectionsmadeonor afterDecember10,2004).Ifthemilitaryleaveisforaperiodof31daysormore,the

Participantcanberequiredtopay102percentofthetotalpremium(determinedinthesame manner as a COBRA continuation coverage premium).

IfcoverageisnotcontinuedduringtheentireperiodofthemilitaryleavebecausetheParticipantdeclinestopaythepremiumortheleaveextendsbeyond18months(24monthsforelectionsmadeonorafterDecember10,2004),thecoveragemustbereinstated upon reemployment within the time specified by law.

5.05 Continuation of Coverage Under COBRA

ContinuationofhealthcoverageunderCOBRA(ConsolidatedOmnibusBudgetReconcilia- tion Act) shall not duplicate health coverage continued under any state or Federal law.

**IMPORTANT NOTE** There may be other coverage options for you and your family. When key parts of the health care law take effect, you’ll be able to buy coverage through the Health Insurance Marketplace. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days.

A. DEFINITIONS

Asusedinthisprovision,thefollowingtermsshallmean:

1. “Entitlement to Medicare” or “Entitled to Medicare” means the covered employee has enrolled in either Medicare Part A or Part B.

2. “Qualified Beneficiary”means: a. acoveredemployee,forterminationorreducedhours; b. a spouse or a dependent child who were covered dependents under the Plan onthedaybeforethecoveredemployee’sQualifyingEventoccurred; c. a child who is born to a covered employee, or placed with a covered employeeforadoption,duringaperiodofCOBRAcontinuationcoverage.

3. “Qualifying Event”foracoveredemployeemeansalossofcoveragedueto: a. terminationofemploymentforanyreasonotherthangrossmisconduct; b. reductioninhoursofemployment.


“Qualifying Event”foracovereddependentmeansalossofcoveragedueto: a. acoveredemployee’sterminationofemployment(foranyreasonother thangrossmisconduct)orreductioninhoursofemployment; b. acoveredemployee’sdeath; c. aspouse’sdivorceorlegalseparationfromacoveredemployee; d. acoveredemployee’sentitlementtoMedicare; e. adependentchild’slossofdependentstatusunderthePlan.

TerminationofemploymentfollowingaQualifyingEventthatisareductioninhoursofemploymentisnotasecondQualifyingEvententitlingtheQualifiedBeneficiarytoanextensionoftheperiodofCOBRAcoveragecontinuation.

4. “Timely Contribution Payment”meansthattherequiredcontributionpaymentismadewithintheapplicabletimeperiod(fortheinitialcontributionpayment,within 45daysofthedatethattheQualifiedBeneficiarymadetheinitialelectionforcontinuationcoverage;forsubsequentcontributionpayments,within30 days oftheduedate).ATimelyContributionPaymentisdeemedtohavebeenmadeifit is not significantly less than the amount due unless the qualified Beneficiary is notifiedofthedeficiencyandgiven30 days to pay the balance.

B. CONTINUATION OF HEALTH COVERAGE NOTICE AND ELECTION PROCEDURES

ThefollowingproceduresforcontinuationofbenefitsunderCOBRAareherebyadoptedbythePlan:

GENERAL NOTICE (INITIAL COBRA NOTICE):

AgrouphealthplansubjecttotherequirementsofCOBRAmustprovidewrittennotice toeachcoveredemployeeandspouse(ifapplicable)within90daysaftercoverage

underthePlancommencesoftherighttocontinuecoverage.(IfaQualifyingEventoccurs during the first 90daysofcoverageunderthePlanandbeforethegeneralnotice has been distributed, the Plan may provide only the COBRA election notice, as describedbelow).Inlieuof,orinadditionto,suchwrittennotice,thePlanAdminis-

tratorisherebyprovidingthegeneralnoticetotheemployeebydeliveryoftheSummary Plan Description.

ThePlanmaynotifyacoveredemployeeandthecoveredemployee’sspousewithasinglegeneralnoticeaddressedtotheirjointresidence,providedthePlan’slatestinfor-

mation indicates that both reside at that address. However, when a spouse’s coverage under the Plan begins later than the employee’s coverage, a separate general notice must be sent to the spouse within 90daysafterthespouse’scoveragecommences.

NOTE: ItisimportantforthePlanAdministratortobekeptinformedofthecurrentaddressesofallCoveredPersonsunderthePlanwhoare,orwhomaybecome,qualified Beneficiaries.

EMPLOYER’S NOTICE OF QUALIFYING EVENT AND NOTICES THAT QUALIFIED BENEFICIARIES MUST PROVIDE:

Continuationofhealthcoverageshallbeavailabletoanemployeeand/orhiscovereddependentsupontheoccurrenceofaQualifyingEvent.


Tocontinuehealthcoverage,thePlanAdministratormustbenotifiedinwritingof aQualifyingEventby:

1. the Employer, within 30daysofthelaterof:(1)thedateofsucheventor, (2)thedateoflossofcoverageduetotheevent,iftheQualifyingEventis: a. foracovereddependent,thecoveredemployee’sdeath; b. thecoveredemployee’stermination(otherthanforgrossmisconduct)or reductioninhours; c. foracovereddependent,thecoveredemployee’sentitlementtoMedicare.

2. the employee or a qualified Beneficiary, within 60daysofthelaterof:(1)thedate ofsuchevent,(2)thedateoflossofcoverageduetotheevent,or(3)thedateon whichaQualifiedBeneficiaryisinformedthroughthePlan’sSummaryPlanDescrip- tionorgeneralnoticeofbothhisobligationtoprovidenoticeandtheprocedures

forprovidingsuchnotice,iftheQualifyingEventis: a. foraspouse,divorceorlegalseparationfromacoveredemployee; b. foradependentchild,lossofdependentstatusunderthePlan;or c. theoccurrenceofasecondQualifyingEventafteraQualifiedBeneficiary hasbecomeentitledtocontinuationcoveragewithamaximumdurationof 18 (or 29) months.

An employee or qualified Beneficiary who does not provide timely notice to the EmployerofoneoftheabovesuchQualifyingEventsmaylosehisrightsunderCOBRA.

Uponterminationofemploymentorreductioninhours,aQualifiedBeneficiarywhoisdeterminedunderTitleIIorTitleXVIoftheSocialSecurityActtobedisabledonsuch date, or at any time during the first 60daysofCOBRAcontinuationcoverage,willbeentitledtocontinuecoverageforupto29monthsifthePlanAdministratorisnotifiedofsuchdisabilitywithin60daysfromthelaterof(andbeforetheendofthe18-monthperiod):(1)thedateofdetermination,(2)thedateonwhichtheQualifyingEvent occurs, (3) the date on which the qualified Beneficiary loses coverage, or (4) the dateonwhichtheQualifiedBeneficiaryisinformedthroughthePlan’sSummaryPlanDescriptionorgeneralnoticeofboththeobligationtoprovidethedisabilitynoticeandthePlan’sproceduresforprovidingsuchnotice.IfaQualifiedBeneficiaryentitledtothedisabilityextensionhasnon-disabledfamilymemberswhoareentitledtoCOBRAcontinuationcoverage,thenon-disabledfamilymembersarealsoentitledtothedisabilityextension.

AQualifiedBeneficiarywhoisdisabledunderTitleIIorTitleXVIoftheSocialSecurityActmustnotifythePlanAdministratorwithin30daysfromthelaterof:(1)thedate

offinaldeterminationthatheisnolongerdisabled,or(2)thedateonwhichtheindi- vidualisinformedthroughthePlan’sSummaryPlanDescriptionorgeneralnoticeof

boththeresponsibilitytoprovidesuchnoticeandthePlan’sproceduresforprovidingsuch notice.

PLAN ADMINISTRATOR’S NOTICE OBLIGATION – ELECTION NOTICE:

The Plan Administrator must, within 14daysofreceivingnoticeofaQualifyingEvent,notifyanyQualifiedBeneficiaryofhisrighttocontinuecoverageunderthePlan.Notice to a qualified Beneficiary who is the employee’s spouse shall be notice to all other qualified Beneficiaries residing with such spouse when such notice is given.

ELECTION PROCEDURES:

AQualifiedBeneficiarymustelectContinuationofHealthCoveragewithin60 days fromthelaterofthedateoftheQualifyingEventorthedatenoticewassentbythePlan Administrator.


Anewspouse,anewbornchild,orachildplacedwithaQualifiedBeneficiaryforadoptionduringaperiodofCOBRAcontinuationcoveragemaybeaddedtothePlanaccordingtotheenrollmentrequirementsfordependentcoverageunderthe“ELIGIBILITYREQUIREMENTS”sectionofthePlan.AQualifiedBeneficiarymayalso

add new dependents during an open enrollment period held once each year at a time and in accordance with the procedures established by the Plan Administrator.

Any election by an employee or his spouse shall be deemed to be an election by any other qualified Beneficiary, though each qualified Beneficiary is entitled to an individ- ualelectionofcontinuationcoverage.

Upon election to continue health coverage, a qualified Beneficiary must, within 45 days ofthedateofsuchelection,payallrequiredcontributionstodatetothePlanAdminis- trator.AllfuturecontributionpaymentsbyaQualifiedBeneficiarymustbemadetothe

PlanAdministratorandareduethefirstofeachmonthwitha30-day grace period.

Iftheinitialcontributionpaymentisnotmadewithin45daysofthedateoftheelec- tion,COBRAcoveragewillnottakeeffect.Iffuturecontributionpaymentsarenot made within the allotted 30-day grace period, COBRA coverage will be terminated

retroactivelybacktotheendofthemonthinwhichthelastfullcontributionpaymentwas made.

Exceptasprovidedherein,iftheinitialcoverageelectionandrequiredcontributionpayments are made in a timely manner, as described in this section, coverage under the PlanwillbereinstatedretroactivelybacktothedateoftheQualifyingEvent.

IfaQualifiedBeneficiarywaivesCOBRAcoverage,hemayrevokethewaiveratanytime duringtheelectionperiod.TheQualifiedBeneficiarywouldbeeligibleforcontinuation

ofcoverageprospectivelyfromthedatethatthewaiverisrevoked,ifallotherrequire- ments, such as Timely Contribution Payments, are met.

PLAN ADMINISTRATOR’S NOTICE OBLIGATION – NOTICE OF UNAVAILABILITY OF CONTINUATION COVERAGE:

ThePlanAdministratormustprovideanoticeofunavailabilitytoanindividualwithin14daysafterreceivingarequestforcontinuationcoverageifthePlandeterminesthat such individual is not entitled to continuation coverage. The notice must include anexplanationastowhytheindividualisnotentitledtoCOBRA.ThisnoticemustbeprovidedregardlessofthebasisofthedenialandregardlessofwhetheritinvolvesafirstorsecondQualifyingEventorarequestfordisabilityextension.

PLAN ADMINISTRATOR’S NOTICE OBLIGATION – EARLY TERMINATION NOTICE:

The Plan Administrator must provide a notice to qualified Beneficiaries when COBRA terminatesearlierthanthemaximumperiodofCOBRAapplicabletotheQualifyingEventassoonaspracticablefollowingitsdeterminationthatcontinuationcoverageshall terminate. This notice must contain the reason that continuation coverage has terminatedearlierthanthemaximumperiodtriggeredbytheQualifyingEvent,thedateofterminationofcontinuationcoverage,andanyrightstheQualifiedBeneficiarymay have under the Plan or under applicable law to elect alternative group or individual coverage (such as a conversion right).

TRADE ACT OF 2002:

ThePlanshallfullycomplywiththeTradeActof2002astheActappliestoemployeewelfarebenefitplans.


PAPERWORK REDUCTION ACT STATEMENT:

AccordingtothePaperworkReductionActof1995(Pub.L.104-13)(PRA),nopersonsarerequiredtorespondtoacollectionofinformationunlesssuchcollectiondisplaysa

validOfficeofManagementandBudget(OMB)controlnumber.TheDepartmentnotes thataFederalagencycannotconductorsponsoracollectionofinformationunlessitis approved by OMB under the PRA, and displays a currently valid OMB control number, andthepublicisnotrequiredtorespondtoacollectionofinformationunlessitdisplays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any

otherprovisionsoflaw,nopersonshallbesubjecttopenaltyforfailingtocomplywithacollectionofinformationifthecollectionofinformationdoesnotdisplayacurrentlyvalid OMB control number. See 44 U.S.C. 3512.

Thepublicreportingburdenforthiscollectionofinformationisestimatedtoaverageapproximatelyfourminutesperrespondent.Interestedpartiesareencouragedtosendcommentsregardingtheburdenestimateoranyotheraspectofthiscollectionofinformation,includingsuggestionsforreducingthisburden,totheU.S.DepartmentofLabor,OfficeoftheChiefInformationOfficer,Attention:DepartmentalClearanceOfficer,200ConstitutionAvenue,N.W.,RoomN-1301,Washington,DC20210oremailDOL_PRA_PUBLIC@dol.govandreferencetheOMBControlNumber1210-0123.

C. PREMIUMS FOR COBRA COVERAGE

TheQualifiedBeneficiarymayberequiredtopaypremiumsforanyperiodofCOBRAcoverageequalto102%oftheapplicablepremium,inaccordancewithapplicablelaw.However,anyQualifiedBeneficiary(includingallfamilymembersofsuchindividualwhoareQualifiedBeneficiaries)whoisentitledtothedisabilityextension(asspecifiedabove),mayberequiredtopaypremiumsequalto150%oftheapplicablepremiumforthecoverageperiodfollowingtheinitial18-month period.

AQualifiedBeneficiarywillbenotifiedbythePlanAdministratoroftheamountoftherequiredcontributionpaymentandthecontributionpaymentoptionsavailable.

ThecostofCOBRAcoveragemaybesubjecttofutureincreasesduringtheperioditremainsineffect.

D. TERMINATION OF COVERAGE FOR COBRA

COBRAcontinuationcoveragewillendupontheearliestofthefollowingtooccur:

1. ifanemployeeisterminatedorhashis/herhoursreduced: a. 18monthsfromthedateoftheQualifyingEvent;or b. 29monthsfromthedateoftheQualifyingEventiftheQualifiedBeneficiary isdeterminedunderTitleIIorTitleXVIoftheSocialSecurityActtobedisabled on such date or at any time during the first 60daysofCOBRAcontinuation

coverageandprovidesnoticeasrequiredbythePlan(includingCOBRAcon- tinuationcoverageofnon-disabledfamilymembersoftheQualifiedBene- ficiaryentitledtothedisabilityextension). 2. theday,afterthe18-monthcontinuationperiod,whichbeginsmorethan30 days fromthedateofafinaldeterminationunderTitleIIorTitleXVIoftheSocial

Security Act that a qualified Beneficiary, entitled to 29 months, is determined to benolongerdisabled(includingCOBRAcontinuationcoverageofnon-disabledfamilymembersoftheQualifiedBeneficiaryentitledtothedisabilityextensionwho is no longer disabled).


3. foracovereddependent,36monthsfromthedateoftheQualifyingEventiftheQualifyingEventis:

a. thecoveredemployee’sdeath; b. thecoveredemployee’sentitlementtoMedicare; c. aspouse’sdivorceorlegalseparationfromacoveredemployee;or d. adependentchild’slossofdependentstatusunderthePlan.

4. ifanyoftheQualifyingEventslistedin3.occursduringthe18-month period (or 29-monthperiodifthereisadisabilityextension)afterthedateoftheinitial

QualifyingEventlistedin1.,coverageterminates36monthsafterthedateoftheinitialQualifyingEventlistedin1.

5. the date on which the Employer ceases to provide any group health plan coverage to any employee.

6. thedateoftheQualifyingEventiftheQualifiedBeneficiaryfailstomaketheinitial contribution payment within 45daysofthedateoftheelection.

7. thelastdayofthemonthinwhichthelastcontributionpaymentwasmadeiftheQualifiedBeneficiaryfailstomakefuturecontributionpaymentswithintheallotted 30-day grace period as described in this section.

8. aqualifiedbeneficiarybecomescovered,afterelectingcontinuationcoverage,underanothergrouphealthplanthatdoesnotimposeanypre-existingconditionexclusionforapre-existingconditionofthequalifiedbeneficiary(note:thereare

limitationsonplans’imposingapreexistingconditionexclusionandsuchexclu- sionswillbecomeprohibitedbeginningin2014undertheAffordableCareAct).

9. thefirstdayofthemonthinwhichaQualifiedBeneficiarybecomesentitled to Medicare.

10. the date this Plan terminates.

5.06 Termination of Coverage

(a) AnAssociate’scoverageunderthePlanterminatesontheearliestofthefollowing:

(i) dateoftermination; (ii) dateofterminationofthePlan; (iii) dateofMedicareelection; (iv) dateanAssociateceasestomeetthePlan’seligibilityrequirements; (v) dateallcoverageorcertainbenefitsareterminatedforEmployeesby

modificationofthePlan; (vi) lastdayofthemonthforwhichtherequiredcontributionhasbeenpaidifthe

requiredcontributionfor1 pay period is more than 30daysinarrears; (vii) date an Associate becomes covered under another Group Health Plan as a

Dependent;or (viii)datetheAssociate’scoverageterminatesforanyreason.

(b) DependentcoverageunderthePlanshallterminateontheearliestofthefollowing:

(i) dateofPlantermination; (ii) dateinwhichtheEmployeeterminatesemployment; (iii) dateanEmployeeceasestomeetthePlan’seligibilityrequirements; (iv) dateallcoverageorcertainbenefitsareterminatedforDependentsby

modificationofthePlan; (v) dateaDependentfailstomeetthedefinitionofaDependent;


(vi) lastdayofthemonthforwhichtherequiredcontributionhasbeenpaidiftherequiredcontributionfor1 pay period is more than 30 days in arrears.

(vii) date the Dependent becomes covered under another Group Health Plan as an Employee;or

(viii)datetheEmployee’sorDependent’scoverageterminatesforanyreason.

5.07 Rehired or Transferred Employees

Rehired Employees. An Employee’s or Dependent’s coverage under the Plan that ends by reasonoftheEmployee’sterminationofemploymentwillbecomereinstatedonthedatetheEmployeeresumesemploymentifsuchdateiswithinthesameFiscalYearandiswithin30daysimmediatelyfollowingthedateoftermination.

IfanEmployeeisrehiredafter30daysorinthefollowingFiscalYear,theemployeewillbe treatedasanewEmployee(exceptinthecasewhereCOBRAhasbeenelectedandcontinued with no lapse in coverage).

5.08 Participant Contributions

Contributionrequirementsshallbedeterminedonanannualbasisandshallbecommuni- catedpriortotheannualelectionperiodfortheElPasoChildren’sHospitalAssociateHealth

Benefits Plan. Mandatory participation in the Health Risk Assessment (HRA) program is a requirementforeligibilityinthehealthplan.


ARTICLE VI

MEDICAL BENEFITS

6.01 Benefits Provided

ThePlanprovidescoverageforawiderangeofservicesandsuppliesprovidedthattheyare consideredCoveredExpenses.CoveredExpenseswillbeeligibleforreimbursementiftheyare:

(a) MedicallyNecessaryandAppropriate; (b) Prescribed,renderedorfurnishedbyaProvider; (c) NotinexcessoftheAllowableAmount;and (d) ProvidedforcareandtreatmentofacoveredIllnessorAccidentalInjury.

6.02 Deductibles and Co-Pays

Applicable deductible and/or co-pay amounts and Benefit Percentages payable are listed in the Schedule of Benefits.Coveredmedicalexpensesaresubjecttoanylimitationsspecifiedin the Schedule of Benefits.

6.03 Covered Medical Expenses

Coveredmedicalexpensesinclude,butarenotlimitedto,chargesforthefollowing:

1) Allergy Testing, Allergy Injections and Allergy Serums. Allergy testing, allergy injections,andallergyserumsdispensedand/oradministeredataPhysician’soffice,andthe syringes necessary to administer them.

2) Ambulance Services.Airambulance(ifMedicallyNecessary)orgroundambulancefortransportationtoorfromthenearestappropriateHospitalbyalicensedambulanceservice.

3) Ambulatory Surgical Facility.Treatment,servicesandsuppliesfurnishedbyanambulatorysurgicalfacility.

4) Anesthetics.Anestheticsandtheirprofessionaladministrationandservicesofananesthesiologist.

5) Birth Control (Family Planning/Contraceptive Counseling).Chargesfor:

•Officevisitforcontraceptivepurposes. •Depo-Proverainjectionsdispensedand/oradministeredataPhysician’sofficeif

MedicallyNecessaryorforcontraceptivepurposes. •Lunelleinjectionsdispensedand/oradministeredataPhysician’sofficefor

contraceptive purposes. •ServicesandsuppliesrelatedtoinsertionandremovalofNorplantandotherbirth

control devices are covered the same as any other Illness. •Depo-ProveraandLunelleinjectionsdispensedbyapharmacist,arecoveredunder

the Schedule of Benefits (Prescription Drug Benefits).

6) Birthing Center.Care,treatmentandservicesfurnishedbyabirthingcenter(please relyontheadviceofyourPhysicianwhenconsideringabirthingcenter).

7) Blood and Blood Derivatives.Bloodtransfusionservices,includingthecostofwholeblood or blood plasma not donated or replaced.

8) Chemotherapy/Radiation Therapy. Chemotherapy, radiation therapy, and treatment withradioactivesubstances;materialsandservicesofatechnician.


9) Colorectal Cancer Screening (CRC).PersonsatriskforCRC(familyhistoryofCRC,previousadeomatouspolyps,inflammatoryboweldisease,previousresectionofCRC,geneticsyndromes)mayusemoreintensivescreeningeffortswhichincludesAMArecommendedscreeningforcolorectalcancerincluding:

a. anannualfecaloccultbloodtesting; b.flexiblesigmoidoscopyevery3to5yearsfromage50forpersonsataveragerisk; c. colonoscopy; d. double-contrast barium enema procedures which screen the entire colon.

10) Contact Lenses or Eyeglasses.Initialpurchaseofcontactlensesoreyeglassesbutnotbothifrequiredfollowingcataractsurgery.

11) Cosmetic Procedures/Reconstructive Surgery.Reconstructivesurgeryisperformedinci- dental to an injury, sickness, or congenital anomaly when the primary purpose is to im- provefunctioningoftheinvolvedpartofthebody.Thefactthatphysicalappearance maychangeorimproveasaresultofreconstructivesurgerydoesnotclassifysuchsurgery ascosmeticwhenafunctionalimpairmentexists,andthesurgeryrestoresorimproves

function.Forreconstructivesurgerytobeconsideredmedicallynecessarytheremustbeareasonableexpectationthattheprocedurewillimprovethefunctionalimpairment.

12) Diabetic Education.ParticipationintheUniversityMedicalCenterofElPasoDiabeticManagement Program will be provided at 100% or with a PPO Provider.

13) Diagnostic X-Ray and Laboratory Services.DiagnosticX-rayandlaboratoryexamina- tions;servicesofaradiologistorpathologist.

14) Dental Treatment in Mouth or Oral Cavity.Coverageislimitedto:

•surgicaltreatmentoffracturesanddislocationsofthejaworfortreatmentofanAccidentalInjurytosound,naturalteeth,includingreplacementofsuchteeth,withinsixmonthsafterthedateoftheAccidentalInjury(exceptwhendelayoftreatmentisMedicallyNecessary);

•surgeryneededtocorrectanAccidentalInjurytothejaws,cheeks,lips,tongue, floorandroofofthemouth; • Ifcrowns,dentures,bridges,orin-mouthappliancesareinstalledduetoinjury,

coveredexpensesonlyincludechargesfor: — Thefirstdentureorfixedbridgeworktoreplacelostteeth; — Thefirstcrownneededtorepaireachdamgedtooth;and — Anin-mouthapplianceusedinthefirstcourseoforthodontictreatmentafter the injury — Replacementofsuchteethwillbecovered,within six months after the date of the Accidental Injury(exceptwhendelayoftreatmentisMedicallyNecessary)

•removalofnon-odontogeniclesions,tumorsorcysts; •incisionanddrainageofnon-odontogeniccellulitis; •surgicaltreatmentofaccessorysinuses,salivaryglands,ductsandtongue; •treatmenttocorrectanon-odontogeniccongenitaldefectthatresultsinafunctional

defectofaCoveredDependentChild; • anesthesiafordentalservicesisnotacoveredbenefitunderthemedicalplan; •incisionanddrainageofnon-odontogeniccellulitis; •surgicaltreatmentofaccessorysinuses,salivaryglands,ductsandtongue; •treatmenttocorrectanon-odontogeniccongenitaldefectthatresultsinafunctional

defectofaCoveredDependentChild; • anesthesia/sedationfordentalservicesisnotacoveredbenefitunderthemedicalplan.


15) Durable Medical Equipment.Rental,initialpurchase,orreplacementofDurableMedical Equipment.Purchaseiscoveredonlyiflong-termuseisplannedandtheequipment

cannot be rented or it is less costly to purchase than to rent. Repair or replacement willbecoveredwhenrequiredduetogrowthordevelopmentofaDependentChild,MedicalNecessitybecauseofachangeintheCoveredParticipant’sphysicalcondition,ordeteriorationfromnormalwearandtearifprescribedbytheattendingPhysician.Replacementiscoveredifitislikelytocostlesstobuyareplacementthanrepairorrentlikeequipment.Covereditemsinclude,butarenotlimitedto,crutchesandbraces,adurablebracespeciallymadeforandfittedtotheCoveredParticipant,andrentalofwheelchairsandHospitalbeds.Chargesformorethanoneitemofequipmentforthesame or similar purpose are not covered.

16) Global Billing Maternity CareforallconfirmedpregnancieseffectiveOctober1,2012consistsofantepartumcare,deliveryandpostpartumcare,includingthefollowing;

• hospitaladmission • patienthistory • labormanagement • postpartumofficevisit,vaginalorcesareansectiondelivery • vaginalorcesareansectiondelivery,afterpreviouscesareandelivery • hospitaldischarge • andallapplicablepostoperativecare.

Services that are notincludedintheglobalbasisinclude:

• Antepartumconsultationpaidtothesameprovider,fordatesofserviceeitherwithinthefrom-throughperiodoftheglobalbillingwithin270dayspriortotheglobalOBdelivery date

• hospitalvisitsthatarerelatedtotheOBdelivery • postpartumconsultationsthatarerelatedtothedeliverypaidtothesameprovider

withinthe45dayfollow-upperiodoftheglobalOBdeliverydate. • Laboratories • Ultrasounds

Global claims are subject to the 1 year timely filing, based on the delivery date.

17) Hearing Exam Covered Expensesincludechargesforanaudiometrichearingexamiftheexamisperformedby:

• ThePrimaryCareProviderwhocanalsoreferformorespecializedcaretoacertifiedphysicianinthefollowingcategories:

• Aphysiciancertifiedasanotolaryngologistorotologist;or • Anaudiologistwho:

— Islegallyqualifiedinaudiology;or — HoldsacertificateofClinicalCompetenceinAudiologyfromtheAmerican

SpeechandHearingAssociation(intheabsenceofanyapplicablelicensingrequirements);and

— Performstheexamatthewrittendirectionofalegallyqualifiedotolaryngologistor otologist.

All covered expensesforthehearingexamaresubjecttoanyapplicabledeductible, co-pay and payment percentage shown in your Schedule of Benefits.


18) Home Health Care and Skilled Nursing. For covered participants who meet the criteria for“HomeboundStatus”:1.Patientsleavehomeinfrequentlyforonlyshortdurationsoftimeforreasonsotherthentoseekmedicalcarethattheycannotreceiveathome;2.Whenhomeboundpatientsleavehome,itmusttakegreatandtaxingeffortand/or

requiremaximumassistance.Patientsmay,however,leavehometoattendadultdaycare programsthatmeetcertainrequirementsandreligiousservicesandremainhomebound.

ChargesbyaHomeHealthCareAgencyonitsownbehalfforCoveredExpensesand suppliesfurnishedinthepatient’shomeinaccordancewithahomehealthcareplan madebytheattendingPhysician;part-timeorintermittentnursingcarebyaregistered

nurse(R.N.)oralicensedpracticalnurse(L.P.N.)orlicensedvocationalnurse(L.V.N.);and home health aide services provided in conjunction with nursing services are covered underthePlaniftheattendingPhysiciancertifiesthattreatmentoftheconditionwould requireconfinementasaHospitalinpatientintheabsenceofhomehealthcare.Home

healthcareexpensesshallnotincludechargesfor:servicesorsuppliesnotincludedin thehomehealthcareplan;servicesofapersonwhoordinarilyresidesinthepatient’s homeorisamemberofthepatient’sfamily,orDependentsofthepatient;transportationservices;custodialcare.

PersonalCareProvidersarenotcovered.ThefollowingareexamplesofaPersonal CareProvider:

• Assistingwitheating,bathing,dressing,personalhygiene,housekeepingchores,transportationandactivitiesofdailyliving.

19) Hospice Care.Servicesandsuppliesfurnishedinalicensedinpatienthospicefacilityorin the patient’s home by a licensed hospice care program when the attending Physician certifiesthatlifeexpectancyis6monthsorless.HospicecareexpensesincludechargesforbereavementcounselingoftheCoveredParticipant’simmediatefamilypriorto,andwithin3monthsafter,theCoveredParticipant’sdeathandchargesforrespitecareprovidedtogivetemporaryrelieftothefamilyorothercaregiversinemergenciesand/orfromthedailydemandsofcaringforaterminallyillperson.

20) Hospital Care (Inpatient).Thefollowingservicesandsupplieswhileaninpatientisat aHospital:

•dailyroomchargeinaHospital,butnottoexceedthedailyrateequaltotheaverage Hospital semi-private room charge (charges when a Hospital private room accommo- dation has been used will be reimbursed at the average semi-private room rate in

thefacility); •chargesforconfinementinanintensivecareunit; •meals,specialdiets,nursingcare; •maternityandroutinenursingcarewhilemotherisHospitalconfined.AHospital

lengthofstayforthemotherornewbornDependentChildwillbeatleast48hoursfollowingavaginaldelivery,or96hoursfollowingacesareansection.The48-hourperiod[or96-hourperiodifapplicable]beginsatthetimeadeliveryoccursintheHospital[orinthecaseofmultiplebirths,atthetimeofthelastdelivery]or,ifthe

delivery occurs outside the Hospital, at the time a mother and/or newborn are admitted.Themother’sornewborn’sattendingprovider,afterconsultingwiththe

mother, may discharge the mother or her newborn earlier than 48 hours [or 96 hours, ifapplicable]afterdelivery; •operating,delivery,recoveryandothertreatmentrooms; •prescribeddrugsandmedications; •dressingsandcasts; •useofHospitalequipment,laboratoryandradiologyservices; •treatmentbyaPhysicianorsurgeon.


21) Hospital Care (Outpatient). Treatment,servicesandsuppliesfurnishedbyaHospitalonan outpatient basis to a Covered Participant not admitted as a registered bed patient.

22) Immunizations. ExpensesrelatedtoImmunizationsasrequiredbylaworasprescribedby a Physician subject to coverage limits specified in the Summary of Benefits.

23) Injectable and Intravenous Prescription Medications. CoveredExpensesassetforthinthe Summary of Benefits under Prescription Drugs.

24) Insulin and Diabetic Supplies. RefertoPrescriptionDrugBenefitsintheSummary of Plan Benefitsforcoverageofinjectableinsulin,insulinsyringes,chemstripsandbloodlancets.InsulinpumpsandbloodglucosemonitorsarecoveredthroughthePlanifnotused as convenience items.

25) Mastectomy. The Federal Women’s Health and Cancer Rights Act, signed into law on October21,1998,containscoveragerequirementsforbreastcancerpatientswhoelectreconstructioninconnectionwithaMastectomy.TheFederallawrequiresgrouphealthplans that provide Mastectomy coverage to also cover breast reconstruction Surgery andprosthesesfollowingMastectomy.Asrequiredbylaw,youarebeingprovidedthisnoticetoinformyouabouttheseprovisions.ThelawmandatesthatindividualsreceivingbenefitsforaMedicallyNecessaryMastectomywillalsoreceivecoveragefor:

a. ReconstructionofthebreastonwhichtheMastectomyhasbeenperformed;

b.Surgeryandreconstructionoftheotherbreasttoproduceasymmetricalappearance;and

c. ProsthesesandphysicalcomplicationsfromallstagesofMastectomy,includinglymphedemas;inamannerdeterminedinconsultationwiththeattendingPhysicianand the patient.

Yourmedicalplan’scoverageofamedicallynecessarymastectomyalsoincludespost-mastectomycoverageforreconstructionofthebreast,surgeryontheotherbreasttoachievetheappearanceofsymmetry,prostheses,andphysicalcomplicationduringanystageofthemastectomy,includinglympedemas.Thiscoveragewillbesubjecttothesame annual Deductible and coinsurance provisions that currently apply to Mastectomy coverage, and will be provided in consultation with you and your attending Physician.

26) Medical and Surgical Supplies. Casts, splints, trusses, surgical dressings, and other devicesusedinthereductionoffracturesanddislocations.

27) Mental and Nervous Disorders. ServicesprovidedfortreatmentofMentalandNervousDisorders and services provided by a Physician, including Group Therapy and collateral visitswithmembersofthePatient’simmediatefamily.

28) Newborn Care. Routinecareofahospital-confinednewbornchild,providedthatcoverageforthenewbornchildisrequested,ifnecessary,accordingtotheeligibilityrequirementsofthePlan.ThePlanwillcoverupto5daysofhospitalizationoruntilthemother’sdischarge,whicheveroccursfirst,onthesamebasisasanIllnessofsuchnewborn child, including routine nursery care, physician charges, necessary laboratory tests,andcircumcision.Suchchargeswillbeconsideredseparatefromthemother’scharges.Doesnotcoveranewbornofadependentdaughter.

29) Nursing Services. Servicesofaregisterednurse(R.N.),licensedvocationalnurse(L.V.N.), or licensed practical nurse (L.P.N.), other than a person related by blood or marriage. ThePlanprovidesbenefitsforskillednursingcarefurnishedbyaregisterednurseora licensedpracticalorvocationalnurseiftheservicesofaregisterednursearenotavail- able.In-Hospitalprivatedutynursingservicesarenotcovered.Chargesforskillednurs- ing services provided in the home are covered under the Home Health Care provision.


30) Nutritional Counseling. ExpensesrelatedtoNutritionalCounselingwhichareMedically Necessary according to evaluation by a Registered Dietician when provided at University MedicalCenterofElPaso,TexasTechPhysiciansorPPOProviders,limitedtotwelve

sessions per fiscal year.

31) Occupational Therapy. Chargesforservicesrequiringthetechnicalmedicalproficiencyandskillsofaregisteredorlicensedoccupationaltherapistandrenderedinaccordancewith a Physician’s specific instructions as to type and duration to restore or improve lost orimpairedfunction.Servicesforoutpatientoccupationaltherapyarecoveredonlywhen the Covered Participant is able to actively participate in such therapy, and there is documentedcontinuousphysicalimprovement.NocoveragewillbemadeforWorkers’Compensation related Illness or Injuries.

32) Organ Transplants. CoveredExpensesincurredforhuman-to-humanorganortissuetransplantsarecoveredsubjecttothefollowing:

•eligibleorgantransplantprocedureswhicharemedicallynecessaryandappropri- atefortheconditionbeingtreatedandwhichhavebeenconfirmedbymedical

management/utilizationreviewandacompletesecondopinionbyaboardcertifiedphysicianandanorgantransplantreviewcommitteeare:

•hearttransplants •heartandlungtransplants •kidneytransplants •livertransplants •bonemarrowtransplants/stemcelltransplants

—Ifthetransplantprocedureisahematopoeticstemcelltransplant,coveragewillbeprovidedforthecostoftheacquisitionofstemcells.Thismaybeeitherperipherally or via bone marrow aspiration as clinically indicated, and is applicable to both the patient as the source (autologous) and related or unrelated donor asthesource(allogeneic).Coveragewillalsobeprovidedforsearchchargestoidentifyanunrelatedmatch,treatmentandstoragecostsofthestemcells,uptothetimeofreinfusion.(Theharvestingofthestemcellsneednotbeperformedwithin the transplant benefit period.) “Benefit Period” means the period that beginsonthedateoftheinitialevaluationandendsonCoveredEmployeeslastdayofterminationdate.(Ifthetransplantisabonemarrowtransplant,thedatethemarrowisre-infusedisconsideredthedateofthetransplant.)

•tissuetransplantprocedures,jointreplacementsandotherspecifiedprocedureswhicharemedicallynecessaryandappropriatefortheconditionbeingtreatedandwhichhavebeenconfirmedbymedicalmanagement/utilizationreviewanda

completesecondopinionbyboardcertifiedphysiciansare: •corneatransplant •arteryorveintransplants •jointreplacements •heartvalvereplacements •implantableprostheticlensesinconnectionwithcataracts •prostheticbypassorreplacementvessels •Additionalconsiderationfororgantransplantinclude: •Benefitsareavailableforhumanorgan,tissue,andbonemarrowtransplantation,

subject to determination made on an individual case by case basis in order to establish Medical Appropriateness and transplant evaluation recommendations by

anaccreditedtransplantcenterofexcellence.


Covered Transplant Expenses

Theterm“CoveredExpenses”withrespecttotransplantsincludesthereasonableandcustomaryexpensesforservicesandsupplieswhicharecoveredunderthisplan(orwhich are specifically identified as covered only under this provision) and which are medicallynecessaryandappropriatetothetransplant,including:

•OrganTransplantServicesareprovidedonlythroughthePreferredAdministratorsNetwork,InterlinkTransplantNetworkorotherfacilitycontractsasapprovedbythePlanAdministratorandthestoplosscompany.NobenefitsareprovidedfororgantransplantproceduresunlessthefacilityandnetworkcontractisapprovedbythePlan Administrator

•BenefitswillbeprovidedonlywhentheHospitalandPhysiciancustomarilycharge atransplantrecipientforsuchcareandservices. •Donorexpenses(professionalfeesandfacilitycharges)willbeconsideredeligible

expenseswhenaCoveredParticipantistherecipientoftheorgandonationasfollows:

1)ifthedonoriscoveredbyanotherbenefit/insuranceplanthatplanwillbeconsideredprimaryfortheexpensesemployeedwiththeorganharvestingprocedureandthisPlanwillbesecondary;

2)ifthedonorisnotcoveredbyanotherbenefit/insuranceplanthisPlanwill be primary.

•Donorexpenses(professionalfeesandfacilityexpenses)willbeconsideredeligibleexpenseswhenaCoveredParticipantisthedonoroftheorganforapersonwhoisnotcoveredbythisPlanasfollows:

1)iftherecipient’sbenefit/insuranceplanprovidescoveragefororgandonation,thatplanwillbeconsideredprimaryandthisplanwillbesecondary;

2)iftherecipient’sbenefit/insuranceplandoesnotprovidefororgandonation thisPlanwillprovideabenefitallowanceforthedonationprocedureexpenses.

•WhenthedonorandrecipientarebothCoveredParticipants,benefitswillbepaidunder recipient.

•Benefitsfororganprocurementexpenseswillbeconsideredeligibleexpenses. •Benefitspaidfororgandonorexpensesandprocurementwillbeappliedtothe

benefitmaximumsoftheCoveredParticipant.

INTERLINK Exclusive Provider Organization (EPO) Network Benefits

TheplanincludesaCentersofExcellencetransplantbenefitandofferstransplantbene- fits to eligible candidates through the INTERLINK Health Services (“INTERLINK”) Transplant COEEPOnetwork.CoveragefortransplantservicesrenderedatanINTERLINKcreden- tialed Transplant COE program will be paid at the benefit coverage amounts based on the providers selected Schedule of Benefits. Co-payments, deductibles and other member responsibilitiesstillapply.ToviewthecurrentlistofeligibleTransplantCOEtransplant

providers, please visit www.interlinkhealth.com/TransplantCOE.

Emergency Transplant Care At NON-INTERLINK Transplant COE Providers

Coverageforunplannedandunscheduledemergencytransplantation(“EmergencyTransplant”) is a benefit included in the Plan, to be paid according to the contract termsnegotiatedbyINTERLINKandagreedtobyPlan,orPlan’sagent,andProvider;however,ifpaymenttermscannotbeagreeduponwithin10daysoftheemergencytransplant,thenthetransplantshallbepaidat110%ofMedicareallowableandbe


consideredpaymentinfull.ThetransplantinghospitalmustprovidethefollowingdocumentstoINTERLINK,whowillthenforwardthemontothePlan,within24hoursoftheEmergencyTransplant:

1)Aletterfromthetransplantinghospital’sSurgicalDirectordetailingthemedicalconditionsleadingtotheEmergencyTransplant;

2)AcopyoftheUnitedNetworkForOrganSharing(“UNOS”)Status1ListingRequestandStatus1AconfirmationNoticeFromUNOS;and

3)AdetailedcontractproposalfortheEmergencyTransplant.

Medical Hardships Proposed Transplant Care: NON-EPO Transplant Exceptions

ThePlanmayapprovenon-TransplantCOEtransplantcarefordocumentedMedicalHardship cases, to be paid according to the contract terms negotiated by INTERLINK andagreedtobyPlan,orPlan’sagent,andProvider;however,ifpaymenttermscannotbeagreeduponwithin10daysofProvider’sbillingproposaltoPlan,thenpaymentshallbepaidat110%ofMedicareallowable.MedicalHardship,asusedhere,couldincludesuchinstanceswherethepatientmaybetoomedicallyfrailtotravel,re-transplantationfollowingasuccessfultransplantbythesametransplantteam,oralivingdonorhardship.Forconsideration,MedicalHardshipformsmustbesubmittedtoINTERLINKwithin3businessdaysofthePlanbeingcontactedfortransplantbenefitsorapprovalforevaluation.AllinformationwillbeforwardedtothePlanforconsideration. For Medical Hardship transplant benefit consideration, the transplant centermustcompleteandsubmitthefollowingforms:

1)AletterfromtheSurgicalDirectortotheplandetailingthemedicalconditionssupportingtheMedicalHardship;

2)AcompletedMedicalHardshipForm:KeyOutcomeIndicatorsWorksheet;

3)AcompletedMedicalHardshipForm:TransplantBillingReportTableforthepriorthreeyearsoftransplantbillinghistory;and

4)AdetailedcontractproposalfortheproposedMedicalHardshiptransplant.MedicalHardshipFormscanbedownloadedfrom:www.interlinkhealth.com/medicalhardship.

COVERAGE FOR ORGAN AND/OR TISSUE TRANSPLANTS

Pre-Authorization Requirement for Organ Transplant

CoveredExpensesincurredinconnectionwithanyorganortissuetransplantlistedinthisprovisionwillbecoveredsubjecttoreferraltoandpre-authorizationbythePlanAdministrator’sauthorizedreviewspecialist.Transplantcoverageisofferedunderthis

PlanthroughanEPOnetworkofcredentialedandvolumemonitoredtransplantpro- fessionalsandfacilities.Coverageisalsoprovidedfortransplantservicesobtainedout- sidetheEPOforEmergencyTransplants,andforcertaintransplantcasesinvolvinga

Plan approved Medical Hardship condition.

Nobenefitsareprovidedfororgantransplantproceduresunlessthefacilityandnetwork contract is approved by the Plan Administrator.

Assoonasreasonablypossible,butinnoeventmorethanten(10)daysafteraCovered Person’s attending physician has indicated that the Covered Person is a potential candi- dateforatransplant,theCoveredPersonorCoveredPerson’sphysicianshouldcontact

thePlanAdministratorforreferraltothenetwork’smedicalreviewspecialistforevalu- ationandpre-authorization.Acomprehensivetreatmentplanmustbedevelopedfor

thisplan’smedicalreview,andmustincludesuchinformationasdiagnosis,thenatureofthetransplant,thesettingoftheprocedure,(i.e.,nameandaddressofthehospital),


anysecondarymedicalcomplications,afiveyearprognosis,two(2)qualifiedopinionsconfirmingtheneedfortheprocedure,aswellasadescriptionandtheestimatedcostoftheproposedtreatment.(Oneorbothconfirmingsecondopinionsmaybewaivedbythe plan’s medical review specialist.) Additional attending physician’s statements may alsoberequired.Anon-networkhospitalmayprovideacomprehensivetreatmentplanindependentoftheEPO,butthiswillbesubjecttoaMedicalHardshipreviewandmayresultinnobenefitcoverageforthetransplantatthatcenter.AllpotentialtransplantcaseswillbeassessedfortheirappropriatenessforLargeCaseManagement.

Organ Transplant Network

Asaresultofthepre-authorizationreview,theCoveredPersonwillbeaskediftheywishforassistancegatheringinformationaboutparticipatingtransplantprograms.Theterm“participatingtransplantprogram”meansalicensedhealthcarefacilityandtransplant program that has met INTERLINK’s quality Assurance Program standards forparticipation,andbeendeclaredaTransplantCOEprogrambyINTERLINKHealthServices’QualityAssuranceCommittee.Thetransplantnetwork’sgoalistoperformnecessarytransplantsinthemostappropriatesettingfortheprocedureusingsomeofthenation’smostexperiencedandqualifiedtransplantteams.

Re-Transplantation

Re-transplantationwillbecovereduptotwore-transplants,foratotalofthreetrans- plants per person.

33) Orthotic Devices. OrthoticDevicesusedtosupport,align,preventorcorrectdeform- ities,ortoimprovethefunctionofmovablepartsofthebody.Repairorreplacementof

coveredOrthoticDeviceswillbecoveredwhenrequiredduetogrowthordevelopment ofaDependentChild,medicalnecessitybecauseofachangeinthecoveredparticipant’s physicalcondition,ordeteriorationfromnormalwearandtearfordependentchildren

uptoage18,ifrecommendedbytheattendingphysician.Orthoticdevicesfordepend- ent children are based on medical necessity.

Supportivefootdevicesforadults(suchasarchsupports)andorthopedicshoesarecovered when prescribed by an In-Network Physician.

34) Oxygen.Oxygenorothergasesandrentalofequipmentforitsadministrationinclud- ingIPPB(IntermittentPositivePressureBreathing)equipment.

35) Physical Therapy. ServicesofalicensedphysicaltherapistorPhysicianfornon-Workers’ CompensationIllnessesorInjuries,butlimitedtoservicesrequiringthetechnicalmedical proficiencyandskillsofarecognizedphysicaltherapistandrenderedinaccordance

with a Physician’s specific instructions as to type and duration.

36) Physician Care. ProfessionalservicesofaPhysicianforsurgicalandmedicalcare,includingbutnotlimitedto,surgery,anesthesia,inpatientmedicalvisits,consultations,office

visits,andofficetreatment.

37) Preadmission or Preoperative Testing.TestsorexamsrelatingtosurgeryforaCoveredParticipantwhoisscheduledforsurgery.


38) Prescription Drugs.Drugsrequiringaprescriptionundertheapplicablestatelaw.ExamplesofcoveredPrescriptionDrugsinclude:

•Adderall •Contraceptives(oralandinjectable) •Dexedrine •Dextrostat •Federallegendprescriptiondrugs •Injectableinsulin,insulinsyringes,chemstrips,andbloodlancets •Injectables(otherthaninsulin) •I.V.medicationsprescribedbyalicensedphysiciananddispensedbyalicensed

pharmacist •Non-insulinneedles/syringes •Pre-natalprescriptionvitamins

39) Pregnancy Care. CareandtreatmentforpregnancyandcomplicationsofpregnancyarecoveredforacoveredAssociate,Spouseordependentdaughter.

40) Prosthetic Devices. Prostheticdevicessuchasartificiallimbsoreyes.Afteramastectomy anexternalbreastprosthesisiscovered,andalsothefirstbramadesolelyforusewith

theexternalbreastprosthesis.ProstheticdevicerepairorreplacementwillbecoveredwhenrequiredduetogrowthordevelopmentofaDependentChild,MedicalNecessitybecauseofachangeintheCoveredParticipant’sphysicalcondition.

41) Psychiatric Day Treatment Facilities. CoveredExpensesincurredfortreatmentinapsychiatricdaytreatmentfacilityforamentalornervousdisorderiftheattendingPhysiciancertifiesthatsuchtreatmentisinlieuofHospitalization,willbesubjecttothesame benefits and limitations as applicable to treatment provided on an inpatient basis formentalornervousdisorders,asspecifiedintheSchedule of Benefits. Any benefits so provided are considered as inpatient care and treatment in a Hospital.

42) Rehabilitation Facilities. Servicesandsuppliesincludingroomandboardfurnishedbyarehabilitationfacility.TheCoveredParticipantmustbeunderthecontinuouscareofaPhysicianandtheattendingPhysicianmustcertifythattheindividualrequiresnursingcare 24 hours a day. A registered nurse or a licensed vocational or practical nurse must rendernursingcare.Theconfinementcannotbeprimarilyfordomiciliary,custodial,personaltypecare,careduetosenility,alcoholism,drugabuse,blindness,deafness,mentaldeficiency,tuberculosis,ormentalandnervousdisorders.Chargesforvocationaltherapy or custodial care are not covered.

43) Routine Care. Services as specified in the Summary of Benefits as well as gamma globulin injections.

44) Skilled Nursing Facilities. Servicesandsuppliesincludingroomandboardfurnished byaskillednursingfacility.

45) Specialty Medications. “Specialty” medications mean high-cost oral or injectable medi- cationsusedtotreatcomplexchronicconditions.Thesearehighlycomplexmedications,

typicallybiology-based,thatstructurallymimiccompoundsfoundwithinthebody.High-touchpatientcaremanagementisusuallyrequiredtocontrolsideeffectsandensurecompliance.Specializedhandlinganddistributionarealsonecessarytoensureappropriate medication administration.


46) Speech Therapy. Chargesforservicesofalicensedspeechtherapist(or,instatesnot requiringalicense,onewhoholdsaCertificateofClinicalCompetencefromtheAmeri- can Speech and Hearing Association) when rendered in accordance with a Physician’s

specificinstructionsastotypeanddurationbutonlywhennecessary:

•torestorelossoffunctionalspeechorswallowingafteralossorimpairmentofademonstrated,previousabilitytospeakorswallow;

•todeveloporimprovespeechaftersurgerytocorrectadefectthatbothexistedatbirthandimpairedorwouldhaveimpairedtheabilitytospeak;

•foraspeechimpedimentduetocerebralpalsy; •totreatdysphasiafollowingsurgery; •treatmentoffluency(stuttering)disorders; •voicedisorderssecondarytovocalabuse/misuse; •dysphagiafollowingsurgery.

Speech and Language impairments in children three to eight years as determined via standardizedornon-standardizedtesting.Sessionsfortheabovenotedaretobefortyfive-sixtyminutesindurationtwo-threetimesaweek.

Speechtherapyfortreatmentofdelaysinspeechdevelopment,exceptasspecificallyprovidedinthissectionofMedicalBenefits.Forexample,theplandoesnotcovertherapywhenitisusedtoimprovespeechskillsthathavenotfullydeveloped.

47) Spinal Adjustments. Skeletal adjustments, manipulation or other treatment in connec- tionwiththedetectionandcorrectionbymanualormechanicalmeansofstructural

imbalanceorsubluxationinthehumanbodyperformedbyaPhysicianorChiropractortoremovenerveinterferenceresultingfrom,orrelatedto,distortion,misalignmentorsubluxationof,orin,thevertebralcolumn.

48) Sterilization Procedures. Voluntarysterilizationproceduresforwomenarecoveredat100%withanyofourIn-NetworkProviders.AnyVoluntarysterilizationproceduresformenarecoveredonthesamebasisasforanyotherIllness.

49) Substance Abuse. Servicesprovidedfortreatmentofsubstanceabuseconditions.

50) Temporomandibular Joint Dysfunction (TMJ). Onlyopen-cuttingoperationsfortreat- mentofTMJarecovered.

51) Treatment in Mouth or Oral Cavity. Coverageislimitedto:

•surgicaltreatmentoffracturesanddislocationsofthejaworfortreatmentofanAccidentalInjurytosound,naturalteeth,includingreplacementofsuchteeth,withinsixmonthsafterthedateoftheAccidentalInjury(exceptwhendelayoftreatmentisMedicallyNecessary);

•surgeryneededtocorrectanAccidentalInjurytothejaws,cheeks,lips,tongue, floorandroofofthemouth; • Ifcrowns,dentures,bridges,orin-mouthappliancesareinstalledduetoinjury,

coveredexpensesonlyincludechargesfor: —Thefirstdentureorfixedbridgeworktoreplacelostteeth; —Thefirstcrownneededtorepaireachdamagedtooth;and —Anin-mouthapplianceusedinthefirstcourseoforthodontictreatmentafter the injury —Replacementofsuchteethwillbecovered,withinsixmonthsafterthedateof theAccidentalInjury(exceptwhendelayoftreatmentisMedicallyNecessary)


•removalofnon-odontogeniclesions,tumorsorcysts; •incisionanddrainageofnon-odontogeniccellulitis; •surgicaltreatmentofaccessorysinuses,salivaryglands,ductsandtongue; •treatmenttocorrectanon-odontogeniccongenitaldefectthatresultsinafunctional

defectofaCoveredDependentChild; • anesthesiafordentalservicesisnotacoveredbenefitunderthemedicalplan.

52) Vaccinations. Expensesformedicallynecessaryvaccinationsarecoveredat100%withanyofourin-networkproviders.Pleasenotethatimmunizationsthatareadministeredsolelyforthepurposeoftraveloroccupationarenotcovered.

53) Wellness Benefit. Preventive Benefits as specified in the Schedule of Benefits.

6.04 Expense Limitations

CoveredExpensesaresubjecttoanylimitationsspecifiedintheSchedule of Benefits as well as Articles IV and V.


ARTICLE VII

EXCLUSIONS

7.01 Claims Submitted After One Year

Nobenefitswillbepaidforanyclaimsfiledmorethanoneyearafteracoveredserviceorsupply was incurred.

7.02 Miscellaneous Restrictions on Benefits NocoverageisprovidedunderthePlanforexpensesincurredfortreatment,servicesand

suppliesduetoanInjuryorIllnesswhich:

(a) theCoveredParticipanthasnolegalobligationtopay; (b) areprovidedbyamemberofthepatient’simmediatefamily; (c) nochargewouldhavebeenmadeifthepatienthadnohealthcoverage; (d) resultdirectlyorindirectlyfromwar,whetherdeclaredorundeclared; (e) arefurnishedinagovernmentownedoroperatedfacilityoranyotherHospital wherecareisprovidedatgovernmentexpense,unlessitisnon-servicerelated; (f) resultsfromorsustainedduetoparticipationinariotorinsurrection; (g) areforthepreparationofmedicalreportsoritemizedbills;or (h) arefortraveloraccommodations,whetherornotrecommendedbyaPhysician.

7.03 Exclusions

Acupuncture or Hypnosis.ChargesforacupunctureorhypnosisunlessperformedbyaPhysicianandinlieuofanesthesia.

Alcohol. ToaPlanParticipant,arisingfromtakingpartinanyactivitymadeillegalduetotheuseofalcohol.ExpenseswillbecoveredforInjuredPlanParticipantsotherthanthepersonpartakinginanactivitymadeillegalduetotheuseofalcohol,andexpensesmaybecoveredforSubstanceAbusetreatmentasspecifiedinthisPlan,ifapplicable.Thisexclusiondoesnotapply(a)iftheinjuryresultedfrombeingthevictimofanactofdomesticviolence,

or(b)resultedfromamedicalcondition(includingbothphysicalandmentalhealthconditions).

Complications Arising under Excluded Benefit Treatments. Benefitswillnotbepaidforservicesortreatmentthataretheresultofcomplicationsthatoccurfromservicesortreat-

mentsthatareexcludedfromcoveragebythisPlan.Thisexclusionincludeschargesforcomplicationsresultingfromanyexcludedservicesorprocedures,including,butnotlimitedto, any reversal procedure unless otherwise covered.

Cosmetic Procedures. ChargesforCosmeticSurgerywiththefollowingexceptions:

a) Treatmentprovidedforthecorrectionofdefectsincurredinanaccidentalinjurysustainedbytheparticipant;or

b) Treatmentprovidedforreconstructivesurgeryfollowingcancersurgery;or c) Surgeryperformedonanewbornchildforthetreatmentorcorrectionofacongenital

defect;or d) Surgeryperformedonacovereddependentchild(otherthananewbornchild)

undertheageof19forthetreatmentorcorrectionofcongenitaldefectotherthanconditionsofthebreast;or

e) Reconstructionofthebreastonwhichamastectomyhasbeenperformed;surgeryandreconstructionoftheotherbreasttoachieveasymmetricalappearance;andprosthesisandtreatmentofphysicalcomplications,includinglymphedemas,atallstagesofthemastectomy;or


f) Reconstructivesurgeryperformedonacovereddependentchildundertheageof19duetocraniofacialabnormalitiestoimprovethefunctionof,orattempttocreateanormalappearanceofanabnormalstructurecausedbyacongenitaldefect,developmentaldeformities,trauma,tumors,infections,ordisease.

Counseling. Chargesformaritalcounselingandothercounselingservicesarenotcovered.CounselingchargesarecoveredforNutritionalCounselingandforbereavementcounselingunder the Hospice Care provisions.

Dental Services: any treatment, services or supplies related to the care, filling, removal or replacementofteethandthetreatmentofinjuriesanddiseasesoftheteeth,gums,andotherstructuressupportingtheteeth.Thisincludesbutisnotlimitedto:

• servicesofdentists,oralsurgeons,dentalhygienists,andorthodontistsincludingapicoectomy(dentalrootresection),rootcanaltreatment,softtissueimpactions,removalofbonyimpactedteeth,treatmentofperiodontaldisease,alveolectomy,augmentation and vestibuloplasty and fluoride and other substances to protect, cleanoraltertheappearanceofteeth;

• dentalimplants,falseteeth,prostheticrestorationofdentalimplants,plates,dentures, braces, mouth guards, and other devices to protect, replace or reposition teeth;and

• non-surgicaltreatmentstoalterbiteorthealignmentoroperationofthejaw,includingtreatmentofmalocclusionordevicestoalterbiteoralignment.

• anesthesiafordentalservicesisnotacoveredbenefitunderthemedicalplan.PleaserefertocoveredbenefitunderDentalTreatmentinMouthorOralCavity,page 57.

Durable Medical Equipment. Chargesforpurchase,orreplacementofmorethanoneitemofDurableMedicalEquipmentorsurgicalequipmentifitisforthesameorsimilarpurpose.

Educational Services. Anychargeforanyservicesorsuppliesrelatedtoeducation,trainingservicesortesting,including:

• Specialeducation; • Remedialeducation,jobtrainingandjobhardeningprograms; • Evaluationortreatmentoflearningdisabilities,minimalbraindysfunction,

developmental, learning and communication disorders, behavioral disorders, (including pervasive developmental disorders) training or cognitive rehabilitation, regardlessoftheunderlyingcause;and

• Services,treatment,andeducationaltestingandtrainingrelatedtobehavioral(conduct) problems, learning disabilities and delays in developing skills.

• ExamplesofDevelopmentalDisorders;non-covereddiagnosesincludePervasiveDevelopmental Disorders (including Autism), Down Syndrome, and Cerebral Palsy,

as they are considered both developmental and/or chronic in nature.

Error. Anychargeforcare,supplies,treatment,and/orservicesthatarerequiredtotreatinjuriesthataresustainedoranillnessthatiscontracted,includinginfectionsandcomplications,whilethePlanParticipantwasunder,anddueto,thecareofaProviderwhereinsuchillness,injury,infectionorcomplicationisnotreasonablyexpectedtooccur.Thisexclusionwillapplytoexpensesdirectlyorindirectlyresultingfromthecircumstancesofthecourseoftreatmentthat,intheopinionofthePlanAdministrator,initssolediscretion,unreasonablygaverisetotheexpense.

Excess. ThatarenotpayableunderthePlanduetoapplicationofanyPlanmaximumorlimitorbecausethechargesareinexcessoftheUsualandCustomaryamount,orareforservicesnotdeemedtobeReasonableorMedicallyNecessary,baseduponthePlanAdministrator’sdeterminationassetforthbyandwithinthetermsofthisdocument.


Exercise and Exercise Equipment. Chargesforexerciseequipmentorexerciseprogramssuchasforweightreduction(exceptforaMedicallyNecessarycardiacrehabilitationprogramfollowingmyocardialinfarctionand/orcardiacsurgery).

Experimental or Investigational.ForservicesthatareconsideredExperimentalorInvestigational as described by this Plan.

Family Member. ThatareperformedbyapersonwhoisrelatedtotheParticipantasaspouse,parent,child,brotherorsister,whethertherelationshipexistsbyvirtueof“blood”or “in law”.

Foot Care. Chargesforthetreatmentofbunions(excludingcapsularorbonesurgery),corns,calluses,fallenarches,flatfeet,androutinetrimmingoftoenails,exceptwhenMedically Necessary due to an Illness.

Hearing. Chargesforarenotcoveredfor:

• HearingAides • Replacementpartsorrepairsforahearingaid;and • Anytests,appliances,anddevicesfortheimprovementofhearing(includinghearing

aidsandamplifiers),ortoenhanceotherformsofcommunicationtocompensateforhearinglossordevicesthatsimulatespeech,exceptotherwiseprovided.

• SurgicalImplantsincludingtheCochlearEar

Home Health Care. Homehealthcareexpensesexcludechargesfor:servicesorsuppliesnotincludedinthehomehealthcareplan;servicesofapersonwhoordinarilyresidesinthepatient’shomeorisamemberofthepatient’sfamily,orDependentsofthepatient;transportationservices;andcustodialcare.

Hospitalization and/or Surgery. Chargesarenotcoveredfor:

• substanceabuse,unlessthepatientisundergoingaprogramoftherapysupervisedbyaPhysicianwhocertifiesthatafollow-upprogramhasbeenestablishedwhichincludes therapy at least once a month or includes attendance at least twice a month atameetingoforganizationsdevotedtothetreatmentofthecondition.

• non-emergencyHospitaladmissionsoneitheraFridayoraSaturdayunlessasurgicalprocedureisperformedwithin24hoursofadmission.

• primarycontrolorchangeofthepatient’senvironmentand/orduringwhichthepatientreceivespsychiatriccarethatcouldhavebeensafelyandadequatelyprovidedonanoutpatientbasisorinalesserfacilitythanaHospital.

• careinahealthresort,resthome,nursinghome,residentialtreatmentcenter,oranyinstitution primarily providing custodial care.

• custodialcareforaCoveredParticipantwhoismentallyorphysicallydisabledandisnot under specific medical, surgical or psychiatric treatment which is likely to reduce the disability or enable the patient to live outside an institution providing care.

• hospitalcareandservicesorsupplieswhentheCoveredParticipant’sconditiondoesnotrequireconstantdirectionandsupervisionbyaPhysician,constantavailabilityoflicensednursingpersonnelandimmediateavailabilityofdiagnostictherapeuticfacilitiesandequipmentfoundonlyintheHospitalsettingoriftheprimarycauseofsuchaconfinementwasforrestorcustodialcare.

• in-Hospitalprivatedutynursingservices. • surgeryutilizedastreatmentofneurosis,psychoneurosis,psychopathy,psychosisand

other mental, nervous and emotional Illness.

Injury Caused by Engaging in Illegal Act. For injury caused by or contributed to by engaging in an illegal act or occupation, by committing or attempting to commit any crime, criminal act,orothercriminalbehavior.Itisnecessaryforapersontobechargedorconvictedinorderforthisexclusiontoapply.


Learning Deficiencies. Chargesforlearningdeficienciesandbehavioralproblems(includingemployeediagnostictesting),whetherornotemployeedwithamanifestmentaldisorderorotherdisturbance,exceptforAttentionDeficitDisorder(ADD)andAttentionDeficitHyperactivity Disorder (ADHD).

Massage. Chargesformassageorforanyrolfingservicesand/orsupplies.

Morbid Obesity and Obesity. Charges in connection with treatments, surgical procedures orprogramsforobesity,morbidobesity,dietarycontrolorweightreduction,whetherMedicallyNecessaryornot,andforanycomplicationsarisingoutofnon-coveredservices.

No Legal Obligation. ThatareprovidedtoaParticipantforwhichtheProviderofaservicecustomarilymakesnodirectcharge,orforwhichtheParticipantisnotlegallyobligatedtopay,orforwhichnochargeswouldbemadeintheabsenceofthiscoverage,includingbutnotlimitedtofees,care,supplies,orservicesforwhichaperson,companyoranyotherentityexcepttheParticipantorthisbenefitplan,maybeliablefornecessitatingthefees,care,supplies,orservices;

Not-Medically Necessary. ChargesfortreatmentandcarewhicharenotgenerallyacceptedintheUnitedStatesasbeingnecessaryandappropriateforthetreatmentofthepatient’sIllness or Injury.

Not Transported. Chargesfortransportation,includingambulancecharges,whentranspor- tationofthepatientwasnotnecessary,didnotoccur,orwasrefusedbythepatient.

Occupational. Foranycondition,Illness,Injuryorcomplicationthereofarisingoutoforinthecourseofemployment,includingself-employment,oranactivityforwageorprofit.

If you are covered as a Dependent under this Plan and you are self-employed or employed by an employer that does not provide health benefits, make sure that you have other medical benefits to provide for your medical care in the event that you are hurt on the job. In most cases workers compensation insurance will cover your costs, but if you do not have such coverage you may end up with no coverage at all.

On-Line Counseling or Consultations. Chargesforon-linecounseling,on-lineconsultations,andanyrelatedon-lineservicestheCoveredPersonmakestoorreceivesfromanyPhysician,practitionerorfacility.

Orthognathic Conditions. ChargesrelatedtotreatmentofOrthognathicconditions,including employee diagnostic procedures.

Other than Attending Physician. Anychargeforcare,supplies,treatment,and/orservicesotherthanthosecertifiedbyaPhysicianwhoisattendingtheParticipantasbeingrequiredforthetreatmentofInjuryorDisease,andperformedbyanappropriateProvider.

Out of Country. FormedicalcareorservicesrenderedoutsideoftheUnitedStates(includingitsterritories)EXCEPTfortreatmentofinjuryorsuddenacuteillnesswhiletravelingforaperiodnottoexceedninety(90)days,orwhileattendinganaccreditedschoolabroadonafull-timebasisandmeetingalloftherequirementsdefinedintheprovisionsforeligibility.

Personal Hygiene. Chargesforpersonalhygiene,comfort,orconvenienceitems,including,but not limited to, air conditioners, humidifiers, air purification units, electric heating units, orthopedic mattresses, blood pressure instruments, scales, and first aid supplies.

Personal Comfort and Convenience Items. Anyserviceorsupplyprimarilyforyourconven- ienceandpersonalcomfortorthatofathirdparty,including:Telephone,television,internet, barberorbeautyserviceorotherguestservices;housekeeping,cooking,cleaning,shopping,

monitoring,securityorotherhomeservices;andtravel,transportation,orlivingexpenses,rest cures, recreational or diversional therapy.


Prescription Drugs. Thislistisnotinclusiveofallcovered/notcovereddrugs.ForaninclusivelistreviewthePrescriptionSolutionsdrugformularyatwww.preferredadmin.net.

•Anabolicsteroids •Anorectics(anydrugusedforthepurposeofweightloss) •Anorexiants(exceptforAdderall,Dexedrine,andDextrostat) •Cosmetics •DrugsormedicinesdispensedmorethanoneyearafterthedateofthePrescription

order •Fertilitymedications •Fluoridesupplements •Investigationalorexperimentaldrugsincludingcompoundedmedicationsfornon-

FDA approved use •Medicaldevicesandothersupplies(exampleDiabetesbloodlevelmonitoriscovered

under the Plan) •NochargeprescriptionsavailableunderWorkers’Compensation,orothercity,state

orfederalgovernmentalprogram •Non-legenddrugsotherthaninsulin •RetinAafterage26 •Rogaine •Viagraandsimilardrugs •Vitamins(prescriptionorotherwise)exceptforprescriptionpre-natalvitamins

Prosthetic Devices. Chargesforrepairorreplacementofprostheticdevices,exceptwhenrequiredduetogrowthordevelopmentofaDependentChild,MedicalNecessitybecauseofachangeintheCoveredParticipant’sphysicalcondition,ordeteriorationfromnormalwearandtearifrecommendedbytheattendingPhysician.

Radioactive Materials. Forchargesinconnectionwithtreatmentforexposuretoradioactivematerials.

Routine Care. Chargesforroutineorpreventivecare,immunizations,orvaccinationsexceptas otherwise specified in the Schedule of Benefitsorforgammaglobulininjections.

Self Inflicted Injuries. Chargesfor:

•intentionallyself-inflictedInjury,unlesssuchInjuryresultsfrommedicalcondition(physical or mental health condition) or domestic violence.

•injuryresultingfromorsustainedduetobeingengagedinanillegaloccupation,commissionofanassaultorfeloniousact.Thisexclusiondoesnotapply(a)iftheinjuryresultedfrombeingthevictimofanactofdomesticviolence,or(b)resultedfromamedicalcondition(includingbothphysicalandmentalhealthconditions).

Sexual Health and Family Planning. Chargesfor:

• Treatmentofinfertilitywiththeconfirmeddiagnosisofinfertilityorpurposeoftreatmentisfordiscoveryofinfertility,isnotacoveredinfertilitytreatment,servicesandfertilizationattempts,includingbutnotlimitedto:artificialinsemination,Pergonaltherapyforinfertility,in-vitrofertilization,microsurgeryforinfertilitytreatment, and HCG injections

•expensesrelatedtoadoption •surrogatemotherandallrelatednewbornDependentChildexpenses •electiveabortions,unlessthelifeofthemotherisendangeredorthepregnancy istheresultofacriminalact • sexualtransformation,includingsextransformationsurgeryandallexpensesin

connection with such surgery •treatmentofsexualdysfunctionsnotrelatedtoorganicdisease •reversalorattemptedreversalofsterilization


Subrogation, Reimbursement, and/or Third Party Responsibility. OfanInjuryorSicknessnotpayablebyvirtueofthePlan’ssubrogation,reimbursement,and/orthirdpartyresponsibilityprovisions.

Therapy. Forphysicalorpsychologicaltherapywherethemethodoftreatmentisart,play,music,drama,reading,massage,homeeconomicsorrecreationalactivities.Nocoveragefortherapytocorrectpre-speechdeficienciesortoimprovespeechskillsthathavenotyetfullydeveloped.

TMJ. Chargesfortreatment,otherthanbyanopen-cuttingoperation,oftemporomandib- ularjointdysfunction.

Tuition and/or Special Training. Chargesfortuitionorspecialeducationandforeducationaltesting or training are not covered.

Unauthorized Services. ThisincludesanyserviceobtainedbyoronbehalfofacoveredpersonwithoutPrecertificationbyPreferredAdministratorswhenrequired.Thisexclusiondoes not apply in a Medical Emergency or in an Urgent Care situation as long as the Medical Emergency does not turn into an Inpatient Stay.

Vax-D Therapy. ForVax-Dtherapy.

Vision. Vision-relatedservicesandsupplies,exceptasdescribedintheMedical Benefit Section. Theplandoesnotcover:

•Specialsuppliessuchasnon-prescriptionsunglassesandsubnormalvisionaids; •Visionserviceorsupplywhichdoesnotmeetprofessionallyacceptedstandards; •Eyeexamsduringyourstayinahospitalorotherfacilityforhealthcare; •Eyeexamsforcontactlensesortheirfitting; •Eyeexercises; •Eyeglassesorduplicateorspareeyeglassesorlensesorframes; •Replacementoflensesorframesthatarelostorstolenorbroken; •Acuitytests; •Eyesurgeryforthecorrectionofvision,includingradialkeratotomy,LASIKand

similarprocedures; •Servicestotreaterrorsofrefraction; •VisualTraining(orthoptics);and •Radialkeratotomysurgery,orthokeratology,andanyeyesurgiesinlieuofcorrective

lenses

Vitamins. Chargesfornutritionalsupplementsandprescriptionvitamins(exceptforpre-natalvitaminsrequiringaprescriptionunderthePrescriptionDrugProgram).


ARTICLE VIII

CLAIMS PROCEDURES

8.01 Claims

ClaimsshallbesubmitteddirectlytoPreferredAdministrators.Instructions for submitting claims are described on the Employee Identification Card.

8.02 Reporting of Claims from Associates

A Reimbursement Form can be downloaded at www.prefererredadmin.net.Thisformneedsto becompletediftheproviderisnotsubmittingtheclaimontheAssociate’sbehalf.Associates mustsubmitanitemizedbillforaclaimtobeprocessed.Receipts,balanceduestatements andcancelledchecksarenotacceptablereplacementsfortheitemizedbill.Completedclaim formsandoriginalbillsforCoveredExpensesmustbesubmittedwithinoneyearafterthe dateofservice.IfAssociateshaveadditionalquestions,pleasecontactPreferred Administra- tors Customer Service Department at 915-532-3778from7:00amto5:00pm.

a. All member reimbursements from members, should be reported promptly. Thedeadlineforfilingaclaimisoneyearafterthedateofservice. b. No payment will be made for claims submitted after one year from date of service,

except due to the legal incapacity of the Member. c. All member reimbursements will be processed accordingly to benefits applied and

provider participation.

8.03 Receipt of a Complete Claim

Uponreceiptofacompleteclaim,PreferredAdministratorswillapproveordenytheclaim withinthirty(30)daysandwillprovidetheMemberwithanExplanationofBenefitsState- mentthatdescribesthebenefitdeterminationandtheamountpaid.IftheMemberdisagrees withthebenefitdetermination,theMembermaycontactPreferredAdministratorsto

appeal the Adverse Benefit Determination.

8.04 Receipt of an Incomplete Claim

Uponreceiptofanincompleteclaim,PreferredAdministratorswilladvisetheMemberofthe needforadditionalinformationorthatarequestforadditionalinformationhasbeenmade

totheprovider,withinthirty(30)daysofreceiptoftheclaim.PreferredAdministratorswill waitforthirty(30)daysfortherequestedinformationtocompletetheclaim.Iftherequest- edinformationisnotsubmittedbytheMemberortheproviderwithinthirty(30)days,

PreferredAdministratorswilldenytheclaimandsoadvisetheMember.IftheMemberortheprovidersubmitstherequestedclaimsinformationwithinthethirty(30)days,PreferredAdministratorswillcompletetheprocessingoftheclaimwithin30daysofthereceiptoftherequestedinformationandissueanExplanationofBenefitsStatementtotheMember.

a. Definition for Incomplete Claim–shallmeanaclaimwhich,ifproperlycorrectedtocompletion,maybecompensableforthecoveredprocedure,butlacksimportantormaterialelementswhichpreventpaymentoftheclaim.

b. IftheMemberortheproviderhasnotsubmittedtherequestedclaimsinformationwith- inthethirty(30)days,PreferredAdministratorsshalldenytheclaim.Anychangeinthe

claim payment status shall be appealed under the Plan Complaints and Appeals Process. c. No payment shall be made for incomplete claims which are not corrected to comple- tion within one year from date of service.


8.05 Unclaimed Benefits

a. IfanyamountpayableunderthePlanisnotclaimedoranycheckissuedremainsuncashedforoneyearfromtheearlierofthedateofserviceorthedatethecheck

wasissued,theamountwillbeforfeitedtothePlanandwillceasetobealiabilityofthePlan,providedPreferredAdministratorshasexercisedreasonableeffortstomakesuch payments.

8.06 Covered Participant’s Responsibilities to Update Records

a. EachCoveredAssociatemustprovidePreferredAdministratorswiththeCoveredAssociate’s and each Dependent’s current address. Any notices concerning the Plan will bedeemedgivenifdirectedtotheaddressonfileandmailedbyregularUnitedStatesmail.PreferredAdministratorsshallhavenoobligationordutytolocateaCoveredAssociate.IfaCoveredAssociatebecomesentitledtoapaymentunderthisPlanandpaymentisdelayedorcannotbemadebecause:

b. thecurrentaddressaccordingtoEmployerrecordsisincorrect;

c. theCoveredAssociatefailstorespondtothenoticesenttothecurrentaddressaccordingtoEmployerrecords;

d. ofconflictingclaimstothepayments;

e. ofanyotherreason;or

f. theamountofpayment,ifandwhenmade,willbedeterminedundertheprovisions ofthisPlanwithoutpaymentofanyinterestorearnings.


ARTICLE IX

STANDARD COMPLAINT PROCESS

STANDARD COMPLAINT PROCESS9.01 All Complaints will be Handled by the Compliance Department.

1. ElPasoFirstHealthPlans,Inc.(d/b/aPreferredAdministrators)hasaprocessinplaceforPlan complaints and appeals. The Compliance Department, in collaboration with the Member Services Department, the Provider Relations Department, Claims Department and the Health Services Department, coordinates the complaints and appeals process. TheChiefExecutiveOfficer(CEO),throughtheDirectorofCompliance,hasprimaryresponsibilityforensuringthatcomplaintsareresolvedincompliancewithwrittenpoliciesandwithinthetimerequired.

2. PreferredAdministratorshasdesignatedCustomerServiceRepresentativestoassist MembersandCoveredParticipants(hereafterreferredtoasMembers)withthe

complaints process. All complaints must be submitted verbally or in writing. Written complaintswillbeacceptedfromtheMemberortheMember’sLegalRepresentative.MembersmaycontactPreferredAdministratorsCustomerServiceDepartmenttorequestassistanceonhowtosubmitaverbalorwrittencomplaint.Thecomplaint

mustbemailedorfaxedto:

Preferred Administrators Complaints and Appeals Unit 1145 Westmoreland Drive ElPaso,Texas79925 Fax(915)298-7872

3. Thefollowingdatawillberequired:

1) Date complaint was received 2) Member’s name and address 3) Member’s phone number 4) Provider’s name 5) Health Plan identification number 6)Dateofservice 7)Detailsoftheexactnatureofthecomplaint 8) Documentation to support the complaint

4. Withinfive(5)businessdaysofreceiptoftheverbalorwrittencomplaint,theComplaints and Appeals Unit will mail the Member an acknowledgment letter. The complaintresolutionwillbecompletednolaterthanthirty(30)calendardaysfollow-

ingthereceiptoftheverbalorwrittencomplaint.

5. Alldocumentationrelatingtocomplaintswillbeloggedandreadilyavailableforreview.

APPEALS PROCESS

9.02 Standard Administrative Appeals Process

All Administrative Appeals will be handled by the Compliance Department.

1. Membershavetherighttoappealadissatisfactionordisagreementofacomplaintresolutionthatwasnotduetobenefitexclusionforanexperimental,investigational

or non-covered benefit.

2. Appeals related to a medical determination, denial, reduction, suspension or termina- tionmustfollowtheAdverseAppealProcess.


3. Thestandardappealmustbemailedorfaxedto:

Preferred Administrators Complaints and Appeals Unit 1145 Westmoreland Drive ElPaso,Texas79925 Fax(915)298-7872

4. Withinfive(5)businessdaysofreceiptofthewrittenappeal,theComplaintsandAppeals Unit will mail the Member an acknowledgment letter. The appeal resolution willbecompletednolaterthanthirty(30)calendardaysfollowingthereceiptofthewritten appeal.

5. Alldocumentationrelatingtoappealswillbeloggedandreadilyavailableforreview.

9.03 Adverse Determination Appeal

1. Members(theMember’sproviderofcarecanalsobetheMember’sLegalRepresenta- tive)havetherighttoappealadissatisfactionordisagreementwithanadverse

determination resolution.

2. Benefitexclusionssuchasexperimental,investigationalornon-coveredbenefitswillnotbeeligibleforanappealofanadversedetermination.

3. MembersmayrequestanexternalIndependentReviewOrganization(IRO)atany timeinlieuofPreferredAdministrators’internalreviewprocess.Pleaseseecriteria forrequestinganIROinSection6.c.

4. Internal Review: AmemberortheirLegalRepresentativehastherighttoexpressdissatisfactionordisagreementwithanadversedeterminationthroughtheplan’sinternal review.

Appeals can be made verbally or in writing. Instructionsforfilingtheappealshallbe included in the adverse determination notification. The adverse determination notificationissentoutwithinthree(3)workingdaysofreceiptofanauthorizationrequest,providedthatalltheinformationneededtomakeadeterminationisincluded.

a. PREFERRED ADMINISTRATORS REqUIRES THAT APPEALS BE FILED WITHIN THIRTy (30) DAyS OF THE NOTICE OF THE ADVERSE DETERMINATION.

b. PreferredAdministratorsrequiresthefollowinginformationfortheappeal: 1) Acoverletter–LettermustincludetheMember’sname; 2) HealthPlanidentificationnumber; 3) PreferredAdministrator’sreferencenumber(fromtheNoticeofDetermination); 4) Dateofservice; 5) Astatementinclearandconcisetermsofthereasonorreasonsfordisagreement withthehandlingoftheclaim; 6) Acopyofthemedicalrecordifnotpreviouslysubmitted;and 7) Anyneworadditionalinformation.

Adverseappealsmustbemailedto:

Preferred Administrators Attention: Health Services Department – Appeals Unit 1145 Westmoreland Drive El Paso, Tx 79925

c. IMPORTANT: Failure to include any theories or facts in the appeal will result in their being deemed waived. In other words, the Member will lose the right to raise factual arguments and theories which support this claim if the Member fails to include them in the appeal.


d. All appeals are date stamped and logged in the Adverse Determination Appeals Log.Notlaterthanthefifth(5th)workingdayofreceiptoftheappeal,PreferredAdministratorswillsendaletteracknowledgingthedateofreceiptoftheappeal.

e. A resolution to the appeal will be made as soon as practicable, but not later than thirty(30)workingdaysfromthedatetheappealwasreceived.Acopyofthereso- lution letter will be mailed to the Member or the person acting on the Member’s

behalf,andtheMember’sphysicianorotherhealthcareprovider.Theappealresolutionletterwillinclude:

1) Aclearandconcisestatementoftheclinicalbasisforthedenial; 2) Thespecialtyofthephysicianorotherhealthcareproviderwhomadethedecision;

3) Therightsfortheappealingpartytoseekaspecialtyreviewandtheprocedureforfiling;and

4) AcopyoftheresolutionletterwillbemailedtoboththeProviderandtheMember.

5. Specialty Review for an Adverse Determination.

a. PreferredAdministratorsmayconsultahealthcareprofessionalwhohasappro- priatetrainingandexperienceinthefieldofmedicineinvolvedinthemedical

judgment, who is neither an individual who was consulted in connection with the previousmedicaldeterminationnorthesubordinateofanysuchindividual.

b. ArequestforaSpecialtyReviewmustbemadewithinten(10)daysofadversedeter- mination. It must be made in writing by the Member’s health care provider, and state agoodcauseforhavingaparticulartypeofspecialtyproviderreviewthecase.

c. Appealsinvolvingbenefitsexclusionssuchasexperimental,investigationalornon-coveredbenefitswillnotbeeligibleforthisreview.

6. External Review or Appeal Process.

a. External Review. Besides the Internal Review process described above, the Plan alsoallowsanExternalReviewprocess,underlimitedcircumstances.InanExternalReview, the Adverse Determination is reviewed by an IRO, and their decision is binding on the Member, the Member’s Legal Representative, and the Plan.

b. What is an IRO? AnIndependentReviewOrganization,orIRO,isanindependentthirdpartywhoconductsexternalreviewofaservicedeniedbyahealthplan.PreferredAdministratorswilluseIROswhoareaccreditedbytheUtilizationReviewAccreditationCommission(URAC)orbyasimilarnationally-recognizedaccreditingorganizationtoconducttheexternalreview.

c. Criteria for Requesting an IRO. ThefollowingcriteriamustbemettorequestanIRO:

1) TheMemberisorwascoveredunderPreferredAdministratorsatthetimethe healthcareservicewasrequested;orinthecaseofaretrospectivereview,was coveredunderPreferredAdministratorsatthetimethehealthcarewasprovided. 2) TheAdverseDeterminationdoesnotrelatetotheMember’sfailuretomeetthe

requirementsforeligibilityunderthetermsofPreferredAdministrators. 3) TheMemberhasexhaustedPreferredAdministratorsinternalappealsprocess. 4) TheMemberhasprovidedalltheinformationandformsrequiredtoprocessan

externalreview. 5) TheIROdoesnotapplytoadenial,reduction,terminationorafailuretoprovide

paymentforabenefitbasedonadeterminationthataMemberorbeneficiaryfailstomeettherequirementsforeligibilityunderthetermsofPreferredAdmin-

istrators.BenefitsnotcoveredandpayableundertheprovisionsofPreferredAdministratorswillnotbeconsideredforreviewbyanIRO.

6) TheMemberortheirLegalRepresentativemayrequestanexternalappealwith- infour(4)monthsofreceiptofresolutionletterexcludingholidaysandweekends.


d. Process for Requesting an IRO. Ifthedecisionismadetoupholdtheadversedetermination, the Member or their representative has the right to have this decisionreviewedbyanIRO.ThereisnocosttotheMemberforfilinganIRO.However,theabovecriteriaforrequestinganIROmustbemet.

e. TorequestareviewbyanIRO,theMembermustsubmittherequestinwritingto:

Preferred Administrators Attention: Health Services Department – Appeals Unit 1145 Westmoreland Drive El Paso, Tx 79925

f. ThefollowinginformationwillberequiredfortheIRO: 1) anymedicalrecordsrelevanttothereview; 2) anydocumentsusedbyPreferredAdministratorsinmakingthedetermination; 3) thewrittennotificationsentbyPreferredAdministrators; 4) anydocumentsandotherwritteninformationsubmittedinsupportoftheappeal; 5) alistofeachphysicianorotherhealthcareproviderwhohasprovidedcareto

the Member and may have medical records relevant to the appeal.

g. PreferredAdministratorswillconductapreliminaryreviewtodeterminewhethertherequestmeetsthereviewabilityrequirementsforexternalreviewtosetforthinSection6c:CriteriaforRequestingIRO.

h. Uponadeterminationthatarequestiseligibleforexternalreview,PreferredAdministratorswillassignanIROandnotifytheMemberoftheassignedIRO.

i. PreferredAdministratorswillprovideortransmitallnecessarydocumentsandinformationconsideredinmakingtheadversedeterminationorfinalinternaldeterminationtotheassignedIRObyfaxwithinthreedaysofreceiptoftheinformation.PreferredAdministratorswillprovidealistofeachphysicianorotherhealth care provider who have provided care to the enrollee and that may have medical records relevant to the appeal.

j. TheIROwillreviewthedocumentationandinformationsubmitted.TheIROwillprovideafinalexternalreviewdecisionasexpeditiouslyastheclaimant’smedicalconditionorcircumstancesrequire.

k. ImmediateappealtoanIROcanbemadeincircumstancesinvolvingaMember’slifethreateningconditionandwillnotberequiredtocomplywithproceduresforaninternalreviewoftheutilizationreviewagent’sadversedetermination.

l. TheIROhastwenty(20)daystomakeadecisionfornon-lifethreateningcasesandeight(8)daystomakeadecisionforlifethreateningcases.TheIROwillnotifytheMemberofitsdecision.

7. Expedited Appeal for an Adverse Determination.

a. TheMemberortheirrepresentativemayrequestanexpeditedappealfordenialofemergencycareorcontinuedhospitalization.Theexpeditedappealmustbemadeinwriting.Theprocessforrequestinganexpeditedappealofanadversedeterminationwillbemadebyahealthcareprofessionalwhohasappropriatetrainingandexperienceinthefieldofmedicineinvolvedinthemedicaljudgment,who is neither an individual who was consulted in connection with the previous medicaldeterminationnorthesubordinateofanysuchindividual.

b. TheMemberortheirrepresentativemayrequestanexpeditedappealif: 1) TheadversedeterminationinvolvesamedicalconditionoftheMemberfor

whichthetimeframeforcompletionofastandardinternalappealwouldseriouslyjeopardizethelifeorhealthoftheMember,orwouldjeopardizetheMember’sabilitytoregainmaximumfunction;or


2) TheMemberhasamedicalconditionwherethetimeframeforcompletionofastandardexternalreviewwouldseriouslyjeopardizethelifeorhealthoftheclaimantorwouldjeopardizetheMember’sabilitytoregainmaximumfunction,orifthefinalinternaldeterminationconcernsanadmission,availabilityofcare,continuedstayorhealthcareserviceforwhichtheMemberreceivedemergencyservices,buthasnotbeendischargedfromafacility.

c. Appealsinvolvingbenefitsexclusionssuchasexperimental,investigationalornon-coveredbenefitswillnotbeeligibleforthisreview.

d. TimeframeforResolutionofExpeditedAppeal.Resolutionofanexpeditedappealwillbebasedonthemedicalimmediacyofthecondition,procedure,ortreatmentunderreview,providedthattheresolutiontotheappealdoesnotexceedone(1)workingdayfromthedatealltheinformationnecessarytocompletetheappealisreceived.Initialnoticeofthedecisionmaybedeliveredorally,followedbywrittennoticeofthedeterminationwithin(3)threedays.

Appealsinvolvingbenefitsexclusionssuchasexperimental,investigationalornon-coveredbenefitswillnotbeeligibleforthisreview.

8. Determination of Appeal

a. IfthefinaldeterminationoftheappealisadversetotheMemberandisupheld,PreferredAdministratorswillrecoversuchcosts.

b. Ifthedeterminationoftheappealisreversed,PreferredAdministratorswillprovidecoverageorpaymentfortheclaimwithoutdelay,regardlessofwhethertheplanintendstoseekjudicialreviewoftheexternalreviewdecisionandunlessoruntilthere is a judicial decision otherwise.

c. AcopyoftheresolutionletterwillbemailedtoboththeproviderandtheMember.

9. IMPORTANT TIMEFRAMES TO REMEMBER

a. Adeterminationforarequestedservicewillbemadewithinthree(3)workingdaysofreceiptofalltheinformationnecessarytomakeadetermination.

b. Ifrequestforadditionalinformationismade,theMemberorMember’srepresenta- tivehasten(10)daystosubmittheadditionalinformationfortherequestedservices.

c. Ifservicesareconsiderednotmedicallynecessaryorappropriate,theMembermay appealthedecisionwithinthirty(30)daysofreceiptoftheNoticeofAdverse

Determination.

d. Aletterofacknowledgementwillbeissuedwithinfive(5)daysofreceiptof the appeal.

e. Theappealwillbereviewedwithinareasonableperiodoftimeappropriatetothemedicalcircumstances,butnotlaterthanthirty(30)daysafterreceiptoftheappeal.

f. TheMemberortheirLegalRepresentativemayrequestanexternalappealwithinfour(4)monthsofreceiptofresolutionletterexcludingholidaysandweekends.

g. Uponreceiptofrequestforexternalreview,PreferredAdministratorswillreviewthe documentationtodetermineiftherequestmeetsthecriteriaforexternalreview; and will submit the documentation to the IRO as soon as possible, taking into account themedicalexigencies,butnotlaterthanthree(3)workingdaysafterreceiptofthe

requestforexternalreview.

h. TheIROhastwenty(20)daystomakeadecisionfornon-lifethreateningcasesandeight(8)daystomakeadecisionforlifethreateningcases.TheIROwillnotifytheMemberofitsdecision.



9.04 Appeal Process for Special EPCH/UMC/TT Benefit Coverage: • Membershaveuptosixty(60)calendardaystofileanappealforeachbilledservice fromthedateonthefirstExplanationofBenefits(EOB)Form.

• AllappealswillbereviewedbyPreferredAdministratorstoensuretheymeettheapplicable criteria (i.e. filed on a timely basis, pre-authorization received).

• PreferredAdministratorswillnotifythememberthattheappealhasbeenreceived.

• PreferredAdministratorsprovidesallrelevantinformationrelativetotheappeal (Prior Authorization obtained, medical necessity confirmed) toEPCHforfinalapproval.

• OnceafinaldeterminationismadebyEPCH,PreferredAdministratorsnotifiesthememberinwritingwithinfive(5)daysofthedetermination.

• IftheoutcomeallowstheEPCH/UMC/TTlevelofbenefit,PreferredAdministratorswillreview the amounts and accumulators and process any changes accordingly.

ARTICLE X

MISCELLANEOUS

10.01 Plan Interpretation

ThePlanAdministratorhastheauthorityanddiscretiontointerpretthetermsofthePlan,including the authority and discretion to resolve inconsistencies or ambiguities between the provisionsofthisdocumentandtheprovisionsofthePlan’sSchedule of Benefits, or any otherdocumentthatformsapartofthePlan.However,thetermsofthisdocumentmaynotenlargetherightsofaCoveredParticipanttobenefitsavailableunderanyWelfareProgram.

10.02 Exclusive Benefit

ThisPlanhasbeenestablishedfortheexclusivebenefitofCoveredParticipantsandexceptasotherwiseprovidedherein,allcontributionsunderthePlanmaybeusedonlyforsuchpurpose.

10.03 Non-Alienation of Benefits

Nobenefit,rightorinterestofanyCoveredParticipantunderthePlanaresubjecttoanticipation,alienation,sale,transfer,assignment,pledge,encumbranceorcharge,seizure,attachmentorlegal,equitableorotherprocess,orbeliablefor,orsubjectto,thedebts,liabilitiesorotherobligationsofsuchperson,exceptasotherwiserequiredbylaw,orasotherwiseprovidedinaWelfareProgram.

10.04 Limitation of Rights

Theestablishment,existenceoramendmenttothePlanshallnotoperateorbeconstruedto:

(a) giveanypersonanylegalorequitablerightagainsttheEmployeroritsAffiliates,exceptasexpresslyprovidedhereinorrequiredbylaw;or

(b) createacontractofemploymentwithanyEmployee,obligatetheEmployeroroneofitsAffiliatestocontinuetheserviceofanyEmployee,oraffectormodifythetermsofan Employee’s employment in any way.

10.05 Governing Laws

ThePlanisgovernedbyERISA.InnoeventshalltheEmployerguaranteethefavorabletaxtreatment sought by this Plan.

10.06 Severability

IfanyprovisionofthePlanisheldinvalidorunenforceable,itsinvalidityorunenforceabilityshallnotaffectanyotherprovisionofthePlan,andthePlanareconstruedandenforcedasifsuchinvalidorunenforceableprovisionhadnotbeenincludedherein.

10.07 Captions

Captionsareusedasamatterofconvenienceandforreference,anddonotdefine,limit,enlargeordescribethescopeorintentofthePlannoraffectthePlanortheconstructionofanyofitsprovisions.

10.08 Construction

WheneverusedinthisPlan,themasculinegendershallincludethefeminineandthepluralformshallincludethesingular.


10.09 Expenses

TheexpensesofadministeringthePlan,includingwithoutlimitationtheexpensesofthePlanAdministratorproperlyincurredintheperformanceofitsdutiesunderthePlan,willbepaidbythePlan,andallsuchexpensesincurredbytheEmployerwillbereimbursedbythePlan,unlesstheEmployerinitsdiscretionelectstopaysuchexpensesfromassetsotherthanassetsofthePlanornottosubmitsuchexpensesforreimbursement.

10.10 Claim Determination Period

The claims determination period starting February 1, 2012 and ending September 30, 2012 shallbetheinitialPlanYear.ThereaftertheClaimDeterminationperiodandPlanYearshallcommenceeachOctober1.However,itdoesnotincludeanypartofayearduringwhichapersonhasnocoverageunderthisPlanoranypartofayearbeforethedatethisCoordinationofBenefits(COB)provisionorasimilarprovisiontakeseffect.

10.11 Right to Receive and Release Necessary Information TheThirdPartyAdministratormayreleaseorobtainanyinformationdeemednecessaryto implement this Plan unless otherwise mandated by law. Any person who claims benefits under thePlanshallberequiredtoprovideanyinformationrequestedbythePlanAdministrator.

10.12 Facility of Payment

PaymentsunderanotherplanmaybereimbursedtothatPlanif,atthediscretionofthePlanAdministrator,paymentwasdueunderthisPlan.SuchpaymentwillfulfillthePlanSponsor’sresponsibilitytotheextentofsuchpayment.

10.13 Right to Recovery In accordance with section 8.06B, whenever payments have been made by this Plan with

respecttoAllowableExpensesinatotalamount,atanytime,inexcessofthemaximumamountofpaymentnecessaryatthattimetosatisfytheintentofthisArticle,thePlanshallhavetherighttorecoversuchpayments,totheextentofsuchexcess,fromanyoneormoreofthefollowingasthisPlanshalldetermine:anypersontoorwithrespecttowhomsuchpayments were made, or such person’s legal representative, any insurance companies, or any otherindividualsororganizationswhichthePlandeterminesareresponsibleforpaymentofsuchAllowableExpenses,andanyfuturebenefitspayabletotheParticipantorhisorherDependents.Pleasesee8.06Baboveformoredetails.


ARTICLE XI

SUBROGATION, REIMBURSEMENT,AND THIRD PARTY RECOVERY PROVISION

11.01 Payment Condition

1. ThePlan,initssolediscretion,mayelecttoconditionallyadvancepaymentofbenefitsin those situations where an injury, sickness, disease or disability is caused in whole or inpartby,orresultsfromtheactsoromissionsofPlanParticipants,PlanParticipants,and/or their dependants, beneficiaries, estate, heirs, guardian, personal representative, orassigns(collectivelyreferredtohereinafterinthissectionas“PlanParticipant(s)”)orathirdparty,whereanypartybesidesthePlanmayberesponsibleforexpensesarisingfromanincident,and/orotherfundsareavailable,includingbutnotlimitedtono-fault,uninsuredmotorist,underinsuredmotorist,medicalpaymentprovisions,thirdpartyassets,thirdpartyinsurance,and/orgrantor(s)ofathirdparty(collectively“Coverage”).

2. PlanParticipant(s),hisorherattorney,and/orlegalguardianofaminororincapaci- tatedindividualagreesthatacceptanceofthePlan’sconditionalpaymentofmedical

benefitsisconstructivenoticeoftheseprovisionsintheirentiretyandagreestomaintainonehundredpercent(100%)ofthePlan’sconditionalpaymentofbenefitsorthefullextentofpaymentfromanyoneorcombinationoffirstandthirdpartysourcesintrust,withoutdisruptionexceptforreimbursementtothePlanorthePlan’sassignee.ByacceptingbenefitsthePlanParticipant(s)agreesthePlanshallhaveanequitablelienonanyfundsreceivedbythePlanParticipant(s)and/ortheirattorneyfromanysourceandsaidfundsshallbeheldintrustuntilsuchtimeastheobligationsunderthisprovisionarefullysatisfied.ThePlanParticipant(s)agreestoincludethePlan’snameasaco-payeeonanyandallsettlementdrafts.

3. In the event a Plan Participant(s) settles, recovers, or is reimbursed by any Coverage, thePlanParticipant(s)agreestoreimbursethePlanforallbenefitspaidorthatwillbepaidbythePlanonbehalfofthePlanParticipant(s).IfthePlanParticipant(s)failstoreimbursethePlanoutofanyjudgmentorsettlementreceived,thePlanParticipant(s)willberesponsibleforanyandallexpenses(feesandcosts)employeedwiththePlan’sattempt to recover such money.

4. IfthereismorethanonepartyresponsibleforchargespaidbythePlan,ormayberesponsibleforchargespaidbythePlan,thePlanwillnotberequiredtoselectaparticularpartyfromwhomreimbursementisdue.Furthermore,unallocatedsettlementfundsmeanttocompensatemultipleinjuredpartiesofwhichthePlanParticipant(s)is/areonlyoneorafew,thatunallocatedsettlementfundisconsidereddesignatedasan“identifiable”fundfromwhichthePlanmayseekreimbursement.

11.02 Subrogation

1. As a condition to participating in and receiving benefits under this Plan, the Plan Participant(s) agrees to assign to the Plan the right to subrogate and pursue any and allclaims,causesofactionorrightsthatmayariseagainstanyperson,corporationand/orentityandtoanyCoveragetowhichthePlanParticipant(s)isentitled,regardlessofhowclassifiedorcharacterized,atthePlan’sdiscretion.

2. IfaPlanParticipant(s)receivesorbecomesentitledtoreceivebenefits,anautomaticequitablelienattachesinfavorofthePlantoanyclaim,whichanyPlanParticipant(s)mayhaveagainstanyCoverageand/orpartycausingthesicknessorinjurytotheextentofsuchconditionalpaymentbythePlanplusreasonablecostsofcollection.


3. ThePlanmay,atitsdiscretion,initsownnameorinthenameofthePlanParticipant(s)commenceaproceedingorpursueaclaimagainstanypartyorCoveragefortherecoveryofalldamagestothefullextentofthevalueofanysuchbenefitsorconditional payments advanced by the Plan.

4. IfthePlanParticipant(s)failstofileaclaimorpursuedamagesagainst: (a) theresponsibleparty,itsinsurer,oranyothersourceonbehalfofthatparty; (b) any first party insurance through medical payment coverage, personal injury

protection,no-faultcoverage,uninsuredorunderinsuredmotoristcoverage; (c) anypolicyofinsurancefromanyinsurancecompanyorguarantorofathirdparty; (d) worker’scompensationorotherliabilityinsurancecompany;or, (e) anyothersource,includingbutnotlimitedtocrimevictimrestitutionfunds,any

medical,disabilityorotherbenefitpayments,andschoolinsurancecoverage;thePlanParticipant(s)authorizesthePlantopursue,sue,compromiseand/orsettleany such claims in the Plan Participant(s)’ and/or the Plan’s name and agrees to fullycooperatewiththePlanintheprosecutionofanysuchclaims.ThePlanParticipant(s) assigns all rights to the Plan or its assignee to pursue a claim and

therecoveryofallexpensesfromanyandallsourceslistedabove.

11.03 Right of Reimbursement

1. ThePlanshallbeentitledtorecover100%ofthebenefitspaid,withoutdeductionforattorneys’feesandcostsorapplicationofthecommonfunddoctrine,makewhole doctrine, or any other similar legal theory, without regard to whether the PlanParticipant(s)isfullycompensatedbyhis/herrecoveryfromallsources.ThePlanshallhaveanequitablelienwhichsupersedesallcommonlaworstatutoryrules,doctrines,andlawsofanystateprohibitingassignmentofrightswhichinterfereswithorcompromisesinanywaythePlan’sequitablelienandrighttoreimbursement.TheobligationtoreimbursethePlaninfullexistsregardlessofhowthejudgmentorsettlement is classified and whether or not the judgment or settlement specifically designatestherecoveryoraportionofitasincludingmedical,disability,orotherexpenses.IfthePlanParticipant(s)’recoveryislessthanthebenefitspaid,thenthe

Planisentitledtobepaidalloftherecoveryachieved.

2. Nocourtcosts,experts’fees,attorneys’fees,filingfees,orothercostsorexpensesoflitigationmaybedeductedfromthePlan’srecoverywithouttheprior,expressedwrittenconsentofthePlan.

3. ThePlan’srightofsubrogationandreimbursementwillnotbereducedoraffectedasaresultofanyfaultorclaimonthepartofthePlanParticipant(s),whetherunderthedoctrinesofcausation,comparativefaultorcontributorynegligence,orothersimilardoctrine in law. Accordingly, any lien reduction statutes, which attempt to apply such laws and reduce a subrogating Plan’s recovery will not be applicable to the Plan and will not reduce the Plan’s reimbursement rights.

4. TheserightsofsubrogationandreimbursementshallapplywithoutregardtowhetheranyseparatewrittenacknowledgmentoftheserightsisrequiredbythePlanandsigned by the Plan Participant(s).

5. ThisprovisionshallnotlimitanyotherremediesofthePlanprovidedbylaw.Theserightsofsubrogationandreimbursementshallapplywithoutregardtothelocation

oftheeventthatledtoorcausedtheapplicablesickness,injury,diseaseordisability.


11.04 Excess Insurance

1. Ifatthetimeofinjury,sickness,diseaseordisabilitythereisavailable,orpotentiallyavailableanyCoverage(includingbutnotlimitedtoCoverageresultingfromajudgment at law or settlements), the benefits under this Plan shall apply only as an excessoversuchothersourcesofCoverage,exceptasotherwiseprovidedforunder

thePlan’sCoordinationofBenefitssection.

ThePlan’sbenefitsshallbeexcessto:

(a) theresponsibleparty,itsinsurer,oranyothersourceonbehalfofthatparty; (b) any first party insurance through medical payment coverage, personal injury

protection,no-faultcoverage,uninsuredorunderinsuredmotoristcoverage; (c) anypolicyofinsurancefromanyinsurancecompanyorguarantorofathirdparty; (d) workers’compensationorotherliabilityinsurancecompany;or (e) anyothersource,includingbutnotlimitedtocrimevictimrestitutionfunds,any


11.05 Separation of Funds

1. BenefitspaidbythePlan,fundsrecoveredbythePlanParticipant(s),andfundsheldintrustoverwhichthePlanhasanequitablelienexistseparatelyfromthepropertyandestateofthePlanParticipant(s),suchthatthedeathofthePlanParticipant(s),orfilingofbankruptcybythePlanParticipant(s),willnotaffectthePlan’sequitablelien,thefundsoverwhichthePlanhasalien,orthePlan’srighttosubrogationandreimbursement.

11.06 Wrongful Death

1. IntheeventthatthePlanParticipant(s)diesasaresultofhisorherinjuriesandawrongfuldeathorsurvivorclaimisassertedagainstathirdpartyoranyCoverage,thePlan’s subrogation and reimbursement rights shall still apply, and the entity pursuing saidclaimshallhonorandenforcethesePlanrightsandtermsbywhichbenefitsarepaidonbehalfofthePlanParticipant(s)andallothersthatbenefitfromsuchpayment.

11.07 Obligations

1. ItisthePlanParticipant(s)’obligationatalltimes,bothpriortoandafterpaymentofmedicalbenefitsbythePlan:

(a) tocooperatewiththePlan,oranyrepresentativesofthePlan,inprotectingitsrights, including discovery, attending depositions, and/or cooperating in trial to preservethePlan’srights;

(b) toprovidethePlanwithpertinentinformationregardingthesickness,disease,disability,orinjury,includingaccidentreports,settlementinformationandanyotherrequestedadditionalinformation;

(c) totakesuchactionandexecutesuchdocumentsasthePlanmayrequiretofacilitateenforcementofitssubrogationandreimbursementrights;

(d) todonothingtoprejudicethePlan’srightsofsubrogationandreimbursement; (e) to promptly reimburse the Plan when a recovery through settlement, judgment,

awardorotherpaymentisreceived;and (f) tonotsettleorrelease,withoutthepriorconsentofthePlan,anyclaimtotheex- tent that the Plan Participant may have against any responsible party or Coverage.


2. IfthePlanParticipant(s)and/orhisorherattorneyfailstoreimbursethePlanforallbenefitspaidortobepaid,asaresultofsaidinjuryorcondition,outofanyproceeds,judgmentorsettlementreceived,thePlanParticipant(s)willberesponsibleforanyandallexpenses(whetherfeesorcosts)employeedwiththePlan’sattempttorecoversuchmoneyfromthePlanParticipant(s).

3. The Plan’s rights to reimbursement and/or subrogation are in no way dependant upon the Plan Participant(s)’ cooperation or adherence to these terms.

11.08 Offset

1. FailurebythePlanParticipant(s)and/orhisorherattorneytocomplywithanyoftheserequirementsmay,atthePlan’sdiscretion,resultinaforfeitureofpaymentbythePlanofmedicalbenefitsandanyfundsorpaymentsdueunderthisPlanonbehalfofthe Plan Participant(s) may be withheld until the Plan Participant(s) satisfies his or her obligation.

11.09 Minor Status

1. In the event the Plan Participant(s) is a minor as that term is defined by applicable law, the minor’s parents or court-appointed guardian shall cooperate in any and all actions bythePlantoseekandobtainrequisitecourtapprovaltobindtheminorandhisorherestateinsofarasthesesubrogationandreimbursementprovisionsareconcerned.

2. Iftheminor’sparentsorcourt-appointedguardianfailtotakesuchaction,thePlanshallhavenoobligationtoadvancepaymentofmedicalbenefitsonbehalfoftheminor.Anycourtcostsorlegalfeesemployeedwithobtainingsuchapprovalshallbepaid by the minor’s parents or court-appointed guardian.

11.10 Language Interpretation

1. ThePlanAdministratorretainssole,fullandfinaldiscretionaryauthoritytoconstrueand interpretthelanguageofthisprovision,todetermineallquestionsoffactandlawaris- ing under this provision, and to administer the Plan’s subrogation and reimbursement

rights. The Plan Administrator may amend the Plan at any time without notice.

11.11 Severability

1. Intheeventthatanysectionofthisprovisionisconsideredinvalidorillegalforanyreason,saidinvalidityorillegalityshallnotaffecttheremainingsectionsofthisprovisionandPlan.Thesectionshallbefullyseverable.ThePlanshallbeconstrued

andenforcedasifsuchinvalidorillegalsectionshadneverbeeninsertedinthePlan.


ARTICLE XII

COORDINATION OF BENEFITS

12.01 Benefits Subject to This Provision ThisprovisionshallapplytoallbenefitsprovidedunderanysectionofthisPlan.

12.02 Excess Insurance

Ifatthetimeofinjury,sickness,diseaseordisabilitythereisavailable,orpotentiallyavail- ableanyCoverage(includingbutnotlimitedtoCoverageresultingfromajudgmentatlaw

orsettlements),thebenefitsunderthisPlanshallapplyonlyasanexcessoversuchothersourcesofCoverage.ThePlan’sbenefitswillbeexcessto,wheneverpossible:

a) anyprimarypayerbesidesthePlan; b) any first party insurance through medical payment coverage, personal injury

protection,no-faultcoverage,uninsuredorunderinsuredmotoristcoverage; c) anypolicyofinsurancefromanyinsurancecompanyorguarantorofathirdparty; d) workers’compensationorotherliabilityinsurancecompany;or e) anyothersource,includingbutnotlimitedtocrimevictimrestitutionfunds,any


12.03 Vehicle Limitation

Whenmedicalpaymentsareavailableunderanyvehicleinsurance,thePlanshallpayexcessbenefitsonly,withoutreimbursementforvehicleplanand/orpolicydeductibles.ThisPlanshallalwaysbeconsideredsecondarytosuchplansand/orpolicies.Thisappliestoallformsofmedicalpaymentsundervehicleplansand/orpoliciesregardlessofitsname,titleorclassification.

12.04 Allowable Expenses

“AllowableExpenses”shallmeantheUsualandCustomarychargeforanyMedicallyNecessary,Reasonable,eligibleitemofexpense,atleastaportionofwhichiscoveredunderthisPlan.WhensomeOtherPlanprovidesbenefitsintheformofservicesratherthancashpayments,thereasonablecashvalueofeachservicerendered,intheamountthatwouldbepayableinaccordancewiththetermsofthePlan,shallbedeemedtobethebenefit.Benefits payable under any Other Plan include the benefits that would have been payable hadclaimbeendulymadetherefore.

12.05 Claim Determination Period

“Claim Determination Period” shall mean each calendar year.

12.06 Effect on Benefits

A. Application to Benefit Determinations

Theplanthatpaysfirstaccordingtotherulesinthesectionentitled“OrderofBenefitDetermination”willpayasiftherewerenootherplaninvolved.Thesecondaryandsubsequentplanswillpaythebalancedueupto100%ofthetotalAllowableExpenses.Whenthereisaconflictintherules,thisPlanwillneverpaymorethan50%ofAllow-

ableExpenseswhenpayingsecondary.BenefitswillbecoordinatedonthebasisofaClaim Determination Period.

When medical payments are available under automobile insurance, this Plan will pay excessbenefitsonly,withoutreimbursementforautomobileplandeductibles.ThisPlanwillalwaysbeconsideredthesecondarycarrierregardlessoftheindividual’selectionunder personal injury protection (PIP) coverage with the automobile insurance carrier.


Incertaininstances,thebenefitsoftheOtherPlanwillbeignoredforthepurposes ofdeterminingthebenefitsunderthisPlan.Thisisthecasewhen:

1. TheOtherPlanwould,accordingtoitsrules,determineitsbenefitsafterthebenefitsofthisPlanhavebeendetermined;and

2. Therulesinthesectionentitled“OrderofBenefitDetermination”wouldrequirethisPlantodetermineitsbenefitsbeforetheOtherPlan.

B. Order of Benefit Determination

Forthepurposesofthesectionentitled“ApplicationtoBenefitDeterminations,” therulesestablishingtheorderofbenefitdeterminationare:

1. Aplanwithoutacoordinatingprovisionwillalwaysbetheprimaryplan; 2. Thebenefitsofaplanwhichcoversthepersononwhoseexpensesclaimisbased,

otherthanasadependent,shallbedeterminedbeforethebenefitsofaplanwhichcoverssuchpersonasadependent;

3. Ifthepersonforwhomclaimismadeisadependentchildcoveredunderbothparents’plans,theplancoveringtheparentwhosebirthday(monthanddayofbirth,notyear)fallsearlierintheyearwillbeprimary,except:

a. When the parents are separated or divorced, and the parent with the custody ofthechildhasnotremarried,thebenefitsofaplanwhichcoversthechildasadependentoftheparentwithcustodywillbedeterminedbeforethebenefitsofaplanwhichcoversthechildasadependentoftheparentwithoutcustody;or

b.Whentheparentsaredivorcedandtheparentwithcustodyofthechildhasremarried,thebenefitsofaplanwhichcoversthechildasadependentoftheparentwithcustodyshallbedeterminedbeforethebenefitsofaplanwhichcoversthatchildasadependentofthestepparent,andthebenefitsofaplanwhichcoversthatchildasadependentofthestepparentwillbedeterminedbeforethebenefitsofaplanwhichcoversthatchildasadependentoftheparent without custody.

Notwithstanding the above, if there is a court decree which would otherwise establish financial responsibility for the child’s health care expenses, the benefits of the plan which covers the child as a dependent of the parent with such financial responsibility shall be determined before the benefits of any Other Plan which covers the child as a dependent child; and

4. Whentherulesabovedonotestablishanorderofbenefitdetermination,thebenefitsofaplanwhichhascoveredthepersononwhoseexpensesclaimisbasedforthelongerperiodoftimeshallbedeterminedbeforethebenefitsofaplanwhichhascoveredsuchpersontheshorterperiodoftime.

12.07 Right to Receive and Release Necessary Information Forthepurposeofdeterminingtheapplicabilityofandimplementingthetermsofthis

provisionoranyprovisionofsimilarpurposeofanyOtherPlan,thisPlanmay,withouttheconsentofornoticetoanyperson,releasetoorobtainfromanyinsurancecompany,orotherorganizationorindividual,anyinformationwithrespecttoanyperson,whichthePlandeemstobenecessaryforsuchpurposes.AnypersonclaimingbenefitsunderthisPlanshallfurnishtothePlansuchinformationasmaybenecessarytoimplementthisprovision.


12.08 Facility of Payment

Whenever payments which should have been made under this Plan in accordance with this provision have been made under any Other Plans, the Plan Administrator may, in its solediscretion,payanyorganizationsmakingsuchotherpaymentsanyamountsitshalldeterminetobewarrantedinordertosatisfytheintentofthisprovision,andamountssopaidshallbedeemedtobebenefitspaidunderthisPlanand,totheextentofsuchpayments,thisPlanshallbefullydischargedfromliability.

12.09 Right of Recovery

In accordance with section 8.06B, whenever payments have been made by this Plan with respecttoAllowableExpensesinatotalamount,atanytime,inexcessofthemaximumamountofpaymentnecessaryatthattimetosatisfytheintentofthisArticle,thePlanshallhavetherighttorecoversuchpayments,totheextentofsuchexcess,fromanyoneormoreofthefollowingasthisPlanshalldetermine:anypersontoorwithrespecttowhomsuchpayments were made, or such person’s legal representative, any insurance companies, or any otherindividualsororganizationswhichthePlandeterminesareresponsibleforpaymentofsuchAllowableExpenses,andanyfuturebenefitspayabletotheParticipantorhisorherDependents.Pleasesee8.06Baboveformoredetails.

12.10 Coordination with Medicare

IfanactiveAssociatecoveredbythePlanisage65orolderandhasMedicarePartA,thePlanistheprimarypayer,andMedicareisthesecondarypayerofbenefitsprovidedunderboththePlanandMedicarePartAorB.ThesameappliestoaSpouseiftheSpouseofanactiveEmployeeisage65oroverandhasMedicarePartA,oriftheSpouseisemployedandis age 65 or over and has Medicare Part A.

WhenaCoveredParticipantiseligibleforMedicare,Medicarewillpayprimaryorsecondarytotheextentstatedinfederallaw.WhenMedicareistheprimarypayer,thePlanwillbaseits payment upon benefits that would have been paid by Medicare under Parts A and B, regardlessofwhetherthepersonwasenrolledunderbothparts.


ARTICLE XIII

AMENDMENT AND TERMINATION

13.01 Amendment

The Employer reserves the right to amend the Plan at any time. Each amendment to the Plan will be made only pursuant to action by the Human Resources Department. Upon such action,thePlanwillbedeemedamendedasofthedatespecifiedastheeffectivedatebysuchactionorintheinstrumentofamendment.Theeffectivedateofanyamendmentmaybebefore,onorafterthedateofsuchaction.

13.02 Termination

TheEmployerexpectstocontinuethePlanindefinitely,butcontinuanceisnotassumedasacontractualobligation.TheEmployerreservestherightatanytimebyactionofitsBoardofDirectors or other governing body to terminate the Plan, in whole or in part, at any time.

IfthePlanisterminated,noSalaryReductionshallbemade.

13.03 Effect on Other Benefits

The right to amend or terminate the Plan includes the right to change, limit, curtail, or eliminatecoverageorbenefitsforanytreatment,procedure,orservice(includingwithrespect to Covered Participants who are receiving benefits or Covered Participants who are FormerEmployeesorretirees),regardlessofwhetherthecoverageorbenefitsrelatetoanInjury,defect,Illness,ordiseasethatwascontractedorthatoccurredbeforetheeffectivedateofamendmentortermination.


ARTICLE XIV

HIPAA PRIVACY RULE

EffectiveApril14,2003,theElPasoChildren’sHospitalandItsAffiliatesAssociateHealthBenefitFundPlan(hereinafterreferredtoasthe“Plan”)conformswiththerequirementsof§164.504(f)oftheHealthInsurancePortabilityandAccountabilityActof1996anditsimplementingregulations,45C.F.R.parts160through164(theregulationsarereferredtohereinasthe“HIPAAPrivacyRule”and§164.504(f)isreferredtoas“the‘504’provisions”)byestablishingtheextenttowhichthePlanSponsorwillreceive,use,and/ordiscloseProtectedHealthInformationandSensitivePersonalInformation(hereinafterreferredtoas“PHIandSPI,respectively“).EffectiveFebruary18,2010,theUniversityMedicalCenterofElPasocompliedwiththeHITECHPrivacyActprovisions.EffectiveSeptember1,2012theUniversityMedicalCenterofElPasocompliedwithTexasPrivacyLawasupdatedbyHP300(2011).MemberscanrequestacopyoftheNoticeofPrivacyPracticeoritcanbeaccessed through www.preferredadmin.net.

14.01 Plan’s Designation of Person/Entity to Act on Its Behalf ThePlanhasdeterminedthatitisagrouphealthplanwithinthemeaningoftheHIPAA

PrivacyRule,andthePlandesignatesUniversityMedicalCenterofElPasototakeallactionsrequiredtobetakenbythePlaninconnectionwiththeHIPAAPrivacyRule(e.g.,enteringintobusinessAssociatecontracts;acceptingcertificationfromthePlanSponsor).

14.02 The Plan’s Disclosure of PHI/SPI to the Plan Sponsor/ Required Certification of Compliance by Plan Sponsor

ExceptasprovidedbelowwithrespecttothePlan’sdisclosureofsummaryhealthinforma- tion,thePlanwill(a)disclose/SPItothePlanSponsor,or(b)providefororpermitthedis- closureof/SPItothePlanSponsorbyahealthinsuranceissuerorHMOwithrespecttothe

Plan,onlyifthePlanhasreceivedacertification(signedonbehalfofthePlanSponsor)that:

(a) thePlanDocumenthasbeenamendedtoestablishthepermittedandrequiredusesanddisclosuresofsuchinformationbythePlanSponsor,consistentwiththe“504”provisions;

(b) thePlanDocumenthasbeenamendedtoincorporatethePlanprovisionssetforthinthissection;and

(c) the Plan Sponsor agrees to comply with the Plan provisions as modified by this section.

14.03 Permitted Disclosure of Individuals’ /SPI to the Plan Sponsor

ThePlan(andanybusinessAssociateactingonbehalfofthePlan),oranyhealthinsuranceissuer or HMO servicing the Plan, will disclose individuals’ /SPI to the Plan Sponsor only to permitthePlanSponsortocarryoutplanadministrationfunctions.Suchdisclosurewillbeconsistentwiththeprovisionsofthissection.

Alldisclosuresofthe/SPIofthePlan’sindividualsbythePlan’sbusinessAssociate,healthinsuranceissuer,orHMOtothePlanSponsorwillcomplywiththerestrictionsandrequire-

mentssetforthinthissectionandinthe“504”provisions.

ThePlan(andanybusinessAssociateactingonbehalfofthePlan)maynotpermitthehealth insuranceissuerorHMO,todiscloseindividuals’/SPItothePlanSponsorforemployment-

related actions and decisions, or in connection with any other benefit or Associate benefit planofthePlanSponsor.


ThePlanSponsorwillnotuseorfurtherdiscloseindividuals’/SPIotherthanasdescribedinthe Plan Document and permitted by the “504” provisions.

The Plan Sponsor will ensure that any agent(s), including a subcontractor, to whom it providesindividuals’/SPIreceivedfromthePlan(orfromthePlan’shealthinsuranceissueror HMO), agrees to the same restrictions and conditions that apply to the Plan Sponsor with respect to such /SPI.

ThePlanSponsorwillnotuseordiscloseindividuals’/SPIforemployment-relatedactionsanddecisions,orinconnectionwithanyotherbenefitorAssociatebenefitplanofthe

Plan Sponsor.

ThePlanSponsorwillreporttothePlananyuseordisclosureof/SPIthatisinconsistentwiththeusesordisclosuresprovidedforinthePlanDocuments(asamended)andinthe“504”provisions,ofwhichthePlanSponsorbecomesaware.

14.04 Disclosure of Individuals’ /SPI/Disclosure by the Plan Sponsor ThePlanSponsorwillmakethe/SPIoftheindividualwhoisthesubjectofthe/SPIavailable

tosuchindividualinaccordancewith45C.F.R.§164.524.

InaccordancewithTexasHB300,thePlanSponsorwillmakeanelectronicrecordavailablewithin15daysofanindividual’swrittenrequest.AllelectronicPHIorsensitivepersonalinformationcreatedorreceivedbythePlanSponsorissubjecttoelectronicdisclosure.

ThePlanSponsorwillmakeindividuals’/SPIavailableforamendmentandincorporateanyamendmentstoindividuals’/SPIinaccordancewith45C.F.R.§164.526.

The Plan Sponsor will make and maintain an accounting so that it can make available those disclosuresofindividuals’/SPIthatitmustaccountforinaccordancewith45C.F.R.§164.528.

The Plan Sponsor will make its internal practices, books and records relating to the use and disclosureofindividuals’/SPIreceivedfromthePlanavailabletotheU.S.DepartmentofHealthandHumanServicesforpurposesofdeterminingcompliancebythePlanwiththeHIPAA Privacy Rule.

ThePlanSponsorwill,iffeasible,returnordestroyallindividuals’/SPIreceivedfromthePlan (or a health insurance issuer or HMO with respect to the Plan) that the Plan Sponsor stillmaintainsinanyformaftersuchinformationisnolongerneededforthepurposeforwhich the use or disclosure was made. Additionally, the Plan Sponsor will not retain copies ofsuch/SPIaftersuchinformationisnolongerneededforthepurposeforwhichtheuseordisclosurewasmade.If,however,suchreturnordestructionisnotfeasible,thePlanSponsorwilllimitfurtherusesanddisclosurestothosepurposesthatmakethereturnordestructionoftheinformationinfeasible.

AnybreachofunencryptedPHIorsensitivepersonalinformationwillbedisclosedasquicklyaspossibletotheindividualwhoseinformationwas,orbelievedtohavebeenacquiredbyanunauthorizedperson.Thisdisclosurealsoappliestonon-Texasresidents.

ThePlanSponsorwillensurethattherequiredadequateseparation,describedelsewhereinthis section, is established and maintained.


14.05 Disclosures of Summary Health Information and Enrollment and Disenrollment Information to the Plan Sponsor

The Plan, or a health insurance issuer or HMO with respect to the Plan, may disclose summaryhealthinformationtothePlanSponsorwithouttheneedtoamendthePlandocumentsasprovidedforinthe“504”provisions,ifthePlanSponsorrequeststhesummaryhealthinformationforthepurposeof:

(a) obtainingpremiumbidsfromhealthplansforprovidinghealthinsurancecoverageunderthePlan;or

(b) modifying,amending,orterminatingthePlan.

The Plan, or a health insurance issuer or HMO with respect to the Plan, may disclose enroll- mentanddisenrollmentinformationtothePlanSponsorwithouttheneedtoamendthe

PlanDocumentsasprovidedforinthe“504”provisions.

14.06 Required Separation between the Plan and the Plan Sponsor Inaccordancewiththe“504”provisions,followingisadescriptionoftheEmployees,classes

ofEmployees,orworkforcemembersunderthecontrolofthePlanSponsorwhomaybegivenaccesstoindividuals’/SPIreceivedfromthePlanorfromahealthinsuranceissuerorHMO servicing the Plan.

1. Analysts/Administrators; 2. HumanResourcesPersonnel; 3. InformationTechnologyPersonnel; 4. ClericalPersonnel; 5. Supervisors/Managers; 6. Compliance Personnel quality Assurance Unit.

TheabovelistreflectstheEmployees,classesofEmployees,orotherworkforcemembersofthePlanSponsorwhoreceiveindividuals’/SPIrelatingtopaymentunder,healthcareoperationsof,orothermatterspertainingtoplanadministrationfunctionsthatthePlanSponsorprovidesforthePlan.Theseindividualswillhaveaccesstoindividuals’/SPIsolelytoperformtheseidentifiedfunctions,andtheywillbesubjecttodisciplinaryactionand/orsanctions(includingterminationofemploymentoraffiliationwiththePlanSponsor)foranyuseordisclosureofindividuals’/SPIinviolationof,ornon-compliancewith,theprovisionsofthissection.

The Plan Sponsor will promptly report any such breach, violation, or non-compliance to the Plan and will cooperate with the Plan to correct the violation or non-compliance, to impose appropriatedisciplinaryactionand/orsanctions,andtomitigateanydeleteriouseffectofthe violation or non-compliance.


ARTICLE XV

HIPAA SECURITY STANDARDS

ThissectionisintendedtobringtheUniversityMedicalCenterofElPasoandItsAffiliatesEmployeesBenefitFund(hereinafter“Plan”)intocompliancewiththerequirementsof45C.F.R.§164.314(b)(1)and(2)oftheHealthInsurancePortabilityandAccountabilityActof1996anditsimplement-ingregulations,45C.F.R.parts160,162,and164(theregulationsarereferredtohereinasthe“HIPAA Security Standards”) by establishing the Plan Sponsor’s obligations with respect to the securityofElectronicProtectedHealthInformation.Theobligationssetforthbelowareeffectiveon April 20, 2005.

15.01 Definitions

1. “Electronic Protected Health Information”hasthemeaningsetforthin45C.F.R.§160.103,asamendedfromtimetotime,andgenerallymeansprotectedhealthinformationthatistransmittedormaintainedinanyelectronicmedia.

2. “Plan” means the El Paso Children’s Hospital Associate Health Benefit Plan Associate.

3. “Plan Document” means the group health plan’s governing documents and instruments (i.e., the documents under which the group health plan was established and is

maintained),includingbutnotlimitedtothePlanDocumentoftheElPasoChildren’sHospital Associate Health Benefit Plan Associate.

4. “Plan Sponsor”meanstheentityasdefinedatsection3(16)(B)ofERISA,29U.S.C. §1002(16)(B).ThePlanSponsorisElPasoChildren’sHospital.

5. “Security Incidents”hasthemeaningsetforthin45C.F.R.§164.304,asamendedfromtimetotime,andgenerallymeanstheattemptedorsuccessfulunauthorizedaccess,use,disclosure,modification,ordestructionofinformationorinterferencewithsystemsoperationsinaninformationsystem.

15.02 Plan Sponsor Obligations

WhereElectronicProtectedHealthInformationwillbecreated,received,maintained,ortransmittedtoorbythePlanSponsoronbehalfofthePlan,thePlanSponsorshallreasonablysafeguardtheElectronicProtectedHealthInformation(PHI/SPI)asfollows:

1. PlanSponsorshallimplementadministrative,physical,andtechnicalsafeguardsthatreasonablyandappropriatelyprotecttheconfidentiality,integrity,andavailabilityofthe Electronic PHI/SPI that Plan Sponsor creates, receives, maintains, or transmits on behalfofthePlan;

2. PlanSponsorshallensurethattheadequateseparationthatisrequiredby45C.F.R. §164.504(f)(2)(iii)oftheHIPAAPrivacyRuleissupportedbyreasonableandappropriate

securitymeasures;

3. Plan Sponsor shall ensure that any agent, including a subcontractor, to whom it provides Electronic PHI/SPI agrees to implement reasonable and appropriate security measures to protectsuchInformation;and


4. PlanSponsorshallreporttothePlananySecurityIncidentsofwhichitbecomesaware asdescribedbelow:

(a)PlanSponsorshallreporttothePlanwithinareasonabletimeafterPlanSponsorbecomesaware,anySecurityIncidentthatresultsinunauthorizedaccess,use,disclosure,modification,ordestructionofthePlan’sElectronicProtectedHealth.

(b) Plan Sponsor shall report to the Plan any other Security Incident on an aggregate basiseveryyear,ormorefrequentlyuponthePlan’srequest.

NOTE: ThePlanSponsorshallhaveareasonableperiodoftimeafterlearningofasecurityincidenttoreportanysuccessfulattempttothePlan,butcanaggregatethedatarelatingtounsuccessfulattemptsandreportthatinformationtothePlanonalessfrequentbasis.

Yourhealthinformation(ProtectedHealthInformation/SensitivePersonalInformation) createdorreceivedbyPreferredAdministratorsissubjecttoelectronicdisclosure.



NOTES


NOTES

Si usted requiere este manual en Español,por favor comuníquese con PreferredAdministrators al 915-532-3778 o gratisal 1-877-532-3778 si llama fuera de El Pasode 7 am a 5 pm de Lunes a Viernes.

10/2013 E�ective October 2013

El Paso Children’s HospitalEmployee Health Benefit Fund Plan

PLAN DOCUMENT