Health
Benefits Plan
Table of Contents
III. ELIGIBILITY AND ENROLLMENT
SELF PAY DURING LABOR DISPUTE OR LEAVE OF ABSENCE
COBRA CONTINUED COVERAGE RIGHTS
SERVICES PROVIDED BY NETWORK PROVIDERS
SERVICES MUST BE OBTAINED FROM NETWORK PROVIDERS
WHEN YOU NEED TO SUBMIT A CLAIM
BENEFITS WHICH ARE MEDICALLY NECESSARY
SERVICES OF NETWORK PHYSICIANS
Benefits for Rehabilitative Treatment
Temporomandibular Joint Disorders (TMJ)
Benefits for Mental Health Treatment
Services of a Network Pharmacy
MAXIMUM LIMIT OF MAJOR MEDICAL BENEFITS
VIII. EXCLUSIONS AND WAITING PERIODS
PHYSICIAN/HOSPITAL SERVICES FOR DENTAL TREATMENT
XIV. APPEAL OF A CLAIM DENIAL - ALL CLAIMS
XV. CUSTOMER SERVICE DIRECTORY
This brochure is a
description of the benefits available under your plan with Skagit County PUD arranged
through the Public Utility Risk Management Services (PURMS) Self-Insurance Fund
and Administered by Pacific Underwriters.
Skagit County PUD offers an
excellent benefit package covering a broad range of services for injury and
illness. This plan provides coverage for employees and dependents enrolled with
Skagit County PUD. The plan allows you a wide choice of network providers
through the First Choice Health Network who have agreed to accept the
"reasonable amount" as payment for services to employees.
In this brochure, Skagit
County PUD is referred to as the "Company", First Choice Health
Network is referred to as the "Network", Pacific Underwriters is referred
to as the "Administrator" and the PURMS Self-Insurance Fund is referred
to as the "Fund". The PURMS Self-Insurance Agreement has several terms
and conditions which may affect the procedures outlined in this booklet. A copy
of the agreement is available at the Company or Administrator's office.
Covered Providers:
A. Network Providers. The Fund
has made special arrangements through the Network to provide services to
employees and their dependents. Network Providers agree to help control costs
and to provide quality health care at a reduced cost to those covered by this
plan. If you choose to obtain services from a non-network provider, the Fund
will pay a percentage of the amount that would have been paid had the services
been provided by a Network Provider. It is the
patient's responsibility to ascertain that the provider of service is a Network
Provider. The list of Network Providers is subject to change, and an up-to-date
list is available on the First Choice Health website at www.fchn.com. The patient
must also comply with certain cost containment provisions that are explained
under "How Your Coverage Works " beginning
on Page 7 of this booklet.
B.
Acupuncturist. For necessary care and treatment by a licensed
acupuncturist.
C.
Chiropractor. For necessary care and treatment by a licensed
chiropractor.
D.
Naturopath. For necessary care and treatment by a licensed
naturopath.
E.
Massage Therapist. For
necessary care and treatment by a licensed massage therapist. Massage therapy
services must be ordered by a physician.
Emergency Care or Referred Care within the State of
Coverage will be provided
for emergency care or referred care to the extent such services and supplies
would have been provided under this contract if such service had been received
from a Network Provider.
Emergency Care World-Wide
If a medical emergency or
accidental injury occurs to an Employee while traveling, coverage shall be
provided to the extent such services and supplies would have been provided
under this contract if such services had been received from or referred by a
Network Physician. See Page 7—How Your Coverage Works—for
an explanation of how your claim from Network Provider will be processed.
Services of Registered Nurses or Community Mental
Health Agency
When services are provided
by a registered nurse which are within the lawful scope of such nurse's license
or from a community mental health agency and such services would have been covered
if rendered by a Network Physician, the Administrator will reimburse you for
the cost of services but not to exceed the amount which would have been paid to
a Network Provider.
III. ELIGIBILITY AND ENROLLMENT
This coverage is available
to employees of the PUD who are employed full-time or on a regular schedule
totaling not less than 30 hours per week, and their "dependents".
A "dependent" is
defined as:
Enrollment (except for
newborns and adoptive children) is contingent upon receipt by the Administrator
of a fully completed and signed application for coverage on the Administrator's
regular forms, and acceptance by the Administrator by delivery to you of
identification cards.
New employees and their
eligible dependents may enroll to be effective:
a.
On the first day
of the month following the date of employment, however,
b.
If the date of
employment is the first working day of the calendar month, enrollment will be
effective on the date of employment.
Application must be made to
the Administrator within 30 days following the date such enrollment is
effective.
Newly acquired dependents
(except a newborn or an adoptive child) may be enrolled to be effective on the
first day of the month following the date of the dependent's acquisition
provided application is made within 60 days of acquisition.
A spouse who loses his or
her own medical coverage because of termination of employment, loss of
eligibility, or termination of another group medical plan may be enrolled to be
effective on the first day of the month following the date of loss of coverage
provided application is made within 60 days of the termination of such other
coverage, together with confirmation of the reason for loss of coverage. A
newborn child shall become eligible commencing with the day of birth, provided
application is made for coverage within 60 days of the child's birth.
A child placed for adoption
with the Insured or for whom the Insured has assumed a total or partial legal
obligation for support in anticipation of adoption will be eligible on the date
the legal obligation is assumed, provided application is made within 60 days of
such assumption of the legal obligation. Those employees who fail to enroll at
the time of eligibility or open enrollment may have an additional opportunity
to enroll in the event of acquisition of a new dependent as a result of
marriage, birth, adoption, or placement for adoption, provided that enrollment
is requested within 31 days of marriage, or within 60 days of birth, adoption
or placement for adoption.
If a covered employee is
hospitalized at the time coverage would otherwise have been effective, the
employee's coverage will become effective on the day following discharge from
the hospital (this provision does not apply to newborns who are enrolled within
60 days of birth or to children placed for adoption within 60 days of
placement).
In the case of a strike,
lockout or other labor dispute or an authorized leave of absence where the employer
discontinues payment for coverage under this contract, you may pay the monthly
payments as they become due for a period not to exceed six months.
If you and/or
your covered dependents lose coverage under a group health plan due to
termination of employment (for reasons other than gross misconduct), or a
reduction of hours, you may purchase continued coverage under the group plan
for you, your enrolled spouse and/or dependent children for up to 18 months. If
you elect continuation of coverage, you must pay the full cost of coverage each
month. Individuals who are entitled to Medicare may or may not be eligible for
continuation coverage. If an Employee at any time during the first 60 days of COBRA
coverage is determined to be disabled by Social Security, the continuation
period for you and eligible dependents is extended to 29 months. The person
designated as disabled must notify his/her employer within 60 days of the date
of determination by Social Security, and within 30 days of any loss of
disability status as described in “Your
Responsibilities” below.
If your spouse or dependent
children (if any) are enrolled
in the plan and lose coverage due to one of the following events, they may
purchase continued coverage under the group plan for up to 36 months:
Î
Death of
employee;
Î
Divorce or legal
separation of the employee and spouse;
Î
The employee
becomes entitled to Medicare; or
Î
A dependent child
is no longer a dependent child as defined by the plan.
Again, your spouse or
dependent must pay the full cost of coverage each month. A higher amount may be
charged during the period of extended coverage while disabled. Proof of
insurability is not required for you or your family to continue coverage in
these circumstances. The right to continue purchasing group coverage may
terminate before 18, 29, or 36 months (whichever applies) if:
Î
You fail to pay
the required premium on time;
Î
Your employer
terminates all group health plans for all employees;
Î
The person
continuing coverage becomes entitled for Medicare;
Î
The person
continuing coverage is covered under another group health plan not maintained by
the employer. Other coverage will not terminate your continued coverage so long
as you have a pre-existing condition which is not covered under the other
employer's plan due to a plan exclusion or limitation; or
Î
The person
continuing coverage due to disability under the Social Security Act is
determined to have recovered.
Your Responsibilities
If you want continuation
coverage when you become divorced or legally separated, or when your dependent
child is no longer a dependent child under the terms of the plan, you must immediately
notify your employer in writing, within
60 days of the date of the qualifying event, or the date coverage
ceased under the plan (whichever is later). If, while self-paying as a result
of termination of employment or reduction of hours, you or your dependent
receive a determination from the Social Security Administration of disability,
the disabled individual must notify his/her employer within the initial
18-month coverage period and within 60 days of Social Security's disability
determination. Verbal notice is not binding until confirmed in writing. The
employee designated as disabled must notify the contract holder within 30 days
of any loss of disability status.
In the other qualifying
circumstances, you will be notified that continuation coverage is available and
you must then make an election. If you do not receive notice of your
opportunity to elect continuation coverage, contact your employer for an
election form.
Election Period
You must decide whether or
not you want to purchase continued coverage within 60 days after the date you
are notified of your eligibility for continuation coverage, or the date
coverage would otherwise terminate (whichever is later).
Multiple Events
If you become entitled to
Medicare or if your dependent(s) suffer more than one qualifying event, your
spouse and/or your dependent children may be eligible for an additional period
of continuation coverage not to exceed a total of 36 months.
Your COBRA rights are
subject to change. Coverage will be provided only as required by law. If the law changes, your rights will change accordingly.
Plan benefits may be
continued as retiree coverage for employees and commissioners meeting the
eligibility criteria outlined in the District’s Retired Employees’ Health and
Welfare Plan Policy #1011. The cost of
retiree coverage premiums are the responsibility of the retiree. Plan benefits for retirees are reduced upon
eligibility for Medicare, regardless of whether or not Medicare enrollment
occurs.
Except as provided under “Self
Pay During Labor Disputes Or Leave Of Absence”, “Leaves Under The Family And Medical
leave Act (FMLA)”, and “Cobra Continued Coverage Rights”, coverage under this
plan will terminate on the last day of the month in which the person ceases to
be eligible or when the required monthly premium is not paid when due; OR if a employee or dependent is a registered inpatient in an
accredited hospital at the time his coverage would otherwise terminate, and
remains continuously hospitalized for the same injury or illness which
necessitated the hospitalization, the Fund shall continue to provide the
benefits of the contract until you or dependent is discharged form the hospital or until the maximum benefits of the
contract have been paid, whichever occurs first.
In general, by presenting
your identification card to your Network Physician or hospital, their charges
will be billed directly to the Administrator. Except for co-payment
requirements for office services, hospital admissions, emergency room services,
psychiatric care and prescription drugs, Network Providers agree to accept the
Fund's payment as payment in full for most covered services. Other services to
include durable medical equipment will be paid at a coinsurance percentage for
the first $500 of expenses per calendar year and at 100% thereafter.
Specified services of
Designated Referral Centers are paid in full.
Except as specified on page
3, and Other Benefits on page 19, care must be obtained from a Network Provider
in order to receive the full benefits of this contract. If you choose to obtain
services from a Provider who is not a Network Provider, benefits will be limited
to 70 percent of the usual amount paid a Participating Provider as determined
by The Fund, however, Anesthesiologists will be paid at the Network Provider
percentage.
Many routine surgical procedures
can be safely performed on an outpatient basis and at less cost than an
inpatient stay. Your Network Physician will perform certain surgical procedures
only on an outpatient basis, unless you have a medical condition that make
hospitalization necessary. If you choose not to have the procedure performed on
an outpatient basis, full contract benefits will be provided except that you
will be responsible for all room and board charges for the following
procedures:
1.
Esophagoscopy
2.
Gastroscopy
(flexible Fiberoptic)
3.
Colonoscopy
(flexible Fiberoptic)
4.
Duodenoscopy (flexible fiberoptic)
When you have obtained care
from a non-participating physician, obtain an itemized statement showing date
of service, description of services rendered, and charges together with a
description of the condition treated. A copy of itemized charges must be
presented to the Administrator so that the appropriate reimbursement can be
made to you.
For prescriptions
purchased from a Network Pharmacy, present your ID card to the pharmacy and pay
the co-pay. A current list of
Network Pharmacies can be obtained from the Administrator.
For prescriptions not
purchased from a Network Pharmacy, pay for your prescription, and mail your
receipt and prescription “stub” to the Administrator for a reimbursement.
Proof of expense must be submitted to the
administrator within twelve months of the date the service was provided.
Except for the sterilization
and well-care benefits, contract benefits are limited to those medically necessary
services or supplies provided by a hospital, physician, or other provider to
identify or treat an illness or injury without which the life or health of a employee would be endangered and which determined by the
plan are:
When applied to an
inpatient, it further means that the employee's medical symptoms or condition require
that the services or supplies cannot be safely provided to the employee as an
outpatient. Hospital admissions the day or night before surgery are generally
not considered to be medically necessary.
The Administrator may elect
to provide alternative benefits that are not listed as covered services in this
contract. The alternative covered benefits shall be determined on a
case-by-case basis by the Administrator for services that it deems are
medically necessary, cost-effective, and agreeable to you or your dependent,
and provider. The Administrator shall not be committed to provide these same or
similar alternative benefits for another employee or dependent, nor shall the
Administrator lose the right to strictly apply the express provisions of this
contract for future services or benefits.
As an alternative to
hospitalization or institutionalization of a covered employee and with the intent
to cover placement of the covered employee in the most appropriate and cost-effective
setting, this Contract shall include substitution of home health care, provided
in lieu of hospitalization or other institutional care, furnished by home
health, hospice and home care agencies licensed under RCW 70.127, and as
hereafter amended, at equal or lesser cost. Such expenses may include coverage
for durable medical equipment which permits the covered employee to stay at
home, care provided in Alzheimer's centers, adult family homes, assisted living
facilities, congregate care facilities, adult day health care, home health,
hospice and home care, or similar alternative care arrangements which provide
necessary care in less restrictive or less expensive environments.
Substitution of less
expensive or less intensive services shall be made only with the consent of the
covered employee and upon the recommendation of the covered employee's
attending physician or licensed health care provider that such services will
adequately meet the covered employee's needs. The decision to substitute less
expensive or less intensive services shall be determined based on the medical
needs of the covered employee.
The Administrator may
require that home health agencies or similar alternative care providers have
written treatment plans approved by the covered employee's attending physician
or other licensed health care provider. Alternative care benefits will be
limited to no less than the maximum benefits which would be payable for
hospital or other institutional expenses under the contract, and will include
all deductible and coinsurances which would be payable by the covered employee
under the hospital or other institutional expense coverage under this Contract.
Nothing contained in this
provision shall be construed to provide coverage for custodial care.
Subject to the requirements
outlined under “How Your Coverage Works”, the Company will provide the covered
individual with the benefits hereafter stated for medical, surgical, and
hospital expenses actually incurred which are reasonable and necessary for the
treatment of an illness, injury, pregnancy, or physical disability of such
person, plus the specified well-care, subject to the maximum lifetime limit and
other terms, limitations and exclusions herein stated.
When the covered individual
has incurred $500 in coinsurance in any one calendar year, payment will
increase to 100% of the reasonable charge for further covered services incurred
during the same calendar year by that covered employee. The stop-loss does not
apply to outpatient rehabilitative treatment.
Except as provided under “Other
Benefits”, the stop-loss provision does not apply to services provided by
non-Network Providers except in the cases of emergency or referred care or when
the care is provided by a registered nurse; nor does stop-loss apply to
outpatient rehabilitative treatment.
The Network Physicians
agree to furnish to the covered individual the following services and to accept
The Fund's fee schedule as payment in full.
The Administrator will pay
the Network Physician's charge up to the fee schedule allowance less any
required co-payment for each of the well-care benefits.
Î
Charges for
hearing aids that do not meet professionally accepted standards of practice, including
charges for any services or supplies that are experimental in nature.
Î
Replacement of
hearing aids that are lost, broken or stolen unless the replacement occurs after
the three-year period described above.
The benefits of this plan
will be provided for all medically necessary services or supplies relating to
all transplants as follows, as determined by the Administrator:
A transplant recipient who
is covered under this plan will be eligible for the following transplants,
subject to the conditions and limits described in the Benefit.
1.
Heart
2.
Heart/Lung
(combined)
3.
Kidney
4.
Kidney/Pancreas
(combined)
5.
Lungs - single/bilateral
6.
Liver
7.
Bone marrow
(including self-donated and unrelated donors) or other forms of stem cell
rescue only as specified below.
8.
Lungs—lobar
9.
Cornea
10.
Other forms of
stem cell rescue (only covered for certain conditions-see contract)
11.
Small Bowel
12.
Small Bowel/Liver
Donor Organ Benefits:
Donor organ
procurement costs will be covered to a maximum of $25,000 per transplant
provided the recipient is covered for the transplant under this contract. Donor
organ procurement benefits are limited to selection, removal of the organ,
storage, transportation of the surgical harvesting team and the organ, and such
other medically necessary procurement costs as determined by the Administrator.
Donor benefits will be charged against the recipient's benefit limits.
Limitations
The benefits of this
section will be limited as follows:
With regard to autologous
(self-donor) bone marrow transplants or associated high-dose chemotherapy,
coverage is available for treatment only for the following
malignancies/conditions:
1.
Non-Hodgkins lymphoma
2.
Hodgkins lymphoma
3.
Neuroblastoma
4.
Acute lymphocytic
or non-lymphocytic leukemias
5.
Germ cell
6.
Multiple myeloma
which is newly diagnosed or is in remission.
Autologous bone marrow
transplants or associated high-dose chemotherapy for other conditions will not
be covered.
With regard to allogeneic
(related or unrelated) bone marrow transplants or associated highdose chemotherapy, coverage is available for treatment
only for the following malignancies/conditions:
Allogeneic bone marrow
transplants or associated high-dose chemotherapy for conditions other than
those listed above will not be covered.
No benefits will be
provided for the following:
Services provided to an
Employee while confined as an inpatient will be paid in full less a $200 co-payment
for each admission. Room and board charges will be limited to the semi-private
rate (private room if medically necessary,
or if semi-private rooms do not exist in the facility).
The following services
provided to an Employee for outpatient care will be paid as follows:
Î
Outpatient
treatment will be limited to surgery; radiation therapy; chemotherapy, and
diagnostic procedures such as scans will be paid in full.
Emergency room services
will be paid in full less a $50 co-payment for each visit (waived if directly admitted
to the hospital as an inpatient).
NOTE: Benefits for
rehabilitative treatment, psychiatric treatment, temporomandibular
joint dysfunction, organ transplants, PTCA or open-heart surgical procedures
and sterilization are limited and specified elsewhere.
Covered Services:
Benefits are limited to the
following services in the patient's home and must be provided by employees of the
Home Health Care Agency:
o
Massage Therapy
is covered under the Physical Therapy Benefit and must be ordered by a
physician.
NOTE: For medical equipment
or prescription drugs see “Other Benefits” of this plan.
Exclusions of Home Health
Benefit:
Hospice services provided
by a Network Hospice for medically necessary treatment or palliative care
(medical relief of pain and other symptoms) to the terminally ill patient for a
maximum limit of six (6) months.
Conditions for Coverage:
The patient's Network
Physician must establish or approve and periodically review, at least every 60
days, a written treatment plan.
Covered Inpatient Services:
When the patient is
confined as an inpatient in a Network Hospice that is not an approved hospital,
the same benefits that are available in the home will be available to the
patient as an inpatient. In addition a semi-private room benefit will be
provided. This inpatient hospice benefit will be limited to 14 days during the
six-month period.
Limitations
Î
Visits of four or
more hours in which skilled care is required by a registered nurse, licensed practical
nurse, or home health aide, shall be limited to a combined total of 120 hours
or six months, whichever is greater.
Î
Respite care of
four or more hours per day in which no skilled care is required will be limited
to a combined total of 120 hours per three-month period.
Exc1usions
of Hospice Benefit:
Benefits
will not be provided for the following:
1.
Services for
spiritual counseling or bereavement counseling.
2.
Services to other
family employees.
3.
Services of
volunteers, household employees, family or friends.
4.
Food, c1othing,
housing or transportation. (See the ambulance benefit of his plan.)
5.
Supportive
environmental materials such as, but not limited to, ramps, handrails, or air conditioners.
6.
Homemaker or
housekeeping services, except a specifically provided above under the home
health aide benefit.
7.
Financial or
legal counseling services.
8.
Custodial or
maintenance care, except the benefits will be provided for palliative care to a
terminally ill patient, subject to the limits stated.
9.
Services or
supplies not ine1uded in the written treatment plan, not specifically set forth
as a covered benefit, or limited or exe1uded under the regular limitations and
exe1usions of this plan.
For
maternity and newborn care, the attending provider in consultation with the
patient makes the following decisions regarding the following:
Î Length of inpatient stay;
Î Inpatient post-delivery care;
Î Follow-up care to include type and location that may
include home health care agencies and registered nurses.
Benefits
for maternity care will be provided to a female employee or spouse of a male
employee, and will include care required for a vaginal delivery, cesarean
section, ectopic pregnancy, and abortion.
Professional
and hospital services for maternity care will be paid the same as for any other
medical condition. Circumcision of a newborn, and screening
and diagnostic procedures which are medically necessary for prenatal
diagnosis of congenital disorders of the fetus will also be provided a person
eligible for maternity care under this contract. No benefit will be provided
for elective sex typing or paternal typing.
Contract
benefits relating to complications of pregnancy will be provided any Employee
limited to the following:
Complications
of pregnancy do not include false labor, occasional spotting, prescribed or
recommended rest, morning sickness, pre-eclampsia, or
any similar condition associated with the management of a difficult pregnancy
that does not constitute, in the judgment of the Administrator, a medically
distinct complication of pregnancy.
The
benefits are not subject to the waiting period provisions.
Benefits
for well newborn care will be equivalent to the coverage of the child's mother
for up to three weeks, even if there are separate hospital admissions, and
include hospital nursery charges, professional services, and follow-up care.
Coverage
for an ill newborn or a well newborn whose mother is not covered under the contract
will be provided to the same extent as any other dependents.
Benefits
for a newborn are not subject to any waiting period provisions.
Benefits
will be provided for services of a Network Treatment Facility for medically
necessary inpatient and outpatient treatment of chemical dependency, including
detoxification and supportive services. Benefits provided for treatment will be
the same as benefits provided for treatment of other illness conditions under
this plan.
Benefits
will be limited to a maximum of $10,000 during any consecutive 24-month period.
In situations where a covered employee is under court order to undergo a
chemical dependency assessment or treatment, or in situations related to
deferral of prosecution, deferral of sentencing or suspended sentencing, or in
situations pertaining to motor vehicle driving rights and the Washington State
Department of Licensing, the covered employee must furnish at his or her
expense
not
less than ten (10) and no more than thirty (30) working days before treatment
is to begin, an initial assessment of the need for chemical dependency
treatment and a treatment plan, made by an individual of the patient's choice
who is a physician or a qualified counselor employed by an approved treatment
facility to enable the Administrator to make its own evaluation of medical
necessity prior to scheduled treatment.
In
addition, medically necessary detoxification, which occurs while an individual
is not yet enrolled in chemical dependency treatment, is covered under the
Emergency Room benefit of this plan.
Benefits
for rehabilitative treatment which are necessary to restore and improve
function that was previously normal but lost following an accidental injury or
illness, for treatment of neurodevelopmental disabilities, or treatment of
congenital anomalies of a newborn covered from birth will be provided as
follows:
Outpatient
Services
Physical, speech, and occupational therapy will be
provided at 80 percent of the Network Provider's reasonable charge to a maximum
of $750 per calendar year. The benefit maximum may be extended upon submission
by the treatment physician of a treatment plan meeting the approval of the
Administrator up to an additional $2,000 per calendar year. The stop-loss
provision of the contract does not apply to this benefit.
Inpatient
Services
Subject to prior approval by the Administrator of a
written plan of treatment; benefits for rehabilitative treatment at a Medicare certified
facility will be provided at 80 percent of the reasonable charge subject to the
stop-loss limit and the following.
Limitations
1.
The covered
employee must have been covered by a contract with the Company when the illness
or injury occurred and continually since that time.
2.
Treatment must
begin within 12 months of the injury or illness and will be provided to a maximum
of 12 months from the date treatment begins; however, benefits will terminate
at such time that further significant restoration and improvement of function cannot
be documented.
3.
Spinal
Manipulations are limited to 12 per calendar year.
4.
Acupuncture
treatments arc limited to 12 per calendar year.
Maximum
Benefits
Benefits under this section shall not exceed $1,000
per day to a maximum of $10,000 per condition, except that up to $30,000 will
be provided for cerebral vascular accident, brain injury, or spinal cord
injury.
Neurodevelopmental
Therapies
The above benefits will be provided for neurodevelopmental
therapies for covered employee's dependent age six and under where the services
are necessary to restore and improve function or to maintain a condition where
significant deterioration in the covered employee's condition will result to a maximum
of $2,000 per calendar year. Benefits provided for treatment of
neurodevelopmental therapies will apply to the overall benefit maximum for
outpatient and/or inpatient care.
No benefits will be provided for:
a.
Custodial care.
b.
Maintenance;
non-medical self help; recreational; vocation, or
education therapy.
c.
Learning
disabilities.
d.
Psychiatric care.
e.
Alcohol, drug or
chemical substance abuse rehabilitation.
f.
Gym or swim
therapy.
Benefits
of this contract will be provided on the same basis as for other injuries or
musculoskeletal disorders for treatment of temporomandibular
joint disorders to a maximum of $1,000 per calendar year and limited to a
combined lifetime maximum of $5,000 as to any one covered employee.
"Temporomandibular Joint Disorders" shall include those
disorders which have one or more of the following characteristics: Pain in the
musculature associated with the temporomandibular joint,
internal derangements of the temporomandibular joint,
arthritic problems with the temporomandibular joint,
or an abnormal range of motion or limitation of motion of the temporomandibular joint.
Covered
services are limited to those which are:
The
Company will provide the following services of a Network Mental Health
Provider, hospital, or other Plan Designated Provider when such services are
referred by a Network Provider:
Subject
to the required co-payment, benefits for services of a Network Pharmacy will be
paid in full for drugs and medicines directly related to the treatment of
illness or injury and prescribed by a Provider, subject to the following
conditions:
Subject
to the required co-payment, benefits for services of a participating mail order
pharmacy will be paid in full for drugs and medicines directly related to the
treatment of illness or injury and prescribed by a Provider, subject to the
following conditions.
Notwithstanding
any provisions of this contract to the contrary, coverage shall not be excluded
for a drug prescribed by a physician for off-label use, meaning that the
prescribed use is other than that stated in its Federal Food and Drug
Administration (FDA) approved labeling, if such drug is recognized as effective
in one of the Standard Reference Compensia, or if not
in the majority of relevant peer-reviewed medical literature, or by the Federal
Secretary of Health and Human Services.
Medically
necessary services associated with the administration of any such drug will be
covered in accordance with other benefit provisions of this contract.
Benefits
for the following services are provided at 80 percent of the provider's
reasonable charge subject to the stop-loss limit.
Î Ambulance Transportation—Benefits will be provided for
licensed ground, air and sea ambulance services used to transport you from the
place where you are injured or stricken by illness to the nearest accredited
general hospital where adequate facilities for treatment are available. No other
expense for travel will be covered.
Î Special Equipment—Special equipment and supplies for
which the covered employee has an immediate need: casts; splints; braces;
surgical and orthopedic appliances; colostomy bags and supplies required for
their use; catheters; syringes and needles medically necessary for diabetes or
allergies; dressings medically necessary for wounds, cancer, burns, or ulcers;
oxygen.
Î Prostheses—Purchases of a prosthesis provided for
functional reasons when replacing a missing body part. No benefits will be
provided for cosmetic prostheses except for external and internal breast
prosthesis necessary because of a mastectomy. Replacement of external breast
prosthesis is limited to once every three calendar years.
Î Durable Medical Equipment—Rental (or, at the election
of the Administrator, purchase in lieu of rental) of necessary durable medical
equipment when prescribed by a physician for therapeutic use, including the
following: crutches, iron lung, wheelchair, kidney dialysis equipment, hospital
beds, traction equipment, and equipment for administration of oxygen. No
benefits will be provided for such items as air conditioners, dehumidifiers,
purifiers, arch supports, corrective shoes, heating pads, deluxe equipment such
as motorized wheelchairs, or beds, enuresis training equipment, exercise
cycles, or whirlpool baths.
Î Blood Bank Charges—Administration of blood and its
derivatives and cross-matching.
Î Dental Services for Injury - Dental repair as a result
of injury will be paid up to a limit of $750 for each separate injury occurring
while covered hereunder. Replacement of dental fillings, repair of deciduous
teeth, repair or replacement of plates or bridgework is excluded.
Î Sterilization - Services relating to surgical
sterilization to a maximum of $I,000.
Î PKU - Formulas necessary for treatment of
phenylketonuria (PKU). Waiting period provisions of this contraet
do not apply to this benefit.
Î Diabetic Training - Diabetic training programs will be
provided to a maximum of $ 150 per calendar year.
VIII. EXCLUSIONS AND WAITING PERIODS
Benefits
arc not provided for:
1.
Impotency,
infertility, sterility; treatment or surgery for trans-sexualism;
reversal of sterilization; artificial insemination; in vitro fertilization.
2.
Military or
war-related injury or illness.
3.
Any injury sustained
while practicing for or competing in professional or semiprofessional competition.
4.
Services provided
by a federal or state governmental hospital, except as required by law.
5.
Hospitalization
solely for diagnostic purposes or for custodial or convalescent care.
6.
Treatment for
dental conditions; services performed by dentists and/or oral surgeons and hospitalization
for these services. This exclusion does not apply to treatment of a fractured jaw
or to the specific benefit for injury to teeth or treatment of temporomandibular joint dysfunction, nor to any dental
coverage exhibits to which the group has elected coverage.
7.
Treatment for
obesity including surgery and complications thereof; however, office visits for
the treatment of obesity is covered.
8.
Services,
supplies and procedures for cosmetic, plastic and reconstructive purposes,
except that the following will be provided:
a.
Care related to
an injury occurring while covered under the contract.
b.
Repair of a
congenital anomaly of a newborn covered at birth under the contract.
c.
Post mastectomy
reconstructive surgery.
9.
Treatment which
is experimental or investigative in nature, meaning any service, prescription, treatment,
procedure, facility, equipment, drug, drug usage, medical device or supply that:
a.
Final
governmental approval from the appropriate government regulatory bodies;
b.
Conclusive
scientific evidence proves the service or supply to be efficacious;
c.
The service shows
a demonstrable benefit for a particular condition, illness or disease and that
the benefits(s) outweigh the risk(s);
d.
The service
results in greater benefits for a particular condition, illness or disease than
other generally available services;
e.
Evidence supports
that the resulting improvements are attainable outside of the research or investigational
setting; or
10.
Has been
determined by the Administrator as not being in general use in the medical
community in the state of
11.
Milieu therapy
(treatment is an institution intended primarily to provide a change in environment
or a controlled environment).
12.
Any service to
the extent it is payable under Title XVIII of the Social Security Act of 1965 (Medicare)
as amended or to the extent it would have been payable if you or dependent had made
proper application for coverage or had obtained service from a provider
recognized by the Medicare Program.
13.
Any care to
dependent children for pregnancy, except as provided for complications of pregnancy.
14.
Intentionally
self-inflicted injuries and attempted suicide.
15.
Services and
benefits to the extent for which the covered employee may be eligible as a
result of automobile medical, automobile no-fault insurance, personal injury
protection ("PIP") or similar contract of insurance.
16.
Biofeedback.
17.
Routine foot
care; orthotics; except as required by the Diabetic Cost Reduction Act.
18.
Treatment
resulting from drug or chemical abuse except as provided for rehabilitation.
19.
Chiropractic
coverage (see Limitations).
Organ
Transplants: No benefits will be provided for services related to an organ
transplant until the covered employee has been covered under this contract (or
another contract with the Administrator that also covers the transplant) for a
period of 12 consecutive months, whether or not the condition is preexisting or
an emergency. This provision does not apply to newborns or adoptive children.
Preexisting
Conditions: No benefits will be provided for services related to preexisting
conditions until the covered employee has been covered under this contract for
a period of three consecutive months. Covered employees who were previously
covered by another similar health insurance plan (including an employer
provided self-funded health plan) within the 3-month period immediately preceding
the date of application for coverage under this plan will receive credit for
the months continuously covered under the prior plan toward these waiting
periods. These waiting periods do not apply to newborns or adoptive children or do they apply to covered benefits for maternity care. A
preexisting condition is a condition for which medical advice was given, or for
which a health care provider recommended or provided treatment within three
months prior to the effective date of coverage.
This provision does not apply to children under age 19.
EXAMS: One eye refraction each 24-month period. The Covered
individual is subject to a $10 co-payment for this service.
HARDWARE: An allowance of $250 per family toward prescription
eyeglass lenses and frames, or contact lenses, including expenses associated
with their fitting, is provided once every calendar year.
You
may be covered under more than one health care plan. If so, payment of benefits
will be coordinated between the plans so as not to pay more than the actual
cost of the services you received.
The
plan that pays first pays all the expenses allowed under its coverage. Then the
other plan pays the remaining allowed expenses. Co-pays, coinsurance, and other
cost-sharing arrangements are not included in the coordination of benefit
payments, and will be your responsibility to pay.
Some
plans do not have a Coordination of Benefits provisions. If your other plan
does not have one, that plan will pay its benefits first. Your plan will pay
the rest of your covered expenses but not more than would have been paid if you
had not had another health care plan.
If
your other plan(s) have a Coordination of Benefits
provision, benefits will be paid by the plans in the following order:
i. The plan of the parent with custody.
ii. The plan of the spouse of the parent with custody.
iii. The plan of the parent without custody.
iv. The plan of the spouse of the parent without custody.
Notwithstanding
paragraphs a. and b. above, if there is a court decree that established
financial responsibility for the health care of the child, the benefits of the
plan that covers the child as a dependent of the parent with such financial responsibility
shall be exhausted first.
When
the above rules do not establish an order of benefit determination, the
benefits of a plan that has covered the patient for the longer period of time
shall be determined before the benefits of a plan that has covered such patient
the shorter period of time. However, for a retired or laid-off employee and his
or her dependents covered by this plan, the benefits of this plan will be
determined after the benefits of any other plan covering such a person as an
active employee or dependent thereof except; if the other plan does not have a
provision regarding retired or laid-off employees, resulting in each plan
determining its benefits after the other, this plan's provision for retired or
laid-off employees shall not apply.
If
none of the above rules establishes an order of benefits determination, the
benefits of the plan that has covered an employee for the longer period of time
shall be determined before the benefits of the plan that has covered an
employee for the shorter period of time.
If
you or a covered dependent is injured due to the act or omission of another
party who is legally liable, the benefits of this contract will be available,
provided you agree to cooperate with the Fund in its subrogation rights and you
agree to reimburse the Fund for the amount it has paid if you recover from the
party who is liable. Such reimbursement will be limited to the amount collected
which is in excess of that necessary to fully compensate you for the total loss
sustained.
The
subrogation and indemnity rights of the Fund shall extend to any recovery by a
dependent or by a covered employee or personal representative of a patient, if
the patient dies.
When
reasonable collection costs and reasonable legal expenses have been incurred in
recovering payments which benefit both the covered employee and the Fund,
whether incurred in an action for damages or otherwise, there shall be an
equitable apportionment of such collection costs and legal expenses.
I.
Introduction
Individually
identifiable health information ("Health Information") regarding all
Covered Employees and dependents participating in the Health Plan ("Plan
Participants") is currently and will continue to be provided by the
Administrator for the Health Plan to the Plan Sponsor, and to specified
employees or classes of employees in the Plan Sponsor's workforce, to the
minimum extent necessary for the Plan Sponsor to perfOTIl1 certain Plan
Administrative Functions on behalf of the Health Plan. When Health Information
is provided from the Plan, through the Administrator, to the Plan Sponsor, it
is Health Information that is protected ("Protected Health
Information" or "PHI") by the privacy requirements contained in
the Health Insurance Portability and Accountability Act of 1996
("HIPAA"), and its implementing regulations contained in 45 CFR Part
160 and Part 164, Subparts A and E (the "Privacy Rules").
HIPAA
and the Privacy Rules restrict the Plan Sponsor's ability to use and disclose
PHI. The following HIPAA definition of PHI applies to this section:
Protected health information means information that is
created or received by the Plan and relates to the past, present, or future
physical or mental health or condition of a participant; the provision of
health care to a participant; or the past, present, or future payment for the
provision of health care to a participant; and that identifies the participant or
for which there is a reasonable basis to believe the information can be used to
identify the participant. Protected health information includes information of
persons living or deceased.
The
Plan Sponsor shall have access to, use and disclose PHI relating to the Health
Plan ("Plan PHI"), received from and through the Administrator, only
as permitted under this section, or as otherwise required or permitted by
HIPAA.
II.
Provision of Protected Health Information to the Plan Sponsor
"Summary Health Information" means: information
that: (a) summarizes the claims history, claims expenses or type of claims
experienced by individuals for whom a plan sponsor had provided health benefits
under a Health Plan; and (b) from which the information described at 45 CFR §
I64.514(b)(2)(i) has been deleted, except that the geographic information
described in 45 CFR § 164.514(b)(2)(i)(B) need only be aggregated to the level
of a five-digit zip code.
Notwithstanding the provisions of this section to the
contrary, in no event shall the Plan Sponsor be permitted to use or disclose
PHI in a manner that is inconsistent with 45 CFR § 164.504(f).
1.
Not use or
further disclose the Shared PHI other than as permitted or required by the Coverage
Booklet or as required by law.
2.
Ensure that any
agents, including any subcontractor to whom the Plan Sponsor provides the
Shared PHI, agrees to the same restrictions and conditions that apply to the Plan
Sponsor with respect to Shared PHI.
3.
Not use or
disclose the Shared PHI for employment-related actions or decisions or in connection
with any other benefit or employee benefit plan of the Plan Sponsor.
4.
Report to the
Administrator, acting on behalf of the Health Plan, any use or disclosure of
the Shared PHI that is inconsistent with the uses or disclosures provided for
of which it becomes aware.
5.
Make available
Shared PHI to comply with the right of a Plan Participant to have access to his
or her own PHI in the possession of the Plan Sponsor, in accordance with 45 CFR
§ 164.524.
6.
Make available
Shared PHI to comply with the right of a Plan Participant to request amendment
of his or her PHI and to incorporate proper amendments agreed to by the Plan
Sponsor, in accordance with 45 CFR § 164.526.
7.
Make available
the information required to comply with the right of a Plan Participant to
receive an accounting of the uses and disclosures that have been made of the Shared
PHI relating to the Participant, in accordance with 45 CFR § 164.528.
8.
Make the Plan
Sponsor's internal practices, books, and records relating to the use and disclosure
of Shared PHI available to the Secretary of Health and Human Services for purposes
of determining compliance by the Plan Sponsor with the Privacy Rules.
9.
If feasible,
return or destroy all Shared PHI that the Plan Sponsor still maintains in any
form and retain no copies of such PHI when no longer needed for the purpose for
which disclosure was made, except that, if such return or destruction is not
feasible, limit further uses and disclosures to those purposes that make the
return or destruction of the
information infeasible.
10.
Ensure that the
separation (i.e., the "firewall") required by the Privacy Rules
between the Health Plan (i.e., the "Authorized Employees" of the Plan
Sponsor that handle PHI on behalf of the Plan) and the Plan Sponsor (i.e., the
rest of the Plan Sponsor's employees that have no access to the PHI) is
consistently maintained.
The
employee will be reimbursed up to an amount equal to 70 percent of the
reasonable and customary charges made for orthodontic treatment incurred while
covered under this plan up to a lifetime maximum of $1,800.
The
dental benefits are an addition to your group medical coverage and the
eligibility provisions of this plan are the same as those of your medical plan.
All provisions and conditions of your medical coverage will apply which do not
directly conflict with these dental benefits, including provisions relating to
subrogation, coordination of benefits, and exclusions and limitations.
You
choose the Dentist: You may choose with complete freedom anyone of the many
licensed dentists in the community.
Maximum
Benefit: This dental plan will provide benefits for the services of licensed
dentist for those services listed in the Summary of Benefits to a maximum of $2,000
per calendar year.
Annual
Deductible Amount: There is no annual deductible under this dental plan.
In
most instances, the dentist who performs the examination and treatment will
bill the Administrator for his/her services. Should you receive a private
billing statement, submit an itemized billing including your name, Social
Security Number and group name to our office to receive reimbursement.
All
payment of benefits is based on the appropriate percentage of the usual,
customary and reasonable charge. This means the lesser of:
Î The charge made by a covered provider of service; or
Î The prevailing charge for the service in the area by
those of a similar professional standing.
You
will be responsible for the balance for your dentist's charges that are not
paid by the plan.
PREVENTATIVE
AND DIAGNOSTIC SERVICES
This
plan pays 100% of the usual, customary and reasonable charges for the following
services:
Î Oral examination -limited to two examinations in any calendar
year.
Î Dental x-rays. (A complete series of intra-oral films
and panoramic films is limited to once in any calendar year.)
Î Prophylaxis (cleaning, scaling and polishing)-Iimited to two treatments in any calendar year.
Î Topical application of fluoride.
Î Oral hygiene instruction-limited to three sessions.
Î Plastic sealants for permanent teeth.
Î Space maintainers.
BASIC
SERVICES
This
plan pays 90% of the usual, customary and reasonable charges for the following
services:
Î Amalgam and composite restorations. (Composite covered
only on teeth anterior to the first molar; otherwise, amalgam allowances will
apply.)
Î Gold foil restorations.
Î Extractions.
Î General anesthesia. (Local anesthesia included in
allowance for procedure.) Benefits are not available for nitrous oxide.
Î Endodontics, including direct pulp capping, pulpotomy and root canal therapy.
Î Stainless steel crowns.
Î Apicoectomy and root resections.
Î Repair of relining of dentures.
Î Re-cementing onlays or
crowns.
Î Repair or re-cementing bridges.
Î Oral surgery, root surgery, alveoplasty,
replantation, removal of ondontogenic cyst and incision
and drainage of abscesses, and surgical extractions.
Î Periodontal procedures, including:
o
Examination
o
Scaling and root planing
o
Occlusal adjustment and guards
o
Gingiveetomy and gingivoplasty (gum
surgery)
o
Gingival
curettage (seraping of gums)
o
Osseous (bone)
surgery
MAJOR
SERVICES
This
plan pays 75% of the usual, customary and reasonable charges of the following:
Î Gold inlay restorations.
Î Plastic, porcelain, non-precious metal, semi-precious
metal or gold crown. (Porcelain crowns covered only on teeth anterior to first
molar; otherwise, the metal allowance is provided.)
Î Temporary dentures, tissue conditioning prosthetics -
for replacement of anterior teeth extracted with the previous 30 days. (No
other temporary prosthetics provided.)
Î Temporary crowns - for immediate out-of-area emergency
treatment only. (No other temporary crowns provided.)
Î Prosthetics, including implants, bridges, dentures, or
partials.
TEMPOROMANDIBULAR
JOINT DISORDERS
Treatment
of temporomandibular joint disorders not paid as any
other injury or musculoskeletal disorder covered under the contract to a
maximum of $1,000 per calendar year and limited to a combined lifetime limit of
$5 ,000 as to anyone patient.
“Temporomandibular joint disorders” shall include those
disorders which have one or more of the following characteristics: Pain in the
musculature associated with the temporomandibular joint,
internal derangements of the temporomandibular joint,
arthritic problems with the temporomandibular joint,
or an abnormal range of motion or limitation of motion of the temporomandibular joint.
Covered
services are limited to those that are:
Where
more than one procedure may be considered as an alternative treatment, the
applicable amount for the procedure customarily provided for similar cases will
apply.
1.
Appliances or
restorations for the pUl1Jose of increasing vertical dimension or to restore
occlusion except as provided in the Special Orthodontic Benefits.
2.
Charges from any
provider other than a licensed dentist or denturist.
3.
Charges for
broken appointments or filling out forms.
4.
Charges as a
result of injuries related to semi-professional or professional athletic
contests, including practice.
5.
Conditions
related to military service or acts of war.
6.
Congenital
malformations, except as provided to a dependent child covered at birth under this
contract.
7.
Correction of
malocclusion, including extraction of teeth for tooth guidance procedures, and other
orthodontic services, except as specifically provided for treatment of temporomandibular
joint disorders or as provided in the Special Orthodontic Benefits.
8.
Cosmetic
dentistry or surgery, except as provided to a dependent child covered at birth
under the contract for treatment of a congenital condition.
9.
Crowns and
bridges or other prosthetic devices, or fitting of, if ordered prior to patient's
effective date under this plan; or installed or delivered more than 30 days
after the patient's coverage terminates.
10.
Replacement of
lost or stolen items.
11.
Services payable
by any government agency or through Worker's Compensation or similar laws.
12.
Expenses for
replacement, within five years, of a prosthetic appliance or fixed bridge
furnished under this exhibit.
13.
Expenses not
recommended by a dentist, denturist, or dental hygienist working within the scope
of his or her license.
14.
Services or
supplies not specifically provided in the Summary of Benefits.
Physician
and/or hospital benefits of the medical/surgical/hospital contract will be
provided in connection with a covered procedure of the dental plan when such
care is necessary to safeguard the patient's life.
XIV. APPEAL OF A CLAIM DENIAL - ALL CLAIMS
The
complete Appeal Procedures are in the Self-Insurance Agreement available at the
Company office.
If
there are any questions about a claim payment, the Administrator should be
contacted. If it is desired to initiate an Appeal Procedure because there is a
disagreement with the reasons why the claim was denied, the Administrator
should be notified in writing. A request for a review of the claim and examination
of any pertinent documents may be made by the claimant or anyone authorized to
act on his or her behalf. The reasons why it is believed that the claim should
not have been denied, as well as any data, questions or appropriate comments,
should be submitted in writing.
The
responsibility for full or final determinations of eligibility for benefits;
interpretation of terms; determinations of claim; and appeals of claim denied
in whole or in part under the Plan rests exclusively with the Administrator.
XV. CUSTOMER SERVICE DIRECTORY
Phone:
1.800.562.5226
Fax:
206.248.0130
Administrator:
Richard (Dick) Rodruck
Claims
Consultants:
Diane Christensen
Bambi Harrison
Coverage
Questions:
Diane Christensen
Bambi Harrison
Ryan VanAckeren
Eligibility:
Ryan VanAckeren
Bambi Harrison
Diane Christensen
Correspondence
and Claim Filing Address:
Pacific Underwriters
Seattle, WA 98166
12/1/2009
Date Signature