NATIONAL FRANCHISEE ASSOCIATION HEALTH + MEDICAL PLAN · 2016. 9. 12. · 2NATIONAL FRANCHISEE ASSOCIATION HEALTH + MEDICAL PLAN National Franchisee Association Health + Medical Plan

An Independent Licensee of the Blue Cross and Blue Shield Association

Effective: May 1, 2010 Revised: May 1, 2014

NATIONAL FRANCHISEE ASSOCIATION HEALTH + MEDICAL PLAN Summary Plan Descript ion

NATIONAL FRANCHISEE ASSOCIATION HEALTH + MEDICAL PLAN

INTRODUCTION

This is a summary of the National Franchisee Associat ion Health + Medical Plan adopted by your employer (the “ Plan” ). The National Franchisee Associat ion Health + Medical Plan is available only to members of the National Franchisee Associat ion (“ NFA” ). This booklet is provided to help you understand how the Plan w orks. It highl ights w hat types of expenses are covered under the Plan, def init ions you need to know , how to f ile claims and w hat your legal rights are under the Plan. Your employer, as a member of the National Franchisee Associat ion, is sponsoring this self -funded ERISA employee health plan w hich provides medical benefits for all covered employees and their covered dependent(s). Stop loss reinsurance is being purchased to protect the Plan Sponsor from unpredictable claims experience. Each covered person is ent it led to the benefits out lined in this Plan Document. To obtain benefits from the Plan, the covered person must ult imately submit a diagnost ic bill to the Contract Administrator, Comprehensive Benefits Administrator, Inc. dba CBA Blue, for processing. This claim submission is required for reimbursement to the employee or direct payment to the service provider by the National Franchisee Associat ion Health + Medical Plan. In any event w here a quest ion may arise as to a claim for benefits or denial of a claim for benefits, the Employer, the Contract Administrator (the third party administrator) and any other persons that may be associated w ith the Plan’s operat ion w ill be guided solely by this Plan document, w hich is also the Summary Plan Descript ion w ithin the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ ERISA” ). A clerical error w ill neither invalidate the employee’s coverage if otherw ise validly in force nor continue coverage otherw ise validly terminated. Comprehensive Benefits Administrator, Inc. dba CBA Blue, an independent licensee of the Blue Cross and Blue Shield Associat ion, provides administrat ive claims payment services only and does not assume any f inancial risk or obligat ion w ith respect to claims.

TABLE OF CONTENTS

GENERAL INFORMATION 1 SCHEDULE OF BENEFITS 2 GENERAL PROVISIONS 45

PLAN ENROLLMENT 45

COORDINATION OF BENEFITS 47

TERMINATION OF BENEFITS 49

MILITARY LEAVE 49 REINSTATEMENT OF COVERAGE 49

EXTENSION OF BENEFITS (COBRA) 50

PLAN DETAILS 54 MEDICAL COVERED EXPENSES 61 GENERAL MEDICAL EXCLUSIONS AND LIMITATIONS 67 CLAIM FILING PROCEDURES 71 CLAIM REVIEW PROCEDURES 72 MISCELLANEOUS PROVISIONS 78 ERISA STATEMENT OF RIGHTS 86 DEFINITIONS 87

GENERAL INFORMATION

1 NATIONAL FRANCHISEE ASSOCIATION HEALTH + MEDICAL PLAN

GENERAL INFORMATION

Plan Sponsor: Federal Tax Identification Number: [PLACE STICKER HERE] Name of the Plan: Plan Number: Plan Administrator: Plan Sponsor, act ing through its exclusive agent, Allison Hazen, Trustee of the

NFA Member Plan Master Trust and exclusive agent of the Sponsor: 61 Overlook Drive South Burlington, VT 05403-7887 Phone: 802-865-5291 Cell: 802-922-3548 Group Number: 50704 Benefits Covered: Medical benefits under the National Franchisee Associat ion Health + Medical Plan Plan Effective Date: May 1, 2010 Plan Anniversary Date: May 1st Plan Year Ends: April 30 th Plan Revision Date: May 1, 2014 – This document replaces the previous Employee Healt h Plan Document in its ent irety. All claims incurred prior to May 1, 2014 w ill be governed by the terms of the Plan in effect prior to this revision date. Contract Administrator/Pre-Certification Administrator: Comprehensive Benefits Administrator, Inc. dba CBA Blue P.O. Box 2365 South Burlington, VT 05407-2365 Customer Service & Pre-Cert if icat ion: (888) 222-9206 Agency for Service of Legal Process: Allison Hazen, Trustee of the NFA Member Plan Master Trust

and exclusive agent of the Sponsor 61 Overlook Drive South Burlington, VT 05403-7887 Phone: 802-865-5291 Cell: 802-922-3548 Contributions: The Plan is contributory. Eligibility Requirements: All salaried employees and all full-t ime hourly “ non-crew ” employees w orking an average of thirty (30) hours per w eek. Dependent Children’s Coverage: Married or unmarried dependent children up to tw enty-six (26) years of age. Eligibility Date: First day of the month follow ing sixty (60) days of cont inuous employment unless the w ait ing period is w aived as a condit ion of employment. Termination Date: See “ Terminat ion of Benefits” sect ion.


National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Platinum HSA Plan

Benefit

In-Network

Out-of-Network

Deductible: The amount an individual or family must pay each plan year before payments begin for services.

$1,250 per individual $2,500 per family


Plan Coinsurance: 100% 100%

Out-of-Pocket Expense Limit: The maximum amount of money that any individual or family w ill have to pay towards covered health expenses during any one plan year (includes deductible).



Preventive Services: 100% Deductible; 100%

Physician’s Office Visits:

Deductible; 100%

Deductible; 100%

Colonoscopies/Flexible Sigmoidoscopies (Routine): 100% Deductible; 100%

Colonoscopies/Flexible Sigmoidoscopies (Diagnostic):

Deductible; 100%

Deductible; 100%

Chiropractic Care: Maximum of $1,000 per plan year.

Deductible; 100%

Deductible; 100%

Outpatient Diagnostic Laboratory Services:

Deductible; 100%

Deductible; 100%

Outpatient Diagnostic Testing/X-Ray Services:

Deductible; 100%

Deductible; 100%

Outpatient Physical, Occupational, and Speech Therapy: Combined maximum of 30 visits per plan year.

Deductible; 100%

Deductible; 100%

Home Health Care: Maximum of 25 visits per plan year.

Deductible; 100%

Deductible; 100%

Outpatient Private Duty Nursing:

Deductible; 100%

Deductible; 100%

Urgent Care Services:

Deductible; 100%

Deductible; 100%



Benefit

In-Network

Out-of-Network

Emergency Room Services: Deductible; 100% In-netw ork deductible; 100%

Ambulance Services: Deductible; 100% In-netw ork deductible; 100%

Anesthesiology Services: Deductible; 100% Deductible; 100%

Inpatient Hospital Services: Deductible; 100% Deductible; 100%

Skilled Nursing Facility: Maximum of 100 days per plan year.

Deductible; 100% Deductible; 100%

Inpatient Rehabilitation Hospital Care: Deductible; 100% Deductible; 100%

Prenatal Maternity Care: Deductible; 100% applies to f irst visit to confirm

pregnancy; then 100% thereafter Deductible; 100%

Hospice Facility/Home Hospice:


Durable Medical Equipment: Deductible; 100% Deductible; 100%

Wigs/Artificial Hairpieces: (After radiation therapy or chemotherapy); Maximum of 2 per covered person per lifetime.


Dialysis: Maximum of 40 visits per plan year. Deductible; 100% Deductible; 100%

Inpatient Mental Health/Substance Abuse: Deductible; 100% Deductible; 100%

Outpatient Mental Health/Substance Abuse: Deductible; 100% Deductible; 100%

Pre-Admission Certification Penalty: Inpatient stays, organs transplants, t issue transplants, & certain outpatient services (see page 58 for a list of these services)

$500 non-compliance penalty $500 non-compliance penalty

Prescription Drug Benefit (Retail– 30 Day Supply)

Deductible; 100%

Not Covered



Benefit

In-Network

Out-of-Network

Prescription Drug Benefit (Mail Order – 90 Day Supply)

Deductible; 100% N/A

NOTES:

1. This Plan is part icipat ing w ith Blue Cross Blue Shield of Vermont preferred provider netw ork as w ell as the BlueCard Program. These preferred providers w ill bill the Contract Administrator direct ly and w rite off charges that exceed their contractual allow ances.

2. All covered charges billed by non-part icipat ing providers w ill be subject to a maximum allow able benefit .

3. All other covered benefits not listed above w ill be subject to deduct ible, then payable at 100%.

4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out-of-netw ork deduct ible and coinsurance amounts are not combined. 6. Prescript ion drugs are applied to the medical deduct ible and out-of-pocket maximum. 7. Precert if icat ion penalt ies are not applied to the deduct ible or out -of-pocket maximum. 8. For tw o-person or family coverage, expenses incurred by each person accumulates and is

credited tow ard the one family deduct ible. The Plan w ill not pay benefits unt il the family deduct ible amounts has been completely sat isf ied by any combinat ion of covered part icipants included under tw o-person or family coverage.


National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Platinum Choice Plan

Benefit

In-Network

Out-of-Network


$500 per individual $1,000 per family



Out-of-Pocket Expense Limit: The maximum amount of money that any individual or family w ill have to pay towards covered health expenses during any one plan year (includes deductible and medical copayments). Does not apply to prescription drugs.




Physician’s Office Visits: One copayment per physician per day.

$20 copayment for PCP

$30 copayment for specialist

Deductible; 60%

Colonoscopies/Flexible Sigmoidoscopies (Routine): 100%

60% to a maximum of $3,000 per plan year; then deductible

and 60%

Colonoscopies/Flexible Sigmoidoscopies (Diagnostic): Deductible; 80% Deductible; 60%

Chiropractic Care: Maximum of $1,000 per plan year. $30 copayment Deductible; 60%

Outpatient Diagnostic Laboratory Services: Deductible; 80% Deductible; 60%

Outpatient Diagnostic Testing/X-Ray Services: Deductible; 80% Deductible; 60%



Home Health Care: Maximum of 25 visits per plan year. Deductible; 80% Deductible; 60%

Outpatient Private Duty Nursing: Deductible; 80% Deductible; 60%

Urgent Care Services: $40 copayment Deductible; 60%



Benefit

In-Network

Out-of-Network

Emergency Room Services: Copayment waived if admit ted.

$150 copayment, deductible; then 80%

$150 copayment, in-netw ork deductible; then 80%

Ambulance Services: Deductible; 80%

In-Netw ork deductible, then 80%

Anesthesiology Services: Deductible; 80% Deductible, 60%

Inpatient Hospital Services: $200 copayment per visit; then

deductible and 80% $200 copayment per visit; then

deductible and 60%


$200 copayment per visit; then deductible and 80%


Inpatient Rehabilitation Hospital Care $200 copayment per visit; then deductible and 80%


Prenatal Maternity Care: $20 PCP/$30 Specialist applies to f irst visit to confirm






Deductible; 80% Deductible, 60%

Dialysis Maximum of 40 visits per plan year. Deductible; 80% Deductible; 60%

Inpatient Mental Health/Substance Abuse: $200 copayment per visit; then


deductible and 60%

Outpatient Mental Health/Substance Abuse:

$20 copayment

Deductible; 60%




Deductible: $50 per individual/$100 per family per

plan year; then Generic: $10 copayment

Preferred Brand: $30 copayment Non-Preferred Brand: $55

copayment

Not Covered



Benefit

In-Network

Out-of-Network





copayment

N/A

Prescription Drug Out-of-Pocket Maximum: $500 per individual $1,000 per family

Not Covered

NOTES:



3. All other covered benefits not listed above w ill be subject to deduct ible, then payable at 80% in-netw ork and 60% out -of-netw ork.

4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out -of-pocket maximum. 7. Prescript ion drug copayments are not applied to the medical deduct ible or out -of-

pocket maximum. They apply to a separate prescript ion drug deduct ible and out -of-pocket maximum.

8. Precert if icat ion penalt ies are not applied to the deduct ible or out -of-pocket maximum.

9. The $50 individual/$100 family prescript ion drug plan year deduct ible is a combined deduct ible for both retail and mail order prescript ions.


National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Platinum Preferred Plan

Benefit

In-Network

Out-of-Network










$20 copayment

Deductible; 60%



and 60%












Benefit

In-Network

Out-of-Network



$75 copayment, in-network deductible; then 80%








Prenatal Maternity Care: $20 copayment applies to f irst visit to confirm pregnancy; then

100% thereafter Deductible; 60%





Deductible; 80% Deductible, 60%




$20 copayment

Deductible; 60%







copayment

Not Covered



Benefit

In-Network

Out-of-Network





copayment

N/A

Prescription Drug Out-of-Pocket Maximum: $500 per individual $1,000 per family

Not Covered

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out-of-pocket maximum. 7. Prescript ion drug copayments are not applied to the medical deduct ible or out -of-





National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Gold HSA Plan

Benefit

In-Network

Out-of-Network









Physician’s Office Visits: Deductible; 90% Deductible; 70%



Chiropractic Care: Maximum of $1,000 per plan year. Deductible; 90% Deductible; 70%







Urgent Care Services: Deductible; 90% Deductible; 70%



Benefit

In-Network

Out-of-Network

Emergency Room Services:

Deductible; 90%

In-Netw ork deductible; 90%



Anesthesiology Services: Deductible; 90%

Deductible; 70%


















Deductible; 90% Not Covered



Benefit

In-Network

Out-of-Network


Deductible; 90% N/A

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. Prescript ion drugs are applied to the medical deduct ible and out-of-pocket

maximum. 7. Precert if icat ion penalt ies are not applied to the deduct ible or out -of-pocket

maximum. 8. For tw o-person or family coverage, expenses incurred by each person accumulates

and is credited tow ard the one family deduct ible. The Plan w ill not pay benefits unt il the family deduct ible amounts has been completely sat isf ied by any combinat ion of covered part icipants included under tw o-person or family coverage.


National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Gold Basic Plan

Benefit

In-Network

Out-of-Network










Primary Care Physician: $25

copayment Specialist: $45 copayment

Deductible; 60%



and 60%













Benefit

In-Network

Out-of-Network







Inpatient Hospital Services: $300 copayment per visit; then deductible and 80%

















deductible and 60%


$25 copayment

Deductible; 60%







copayment

Not Covered



Benefit

In-Network

Out-of-Network





copayment

N/A

Prescription Drug Out-of-Pocket Maximum: $6,350 per individual $12,700 per family

Not Covered

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out -of-pocket maximum. 7. Prescript ion drug copayments are not applied to the medical deduct ible and out-of-

pocket maximum. 8. Precert if icat ion penalt ies are not applied to the deduct ible or out-of-pocket

maximum. 9. The $50 individual/$100 family prescript ion drug plan year deduct ible is a

combined deduct ible for both retail and mail order prescript ions.


National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Gold Choice Plan

Benefit

In-Network

Out-of-Network












Deductible; 60%



and 60%













Benefit

In-Network

Out-of-Network












Inpatient Rehabilitation Hospital Care: $300 copayment per visit; then deductible and 80%












deductible and 60%


$20 copayment

Deductible; 60%







copayment

Not Covered



Benefit

In-Network

Out-of-Network





copayment

N/A

Prescription Drug Out-of-Pocket Maximum: $1,000 per individual

$2,000 per family Not Covered

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out -of-pocket maximum. 7. Prescript ion drug copayments are not applied to the medical deduct ible and out -of-





National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Gold Preferred Plan

Benefit

In-Network

Out-of-Network












Deductible; 60%



and 60%













Benefit

In-Network

Out-of-Network
























deductible and 60%


$20 copayment

Deductible; 60%







copayment

Not Covered



Benefit

In-Network

Out-of-Network





copayment

N/A

Prescription Drug Out-of-Pocket Maximum: $2,000 per individual

$4,000 per family Not Covered

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out -of-pocket maximum. 7. Prescript ion drug copayments are not applied to the medical deduct ible and out -of-





National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Silver HSA Plan

Benefit

In-Network

Out-of-Network






















Benefit

In-Network

Out-of-Network


Deductible; 80%





Deductible; 60%





















Benefit

In-Network

Out-of-Network


Deductible; 80% N/A

NOTES:



3. All other covered benefits not list ed above w ill be subject to deduct ible, then payable at 80% in-netw ork and 60% out-of-netw ork.

4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. Prescript ion drugs are applied to the medical deduct ible and out-of-pocket

maximum. 7. Precert if icat ion penalt ies are not applied to the deduct ible or out -of-pocket




National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Silver Basic Plan

Benefit

In-Network

Out-of-Network












Deductible; 50%



and 50%













Benefit

In-Network

Out-of-Network
























deductible and 50%


$30 copayment

Deductible; 50%





plan year; then 70% coinsurance Not Covered



Benefit

In-Network

Out-of-Network



plan year; then 70% coinsurance N/A


Not Covered

NOTES:



3. All other covered benefits not listed above w ill be subject to deduct ible, then payable at 70% in-netw ork and 50% out-of-netw ork.

4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out -of-pocket maximum. 7. Prescript ion drug copayments are not applied to the medical deduct ible or out-of-

pocket maximum. They apply to a separate prescript ion drug deduct ible and out-of-pocket maximum.




National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Silver Choice Plan

Benefit

In-Network

Out-of-Network












Deductible; 60%



and 60%













Benefit

In-Network

Out-of-Network
























deductible and 60%


$30 copayment

Deductible; 60%







copayment

Not Covered



Benefit

In-Network

Out-of-Network




Preferred Brand: $100 copayment

Non-Preferred Brand: $160 copayment

N/A


Not Covered

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out -of-pocket maximum. 7. Prescript ion drug copayments are not applied to the medical deduct ible or out -of-





National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Silver Preferred Plan

Benefit

In-Network

Out-of-Network












Deductible; 50%



and 50%













Benefit

In-Network

Out-of-Network
























deductible and 50%


$30 copayment

Deductible; 50%







copayment

Not Covered



Benefit

In-Network

Out-of-Network





copayment

N/A


Not Covered

NOTES:









National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Bronze HSA Plan

Benefit

In-Network

Out-of-Network






















Benefit

In-Network

Out-of-Network


Deductible; 100%





Deductible; 100%





















Benefit

In-Network

Out-of-Network


Deductible; 100% N/A

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out-of-netw ork deduct ible and coinsurance amounts are not combined. 6. Prescript ion drugs are applied to the medical deduct ible and out-of-pocket

maximum. 7. Precert if icat ion penalt ies are not applied to t he deduct ible or out -of-pocket




National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Bronze Basic Plan

Benefit

In-Network

Out-of-Network










Combined total of 1 visit paid at 100% (combined w ith

urgent care); then subject to deductible; 50%

Deductible; 50%

Colonoscopies/Flexible Sigmoidoscopies (Routine):

100% 50% to a maximum of $3,000 per plan year; then deductible

and 50%











Urgent Care Services:

Combined total of 1 visit paid at 100% (combined w ith PCP/specialist physician’s

off ice visits); then subject to deductible; 50%

Deductible; 50%



Benefit

In-Network

Out-of-Network















pregnancy; then 100% thereafter

Deductible; 50%







Inpatient Mental Health/Substance Abuse: $400 copayment per visit; then deductible and 50%



Combined total of 1 visit paid at 100% (combined w ith

physician’s off ice visit and urgent care); then subject to

deductible; 50%

Deductible; 50%



Prescription Drug Benefit (Retail – 30 Day Supply)


plan year; then 50% coinsurance

Not Covered



Benefit

In-Network

Out-of-Network




N/A


Not Covered

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out -of-pocket maximum. 7. Prescript ion drugs are not applied to the medical deduct ible or out -of-pocket

maximum. They apply to a separate prescript ion drug deduct ible and out -of-pocket maximum.




National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Bronze Choice Plan

Benefit

In-Network

Out-of-Network










Primary Care Physician: $40 copayment

Specialist: $60 copayment Deductible; 50%



and 50%














Benefit

In-Network

Out-of-Network
















Deductible; 50%










$40 copayment

Deductible; 50%






Not Covered



Benefit

In-Network

Out-of-Network




N/A


Not Covered

NOTES:




4. All in and out -of-netw ork benefit maximums are combined. 5. All in and out -of-netw ork deduct ible and coinsurance amounts are not combined. 6. All medical copayments are applied to the out -of-pocket maximum. 7. Prescript ion drugs are not applied to the medical deduct ible or out -of-pocket

maximum. They apply to a separate prescript ion drug deduct ible and out -of-pocket maximum.




National Franchisee Association Health + Medical Plan Schedule of Medical Benefits Bronze Preferred Plan

Benefit

In-Network

Out-of-Network










Primary Care Physician: $40 copayment

Specialist: $60 copayment Deductible; 50%



and 50%














Benefit

In-Network

Out-of-Network
















Deductible; 50%










$40 copayment

Deductible; 50%








Not Covered



Benefit

In-Network

Out-of-Network






N/A


Not Covered

NOTES:





pocket maximum. They apply to a separate prescript ion drug deduct ible and out-of-pocket maximum.



GENERAL PROVISIONS


GENERAL PROVISIONS

PLAN ENROLLMENT

Eligibility: Only employees w ho sat isfy the eligibility requirements set forth in the “ General Information” sect ion are eligible for coverage under this Plan. The dependent(s) of a covered employee w ill become eligible for coverage on the date of the employee’s eligibility for coverage or on the date w hich the employee acquires the dependent.

If an employee and spouse are both eligible for coverage as employees under the Plan, only one (1)

w ill be eligible to enroll dependent(s). Also, an employee cannot be covered as an employee and a dependent.

Plan Enrollment: To become covered under the Plan, an employee must enroll themselves and/or

their dependents for coverage w ithin thirty-one (31) days of the eligibility date. The employee and dependents w ill be enrolled w hen a benefit enrollment form is completed, signed, and delivered to the employer w ithin the t ime limit . Should the enrollment occur more than thirty -one (31) days follow ing the eligibility date, the employee and/or dependents w ill only be eligible to enroll during the annual open enrollment period described below or, in certain circumstances, during a special enrollment period. Should mult iple plan opt ions exist, an employee may sw itch plan opt ions during an annual open enrollment period or special enrollment period.

Annual Open Enrollment Period: There w ill be an annual open enrollment period preceding the

Plan’s anniversary date. The effect ive date of coverage w ill be the Plan’s anniversary date. Special Enrollment Periods: Individuals are eligible for special enrollment for the follow ing reasons:

1. If an employee acquires a dependent through marriage, birth, adoption, or placement for adoption, the dependent (and if not otherw ise enrolled, the employee and eligible dependents) may be enrolled under this Plan. The request to enroll must be w ithin thirty -one (31) days of the event. If enrollment is not requested w ithin thirty-one (31) days follow ing the event, the dependents w ill only be eligible to enroll during the annual open enrollment period. The effect ive date of coverage for dependents and/or employees enrolling during a special enrollment period w ill be the date of the event.

2. If an employee declines enrollment in the Plan for themselves or their dependents because the employee or dependents have other health coverage, the employee may in the future be able to enroll themselves and/or their dependents in the Plan, provided they are otherw ise eligible for coverage under the terms of the Plan, they meet certain condit ions including any one of those set forth below and they request enrollment w ithin thirty -one (31) days of that condit ion being sat isf ied:

w hen enrollment w as declined under this Plan for employee and/or dependent coverage, the employee and/or dependent had COBRA continuat ion coverage under another health plan, and COBRA continuat ion coverage under that other plan has since been exhausted; or

if the other coverage that applied to the employee and/or dependent when coverage was declined was not COBRA continuation coverage, employer contributions toward the other coverage have ceased, regardless of whether coverage under the other employer’s plan has terminated; or

GENERAL PROVISIONS


if the other coverage that applied to the employee and/or dependent when coverage was declined was not COBRA continuation coverage, the other coverage has been terminated as a result of:

a. loss of eligibility as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, and any loss of eligibility after a period that is measured by reference to any of the foregoing; or

b. the employee and/or dependent moving out of an HMO service area if HMO coverage terminates for that reason and, no other plan options are available to the employee/dependent; or

c. the other plan ceasing to offer coverage to the group of similarly situated individuals that include the employee and/or dependent; or

d. the dependent losing dependent status per plan terms; or e. the other plan terminating a benefit package option and no substitution is

offered.

The effect ive date of coverage w ill be the date follow ing the date of the loss of the other coverage. The Plan’s w ait ing period w ill not be applied. 3. If an employee’s or dependent’s Medicaid or Children’s Health Insurance Program (CHIP)

coverage is terminated as a result of loss of eligibility, or if the employee or dependent becomes eligible for a state-granted premium subsidy tow ards employer health coverage under either Medicaid or CHIP, the employee may request to be enrolled in this Plan. The employee’s request to enroll must be made w ithin sixty (60) days of the date on w hich the employee or dependent either (a) loses eligibility under Medicaid or CHIP or (b) becomes eligible for a state-granted premium subsidy tow ards employer health coverage under either Medicaid or CHIP. The effect ive date of coverage w ill be the f irst day of the month follow ing the employee’s request to enroll in this Plan.

Qualified Medical Child Support Orders: If an employee is required to provide benefits for his

dependent child under the direct ion of a court order and the employee is not enrolled in the Plan, the employee may enroll himself and his dependent child provided enrollment is requested w ithin thirty (30) days of issuance of the court order. The Plan’s open enrollment provision w ill not apply. The effect ive date of coverage w ill be the date of the court order. How ever, if the employee has not yet sat isf ied the Plan’s w ait ing period, coverage w ill become effect ive after sat isfact ion of such w ait ing period.

If an employee is required to provide benefits for their ex-spouse under the direct ion of a court order, the employee may cont inue to cover their ex-spouse under the Plan, or enroll their ex-spouse in the Plan provided enrollment occurs w ithin thirty -one (31) days of the receipt of the court order. The effect ive date of coverage w ill be the date of the court order.

COORDINATION OF BENEFITS (COB)


COORDINATION OF BENEFITS (COB) This Plan contains a Non-Duplicat ion of Benefits provision as part of coordinat ion of benefits. This means that w hen this Plan is the secondary plan, the benefits paid from all the plans combined may not total more than the amount this Plan w ould have paid on its ow n. When this plan is the secondary payer, the plan w ill coordinate payment w ith the primary plan in such a w ay that w hen this plan’s payment is combined w ith the primary plan’s payment, the total does not exceed the amount this plan w ould have paid if it w ere primary. If a plan does not have its ow n COB rules, it w ill be primary to this Plan (that is, it w ill pay benefits before this Plan does). Even if a plan does have its ow n COB rules, the f irst of this Plan’s follow ing COB rules to apply w ill determine w hich of the plans is primary:

1. Non-Dependent/Dependent - Any plan under w hich the covered person is covered as an employee, member or subscriber (that is, other than as a dependent) w ill pay f irst . Any plan under w hich the covered person is covered as a dependent of the employee w ill pay second.

2. Dependent Child/Parents Not Separated or Divorced - If a dependent child is covered

under the plans of both the child’s parents, and the parents are not separated or divorced (regardless of w hether they w ere ever married), the plan of the parent w hose birth date occurs earlier in the calendar year w ill pay f irst , and the plan of the parent w hose birth date occurs later in the calendar year w ill pay second. If the birth dates of the parents are the same, the plan w hich has covered a parent for the longest period of t ime w ill pay benefits before the plan of the other parent.

3. Dependent Child/Separated or Divorced Parents - Where a dependent child is covered

under the plans of both parents, the parents are separated or divorced from one another, and there is otherw ise no court decree sett ing forth the responsibility for the child’s health care costs:

a) the plan under w hich the child is covered as a dependent of the custodial parent w ill pay f irst ; b) the plan under w hich the child is covered as a dependent of the custodial parent ’s spouse w ill pay second; and c) the plan under w hich the child is covered as a dependent of the non-

custodial parent w ill pay third.

4. Act ive/Inact ive Employee - Any plan under w hich the covered person is covered as an act ive employee (or as that employee’s dependent) w ill pay f irst . Any plan under w hich the covered person is covered as a laid off or ret ired employee (or as that employee’s dependent) w ill pay second. If the other plan does not have this rule, and if , as a result , the plans do not agree on the order of benefits, this rule is ignored.

5. Continuat ion Coverage - Any plan under w hich the covered person is covered as an

employee (or as that employee’s dependent) w ill pay f irst . Any plan under which the covered person is covered under a right of cont inuation as provided under federal or state law (for example, under the Consolidated Omnibus Budget Reconciliat ion Act of 1985), w ill pay second. If the other plan does not have this rule, and if , as a result , the plans do not agree on the order of benefits, this rule is ignored.

If none of the above rules determine the order of benefits, the plan w hich has covered the eligible person for the longest period of t ime w ill pay f irst ; the plan w hich has covered the eligible person for the shortest period of t ime w ill pay last.

COORDINATION OF BENEFITS (COB)


Right to Receive and Release Needed Information: The Plan may release or receive any information needed to enforce this provision. Any person claiming benefits under this Plan must furnish the Plan w ith any information requested by the Plan to enforce the COB provisions in accordance w ith the HIPAA Privacy Requirements. Right to Make Payments: Should another plan provide benefits w hich should have been paid by this Plan, the Plan has the right to make payment to the other plan direct ly. That payment w ill sat isfy the obligat ion of this Plan. Right to Recovery: The Plan has the right to recover from the covered person any overpayment made if the Plan w as not made aw are of the other available benefits. Coordination with Other Liability: This Plan w ill pay benefits secondary to the covered person’s personal automobile insurance (including, but not limited to, no-fault insurance and uninsured motorist coverage) or other liability insurance policies through w hich medical payments may be made for expenses result ing from or in connect ion w ith an accidental injury. Coordination with Prescription Claims: There is no coordinat ion of benefits w ith prescript ion drugs.

TERMINATION OF BENEFITS MILITARY LEAVE

REINSTATEMENT OF COVERAGE


TERMINATION OF BENEFITS An employee’s and/or a dependent’s coverage under the Plan w ill terminate:

1. on the date the Plan terminates; or 2. on the date an employee w ithdraw s from the Plan; or 3. on the date an employee is no longer eligible; or 4. on the date w hich an employee is terminated, unless cont inuat ion coverage, as

provided herein, is elected; or 5. on the date a dependent w ithdraw s from the Plan or a dependent ceases to meet

the def init ion of a dependent as def ined herein or dependent coverage is discontinued under the Plan for any reason, unless cont inuat ion of coverage, as provided herein, is elected; or

6. on the date w hen an employee or dependent enters the military, naval, or air force

of any country or internat ional organizat ion on a full-t ime, act ive-duty basis other than scheduled drills or other training not exceeding one (1) month in any calendar year (see Military Leave sect ion below ); or

7. on the last date of the period for w hich contribut ion has been made if the employee

fails to make any required contribut ion.

The Plan Sponsor, in its sole discret ion, may cause a covered person’s coverage under the Plan to terminate if the covered person provides false information or makes misrepresentat ions in connect ion w ith a claim for benefits; permits a non-part icipant to use a membership or other ident if icat ion card for the purpose of w rongfully obtaining benefits; obtains or attempts to obtain benefits by means of false, misleading or fraudulent information, acts or omissions; fails to make any copayment, supplemental charge, or other amount due w ith respect to a benefit ; behaves in a manner disrupt ive, unruly, abusive, or uncooperat ive to the extent that the Plan is unable to provide benefits to him or her; or threatens the life or w ell-being of personnel administering the Plan or of providers of services or benefits.

MILITARY LEAVE The Uniformed Services Employment and Reemployment Rights Act of 1994 ("USERRA" ) provides special cont inuat ion coverage to covered employees w ho otherw ise lose health insurance coverage under the Plan because they leave employment to serve in the uniformed services. Under USERRA, affected covered employees and their dependents must be offered the right to cont inue coverage for up to tw enty-four (24) months. The employer may charge 102% of the applicable premium, provided the length of the military leave is longer than thirty (30) days. However, on the date that the employee completes his active duty and returns to full-t ime employment, the employee and his eligible dependents w ill be re-enrolled in the Plan and coverage w ill be provided immediately. However, any limitations on the employee’s or dependent’s coverage which were in affect before the active military duty leave w ill continue to apply. REINSTATEMENT OF COVERAGE If the employee terminates for any reason and is rehired w ithin thirty (30) days, coverage may be reinstated on the f irst day of the month follow ing rehire, if the enrollment requirements are completed w ithin thirty-one (31) days. All accumulated plan year maximums w ill apply. If the employee is rehired after thirty (30) days, or if the employee fails to enroll as required by the plan, they w ill be considered a new employee.

EXTENSION OF BENEFITS (COBRA)


EXTENSION OF BENEFITS (COBRA) Qualif ied beneficiaries may elect to cont inue coverage under the Plan w hen their coverage terminates due to a “ qualifying event.” Depending on the type of qualifying event, “ qualif ied benef iciaries” can include the employee covered under the Plan and the employee’s covered dependents. These rights are protected under the Consolidated Omnibus Budget Reconciliat ion Act (COBRA) of 1986. A child w ho is born to or placed for adoption w ith the covered employee during a period of COBRA coverage w ill be eligible to become a qualif ied beneficiary. In accordance w ith the terms of the Plan and the requirements of federal law , these qualif ied beneficiaries can be added to COBRA coverage upon proper not if icat ion to the Plan Administrator of the birth or adoption. Continuat ion coverage is the same coverage that the Plan gives to other part icipants or beneficiaries under the Plan w ho are not receiving cont inuat ion coverage. Each qualif ied beneficiary w ho elects cont inuat ion coverage w ill have the same rights under the Plan as other part icipants or beneficiaries covered under the Plan.

The employee has the right to choose COBRA continuat ion of coverage under the Plan if coverage terminates for any of the follow ing qualifying events:

1. The employee’s terminat ion of employment for reasons other than gross misconduct.

2. The employee’s ret irement or reduct ion in hours of employment.

The employee’s spouse has the right to choose COBRA continuat ion of coverage under the Plan if coverage terminates for any of the follow ing qualifying events:

1. The employee’s terminat ion of employment for reasons other than gross misconduct.

2. The employee’s ret irement or reduct ion in hours of employment.

3. The employee’s death.

4. The employee’s divorce or legal separat ion.

5. The employee becomes enrolled in Medicare benefits (Part A, Part B or both).

The employee’s dependent children have the right to choose COBRA continuat ion of coverage under the Plan if coverage terminates for any of the follow ing qualifying events:

1. The employee’s terminat ion of employment for reasons other than gross

misconduct. 2. The employee’s ret irement or reduct ion in hours of employment.

3. The employee’s death.

4. The employee’s divorce or legal separat ion.

5. The employee becomes enrolled in Medicare benefits (Part A, Part B or both).

6. The employee’s dependent child ceases to be an eligible dependent as such term is

defined in the Plan.



Similar rights may apply to certain employees, spouses and dependent children if the employer commences a bankruptcy proceeding and these individuals lose coverage. The Plan w ill of fer COBRA continuat ion coverage to qualif ied beneficiaries only after the Plan Administrator has been not if ied that a qualifying event has occurred. When the qualifying event is the end of employment or reduct ion of hours of employment, death of the employee, or enrollment of the employee in Medicare (Part A, Part B, or both), the employer must notify the Contract Administrator of the qualifying event w ithin thirty (30) days of any of these events on the form provided by the Contract Administrator to the employer.

For the other qualifying events (divorce or legal separat ion of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), the qualif ied beneficiary must not ify the Plan Administrator. The Plan Administrator must be not if ied in w rit ing w ithin sixty (60) days after the qualifying event occurs.

Once the Plan Administrator receives not ice that a qualifying event has occurred, COBRA continuat ion coverage w ill be offered to each of the qualif ied beneficiaries. The Plan Administrator must not ify the qualif ied beneficiary in w rit ing of their right to COBRA continuat ion of coverage w ithin fourteen (14) days from the date the Plan Administrator is not if ied of a qualifying event.

The qualif ied beneficiary has sixty (60) days from the date of the w rit ten not ice or qualifying event, w hichever is later, to not ify the Plan Administrator of their decision to elect COBRA continuat ion of coverage. To receive COBRA continuat ion of coverage, no evidence of insurability w ill be required, but a monthly premium w ill be charged. If cont inuation of coverage is not elected on a t imely basis, group health insurance coverage w ill end.

If Medicare ent it lement occurs prior to a qualifying event, then COBRA begins on the date of Medicare ent it lement.

For each qualif ied beneficiary w ho elects COBRA continuat ion coverage, COBRA continuat ion coverage w ill begin on the day follow ing the date of the qualifying event.

COBRA continuat ion coverage is a temporary cont inuat ion of coverage. When the qualifying event is the death of the employee, the employee’s divorce or legal separat ion, or a dependent child losing eligibility as a dependent child, COBRA continuat ion coverage lasts for up to thirty -six (36) months.

If a qualifying event that is a terminat ion of employment or reduct ion of hours occurs w ithin eighteen (18) months after the covered employee becomes enrolled in Medicare, then the maximum coverage period for the spouse and dependent children w ho are qualif ied beneficiaries receiving COBRA coverage w ill end thirty-six (36) months from the date the employee became enrolled in Medicare (but the covered employees’ maximum coverage period w ill be eighteen (18) months). This extension is available only if the covered employee becomes enrolled in Medicare w ithin eighteen (18) months before the terminat ion of employment or reduct ion of hours occurs.

When the qualifying event is the end of employment or reduct ion of the employee’s hours of employment, COBRA continuat ion coverage lasts for up to eighteen (18) months. There are tw o w ays in w hich this eighteen (18) month period of COBRA continuat ion coverage can be extended.



Disability extension of 18-month period of continuation coverage If a qualif ied beneficiary is determined by the Social Security Administrat ion to be disabled at any t ime during the f irst sixty (60) days of COBRA continuat ion coverage and the Plan Administrator is not if ied in a t imely fashion, the employee and his covered dependents can receive up to an addit ional eleven (11) months of COBRA continuat ion coverage, for a total maximum of tw enty -nine (29) months. The qualif ied beneficiary must make sure that the Plan Administ rator is not if ied in w rit ing of the Social Security Administrat ion’s determinat ion w ithin sixty (60) days of the date of the determinat ion and before the end of the eighteen (18) month period of COBRA continuat ion coverage. If a qualif ied beneficiary is determined by the Social Security Administrat ion to no longer be disabled, then the beneficiary must not ify the Plan w ithin thirty (30) days of determinat ion by the Social Security Administrat ion. Second qualifying event extension of 18-month period of continuation coverage

If the employee’s family experiences another qualifying event w hile receiving COBRA continuat ion coverage, the spouse and dependent children can get addit ional months of COBRA continuat ion coverage, up to a maximum of thirty-six (36) months. This extension is available to the spouse and dependent children if the former employee dies, gets divorced or legally separated. This extension may be available to a spouse or dependents if the former employee enrolls in Medicare. The extension is also available to a dependent child w hen that child stops being eligible under the Plan as a dependent child. In all of these cases, the qualified beneficiary must make sure that the Plan Administrator is notified in writing of the second qualifying event within sixty (60) days of the second qualifying event. In no event w ill COBRA coverage cont inue beyond thirty -six (36) months from the date of the original qualifying event. Monthly Premium

1. The monthly premium w ill be 102% or, if applicable, 150% of the applicable premium (w hich for self -funded plans, is based on reasonable actuarial est imates or on past costs). All premium payments are due in advance and include the cost of the next month of COBRA continuat ion of coverage.

2. The init ial premium payment is due w ithin forty-f ive (45) days of elect ing COBRA

continuat ion of coverage. The payment must cover all premiums due from the date of the qualifying event.

3. The maximum grace period for payment of monthly COBRA coverage premiums w ill

not exceed thirty (30) days from the due date established by the Plan Administrator or their authorized agent.

Termination of COBRA continuation coverage COBRA continuat ion of coverage may be terminated prior to the expirat ion of the applicable t ime period as follow s:

1. The Plan Administrator no longer provides group health and/or dental coverage to any of its employees.



2. The applicable monthly premium for COBRA coverage is not paid w ithin thirty (30) days of the established due date.

3. The person w ho has elected COBRA coverage becomes enrolled in Medicare

benefits (Part A, Part B or both). COBRA coverage w ill terminate on the f irst day of the person’s birthday month. Should the person’s birthday be on the f irst day of the month, then COBRA coverage w ill terminate on the f irst day of the month prior to the person’s birthday.

4. The qualif ied beneficiary w ho has elected COBRA coverage becomes covered under

another group health and/or dental plan w hich does not contain any exclusion or limitat ion w ith respect to any preexist ing condit ion of such covered person.

(NOTE: Should COBRA continuat ion provide coverage for such “ preexist ing” condit ions, COBRA continuat ion of coverage w ill be primary for the applicable preexist ing condit ions only and w ill provide secondary coverage to all other covered expenses.)

5. The unique disability cont inuat ion period w ill end as of the f irst day of month that begins more than thirty (30) days after the date of f inal determinat ion under the Social Security Act that the qualif ied beneficiary is no longer disabled.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) rest ricts the extent to w hich group health plans may impose pre-exist ing condit ion limitat ions. HIPAA coordinates COBRA' s other coverage cut -off rule w ith these new limits as follow s. If the covered employee becomes covered by another group health plan and that plan contains a pre-exist ing condit ion limitat ion that affects the covered employee, the covered employee' s COBRA coverage cannot be terminated. How ever, if the other plan' s pre-exist ing condit ion rule does not apply to the covered employee by reason of HIPAA' s restrict ions on pre-exist ing condit ion clauses, the Plan may terminate the covered employee' s COBRA coverage. The covered employee does not have to show that he or she is insurable to choose cont inuat ion coverage. How ever, continuat ion coverage under COBRA is provided subject to the covered employee' s eligibility for coverage; the Plan Administrator reserves the right to terminate the covered employee' s coverage retroact ively if he or she is determined to be ineligible. Note: Some of the changes under the Affordable Care Act (described below ) may be relevant to a covered employee’s decision to elect COBRA: First , there may be other coverage opt ions for a covered employee and the employee’s family. Beginning January 1, 2014, individuals w ill be able to buy coverage through the Health Insurance Marketplace. In the Marketplace, the individual could be eligible for a new kind of tax credit that low ers his or her monthly premiums right aw ay. Covered employees w ill be able to see w hat the premiums, deduct ibles, and out -of-pocket costs w ill be before making a decision to enroll in the Marketplace. Being eligible for COBRA does not limit a covered employee’s eligibility for coverage for a tax credit through the Marketplace.

Second, health plans w ill be prohibited from imposing preexist ing condit ion exclusions beginning in plan years w hich commence on or after January 1, 2014. Because this requirement applies on a plan year basis, the exclusion may not apply immediately to all plans. Keep Plan Informed of Address Changes In order to protect the part icipant ’s family’s rights, the part icipant should keep the Plan Administrator informed of any changes in the addresses of family members. The part icipant should also keep a copy, for his or her records, of any not ices sent to the Plan Administrator.

PLAN DETAILS


PLAN DETAILS Preferred Provider Network Program The Plan includes access to Blue Cross Blue Shield of Vermont’s preferred provider netw ork and the BlueCard Program in order to obtain discounts from part icipat ing providers for covered medical care. The plan ident if icat ion card ident if ies the selected preferred provider netw ork and a current list of the part icipat ing providers w ill be furnished to covered persons automatically by the Plan Sponsor. Use of the netw ork is voluntary and the benefits of ut ilizing part icipat ing providers include provider fee discounts, direct billing to the Plan for covered services, and netw ork provider w rite-offs of any charges in excess of the discounted fee schedule. If a covered person is referred by an in-netw ork provider to a specialist and no provider exists for that area of specialty w ithin the preferred provider netw ork, then the covered person may seek services of an out -of-netw ork specialist and benefits for covered services w ill be paid as though they w ere furnished by an in-netw ork provider. Benefits related to covered services that begin at an in-netw ork facility or provider, and subsequently result in charges from an out -of-network facility or provider, w ill be paid at the in-netw ork benefit level subject to the maximum allow able benefit . (Example: Laboratory w ork for a sample that is draw n during a visit to an in-network physician or hospital, and the sample is subsequently sent to an out -of-netw ork lab or pathologist, then the laboratory fees and pathologist fees w ill be paid at the in-netw ork benefit level subject to the maximum allow able benefit .) Should the covered person choose services from an out -of-netw ork provider or facility, then the services w ill be paid at the out -of-netw ork benefit level. Out-of-Area Services We have a variety of relationships w ith other Blue Cross and/or Blue Shield Licensees referred to generally as “ Inter-Plan Programs” . Whenever you obtain health care services outside of the Vermont service area, the claims for these services may be processed through one of these Inter -Plan Programs, w hich include the BlueCard® Program and may include negotiated National Account arrangements available betw een us and other Blue Cross and Blue Shield Licensees. Typically, w hen accessing care outside of the Vermont service area, you w ill obtain care from health care providers that have a cont ractual agreement (i.e. are “ preferred providers” ) w ith the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“ Host Blue” ). In some instances, you may obtain care from non-preferred health care providers. Our payment pract ices in both instances are described below . The BlueCard® Program Under the BlueCard® Program, w hen you access covered health care services w ithin the geographic area served by a local Blue Cross Blue Shield Plan (“ Host Blue” ), w e w ill remain responsible for fulf illing our contractual obligat ions. How ever, the Host Blue is responsible for contract ing w ith and generally handling all interact ions w ith its preferred health care providers. Whenever you access covered health care services outside our service area and the claim is processed through the BlueCard® Program, the amount you pay for covered health care services is calculated based on the low er of:

The billed covered charges for your covered services; or

The negotiated price that the Host Blue makes available to us. Often, this “ negotiated price” w ill be a simple discount that ref lects an actual price that the Host Blue pays to your health care provider. Sometimes, it is an est imated price that takes into account special arrangements w ith your health care provider or provider group that may include types of sett lements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of health care providers after taking into account the same types of transact ions as w ith an est imated price.

PLAN DETAILS


Est imated pricing and average pricing, going forw ard, also take into account adjustments to correct for over- or under est imation of modif icat ions of past pricing for the types of transact ion modif icat ions noted above. How ever, such adjustments w ill not affect the price w e use for your claim because they w ill not be applied retroact ively to claims already paid. Law s in a small number of states may require the Host Blue to add a surcharge to your calculat ion. If any state law s mandate other liability calculat ion methods, including a surcharge, w e w ould then calculate your liability for any covered health care services according to applicable law . When covered health care services are provided outside of our service area by non-preferred health care providers, the amount you pay for such services w ill generally be based on either the Host Blue’s non-preferred health care provider local payment or the pricing arrangements required by applicable state law . In these situat ions, you may be liable for the dif ference betw een the amount that the non-preferred health care provider bills and the payment w e w ill make for the covered services as set forth in this paragraph. In certain situat ions, w e may use other payment bases, such as billed covered charges, the payment w e w ould make if the health care services had been obtained w ithin our service area, or a special negotiated payment, as permitted under Inter-Plan Programs Policies, to determine the amount w e w ill pay for services rendered by non-preferred health care providers. In these situat ions, you may be liable for the dif ference betw een the amount that the non-preferred health care provider bills and the payment w e w ill make for the covered services as set forth in this paragraph. Transition of Care for some Ongoing Medical Treatment: Prior to the covered persons employer’s original effect ive date in this plan, if the covered person w as receiving on-going medical care for pregnancy (second or third trimester only), cardiac rehabilitat ion, physical/occupational/speech therapy, radiat ion therapy or chemotherapy, mental health or substance abuse treatment, or post -surgical care for surgery performed prior to the covered persons employer’ s effect ive date in this Plan, expenses for these services w ill be considered at the in-netw ork level of benefits for the f irst sixty (60) days from your employer’s effect ive date in this plan for medical care or through delivery and post-partum care for pregnancy (init ial hospital conf inement for new born), even if the covered persons physician or pract it ioner is not current ly a part of the PPO netw ork . To qualify for these transit ion benefits, the covered person must call the Contract Administrator before cont inuing services. If the covered person does not call, covered services will be considered at the out-of-network level of benefits. If the covered person qualif ies because they are in the second or third trimester of pregnancy, benefits w ill be considered at the in-netw ork level through delivery and post -partum care. (For the new born, this benefit applies only to the nursery charges during the init ial hospital conf inement. The covered person must select a pediatrician in the netw ork in order to receive the in-netw ork level of benefits for the init ial exam and subsequent baby care. If the covered person’s new born must be transferred to another hospital after delivery, an in-netw ork hospital should be selected or services w ill be considered at the out -of-netw ork level of benefits). Employees and their eligible dependents w ho do not call or w ho elect to remain w ith their out -of-netw ork provider after the approved transit ion benefit period w ill have their covered expenses paid at the out-of-netw ork benefit level. When the covered person calls the Contract Administrator they need to have the follow ing information ready:

Date their condit ion or treatment began;

Ant icipated due date (if the covered person is pregnant);

Type of care or treatment plan;

Name and telephone number of their physician or pract it ioner. The covered persons physician or pract it ioner may already be a member of the PPO netw ork. If so, the covered person w ill not need to use this transit ion benefit as their services already qualify for the higher level of benefits. To determine if the covered person’s provider belongs to the netw ork, to locate a physician or pract it ioner in your area, or to f ind out how to nominate your current physician or pract it ioner for membership in the PPO netw ork, call the Contract Administrator.

PLAN DETAILS


Preventive Services: Charges for preventive care services are covered expenses. Charges can include rout ine physical examinat ions (including breast and pelvic), gynecological exams, immunizat ions, vaccinat ions, inoculat ions, consultations, rout ine x -ray and laboratory services (e.g. cholesterol screenings, TSH, rest ing EKG’s, fecal occult blood tests and double contrast barium enemas), pap smears (including laboratory fees), x-rays, rout ine vision exams including refract ion, mammograms, prostate cancer screenings (including PSA tests and digital rectal exams), and sterilizat ion procedures for w omen. The list of preventive care services covered under this benefit may change periodically based upon the recommendation of the United States Preventive Services Task Force, the Advisory Committee on Immunizat ion Pract ices of the Centers for Disease Control and Prevention, and the Health Resources and Services Administ rat ion. Informat ion on the recommendations of these agencies can be found at: http://w w w .uspreventiveservicestaskforce.org/uspstf /uspsabrecs.htm or at https://w w w .healthcare.gov/prevention. Please see the applicable “ Schedule of Benefits” to determine payment level. Physician’s Office Visits: Charges for physician’s off ice visits w hen the employee or their dependent(s) incur expenses as a result of an illness or accidental injury are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. For Plans w ith copayments, incidental services provided at the t ime of a physician’s off ice visit and included under the copayment may include allergy inject ions and test ing, immunizat ions, laboratory tests such as strep tests, urinalysis, and cholesterol screenings. Examples of services that may be provided in a physician’s off ice that are not included under the copaymen t are surgeries and related anesthesia expenses, 24 hour EKG tests, MRIs, CT Scans, PET Scans, physical/occupational/speech therapy services, chemotherapy and radiat ion therapy, and bone density tests. These services are subject to the plan year deduct ible and coinsurance provisions. Colonoscopies/Flexible Sigmoidoscopies (Routine): Charge for rout ine colonoscopies and sigmoidoscopies, including anesthesiology services are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Colonoscopies/Flexible Sigmoidoscopies (Diagnostic): Charge for diagnost ic colonoscopies and sigmoidoscopies, including anesthesiology services are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Chiropractic Care: Charges for home, off ice, and nursing home visits, as w ell as examinat ions, x -rays, consultat ions, spinal manipulat ions, electrical st imulat ion, and interpretat ion are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Outpatient Diagnostic Laboratory Services: Charges for outpat ient diagnost ic laboratory services rendered in an independent facility or outpat ient hospital are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Outpatient Diagnostic Testing/X-Ray Services: Charges for outpat ient diagnost ic test ing/x-ray services rendered in an independent facility or outpat ient hospital and all outpat ient CT scans, PET scans, and MRI’s are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Outpatient Physical, Occupational, and Speech Therapy: Charges for outpat ient physical, occupational, and speech therapy are covered expenses to a combined maximum of thirty (30) visits per covered person per plan year. Please see the applicable “ Schedule of Benefits” to determine payment level. Addit ional visits may be authorized if medically necessary. The covered person should contact the Contract Administ rator for authorizat ion. Home Health Care: Charges for home health care services are covered expenses to a maximum of tw enty-f ive (25) visits per covered person per plan year. Please see the applicable “ Schedule of Benefits” to determine payment level. Addit ional visits may be authorized if medically necessary. The covered person should contact the Contract Administrator for authorizat ion. Outpatient Private Duty Nursing: Charges for outpat ient private duty nursing care are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level.

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm%20or%20at%20https:/www.healthcare.gov/prevention


PLAN DETAILS


Urgent Care Services: Charges for urgent care services are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level.

Emergency Room Services: Charges for emergency room services are covered expenses. Charges may include facility fees, physician fees, x-rays, laboratory tests, and other necessary services and supplies, unless otherw ise specif ied herein. Please see the applicable “ Schedule of Benefits” to determine payment level. The copayment w ill be w aived if the covered person is admitted to the hospital as an inpat ient. The amount the plan pays for out -of-netw ork benefits (e.g. maximum allow able benefit), w ill be reduced by the in-netw ork copayment or coinsurance that the individual w ould be responsible for if the emergency services w ere provided in-netw ork. Ambulance Services: Charges for ambulance services for inpat ients or outpatients receiving accident or illness care to and from the hospital or medical facility w here treatment is given are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Anesthesiology Services: Charges for inpat ient and outpat ient anesthesiology services are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Inpatient Hospital Services: Charges for inpat ient hospital services may include room and board, operat ing room, x-rays, physical therapy, radiat ion therapy, chemotherapy, prescript ion drugs, anesthesia, laboratory expenses, intensive care unit, physician charges, and other necessary services and supplies, unless otherw ise specif ied herein, incurred during any period of hospital conf inement are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Skilled Nursing Facility: Charges for conf inement in a skilled nursing facility are covered expenses to a maximum of one hundred (100) days per covered person per plan year. Please see the applicable “ Schedule of Benefits” to determine payment level. Inpatient Rehabilitation Hospital Care: Charges for inpat ient rehabilitat ion hospital services are covered expenses. Please see the applicable “ Schedule of Benefits” t o determine payment level. Maternity Care (Prenatal Care): Charges for prenatal maternity care are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Hospice Facility/Home Hospice: Charges for hospice facility/home hospice are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Please see the applicable “ Schedule of Benefits” to determine payment level. Durable Medical Equipment: Charges for durable medical equipment are covered expenses. Please see the applicable “ Schedule of Benefits” to determine payment level. Wigs/Artificial Hairpieces (after radiation therapy or chemotherapy): Charges for w igs or art if icial hairpieces after radiat ion therapy or chemotherapy are covered expenses to a maximum of tw o (2) w igs or art if icial hairpieces per covered person per lifet ime. Please see the applicable “ Schedule of Benefits” to determine payment level. Dialysis: Charges for dialysis are covered expenses to a maximum of forty (40) visits per covered person per plan year. Please see the applicable “ Schedule of Benefits” to determine payment level.

PLAN DETAILS


Pre-Admission Certification Penalty: The Plan requires that all non-emergency hospital admissions, organ and t issue transplants, and the below listed outpat ient services be pre-cert if ied and authorized by the Contract Administrator. This does not include hospital stays in connect ion w ith childbirth for the mother or new born child w hich are forty -eight (48) hours or less for vaginal deliveries, or ninety-six (96) hours or less for cesarean sect ion deliveries. When a doctor recommends that the employee or dependent be admitted to a hospital or receive one of the below listed outpat ient services, it is the employee’s responsibility to not ify the Plan and to obtain pre-cert if icat ion and authorizat ion of the hospital admission and outpat ient service. It is the employee’s responsibility to be sure that in the event of an emergency admission, the Contract Administrator is not if ied w ithin forty-eight (48) hours. Failing to obtain pre-cert if icat ion w ill not result in a reject ion of the claim, but a penalty of $500 w ill be applied. The penalty does not apply tow ard the out -of-pocket maximum. In the event that an employee or dependent incur expenses for services w hich have not been pre-cert if ied and authorized, a thorough review w ill be conducted of the services to determine medical necessity at the point of claim. If the review process ident if ies care w hich is not medically necessary, services w ill not be covered under the Plan. In order for the Plan to approve the inpat ient stay, the attending physician must cert ify to the Contract Administrator that, in the physician’s professional opinion, the stay is necessary for t he condit ion. The Plan reserves the right to request an independent medical opinion by a physician of the Plan’s choice. The follow ing procedures must be pre-cert if ied: CT Scans MRI’s MRA’s PET Scans Dexascan Carpal tunnel surgery Sleep studies Diagnost ic colonoscopy Gastric endoscopy Cardiac thallium stress test Cardiac echocardiography More than 2 obstetrical ultrasounds per pregnancy Home health care visits in excess of the plan year visit limits Outpat ient Physical, Occupational, and Speech Therapy v isits in excess of the plan year visit limits Retail Prescription Drug Plan: The Plan includes a prescript ion drug program. Prescript ions f illed at part icipat ing pharmacies are limited to a maximum thirty (30) day supply. Please see the applicable “ Schedule of Benefits” to determine payment level.

A list of part icipat ing pharmacies can be obtained from your Human Resource Off ice.

Prescript ions purchased at non-part icipat ing pharmacies are not covered expenses.

Compound drugs that are not available from a part icipat ing pharmacy w ill be considered a covered expense subject to the applicable part icipat ing pharmacy copayment or deduct ible and coinsurance.

When f illing a prescript ion for w hich a generic drug is available and the covered person chooses the brand name drug, the covered person w ill be responsible for paying the brand name drug copayment plus the dif ference in cost betw een the generic and the brand name drug.

All prescribed FDA approved generic oral contraceptives for w omen are covered at 100% w hen received from a part icipat ing pharmacy or in-netw ork provider. The brand version w ill be covered at 100% w hen received from a part icipat ing pharmacy or in-netw ork provider only if medically necessary or a generic equivalent is not available.

PLAN DETAILS


When applicable, the retail and mail order prescript ion plan year deduct ible is combined for both retail and mail order prescript ions.

Mail Order Maintenance Prescription Drug Program: Maintenance drugs to treat illnesses should be purchased through the mail order program. These illnesses usually include: diabetes, epilepsy, anemia, chronic const ipat ion, arthrit is, high blood pressure, tuberculosis, various gastric disease, emphysema, menopause, mental and nervous disorders, thyroid disease, adrenal disease, ulcers, and any other condit ion that requires cont inuous medicat ion. Please see the applicable “ Schedule of Benefits” to determine payment level. When f illing a prescript ion for w hich a generic drug is available and the covered person chooses the brand name drug, the covered person w ill be responsible for paying the brand name drug copayment plus the dif ference in cost betw een the generic and the brand name drug.

Specialty Pharmacy medicat ions are recommended to manage specif ic high cost medicat ions. Services include access to, and support for, most pharmaceutical and biologic products that have high acquisit ion costs, are dif f icult to manage, and present reimbursement challenges. These medicat ions are payable at 80% to a maximum of $150 copayment per prescript ion.

There is no copayment for Prilosec OTC™ and OTC Loratadine, how ever, a physician’s prescript ion is required.

There is no copayment for OTC Zaditor® and Alaw ay®, how ever, a physician’s prescript ion is required.

Non-narcot ic analgesics for the treatment of migraines (e.g. Amerge, Frova, Imitrex, Maxalt , Relpax, and Zomig) are limited to a combined quantity of eighteen (18) per month for all forms of medicat ions.

Female libido enhancement drugs and male impotence medicat ions, including Viagra are limited to a maximum of eight (8) tablets per month.

Stadol Nasal Spray is limited to tw o (2) bott les per month.

Prozac Weekly is limited to four (4) capsules per month.

All prescribed FDA approved generic oral contraceptives for w omen are covered at 100% w hen received from a part icipat ing pharmacy or in-netw ork provider. The brand version w ill be covered at 100% w hen received from a part icipat ing pharmacy or in-netw ork provider only if medically necessary or a generic equivalent is not available.

When applicable, the retail and mail order prescript ion plan year deduct ible is combined for both retail and mail order prescript ions. Step Therapy Program: The Plan has implemented a Step Therapy program in order to control overall plan costs and to assure members access to clinically appropriate medicat ions to treat all condit ions. The Step Therapy program establishes an order of drug therapy opt ions w ithin select categories for covered persons to follow that may affect their access to, and out -of-pocket costs for, medicat ions covered under the Step Therapy program. The Step Therapy program ensures that the covered person receives clinically appropriate, cost-effect ive medicat ion based on their prescript ion history. Step Therapy guidelines maintain open access for covered persons and encourages the ut ilizat ion of low er cost medicat ions.

PLAN DETAILS


The order of medicat ion usage w ill include generic and select ed over-the-counter drugs f irst at the low est copayments for the covered person to preferred brand name drugs at the middle copayment, and f inally non-preferred brand name drugs at the highest copayment. The goal of the Plan is to achieve successful treatment outcomes at the most eff icient cost to the plan.

The covered person w ill receive communicat ion from RESTAT or their pharmacist if a prescript ion is w rit ten for them in one of the covered categories listed above. Please visit RESTAT’s w ebsite at w w w .restat.com for the most current version of the Step Therapy guidelines and formulary list .

http://www.restat.com/

MEDICAL COVERED EXPENSES



Expenses incurred for the follow ing medical, health care services, and supplies w ill be considered a covered expense, provided the expenses are (i) medically necessary to treat an illness or injury or furnished in connect ion w ith part icipat ion of a covered person in a “ Clinical Trial,” as such term is defined here, (ii) prescribed or approved by an attending physician, and (iii) incurred during a period that coverage w as in effect in accordance w ith the applicable provisions of the Plan. Payment of such expenses w ill be subject to all applicable deduct ibles, coinsurance limits, the maximum individual limit , and all other limitat ions described herein.

1. Inpat ient hospital charges for room and board, operat ing room, x -rays, physical therapy,

radiat ion therapy, chemotherapy, prescript ion drugs, anesthesia, laboratory expenses, intensive care unit , and other necessary services and supplies during any one (1) period of hospital conf inement, as show n below . Should the facility have no semi-private rooms or less expensive accommodations available, or the pat ient ’s condit ion requires the employee or the employee’s covered dependent to be isolated for their ow n health or the health of others, the private room rate w ill be allow ed. Room and Board:

semi-private room allow ance...................semi-private room rate private room allow ance....................... ....semi-private room rate intensive care allow ance.........................actual charge (not to exceed the maximum

allow able benefit )

2. Outpat ient hospital charges for necessary services and supplies incurred as a result of an illness, accident, or as a result of outpat ient surgery performed (if performed on the same day), including charges for x-ray and laboratory expenses, physical therapy, radiat ion therapy, and chemotherapy.

3. Charges for inpat ient physician visits w hile the employee or their dependents are hospital

conf ined as a result of an illness or an accidental injury. No benefits w ill be paid for more than one (1) visit per day by any one (1) physician or for the treatment received in connect ion w ith, on, or after the date of an operat ion for w hich a surgical expense benefit is payable under the Plan if such treatment is given by the physician w ho performed the operat ion.

4. All charges of a professional anesthesiologist, radiologist, or pathologist. 5. Charges for pre-admission test ing, exams, x-ray and laboratory examinat ions on an

outpat ient basis made prior to a scheduled hospital admission and related to a condit ion previously diagnosed.

6. Charges for medically necessary ground ambulance service for inpat ients or for outpat ients

receiving accident or illness care to and from the hospital or medical facility w here treatment is given. Air ambulance is considered a covered expense if it is medically necessary and the ground ambulance is not advisable.

7. Emergency room charges for treatment of an illness or an accidental injury. 8. Diagnost ic x-rays and laboratory charges for expenses incurred as a result of an illness or

injury. No benefits are payable for dental care except as provided for in this Plan.

9. Charges for physical therapy by a qualif ied pract it ioner. 10. Charges for speech therapy from a qualif ied pract it ioner to restore speech loss due to an

illness, injury, or surgical procedure. 11. Charges for occupational therapy, excluding supplies.



12. Charges for oral surgery, limited to: excision of tumors and cysts of the jaw s, cheeks, lips, tongue, roof and f loor of mouth; treatment of an accidental injury to the jaw s, cheeks, lips, tongue, roof and f loor of mouth; excision of exostoses of jaw s and hard palate; treatment of cleft lip and palate; external incision and drainage of cellulit is; incision of accessory sinuses, salivary glands or ducts; frenectomies; and removal of fully or part ially impacted teeth. If the covered person has elected both medical and dental coverage, expenses for frenectomies w ill be considered under the medical port ion of this Plan.

13. Charges for the surgical and non-surgical treatment of temporomandibular joint syndrome

(TMJ) w ill be covered. 14. Charges for orthognathic surgery.

15. Charges for physician’s surgical services for treatment of an injury or illness, if performed in

an inpat ient or outpat ient unit of a hospital, a free standing facility, a physician’s off ice, or a dentist or an oral surgeon’s services for the treatment of an accidental injury to sound natural teeth w ill be considered a covered expense. Injuries caused by bit ing or chew ing are not considered accidental injuries.

16. Charges for medically necessary private duty nursing care rendered on an outpat ient basis

by a registered graduate nurse (RN) or, services of a licensed pract ical nurse (LPN) w hen cert if ied by the attending physician and a registered graduate nurse (RN) is not available, but only for nursing dut ies and excluding custodial care.

17. Charges for x-ray, laboratory, and radium expenses excluding dental x-rays, unless rendered

for the treatment of a fractured jaw , cysts, tumors or injury to sound natural teeth as a result of an accident w ill be considered covered expenses.

18. Charges for the professional services of a legally qualif ied physician for the care of a

covered illness or accidental injury. 19. Charges for physician’s home and off ice visits w hen the employee or his dependent incur

expenses as a result of an illness or accidental injury. 20. Charges for services of a surgeon and an assistant surgeon if t w o (2) or more procedures

are performed during the course of a single operat ion through the same incision or in the same operat ive f ield. The fees w ill be limited to the sum of the maximum allow able benefit for the largest amount billed for one procedure plus f if ty (50%) of the sum of the maximum allow able benefit billed for all other procedures performed. Benefits are payable for the professional services of a legally qualif ied physician in rendering technical assistance to the operat ing surgeon w hen required in connect ion w ith a surgical procedure performed on an inpat ient basis (benefits w ill not exceed tw enty (20%) of the maximum allow able benefit for the procedure performed w hen the assistant is a physician and ten (10%) w hen the assistant is a PA). How ever, no benefits are payable for surgical assistance rendered in a hospital w here it is rout inely available as a service provided by a hospital intern, resident, or house off icer.

21. Charges for medically necessary dressings and medicines, including prenatal vitamins for w hich a physician’s prescript ion is required and dispensed by a licensed pharmacy.

22. Charges for birth control methods. All prescribed Food and Drug Administrat ion (FDA)

approved contraceptive methods for w omen, and pat ient education and counseling for all w omen w ith reproduct ive capacity are covered at 100% at the in-netw ork benefit level or w hen received from a part icipat ing pharmacy. All prescribed brand oral contraceptives w ill be covered at 100% w hen received from a part icipat ing pharmacy or in-network provider only if medically necessary or a generic equivalent is not available.



23. Charges for diabet ic supplies such as insulin, accustrips, lancets, syringes, and insulin infusion pumps, necessary for the administrat ion of prescript ion drugs and professional instruct ions, not including printed material for their use. Nutrit ional counseling for the treatment of diabetes w ill be considered a covered expense.

24. Charges for oxygen and the rental of equipment for its administrat ion. 25. Charges for rehabilitat ive care, as def ined herein.

26. Charges for sterilizat ions. 27. Charges for art if icial limbs or eyes, casts, splints, trusses, crutches, braces (except dental),

cervical collars, head halters, tract ion apparatus or prosthet ic appliances to replace lost body parts or to aid in their funct ion w hen impaired, rental or purchase (if appropriate) of a w heelchair or hospital type bed and the rental of durable medical equipment w hich has no personal use in the absence of the condit ion for w hich it w as prescribed (rental charges w ill not exceed the retail purchase price of such equipment). The replacement of prosthet ic devices are covered only if it is required because of the covered person’s physical change.

28. Charges for abort ions are covered expenses w hen the physical or mental health of the

mother w ould be in danger if the fetus w ere carried to term. The attending physician w ill determine w hen the health of the mother is in danger.

29. Charges for select ive or non-select ive reduct ion of mult iple pregnancy provided every effort

is taken to ensure the health of the remaining fetus(es) w hen one (or more) fetus is abnormal, w hen the mother’s health is in danger, or there are three (3) or more fetuses and they are all likely to be spontaneously aborted or delivered prematurely w ith a high risk of either dying or being harmed. This is not a covered benefit if the fetus(es) are a result of infert ility services that are not covered.

30. Charges for blood and/or plasma and the equipment for its administrat ion. 31. Charges for maternity care including prenatal, delivery, and postpartum care as w ell as

charges arising from complicat ions that may occur during maternity and delivery. Routine ultrasounds are limited to tw o (2) per pregnancy. Addit ional ultrasounds may be authorized if medically necessary. The covered person should contact the Contract Administrator for authorizat ion. Comprehensive lactat ion support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for rent ing breastfeeding equipment are payable at 100% at the in-netw ork benefit level.

32. Convalescent Hospital/Extended Care Facility/Skilled Nursing Facility charges for not more than one hundred (100) days per plan year, but not in excess of a daily charge for room and board, services, and supplies equal to one-half (1/2) of the discharging hospital’s semi-private room rate; provided how ever, the conf inement in such a hospital or facility begins not more than fourteen (14) days after a period of conf inement in a general hospital of at least f ive (5) consecutive days. The covered person must be under the care of an attending physician w ho determines the cont inuing need for the hospital or facility stay.

33. New born care charges are a covered expense for an employee’ s new born dependents.

Charges for care of new born children to include hospital charges for nursery room and board and miscellaneous expenses, charges by a pediatrician for attendance at a cesarean sect ion, charges for physician examinat ion for a new born w hile hospital conf ined and charges for circumcisions.

34. Chiropractic Care: Charges for home, off ice, and nursing home visits as w ell as

examinat ions, x-rays, consultat ions, spinal manipulat ions, electrical st imulat ion, and interpretat ion are covered expenses.



35. Organ transplant benefits to include charges for organ transplants and peripheral stem cell t ransplants for the treatment of cancer are considered a covered expense w hen the transplant procedure is not considered experimental/invest igat ive and the covered person is considered an eligible recipient. Donor charges are considered a covered expense provided charges are not covered under any insurance policy the donor may hold. Donor charges are limited to:

a) evaluat ing the organ or t issue; b) removing the organ or t issue from the donor; and c) transport ing the organ or t issue from w ithin the United States and Canada to

the transplant site.

36. Hospice care charges, as def ined herein. Benefits are payable for up to six (6) months of services.

37. Preventive Care: Charges for rout ine physical examinat ions, w ell-baby care, and w ell-adult care are covered expenses. Charges can include examinat ions (including breast and pelvic), gynecological exams, immunizat ions, vaccinat ions, inoculat ions, consultat ions, rout ine x -ray and laboratory services (e.g. cholesterol screenings, TSH, rest ing EKG’s, fecal occult blood tests and double contrast barium enemas), pap smears (including laboratory fees), rout ine vision exams including refract ions, x-rays, mammograms, prostate cancer screenings (including PSA tests and digital rectal exams), sterilizat ion procedures for w omen, and EKG’s. The list of preventive care services covered under this benefit may change periodically based upon the recommendation of the United States Prevent ive Services Task Force, the Advisory Committee on Immunizat ion Pract ices of the Centers for Disease Control and Prevention, and the Health Resources and Services Administrat ion. Information on the recommendations of these agencies can be found at: http://w w w .uspreventiveservicestaskforce.org/uspstf /uspsabrecs.htm or at https://w w w .healthcare.gov/prevention.

38. Mental Health Care and Substance Abuse: Charges result ing from inpat ient mental health care and alcohol and/or drug addict ion in a hospital, public or licensed mental hospital, drug/alcohol abuse treatment facility, day treatment facility, or outpat ient mental health services provided by a board cert if ied physician, a licensed psychologist, clinical or cert if ied social w orker or cert if ied alcohol counselor (C.A.C.) w ill be considered covered expenses. Benefits include treatment of or related to eat ing disorders and attent ion def icit disorders (ADD or ADHD). Tw o (2) days of treatment in an Outpat ient Day Treatment Program are equivalent to one (1) day of inpat ient care.

39. Home Health Care: Charges for the follow ing services or supplies furnished to the covered

person at home:

A. Part-t ime intermit tent nursing care by or under the supervision of a registered professional nurse (RN); and/or visits by persons w ho have completed a home health aide training course under the supervision of registered nurse for the purpose of giving personal care to the pat ient w ith a maximum of one (1) visit per day for up to a maximum of tw enty -f ive (25) visits per plan year. Four (4) hours const itutes one (1) home health care visit .

B. Physician’s home and off ice visits, physical therapy, occupational therapy,

and speech therapy.

C. Medical supplies, laboratory services, drugs, and equipment prescribed by a physician to the extent such items w ould have been covered if you or your dependent had been hospitalized.





D. Exclusions and Limitations: In no event w ill home health care expenses include charges for loss result ing from services solely for custodial care, transportat ion services, any period during w hich you or your dependent are not under the cont inuing care of a physician, injury, or sickness arising out of or in the course of employment, declared or undeclared w ar or act of w ar.

40. Any taxes and/or surcharges applied to a covered expense are considered eligible expenses

w hen the tax or surcharge is mandated by state or federal government unt il such t ime that ERISA preemption is clearly established by law prohibit ing the applicable tax and/or surcharge.

41. Any of the follow ing services in connect ion w ith a mastectomy: a) all stages of reconstruct ion of the breast on w hich the mastectomy is

performed; b) surgery and reconstruct ion of the other breast to produce a symmetrical

appearance; and c) prostheses and treatment of physical complicat ions of the mastectomy,

including lymphedema. The Women’s Health and Cancer Rights Act of 1998 requires the Plan Sponsor to not i fy you, as a covered part icipant or dependent under this Plan, of your rights related to benefits provided through the Plan in connect ion w ith a mastectomy. You as a covered part icipant or dependent under this Plan have rights for coverage to be provided in a manner determined in consultat ion w ith your attending physician for the above referenced services.

42. Charges for mastectomy bras are a covered expense to a maximum of tw o (2) bras per covered person per plan year.

43. Charges for a w ig or hairpiece, only after chemotherapy or radiat ion therapy to a maximum

of tw o (2) w igs or hairpiece per covered person per lifet ime. 44. Charges for off ice visits for the treatment of smoking cessat ion. Prescript ion and over-the-

counter smoking cessat ion aids w ill be covered under the prescript ion drug plan. 45. Charges for second and third surgical opinions. 46. Charges for treatment of or related to sleep disorders. 47. Charges for allergy test ing and allergy inject ions (including serum). 48. Charges for amniocentesis, including any genetic test ing or genetic counseling performed in

connect ion w ith the procedure. 49. Charges for compression garments (e.g. Jobst garments). 50. Charges for B-12 inject ions. 51. Charges for the init ial prescript ion contact lenses or eyeglasses, including the ex aminat ion

and f it t ing of the lenses, to replace the human lens lost through intraocular surgery. 52. Charges for non-naroct ic analgesics for the treatment of migraines (e.g. Amerge, Frova,

Imitrex, Maxalt , Relpax, and Zomig), limited to a combined quantity of eighteen (18) per month for all forms of medicat ions.

53. Charges for female libido enhancement drugs and male impotence medicat ions, including

Viagra to a maximum of eight (8) tablets per month.



54. Charges for Stadol Nasal Spray, limited to tw o (2) bott les per month. 55. Charges for testosterone replacement (e.g. Androderm, Androgel, Test im, Striant). 56. Charges for Prozac Weekly, limited to four (4) capsules per month. Prior authorizat ion may

apply. 57. Charges for podiatry surgery, limited to open cutt ing procedures of the foot. 58. Charges for non-surgical treatment of the feet, including treatment of metabolic or

peripheral-vascular disease. 59. Charges for intravenous (IV) antibiot ic infusion therapy w hether in a home, physician’s

off ice, clinic, or outpat ient hospital sett ing. 60. Charges for infert ility test ing, only to establish the init ial diagnosis of infert ility. 61. The Plan w ill reimburse otherw ise eligible medical covered expenses for “ pat ient care

services,” as such term is def ined herein, furnished in connect ion w ith part icipat ion of a covered person in a “ Clinical Trial,” as such term is def ined herein, w hich is intended to t reat cancer or other life-threatening condit ion in a pat ient w ho has been so diagnosed. A copy of the “ Clinical Trial” protocol may be required in order to determine if benefits are available under this Plan. Nothing herein shall create a presumption that the Employer recommended, directed, endorsed or required any covered person’s part icipation in a Clinical Trial.

GENERAL MEDICAL EXCLUSIONS AND LIMITATIONS



1. Expenses for conf inement, treatment, services, or supplies except to the extent herein provided w hich are:

a) not furnished or ordered by a recognized provider and not medically

necessary to diagnose or treat a sickness or injury; b) experimental or invest igat ional in nature.

2. Expenses for services for disease or injury sustained as a result of w ar, declared or

undeclared. For all purposes of this Plan, terrorism is considered an act of war.

3. Expenses for services for disease or injury sustained as a result of part icipat ion in a riot or civil disobedience, or w hile committ ing or attempting to commit a criminal act or engage in an illegal act ivity.

4. Expenses incurred in connect ion w ith any accidental bodily injury or illness arising out of o r

in the course of any employment, regardless of w hether the employment is for prof it or compensation. This exclusion applies to all covered individuals, including but not limited to, self employed individuals w ho choose not to provide themselves w ith insurance coverages such as, but not limited to, w orkers’ compensation and occupational disease, regardless of w hether such coverage or coverages are required by law .

5. Expenses incurred w hile on full-t ime act ive duty in the armed forces of any country,

combinat ion of countries or internat ional authority. 6. Expenses for treatment or services rendered outside of the United States of America or its

territories, except for accidental injuries or a medical emergency. 7. Expenses for dental services, except to the extent herein provided. 8. Expenses for vision therapy or orthopt ics, except follow ing surgery to the muscles

controlling the eye or in treatment of strabismus. 9. Expenses incurred for or in connect ion w ith any correct ive treatment or surgery to correct a

refract ive error (i.e. such as hyperopia, myopia, ast igmatism, LASIK, keratomileusis surgery, or radial keratotomy, etc.) or f it t ing or actual cost of correct ive lenses except to the extent herein provided (i.e. intra-ocular implant of lenses in the treatment of cataracts).

10. Expenses for hearing examinat ions or hearing aids unless medically necessary due to a birth

defect, t rauma, or illness causing hearing loss. 11. Expenses for treatment, services, supplies, and facilit ies provided by or in a hospital ow ned

or operated by any government or agency thereof w here such care is provided at government expense under a plan or program established pursuant to the law s or regulat ions of any government or under a plan or program under w hich any government part icipates other than as an employer. The term “ any government” includes the federal, veteran, state, provincial, municipal, local government, or any polit ical subdivision thereof, of the United States or any other country. The Plan w ill not exclude benefits for a covered person w ho receives billable medical care at any of the above facilit ies.



12. Expenses for treatment, services, or supplies provided by the employee, spouse, parent, son, daughter, brother, or sister of a covered person or by a member of the covered person’s household.

13. Expenses for w hich there is no legal obligat ion to pay or for w hich no charges w ould be made if the person had no medical or dental coverage.

14. Expenses for services for w hich the covered person recovers the cost by legal act ion or

sett lement. 15. Expenses for reverse sterilizat ions. 16. Expenses for transsexual surgery or related procedures. 17. Expenses for rehabilitat ive care, as def ined herein, in excess of one (1) year’s conf inement. 18. Expenses for cosmetic or reconstruct ive surgery, except for expenses:

a) to repair or alleviate the damage from an accident; or b) incurred for reconstruct ive surgery follow ing a mastectomy or for surgery

and reconstruct ion of the other breast to produce symmetrical appearance; or

c) incurred as a result of a birth defect. 19. Expenses solely for sanitarium, rest, or custodial care.

20. Expenses for rout ine foot care, to include treatment of corns, callouses, bunions (except

capsular or bone surgery), f lat feet, fallen arches, w eak feet, or chronic foot strain. 21. Expenses incurred for w eight control by surgical procedures, w eight loss programs or a

gastric bypass; w hether or not it has been determined that the services are medically necessary or the services are under the direct ion of a physician.

22. Expenses for telephone, radio, television, and beautif icat ion services or for the preparat ion of reports, evaluat ions and forms, phone consultat ions, or for missed appointments or for t ime spent traveling or in connect ion therew ith that may be incurred by the physician or dent ist or other health care professional in the course of rendering services.

23. Expenses for procedures w hich do not correct the condit ion of infert ility but are used to

induce pregnancy such as art if icial inseminat ion, in-vitro fert ilizat ion, embryo transplantat ion, hormone therapy or gamete intra-fallopian transfer (GIFT).

24. Routine or elect ive expenses except as set forth herein. [i.e. shoe inserts, ankle pads,

printed material, arch supports, foot orthot ics, orthopedic or correct ive shoes and other support ive appliances for the feet, elast ic stockings, f luoride, anabolic steroids, irrigat ion solut ions, vitamins (except prenatal), over-the-counter vitamins, nutrit ional or dietary counseling (except w hen related to diabetes), food supplements, and any “ over the counter drug” w hich can be purchased w ith or w ithout a prescript ion or w hen no injury or illness is involved].

25. Expenses for breast reduct ion surgery.



26. Expenses incurred prior to the covered person’s effect ive date of coverage or follow ing the terminat ion date of coverage.

27. Expenses in excess of the maximum allow able benefit in the locality w here it is rendered. 28. Expenses for rolf ing. 29. Expenses for acupuncture. 30. Expenses for massage therapy or rolf ing. 31. Expenses for biofeedback training or equipment. 32. Expenses for surrogacy. 33. Expenses for injuries that result f rom being in any aircraft being used for one or more of the

follow ing: test or experimental purposes; speed test; exhibit ion or stunt f lying; and for injuries that result f rom riding in or on a motorized vehicle of any type designed for or primarily used for racing, speed tests, or hazardous exhibit ion purposes.

34. Expenses for complicat ions arising from any non-covered surgery or treatment, except as

required by law . 35. Expenses for educational, vocat ional, or training services and supplies, except as specif ied

in the Medical Covered Expenses sect ion. 36. Expenses related to insert ion or maintenance of an art if icial heart. 37. Expenses for treatment of behavioral or conduct disorders. 38. Expenses for maintenance care. 39. Expenses for education, counseling, job training, or care for learning disorders or behavioral

problems, w hether or not services are rendered in a facility that also provides medical and/or mental/nervous treatment.

40. Expenses for adoption services. 41. Expenses for hypnosis. 42. Expenses for genetic counseling or genetic test ing, except as provided herein. 43. Expenses for marital, family, or sex counseling. 44. Expenses for equipment such as air condit ioners, air purif iers, dehumidif iers, heat ing pads,

hot w ater bott les, w ater beds, sw imming pools, hot tubs and any other clothing or equipment w hich could be used in the absence of an illness or injury.

45. Expenses for medicat ions w hich are taken by or administered to a covered person, in w hole

or in part , w hile they are a pat ient in a licensed hospital. 46. Expenses for drugs w hose sole purpose is to promote or st imulate hair grow th (e.g Rogaine

or Propecia) or for cosmetic purposes only (e.g. Renova or Vaniqa).



47. Expenses for immunizat ion agents. 48. Expenses for anorexiants or w eight loss medicat ions. 49. Expenses for extemporaneous or compounded dosage forms of natural estrogen or

progesterone, including, but not limited to, oral capsules, suppositories, and troches. 50. Expenses related to “ Never Events.” These events are procedures performed on the w rong

side, w rong body part, w rong procedure, or w rong person. These “ Never Events” are not medically necessary as they are not required to diagnose or treat an illness, injury, disease or its symptoms and are not consistent w ith generally accepted standards of medical pract ice.

CLAIM FILING PROCEDURES


CLAIM FILING PROCEDURES

Written not ice of the employee or the employee’s dependent’s claim (proof of claim) must be given to the Contract Administrator as soon as is reasonably possible but w ithin tw elve (12) months after the occurrence or commencement of any loss covered by the Plan. Failure to furnish w rit ten proof of claim w ithin the t ime required w ill invalidate the claim. It is the employee’s responsibility to inform his provider(s) of this claim submission t ime limit . Filing an In-Network or Out-of-Network Medical Claim: To obtain benefits under this Plan, a diagnost ic bill must be submitted that provides suff icient information, including the employee’s name, claimant’s name, claimant’s address, and Plan number to allow the Contract Administrator to properly adjudicate each claim. The Contract Administrator may require addit ional forms and information to assist them in this process. The covered person should instruct their medical care providers, both in-netw ork and out -of-network, to mail claims to the follow ing address:

CBA Blue P.O. Box 2365

South Burlington, VT 05407-2365

[Should the employee have any quest ions, please feel free to call or w rite to the Contract Administrator.]

CLAIM REVIEW PROCEDURES



I. Failure to Follow Pre-Service Claim Procedures:

In the case of a failure by a claimant or an authorized representat ive of a claimant to follow the Plan' s procedures for f iling a Pre-Service Claim, the claimant or representat ive w ill be not if ied of the failure and the proper procedures to be followed in f iling a claim for benefits as soon as possible, but not later than f ive (5) days (tw enty-four (24) hours in the case of a failure to f ile a Claim involving Urgent Care) follow ing the failure. This not if icat ion w ill be oral unless w rit ten cert if icat ion is requested by the claimant or authorized representat ive. This sect ion shall only apply in the case of a failure that:

1. Is a communicat ion by a claimant or an authorized representat ive of a claimant

that is received by the Pre-Cert if icat ion Administrator; and

2. Is a communicat ion that names a specif ic claimant; a specif ic medical condit ion or symptom; and a specif ic treatment, service or product for w hich approval is requested.

II. Timing of Notice of Benefit Claim Determinations: (a) Provisions Applicable to All Benefits Under the Plan.

(i) The various t ime periods set forth in this Sect ion II w ithin w hich benefit determinat ions must be made shall begin at the t ime a claim is f iled in accordance w ith the Plan' s procedures w ithout regard to w hether all the information necessary to make a benefit determination accompanies the f iling.

(ii) If any period of t ime set forth in this Sect ion II is extended because of a

claimant ' s failure to submit information necessary to decide a claim, the period for making the benefit determinat ion shall be tolled from the date on w hich the not if icat ion of the extension is sent to the claimant unt il the earlier of: (a) the date on w hich the claimant responds to t he request for addit ional information, or (b) the last day of the period provided to the claimant to respond to the request for addit ional information.

(b) Addit ional Provisions Applicable to Health Benefits.

(i) Urgent Care Claims: In the case of a Claim involving Urgent Care, the Contract Administrator w ill not ify the claimant of the Plan' s benefit determinat ion (w hether adverse or not) as soon as possible, taking into account the medical urgencies, but not later than seventy-tw o (72) hours after receipt of the claim by the Contract Administrator, unless the claimant fails to provide suff icient information to determine w hether, or to w hat extent, benefits are covered or payable under the Plan. In the case of such a failure, the Contract Administrator w ill not ify the claimant as soon as possible, but not later than tw enty -four (24) hours after receipt of the claim by the Contract Administrator, of the specif ic information necessary to complete the claim. The claimant w ill be afforded a reasonable amount of t ime, taking into account the circumstances, but not less than forty-eight (48) hours, to provide the specif ied information. Notif icat ion of any Adverse Benefit Determinat ion w ill be made in accordance w ith the requirements set forth in Sect ion III, Writ ten Denial Provisions, below . The Contract Administrator w ill not ify the claimant of the Plan' s benefit determinat ion as soon as possible, but in no case later than forty-eight (48) hours after the earlier of:

1. The Contract Administrator' s receipt of the specif ied information, or

2. The end of the period afforded the claimant to provide the specif ied

addit ional information.



(ii) Concurrent Care Decisions: If an ongoing course of treatment to be provided over a period of t ime or number of treatments has been approved by the Plan, any reduct ion or terminat ion by the Plan of such course of treatment (other than by Plan amendment or terminat ion) before the end of such period of t ime or number of treatments shall const itute an Adverse Benefit Determinat ion. The Contract Administrator w ill not ify the claimant, in a manner in accordance w ith the Writ ten Denial provisions set forth below , of the Adverse Benefit Determinat ion at a t ime suff icient ly in advance of the reduct ion or terminat ion to allow the claimant to appeal and obtain a determinat ion on review of that Adverse Benefit Determinat ion before the benefit is reduced or terminated.

Any request by a claimant to extend the course of treatment beyond the period of t ime or number of treatments that is a Claim involving Urgent Care shall be decided as soon as possible, taking into account the medical urgencies, and the Contract Administrator shall not ify the claimant of the benefit determinat ion, w hether adverse or not, w ithin tw enty-four (24) hours after receipt of the claim by the Contract Administrator, provided that any such claim is made to the Contract Administrator at least tw enty-four (24) hours prior to the expirat ion of the prescribed period of t ime or number of treatments. Notif icat ion of any adverse determinat ion concerning a request to extend the course of treatment, w hether involving Urgent Care or not, shall be made in accordance w ith the Writ ten Denial provisions set forth below , as appropriate.

(iii) Pre-Service Claim: In the case of a Pre-Service Claim, the Contract

Administrator shall not ify the claimant of the Plan' s benefit determinat ion (w hether adverse or not) w ithin a reasonable period of t ime appropriate to the medical circumstances, but not later than f if teen (15) days after receipt of the claim by the Contract Administrator. The period may be extended one t ime by the Plan for up to f if teen (15) days, provided that the Contract Administrator determines that such an extension is necessary due to matters beyond the control of the Plan and not if ies the claimant, prior to the expirat ion of the init ial f if teen (15) day period, of the circumstances requiring the extension of t ime and the date by w hich the Plan expects to render a decision. If such an extension is due to a failure of the claimant to submit the information necessary to decide the claim, the not ice of extension shall specif ically describe the information, and the claimant shall be afforded at least forty -f ive (45) days from receipt of the not ice w ithin w hich to provide the specif ied information. Notif icat ion of any Adverse Benefit Determinat ion pursuant to this paragraph shall be made in accordance w ith the Writ ten Denial provisions set forth below .

(iv) Post-Service Claim: In the case of a Post -Service Claim, the Contract

Administrator shall not ify the claimant, in accordance w ith the Writ ten Denial provisions set forth below , of the Plan' s Adverse Benefit Determinat ion w ithin a reasonable period of t ime, but not more than thirty (30) days after receipt of the claim. This period may be extended one t ime by the Contract Administrator for up to f if teen (15) days, provided that the Contract Administrator determines that such an extension is necessary due to matters beyond the control of the Plan and not if ies the claimant prior to the expirat ion of the init ial thirty (30) day period, of the circumstances requiring the extension of t ime and the date by w hich the Plan expects to render a decision. If such an extension is due to a failure of the claimant to submit the information necessary to decide the claim, the not ice of extension shall specif ically describe the information, and the claimant shall be afforded at least forty-f ive (45) days from receipt of the not ice w ithin w hich to provide the specif ied information.



(c) Addit ional Provisions Applicable to Benefits other than Health Benefits. If a claim for benefits other than health benefits is w holly or part ially denied, the Contract Administrator shall not ify the claimant of the Adverse Benefit Determinat ion w ithin a reasonable period of t ime not to exceed ninety (90) days after receipt of the claim by the Contract Administrator, unless the Contract Administrator determines that special circumstances require an extension of t ime for processing the claim. If the Contrac t Administrator determines that such an extension is required, w rit ten not ice (in accordance w ith the Writ ten Denial provisions set forth below ) of the extension shall be provided to the claimant prior to the terminat ion of the ninety (90) day period. In no event shall such extension exceed a period of ninety (90) days from the end of the init ial ninety (90) day period. The not ice of the extension provided to the claimant shall indicate the circumstances requiring an extension and the date by w hich the Contract Administrator expects to render the benefit determinat ion.

III. Written Denial Provisions

(a) Provisions Applicable to All Benefits under the Plan. The Contract Administrator shall provide a claimant w ith w rit ten or electronic not if icat ion of any determinat ion of a claim. In the case of an Adverse Benefit Determinat ion, the not if icat ion shall set forth in a manner calculated to be understood by the claimant:

(i) The specif ic reason(s) for the denial;

(ii) Specif ic references to pert inent Plan provisions upon w hich the denial is based;

(iii) A descript ion of any additional material or information necessary for the

claimant to perfect the claim, and an explanation of w hy such material or information is necessary;

(iv) An explanation of the Plan’s claim review procedures and the t ime limits

applicable to such procedures, including a statement of the claimant’s right to bring a civil act ion under Sect ion 502(a) of ERISA follow ing an adverse determinat ion on review .


In the case of an Adverse Benefit Determinat ion concerning health benefits, the not if icat ion shall also set forth in a manner calculated to be understood by the claimant:

(i) The specif ic internal rule, guideline, protocol, or other similar criterion if such

rule, guideline, protocol or other similar criterion w as relied upon in making the adverse determinat ion, or a statement that a copy of such rule, guideline, protocol or other similar criterion w ill be provided free of charge to the claimant upon request;

(ii) If the Adverse Benefit Determinat ion is based on a medical necessity or

experimental treatment or similar exclusion or limit , either an explanation of the scient if ic or clinical judgement for the determinat ion, applying the terms of the Plan to the claimant’s medical circumstances, or a statement that such explanation w ill be provided free of charge upon request;

(iii) In the case of an adverse determinat ion concerning a Claim involving Urgent

Care, a descript ion of the expedited review process applicable to such claims; and

(iv) In the case of a f inal internal Adverse Benefit Determinat ion, a discussion of the

decision.

In the case of an Adverse Benefit Determinat ion concerning an Urgent Care Claim, the information described above in this Sect ion III may be provided to the claimant orally, provided that a w rit ten or electronic not if icat ion is furnished to the claimant not later than three (3) days after the oral not if icat ion.



IV. Appeal of Adverse Benefit Determinations (a) Provisions Applicable to All Benefits under the Plan.

(i) Each claimant shall be afforded a full and fair review of any Adverse Benefit Determinat ion. In addit ion to complying w ith the other requirements described in these Claim Filing Procedures, the Contract Administrator w ill provide a claimant, free of charge, w ith any new or addit ional evidence considered, relied upon, or generated by the Contract Administrator in connect ion w ith its review of a claimant’s appeal. Such information w ill be provided as soon as possible and suff icient ly in advance of the date on w hich the not ice of f inal internal Adverse Benefit Determinat ion is to be provided to the claimant so that the claimant w ill have a reasonable opportunity to respond prior to that date. In addit ion, if the Contract Administrator intends to issue an Adverse Benefit Determinat ion on a claimant’s appeal that is based on a new or addit ional rat ionale from the one on w hich the claim w as originally decided, the claimant shall be provided, free of charge, w ith the new or addit ional rat ionale. The rat ionale w ill be provided as soon as possible and suff icient ly in advance of the date on w hich the not ice of f inal internal Adverse Benefit Determinat ion is to be provided to the claimant so that the claimant w ill have a reasonable opportunity to respond prior to that date.

(ii) Each claimant may appeal an Adverse Benefit Determinat ion w ithin one hundred

eighty (180) days follow ing receipt of not if icat ion of the Adverse Benefit Determinat ion.

(iii) In connect ion w ith such review , the claimant shall have the opportunity to

submit any w rit ten comments, documents, records or other information the claimant believes is relevant.

(iv) In connect ion w ith such review , the claimant shall be provided, upon request

and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claimant ' s appeal.

(v) The review of the Adverse Benefit Determinat ion shall take into account all

comments, documents, records and other information submitted by the claimant that relate to the claim, w ithout regard to w hether such information w as submitted or considered in the init ial benefit determinat ion.


(i) The review shall not afford deference to the init ial Adverse Benefit

Determinat ion.

(ii) The review shall be conducted by an appropriate named f iduciary of the Plan w ho is neither the individual w ho made the Adverse Benefit Determinat ion that is the subject of the review , nor a subordinate of such individual.



(iii) In deciding an appeal of an Adverse Benefit Determinat ion that is based in w hole or in part on a medical judgment, including determinat ions w ith regard to w hether a part icular treatment, drug, or other it em is experimental, invest igat ional, or not medically necessary or appropriate, the person conduct ing the review w ill consult w ith a health care professional w ho has appropriate training and experience in the f ield of medicine involved in the medical judgment. The health care professional engaged for purposes of consultat ion in accordance w ith the previous sentence shall be an individual w ho is neither an individual w ho w as consulted in connect ion w ith the Adverse Benefit Determinat ion that is the subject of the appeal nor the subordinate of any such individual.

(iv) The ident ity of medical or vocat ional experts w hose advice w as obtained on

behalf of the Plan in connect ion w ith a claimant' s Adverse Benefit Determinat ion, w ithout regard to w hether the advice w as relied upon in making the benefit determinat ion, w ill be provided to the claimant upon request.

(v) In the case of a Claim involving Urgent Care, an expedited review process w ill

be provided, pursuant to w hich a request for an expedited appeal to an Adverse Benefit Determinat ion may be submitted orally or in w rit ing by the claimant and all necessary information, including the Plan' s benefit determinat ion on review , shall be transmitted between the Plan and the claimant by telephone, facsimile, or other available similarly expedit ious method.

V. Timing of Notice of Benefit Determination Following Review (a) Provisions Applicable to All Benefits under the Plan.

(i) The various t ime periods set forth in this Sect ion V w ithin w hich the review of an Adverse Benefit Determinat ion must be completed shall begin at the t ime an appeal is f iled in accordance w ith the procedures of the Plan, w ithout regard to w hether all the information necessary to make a determinat ion on review accompanies the f iling.

(ii) If the period set forth in this Sect ion V is extended as permitted herein due to a

claimant ' s failure to submit information necessary to decide a claim, the period for making the determinat ion on review shall be tolled from the date on w hich the not if icat ion of the extension is sent to the claimant unt il the date on w hich the claimant responds to the request for addit ional information.


(i) Urgent Care Claims: In the case of a Claim involving Urgent Care, the Contract Administrator shall not ify the claimant, in accordance w ith the Notif icat ion of Benefit Determinat ion provisions below , of the Plan' s benefit determinat ion on review as soon as possible, taking into account the medical urgenc ies, but not later than seventy-tw o (72) hours after receipt of the claimant ' s request for review of an Adverse Benefit Determinat ion by the Plan.

(ii) Pre-Service Claims: In the case of a Pre-Service Claim, the Contract

Administrator shall not ify the claimant, in accordance w ith the Notif icat ion of Benefit Determinat ion provisions below , of the Plan' s benefit determinat ion on review w ithin a reasonable period of t ime appropriate to the medical circumstances. Such not if icat ion shall be provided not later than thirty (30) days after receipt by the Plan of the claimant' s request for review of an Adverse Benefit Determinat ion.

(iii) Post-Service Claims: In the case of a Post -Service Claim, the Contract

Administrator shall not ify the claimant, in accordance w ith the Notif icat ion of Benefit Determinat ion, of the Plan' s benefit determinat ion on review w ithin a reasonable period of t ime. Such not if icat ion shall be provided not later than sixty (60) days after receipt by the Plan of the claimant ' s request for review of an Adverse Benefit Determinat ion.



VI. Notification of Benefit Determination

(a) Provisions Applicable to All Benefits under the Plan. The Contract Administrator shall provide a claimant w ith a w rit ten or electronic not if icat ion of a Plan' s benefit determinat ion on review . In the case of an Adverse Benefit Determinat ion, the not if icat ion shall set forth, in a manner calculated to be understood by the claimant:

(i) The specif ic reason(s) for the adverse determinat ion; (ii) Reference to the specif ic Plan provisions on w hich the benefit determinat ion is

based;

(iii) A statement that the claimant is ent it led to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant ' s claim for benefits;

(iv) A statement describing any voluntary appeal procedures offered by the Plan and

the claimant' s right to obtain the information about such procedures, and a statement of the claimant' s right to bring an act ion under Sect ion 502(a) of ERISA; and

(v) A statement describing the claimant’s right, if any, to request external review

of a f inal internal Adverse Benefit Determinat ion or Adverse Benefit Determinat ion, as provided under the Patient Protect ion and Affordable Care Act of 2010.

(b) Provisions Applicable to Health Benefits. In the case of an Adverse Benefit Determinat ion on review concerning health benefits, the not if icat ion shall also set forth, in a manner calculated to be understood by the claimant:

(i) The specif ic internal rule, guideline, protocol, or other similar criterion if such rule, guideline, protocol or other similar criterion w as relied upon in making the adverse determinat ion (a copy of such rule, guideline, protocol or other similar criterion w ill be provided free of charge to the claimant upon request);

(ii) If the Adverse Benefit Determinat ion is based on a medical necessity or

experimental treatment or similar exclusion or limit , either an explanation of the scient if ic or clinical judgment for the determinat ion, applying the terms of the Plan to the claimant' s medical circumstances, or a statement that such explanation w ill be provided free of charge upon request; and

(iii) The follow ing statement: "You and your plan may have other voluntary

alternat ive dispute resolut ion opt ions, such as mediat ion. One w ay to f ind out w hat may be available is to contact your local U.S. Department of Labor Off ice and your State insurance regulatory agency."

MISCELLANEOUS PROVISIONS


MISCELLANEOUS PROVISIONS Discharge: All plan benefits made in accordance w ith the terms and provisions contained herein w ill discharge the Plan Sponsor from all future liability to the extent of the payments so made. Discretionary Authority: The Plan Administrator has the authority to interpret the Plan and to determine all quest ions that arise under it. This w ill include, but is not limited to: sat isfact ion of eligibility requirements, determinat ion of medical necessity, and interpretat ion of terms contained in this document. The Plan Administrator’s decisions w ill be b inding on all employees, dependents, and beneficiaries. Except for funct ions reserved by the Plan to the Employer or Board of Directors, the Plan Administrator w ill control and manage the operat ion and administrat ion of the Plan. In accordance w ith Sec. 503 of Tit le I of ERISA, the Plan Administrator w ill designate one or more named f iduciaries under the Plan, each w ith complete authority to review all denied claims for benefits under the Plan w ith respect to w hich it has been designated named f iduciary ( including, but not limited to, the denial of cert if icat ion of medical necessity of hospital or medical treatment). In exercising its f iduciary responsibilit ies, the named f iduciary w ill have discret ionary authority to determine w hether and to w hat extent part icipants and beneficiaries are ent it led to benefits and to construe disputed or doubtful Plan terms. The named f iduciary w ill be deemed to have properly exercised such authority unless it has abused its discret ion hereunder by act ing arbitrarily and capriciously. Federal Guidelines for a Plan Subject to the Employee Retirement Income Security Act of 1974 (ERISA): This Plan w ill comply w ith all federal law and guidelines relat ive to w elfare benefit plans under ERISA. These federal law s and guidelines w ill supersede any provisions and terminology contained herein w hich may be to the contrary. Family and Medical Leave Policy: All eligible employees have the right to take family and medical leave according to the provisions of the federal and state law s as amended from t ime to t ime. Increases/Decreases in Coverage: Any amendments to the Plan providing an increase in the amount of a covered employee’s and/or dependent’s coverage w ill become effect ive as of the date of such amendment, provided coverage is in effect on the date of such amendment. Any amendment to the Plan providing a decrease in the amount of a covered employee’s and/or dependent’s coverage w ill begin on the effect ive date of such amendment. Invalidity of Certain Provisions: If any provisions of the Plan w ill be held invalid or unenforceable, such invalidity or enforceability w ill not affect any other provision herein and this Plan w ill be construed and enforced as if such provisions had not been included. Medicare Provision: All eligible employees and their dependents, age sixty-f ive (65) and over, w ho are eligible for coverage under the Plan, w ill be provided w ith coverage under this Plan on the same basis as available to covered employees under the age of sixty -f ive (65). Each employee over the age of sixty-f ive (65) has the right to reject the employer provided group health plan and elect to have Medicare for the employee and their spouse as their only coverage. Should the employee elect this opt ion, Medicare w ill become the employee’s health insurance coverage. The absence of any w rit ten documentat ion to the contrary w ill construe this Plan as primary.



For an eligible employee or dependent under age sixty-f ive (65), if Medicare eligibility is due solely to end-stage renal disease (ESRD), the Plan w ill be primary only during the f irst thirty (30) months of Medicare coverage. Thereafter, the Plan w ill be secondary w ith respect to Medicare Coverage. If an eligible employee or dependent is under age sixty-f ive (65) w hen Medicare eligibility is due solely to ESRD, and the employee or dependent subsequently attains age sixty -f ive (65), the Plan w ill be primary for a full thirty (30) months from the date of ESRD eligibility. Thereafter, Medicare w ill be primary and the Plan w ill be secondary. If an eligible employee or dependent is age sixty -f ive (65) or over, w orking and develops or is undergoing treatment for ESRD, the Plan w ill be primary for a full thirty (30) months from the date of ESRD eligibility. Thereafter, Medicare w ill be primary and the Plan w ill be secondary. This provision w ill comply w ith the Social Security Act as amended from t ime to t ime. Qualified Medical Child Support Orders: Part icipants and beneficiaries may obtain upon request from the Contract Administrator, w ithout charge, a copy of the Plan' s procedures relat ing to qualif ied medical child support orders. Right to Make Payments: The Plan Administrator has the right to pay any other organizat ion as needed to properly deliver plan benefits. These payment s that are made in good faith are considered benefits paid under this Plan. Also, they discharge the Plan Administrator from further liability to the extent that payments are made. Right to Receive and Release Necessary Information: For the purpose of determining the applicability of and implementing the terms of this provision of this Plan, or any provision of similar purpose of another plan, the Plan Administrator may release to or obtain from any other insurance company or other organizat ion or person any information w ith respect to any person w hich the Contract Administrator deems to be necessary for such purposes. Any person claiming benefits under this Plan w ill furnish to the Contract Administrator such information as may be required to implement this provision in accordance w ith the HIPAA Privacy Requirements. Right to Recovery: Whenever the Plan has allow ed benefits to be paid w hich have been paid or should have been paid by any other plan, or w hich w ere erroneously paid, the Plan w ill have the right to recover any such excess payments from the appropriate party. Right to Amend the Plan: The Plan Sponsor has the authority to amend the Plan Document, modifying any of the provisions herein, or terminat ing the Plan at any t ime w ithout the consent of or not ice to any covered person hereunder. The Plan may be amended, modified, or terminated as required by plan ut ilizat ion, costs, market forces, federal legislat ion, or other general business concerns of the Plan Sponsor. When a Plan amendment, modif icat ion, or terminat ion is executed, the Plan Sponsor w ill provide not ice of such act ion, in w rit ing, to all covered persons. Should the Plan be amended and, thereby, terminated, the Plan Administrator w ill provide for: First : Payment of benefits to each covered person of all covered expenses for services

w hich w ere incurred w hile the Plan w as in effect. Second: Payment of expenses incurred in the liquidat ion and distribut ion of the Plan and any

payments due to the Plan Administrator.



Third: Direct disposit ion of all assets, if applicable, held in the Plan to covered persons as determined by the Plan Administrator, subject to the limitat ions contained herein and any applicable requirements of law or regulat ion.

Subrogation, Reimbursement & Third Party Recovery Provision:

Payment Condition

1. The Plan, in its sole discret ion, may elect to condit ionally advance payment of benefits in those situat ions w here an injury, sickness, disease or disability is caused in w hole or in part by, or results from the acts or omissions of Plan Part icipants, and/or their dependents, beneficiaries, estate, heirs, guardian, personal representat ive, or assigns (collect ively referred to hereinafter in this sect ion as “ Plan Part icipant(s)” ) or a third party, w here any party besides the Plan may be responsible for expenses arising from an incident, and/or other funds are available, including but not limited to no-fault , uninsured motorist , underinsured motorist , medical payment provisions, third party assets, third party insurance, and/or grantor(s) of a third party (collect ively “ Coverage” ).

2. Plan Part icipant(s), his or her attorney, and/or legal guardian of a minor or incapacitated

individual agrees that acceptance of the Plan’s condit ional payment of medical benefits is construct ive not ice of these provisions in their ent irety and agrees to maintain one hundred percent (100%) of the Plan’s condit ional payment of benefits or the full extent of payment from any one or combinat ion of f irst and third party sources in trust, w ithout disrupt ion except for reimbursement to the Plan or the Plan’s assignee. By accepting benefits the Plan Part icipant(s) agrees the Plan shall have an equitable lien on any funds received by the Plan Part icipant(s) and/or their attorney from any source and said funds shall be held in trust unt il such t ime as the obligat ions under this provision are fully sat isf ied. The Plan Part icipant(s) agrees to include the Plan’s name as a co-payee on any and all sett lement drafts.

3. In the event a Plan Part icipant(s) sett les, recovers, or is reimbursed by any Coverage, the

Plan Part icipant(s) agrees to reimburse the Plan for all benefits paid or that w ill be paid by the Plan on behalf of the Plan Part icipant(s). If the Plan Part icipant(s) fails to reimburse the Plan out of any judgment or sett lement received, the Plan Part icipant(s) w ill be responsible for any and all expenses (fees and costs) associated w ith the Plan’s attempt to recover such money.

4. If there is more than one party responsible for charges paid by the Plan, or may be

responsible for charges paid by the Plan, the Plan w ill not be required to select a part icular party from w hom reimbursement is due. Furthermore, unallocated sett lement funds meant to compensate mult iple injured part ies of w hich the Plan Part icipant(s) is/are only one or a few , that unallocated sett lement fund is considered designated as an “ ident if iable” fund from w hich the plan may seek reimbursement.

Subrogation

1. As a condit ion to part icipat ing in and receiving benefits under this Plan, the Plan Part icipant(s) agrees to assign to the Plan the right to subrogate and pursue any and all claims, causes of act ion or rights that may arise against any person, corporat ion and/or ent ity and to any Coverage to w hich the Plan Part icipant(s) is ent it led, regardless of how classif ied or characterized, at the Plan’s discret ion.

2. If a Plan Part icipant(s) receives or becomes ent it led to receive benefits, an automatic

equitable lien attaches in favor of the Plan to any claim, w hich any Plan Part icipant(s) may have against any Coverage and/or party causing the sickness or injury to the extent of such condit ional payment by the Plan plus reasonable costs of collect ion.

3. The Plan may, at its discret ion, in its ow n name or in the name of the Plan Part icipant(s)

commence a proceeding or pursue a claim against any party or Coverage for the recovery of all damages to the full extent of the value of any such benefits or condit ional payments advanced by the Plan.



4. If the Plan Part icipant(s) fails to f ile a claim or pursue damages against:

a) the responsible party, its insurer, or any other source on behalf of that party; b) any f irst party insurance through medical payment coverage, personal injury

protect ion, no-fault coverage, uninsured or underinsured motorist coverage; c) any policy of insurance from any insurance company or guarantor of a third party; d) w orker’s compensation or other liability insurance company; or e) any other source, including but not limited to crime vict im rest itut ion funds, any

medical, disability or other benefit payments, and school insurance coverage; the Plan Part icipant(s) authorizes the Plan to pursue, sue, compromise and/or sett le any such claims in the Plan Part icipant(s)’ and/or the Plan’s name and agrees to fully cooperate w ith the Plan in the prosecution of any such claims. The Plan Part icipant(s) assigns all rights to the Plan or its assignee to pursue a claim and the recovery of all expenses from any and all sources listed above.

Right of Reimbursement

1. The Plan shall be ent it led to recover 100% of the benefits paid, w ithout deduct ion for attorneys’ fees and costs or applicat ion of the common fund doctrine, make w hole doctrine, or any other similar legal theory, w ithout regard to w hether the Plan Part icipant(s) is fully compensated by his/her recovery from all sources. The Plan shall have an equitable lien which supersedes all common law or statutory rules, doctrines, and law s of any State prohibit ing assignment of rights w hich interferes w ith or compromises in any w ay the Plan’s equitable lien and right to reimbursement. The obligat ion to reimburse the Plan in full exists regardless of how the judgment or sett lement is classif ied and w hether or not the judgment or sett lement specif ically designates the recovery or a port ion of it as including medical, disability, or other expenses. If the Plan Participant(s)’ recovery is less than the benefits paid, then the Plan is ent it led to be paid all of the recovery achieved.

2. No court costs, experts’ fees, attorneys’ fees, f iling fees, or other costs or expenses of

lit igat ion may be deducted from the Plan’s recovery w ithout the prior, expressed w rit ten consent of the Plan.

3. The Plan’s right of subrogation and reimbursement w ill not be reduced or affected as a

result of any fault or claim on the part of the Plan Part icipant(s), w hether under the doctrines of causation, comparat ive fault or contributory negligence, or other similar doctrine in law . Accordingly, any lien reduct ion statutes, w hich attempt to apply such law s and reduce a subrogating Plan’s recovery w ill not be applicable to the Plan and w ill not reduce the Plan’s reimbursement rights.

4. These rights of subrogation and reimbursement shall apply w ithout regard to w hether

any separate w rit ten acknow ledgment of these right s is required by the Plan and signed by the Plan Part icipant(s).

5. This provision shall not limit any other remedies of the Plan provided by law . These

rights of subrogation and reimbursement shall apply w ithout regard to the locat ion of the event that led to or caused the applicable sickness, injury, disease or disability.

Excess Insurance

1. If at the t ime of injury, sickness, disease or disability there is available, or potent ially

available any Coverage (including but not limited to Coverage result ing from a judgment at law or sett lements), the benefits under this Plan shall apply only as an excess over such other sources of Coverage, except as otherw ise provided for under the Plan’s Coordinat ion of Benefits sect ion. The Plan’s benefits shall be excess to:

a) the responsible party, its insurer, or any other source on behalf of that party; b) any f irst party insurance through medical payment coverage, personal injury

protect ion, no-fault coverage, uninsured or underinsured motorist coverage;



c) any policy of insurance from any insurance company or guarantor of a third party; d) w orker’s compensation or other liability insurance company; or e) any other source, including but not limited to crime vict im rest itut ion funds, any

medical, disability or other benefit payments, and school insurance coverage. Separation of Funds Benefits paid by the Plan, funds recovered by the Plan Part icipant(s), and funds held in trust over w hich the Plan has an equitable lien exist separately from the property and estate of the Plan Part icipant(s), such that the death of the Plan Part icipant(s), or f iling of bankruptcy by the Plan Part icipant(s), w ill not affect the Plan’s equitable lien, the funds over w hich the Plan has a lien, or the Plan’s right to subrogation and reimbursement. Wrongful Death In the event that the Plan Part icipant(s) dies as a result of his or her injuries and a w rongful death or survivor claim is asserted against a third party or any Coverage, the Plan’s subrogation and reimbursement rights shall st ill apply, and the ent ity pursuing said claim shall honor and enforce these Plan rights and terms by w hich benefits are paid on behalf of the Plan Part icipant(s) and all others that benefit f rom such payment.

Obligations

1. It is the Plan Part icipant(s)’ obligat ion at all t imes, both prior to and after payment of medical benefits by the Plan:

a) to cooperate w ith the Plan, or any representat ives of the Plan, in protect ing its rights,

including discovery, attending deposit ions, and/or cooperat ing in trial to preserve the Plan’s rights;

b) to provide the Plan w ith pert inent information regarding the sickness, disease, disability, or injury, including accident reports, sett lement information and any other requested addit ional information;

c) to take such act ion and execute such documents as the Plan may require to facilitate enforcement of its subrogation and reimbursement rights;

d) to do nothing to prejudice the Plan’s rights of subrogation and reimbursement; e) to promptly reimburse the Plan w hen a recovery through sett lement, judgment, aw ard

or other payment is received; and f) to not sett le or release, w ithout the prior consent of the Plan, any claim to the extent

that the Plan Part icipant may have against any responsible party or Coverage.

2. If the Plan Part icipant(s) and/or his or her attorney fails to reimburse the Plan for all benefits paid or to be paid, as a result of said injury or condit ion, out of any proceeds, judgment or sett lement received, the Plan Part icipant(s) w ill be responsible for any and all expenses (w hether fees or costs) associated w ith the Plan’s attempt to recover such money from the Plan Part icipant(s).

3. The Plan’s rights to reimbursement and/or subrogation are in no w ay dependent upon the

Plan Part icipant(s)’ cooperat ion or adherence to these terms.

Offset Failure by the Plan Part icipant(s) and/or his or her attorney to comply w ith any of these requirements may, at the Plan’s discret ion, result in a forfeiture of payment by the Plan of medical benefits and any funds or payments due under this Plan on behalf of the Plan Part icipant(s) may be w ithheld unt il the Plan Part icipant(s) sat isf ies his or her obligat ion.



Minor Status

1. In the event the Plan Part icipant(s) is a minor as that term is def ined by applicable law , the minor’s parents or court -appointed guardian shall cooperate in any and all act ions by the Plan to seek and obtain requisite court approval to bind the minor and his or her estate insofar as these subrogation and reimbursement provisions are concerned.

2. If the minor’s parents or court -appointed guardian fail to take such act ion, the Plan shall have no obligat ion to advance payment of medical benefits on behalf of the minor. Any court costs or legal fees associated w ith obtaining such approval shall be paid by the minor’s parents or court -appointed guardian.

Language Interpretation The Plan Administrator retains sole, full and f inal discret ionary authority to construe and interpret the language of this provision, to determine all quest ions of fact and law arising under this provision, and to administer the Plan’s subrogation and reimbursement rights. The Plan Administrator may amend the Plan at any t ime w ithout not ice. Severability In the event that any sect ion of this provision is considered invalid or illegal for any reason, said invalidity or illegality shall not affect the remaining sect ions of this provision and Plan. The sect ion shall be fully severable. The Plan shall be construed and enforced as if such invalid or illegal sect ions had never been inserted in the Plan. The Use and Disclosure of Protected Health Information:

A. Use and Disclosure of Protected Health Information (PHI)

The Plan w ill use and/or disclose protected health information (PHI) (as such term is def ined in the HIPAA regulat ions) to the extent of and in accordance w ith the uses and disclosures permitted or required by the Health Insurance Portability and Accountability Act of 1996 and regulat ions promulgated pursuant thereto ("HIPAA" ). Specif ically, to the extent allow ed by law , the Plan w ill use and disclose PHI for purposes related to health care treatment, payment for health care, and health care operat ions.

B. The Plan Will Use and Disclose PHI in accordance with and as Required by Law and as Permitted by Authorization of the Plan Participant or Beneficiary

The Plan w ill disclose PHI in accordance w ith and as permitted or required by law . For example, (i) the Plan may disclose summary health information to the Plan Sponsor if the Plan Sponsor requests the summary information for the purpose of obtaining premium bids for health insurance coverage under the Plan, or for modifying, amending or terminat ing the Plan; (ii) the Plan may disclose to the Plan Sponsor information on whether an individual is part icipat ing in the Plan or is enrolled in or has disenrolled from a health insurance issuer or HMO offered by the Plan; and (iii) to the extent allow ed by law , the Plan may use and disclose PHI for purposes related to health care treatment, payment for health care, and health care operat ions. Except for these uses and disclosures permitted or required by HIPAA, the Plan shall obtain a w rit ten authorizat ion from the individual w ho is the subject of the PHI prior to a disclosure. "Summary health information" means information that may be individually ident if iable health information and that summarizes the claims history, claims expenses, or type of claims experienced by individuals for w hom the Plan Sponsor has provided health benefits under the Plan; and from w hich ident ifying information has been deleted, except that geographic information may be aggregated at the level of a f ive digit zip code.



C. For Purposes of This Section, the Plan Sponsor is named in the General Information section herein

The Plan has received a cert if icat ion from the Plan Sponsor that the separate Plan documents (if any) have been amended to incorporate the provisions set forth in D, below .

D. With Respect to PHI, the Plan Sponsor Agrees to the Following Conditions

The Plan Sponsor agrees to:

not use or further disclose PHI other than as permitted or required by the Plan documents or as required by law ;

ensure that any agents, including a subcontractor, to w hom the Plan Sponsor provides PHI received from the Plan agree to the same restrict ions and condit ions that apply to the Plan Sponsor w ith respect to such PHI;

not use or disclose PHI for employment -related act ions and decisions unless authorized by an individual in accordance w ith HIPAA;

not use or disclose PHI in connect ion w ith any other benefit or employee benefit plan of the Plan Sponsor unless authorized by an individual in accordance w ith HIPAA;

report to the Plan any PHI use or disclosure that is inconsistent w ith the uses or disclosures provided for of w hich it becomes aw are;

make PHI available to an individual in accordance w ith HIPAA' s access requirements;

make PHI available for amendment and incorporate any amendments to PHI in accordance w ith HIPAA;

make available the information required to provide an accounting of disclosures in accordance w ith HIPAA;

make internal pract ices, books and records relat ing to the use and disclosure of PHI received from the Plan available to the U.S. Secretary of Health and Human Services for the purposes of determining the Plan' s compliance w ith HIPAA; and

if feasible, return or destroy all PHI received from the Plan that the Plan Sponsor st ill maintains in any form, and retain no copies of such PHI w hen no longer needed for the purpose for w hich disclosure w as made (or if return or destruct ion is not feasible, limit further uses and disclosures to those purposes that make the return or destruct ion infeasible); and

implement administrat ive, physical and technical safeguards that reasonably and appropriately protect the conf ident iality, integrity and availability of the electronic protected health information.

E. Adequate Separation Between the Plan and the Plan Sponsor Must Be Maintained

In accordance w ith HIPAA, only the follow ing employees or classes of employees may be given access to PHI:

the benefits manager; and

staff designated by the benefits manager.



The follow ing employees, classes of employees or other persons under the Plan Sponsor' s control may have access to PHI including PHI relat ing to payment under, health care operat ions of, or other matters pertaining to the administrat ion of the Plan in the ordinary course of business:

Benefits Department

F. Limitations of PHI Access and Disclosure

The Plan may disclose PHI to the Plan Sponsor (via the persons described in sect ion E), and the Plan Sponsor may use and further disclose such PHI, only w hen the Plan Sponsor is either: (i) performing plan administrat ion funct ions that the Plan Sponsor performs for the Plan or (ii) act ing on behalf of the Plan; provided that the Plan Sponsor may only use or disclose PHI to the same ext ent as w ould be permitted by the Plan under the HIPAA regulat ions.

G. Noncompliance Issues

If Plan Sponsor personnel do not comply w ith this Plan document, the Plan Sponsor shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanct ions.

H. Security Requirements

The security rule requires plans to comply w ith four (4) general requirements. The plan must:

ensure the conf ident iality, integrity, and availability of all electronic

protected health information that it creates, receives, maintains, or transmits;

protect against any reasonably ant icipated threats or hazards to the security or integrity of the electronic protected health information;

protect against any reasonably ant icipated uses or disclosures of electronic protected health information that are not permitted or required under HIPAA; and

ensure compliance w ith the security standards by its w orkforce.

ERISA STATEMENT OF RIGHTS


ERISA STATEMENT OF RIGHTS

As a part icipant in this Plan, the employee is ent it led to certain rights and protect ion under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan part icipants w ill be ent it led to:

1. Examine, w ithout charge, at the Plan Administrator’s off ice all Plan documents including insurance contracts and copies of all documents f iled by the Plan w ith the U.S. Department of Labor, such as detailed annual reports and plan descript ions.

2. Obtain copies of all Plan documents and other plan information upon w rit ten request

to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies.

3. Receive a summary of the Plan’s annual f inancial report. The Plan Administrator is

required by law to furnish each part icipant w ith a copy of this summary annual report.

4. File suit in a federal court if any materials requested are not received w ithin thirty

(30) days of the part icipant ’s request, unless the materials w ere not sent because of matters beyond the control of the Plan Administrator. The court may require the Plan Administrator to pay up to $110 per day unt il the employee receives the materials.

5. File suit in a state or a federal court if the employee is improperly denied a w elfare

benefit in w hole or in part. The employee must receive a w rit ten explanation of the reason for the denial. The employee has the right to have the Plan review and reconsider the employee’s or their dependent’s claim.

6. Seek assistance from the U.S. Department of Labor or f ile suit in a federal court if :

a) plan f iduciaries misuse the Plan’s money. In addit ion to creat ing rights

for Plan part icipants, ERISA imposes dut ies to the people w ho are responsible for this operation of the Plan. The people w ho operate the employee’s Plan called “ f iduciaries” of the Plan, have a duty to do so prudently and in the interest of the employee and other Plan part icipants.

b) the employee is discriminated against for assert ing the employee’s rights. The employee’s employer may not f ire the employee or otherw ise discriminate against the employee in any w ay to prevent the employee from obtaining a w elfare benefit or exercising the employee’s rights under ERISA.

The court w ill decide w ho should pay court costs and legal fees. Should the employee be successful, the court may require the other party to pay the employee’s legal costs and fees. Group health plans and health insurance issuers generally may not, under federal law , restrict benefits for any hospital length of stay in connect ion w ith childbirth for the mother or new born child to less than forty-eight (48) hours follow ing a vaginal delivery, or less than ninety-six (96) hours follow ing a cesarean sect ion, How ever, federal law generally does not prohibit the mother’s or new born’s attending provider, after consult ing w ith the mother, from discharging the mother or her new born earlier than forty-eight (48) or ninety-six (96) hours as applicable. In any case, plans and issuers may not, under federal law , require that a provider obtain authorizat ion from the plan or the issuer for prescribing a length of stay not in excess of forty -eight (48) hours or ninety-six (96) hours. Should the employee have any quest ions about this statement or about the employee’s rights under ERISA, the employee should contact the nearest off ice of the Employee Benefits Security Administrat ion, U.S. Department of Labor, listed in the telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administrat ion, U.S. Department of Labor, 200 Const itut ion Avenue, N.W. Washington D.C. 20210.

DEFINITIONS


DEFINITIONS

The follow ing w ords and phrases are included here for explanatory purposes only. This list is not intended to include all terms used herein. Any w ord or phrase not specif ically def ined below w ill have its usual and customary meaning. The inclusion of any w ord or phrase below is not intended to imply that coverage is provided under the Plan w ith respect to any such condit ion, service, facility, or person. Accident: An unforeseen or unexplained sudden injury occurring by chance w ithout intent or volit ion. Active Service: An employee w ill be considered in act ive service w ith the employer on a day w hich is one of the employee’s scheduled w ork days if he is performing in the customary manner all of the regular dut ies of their employment w ith the employer on that day, either at one o f the employer’s business establishments or at some locat ion to w hich the employer’s business requires him to t ravel. A regular vacat ion day, properly scheduled in accordance w ith normal pract ices and policies of National Franchisee Associat ion Health + Medical Plan w ill qualify as a scheduled w ork day for purposes of this def init ion. Adverse Benefit Determination: Any of the follow ing: a denial, reduct ion, or terminat ion of, or a failure to provide or make payment (in w hole or in part) for, a benefit , including any such denial, reduct ion, terminat ion, or failure to provide or make payment that is based on a determinat ion of a part icipant’s beneficiary’s eligibility to part icipate in the Plan, and including, w ith respect to group health plans, a denial, reduct ion, or terminat ion of, or a failure to provide or make payment (in w hole or in part) for, a benefit , result ing from the applicat ion of any ut ilizat ion review , as w ell as a failure to cover an item or service for w hich benefits are otherw ise provided because it is determined to be experimental or invest igat ional or not medically necessary or appropriate.

Aggregate: The combined total of all family members. Ambulatory Surgical Center: A facility w hich is not physically attached to a health care faci lity, w hich provides surgical treatment to pat ients not requiring hospitalizat ion, and does not include the off ices of private physicians or dent ists w hether in an individual or group pract ice. Birthing Center: A public or private facility, other than private off ices or clinics of physicians, w hich meets the free standing birthing center requirements of the State Department of Health in the state w here the covered person receives the services. The birthing center must provide: a facility w hich has been established, equipped, and operated for the purpose of providing prenatal care, delivery, immediate postpartum care and care of a child born at the center; supervision of at least one (1) specialist in obstetrics and gynecology; a physician or cert if ied nurse midw ife at all births and immediate postpartum period; extended staff privileges to physicians w ho pract ice obstetrics and gynecology in a area hospital; at least tw o (2) beds or tw o (2) birthing rooms; full-t ime nursing services directed by an R.N. or cert if ied nurse midw ife; arrangements for diagnostic x-ray and lab services; and the capacity to administer local anesthet ic or to perform minor surgery. In addit ion, the facility must only accept pat ients w ith low risk pregnancies, have a w rit ten agreement w ith a hospital for emergency transfers and maintain medical records on each pat ient and child. Claim for benefits: A request for a Plan benefit or benefits made by a claimant in accordance w ith the Plan' s procedure for f iling benefit claims. This includes any Pre-Service Claims and any Post -Service Claims.

DEFINITIONS


Claim involving Urgent Care: Any claim for medical care or treatment w ith respect to w hich the applicat ion of the t ime periods for making non-urgent care determinat ion:

(i) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum funct ion; or

(ii) In the opinion of a physician w ith know ledge of the claimant ' s medical condit ion, w ould subject the claimant to severe pain that cannot be adequately managed w ithout the care or treatment that is the subject of the claim;

Except as set forth in the next paragraph, w hether a claim is a Claim involving Urgent Care is to be determined by an individual acting on behalf of the Plan applying the judgment of a prudent layperson w ho possesses an average know ledge of health and medicine.

Any claim that a physician w ith know ledge of the claimant ' s medical condit ion determines is a Claim involving Urgent Care shall be treated as Claim involving Urgent Care.

Clinical Trial: A Phase I, II, III or IV clinical trial that meets the follow ing condit ions:

1. The clinical trial is intended to treat cancer or other life threatening condit ion in a pat ient w ho has been diagnosed; and

2. The clinical trial has been peer review ed and is approved or funded by at least one of the follow ing:

a. The National Inst itutes of Health, b. The Centers for Disease Control and Prevention, c. The Agency for Health Care Research and Quality, d. The Centers for Medicare and Medicaid Services, e. A cooperat ive group or center of the ent it ies described in a. -d. above, f . A qualif ied non-governmental research ent ity ident if ied in guidelines issued

by the National Inst itutes of Health for center support grants, g. The United States Food and Drug Administrat ion pursuant to an

invest igat ional new drug exemption, h. Under certain condit ions, the United States Department of Defense of

Veterans Affairs, Department of Defense, or Department of Energy, i. Or, w ith respect to Phase II, III and IV clinical trials, a qualif ied

inst itut ional review board. 3. The facility and personnel conduct ing the clinical trial are capable of doing so by

virtue of their experience and training and treat a suff icient volume of pat ients to maintain that expert ise, and

4. The pat ient meets the patient select ion criteria enunciated in the study protocol for part icipat ion in the clinical trial, and

5. The pat ient has provided informed consent for part icipat ion in the clinical trial in a manner that is consistent w ith current legal and ethical standards, and

6. The available clinical or pre-clinical data provide a reasonable expectat ion that the pat ient ’s part icipat ion in the clinical trial w ill provide a medical benefit that is commensurate w ith the risks of part icipat ion in the clinical trial, and

7. The clinical trial must have a preventive, diagnost ic, or therapeutic intent and must, to some extent, assess the effect of the intervent ion on the pat ient .

DEFINITIONS


Coinsurance: Coinsurance percentages represent the port ions of covered expenses paid by the covered person and by the Plan after sat isfact ion of any applicable deduct ible. These percentages apply only to covered expenses w hich do not exceed the maximum allow able benefit . The covered person is responsible for all non-covered expenses and any amount w hich exceeds the maximum allow able benefit for covered expenses. Contract Administrator: Third party claims administrator, hired by the Plan Sponsor to handle the day-to-day administrat ion of the Plan, including:

1. review ing and processing claims for proper benefit payments and providing explanation of benefits to covered employees and/or providers;

2. remitt ing benefit payments for covered expenses under the Plan to covered

employees and/or providers;

3. review ing all claims appeals. Contributory Coverage: Plan benefits for w hich an employee enrolls and agrees to make any required contribut ions tow ard the cost of coverage. Convalescent Hospital/Extended Care Facility/Skilled Nursing Facility: An inst itut ion w hich is licensed pursuant to state and/or local law s and is operated primarily for the purpose of providing treatment for individuals convalescing from injury or illness, including that part or unit of a hospital w hich is similarly const ituted and operated, and:

1. Has organized facilit ies for medical treatment and provides for tw enty-four (24) hour nursing service under the full-t ime supervision of a physician or a registered nurse. Full-t ime supervision means a physician or a registered nurse is regularly on the premises at least forty (40) hours per w eek;

2. Maintains daily clinical records concerning each pat ient and has a w rit ten agreement

or arrangement w ith a physician to provide services and emergency care for its pat ients;

3. Provides appropriate methods for dispensing and administering drugs and medicines;

4. Has transfer agreements w ith one (1) or more hospitals, a ut ilizat ion review

procedures in effect, and operat ional policies developed w ith the advice of and review ed by a professional group including at least one (1) physician. A convalescent hospital/extended care facility w ill not include any inst itut ion w hich is a rest home for the aged, or a place for the treatment of mental disease, drug addict ion or alcoholism, or a nursing home.

5. Qualif ies as an “ extended care facility” under the health insurance provided by Tit le

XVIII of the Social Security Act, at the t ime. Covered Person: A covered employee or a covered dependent as determined under the applicable Plan provision. Custodial Care: Care w hich is designed essentially to help a person in the activit ies of daily l iving and w hich does not require the cont inuous attent ion of trained medical or paramedical personnel. Custodial care includes services that could be performed by a relat ive or friend w ith minimal instruct ion or supervision. Custodial Parent: The parent aw arded custody by court decree. If there is no court decree, the custodial parent is the one w ith w hom the child resides for more than half the year. Day of Confinement: Any period of tw enty-four (24) hours or any part thereof for w hich a full charge for room and board is made by a hospital.

DEFINITIONS


Day Treatment: Mental Health care on an individual or group basis for more than tw o (2) hours but less than tw enty-four (24) hours per day in either a licensed hospital, rural health center, community mental health center. This type of care is also referred to as part ial hospitalizat ion. Deductible: The amount of covered expenses the covered employee must pay during each plan year before the Plan w ill consider expenses for reimbursement. The individual deduct ible applies separately to each covered person. The family deduct ible is the maximum deduct ible applied to each family. When the family deduct ible is sat isf ied, no further deduct ible w ill be applied for any covered family member during the remainder of t hat plan year. Dental Services: Procedures involving the teeth, gums, or support ing structures. Dentist: A duly licensed doctor of dent istry and a dental professional or pract it ioner w ho is duly licensed under appropriate state licensing authorit ies, provided a benefit is claimed for services w hich are w ithin the scope of such person’s license and for w hich a reimbursement under the Plan w ould be made had such services been performed by a doctor of dent istry, and under applicable state law s, such professional or pract it ioner must be treated under the Plan in the same manner as if such services w ere provided by a doctor of dent istry. Dependent:

1. The law ful spouse of an eligible employee; or

2. the married or unmarried child of an eligible employee w ho has not attained their tw enty-sixth (26 th) birthday.

The term “ law ful spouse,” as used above, means an eligible employee' s same or opposite-sex spouse, provided that such individual is legally recognized as the eligible employee' s spouse in any jurisdict ion (such as a State or foreign country), and even if the individual is not recognized as the eligible employee' s spouse in the employee' s State of residence. The w ord “ child” , as used above, w ill include an eligible employee’s natural child, a legally adopt ed child (including a child in the custody of the employee under an interim court order of adoption, w hether or not a f inal adoption order is ever issued), a stepchild, a foster child, or a child for w hom legal guardianship has been granted, but excludes a child w ho is eligible for employee coverage under this Plan. Should an employee have a child covered under the Plan w ho reaches the age at w hich the child w ould otherw ise cease to be a covered person and if such child is then mentally or physically handicapped and incapable of earning his ow n living, the Plan w ill cont inue to consider such child as a dependent beyond such age, w hile such child remains in such condit ion, subject to all of the terms of the Plan, provided the employee has, w ithin thirty -one (31) days of the date on w hich the child attained such age, submitted proof of the child’s incapacity, as described above. The Plan Sponsor w ill have the right to require sat isfactory proof of cont inuance of such mental or physical incapacity and the right to examine such child at any t ime after receiving proof of the child’s incapacity. Upon failure to submit such required proof or to permit such an examinat ion w hen requested by the Plan Sponsor, or w hen the child ceases to be so incapacitated, coverage w ith respect to the child w ill cease. This cont inuation of coverage w ill be subject to all the provisions of the “ Terminat ion of Benefits” sect ion of this Plan except as modif ied herein. Dependent Coverage: Plan benefits extended to the dependent(s) of a covered employee. Durable Medical Equipment: Equipment able to w ithstand repeated use for the therapeutic treatment of an act ive illness or injury. Such equipment w ill not be covered under the plan if it could be useful to a person in the absence of an illness or injury and could be purchased w ithout a physician’s prescript ion.

DEFINITIONS


Effective Date: The date the Plan becomes liable to provide coverage under the terms of the Plan. Eligibility Date: The date an employee and/or their dependent(s) become eligible to enroll in the Plan. Employee: Any employees w ho qualify for employee coverage under the eligibility requirements set forth in the “ General Information” sect ion contained herein. The def init ion of an employee does not include independent contractors, cont ingent w orkers, or leased employees. Employee Coverage: Group medical benefits provided under the Plan on behalf of a covered employee. Employer: The company providing employment to the covered employees. Enrollment Date: The f irst day of coverage under the Plan or, if there is a w ait ing period, the f irst day of the w ait ing period. This date is frequently, but not alw ays, the date of hire. Expense: A charge a covered person is legally obligated to pay. An expense is deemed to be incurred on the date the service or supply is furnished. Experimental/Investigative: A drug, device, medical treatment or procedure that is not the subject of, or in some manner related to, the conduct of a Clinical Trial, as such term is def ined herein, is experimental or invest igat ive:

a) if the drug or device cannot be law fully marketed w ithout approval of the U.S. Food and Drug Administrat ion and approval for market ing has not been given at the t ime the drug or device is furnished; or

b) if the drug, device, medical treatment or procedure, or the pat ient informed consent document ut ilized w ith the drug, device, treatment, or procedure, w as review ed and approved by the treat ing facility’s Inst itut ional Review Board or other body serving a similar funct ion, or if federal law requires such review or approval; or

c) if reliable evidence show s that the drug, device, medical treatment, or procedures is the subject of on-going phase I or phase II clinical trials, is the research, experimental, study or invest igat ional arm of on-going phase III clinical trials, or is otherw ise under study to determine its maximum tolerated dose, its toxicity, its safety, its eff icacy or its eff icacy as compared w ith a standard means of treatment or diagnosis; or

d) if reliable evidence show s that the prevailing opinion among experts regarding the drug, device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its eff icacy or its eff icacy as compared w ith a standard means of treatment or diagnosis.

Reliable evidence w ill mean only published reports and art icles in the authoritat ive medical and scient if ic literature; the w rit ten protocol or protocols used by the treat ing facility or the protoc ol(s) of another facility studying substant ially the same drug, device, medical treatment or procedure; or the w rit ten informed consent used by the treat ing facility or by another facility studying substant ially the same drug, device, medical treatment or procedure. Fiduciary: A f iduciary exercises discret ionary authority or control over management of the Plan or the disposit ion of its assets; renders investment advice to the Plan; or has discret ionary authority or responsibility in the administrat ion of the Plan. Health Care Operations: include, but are not limited to the follow ing act ivit ies:

quality assessment;

populat ion-based act ivit ies relat ing to improving health or reducing health care costs, protocol development, case management and care coordinat ion, disease management, contact ing health care providers and pat ients w ith information about treatment alternat ives and related funct ions;

DEFINITIONS


rat ing provider and plan performance, including accreditat ion, cert if icat ion, licensing or credentialing act ivit ies;

underw rit ing, premium rat ing and other act ivit ies relat ing to the creat ion, renew al or replacement of a contract of health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relat ing to health care claims (including stop-loss insurance and excess of loss insurance);

conduct ing or arranging for medical review , legal services and audit ing functions, including fraud and abuse detect ion and compliance programs;

business planning and development, such as conduct ing cost-management and planning-related analyses related to managing and operat ing the Plan, including formulary development and administrat ion, development or improvement of payment methods or coverage policies;

business management and general administrat ive act ivit ies of the Plan, including, but not limited to:

a) management act ivit ies relat ing to the implementat ion of and compliance w ith HIPAA’s administrat ive simplif icat ion requirements, or

b) customer service, including the provision of data analyses f or policyholders, plan sponsors or other customers;

resolut ion of internal grievances;

the sale, transfer, merger, or consolidat ion of all or part of the " covered ent ity" w ithin the meaning of HIPAA w ith another covered ent ity, or an ent ity that follow ing such act ivity w ill become a covered ent ity and due diligence related to such act ivity; and

consistent w ith the applicable requirements of the regulat ions issued under HIPAA, creat ing de-ident if ied health information or a limited data set, and fundraising f or the benefit of the " covered ent ity" w ithin the meaning of HIPAA.

Health Care Professional: A physician or other health care professional licensed, accredited, or cert if ied to perform specif ied health services consistent w ith State law .

Home Health Care Agency: A licensed and state approved home health care facility possessing a valid cert if icate of approval issued in accordance w ith Tit le XVIII of the Social Security Act and licensed and approved by the appropriate state authorit ies w hich specializes in providing health care and therapeutic services to a person in such person’s home. Home Health Care Plan: A program for care and treatment of a covered person established and approved, in w rit ing, by such covered person’s attending physician, together w ith such physician’s cert if icat ion that the proper treatment of the injury or sickness w ould require conf inement as a resident inpat ient in a hospital or conf inement in a skilled nursing facility as def ined in Tit le XVIII of the Social Security Act, at the t ime, in the absence of services and supplies provided as part of the home health care plan. Hospice: An agency that provides counseling and incidental medical services for a terminally ill individual w ho has been diagnosed by a physician as having a l ife expectancy of six (6) months or less. Room and board may be provided. The agency must meet all of the follow ing tests: (i) approved under any required state or governmental Cert if icate of Need; (ii) provides tw enty -four (24) hour a day, seven (7) day a w eek service; (iii) it is under the full-t ime supervision of at least one (1) duly qualif ied physician; (iv) has a nurse coordinator w ho is a registered graduate nurse w ith at least four (4) years of full-t ime clinical experience. Tw o (2) of these years must involve caring for terminally ill pat ients; (v) has a social service coordinator w ho is licensed in the area in w hich it is located; (vi) the main purpose of the agency is to provide hospice services; (vii) has a full -t ime administrator; (viii) maintains w rit ten records of services given to each pat ient; (ix) its employees are bonded; (x) it provides malpract ice and malplacement insurance; (xi) is established and operated in accordance w ith any applicable state law s.

DEFINITIONS


Hospital: A duly licensed, if required, and legally-const ituted and operated inst itut ion w hich is primarily engaged in providing diagnost ic services, therapeutic services for diagnosis, care and treatment of sick or injured persons on an inpat ient and/or outpat ient basis, and w hich provides such care and treatment: (i) under the supervision of one (1) or more physicians, (ii) w ith tw enty -four (24) hour nursing service under the supervision of one (1) or more physicians licensed to pract ice medicine; and (iii) w hich has organized facilit ies for laboratory and diagnost ic w ork and major surgery. The term “ Hospital” w ill not include, other than incidentally, an inst itut ion w hich is primarily a rest home, a nursing home, a convalescent home, a rehabilitat ion center, an extended care facility, a place (primarily) for the treatment of tuberculosis, mental, emotional, drug or alcoholic disorders, or a home for the aged. Services rendered in the inf irmary or clinic of a college, university, or private boarding school w ill be eligible expenses. In such instances, if a covered person is conf ined in a school facility that does not meet the def init ion of a hospital because it has no operat ing room, benefits may be paid, provided the charges for such conf inement do not exceed the maximum allow able benefit for the disability involved. Hospital Confinement: Being registered as a bed-pat ient in a hospital upon the recommendation of a physician, or as a result of a surgical operat ion, or by reason of receiving emergency medical care. Illness: Sickness or disease w hich results in expenses for medical care, services, and supplies covered by the Plan. Such expense must be incurred w hile the covered person, w hose illness is the basis of the claim, is covered under the Plan. Medical expenses incurred by a covered person because of pregnancy w ill be covered to the same extent as any other illness. Injury: Accidental bodily harm result ing from an accident. Inpatient Basis: Hospital conf inement including one (1) or more days of conf inement for w hich a room and board charge is made by a hospital. Intensive Care Unit: An accommodation in or part of a hospital, other than a post -operat ive recovery room, w hich, in addit ion to providing room and board:

1. Is established by the hospital for the purpose of providing formal intensive care;

2. Is exclusively reserved for crit ically ill pat ients requiring constant audio/visual observat ion prescribed by a physician and performed by a physician or by a specif ically trained registered nurse; and

3. Provides all necessary lifesaving equipment, drugs, and supplies in the immediate

vicinity on a standby basis. Maintenance Therapy: Any treatment, service, or therapy that preserves the member’s level of funct ion and prevents regression of that funct ion. Maintenance therapy begins w hen therapeutic goals of a treatment plan have been achieved or w hen no further funct ional progress is apparent or expected to occur. Maximum Allowable Benefit: An amount a provider is allow ed for a part icular service. If an out -of-netw ork provider charges more than the maximum allow able benefit , the Plan w ill not cover more than the maximum allow able benefit and the person is responsible for the dif ference. Medical Emergency: The sudden, unexpected onset of a medical condit ion w ith severe symptoms that are considered hazardous to the pat ient ’s life, health, or physical w ell-being, requiring urgent and immediate medical attent ion. Medical Intervention: Any medical treatment, service procedure, facility, equipment, drug, device, or supply.

DEFINITIONS


Medically Necessary: Health care services, supplies, or treatment w ill be considered medically necessary if :

a) there is a sickness or injury w hich requires treatment; or b) the conf inement, service, or supply used to treat the sickness or injury is:

- required; - generally professionally accepted as usual, customary, and effect ive

means of treat ing the sickness or injury in the United States; and - approved by regulatory authorit ies such as the Food & Drug

Administrat ion; and c) diagnost ic x-rays and laboratory tests w hen they are performed due to def inite

symptoms of sickness or injury, or they reveal the need for treatment.

Mental Hospital: An inst itut ion (other than a hospital as def ined) w hich specializes in the diagnosis and treatment of mental illness or funct ional nervous disorders and w hich is operated pursuant to law and meets all of the follow ing requirements:

1. Is licensed to give medical treatment and is operated under the supervision of a physician;

2. Offers nursing services by registered graduate nurses (RN) or licensed pract ical

nurses (LPN) and provides, on the premises, all the necessary facilit ies for medical treatment;

3. Is not, other than incidentally, a place of rest or a place for the aged, drug addicts,

or alcoholics; or a place for convalescent, custodial, or educational care. Mental Illness: Neuroses, psychoneuroses, psychoses, and other mental and emotional disorders falling w ithin any of the diagnost ic categories in the mental disorders sect ion of the internat ional classif icat ion of diseases. Never Events: These events, as def ined by The National quality Forum, a private organizat ion w hose members include the American Medical Associat ion (AMA), are “ errors in medical care that are clearly ident if iable, preventable, and serious in their consequences for pat ients, and that indicate a real problem in the safety and credibility of a health care facility.” Newborn Care Charges: Charges for care of new born children as more specif ically def ined herein. Non-Contributory Coverage: Plan benefits for w hich the employee enrolls and for w hich he is not required to make contribut ion tow ard the cost of coverage. Out-of-Pocket Maximum: Under the terms of this Plan, the maximum amount any individual covered under the Plan w ould be required to pay tow ard the maximum allow able benefit on all covered expenses during a plan year. The out-of-pocket maximum w ill be determined by adding the deduct ible, employee share of coinsurance amounts, and medical copayments as set forth by this Plan. Outpatient Basis: Any hospital expenses incurred for w hich no room and board charge is made. Outpatient Mental Health Treatment Facility: A comprehensive, health service organizat ion, a licensed or accredited hospital, or community mental health center or other mental health clinic or day care center w hich furnished mental health services w ith the approval of the appropriate governmental authority, any public or private facility or port ion thereof providing services especially for the diagnosis, evaluat ion, service or treatment of mental illness or emotional disorder.

DEFINITIONS


Payment: Includes act ivit ies undertaken by the Plan to obtain premiums or determine or fulf ill its responsibility for the coverage and provision of plan benefits or to obtain or provide reimbursement for the provision of health care that relate to an individual to w hom health care is provided. These act ivit ies include, but are not limited to, the follow ing:

determinat ion of eligibility, coverage and cost sharing amounts (for example, cost of a benefit , plan maximums and copayments as determined for an individual' s claim);

coordinat ion of benefits;

adjudicat ion of health benefit claims (including appeals and other payment disputes);

subrogation of health benefit claims;

establishing employee contribut ions;

risk adjust ing amounts due based on enrollee health status and demographic characterist ics;

billing, collect ion act ivit ies and related health care data processing;

claims management and related health care data processing, including audit ing payments, invest igat ing and resolving payment disputes and responding to part icipant inquiries about payments;

obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance);

medical necessity review s or review s of appropriateness of care or just if icat ion of charges;

ut ilizat ion review , including precert if icat ion, preauthorizat ion, concurrent review and retrospect ive review ; and

disclosure to consumer report ing agencies related to the collect ion of premiums or reimbursement (the follow ing PHI may be disclosed for payment purposes: name and address, date of birth, Social Security number, payment history, account number and name and address of the provider and/or health plan).

Patient Care Services: Medical covered services, as described in this Plan, that are furnished to an individual enrolled in a Clinical Trial, as such term is def ined here, w hich are consistent w ith the usual and customary standard of care for someone w ith the pat ient ’s diagnosis and, are consistent w ith the study protocol for the Clinical Trial. Notw ithstanding the foregoing, pat ient care services do not include any of the follow ing:

1. The invest igat ional item, device, drug, or service w hich is the subject of the Clinical

Trial; 2. Any other FDA approved drug or device w hich is used during the course of the Clinical

Trial and is paid for by the manufacturer, the distributor or the provider of the drug or device;

3. non-health care services that a pat ient may be required to receive as a result of being enrolled in the Clinical Trial;

4. costs associated w ith managing the research related to the Clinical Trial (including items and services that are provided solely to sat isfy date collect ion and analysis needs and are not used in the direct clinical management of the pat ient;

5. costs that w ould not be covered under the Plan for non-invest igat ional/experimental treatments;

6. any item, service or cost that is reimbursed or otherw ise furnished by the sponsor of the Clinical Trial;

7. the cost of services w hich are not provided as part of the Clinical Trial’s stated protocol or other similar guidelines; or

8. any service that is clearly inconsistent w ith w idely accepted and established standards of care for a part icular diagnosis.

DEFINITIONS


Physician: A duly licensed doctor of medicine, a medical professional, or a pract it ioner w ho is duly licensed under appropriate state licensing authorit ies, provided: (i) a benefit is claimed for services w hich are w ithin the scope of such person’s license and for w hich a reimbursement under the Plan w ould be made had such services been performed by a doctor of medicine, and (ii) under applicable state law s, such professional or pract it ioner must be treated under the Plan in the same manner as if such services w ere provided by a medical doctor. Plan: The National Franchisee Associat ion Health + Medical Plan, as described herein, and adopted by Plan Sponsor, and named in the General Information sect ion herein. Plan Administrator: Plan Sponsor, act ing through its exclusive agent, Allison Hazen, Trustee of the NFA Member Plan Master Trust. Plan Anniversary Date: The date occurring in each plan year w hich is an anniversary of the effect ive date of the Plan. Plan Document: The master contract w hich describes the terms of coverage and associat ion betw een the Contract Administrator and the Plan Sponsor. Plan Sponsor: Your company, named in the General Information sect ion herein. Post-Service Claim: Any claim for a benefit under the Plan that is not a Pre-Service Claim.

Pre-Service Claim: Any claim for a benef it under the Plan w ith respect to w hich the terms of the Plan condit ion receipt of the benefit , in w hole or in part , on approval of the benefit in advance of obtaining medical care.

Prior Plan: The prior group medical plan offered by the Plan Sponsor.

Protected Health Information: Health information, including demographic information, w hich is collected from an individual, and w hich;

is created or received by the Plan;

relates to the past, present, or future physical or mental health or condit ion of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and

a) that ident if ies the individual; or b) w ith respect to w hich there is a reasonable basis to believe that the

information can be used to ident ify the individual; and

is transmitted by electronic media, maintained in any electronic medium, or transmitted or maintained in any other form or medium. Protected Heath Information excludes information in education records covered by the Family Educational Right and Privacy Act, records described at 20 U.S.C. 1232(g)(a)(4)(B)(iv), and employment records held by the Plan Sponsor in its role as employer.

DEFINITIONS


Qualified Beneficiary: Any covered person w ho loses coverage as a result of a qualifying event described in the “ Extension of Benefits” sect ion. These beneficiaries are:

1. covered employees (and their spouses and dependent children) w ho have been terminated for reasons other than the covered employee’s gross misconduct, or have had their hours reduced (result ing in a loss of coverage);

2. w idow ed spouses and dependent children;

3. divorced or legally separated spouses and their dependent children;

4. Medicare ineligible spouses and their dependent children;

5. a covered dependent child w ho no longer meets the Plan’s def init ion of a covered

dependent child;

6. a child born to, or placed for adoption w ith the covered employee during the period of COBRA coverage.

Rehabilitation Hospital: A facility w hich meets all requirements of a hospital (as def ined herein) other than the “ surgical facilit ies” requirements and, in addit ion, meets the follow ing criteria:

1. It must be accredited by the Joint Commission of Accreditat ion of Hospitals and be approved for Federal Medicare Benefits as a qualif ied hospital;

2. It must maintain transfer agreements w ith acute care facilit ies to handle surgical and/or medical emergencies;

3. It must maintain a ut ilizat ion review committee. Rehabilitative Care: Necessary inpat ient medical care (as prescribed by a physician) rendered in a rehabilitat ion hospital (as def ined herein) excluding custodial care or occupational training. Relevant: In the context of w hether a document, record or other information shall be considered " relevant," means the follow ing: a document, record, or other information

(i) relied upon in making the benefit determinat ion;

(ii) submitted, considered, or generated in the course of making the benefit determinat ion, w ithout regard to w hether such document, record, or other information w as relied upon in making the benefit determinat ion;

(iii) demonstrat ing compliance w ith the administrat ive processes and safeguards designed to ensure and to verify that benefit claim determinat ions are made in accordance w ith the governing Plan documents and that, w here appropriate, the Plan provisions have been applied consistent ly w ith respect to similarly situated claimants in making the benefit determinat ion; or

(iv) const itut ing a statement of policy of guidance w ith respect to the Plan concerning the denied treatment opt ion or benefit for the claimant ' s diagnosis, w ithout regard to w hether such advice or statement w as relied upon in making the benefit determinat ion.

In no event should the provisions of this Claim Review Procedures sect ion be interpreted to require any claimant to f ile more than tw o (2) appeals of an Adverse Benefit determinat ion prior to bringing a civil act ion under Sect ion 502(a) of ERISA.

Residential Treatment Facility: A child care inst itut ion that provides resident ial care and treatment for emotionally disturbed children and adolescents. The facility must be accredited as a resident ial t reatment facility by the Council on Accreditat ion of Hospitals or the American Associat ion of Psychiatric Services for Children.

DEFINITIONS


Substance Abuse: Any use of alcohol or drugs w hich produces a state of psychological and/or physical dependence. Substance Abuse Treatment Facility:

1. A public or private facility providing services especially for detoxif icat ion or rehabilitat ion of substance abusers and w hich is licensed to provide such services;

2. A comprehensive health service organizat ion, community mental health clinic or day

care center w hich furnishes mental health services w ith the approval of the appropriate governmental authority, any public or private facility or port ion thereof providing services especially for the rehabilitat ion of substance abusers and w hich is licensed to provide such services.

Totally Disabled: A covered employee shall be considered totally disabled if, as a result of a non-occupational illness or a non-occupational accidental injury, the employee is unable to perform the full duties of his/her occupation or is unable to engage in any gainful occupation.

Treatment: The provision, coordinat ion, or management of health care and related services by one or more health care providers, including the coordinat ion or management of health care by a health care provider w ith a third party; consultat ion betw een health care providers relat ing to a pat ient; and the referral of a pat ient for health care from one health care provider to another. Waiting Period: The period of t ime between the employee’s enrollment date and the employee’s first date of coverage under the Plan.

PLAN DOCUMENT ACCEPTANCE PAGE

APPROVED AND ACCEPTED This Plan Document, know n as the National Franchisee Associat ion Health + Medical Plan, is hereby executed at: _______________________________, _________________ on ____________________ (City) (State) (Date) BY: ____________________________________

TITLE: Trustee of the NFA Member Plan Master Trust act ing as exclusive agent of the Plan Sponsor

allison.hazen

Typewritten Text

South BurlingtonVT5/30/2014

Documents

NATIONAL FRANCHISEE ASSOCIATION HEALTH + MEDICAL PLAN · 2016. 9. 12. · 2NATIONAL FRANCHISEE ASSOCIATION HEALTH + MEDICAL PLAN National Franchisee Association Health + Medical Plan