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HomeMy WebLinkAbout1996-172ORDINANCE NO 96 I%2 AN ORDINANCE ACCEPTING COMPETITIVE BIDS AND AWARDING A CONTRACT FOR THE PURCHASE OF MATERIALS, EQUIPMENT, SUPPLIES OR SERVICES, PROVIDING FOR THE EXPENDITURE OF FUNDS THEREFOR, AND PROVIDING FOR AN EFFECTIVE DATE WHEREAS, the City has solicited, received and tabulated competitive bids for the purchase of necessary materials, equipment, supplies or services in accordance with the procedures of STATE law and City ordinances, and WHEREAS, the City Manager or a designated employee has reviewed and recommended that the herein described bids are the lowest responsible bids for the materials, equipment, supplies or services as shown in the 'Bid Proposals" submitted therefore, and WHEREAS, the City Council has provided in the City Budget for the appropriation of funds to be used for the purchase of the materials, equipment, supplies or services approved and accepted herein, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS SECTION I That the numbered items in the following numbered bids for materials, equipment, supplies, or services, shown in the 'Bid Proposals" attached hereto, are hereby accepted and approved as being the lowest responsible bids for such items BID ITEM uC : �• ��' 1869 ALL HARRIS METHODIST EXHIBIT "A" HEALTH PLAN 1911 ALL DYNA-PAK CORP $171,120 00 1920 1 PRIESTER $ 11,600 00 1920 2 TECHLINE $ 10,980 00 1920 3 WESCO $ 10,320 00 1921 ALL DARR EQUIPMENT $178,837 00 SECTION II That by the acceptance and approval of the above numbered items of the submitted bids, the City accepts the offer of the persons submitting the bids for such items and agrees to purchase the materials, equipment, supplies or services in accordance with the terms, specifications, standards, quantities and for the specified sums contained in the Bid Invitations, Bid Proposals, and related documents SECTION iH That should the City and persons submitting approved and accepted items and of the submitted bids wish to enter into a formal written agreement as a result of the acceptance, approval, and awarding of the bids, the City Manager or his designated representative is hereby authorized to execute the written contract which shall be attached hereto, provided that the written contract is in accordance with the terms, conditions, specifications, standards, quantities and specified sums contained in the Bid Proposal and related documents herein approved and accepted SECTION IV That the Mayor is hereby authorized to execute the Letter Agreement and contract with Harris Methodist for Bid #1869 SECTION V That by the acceptance and approval of the above numbered items of the submitted bids, the City Council hereby authorizes the expenditure of funds therefor in the amount and in accordance with the approved bids or pursuant to a written contract made pursuant thereto as authorized herein SECTION VI That this ordinance shall become effective immediately upon its passage and approval PASSED AND APPROVED this the -4-4 day of 1996 JAtW MILLER, MAYOR ATTEST JENNIFER WALTERS, CITY SECRETARY BY APPROVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY BY ri Yj a EE H I f1n OED NOpN �NM iANN� 8888 88�122 88p8o8 8888 8i388 SOME MHNN NNNN M MNN CMNNN �MN �MMa �MNN N p�p� y)" 1I,� CD 0,00 N W O�- pNNNo 88888p 8888 M M M M N p8p N N N M N o$$$$3°vlSiBiSi N�N{AA{��- MN 1� fmNm(�y �fmmryy� N pV�p y�j �,000 W),moo gg I L)LL u>qAIo 1VF� Q AG -a -a to W W x WWW 11111 .111 ?c SSW W W W SWW! W W SCKKC =W WM'd' DATE AUGUST 6, 1996 1410WAK611iffell TO Mayor and Members of the City Council FROM Ted Benavides, City Manager SUBJECT BID #1869 - HEALTH INSURANCE RECOMMENDATION: We recommend this bid be awarded to the lowest responsible bidder, Harris Methodist Health Plan, at the listed rates (Exhibit A) for a one year contract renewable for two additional years at a maximum increase of 5% for 1998 and 9% for 1999 SUMMARY: This bid is for the Health Insurance Plan for City of Denton employees, retirees, and their dependent family The contract will be for the 1997 year renewable for 1998 and 1999 Rates for 1998 are guaranteed not to exceed a 5% increase and for 1999 a not to exceed a 9% increase Based upon current census data the expenditures for each year are listed on the tabulation sheet attached (Exhibit B) Additional information was presented to Council for consideration during the work session of July 23, 1996 BACKGROUND: Rate Schedule Exhibit A, Cost Comparison Exhibit B PROGRAMS, DEPARTMENTS OR GROUPS AFFECTED. The Health Insurance Program covers all eligible regular full-time and part time employees and their covered dependents in all city departments Also affected are those retirees participating in the Health Plan FISCAL IMPACT The Health Insurance Plan is a participation program with the city paying a set amount and the employee paying a set amount The rate quoted for 1997 reflects an approximate $37,824 00 savings over the 1995/96 budget and an approximate 4 1 % decrease in the employees contribution amount Respectfully submitted Ted Benavides City Manager Approved Name Tom D Shaw, C P M Title Purchasing Agent 756 AGENDA E LV r; 500ts SS42 alag �sB� MNN NNN Nsee�s yB�yNa�ysNee 0 ioyy m� CD m�m 68e418 8S!v8 s Cq M N M N N N �w N V�IRF 6888 MH 8p88pp88 N N N N 68288 I&Aj Q�]� a888 2M�M R((8 1s�83e8 m yQ� N N W N� �� f w NN N N 8 S O S O S O O 8 8 8 8 ppS N M M M p M NNN N p N MNN 23411 N N N M 0,00 v»o, (NNpGp�6y88(AA8��8 BE 1�SS(sue ,-coo v)�Moo H99-6-6-0 -0 -6 so ad .0 *a WWW 0 Q$ al W W W W =WW!W W 1mmmC ==Ww I=Wwwwm ===W W X � k § $■C■§ I$■i■ §m§ § � I g`E�k k Arkrk k k K70R 0§ 2 $§§§g g § §§g§ k » k e � I 96 ) B 2 §IBI§ � BBd I1 j !! $!�!■ � 2 §�§�§ \ § §■§k§ jj §&§a§ DATE AUGUST 6, 1996 TO Mayor and Members of the City Council FROM Ted Benavides, City Manager SUBJECT BID #1911 -REFUSE BAGS RECOMMENDATION: We recommend this bid be awarded to the low bidder, Dyna-Pak Corp, at the per unit price of 52 Bag Roll 2 81 per roll Regular Roll 30 Bag Roll 168 per roll Small Roll for an estimated annual total of $171,120 00 SiTMMARY. This bid is for an annual contract for the purchase of residential refuse bags to be stored in the warehouse for use by the Solid Waste Department The 52 bag rolls are distributed to utility customers twice a year and the 30 bag rolls are handed out to new customers who sign up for utility service between the two distributions Four bid proposals were received in response to ten bid packages mailed to prospective vendors BACKGROUND: Tabulation Sheet PROGRAMS, DEPARTMENTS- OR GROUPS AFFECTED: Warehouse Inventory, Residential Solid Waste, Utility Customers of the City of Denton FISCAi. IMPACT. Budgeted funds for 1996-97 for Warehouse Working Capital #710-043-0582 Respectfully submitted 'red Benavides City Manager Prepared by ic.�.1t/y�n�ati� Name Demse Harpool Title Senior Buyer Ap loved Name Tom D haw, C P M Title Purchasing Agent 752 AGENDA � - - a d� � � d O � � - ., v s� a � sd � �W a a �' --- -- � a � � o�Pr a F- - — N 3 �' � � �� a F Q z w �m m o b n z 3 s F °a �' � a N al z a N O '" a N DATE AUGUST 6, 1996 TO Mayor and Members of the City Council FROM Ted Benavides, City Manager SUBJECT BID # 1920 - DISTRIBUTION TRANSFORMERS RECOMMENDATION: We recommend this bid be awarded to the low evaluated bidder as follows ITEM QUANTITY DESCRIPTION VENDOR PRICE 1 10 EACH 75 KVPM PRIESTER $ 1,160 00 EACH 2 3 EACH 150 KVPM TECHLINE $ 3,660 00 EACH 3 1 EACH 1000 KVPM WESCO $10,320 00 EACH for a total expenditure of $32,900 00 SUMMARY: This bid is for the purchase of padmounted transformers for use at proposed developments and for maintenance stock Transformers are evaluated using a load loss equation to assure lowest operating cost Eight bid proposals were received in response to twenty-two bid packages mailed to vendors BACKGROUND: Tabulation Sheet, Memorandum from Don McLaughlin dated 7-12-96 PROGRAMS DEPARTMENTS OR GROUPS-AFFEOTEIL Electric Distribution, Electric Utilities, Electric Customers of the City of Denton FISCAL IMPS- Budgeted funds for 1996-97, Account #610-103-1031-5880-8925 Respectfully submitted Ted Benavides City Manager Prepared by � Name Denis He arpool Title Senior Buyer Name Tom D Shaw, C P M Title Purchasing Agent 751 AGENDA § | § 2 § \ ! \ ; � � �j � ■ ■ ■ } ■ | 7 \ � —(-- $, c - } $ / ! ; ; « » - ( |.§'§ ow §§ §§ $ ( § / - t1.-- " `-- --- — i:! A Y P! i 3 96 JUL 12 PH ? 06 To Denise Harpool, Senior Buyer From Don McLaughlin, Senior Engineer Electric Engineering Date July 12, 1996 Subject Evaluation of Quotation on bid # 1920 The 75 KVA 120/240 volt single phase pad -mounted, transformers could be used in the following project are for proposed developments at Loop 288 and Audra by the M + M Group, and a proposed development at Teasley Lane and Lillan Miller The utility staff recommends awarding the bid to the low bidder Preferred Sales The 150 KVA 120/208 volt three phase pad -mounted, transformers are to maintain stock for maintenance and operation The utility staff recommends awarding the bid to the low bidder Techline The 1000 KVA 277/480 volt three phase pad -mounted, transformer is to maintain stock for maintenance and operation The utility staff recommends awarding the bid to the low bidder WESCO Sincerely, Donald L McLaughlin .7e��/ � ` Attachments I Exhibit I, Loss / Cost Evaluation II Exhibit II, Total Cost '- - - -- -- EXHIBIT I FOR BID 1920 PAGE Item 1 Loss / Cost Evaluation of Ten 75 KVA, 120/240 Volt Padmounted Loop Single Phase Transformerle MADE NL ILL LOW BID $7,799 Item 2 Loss / Cost Evaluation of Three 150 KVA, 120/208 Volt Padmounted Loop Three Phase Transformer LOW BID $20,299 Item 3 Loss / Cost Evaluation of One 1000 KVA, 277/480 Volt Padmounted Loop Three Phase Transformer 12-Jul-96 02 45 PM H \HOME\E ENG3\TRANX\B1920\B1920 WK3 BIDDER BY LOSSES LOSSES TL LOSSES BID COST CAL COST DELIVERY DAYS Cummins Supply 164 524 688 1530 8720 832 42 KBS Electrical 151 629 780 1190 7900 746 64 Preferred Central 192 455 647 1297 7879134 =$1.7070,936 56 90Techline SESCO SESCO2201020 Howard 147 630 126 Temple GE 39 733 772 $1,649 $8,952 77 VANTRAN VANTRAN 220 580 800 $1,792 $10,306 70 WESCO ABB 155 707 862 $1198 $8286 98 MADE BY NIL LOSSES ILL LOSSES TL LOSSES BID COST CAL COST DELIVERY DAYS 340 1230 1570 4125 2189956 84 Central 283 1553 1836 3849 21837 37 70 4VANTRRAN Cooper 340 1230 1570 4010 21510 86 95 SESCO 520 2340 2860 4512 2933164 90 500 1600 2100 $3,993 $24,328 70 VANTRAN WESCO ABB 378 1275 1651 $3750 $21119 70 BIDDER MADE BY NIL LOSSES LL LOSSES TL LOSSES BID COST CAL COST DELIVERY DAYS KBS Electrical 1322 8481 9803 10865 74590 81 84 Preferred Central 1044 7749 8793 9739 66151 70 Priester Cooper 1322 8481 9803 10564 73573 43 95 SESCO SESCO 1800 10000 11800 $11 041 $83,978 90 Techline Howard 1322 8151 9473 $10 406 $71 995 126 Temple GE 2020 11941 13961 $8,352 $82,868 77 VANTRAN VANTRAN 2080 6600 8680 $11,007 $75431 70 LOW BID $64 594 EXHIBIT II FOR BID 1920 ITEM DESCRIPTION QUANTITY DISTRIBUTOR MANUFACTURER PRICE TOTAL H \HOME\E ENG3\TRANX\B1920\B1920 WK3 11-Jul-96 Total Cost 02 59 PM $32,900 ITEM 1 75 KVA 120/240 1 Phase UG 10 Preferred Central $1 160 $11,800 ITEM 2 150 KVA 120/208 3 Phase UG 3 Techline Howard $3,680 $10,980 ITEM 3 1000 KVA 277/480 3 Phase UG 1 WESCO ABB $10,320 $10,320 DATE AUGUST 6, 1996 TO Mayor and Members of the City Council FROM Ted Benavides, City Manager SUBJECT BID #1921 - ARTICULATED WHEEL LOADER RFCOMMF.NDATION. We recommend this bid be awarded to the lowest bidder, Darr Equipment, in the amount of $178,837 00 SUMMARY. This bid is for the purchase of a 4 5 cubic yard, articulated frame, 4 wheel drive, rubber tire loader The loader will be utilized at the Wastewater Treatment Facility in the sludge/compost project This Caterpillar 960F loader replaces a smaller 1980 model loader The older loader has the engine "locked up" and is no longer economical to repair It will be sold at auction August 15, 1996 The bid price includes a 3 year or 5,000 hour extended warranty BACKGROUND. Tabulation Sheet PROGRAMS, DFPARTMENTs ORGROUPS AFFECTED.- Wastewater Treatment Facility, Sludge/Compost Project and Fleet Operations FISCAL IMPACT Funds for this purchase are available in the 1995/96 budget accounts as follows Motor Pool Replacement #720-025-0584-9104 $ 108,968 00 Wastewater Plant Capital Expenditure #0470-9104 S 69,869.G0 $ 178,837 00 Respectfully submitted Ted Benavides City Manager Approved Name Tom D Shaw, C P M Title Purchasing Agent 755 AGENDA BID # 1921 BID NAME ARTICULATED WHEEL LOADER OPEN DATE 7-9.96 QTY DESORIPTION 1 1 4 5 CUBIC YARD ARTICULATED 4 WHEEL DRIVE LOADER MODEL L-_I- j DARR FUTURE MEGA EQPT EQPT EQPT VENDOR- - VENDOR VENDOR VENDOR $178,837 00 $193,473 00 NO BID CATERPILLAR CASE _- 960 F 921B Harris Methodist Health Insurance HARRIS METHODIST HEALTH INSURANCE COMPANY GROUP ENROLLMENT APPLICATION The Huns Methodist Health Insurance Company, and City of Denton (Group), agree to be bound by the provisions for healthcare service in accordance with this Group Enrollment Application, the Coverage Agreement, the Listing of Benefits, and any amendments and riders Coverage will be for eligible members of Group and their Dependents who enroll in Hams Methodist Health Insurance Company Eligible members of the Group are those persons who are exempt and work a mimlmum of 30 hours ner week and who comply with the provisions of this agreement. The Group agrees that, after the original enrollment period under the Coverage Agreement, each new employee will be given the opportunity to elect membership as procedure of employment Effective dates of Harris Methodist Health Insurance Company Coverage of new Subscribers and of termination of Coverage offered by Group will be (check appropriate box) Coverage Effective Date Data of hire First of month following date of hire XX Other (specify) Termination Effective Date XX Date Employment ends On the first day of each month, Premiums for that month are payable as follows XX In full for the complete month in which coverage begins or ends End of month in which employment ends other (specify) In full if coverage begins on or before i Sth of month or ends on or after the 16th of the month Prorated according to the actual number of days covered Other (specify) The benefits selected by Group are as follows (Circle one) In Vitro Fertilization Yes No This agreement will become effective January 1, 1997 The contract term is 1_ months This agreement will automatically renew for successive twelve (12) month period unless terminated by Harris Methodist Health Insurance Company or the Group in accordance with the provisions for the Coverage Agreement This Agreement will be governed by the laws of the State of Texas All notices should be sent to these administrative addresses HARRIS METHOD HEALT INSURANCE B 'lai o COMPANY } Accepted by Title Title _ -cul n[, Address Fitt As Hlckory Address The Hams Methodist Health Insurance Company and the Group agree that this agreement will not become effective unless at least n/a employees initially enroll in Hams Methodist Health Insurance Company Letter of Understanding City of Denton Bid No. 1869 This Letter of Understanding is between Hants Methodist Health Plan (HMHP) and the City of Denton (City) in connection with Bid No 1869 HMHP and City agree to the following As City employees' needs for additional health care services in the Denton area expand, HMHP is committed to ongoing assessment of these needs and expansion of HMHPs' current network through the recruitment of appropriately qualified providers to serve these needs HMHP guarantees that it meets the minimum bid requirement of having one Denton hospital in its provider network HMHP will maintain at least one Denton hospital in its network Should HMHP be unable to meet the minimum bid requirement of having one Denton hospital in its network, HMHP will pay the lesser of (1) 50% of the consulting contract which would be necessary to rebid City's health benefits program or (11) $30,000 Provided however, nothing in this paragraph relieves HMHP from its obligation to maintain at least one Denton hospital in its network In addition, HMHP will exercise best efforts to enter into a mutually acceptable and commercially reasonable contract for hospital services for City's eligible employees and dependents with the other hospital located in the City HMHP guarantees the 1997 total annual cost of its bid will not exceed $2,573,320 as long as enrollment, plan option participation, plan designs, and blended rates remain exactly as set forth below for every month of the 1997 calendar year ACTIVE HMO Opt -out Plan EE Only EE & Spouse EE & Child EE & Family HMO Plan EE Only EE & Spouse EE & Child EE & Family RETIRED UNDER 65 HMO Opt -out Plan Retiree Only Retiree & Spouse Retiree & Child Retiree & Family ENROLLMENT BLENDED RATES TOTAL 14 $220 07 5 $341 09 12 $294 88 14 $371 90 355 $185 03 86 $287 59 150 $24847 218 $312 59 $220 07 $341 09 $294 88 $371 90 Letter of Understanding City of Denton Bid No 1869 Page 2 of 2 HMO Plan Retiree Only Retiree & Spouse Retiree & Child Retiree & Family RETIRED 65 & OVER HMO Opt -out Plan Retiree Only Retiree & Spouse Retiree & Spouse (I under 65) Retiree & Family (1 under 65) Retiree & Family HMO Plan Retiree Only Retiree & Spouse Retiree & Spouse (I under 65) Retiree & Family (1 under 65) Retiree & Family $185 03 $287 59 $248 47 $312 59 1 $220 07 1 $341 09 0 $341 09 0 $371 90 0 $371 90 5 $185 03 1 $287 59 3 $287 59 0 $312 59 0 $312 59 City understands that the total annual cost of HMHP's bid may increase or decrease depending on the number of eligible employees participating, any shift between plan options or tier, any retroactive terminations, or change in City's selection of non -blended or blended rates Further, HMHP guarantees that the quoted rates in its response to Bid No 1869 will not increase more than 5% for plan year 1998 and will not increase more than 9% for plan year 1999 HMHP understands and agrees that any increase in HMHP's bid shall be consistent with the competitive bidding laws of the State of Texas This Letter of Agreement shall become effective January 1, 1997 and shall be attached to and incorporated into the agreement of the parties authorized by City pursuant to the ordinance approved on the day of , 1996, relating to the award of Bid No 1869 5 The terms and conditions of tins Letter of Understanding are binding contractual obligations and not mere recitals and may be enforced by either party HMHP and City, through their respective duly authorized representatives, have executed this Letter of Understanding to be effective as of January 1, 1997 HARRIS ME14iODIST LTH PLAN CITY OF DENT/O-N,., By D By Thomas Keenan 'Jack M11 r Title Executive Vice President/COO Mayor Wellness and Prevention Program Harris Health Plan, Inc will provide the following wellness and prevention program in conjunction with the City of Denton's bid #1869 ■ Modifiable Claim Audit ($2,000 value) No Charge ■ Health Risk Assessments for City of Denton employees ($25 00 value per assessment) $10 00 per Assessment ■ Monthly Wellness Event ($50 value per event) No Charge ■ Mammography Screening ($65 value per screening) No Charge Note This wellness program was developed as a value added benefit to our bid #1869 for the City of Denton Hams Health Plan is underwriting a portion of the cost as outlined above HARRIS METHODIST HEALTH INSURANCE COMPANY PREMIUM RATES 1997 Hams Methodist Health System Total Monthly Rates City of Denton CERTIFICATE OF INSURANCE INSURANCE BOOKLET for Employees of. CITY OF DENTON (Called the Group) Insured by. Harris Methodist Health Insurance Company (Called HMHIC) Arlington, Texas 76011 The Hams Methodist Health Insurance Company has issued Group Policy No POS-GA-0019 covering Employees of the Group This booklet is your certificate of insurance when a sticker is attached to the inside front cover The sticker will show your name and the effective date of your insurance The benefits of the group policy are described in this booklet Final interpretation is governed by this Policy THE GROUP AGREEMENT UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM. This booklet is your certificate of insurance only when you are insured under the Policy This certificate describes the benefit under the Plan in effect as of January 1, 1997 for all employees. IMPORTANT NOTICE To obtain information or make a complaint You may call Hams Methodist Health Insurance Company's toll-fi-ee telephone number for information or to make a complaint at 1-800-633-8598 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 1-800-252-3439 You may write the Texas Department of Insurance P O Box 149104 Austin, TX 78714-9104 FAX # (512) 475-1771 PREMIUM OR CLAIM DISPUTES. Should you have a dispute concerning your premium or about a claim you should contact the company first If the dispute is not resolved, you may contact the Texas Department of Insurance ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become part or condition of the attached document AVISOIMPORTANTE Para obtener informacion o para someter una queja Usted puede llamar al numero de telefono gratis de Hams Methodist Health Insurance Company's para informacion o para someter una queja al 1-800-633-8598 Puede comumcarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quelas al 1-800-252-3439 Puede escnbir al Departamento de Seguros de Texas P O Box 149104 Austin, TX 787149-9104 FAX # (512) 475-1771 DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concemiente a su prima o a un reclamo, debe comumcarse con la compama prunero Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDI) UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto BENEFIT DESCRIPTION 6 GROUP AND AFFILIATED ORGANIZATIONS 7 ELIGIBILITY AND EFFECTIVE DATE 8 TERMINATION, CONTINUATION OF BENEFITS, AND CONVERSION 12 PAYMENT REQUIREMENTS 17 CLAIMS INFORMATION 19 COORDINATION OF BENEFITS 21 INDEPENDENT AGENTS 27 GLOSSARY OF TERMS 28 TERM AND AMENDMENT OF AGREEMENT 39 MISCELLANEOUS PROVISIONS 40 POS-CER9-92 5 The benefits and provisions of this Plan are described in the attached Schedule of Benefits provided by Harris Methodist Health Insurance Company (HMHIC) This Plan is in effect as of January 1,1997 Validity of the policy shall not be contested except for nonpayment of premiums after it has been in force for two (2) years from its date of issue and that in the absence of fraud no statement made by any person covered by the policy relating to Ins or her insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been to force prior to the contest for a period of two (2) years during such person's lifetime nor unless it is contained in a written instrument signed by hum or her, provided, how-dver, that no such provision shall preclude the assertion at any time of defenses based upon (a) provisions in the policy which relate to eligibility for coverage, (b) provision in group accident and health insurance or disability insurance policies which relate to ovennsurance, (c) provision of disability policies winch relate to the relation of earnings to insurance, or (d) other similar provisions in such policies that limit the amounts of recovery from all sources to no more than one hundred (100%) percent of the total actual losses or expenses incurred, The certificate of coverage, application, schedule of benefits, and group contract attached shall constitute the entire contract between the parties and that in the absence of fraud all statements made by the policyholder or person insured shall be deemed representations and not warranties, and that no such statement shall be used in any contest under the policy, unless a copy of the written instrument containing the statement is or has been furnished to such person or in the event of death or incapacity of the insured person to the individual's beneficiary or personal representative Please see the attached Schedule of Benefits for Deductibles, Maximum Out -of -Pocket Limit, Exclusions, Limitations, and Covered Services Organ rations included under this AgMM= The Group and its affiliated organizations are included under this Agreement Affiliated organizations include all organizations which are a subsidiary to or affiliated with the Group hanBe of Affiliated Orgam=ons The Group shall notify HMHIC, in writing, when an affiliated organization ceases to be a subsidiary of, or affiliated with, the Group When an organization ceases to be a subsidiary of, or affiliated with, the Group, it shall cease to be an included organization Therefore, tlus Agreement shall terminate on the date of such cessation with respect to all Eligible Persons of that organization, except for those persons who on the next day are employees of another affiliated organization and thus Eligible Persons under this Agreement Replacement of Former Policy If an individual is disabled on the effective date, the former policy is liable only to extent of its accrued liabilities and extensions of benefits Regardless of whether the group policyholder or other entity responsible for malung payments to the carver secures replacement coverage Any person covered under the prior plan on the termination date who is eligible for coverage in accordance with the succeeding carver's plan of benefits, in respect of classes eligible and actively at work and nonconfinement rules and who elect such coverage shall be covered under the succeeding carver's on its effective date, provided that any person who would have been covered under the succeeding provisions of this subsection but for the actively at work or nonconfinement rules shall become covered under the succeeding carrier plan when such person satisfies such actively at work and nonconfinement rules When replacing a prior carver's plan, the succeeding carver's plan, in the case of a type of coverage for which Extension of Coverage requires an extension of benefits for a person who is totally disabled shall provide the lesser of (1) the extension of benefits which would have been required by the former policy, or (2) the extension of benefits required for the succeeding former plan, provided, any such benefits may be reduced by any benefits actually payable under the former policy If there is a preexisting condition limitation, other than waiting period, included in the former plan, the level of benefits applicable to preexisting conditions of persons becoming covered in accordance with this section by the succeeding carrier's plan and who are covered under the prior plan during the period of time the limitation applies under the succeeding carrier's plan shall be the lesser of (1) the benefits of the succeeding carrier's plan determined without application of the preexisting conditions limitations, or (2) the benefits of the prior plan The succeeding plan, in applying any waiting period in its plan, shall give credit for the satisfaction or partial satisfaction of same or similar provision under the prior plan is required by the succeeding carrier, the prior carrier shall, at the succeeding carrier's request, furnish a statement of the benefits available or pertinent information sufficient either to permit certification of the benefits available under the prior plan are determined in accordance with all of the definitions, conditions, and covered expenses provisions of the former and not the succeeding carver's plan The benefit determination is made as if the prior plan had not been replaced by the succeeding carrier To be eligible to enroll as an Employee, you must satisfy the following • Employment with the Group, and/or • Eligible under the eligibility criteria established by the Group To be eligible to enroll as a Dependent, you must be • The legal spouse of a Employee, • Determining the dependents or the beneficiaries of an insured, or both, prohibits a distinction on the basis of the marital status or the lack of marital status between the insured and the other parent • (a) A dependent unmarried natural child, and legally adopted child regardless of residence, or (b) foster child, step child, or cluld under Employee's court appointed legal guardianship, residing with Employee or with Employee's present or former spouse (1) under mneteen (19) years of age, or (2) under twenty-five (25) years of age and primarily dependent on the Employee for financial support and attending an accredited college or university, trade or secondary school on a full-time basis, winch has, in writing, verified said attendance or, • (a) A dependent unmarred natural child, or legally adopted child regardless of residence, or (b) foster child, stepchild, or cluld under Employee's court appointed legal guardianship, residing with Employee or with Employee's present or former spouse who is mneteen (19) years of age or older but incapable of self-sustaining employment because of mental retardation or physical handicap which commenced prior to age mneteen (19) (or commenced prior to age twenty-five (25) if such child was attending a recognized college or university, trade or secondary school on a full-time basis when such incapacity occurred), and primarily dependent upon the Employee for support and maintenance Such dependent child must have been a participant either prior to attaining mneteen (19) years of age or twenty-five (25) years of age under the conditions of the previous sentence Employee shall furnish HMHIC proof of such incapacity and dependency within thirty-one (31) days after the dependent child's attainment of the limiting age and from time to time thereafter as HMHIC deems appropriate, but not more frequently than annually • Grandchildren will be eligible for coverage if the child is considered a dependent of the Employees for federal income tax purposes • Managing Conservator Coverage for a minor child who otherwise qualifies as a dependent of a person who is a member of the group may pay benefits on behalf of the cluld to the person who is not a member of the group if a court order providing for the managing conservator of the child has been issued by a court of competent jurisdiction in this or any other state HMHIC is required to pay benefits pursuant to the terms of the policy and as provided by this article on compliance by the person who is not a member of the group with requirements of this Agreement However, any requirements unposed on the managing conservator of the cluld shall not apply in the case of any unpaid medical bill for which a valid assignment of benefits has been exercised in accordance with policy provisions or otherwise, nor to claims submitted by the group member where the group member has paid any portion of a medical bill that would be covered under the terms of the policy Before a person who is not a member of a group is entitled to be paid benefits under the above mentioned paragraph, the person must submit to HMHIC with the claims application written notice that the person (1) is the managing conservator of the child on whose behalf the claims is made, and (2) submit a certified copy of a court order establishing the person as managing conservator or other evidence designated by rule of the Texas Department of Insurance that the person qualifies to be paid the benefits as provided by this section Requirements as defined by the Group for determining the eligibility for participating in HMHIC are material to the execution of this Agreement by HMHIC During the term of this Agreement no change in the Group definition of eligibility participation shall be permitted to affect eligibility or enrollment under this Agreement in any manner unless such change is approved in advance by mutual written agreement between the Group and HMHIC OPEN ENROLLMENT By submitting an Application during an Open Enrollment Period you shall become covered on the Group Effective Date or the Effective Date specified as such for the Open Enrollment Period ON ACQUIRING ELIGIBILITY STATUS If you first meet the eligibility requirements other than during the Open Enrollment Period you may enroll within thirty (30) days of meeting such requirements by submitting an Application You will become covered under HMHIC on the first day you become an Eligible Person provided that the premium applicable to you has been received in accordance with this Agreement OPEN ENROLLMENT Your Dependents, for whom you have applied for coverage in HMHIC by submitting an Application during an Open Enrollment Period, shall be covered as a Dependent on your Effective Date ON ACQUIRING ELIGIBILITY STATUS A newly acquired Eligible Dependent, other than a newborn cluld, and an Eligible Dependent who first meets the eligibility requirements of the Group, other than during an Open Enrollment Period, may be enrolled by the Employee within thirty (30) days of meeting such requirements by submitting an Application Such Eligible Dependent shall be covered under HMHIC as a Dependent on the day he became an Eligible Dependent provided that the premium applicable to the Dependent has been received in accordance with this Agreement described in the PAYMENT REQUIREMENTS Section below Newborn children shall be covered under HMHIC for a period of thirty-one (31) days from the date of birth and shall continue to be covered after that time only if, prior to the expiration of such thirty-one day period, Notification has been submitted for such newborn cluld and the premium applicable to the Dependent has been received in accordance with this Agreement described in the PAYMENT REQUIREMENTS Section Newly adopted cluldren shall be covered under HMHIC as if they were newborn children The thirty-one (31) days grace period for submission of Notification shall commence on the earlier of the date upon winch such child commences residence with you or when the adoption becomes legal PERSONS NOT ELIGIBLE FOR COVERAGE Notwithstanding the foregoing provisions of this Section, you will not be eligible for coverage in HMHIC if • Coverage Previously Terminated You shall not be eligible for coverage if you have had previous coverage terminated by HMHIC for cause, as described in Section TERMINATION, CONTINUATION OF BENEFITS AND CONVERSION of tlus Agreement • Indebtedness You shall not be eligible for coverage if you have unpaid financial obligations arising from prior coverage in HMHIC You or your Eligible Dependent shall not be refused enrollment by HMHIC because of health status, requirements for health services, or the existence of a Pre -Existing condition on the Group Effective Date In addition, your coverage shall not be terminated by HMHIC due to your health status or health care needs If you or your eligible Dependents apply for coverage on a date other than Open Enrollment Period or more than thirty (30) days after becoming an eligible person or eligible Dependent, then you or your eligible Dependent shall be required to submit Evidence of Insurability as required by HMHIC A condition of participation in HMHIC is your Agreement to notify HMHIC of any changes in status that affect you or the ability of the your dependents to meet the eligibility criteria set forth in this Section O - R - 10 Eligibility under this Agreement shall in no event be invalidated by failure of the Group, due to clerical error, to record or report you or your eligible Dependent to HMHIC You shall be eligible if an Application has been completed and submitted to the Group as required under the terms of this Agreement by or on behalf of you or your eligible Dependent and the premium applicable to such coverage had been received by HMHIC "Pre-existing Conditions" means any medical condition which diagnosis was made or treatment received within a six (6) months immediately preceding your effective date of coverage under this Agreement A medical condition has been "diagnosed" if its existence has been identified or recognized by a Physician or other Health Professional A medical condition has been "treated" if any services of a Physician or other Health Professional have been received with respect thereto, including but not limited to office visits or consultations, hospital treatment, laboratory services, X-rays or the dispensing of prescription medication or refills In no event shall the limitation of 50% additional Copayment apply to cost of treatment (which shall include all applicable Copayment as specified in the Schedule of Benefits) following the earlier of (a) the end of a continuous period of twelve (12) months commencing on or after the effective date of the person's coverage during all of which the person has received no medical advice or treatment in connection with such disease or physical condition and (b) the end of the two (2) year period commencing on the effective date of the person's coverage The maximum amount of additional Copayment for a Pre-existing Condition during a Calendar year will not exceed $2,000 00 for any such Covered Person or Dependent, or $4,000 00 total for such Covered Person and his Dependents It 1 :ul►: Y•► • t• 1' I• � ' � I • ' ' 1 I If the Group fails to pay to HMHIC the premium payable hereunder on or before the thirty-first (31) calendar day after such payment is due, this Agreement may be terminated by HMHIC and all benefits shall cease at the end of such thirty-one (31) day grace period Group maybe held liable for the cost of all benefits provided to you by HMHIC during the grace period Group shall remain liable for all premiums (and any interest accrued thereon) not paid prior to termination Interest on late payments from the date such premiums were due may be charged at a rate equal to eighteen percent (18%) per year Unpaid interest shall be due and payable upon notice thereof to the Group from HMHIC If Group remits its delinquent payments to HMHIC within fifteen (15) days of termination date, HMHIC may reinstate Group without requiring a new Group Enrollment Agreement However, HMHIC reserves the right to refuse to reinstate by refunding within five (5) business days all payments made by Group after the date of termination UPON NOTIFICATION This Agreement may be terminated by either HMHIC or the Group upon written notice to the other party at least sixty (60) days prior to the end of the Contract Year Such termination shall occur at midnight on the day preceding the end of the Contract Year In the event that HMHIC terminates this Agreement, if you are Totally Disabled at the date of discontinuance of the group policy or contract, expenses for treatment will continue at least for the period of such total disability or for 90 days, whichever is less For the purposes of this section, the terms "total disability" and "totally disabled" mean (1) with respect to an employee or other primary insured under the policy, the complete mability of the person to perform all of the substantial and material duties and functions of his or her occupation and any other gainful occupation in which such person earns substantially the same compensation earned prior to disability, and (b) with respect to any other person under the policy, confinement as a bed patient in a hospital TERMINATION - FOR CAUSE DEFAULT IN PAYMENT OF PREMIUM If any premium contributions due from you are not paid timely by or on behalf of you, your entitlement to benefits may be terminated not less than thirty-one (31) days after the date such premium was due MISREPRESENTATION If you should make a fraudulent statement or provide any material misrepresentation of fact by or on behalf of you or your Dependent on a Application or Evidence of Insurability form, HMHIC shall have the right to terminate your coverage under this Agreement without any further liability or obligation to you Your entitlement to benefits maybe terminated not less then sixty-one (61) days after such misrepresentation If you correct inaccurate information furnished to HMHIC, POR- RR9-92 12 and HMHIC has not relied upon such incorrect information to its prejudice, the f iriushing of incorrect information shall not constitute a basis for termination of your coverage In the absence of fraud, all statements made by you are considered representations and not warranties and such statements shall not void the coverage or reduce the benefits under this Agreement two (2) years after your Effective Date MISUSE OF IDENTIFICATION CARD Possession of a HMHIC identification card is and of itself confers no rights to services or other benefits The holder of the card must be, in fact, you or an eligible person on whose behalf all applicable premiums under this Agreement have actually been paid When receiving services or other benefits to which you are not entitled pursuant to this Agreement you shalr'be solely responsible for the full payment of any charges associated with the services received If you permit the use of the your identification card by any other person, such card may be confiscated and HMHIC shall have the right to terminate your coverage under this Agreement and the coverage of your Dependents Your entitlement to benefits may be terminated not less than fifteen (15) days written notice after such misuse of the identification card FRAUDULENT USE OF BENEFITS OR SERVICES Fraudulent use by you of services, benefits, providers, facilities, or coverage will result in cancellation of coverage after not less than fifteen (15) day written notice to you TERAINATION OF COVERAGE EMPLOYEE NO LONGER ELIGIBLE PERSON If you cease to be eligible, coverage under this Agreement shall automatically terminate at midnight of that day on which you cease to be eligible DEPENDENT NO LONGER ELIGIBLE DEPENDENT If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall automatically terminate at midnight of the day on which the Dependent ceases to be an Eligible Dependent At the effective date of any termination of your coverage under this Agreement any payments received on your account, applicable to periods after the effective date of the termination of coverage, plus amounts due to you for claims reimbursement, if any, less any amount due to HMHIC or which must be paid by HMHIC on your behalf, shall be refunded to the appropriate parry within thirty-one (31) days HMHIC and the Group shall thereafter have no further liability or responsibility to you except as may be specifically provided in Section UPON NOTIFICATION of this Agreement 13 If, under the provisions of Title X of the Consolidated Ommbus Budget Reconciliation Act of 1985, Public Law 99-272 ("COBRA"), you are granted the right to continuation of coverage beyond the date your coverage would otherwise terminate, or, if COBRA is inapplicable and the provision of an applicable state statute grants you similar rights to continuation of coverage, tlus Agreement shall be deemed to allow continuations of coverage to the extent necessary to comply with the provisions of the applicable statute No evidence of insurability is required If you are eligible for continuation under COBRA you must inform HMHIC of eligibility within 3 months of the effective date CONTINUATION OF COVERAGE Any employee, covered person, or dependent whose insurance under the group policy has been terminated for any reason except involuntary termination for cause, including discontinuance of the group policy in its entirety or with respect to an insured class, and who has been continuously insured under the group policy and under any group policy providing similar benefit which it replaces for at least three consecutive months immediately prior to termination shall be entitled to such continuation privileges Involuntary termination for cause does not include termination for any health related cause HMHIC shall not be required to issue a converted policy covering any person if (a) such person is or could be covered by Medicare, (b) such person is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program, (c) such person is eligible for similar benefits whether or not covered therefor under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, (d) similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of any state or federal law, or (e) the benefits provided under the sources herein enumerated, together with the benefits provided by the continued policy, would result in overinsurance according to HMHIC's standards HMHIC's standards are the reasonable relationship between the actual health care costs in the area in winch the covered person lives at the time of the continuation and must be filed with the commissioner of insurance prior to their use in denying coverage Continuation of group coverage for employees or covered persons and their eligible dependents subject to the eligibility provisions Continuation of group coverage will not include dental, vision care, or prescription drug benefits and must be requested in writing within twenty-one (21) days following the later of (a) the date the group coverage would otherwise terminate, or (b) the date the employee is given notice of the right of continuation by either the employer or the group policy holder In not event may the employee or the covered person elect continuation more than 31 days after the date of such termination An employee or covered person electing continuation must pay to the group policyholder or the employer, on a monthly basis in advance, the amount of contribution required by the policyholder or employer, but not more than the group rate for the insurance being continued under the group policy on the due day of each payment The employee's or the covered person's written election of continuation, together with the first contribution required to establish contributions on a monthly basis in advance, must be given to the policyholder or employer within flurry -one (31) days of the date coverage would otherwise terminate Continuation may not terminate until the earlier of (a) six months after the date the election is made, (b) failure to make timely payments, (c) the date on which the group coverage terminated POS-CERL__ 14 in its entirety, (d) or one of conditions specified in items listed above regarding ineligible person's is met by the individual FAMILY SEVERANCE If coverage ends due to severance of family relationship, by virtue of family or dependent relationship to a person who is a member or eligible for the group for which the health insurance policy, is provided to continue coverage with the group if (1) Previous eligibility for coverage under the health insurance policy ceases because of the severance of the family relationship or the retirement or death of the member of the group, and (2) The family member or dependent has been a member of the group for a period of at least one year or is an infant under one year of age (3) A person who exercises this option, may not be required to take and pass a physical examination as a condition for continuing coverage (4) A person who exercises this option is entitled to coverage under the policy, and exclusions that were not included in the policy may not be included in the group continuation coverage However, if the group policyholder replaces the health insurance policy within the one-year provided, the person may obtain coverage identical in scope to the coverage under the replacement group policy as provided by this article (5) A person covered under group continuation coverage shall pay premiums for the coverage directly to the group policyholder, and the coverage shall provide the person with the option of paying the premiums in monthly installments The group policyholder may require the person to pay a fee of not more than $5 a month for administrative costs (6) Upon initial severance of family relationship, you must inform HMHIC of the severance, upon receipt of the notification HMHIC will send the application to the severed family member immediately (7) Within sixty (60) days from the severance of the family relationship or retirement or death of the member of the group, the dependent must give written notice to the group policyholder of the desire to exercise the option under item (1) of this section or the option expires Coverage under the health insurance policy remains in effect during this sixty (60) day period provided the policy premiums are paid (8) Any period of previous coverage under the health insurance policy is to be used in full or partially satisfaction of any required probationary or waiting periods provided in the contract for dependent coverage (9) If a health insurance policy provides to a group member continuation rights to cover the period between the time that the member retires and the time of eligibility for coverage by Medicare, those same continuation rights shall be made available to the group member's dependents (10) If a person exercises the continuation option under item (1) of this section, coverage of that person continues without interruption and may not be canceled or otherwise terminated until (a) the insured fails to make a premium payment in the time required to make that payment, (b) the insured becomes eligible for substantially similar coverage under another health insurance policy, hospital, or medical service subscriber contract, medical practice or other prepayment plan, or by any other plan or program, or (c) a period of three years has elapsed since the severance of the family relationship or the retirement or death of the member of the group 15 EXTENSION OF MEDICAL BENEFITS HMHIC shall continue to provide medical services if this Agreement terminates while you are Totally Disabled at the date of discontinuance of the group policy or contract at least for the period of such total disability or for 90 days, whichever is less, for expense for treatment of the condition causing such total disability For the purposes of this section, the terms 'total disability" and "totally disabled" mean (1) with respect to an employee or other primary insured under the policy, the complete inability of the person to perform all of the substantial and material duties and functions of his or her occupation and any other gainful occupation in which such person earns substantially the same compensation earned prior to disability, and (b) with respect to any other person under the policy, confinement as a bed patient in a hospital Tins continued coverage will end on the earlier of (1) the period of "total disabihty" is no longer meets the above defined statement, or (2) 90 days from the termination date, or (3) the date you become eligible for similar coverage under another plan eon 16 PREMIUM PAYMENTS The initial rates for the benefits and services under this Agreement shall be due and payable in advance on or before the first (1st) day of the month for which such payment is made or is to be made In accordance with the terms and provisions of the TERM AND AMENDMENT OF AGREEMENT Section of this Agreement, HMHIC shall have the right to change the rate payable under this Agreement at any time when the extent or nature of tins Agreement is changed by Amendment or termination of any provision, or by reason of any provision of law or governmental program or regulation Premiums do not vary by age No proration of the rate shall be made with respect to your coverage under tins Agreement commencing after the first (1st) day of the month A grace period of thirty-one (31) days shall be allowed for each payment payable hereunder, whether due from Group or you The rate required for a newly acquired Eligible Dependent shall be payable initially when the required Application is submitted to HMHIC Thereafter, all payments with respect to such new Eligible Dependent shall be made as otherwise provided in this Agreement Any payments required for newborn children who meet the requirement of the Section ELIGIBILITY AND EFFECTIVE DATE of tlus Agreement shall be initially payable to HMHIC on or before the first day of the next month following the month in which the Notification required under the above mentioned section is submitted to HMHIC Thereafter, all payments with respect to such newborn child shall be made as otherwise required under tlus Agreement NON-CONTRIBUTORY COVERAGE If the coverage basis hereunder is "Non -Contributory", the Group agrees to pay at the principal office of HMHIC, or to its authorized representative, on each payment due date, the sum of the HMHIC rate for the coverage under this Agreement The Group premium for the coverage provided by HMHIC under tlus Agreement shall be determine by the applicable rate then in effect and the number of Members at the monthly intervals established by HMHIC CONTRIBUTORY COVERAGE If the coverage basis hereunder is "Contributory", the Group agrees to pay at the principal office of HMHIC, or to its authorized representative, on each payment due date, the sum of the HMHIC rate for the coverage under this Agreement Group shall permit you to pay your contributory portion of such rate through payroll deduction Procedures for implementing payroll deduction for your portion of such rate shall be the same as those utilized for any Alternative Health Benefit Plan If the Group does not have an Alternative Health Benefit Plan, the procedures shall solely be those as agreed to, in writing, between Group and HMHIC The Group premiums for the coverage provided by HMHIC under this Agreement shall be determined by the applicable rate than in effect and the number of Members at the monthly intervals established by HMHIC Group shall offer HMHIC to all Employees of Group on terms no less favorable with respect to the Group contribution than those applicable to any Alternative Health Benefit Plan as may be available through the Group The Group contributions shall not be changed during the term of this Agreement unless such change is prior approved, in writing, by HMHIC If, however, the Group contributions to the Alternative Health Benefit Plan, as may be available through the Group, is increased during the term of tins Agreement, the Group agrees to also increase POS-CER9-92 17 contributions to HMHIC effective the first monthly payment due following such increase NOTIFICATION BY GROUP Group shall forward completed Applications and any Evidence of Insurability form(s) to HMHIC within ten (10) business days of their receipt from Eligible Persons In the event Group fails to notify HMHIC of the ineligibility of any person for whom the Group has made the monthly prepayment required pursuant to this Agreement, then, such prepayment shall be credited to Group only if HMHIC has not made arrangements for or paid benefits for the ineligible person but in no event will prepayment be credited subsequent to thirty (30) days after the date such person became ineligible. 18 HOW TO FILE A CLAIM You must send your medical bills to HMHIC The claim office address can be found on the back of your I D card When you send your medical bills be sure to include your name, address, and social security number Written notice of claim must be given to the insured within twenty (20) days after the occurrence or commencement of any loss covered by the policy Failure to give notice within such time shall not invalidate or reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible; HMHIC will furnish to the person making claim or to be policyholder for delivery to such person such forms as are usually furnished by it for filing proof of loss If such forms are not furnished before the expiration of fifteen (15) days after the insurer received notice of any claim under the policy, the person making such claims shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time frame fixed in the policy for filing proof of loss, written proof covering the occurrence, character, and extent of the loss for which claims is made HOW AND WHEN ARE CLAIMS PAID? In the case of claim for loss, written proof of such loss must be furnished to the insurer within the ninety (90) days after the commencement of the period for which the insurer is liable Failure to furnish such proof within such time shall not invalidate or reduce any claim if it was not reasonably possible to furnish such proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required All benefits payable under the policy shall be payable not more than sixty (60) days after receipt of proof HMHIC shall have the right and opportunity to examine the person of the individual for whom claim is made when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law PAYMENT TO STATE The Group policy shall provide payment to the Texas Department of Human Resources for the actual cost of medical expenses the department pays through medical assistance for a person insured by the contract if the insured is entitled to payment for the medical expenses by the insurance contract All benefits paid on behalf of the cluld or cluldren under the policy must be paid to the Texas Department of Human Services whenever • the Texas Department of Human Services is paying benefits under the Human Resources Code, Chapter 31, or Chapter 32,1 e , financial and medical assistance service programs administered pursuant to the Human resources code, and POS-CER9-92 19 the parent who is covered by the group policy has possession or access to the cluld pursuant to a court order, or is not entitled to access or possession of the child and is required by the court to pay cluld support No action at law or in equity shall be brought to recover on the policy prior to the expiration of sixty (60) days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all unless brought within three years from the expiration of the time within which proof of loss is required by the policy, Hams Methodist Health Insurance Company will not deny or reduce a claim because of a Pre - Existing Condition if both of the following conditions are met • The claim is for a loss that happened or a disability started after the insurance coverage for that person has been in effect for the earlier of (A) twelve (12) months, with no treatment in connections with such pre-existing condition, or (B) two (2) years, with any treatment for such pre-existing condition • The condition is not excluded from coverage by name or specific description 20 The Harris Methodist Health Insurance Company, Coordination of Benefit and Subrogation of Benefits provision applies to all of the benefits provided under this Agreement The benefits provided by Hams Methodist Health Insurance Company shall be coordinated with any group insurance plan or coverage under governmental programs (excluding Medicaid), including Medicare, to assure that you receive coverage while avoiding double recovery It is, therefore, understood and agreed that should you be covered by or under a Coordinated Plan in addition to coverage under tlus Agreement, the provisions and rules as described in this Section shall determine whether HMHIC or the Coordinated Plan is primarily responsible for paying the cost of benefits, and services provided to you • Services and benefits for military service connected disabilities for which you are legally entitled and for which facilities are reasonably available, shall in all cases be provided before the benefits of this Plan For purposes of this Section only, words and phrases shall have meamng as follows • ALLOWABLE EXPENSE shall mean any Usual and Customary expense of which at least a portion is covered under this Plan covering you when a claim is made When a Coordinated Plan provided benefits in the form of services rather than cash payments, the Usual and Customary cash value of each service provided shall be deemed to be both an Allowable Expense and a benefit paid • CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding any portion of a calendar year occurring prior to the effective date • COORDINATED PLAN shall mean any of the following that provides benefits or services for, or by reason of, medical care or treatment • Coverage under governmental programs, including Medicare (excluding Medicaid), required or provided by any statute unless coordination of benefits with any such program is forbidden by law • Group coverage or any other arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, including any prepayment coverage, group practice basis or individual practice coverage and any coverage for students which is sponsored by, or provided through, a school or other educational institution above the high school level This provision shall apply in determining the benefits payable for the Allowable Expenses incurred by you during a Claim Determination Period 21 The term Coordinated Plan shall be construed separately with respect to each policy, contract, or other arrangement for benefits or services and separately with respect to that portion of any such policy, contract, or other arrangement which reserves the right to take the benefits or services of the other Coordinated Plans into consideration in determining its benefits and that portion which does not Whenever the sum of the benefits that would be payable under this Agreement in the absence of this provision, and the benefits that would be payable under all Coordinated Plans in the absence thereof or amendments of similar purpose to tlus provision would exceed the Allowable Expenses, then the following shall apply • The benefits that would be payable under ttus Agreement shall be reduced to the extent necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Expenses under all Coordinated Plan include the benefits that would have been payable had claim been duly made therefor • If a Coordinated Plan would, according to its rules, determine its benefits after the benefits payable under tlus Agreement have been determined, and the rules as described below would require payment under this Agreement to be determined before the Coordinated Plan, then the benefits of the Coordinated Plans shall not be included for the purpose of determining the benefits under this Agreement The rules establishing the order of benefit determination shall be as follows • The benefits of a Coordinated Plan without a coordination of benefits provision (or a non -duplication provision of similar intent) shall be determined before the benefits of this Agreement • The benefits of a Coordinated Plan which covers you other than as a Dependent shall be determined before the benefits of a Coordinated Plan which covers you as a dependent • The benefits of a Coordinated Plan which covers you as a dependent child of a person whose date of birth, excluding year of birth, occurs earlier in a calendar year, shall be determined before the benefits of a Plan wluch covers you as a dependent of a person whose date of birth, excluding year of birth, occurs later in the calendar year If a Coordinated Plan does not have the provisions of this paragraph regarding dependents, which results either in each Coordinated Plan determining its benefits before the other or in each Coordinated Plan determining its benefits after the other, the provisions of this paragraph shall not apply, and the rule set forth in the Coordinated Plan winch does not have the provisions of this paragraph shall determine the order of benefit determination unless the Legal Separation or Divorce Section shall apply • If the rules provided above or the rules provided in the above section do not establish an order of benefit determination, then the benefits of a Coordinated Plan which covers you, when a claim is made, for the longest period of time shall be determined before the benefits of a Coordinated Plan which covers you for the shorter period of time except as follows 22 • The benefits of a Coordinated Plan cover you as a laid -off part- time or retired employee or as the dependent of such a person shall be determined after the benefits of a Coordinated Plan covering you as a covered member other than as a laid -off or retired employee or dependent of such person • If a Coordinated Plan does not have a provision regarding laid -off or retired employees, and as a result, such Coordinated Plan determines its benefits after the Coordinated Plan with tlus provision, then the provision of the immediately preceding paragraph shall not apply In the event of a legal separation or divorce, the following order of benefits determination shall apply If there is a court decree that establishes financial responsibility for the provision of health insurance coverage for the cluld, the benefits of a Coordinated Plan which covers the cluld as a dependent of the parent with such financial responsibility shall be determined before the benefits of a Coordinated Plan which covers the child as a dependent of the parent without such financial responsibility • In the event of a legal separation or divorce in which the court decree does not establish financial responsibility for the health care expenses of the child then the following shall apply • If the parent with custody of the child has not remained, the benefits of a Coordinated Plan which covers the cluld as a dependent of the parent with custody of the cluld shall be determined before the benefits of a Coordinated Plan which covers that child as a dependent of the parent without custody If the parent with custody of the cluld has remarried, the benefits of a Coordinated Plan which covers the child as a dependent of the parent with custody shall be determined before the benefits of a Coordinated Plan which covers that cluld as a dependent of the stepparent, and the benefits of a Coordinated Plan which covers that cluld as a dependent of the stepparent shall be determined before the benefits of a Coordinated Plan which covers that child as a dependent of the parent without custody Thus, in the event of legal separation or divorce, unless a court decree specifies otherwise, the order of benefit determination described above may be summarized as follows Separated or Divorced and not Remarried (1) Parent with Custody (2) Parent without Custody Separated or Divorced and Remained 23 (1) Parent with custody (2) Stepparent with custody (3) Parent without custody For purposes of determining benefits provided for you, if you are eligible to enroll for Medicare, but do not, HMHIC will assume the amount provided under Medicare to be the amount you would have received if you had enrolled in it You are considered to be eligible for Medicare on the earliest date coverage under Medicare could become effective for you Except as described TEFRA, Medicare benefits will be coordinated to accordance with the policy If you are actively working, you and your covered spouse who are eligible for Medicare will be permitted to choose one of the following options if you, the Employee are age 65 or older and eligible for Medicare OPTION I - The service of the Group Agreement will be provided first and the benefits of Medicare will be provided second OPTION 2 - Medicare benefits only You and your Dependents, if any, will not be covered by the Group Agreement The Group will provide you, the employee, with a choice to elect one of these options at least one month before becoming age 65 All new Employees age 65 or older will be offered these options when hired If Option 1 is chosen, your rights under tins Agreement will be subject to the same requirements as for an Employee or Dependents who are under age 65 There are two different categories of persons eligible for Medicare The calculation and payment of benefits by this Agreement differs from each category, Category 1 Medicare Eligible are Actively working covered Employees age 65 or older who choose Option 1, 2 Age 65 or older covered spouses of actively working employees age 65 or older who choose Option 1, Age 65 or older covered spouses of actively working covered Employees who are under age 65, 4 Actively working covered Employees of groups with 100 or more employees and their covered dependents who are entitled to Medicare by reason of disability other than End Stage Renal Disease (ESRD), and Covered individuals entitled to Medicare solely on the basis of 24 ESRD during a period of up to 18 months after the individual has been determined eligible for ESRD benefits Category 2 Medicare Eligible are Retu-ed employees and their spouses, Covered Employees of groups with less than 100 employees and their covered Dependents who are entitled to Medicare by reason of a disability other than ESRD, and Covered individuals entitled to Medicare solely on the basis of ESRD for more than 12 months after the individual has been determined eligible for ESRD benefits For purposes of administering the provisions of this Section, HMHIC may, without further consent of, or notice to you, release to or obtain from any health care plan, insurance company or other person or organization, any information with respect to you which it deems to be reasonably necessary for such purposes, as to facilitate coordination of benefits, as permitted by law When you receive services or claim benefits under this Agreement you shall furnish HMHIC all information deemed necessary by HMHIC to implement this Section (COORDINATION AND SUBROGATION OF BENEFITS) Whenever payment which should have been made by HMHIC in accordance with this Section has been made by a Coordinated Plan, HMHIC shall have the right, exercisable alone and in its sole discretion, to authorize payment to the Coordinated Plan making such payments any amounts HMHIC shall determine to be warranted in order to satisfy the intent of this Section, and amounts when so paid shall be deemed to be benefits under this Agreement, and, to the extent of such payments, HMHIC shall be fully discharged from liability under this Agreement RIGHT TO RECOVERY Whenever payments have been made by HMHIC with respect to Allowable Expenses in total amount which is, at any time, in excess of the maximum amount of payment necessary at the time to satisfy the intent of this Section, HMHIC shall have the right to recover such payments, to the extent of such excess, from one or more of the following, as HMHIC shall determine any person or persons to, or for, or with respect to whom such payments were made, any insurance company or companies, and orgamzation(s) to which such payments were made DISCLOSURE You agree to disclose to HMHIC at the time of enrollment, at the time of receipt of services and benefits, and from time to time as requested by HMHIC, the existence of other health plan coverage, the identity of the carrier, and the group through which such coverage is provided Subrogation seeks to shift the expense for injuries suffered by you to those responsible for causing them In return for HMHIC providing benefits for injuries, ailments, or disease caused as a result of the negligence, omission or willful act of a third party, you agree to execute any instrument which may be required You also agree to assign to HMHIC the right of recovery against such third party to the extent of benefits paid At the time such benefits are provided or thereafter as HMHIC may request, you also agree to comply with the following provisions • Execute a formal written injury report and assignment to HMHIC` of right to recover the actual benefits paid by HMHIC under dus Agreement for injuries, ailments and disease caused by a third party • Reimburse HMHIC for the actual benefits paid by HMHIC, but not in excess of monetary damages collected, immediately upon receipt of any momes paid by or on behalf of such third party in settlement of any claims ansmg out of injuries, ailments and diseases covered by HMHIC HMHIC shall have a hen on any actual recovery from such third party whether by judgment, settlement, compromise or reimbursement • Execute and deliver such papers and provide such reasonable help (including authorizing bringing suit against such tlurd party in your name and making court appearances) as may be necessary to enable HMHIC to recover the actual benefit paid by HMHIC 26 The relationship between HMHIC and the Group is that of independent contracting entities Neither the Group nor you is the agent or employee of HMHIC, and HMHIC is not the employee or agent of the Group or you 27 (These definitions apply when the following terms are used in this Certificate and the attached Schedule of Benefits ) Actively at work shall mean that the eligible employee must be performing the usual and customary duties of your regular employment during your usual working hours on your effective date of coverage, provided, however that if you are absent from work due to vacation, holiday, jury duty, or other similar circumstances, not caused by injury or illness, you shall be considered actively at work Agreement shall mean Entire Contract which is defined as the Group Contract, Certificate of Coverage, Group Enrollment Agreement, Schedule of Benefits, Applications, Attachments, Riders, Amendments hereto, if any Agreement shall constitute the entire contract between the parties and that in the absence of fraud all statements made the policyholder or person insured shall be deemed representations and not warranties, and that no such statement shall be used in any contest under the policy, unless a copy of the written instrument containing the statement is nor has been furnished to such person or in the event of death or incapacity of the insured person to the individual's beneficiary or personal representative ALTERNATE HEALTH BENEFIT PLAN Alternate Health Benefit Plan shall mean the plan which the Group designates as the alternative to this Agreement Allred Health Professional shall mean any health care provider/physician that provides benefits as set forth in this Agreement and described in the Schedule of Benefits Attachment AMBL1I.ATORY SURGICAL CENTER A specialized facility which is established, operated and staffed primarily for the purpose of performing surgical procedures and which fully meets one of the following two tests • It is licensed as an ambulatory surgical center by the regulatory authority having responsibility for the licensing under the laws of the jurisdiction in which it is located • Where licensing is not required, it meets all of the following requirements • It is operated under the supervision of a licensed doctor of Medicine (M D ) or a doctor of osteopathy (D O ) who is devoted full time to supervision and permits a surgical procedure to be performed only by a duly qualified physician who, at the time the procedure is performed, is privileged to perform the procedure in at least one Hospital in the area POS-CER9-92 28 • It requires in all cases, except those requiring only local infiltration anesthetics, that a licensed anesthesiologist administer the anesthetic or supervise an anesthetist who is administering the anesthetic and that the anesthesiologist or anesthetist remain present throughout the surgical procedure • It provides at least one operating room and at least one post -anesthesia recovery room • It is equipped to perform diagnostic X-ray and laboratory examinations or has arrangement to obtain these services • It has trained personnel and necessary equipment to handle emergency situations • It has immediate access to a blood bank or blood supplies • It provides the full time services of one or more registered graduate nurses (R N ) for patient care in the operating rooms and in the post -anesthesia recovery room • It maintains an adequate medical record for each patient, the record to contain an admitting diagnosis including for all patients except those undergoing a procedure under local anesthesia, a pre -operative examination report, medical history and laboratory tests and/or X-rays, an operative report, and a discharge summary A specialized facility which is primarily a place for delivery of cluldren following a normal uncomplicated pregnancy and which fully meets one of the following two tests It is licensed by the regulatory authority having responsibility for the licensing under the laws of the jurisdiction in which it is located • It meets all of the following requirements • It is operated and equipped in accordance with any applicable state laws • It is equipped to perform routine diagnostic and laboratory examinations such as hematocrit and urinalysis for glucose, protein, bacteria, and specific gravity • It has available to handle foreseeable emergencies, trained personnel and necessary equipment, including but not limited to oxygen, positive pressure mask, suction, intravenous equipment, equipment for maintaining infant temperature and ventilation, and blood expanders • It is operated under the full supervision of a licensed doctor of medicine (M D ) or registered graduate nurse (R N ) • It maintains a written agreement with at least one Hospital in the area for immediate acceptance of patients who develop 29 complications • It maintains an adequate medical record for each patient, the record to contain prenatal history, prenatal examination, any laboratory or diagnostic tests and a postpartum summary • It is expected to chscharge or transfer patients within 24 hours following delivery CALENDAR YEAR A period of one year beginning with January 1 CHEmICAI_ DEPENDENCY TREATMENT CENTER Chemical Dependency Treatment Center shall mean a facility which provides a program for the treatment of chemical dependency pursuant to a written treatment plan approved and monitored by a physician and which facility is also (1) affiliated with a hospital under a contractual agreement with an established system for patient referral, or (2) accredited as such a facility by the Joint commission on Accreditation of Hospitals, or (3) licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse, or (4) licensed, certified, or approved as a chemical dependency treatment program or center by any other state agency having legal authority to so license, certify, or approve COMPLICATIONS OF PREGNANCY Complications of Pregnancy is defined as conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnosis are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompression, missed abortion, and similar medical and surgical conditions of comparable seventy, but shall not include false labor, occasional spotting, physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy, and non -elective cesarean section, termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of gestation in which a viable birth is not possible CONTRACT YEAR Contract year shall mean the period of twelve (12) months commencing on the Group effective date and each twelve (12) month period thereafter, unless terminated COORDINATED POLICY Coordinated Plan shall mean any of the following that provides benefits or services for, or by reason of, medical care or treatment poa-cFa -92 30 Coverage under governmental programs, (excluding Medicaid) including Medicare, required or provided by any statute unless coordination of benefits with any such programs is forbidden by law Group coverage or any other arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, including any prepayment coverage, group practice basis or individual practice coverage and any coverage for students which is sponsored by, or provided through, a school or other educational institution above the high school level Course of Treatment shall mean that period of time represented by an inpatient hospital admission and related discharge during which time treatment has been received by you or your dependents or that period of time authorized by HMHIC as necessary to complete a cycle of treatment and subsequently provide a medical release to you or your dependents Covered Expenses shall mean the services and supplies, detailed in the Schedule of Benefits Attachment, for which a payment is made You and your wife or husband and Dependent children who are covered under the Agreement Crisis Stabilization Unit shall mean a twenty-four (24) hour residential program that is usually short-term in nature and that provides intensive supervision and highly structured activities to persons who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe proportions Custodial Care shall mean 1) that care which is marked by or given to watching and protecting rather that seeking cure, or 2) care which is not a necessary part of medical treatment or recovery, or 3) care comprised of services and supplies that are primarily provided to assist in the activities of daily living A psychiatric day treatment facility shall mean a mental health facility which provides treatment for individuals suffering from acute, mental and nervous disorders in a structured psychiatric program utilizing individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program and that is clinically supervised by a doctor of medicine who is certified in psychiatry by the American Board of Psychiatry and Neurology Day treatment facility may provide coverage for not more than eight hours in a twenty-four (24) hour period, the attending physician certifies that such treatment is in lieu of hospitalization, and 31 the psychiatric treatment facility is accredited by the Program for psychiatric Facilities, or its successor, of the Joints Commission on Accreditation of Hospitals Each full day of treatment in a psychiatric day treatment facility shall be considered equal to one- half of ones day of treatment of mental or emotional illness or disorder in a hospital Dependent shall mean an Eligible Dependent who has satisfied the eligibility and participation requirements specified in this Agreement Domiciliary Care shall mean that care provided in the home, custodial in nature, for persons so disabled or inform as to be unable to live independently Durable Medical Equipment must be able to withstand repeated use, primarily and customarily serve a medical purpose, generally not be used in the absence of illness or injury, require a Physician's order and be appropriate for use in the home Effective Date shall mean the effective date of coverage for you and your Eligible Dependents pursuant to the terms of this Agreement Eligible Dependent shall mean an individual as defined in the ELIGIBILITY AND EFFECTIVE DATE Section of tlus Agreement Eligible Person shall mean an individual as defined in the ELIGIBILITY AND EFFECTIVE DATE Section of this Agreement Emergency care shall mean bona fide emergency services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient seventy, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment or bodily functions, or serious dysfunction to any bodily organ or part See ELIGIBILITY AND EFFECTIVE DATE Section EVIDENCE. OF INSURAMT_.ITY 32 Evidence of Insurability shall mean the documentation of health status as required by HMHIC for Eligible Persons and Eligible Dependents who do NOT meet the following requirements regarding application for coverage (a) apply for coverage during an open enrollment period, or (b) apply for coverage within thirty (30) days of qualifying for coverage Such information shall be reviewed by HMHIC Notification will be sent to the Eligible Person or Eligible Dependents regarding their eligibility for participation in HMHIC EXCLUSION Exclusion shall mean those specific conditions or causes for which coverage by HMHIC is entirely excluded FAMILY DEDUCTIBLE The maximum your entire family will have to pay for Deductible in any year is the amount of Family Deductible shown in Schedule of Benefits This Family Deductible applies no matter how large your family may be Only Covered Expenses which count toward a persorfs Individual Deductible count toward this Deductible MA FDA shall mean the Food and Drug Admimstration, an agency of the United States Government Group shall mean collectively the contracting Group and all affiliated organizations of the Group, to which tlus Agreement is issued and through which as an agent for you and your dependents become entitled to the benefits as set forth in the Schedule of Benefits GROUP EFFECTIVE DATE Group Effective Date shall mean the date specified as such in the Group Enrollment Agreement GROUP ENROLLMENT AGREEMENT Group Enrollment Agreement shall mean that agreement which is executed between HMHIC and the Group for the purpose of making available to Eligible Persons and Eligible Dependents of the Group those benefits which are described in the Certificate of Insurance Such Group Enrollment Agreement shall identify the Group, Group Effective Date, eligibility requirements, rates, and covered benefits HEALTH CARE PROVIDERIPHYSICIAN A licensed or certified provider whose services Harris Methodist Health Insurance Company must cover due to a state law requiring payment of services given within the scope of that provider's license or certification A Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency, Laboratory, Dietitian, Minor Emergency Room Center, Chemical Dependency Treatment Center, Psychiatric Day Treatment facility, Residential Treatment Center, or Crisis Stabilization Unit, or other provider or entity which provides services as set forth in this PO CER9-92 33 Agreement as described in the Schedule of Benefits Attachment 34 An agency or organization which provides a program of home health care and wluch fully meets one of the following tests. • It is approved by Medicare • It is established and operated in accordance with the applicable licensing and other laws • It meets the following tests ♦ It has the primary purpose of providing a home health care delivery system bringing supportive services to the home ♦ It has a full -rime administrator ♦ It maintains written records of services provided to the patient ♦ Its staff includes at least one registered graduate nurse (R N ) or it has nursing care by a registered graduate nurse (R N ) available ♦ Its employees are bonded and it provides malpractice insurance HOSPICE An agency that provides counseling and incidental medical services for a terminally ill individual Room and board may be provided The agency must meet all of the following tests • It is approved under any required state or governmental Certificate of Need • It provides 24 hour -a -day, 7 day -a -week service • It has a nurse coordinator who is a registered graduate nurse (R N ) with four years of full-time clinical experience Two of these years must involve caring for terminally ill patients • It has a social -service coordinator who is licensed in the area in which it is located • The main purpose of the agency is to provide Hospice services • It has a full-time administrator • It maintains written record of services given to the patient • Its employees are bonded • It provides malpractice and malplacement insurance • It is established and operated in accordance with any applicable state laws 35 Hospital shall mean an institution licensed by the State of Texas and which is (1) primarily engaged in providing diagnostic, medical, surgical, or mental health facilities for the care and treatment of miured or sick persons, (2 ) operated under the medical supervision of a staff of legally qualified and licensed physicians, (3 ) provides twenty-four (24) hour -a -day nursing service by or under the direct supervision of a Registered Nurse (R N ), (4 ) provides for overnight care of patients, (5 ) maintaining clerical and ancillary services necessary for the treatment of medical and surgical patients including but not limited to laboratory, X-ray, dietary and medical records library In no event shall the term "hospital" include a convalescent nursing home or any institution or part thereof which is used principally as a convalescent facility, rest facility, nursing facility, facility for the aged, extended care facility, intermediate care facility, skilled nursing facility or facility primarily for rehabilitative services, the term hospital shall pursuant to Chapter 3, Texas Insurance Code, Article 3 72 included treatment in a residential treatment center for children and adolescents, treatment provided by a crisis stabilization unit, psychiatric day treatment, or chemical dependency unit IDENTIFICATION CARD A card that generally describes the benefits of a Plan, that in and of itself confers no rights to services or other benefits The card is the sole property of HMHIC, and HMHIC reserves the right of possession U DIVIDUAL DEDUCTIBLE The Individual Deductible applies to all covered expenses The amount of the Individual Deductible is shown in Schedule of Benefits Low Dose Mammography shall mean the X-Ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad midbreast, with two views for each breast Coverage for 35 year old females or older for an annual screening for the presence of occult breast cancer subject to the same dollar limits, deductibles, and co-insurance factors Medical Emergency shall mean a medical condition so classified by the medical director and which manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient's health in serious jeopardy, or (b) serious impairment of bodily function, or (c) serious dysfunction to any bodily organ or part Examples of conditions which do not usually constitute medical emergencies are colds, mfluenzas, ordinary sprains, cluldren's ear infections, or nausea,and headaches Heart attacks, cardiovascular accidents, poisoning, loss of consciousness or respiration, convulsions, severe bleeding or broken bones are examples of true medical emergencies 36 Shall mean services or supplies which are 0 ) provided for the diagnostic care and treatment of a medical condition; (2) appropriate and necessary for the symptoms, diagnosis or treatment of a medical condition, (3) generally acceptable medical practice, (4 ) performed in the most cost effective and efficient manner appropriate to treat you or your Eligible Dependent's medical condition, and (5 ) provided in accordance with accepted medical standards Medicare shall mean Part A and Part B of Title XVIII of the Social Security Act and any amendments or regulations thereunder. MUUAL OR NERVOUS DISORUR Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind [ See SERIOUS MENTAL ILLNESS for definition of Serious Mental Illness ] NO-FAULT AUTOMOBILE INSURANCE LAW The basic reparations provision of a law providing for payment without determining fault in connection with automobile accidents NURSE PRACTITIONER A person who is licensed or certified to practice as a nurse -practitioner and fulfills both of these requirements • A person licensed by a board of nursing as a registered nurse • A person who has completed a program approved by the state for the preparation of nurse -practitioners OPEN ENROLLMENT PERIOD Open enrollment shall mean a period of at least thirty (30) days during each twelve (12) consecutive months when Eligible Persons may elect to change from the Alternative Health Benefit Plan to HMHIC or from HMHIC to the Alternative Health Benefit Plan Services and supplies furmshed to the individual and required for treatment, other than the professional services of any Physician and any private duty or special nursing services (including intensive nursing care by whatever name called) A licensed or certified provider whose services Harris Methodist Health Insurance Company must cover due to a state law requiring payment of services given within the scope of that provider's license or certification 37 A Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency, Laboratory, Dietitian, Minor Emergency Room Center, Chemical Dependency Treatment Center, Psychiatric Day Treatment facility, Residential Treatment Center, or Crisis Stabilization Unit, or other provider or entity which provides services as set forth in this Agreement as described in the Schedule of Benefits Attachment Pre-existing Condition shall mean a physical condition diagnosed or treated within six months prior to the effective date of coverage Please see ELIGIBILITY AND EFFECTIVE DATE Section w Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency, Laboratory, Minor Emergency Room Center, Residential Treatment Center for children and adolescents, Crisis stabilization Unit, Chemical Dependency Unit, Psychiatric Day Treatment facility or other provider or entity which provides services as set forth in tins Agreement an described in the Schedule of Benefits Attachment An amount measured and determined by Hams Methodist Health Insurance Company by comparing the actual charges for the service or supply with the prevailing charges made for it Hams Methodist Health Insurance Company determines the prevailing charge It takes into account all pertinent factors including • The complexity of the service • The range of services provided • The prevailing charge level in the geographic area where the provider is located and other geographic areas having similar medical cost experience RESIDENTIAL TREATMENT CENTER Residential Treatment Center for Children and Adolescents means a child-care institution that provides residential care and treatment for emotionally disturbed children and adolescents and that is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Hospitals, or the American Association of Psychiatric Services for Children Room, board, general duty nursing, intensive care by whatever name called, and any other service regularly furnished by the hospital as a condition of occupancy of the class of accommodations occupied, but not including professional services of Physician nor special nursing services rendered outside of an intensive care unit by whatever name called The term "sickness" will include a surgical procedure for sterilization and related medical care and treatment and confinement within 30 consecutive days from the procedure POS-CER9-92 38 The term "sickness" will include complication of pregnancy (as described above) The term "sickness" used in connection with newborn children will include congenital defects and birth abnormalities, including premature births SKTJ M NURSING FACILITY If the facility is approved by Medicare as a Skilled Nursing Facility then it is covered by this Agreement If not approved by Medicare, the facility may be covered if it meets the following tests • It is operated under the applicable licensing and other laws • It is under the supervision of a licensed Physician or registered graduate nurse (R N ) who is devoting full time to supervision • It is regularly engaged In providing room and board and continuously provides 24 hour a day skilled nursing care of sick and injured person's at the patient's expense during convalescent stage of an mlury or sickness • It maintains a daily medical record of each patient who is under the care of a duly licensed Physician • It is authorized to administer medications to patients on the order of a duly licensed Physician • It is not, other than incidentally, a home for the aged, the blind or the deaf, a hotel, a domiciliary care home, a maternity home, or a home for alcoholics or drug addicts or the mentally ill Total Disability and totally disabled shall mean (1) with respect to an employee or other primary insured under the policy, the complete inability of the person to perform all of the substantial and material duties and function of his or her occupation and any other gainful occupation in which such person earns substantially the same compensation earned prior to disability, and (2) with respect to any other person/dependent under the policy, confinement as a bed patient in a hospital Utilization Review Department shall mean a department of HMHIC which determines, in its discretion, if a service or supply is medically necessary for diagnosis or treatment of an accidental injury, illness or pregnancy A service or supply is not medically necessary if a less intensive or more appropriate diagnostic or treatment alternative could be used in lieu of the services or supply given 39 This Agreement shall remain in effect for the first Contract Year and thereafter for successive Contract Years unless sooner terminated as provided in Section TERMINATION of this Agreement AMENDMENT • HMHIC and Group may mutually alter or revise the terns of this Agreement and/or Schedule of Benefits and Riders hereto In the event of such alteration or revision, HMHIC shall provide Group with at least sixty (60) days written notice before effective date of Amendment Such notice shall be considered to have been provided when mailed to the Group at the latest date shown on the records of HMHIC The Agreement may be amended at any time, according to any provisions of this Agreement or by written agreement between HMHIC and Group, without consent of you, or any other person having a beneficial interest in it Any such amendment shall be without prejudice to any claim arising prior to the effective date of such amendment HMHIC shall have the right to change the rates and premiums payable hereunder (i) as of any Anniversary Date (in which case the Group shall be notified at least sixty (60) days prior to a change in rates) or (u) in accordance with Section TERM AND AMENDMENT OF AGREEMENT of this Agreement 40 Words used in the masculme shall apply to the feminine where applicable, and, wherever the context of tins Agreement dictates, the plural shall be read as the singular and the singular as the plural The terms "you", "your", and "insured" shall refer to the employee "HMHIC" and "insurer" shall refer to Harris Methodist Health Insurance Company The words "hereof', "herein", "hereunder" and other similar compounds of the word "here" shall mean and refer to the entire Agreement and not to any particular Section or provision All references to Sections and provisions shall mean and refer to Sections and provisions contained in this Agreement unless otherwise indicated HMHIC shall, to the extent legally allowable and without further consent of or notice to you, release to or obtain from any insurance company or other orgamzatton or person any information, with respect to you, which HMHIC deems to be necessary for such purposes as Coordination of Benefits When claiming benefits, you shall furrush HMHIC information as may be necessary to implement this Agreement Group shall periodically forward the information required by HMHIC in conjunction with the administration of the Agreement All records of Group wluch have a bearing on the coverage shall be open for inspection by HMHIC at any reasonable time HMHIC shall not be liable for the fulfillment of any obligation dependent upon such information prior to its receipt in a form satisfactory to HMHIC Incorrect information furnished may be corrected, if HMHIC shall not have acted to its prejudice by relying on it HMHIC shall have the right, at reasonable times, to examine Group's records, including payroll records of the Group having employees covered through this Agreement, with respect to eligibility and monthly premiums under this Agreement ASSIGNMENT Assignment shall mean the authorization to pay benefits directly to the party providing the benefit This may not be construed to (1) provide a coverage or benefit not otherwise available under the health insurance policy, (2) allow assignment of a benefit payment to a person who is not legally entitled to receive such a direct payment, or (3) prohibit an insurer from verifying through the insurer's normal process the health care services provided to the covered person by the physician or health care provider If a written assignment of benefits payable for health care services is made by a covered person and is obtained by or delivered to the insured with the claim for benefits, the benefit payment shall be made by the insurer directly to the physician or other health care provider If a written assignment of benefits is made and delivered or obtained as provided, the insurer is relieved of the obligation to pay and of any liability for paying the benefits for the health care 41 services to the covered person The payment of benefits under an assignment does not relieved the covered person of any contractual responsibility for the payment of deductibles and copayments A physician or other health care provider may not waive copayments or deductibles by acceptance of an assignment Any alterations or revisions to this Agreement shall not be valid unless evidenced by a written amendment which has been signed by (croup and by an officer of HMHIC and attached to the affected document No other person has the authority to change this Agreement or to waive any of its provisions This Agreement is executed and is to be performed in all respects in accordance with all federal and Texas state laws applicable to Health Insurance Companies and all other applicable Texas state laws or regulations The Schedule of Benefits, Group Enrollment Applications, any optional Riders, any Attachments, and any amendments to any other forgoing, form a part of this Agreement as if fully incorporated herem Any direct conflict or ambiguity of this Agreement shall be resolved under terms most favorable to you Agreement shall mean Entire Contract which is defined as the Group Contract, Certificate of Coverage, Group Enrollment Agreement, Schedule of Benefits, Applications, Attachments, Riders, Amendments hereto, if any Upon execution of this Agreement, HMHIC shall provide to you a copy of this Certificate of Coverage; and an Identification Card Such delivery shall be accomplished by mailing postage paid, to the latest address furnished to HMHIC or by delivery from a representative of HMHIC or Group to you In the administration of HMHIC, this Agreement shall be applied uniformly to all similarly situated employees In determining time periods within an event or action is to take place for purposes of HMHIC, no fraction of a day shall be considered, and any act, the performance of which would fall on a Saturday, Sunday, holiday or other non -business day, may be performed on the next following business day, may be performed on the next business day 42 Evidence required of you to HMHIC may be certificate, affidavit, document, or other information which when acting on it considered pertinent and reliable, and signed, made or presented by the proper party or parties If any provision of tins Agreement shall be held invalid or illegal, the rest of tlu&Agreement shall remain in force and effect and shall be construed in accordance with the intentions of the parties as manifested by all provisions hereof including those which shall have been held invalid and illegal Furthermore, in lieu of any provision hereof which is found to be illegal, invalid or unenforceable provision as may be possible and be legal, valid and enforceable without materially changing the purpose and intent of this Agreement The titles and headings of Sections or provisions are included for convenience of references only and are not be considered in construction of the Sections or provisions hereof All HMHIC notices of termination of this Agreement or of your rights will be in writing and shall state the cause of termination, with specific reference to the provision(s) of this Agreement giving rise to the right of termination NOTICE Any notice under this Agreement shall be in writing, and shall be given by United States mail, postage prepaid, addressed as follows HMHIC 611 Ryan Plaza Drive, Suite 900 Arlington, Texas 76011-4009 Group The address specified on the executed Group Enrollment Agreement or the latest address provided, in writing, to HMHIC Employee The latest address provided by you on the Application form actually delivered to HMHIC The effective date of notice is two (2) business days after the date of deposit with the United States Post Office 43 SCHEDULE OF BENEFITS POS PREFERRED PLUS HARRIS METHODIST HEALTH INSURANCE COMPANY 601 Ryan Plaza Drive, Suite 211 Arlington, Texas 76011 1-800-356-7522 (817)462-7800 POSLOSCH 96 i .. .. +�. �,...,�.. ...f. . ,..� ...... V. You and your Eligible Dependents are entitled to receive the services and benefits set forth in this Schedule of Benefits which are Medically Necessary and obtained in accordance with the provisions of the Group Health Care Agreement/Subscnber Certificate of Coverage and/or Certificate of Insurance A The Utilization Review Department determines the Medical Necessity of services You are responsible for notifying the Utilization Review Department (UR) for the services listed below The UR phone number is (817)462-7800 or 1(800) 633-8598 Benefits which are not Medically Necessary will be denied The ultimate decision on your medical care must be made by you and your Physician The Utilization Review Department only determines the Medical Necessity of a service, only services medically necessary are paid for according to the Agreement benefits and provisions Benefits are reduced if you do not call UR prior to receiving services as required The penalty for not calling UR is a 50% reduction in benefit payment The penalty is applied to each confinement, surgical procedure, diagnostic procedure, or treatment plan Within five (5) working days before receiving the following services, you are required to call UR for authorization • Inpatient Admissions (including pregnancy) • Outpatient surgery where the procedure requires an operating room or surgical setting (exception endoscopes, sterilization, and biopsies) • Inpatient Chemical Dependency Treatment • Home IV Therapy • Physical Therapy and Occupational Therapy beyond six (6) visits • Durable Medical Equipment/ Prosthetics • Home Nursing Services • Hearing Aids, if coverage is included • Skilled Nursing Facility • Outpatient Mental/Nervous disorder Other office procedures requiring precertification are • Laser procedures, Thallium stress tests, Cystoscopies, Choriomc villi sampling, Amniocentesis, LEEP/LETZ procedures, and D&C • Artenogram, Aortogram, Myelogram, and Lumbar Puncture B Benefits which are covered under Harris Health Plan, Inc d/b/a Harris Methodist Health Plan (HMHP)are not covered expenses under Harris Methodist Health Insurance Company (HMHIC) No Coordination of Benefits are available between HMHP and HMHIC Benefits Emergency Care which does not meet HMHP's definition will be covered under HMHIC C You must submit your own claim forms for all medical bills for services received from Providers The claim office address is P O Box 90100, Arlington, Texas 76004-3100 Benefits are based on the Reasonable and Customary charges as established by HMHIC The benefits will be POSLOSCH 96 sent in accordance with claims provisions outlined in the Certificate of Coverage document An explanation of benefits (EOB) summary will be sent which explains the amount of benefits paid as well as the amount of payment which is your responsibility D All services and benefits are subject to any stated Copayment or coinsurance amounts, limitations, and exclusions described in this Schedule of Benefits E Any copayment expressed as a percentage of "Total Charges" or flat amount shall mean that portion of the Reasonable and Customary charges as established by HMHIC F This Schedule of Benefits may be supplemented by adding benefit Riders if included with this Group Health Care Agreement/Subscriber Certificate of Coverage, and/or Certificate of Insurance G The relationship between HMHIC and Group is that of independent contracting entities Providers are not agents or employees of HMHIC nor is HMHIC an employee or agent of any Provider Providers shall maintain the physician -patient or professional -patient relationship with you and shall be the only parties responsible to you for the services provided Neither HMHIC or any employee of HMHIC shall be deemed to be engaged in the practice of medicine HMHIC shall in no way supervise the practice of medicine by any Provider, nor shall HMHIC in any manner supervise, regulate or interfere vAth the usual professional relationships between a Provider and you H The following Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 Per Member $500 00 Per Family $1,500 00 Any services which are limited in either daily limits or dollar maximums under HMHP policy will also be counted towards HMHIC's daily limit or dollar maximum POSLOSCH 96 The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 Only one Copayment will be required for covered services performed or furnished on same date of service by the same Provider This Copayment will be the higher of all listed Copayments Benefits Required Copayment Physician office visits $20 00 per visit Adult health assessments, routine physical 50% of Total Charges examinations, well child care, and health education for diagnosis, care and treatment of illness or injury provided by a Physician Annual well woman examination 50% of Total Charges Medically accepted Bone Mass Measurement for 50% of Total Charges Qualified Individuals for detection of low bone mass and to determine the person's risk of osteoporosis and fractures associated with osteoporosis Physician office visits after hours $25 00 per visit Immunizations 50% of Total Charges Home visits $20 00 per visit Allergy diagnosis and/or testing, serum is not covered $75 00 per visit Administered drugs, medications, dressings, splints, $20 00 per visit and casts Diagnostic services, laboratory tests, and x-rays 30% of Total Charges (Including Low -Dose Mammography, will be covered as other x-rays) Ultrasound, MRI, CAT, and non -routine laboratory tests $100 00 per test Surgery and/or anesthesia performed in the $100 00 per procedure physician's office or outpatient setting POSLOSCH 96 All physician fees including anesthesia while 30% of Total Charges the Insured is hospitalized Professional radiology and pathology fees 30% of Total Charges (Including, Low -Dose Mammography) For maternity services, Covered Person shall be entitled to receive medical, surgical, and hospital care from Physicians and other Providers during the term of the pregnancy, upon delivery, and during the postpartum period for normal delivery, for abortion and miscarriages, and for complications of pregnancy Charges related to medical services connected with the home delivery of a newborn and services of mid -wives, unless provided as Emergency Care Services, will not be covered Benefits Required Copayment Physiciani services for maternity care including 30% of Total Charges delivery, hospital visits, and anesthesia Physician care in the hospital for care 30% of Total Charges of Eligible Newborn NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services" for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty POSLGSCH SS .§[EIIrS°o !�+J�� �tt�'Cf �{ °FN�I, t II'sAi7^kii'� 1 R'gw,'kf�wRAC r s r r The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 You shall be entitled to receive Medically Necessary hospital services, subject to all definitions, terms and conditions of this Agreement and Schedule of Benefits If you elect to remain in the hospital beyond the period which is Medically Necessary (as determined by your Physician and HMHIC Utilization Review Department), you will be responsible for non Medically Necessary services directly to the hospital You must notify the Utilization Review department if your stay is extended beyond the authorized time by the Utilization Review Department Benefits INPATIENT HOSPITAL SERVICES Semi -private room, private if Medically Necessary, and all services and medical supplies related to inpatient treatment OUTPATIENT HOSPITAL SERVICES (Including Ambulatory Facilities) Surgery Therapeutic radiation treatment Inbalation therapy Diagnostic testing, laboratory, and x-rays Ultrasound, MRI, CAT, and non -routine laboratory tests Required Copayment 30% of Total Charges $100 00 per procedure 30% of Total Charges 30% of Total Charges 30% of Total Charges $100 00 per test NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services" for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty POSLOSCH96 If ) Ii IOIei f I i I I I If The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 In cases of a Medical Emergency, you are entitled to the benefits and services set forth in this Schedule of Benefits and in this Agreement At the time of a Medical Emergency which results in a hospital admission, you or someone acting on your behalf, shall notify the Utilization Review Department within twenty-four (24) hours or as soon as reasonably possible Upon notification, the Utilization Review Department will evaluate the need for continuation of hospital services Benefits Physician office visits Physician office visits after hours Hospital emergency room and urgent care center services, including physician fees Follow-up care POSLOSCH SB Required Copayment 30% of Total Charges 30% of Total Charges 30% of Total Charges 30% of Total Charges y��{Y���!{![��(ryry'♦�Y���IMMpptt�y�yjjjjy��1Yy�yi�[ �t�i�{r,T .. f. .r ,.. ) ).. _. _..Rr .f...r+... ..... Y PLAi'+�+).�5�O �f+91*F"A The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 Family Planning Services will be available to you on a voluntary basis Covered services will include history, physical examination, related laboratory tests, medical supervision in accordance with generally accepted medical practice, information and counseling on contraception, including advice or prescription for a contraceptive method, education, including education on the prevention of venereal disease, and voluntary sterilization after appropriate counseling Benefits Required Copayment Physician office visits, including related testing, $20 00 per visit education and counseling Fitting and dispensing of IUD and diaphragms $20 00 per visit Tubal ligation $75 00 per procedure Vasectomy $75 00 per procedure NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services" for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty POSLOSCH96 , �orvG' r�e5r s"' s� er� r3+�fiy+fir �f } i <ff �rf A f df ``� `x < `n 4 'r4��` 4s; s`f `s s`''`' f'< The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 Infertility services will be available to you on a voluntary basis Artificial insemination and diagnostic services to determine the cause of infertility will be provided Excluded from services to tLg1 infertility are those, services described in "Exclusions" of this Schedule of Benefits Benefits Required Copayment Physician office visits for diagnosis, non -psychiatric $20 00 per visit counseling, artificial insemination, and sperm count Administration of infertility medications, infertility $20 00 per visit medications not covered Endometrial biopsy, hysterosalpingography and 30% of Total Charges diagnostic laparoscopy Sonogram and/or ovulation kit $75 00 per test or kit NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services„ for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty POSLOSCH 96 The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 You shall be entitled to all necessary care and treatment for chemical dependency on the same basis as that provided for any physical illness to a lifetime maximum of three (3) separate series of treatments Diagnosis and treatment for chemical dependency shall include detoxification and/or rehabilitation on either an inpatient or outpatient basis as determined to be Medically Necessary by a Physician All treatment is subject to the same limitations, exclusions, and copayments as applied to covered services of any other physical illness Note Inpatient Drug Treatment requires precertrfication by the Utilization Review Department A series of treatments is considered to be a planned, structured, and organized program to promote chemical free status which may include different facilities or modalities and is complete when ® You are discharged on medical advice from inpatient detoxification, inpatient rehabilitation treatment, partial hospitalization or intensive outpatient treatment, or ® You have received a serves of these levels of treatments without a lapse in treatment, or m You fail to materially comply with the treatment program for a period of thirty (30) days Benefits Required Copayment Office visits $20 00 per visit Necessary care and treatment for detoxification and/or $20 00 per visit rehabilitation from chemical dependency Intensive outpatient or partial hospitalization 30% of Total Charges NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services" for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty NOTE Any services which are limited in either daily limits or dollar maximums under HMHP policy will also be counted towards HMHIC's daily limit or dollar maximum POSLOSCH96 10 The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through' December 31 OUTPATIENT MENTAL HEALTH SERVICES You shall be entitled to receive up to twenty (20) office visits per Calendar Year for evaluation, crisis intervention and stabilization, and for outpatient therapy in support of the evaluation or crisis intervention The twenty (20) visits maximum may include individual treatment, couple, or family visits Benefits Required Copayment Outpatient office visits for crisis intervention and treatment $20 00 per visit Psychological testing 30% of Total Charges INPATIENT MENTAL HEALTH SERVICES When determined to be Medically Necessary by the Utilization Review Department, you shall be entitled to evaluation, crisis intervention, treatment or any combination thereof for acute conditions Only treatment at the most appropriate level of care as determined by the Utilization Review Department will be authorized Benefits Required Copayment Inpatient hospitalization for up to thirty (30) inpatient 30% of Total Charges days per Calendar Year Psychiatric Day Treatment Facility or Crisis Stabilization 30% of Total Charges Unit or Residential Treatment Center for Children and Adolescents for up to sixty (60) days per Calendar Year Treatment in such facilities will be limited to sixty (60) days of care such that one (1) day of care in a psychiatric day treatment facility center shall be equal to one-half (%) days of hospital (inpatient) care NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty NOTE Any services which are limited in either daily limits or dollar maximums under HMHP policy will also be counted towards HMHIC's daily limit or dollar maximum POSLOSCH 90 �� The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 You shall be entitled to receive Inpatient or Outpatient physical, occupational, and speech therapy rehabilitation services directed and monitored by a Physician or by a licensed or certified physical, occupational, or speech therapist All services must be provided in relation to a covered diagnosis or procedure and must prevent dysfunction, restore functional ability, or facilitate maximal adaptation to impairment Services must be provided according to a specific written treatment plan that details the treatment, including frequency and duration, and provides for ongoing reviews Services are expected to result in significant improvement of the condition within a two (2) month period The two (2) month period commences with the first visit Short term is defined as two (2) months or less Treatment is limited to a maximum of sixty (60) visits per medical episode Rehabilitation services are provided whether you are in a Hospital, nursing facility, or at home Occupational therapy shall mean those services designated to prevent dysfunction, restore functional ability and facilitate maximal adaptation to impairment Coverage is provided for the treatment of loss or impairment of speech or hearing Benefits Required Copayment Short-term rehabilitative services including $20 00 per visit -Outpatient occupational therapy, physical therapy, or 30% of Total Inpatient Charges speech therapy Long-term or maintenance services Not Covered Long term/maintenance services are defined as including Custodial/Domiciliary Care and services which are not skilled in nature and not medically necessary Maximum Benefit Services are limited to a maximum of two (2) months per medical episode for services provided in an Outpatient setting NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertrfied See Item "A" under "Obtaining Health Care Services" for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty NOTE Any services which are limited in either daily limits or dollar maximums under HMHP policy will also be counted towards HMHIC's daily limit or dollar maximum POSLOSCH 96 12 The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 You shall be entitled to services and benefits provided for kidney dialysis upon prior authorization from the Utilization Review Department and only if your Physician determines that such service represents the preferred method of treatment, and you satisfy the criteria for the service involved Coveragelwill be coordinated for you if you are eligible for available coverage under the Medicare provisions for End Stage Renal Disease Benefits Required Copayment Inpatient or outpatient hospital, or outpatient 50% of Total Charges kidney dialysis center Home dialysis (continuous ambulatory pentoneal 50% of Total Charges dialysis) including equipment, training, solutions, cods, drug and surgical supplies NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 Benefits You shall be entitled to both land and air ambulance services for Medically Necessary Emergency Care Services POSLOSCH96 13 Required Copayment 30% of Total Charges j, ; $,g h..`,` iI fl 1, , 11 f p 1 r P The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 "Home health service" means the provision of a health service for payment or other consideration in a patient's residence under a plan of care established, approved in writing, and reviewed at least every two (2) months by the attending Physician and certified by the attending Physician as necessary for medical purposes You shall be entitled to receive home health care services according to a Treatment Plan approved by the Utilization Review Department Treatment will be provided for physical, occupational, speech, or respiratory therapy Home health care services includes Skilled nursing by a registered nurse (RN) or licensed vocational nurse (LVN) under the supervision of at least one registered nurse and at least one physician The service of a home health aide under the supervision of a registered nurse The furnishing of medical equipment and medical supplies other than drugs and medicines Home Health Services provided under this section may not be reimbursed unless the attending Physician certified that hospitalization or confinement in a Skilled Facility would otherwise be required if a treatment plan for home health care was not provided The number of visits for which benefits will be payable are sixty (60) visits in any Calendar Year for each covered person under this policy Excluded benefits include Custodial Care, benefits provided by a person who resides in the covered person's home, or is the Insured of the covered person's family A visit by a Home Health Agency representative is considered one (1) home health care visit Four hours of home health aide service is considered one (1) Home Health Care visit If services extend beyond four hours, each four hours or portion of that period is considered as one (1) Home Health Care visit Benefits Required Copayment Skilled nursing care, physical, occupational, $20 00 per visit speech or respiratory therapy, intravenous solutions, and home health aid services Hospice (home health service only) $20 00 per visit NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services" for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty NOTE Any services which are limited in either daily limits or dollar maximums under HMHP policy will also be counted towards HMHIC's daily limit or dollar maximum POSLOSCH 96 14 f � ff ram{ r r r%rR%f# +>f rf fi %ffr rf%f f>+ Fr The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 You are entitled to receive services in a Skilled Nursing Facility for medical conditions which in the judgement of the Utilization Review Department are subject to significant clinical improvement and which require services which can only be provided at that level of care Services in a Skilled Nursing Facility may be provided in lieu of hospitalization (either in lieu of admission or upon discharge from inpatient care) as Medically Necessary based on acuity of services and patient condition, are limited to sixty (60) days per Calendar Year Benefits Required Copayment Room, Board, medications and supplies 30% of Total Charges while confined in a Skilled Nursing Facility as part of a short-term recovery or rehabilitation program Physician visits while confined to Skilled 30% of Total Charges Nursing Facility NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertified See Item "A" under "Obtaining Health Care Services" for the complete list of other services and procedures which require Utilization Review precertiflcation Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty NOTE Any services which are limited in either daily limits or dollar maximums under HMHP policy will also be counted towards HMHIC's daily limit or dollar maximum POSLGSCH96 15 4 PROV" e%rr" r ) ) t r ) tf 3 The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 You are entitled to prosthetic medical services or medical appliances if Medically Necessary, with authorization from the Utilization Review Department While you are covered under this Agreement, initial prostheses are provided when required due to illness or injury Replacement is provided only when marked physical changes occur which require replacement, and is not provided for items which wear out due to normal usage Benefits Internal prosthetic appliances including internal cardiac pacemakers, and minor devices such as screws, wire mesh, nails, and artificial joints Supply of or replacement of internal breast protheses covered only if initial surgery was result of injury or disease External prosthetic appliances including artificial arms, legs, above or below knee or elbow prostheses, eyes, lenses, external cardiac pacemaker, terminal devices such as hand or hook, rigid or semi -rigid immobilizing devices such as arm, leg, neck or back braces, and ordinary splints, and crutches Required Copayment 30% of Total Charges 30% of Total Charges NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precertefied See Item "A" under "Obtaining Health Care Services" for the complete list of other services and procedures which require Utilization Review precertificateon Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty POSLOSCH 96 16 The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 You are entitled to benefits for certain durable medical equipment as prescribed by a physician, with poor authonzation from the Utilization Review Department Durable medical equipment must be able to withstand repeated use, primarily and customarily serve a medical purpose, generally not useful in the absence of illness or injury, require a physician's order, and be appropriate for use in the home At its option, HMHIC may rent or purchase approved equipment HMHIC retains the right of possession of equipment HMHIC shall have no liability or responsibility for repair or replacement of equipment lost or damaged Equipment not considered durable medical equipment is described in "Exclusions", Section XIX, Number 31 of this Schedule of Benefits Benefits Required Copayment Rental or purchase of medical equipment 30% of Total Charges NOTE You must obtain authorization for most health care services (other than routine office visits) by calling the Utilization Review Department Inpatient admission to any health care facility must always be precerti ied See Item "A" under "Obtaining Health Care Services for the complete list of other services and procedures which require Utilization Review precertification Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction in benefit payment penalty POSLGSCM 06 17 O!F :N TPA $ N87,t The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 If Medically Necessary and authorized by the Company, you are entitled to Kidney transplants, corneal transplants, Inver transplants for children with bdiary atresia and other rare congenital abnormalities, and bone marrow transplants for Aplastic Anemia, leukemia, lymphoma, Severe Combined Immunodeficiency Disease, and Wiscott-Aldrich Syndrome where traditional modalities of medical therapy have been exhausted Benefits for covered transplants, as specified in this section, are provided to the extent that benefits are available under this policy with the following exceptions a medical costs associated with organ procurement (the removal of an organ for a covered transplant) when the recipient is a Covered Person, are limited to a maximum benefit of $10,000 00 for the recipient and donor, b the donor's transportation costs are not covered, c charges related to organ, tissue, or artificial organ transplants, except as specified in this section, are not covered d services provided to a Covered Person acting as a donor for an organ or element of the body are not covered, and e reimbursement for medical expenses of a Irve donor are provided to the extent that benefits remain available Mgr all benefits have been provided on behalf of the Covered Person as the recipient XVIL LIMITED DENTAL $11IRVICES The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1 through December 31 You are entitled to services for the initial stabilization of acute accidental, non -occupational injury, to sound natural teeth with prior authorization by the Utilization Review Department, when provided within thirty (30) days of the accident on an outpatient basis only Limitations and exclusions for dental services are described in this Schedule of Benefits Copayments will be the same as described for other illness or injury services POSLOSCH96 18 The maximum annual Copayments for covered benefits, under this Schedule of Benefits, will not exceed the following in a Calendar Year as described in GLOSSARY OF TERMS, of the Group Agreemerit/Subscriber Certificate of Coverage Benefits Maximum Annual Copayments PeriMember $4,00000 PerFamily $8,000 00 POSLOSCH 96 19 The following services are limited as described below The Utilization Review Department determines the Medical Necessity of services You are responsible for notifying the Utilization Review Department (UR) for the services listed below The UR phone number is (817) 878-5828 Benefits which are not Medically Necessary will be denied The ultimate decision on your medical care must be made by you and your Physician The Utilization Review Department only determines the Medical Necessity of a service, only services medically necessary are paid for according to the Agreement benefits and provisions Benefits are reduced if you do not call UR prior to receiving services as required The penalty for not calling UR is a 50% reduction in benefit payment The penalty is applied to each confinement, surgical procedure, diagnostic procedure, or treatment plan Services which are provided under HMHP are not covered expenses under HMHIC 2 Care and treatment of the teeth or gums, except for oral surgery for tumors or injuries to the law bone or surrounding tissue, is limited to the initial stabilization of acute, accidental, non - occupational injury to sound, natural teeth when provided within thirty (30) days of the accident, on an outpatient basis only 3 Coverage for vision examinations is limited to conditions which require examination to diagnose injury or illness, unless covered by Rider attached to this Agreement 4 The benefit for durable medical equipment is limited to either the total rental cost or the purchase price of such equipment, whichever is less, as determined and authorized in advance by the HMHIC Medical Director or his designee HMHIC will have no liability or responsibility for repair or replacement of equipment lost or damaged 5 Care and treatment provided in hospital owned or operated by federal government is limited to the care for the condition which the law requires to be treated or provided in a public facility 6 The purchase or fitting of eye glasses or contact lens or advice on their care is limited to the initial set of eye glasses, contact lens, or lens implant required following cataract surgery, repair of congenital defect or as required by an accidental injury to you 7 Coverage for reconstructive surgery is limited to surgery necessary to repair a functional disorder resulting from disease, injury (except Congenital defect), Congenital defect reconstructive surgery will be covered Supply or replacement of internal breast protheses is covered only if initial surgery was a result of injury or disease POSIOSCH 96 20 8 Coverage for temporomandibularQaw or craniomandibular) joint (TMJ) is limited to Medically Necessary diagnostic services and/or surgical treatment as determined to be Medically Necessary Charges related to dental services for this condition are not covered Pre�Existing Condition means any disease or physical condition for which the Covered Person received medical advice or treatment for during the continuous six (6) month penod pnor to the effective date of coverage Pre -Existing Conditions are covered under the Policy beginning the earlier of either a the end of a continuous period of twelve (12) months commencing on or after the effective date of the Covered Person's coverage during all of which the Covered Person has received no medical advice or treatment for in connection with such disease or physical condition, or b the end of the two (2) year penod commencing on the effective date of the Covered Person's coverage Pre-existing conditions are covered after the satisfactory completion of a waiting period However, the waiting period will not apply to a Covered Person who was covered under the Policyholder's Prior Plan on the Effective Date of the Policy The Company gives the Covered Person credit for the time he/she was covered under the Prior Plan, if the previous coverage was continuous to a date not more that thirty (30) days prior to the Effective Date of the Policy coverage, exclusive of any applicable waiting period under the policy The maximum amount of additional copayment for a Pre -Existing Condition during a calendar year will not exceed $2,000 for any such Covered Person or Dependent, or $4,000 total for such Covered Person and his/her Dependents If benefits are received under the HMHP policy, no benefits are payable under the HMHIC policy, therefore the Pre -Existing condition clause does not apply to your coverage POSLOSCH88 21 The following services and supplies, and the cost hereof, are excluded from coverage under this Agreement, unless specifically added by Rider to this Schedule of Benefits 1 Charges for services covered or provided under the HMHP Contract 2 Charges related to any service or treatment which a Covered Person would not be legally required to pay, except for Medicaid 3 Charges related to personal, convenience, or comfort items such as personal kits provided on admission to a hospital, television, telephone, newborn infant photographs, guest meals, birth announcements, and other related articles which are not for the specific treatment of illness or injury 4 Charges related to transportation, except charges related to land and air ambulance services for Medically Necessary Emergency Care Services described in this Agreement 5 Charges related to private hospital room and/or private duty nursing unless determined to be medically necessary and authorized by HMHIC Utilization Review 6 Charges related to services rendered by a person who resides in the Covered Person's home, or by an immediate relative of the Covered Person 7 Charges related to services for military or service connected conditions for which the Covered Person is legally entitled, and for which appropriate facilities are reasonably available to the Covered Person 8 Charges related to occupational injury or illness or conditions covered under Worker's Compensation or similar law 9 Charges for health care services primarily for rest, custodial, respite, domiciliary, or convalescent care 10 Charges related to reports, evaluations, or physical examinations not required for health reasons (not Medically Necessary) Excluded items are reports for employment, insurance, camp, adoption, travel, or government licenses 11 Charges related to drugs or medicines, prescnption or non-prescnption, provided to the Covered Person while he or she is not an inpatient, unless specifically provided by a Rider to this Schedule of Benefits 12 Charges related to experimental drugs or substances not approved by the FDA for other than FDA approved indications, and drugs labeled "Caution - limited by Federal Law to investigational use " 13 Charges related to formulas, dietary supplements, or special diets provided to the Covered Person on an outpatient basis POSLOSCH 96 22 14 Charges related to vision care Excluded services are, but not limited to examination for eye glasses, refraction, dispensing, or fitting of eye glass frames and lenses, all types of contact lens, eye exercise and visual training, and orthoptics, except as otherwise specified in this Schedule of Benefits 15 Charges related to radial keratotomy or other radial keratoplasties, and all costs associated with such surgery 16 Charges related to hearing aids, batteries, and examinations for fitting thereof unless added by Rider 17 Charges related to the care and treatment of the feet unless such services are Medically Necessary Exclusions include routine foot care, such as removal of corns, calluses, or the trimming of nails, treatment for flat feet, orthotics, arch supports, or custom fitted braces and splints 18 Charges related to dental care, except as otherwise specified in this Schedule of Benefits, including services related to the care, fillings, removal, or replacement of teeth, treatment of diseases of the teeth or gums, extraction of wisdom teeth, malocclusion or malposition of the teeth and jaws (mandibular hyperplasia/hypoplasia), professional services or anesthesia related to or required for the sole purpose to provide dental care, hospital care, inpatient or outpatient surgery required for any dental care, prescription drugs for dental treatment, dental x-rays, dentures, and dental appliances or prostheses 19 Charges related to surgical procedures and other treatment associated with the treatment of obesity, regardless of associated medical or psychological conditions, including treatment of a complication of surgical treatment for obesity Excluded procedures include, but are not limited to intestinal or stomach bypass surgery, gastric stapling, wiring of the taw, insertion of gastric balloons, or similar procedures 20 Charges related to transsexual surgery, including medical or psychological counseling or hormonal therapy, in preparation for or subsequent to any such surgery 21 Charges related to services for cosmetic surgery or reconstructive surgery, except as otherwise specified as covered in this Schedule of Benefits Cosmetic surgery exclusions include, but are not limited to rhinoplasty, scar revisions, prosthetic penile implants, surgical revision or reformation of any sagging skin on any part of the body, described as relating to the eye lids, face, neck, abdomen, arms, legs or buttocks, liposuction procedures, any services performed in connection with the enlargement, reduction, implantation or appearance of any portion of the body described as the breast, face, lips, taw, chin, nose, ears, or gentiles, hair transplantation, chemical face peels or abrasions of the skin, removal of tattoos, and electrolysis depilation Supply or replacement of internal breast protheses is covered only if initial surgery was a result of injury or disease 22 Charges related to reduction mammoplasty, unless determined to be Medically Necessary by the HMHIC Medical Director of his designee 23 Charges related to reversal of surgically performed sterilization or subsequent resterilization POSLOSCMSS 23 24 Charges related to surrogate parenting, GIFT procedures, and any costs associated with the collection or storage of sperm for artificial insemination including donor fees, and infertility medications unless specifically provided by a Rider 25 Charges related to amniocentesis, ultrasound, or any other procedure performed solely for sex determination of the fetus 26 Charges related to mental health services for psychiatric conditions which are determined by the HMHIC to be not Medically Necessary in nature and beyond the maximum days allowed by HMHIC 27 Charges related to court ordered testing, and special reports not directly related to medical treatment 28 Charges related to services for the treatment of mental retardation and mental deficiency 29 Charges related to employment, vocational, or marriage counseling, behavioral training, remedial education, including evaluation and treatment of learning and developmental disabilities and minimal brain dysfunction, or attention deficit therapy Benefits for the necessary care and treatment of loss or impairment of speech or hearing are excluded thereof unless added by Rider 30 Charges related to services for chronic intractable pain provided by a pain control center, acupuncture, naturopathy, and hypnotherapy, holistic or homeopathic care, including drugs, and ecological or environmental medicine 31 Charges related to durable medical equipment, unless described in this Schedule of Benefits Excluded items are, but not limited to a deluxe equipment, such as motor driven wheel chairs and beds, possessing features of an aesthetic nature or features of a medical nature which are not required by the patient's condition, b items not primarily medical in nature or for the patient's comfort and convenience, such as bed boards, bathtub lifts, over -bed tables, adjust -a -bed, and telephone arms, c physician's equipment such as stethoscope and sphygmomanometer, d exercise equipment such as exercycles and enrollment in health or athletic clubs, e self-help devices not primarily medical in nature, such as sauna or whirlpool baths, chairs, and elevators, f corrective orthopedic shoes and arch supports, g supplies or equipment for common household use, such as but not limited to, air purifiers, central or unit air conditioners, water purifiers, allergenic pillows or mattresses, and water beds, and h research equipment or items deemed to be experimental as determined by the HMHIC HMHIC will have no liability or responsibility for repair or replacement of equipment lost or damaged 32 Charges related to prosthetic medical appliances, except as specified in this Schedule of Benefits Excluded items include, but are not limited to dentures, hearing aids unless specifically provided by a Rider, and contact lens, POSLGSCH96 24 b medical supplies such as elastic stockings, garter belts, arch supports, corsets, and corrective orthopedic shoes, C research devices or items deemed to be experimental as determined by HMHIC, and d replacement, repair, and routine maintenance of covered appliances or braces unless surgically implanted, or replacement required due to a marked change in physical growth or physical requirements 33 Charges related to medical supplies, aids, and appliances except as otherwise specified as covered in this Schedule of Benefits Excluded items include, but are not limited to consumables, disposable supplies, sheaths, bags, gloves, cervical collars, elastic stockings, stethoscopes, blood pressure units, traction apparatus, slings, TENS units or electrical nerve stimulation devices, wigs or hair pieces, dressings, testing supplies, syringes, home testing kits, disposable drapers or incontinent supplies, and over-the-counter medications 34 Charges related to inpatient or outpatient long-term neuromuscular, physical, speech, or occupational therapy services or other rehabilitation services 35 Charges related to recreational, educational, or sleep therapy, and any related diagnostic testing, except as provided by the hospital as part of an approved inpatient hospitalization 36 Charges related to structural changes to a house or vehicle 37 Charges related to any medical, surgical, or health care procedure or treatment held to be experimental or investigational at the time the procedure or treatment is performed HMHIC will utilize findings and assessments of national medical associations, professional societies and organizations, and any appropriate technological body established by any state or federal government or similar entities to determine coverage and/or effectiveness 38 Charges exceeding the Reasonable and Customary amounts as determined by HMHIC POSLGSCH 88 25 10 20 w PRESCRIPTION DRUG RIDER FOR USE ONLY WITH HMHIC HEALTH CARE AGREEMENT In consideration for the timely payment of premiums, and all other terms and conditions of the Group Health Care Agreement, and/or Certificate of Insurance, it is agreed that the benefits of this Rider, together with the terms and conditions of this Rider, shall be added to Agreement as issued if this Rider is accepted by the Group DEFINITIONS Benefits for outpatient prescription drugs provided through this Rider shall be subject to the provisions and definitions of Agreement to which this Rider is a part In addition, for the purpose of this Rider, the following definition shall apply • Prescription Drugs shall mean only those drugs and medicines which are prescribed by a Physician and legally require the written prescription of a Physician before it can be obtained by the Covered Person B . .FIT Benefits limitation and Covered Person cost shall be as follows • 30% Copayment by Covered Person COVERED ITEMS Federal Legend Drugs and compounds requiring a prescription (including insulin), except those specifically excluded Generic Substitutions are covered EXCLUSIONS (2) (3) (4) (6) (8) IUD Devices Th t Prosthetic devices except those dispensed by durable medical erapeu is or provider Appliances, Supports or other non -medical products Medical Supplies except those listed as covered items Contraceptive devices excluding Oral contraceptives Insulin syringes and miscellaneous diabetic supplies, including urine glucose strips Injectable Medications, other than insulin Blood, Blood Plasma and Blood Products, except those dispensed by facility Experimental Drugs Immunization Agents, except those dispensed in the physician's office Fertility Medications Drugs not requiring a prescription (OTC, Vitamins, Cough Syrup, etc ) Drugs to be consumed in an inpatient or other institutional care setting Nicorette gum and blood outpatient POS2RX896 As prescribed up to a maximum of a 30 day supply for each covered prescription or refill Prescriptions shall not be refilled until approximately 75% of the previously dispensed quantity has been consumed, based on dosage instructions of the physician Covered Person must pay in full for any amounts exceeding covered quantities, including lost or misplaced medications A maximum of five (5) refills per prescription shall be covered if allowed by law and authorized by Physician, provided such refills are dispensed within six (6) months of the initial prescription date MONEW 11.1 Benefits under this Rider are available to the Employee and his Dependents (Covered Persons) as identified in this Agreement POS2RX896 Harris Methodist Health Plan HARRIS HEALTH PLAN, INC 611 Ryan Plaza Dr Arlington, TX 76011-4009 (817) 462-7000 1-800-633-8598 GROUP ENROLLMENT AGREEMENT Application is hereby made to Harris Health Plan Inc hereinafter called "Harris Health" by the Applicant named below hereinafter called "Group" for the purpose of making available to Eligible Persons and their Eligible Dependents under a Group Health Care Agreement/Subscriber Certificate of Coverage hereinafter called "Agreement" issued by Harris Health, certain prepaid health care services and benefits The arrangement of the provisions of such services and benefits shall be the subject of the Agreement between Hams Health and Group and shall be based on the statements and representations contained in this Group Enrollment Agreement, a copy of which shall be incorporated by reference and made a part of the Agreement 1 0 GROUP Group Name City of Denton Address 601 Fast Hickory, Suite A City Denton State TX Zip Code 76205 2 0 GROUP EFFECTIVE DATE This Group Enrollment Agreement shall be effective 12 01 A M , Central Time on the day 1st of January nary 1997 3 0 ELIGIBILITY Any person or his/her dependents who meet the eligibility requirements for coverage under the Group's Alternative Health Benefits Plan shall be eligible for coverage under Agreement as specified in Section 3 1 and Section 3 2 of Agreement ' • . • • •• •W4- • • • • • • 1-• •d 4 0 HEALTH CARE SERVICES (BENEFITS) AND COPAYMENTS Eligible Persons and Eligible Dependents of Group are entitled to Health Care Services and Benefits as follows A Basic Health Care Services x Covered - Basic Health Care Services as described in the Schedule of Benefits B Prescription Drug _X Accepted Not Accepted 5 0 COVERAGE BASIS X Contributory Non -Contributory 6 0 SCHEDULE OF RATES Total Monthly Rates Blended Employee Only $185 03 Blended Employee + Spouse $287 59 Blended Employee + Child(ren) $248 47 Blended Employee + Family $312 59 This Group Enrollment Agreement shall be automatically renewed at the end of each Contract period unless terminated by Harris Health or Group as provided in Agreement The first Contract period shall commence as of the Group Effective Date and will remain in effect for twelve (12) consecutive months unless terminated before this date by Harris Health or Group IN WITNESS WHEREOF the undersigned hpe c4used he Group Enrollment Agreement to be executed on the o?014 day of 19 • �. Authorized • Title Address 601 East Hickory. Denton, . 1 Telephonei .. .' PROVIDER GROUP/Renewal c CONTRACT CON/sw P Callan/D Blaine HARRIS H PLAN NC By Title Vice President of Sales Letter of Understanding City of Denton Bid No. 1869 This Letter of Understanding is between Harris Methodist Health Plan (HMHP) and the City of Denton (City) in connection with Bid No 1869 HMHP and City agree to the following As City employees' needs for additional health care services in the Denton area expand, HMHP is committed to ongoing assessment of these needs and expansion of HMHPs' current network through the recruitment of appropriately qualified providers to serve these needs HMHP guarantees that it meets the minimum bid requirement of having one Denton hospital in its provider network HMHP will maintain at least one Denton hospital in its network Should HMHP be unable to meet the minimum bid requirement of having one Denton hospital in its network, HMHP will pay the lesser of (1) 50% of the consulting contract which would be necessary to rebid City's health benefits program or (u) $30,000 Provided however, nothing in this paragraph relieves HMHP from its obligation to maintain at least one Denton hospital in its network In addition, HMHP will exercise best efforts to enter into a mutually acceptable and commercially reasonable contract for hospital services for City's eligible employees and dependents with the other hospital located in the City HMHP guarantees the 1997 total annual cost of its bid will not exceed $2,573,320 as long as enrollment, plan option participation, plan designs, and blended rates remain exactly as set forth below for every month of the 1997 calendar year ACTIVE HMO Opt -out Plan EE Only EE & Spouse EE & Child EE & Family HMO Plan ENROLLMENT 14 5 12 14 BLENDED RATES TOTAL $220 07 $341 09 $294 88 $371 90 EE Only 355 $185 03 EE & Spouse 86 $287 59 EE & Child 150 $248 47 EE & Family 218 $312 59 la t_ 1 lR mo 1I. i Retiree Only 0 $220 07 Retiree & Spouse 1 $341 09 Retiree & Child 0 $294 88 Retiree & Family 0 $371 90 Letter of Understanding City of Denton Bid No 1869 Page 2 of 2 HMO Plan Retiree Only 5 $185 03 Retiree & Spouse 3 $287 59 Retiree & Child 0 $248 47 Retiree & Family 1 $312 59 10311 :4PT- KW@1 Retiree Only 1 $220 07 Retiree & Spouse 1 $341 09 Retiree & Spouse (1 under 65) 0 $341 09 Retiree & Family (1 under 65) 0 $371 90 Retiree & Family 0 $371 90 HMO Plan Retiree Only 5 $185 03 Retiree & Spouse 1 $287 59 Retiree & Spouse (1 under 65) 3 $287 59 Retiree & Family (1 under 65) 0 $312 59 Retiree & Family 0 $312 59 City understands that the total annual cost of HMHP's bid may increase or decrease depending on the number of eligible employees participating, any shift between plan options or tier, any retroactive terminations, or change in City's selection of non -blended or blended rates Further, HMHP guarantees that the quoted rates in its response to Bid No 1869 will not increase more than 5% for plan year 1998 and will not increase more than 9% for plan year 1999 HMHP understands and agrees that any increase in HMHP's bid shall be consistent with the competitive bidding laws of the State of Texas This Letter of Agreement shall become effective January 1, 1997 and shall be attached to and incorporated into the agreement of the parties authorized by City pursuant to the ordinance approved on the day of , 1996, relating to the award of Bid No 1869 5 The terms and conditions of this Letter of Understanding are binding contractual obligations and not mere recitals and may be enforced by either party HMHP and City, through their respective duly authonzed representatives, have executed this Letter of Understanding to be effective as of January 1, 1997 HARRIS ODIST H ^ ALTH PLAN CITY OF DENTON By _ By✓�iiM. C e Thomas Keenan ack Mille Title Executive Vice President/COO Mayor Wellness and Prevention Program Hams Health Plan, Inc will provide the following wellness and prevention program in conjunction with the City of Denton's bid #1869 ■ Modifiable Clain Audit ($2,000 value) No Charge ■ Health Risk Assessments for City of Denton employees ($25 00 value per assessment) $10 00 per Assessment ■ Monthly Wellness Event ($50 value per event) No Charge ■ Mammography Screening ($65 value per screening) No Charge Note This wellness program was developed as a value added benefit to our bid # 1869 for the City of Denton Hams Health Plan is underwriting a portion of the cost as outlined above Harris Methodist Health Plan E2 GROUP HEALTH CARE AGREEMENT/ SUBSCRIBER CERTIFICATE OF COVERAGE HARRIS HEALTH PLAN, INC. P O Box 90100 Arlington, Texas 76004-3100 817/462-7800 1-800/633-8598 GA 992 Harris Health Plan, Inc Health Maintenance Organization PO Box 90100 Arlington, Texas 76004 3100 IMPORTANT NOTICE To obtain information or make a complaint You may call Harris Health Plan, Inc 's toll -free telephone number for information or to make a complaint at 1-800-633-8598 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 1-800-252-3439 You may write the Texas Department of Insurance P O Box 149104 Austin, TX 78714-9104 FAX # (512) 475-1771 ATTACH THIS NOTICE TO YOUR POLICY This notice is for information only and does not become a part or condition of the attached document AVISO IMPORTANTE Para obtener information o para someter una quela Usted puede llamar al numero de telefono gratis de - Harris Health Plan, Inc para informacion o para someter una quela al 1-800-633-8598 Puede comunicarse con el Departmento de Seguros de Texas para obtener informacion acerca de compamas, coberturas, derechos o quelas al 1-800-252-3439 Puede escribir al Departmento de Seguros de Texas P O Box 149104 Austin, TX 78714-9104 FAX # (512) 475-1771 UNA ESTE AVISO A SU POLIZA Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adlunto TABLE OF CONTENTS Page Page 2 80 Independent Agents/Refusal to Accept 1 0 General Definitions Treatment 18 20 Group and Affiliated Organizations 6 8 1 Independent Agents 18 2 1 Organizations Included Under This B 2 Limitation on Liability 19 Agreement 6 8 3 Refusal to Accept Treatment/Excessive 2 2 Change of Affiliated Organizations 6 Treatment 19 30 Eligibility and Effective Date 6 go Exclusions on Service Responsibilities 19 31 Eligible Persons 6 9 1 Major Disaster or Epidemic 19 32 Eligible Dependents 6 9 2 Circumstances Beyond Control 20 33 Change in Group Eligibility Criteria 7 93 Fraudulently Obtained Benefits 20 34 Effective Date for Eligible Persons 7 94 Discontinuance 20 35 Effective Date for Eligible Dependents 7 8 too Member Complaint Resolution Procedure 20 36 Persons Not Eligible for Coverage 37 Conditions of'Eligibility 8 10 1 Complaint Resolution Process 20 38 Notification of Ineligibility 8 10 2 Complaint Resolution Appeal Process 21 39 Clerical Error, 8 110 Health Care Services 21 40 Group and Member Termination, Continuation of 6 11 1 Benefits and Services 21 Benefits and Conversion 41 Termination of Group 8 120 Term and Amendment of Agreement 22 42 Termination of Member — For Cause 9 12 1 Term 22 43 Termination of Member — Other Than for 122 Amendment 22 Cause 10 123 Change of Rates 22 44 Liability Upon Termination 10 10 130 Miscellaneous Provisions 22 45 Continuation;of Coverage 46 Conversion Privilege 11 131 Use of Words 22 50 Payment Requirements 11 132 Records and Information 133 Information from Group 22 22 5 1 Premium Payments 11 134 Assignment 23 52 Notification by Group 12 135 Authority 23 53 Copayments 12 136 Governing Law 23 13 137 Incorporation by Reference 23 60 Claim Provisions 13 B Entire Agreement 23 6 1 Charges Paid by Members 13 139 Information to Member 23 62 Medical Emergency 13 1310 Uniform Rules 23 63 Action on Claim 13 1311 Calculation of Time 23 64 Examination' of Member 13 1312 Evidence 23 65 Limitation Provisions 13 1313 Severability 23 70 Coordination and Subrogation of Benefits 14 1314 Venue 24 24 1315 Waiver of Notice 71 Definitions 14 1316 Headings 24 72 Determination of Benefits 14 1317 Notice of Certain Events 24 73 Order of Benefit Determination 15 1318 Notice of Termination 24 74 Medicare 16 1319 Notice 24 75 Right to Receive and Release Information 76 Facility of Payment 17 17 Attachment A Service Area Map and Description 77 Right of Recovery 17 78 Disclosure 18 79 Subrogation 18 1 Section 1 0 GENERAL DEFINITIONS 1 ACTIVELY AT WORK shall mean that the eligible employee must be performing the usual and cus- tomary duties of his regular employment during his usual working hours on his effective date of coverage, provided, however that if the eligible employee is absent from work due to vacation, holiday, jury duty, or other similar circumstances, not caused by injury or illness, such employee shall be considered actively at work 2 ACUTE shall mean a condition of sudden onset or severe symptomatology which mandates imme- diate intervention 3 AGREEMENT shall mean this Group Health Care Agreement/Subscriber Certificate of Coverage, Group Enrollment Agreement, Applications, all Attachments, Riders, Amendments hereto, if any 4 ALLIED HEALTH PROFESSIONAL shall mean a dentist, nurse, audiologist, optometrist, physician's assistant, clinical psychologist, pharmacist, nutritionist, physical therapist, speech language pathologist, dietician, podiatrist, certified social worker (advanced clinical practitioner) and other professionals engaged in the delivery of health services who are licensed, practice under an insti- tutional license, are certified, or practice under the authority of a Physician or legally constituted professional association, or other authority consistent with the laws of the State of Texas 5 ALTERNATIVE HEALTH BENEFIT PLAN shall mean the plan which the Group designates as the alternative to this Agreement 6 APPLICATION shall mean the form prescribed by Harris Health which each Eligible Person shall on his/her own behalf and or, behalf of his/her Eligible Dependents, be required to complete and submit to Harris Health for the purpose of enrolling himself/herself and such dependents for cover- age hereunder 7 CHEMICAL DEPENDENCY, means the abuse of or psychological or physical dependence on or addiction to alcohol or a controlled substance B CHEMICAL DEPENDENCE TREATMENT CENTER shall mean a facility which provides a program for the treatment of chemical dependence pursuant to a written treatment plan approved and monitored by a physician and which facility is also a affiliated with a hospital under a contract agreement with an established system for patient referral, or b accredited as such a facility by the Joint Commission on Accreditation of Health Care Organi- zations, or c licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse, or d licensed, certified, or approved as a chemical dependency treatment program or center by any other state agency having legal authority to so license, certify or approve 9 COMPLICATIONS OF PREGNANCY shall mean those conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of compa- rable severity Complications or pregnancy shall not include false labor, occasional spotting, physi- cian prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy, non -elective cesarean section, ter- mination of ectopic pregnancy, or spontaneous termination of pregnancy occurring during a period of gestation in which a viable birth is not possible 10 CONTRACT YEAR shall mean the period of twelve (12) months commencing on the Group Effec- tive Date and each twelve (12) month period thereafter, unless otherwise terminated as hereinafter provided 11 CONTROLLED SUBSTANCE shall mean a toxic inhalant or a substance designated as a con- trolled substance in the Chapter 481, Health and Safety Code 2 12 COPAYMENT shall mean the fee as set forth in the Schedule of Benefits which is not covered by premiums payable hereunder, and which must be paid by Members directly to the person or entity providing the service when the service as set forth in the Schedule of Benefits is received 13 COURSE OF TREATMENT shall mean that period of time represented by an inpatient hospital admission and related discharge during which time treatment has been received by a Member or that period of time authorized by a Participating Physician and/or Harris Health as necessary to complete a cycle of treatment and subsequently provide a medical release to the Member 14 CRISIS STABILIZATION UNIT shall mean a twenty-four (24) hour residential program, licensed by Texas Department of Mental Health and Mental Retardation, that is usually short-term in nature and that provides intensive supervision and highly structured activities to persons who are demon- strating an acute demonstrable psychiatric crisis of moderate to severe proportions 15 CUSTODIAL CARE shall mean 1) that care which is marked by or given to watching and protect- ing rather than seeking to cure, or 2) care which is not a necessary part of medical treatment or recovery, or 3) care comprised of services and supplies that are primarily provided to assist in the activities of daily living 16 DEPENDENT shall mean an Eligible Dependent who has satisfied the eligibility and participation requirements specified in this Agreement 17 DOMICILIARY CARE shall mean that care provided for persons so disabled or infirm as to be unable to live independently 18 EFFECTIVE DATE shall mean the effective date of coverage for Eligible Persons and Eligible Dependents pursuant to the terms of this Agreement 19 ELIGIBLE DEPENDENT shall mean an individual as defined in Section 3 2 of this Agreement 20 ELIGIBLE PERSON shall mean an individual as defined in Section 31 of this Agreement 21 EMERGENCY CARE shall mean bona fide emergency services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction to any bodily organ or part 22 EVIDENCE OF INSURABILITY shall mean that an Eligible Person or Eligible Dependent verifies that they were enrolled for the preceeding twelve (12) months in a group or individual plan provid- ing benefits for medical, surgical and hospital expenses, and completes the Evidence of Insurabil- ity form and provides timely any additional documentation of health status as required by Harris Health Such information shall be reviewed by Harris Health and the Eligible Person or Eligible Dependent shall be notified regarding their eligibility for participation in Harris Health 23 EXCLUSION shall mean those specific conditions or causes for which coverage by Harris Health is entirely excluded 24 FDA shall mean the Food and Drug Administration, an agency of the United States government 25 GROUP shall mean collectively the contracting employer and all affiliated organizations of the employer as set forth in Attachment A annexed hereto and made a part hereof, to which this Agreement is issued and through which as agent for Subscriber and not for Harris Health, Sub- scriber and Dependents become entitled to the benefits as set forth in the Schedule of Benefits 26 GROUP EFFECTIVE DATE shall mean the date specified as such in the Group Enrollment Agreement 27 GROUP ENROLLMENT AGREEMENT shall mean that agreement which is executed between Har- ris Health and Group for the purpose of making available to Eligible Persons and Eligible Depen- dents of Group those benefits and services which are described in the Group Health Care Agreement/ Subscriber Certificate of Coverage Such Group Enrollment Agreement shall identity the Group, Group Effective Date, eligibility requirements, rates, and covered benefits 28 HARRIS HEALTH shall mean Harris Health Plan, Inc , a Texas not -for -profit corporation organized as a Health Maintenance Organization (HMO) and licensed by the Texas Department of Insurance 29 HEALTH PLAN shall mean the Health Maintenance Organization operated by Harris Health d/b/a Harris Methodist Health Plan 30 HOSPITAL shall mean an institution licensed by the State of Texas and which is (1) primarily engaged in providing diagnostic medical and surgical facilities for the care and treatment of injured or sick persons, (2) operated under the medical supervision of a staff of legally qualified and licensed physicians, (3) provides twenty-four (24) hour -a -day nursing service by or under the direct supervision of a Registered Nurse (R N ), (4) provides for overnight care of patients, (5) maintains clerical and ancillary services necessary for the treatment of medical and surgical patients including but not limited to laboratory, X-ray, dietary and medical records library In no event shall the term "hospital" include a convalescent nursing home or any institution or part thereof which is used principally as a convalescent facility, rest facility, nursing facility, facility for the aged, extended care facility, intermediate care facility, skilled nursing facility or facility primarily for rehabilitative services, the term hospital shall, pursuant to Chapter 3, Texas Insurance Code, Article 3 72 include treatment in a residential treatment center for children and adolescents and treatment provided by a crisis stabilization unit 31 INDIVIDUAL TREATMENT PLAN shall mean a treatment plan with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program 32 KIDNEY DIALYSIS CENTER shall mean any facility licensed by the State of Texas, approved by Medicare to provide outpatient services and/or instruction in home kidney dialysis treatments and which has contracted with Harris Health to provide care to Members 33 MEDICAL DIRECTOR shall mean the licensed Physician designated by Harris Health and/or such other Physicians as the Medical Director may designate with the prior approval of Harris Health Such physician shall be responsible for supervising the delivery of medical services to Members and for monitoring the quality of medical care rendered to Members 34 MEDICAL EMERGENCY shall mean a medical condition so classified by the medical director and which manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient's health in serious jeopardy, or (b) serious impairment to bodily functions, or (c) serious dysfunction to any bodily organ or part Examples of conditions which do not usually constitute medical emergencies are colds, influenzas, ordinary sprains, children's ear infections, or nausea and headaches Heart attacks, cardiovascular accidents, poisonings, loss of consciousness or respiration, convulsions, severe bleeding or broken bones are examples of true medical emergencies 35 MEDICALLY NECESSARY shall mean services or supplies which are (1) provided for the diagno- sis or care and treatment of a medical condition, (2) appropriate and necessary for the symptoms, diagnosis or treatment of a medical condition, (3) generally acceptable medical practice, (4) per- formed in the most cost effective and efficient manner appropriate to treat the plan Member's medical condition, and (5) provided in accordance with accepted medical standards and Harris Health requirements as approved by the Health Plan's review committees for professional and technical practices and the Health Plan Medical Director 36 MEDICARE shall mean Part A and Part B of Title XVIII of the Social Security Act and any amend- ments or regulations thereunder 37 MEMBER shall mean any Subscriber and/or Dependent 38 MEMBER HOSPITAL shall mean any Hospital which has contracted with Harris Health to provide to Members the services as set forth in the Schedule of Benefits and described in this Agreement 39 NON-MEMBER HOSPITAL shall mean any Hospital which has not contracted with Harris Health to provide to Members the services as set forth in the Schedule of Benefits and described in this Agreement 40 MINOR EMERGENCY CENTER shall mean any licensed facility, not including a Hospital, which provides Physician services for the immediate treatment only of an injury or disease 41 NON -PARTICIPATING PHYSICIAN shall mean a Physician who is not a Participating Physician and to whom a Member is referred for consultation or treatment by a Participating Physician only with prior written approval of Harris Health unless there is a Medical Emergency and a Participating Physician is not available 42 NON -PARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency, Laboratory, Minor Emergency Center, Residential Treatment Facility, Chemi- cal Dependency Treatment Center, or other licensed healthcare professional or other provider or entity which has not contracted with Harris Health to provide to Members the services as set forth in the Schedule of Benefits and described in this Agreement 43 OPEN ENROLLMENT PERIOD shall mean a period of at least thirty (30) days during each twelve (12) consecutive months when Eligible Persons may elect to change from the Alternative Health Benefit Plan to Harris Health or from Harris Health to the Alternative Health Benefit Plan 44 PARTICIPATING PHYSICIAN shall mean any Physician who has contracted with Harris Health to provide to Members the services as set forth in the Schedule of Benefits and described in this Agreement 45 PARTICIPATING PROVIDER shall mean any Physician, Hospital Allied Health Professional, Home Health Agency, Laboratory, Minor Emergency Center, Chemical Dependency Treatment Center, Psychiatric Day Treatment facility or other provider or entity which has contracted with Harris Health to provide to Members the services as set forth in the Schedule of Benefits and described in this Agreement 46 PSYCHIATRIC DAY TREATMENT FACILITY shall mean a mental health facility which provides treatment for individuals suffering from acute mental and nervous disorders in a structured psychi- atric program utilizing individualized treatment plans with specific attainable goals and objectives appropriate both to the patient and the treatment modality of the program and that is clinically supervised by a Physician who is certified in Psychiatry by the American Board of Psychiatry and Neurology The facility shall be licensed by the State of Texas, accredited by the Program for Psy- chiatric Facilities, or its successor, of the Joint Commission on Accreditation of Health Care Orga- nizations, and shall have contracted with Harris to provide to Members the mental health services as set forth in the Schedule of Benefits and described in this Agreement 47 PHYSICIAN shall mean any individual (other than a hospital resident or intern) who is fully licensed and qualified to practice within the scope of the license under the law of the jurisdiction in which treatment is received 48 PRIMARY PHYSICIAN shall mean, with respect to each Member, those Participating Physicians who are designated by Harris Health and identified in writing to Members as Physicians having primary responsibility for coordinating such Member's medical care, providing initial and primary care to Members, maintaining the continuity of such Member's care and initiating referrals for spe- cialist care 49 RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS shall mean a child- care institutlon that provides residential care and treatment for emotionally disturbed children and adolescents, licensed by Texas Department of Mental Health and Mental Retardation, and that is accredited as a residential treatment center by the Council on Accreditation, the Joint Commission on Accreditation of Health Care Organizations or the American Association of Psychiatric Services for Children 50 RIDER shall mean a Schedule provided with this Agreement, and made a part hereof, which sets forth additional benefits and services made available by Harris Health by amending this Schedule of Benefits 51 SCHEDULE OF BENEFITS shall mean the schedule which sets forth the benefits and services that Harris Health shall make available to Members 52 SEMI -PRIVATE shall mean the charge made by a Member Hospital for a room containing two (2) or more beds 53 SERVICE AREA shall mean the geographic area as set forth and annexed hereto as Attachment A 54 SHORT TERM shall mean a course of treatment lasting thirty (30) days or less 5 55 SPECIALIST PHYSICIAN shall mean any Physician who has contracted with Harris Health to pro- vide specialist care to Members upon referral of a Primary Physician or upon referral of another Specialist Physician with the concurrence of the responsible Primary Physician 56 SKILLED NURSING FACILITY shall mean an institution or part thereof, licensed by state or local law that is accredited as an Extended Care Facility by the Joint Commission on Accreditation of Health Care Organizations, or is recognized as a Skilled Nursing Facility by the Department of Health and Human Services under Title XVIII of the Social Security Act (Medicare), as amended 57 SUBSCRIBER shall mean an Eligible Person who has satisfied the eligibility and participation requirements specified in this Agreement 58 TOXIC INHALANT means a volatile chemical under Chapter 484, Health and Safety Code, or abusable glue or aerosol paint under Section 485 001, Health and Safety Code 59 USUAL, CUSTOMARY, AND REASONABLE CHARGES shall mean the charge is (1) the fee charged by a provider in normal practice for a given service, (2) within the range of usual charges by providers for the same service in the geographic area where services are provided to a Mem- ber, and (3) reasonable when taking into consideration any unusual circumstances or medical complications requiring additional time, skill and experience in providing a specific treatment or service Section 2 0 GROUP AND AFFILIATED ORGANIZATIONS 21 ORGANIZATIONS INCLUDED UNDER THIS AGREEMENT The Group and its affiliated organizations are included under this Agreement Affiliated organi- zations include all those organizations which are subsidiary to or affiliated with the Group and located within the Service Area of Harris Health 22 CHANGE OF AFFILIATED ORGANIZATIONS The Group shall notify Harris Health, in writing, when an affiliated organization ceases to be a subsidiary of, or affiliated with, the Group When an organization ceases to be a subsidiary of, or affili- ated with, the Group, it shall cease to be an included organization Therefore, this Agreement shall ter- minate on the date of such cessation with respect to all Eligible Persons of that organization, except for those persons who on the next day are employees of another affiliated organization and thus Eligible Persons under this Agreement Section 3 0 ELIGIBILITY AND EFFECTIVE DATE 31 ELIGIBLE PERSONS To be eligible to enroll as a Subscriber, a person must reside in the Service Area and be an Eli- gible Person as follows • In the employment of the Group or a bona fide Member of the Group, and/or • Eligible under the eligibility criteria established by the Group, and Entitled on his or her behalf to participate in the medical and hospital care benefits arranged by the Group 32 ELIGIBLE DEPENDENTS To be eligible to enroll as a Dependent, a person must reside in the Service Area and be • The legal spouse of a Subscriber, • A dependent unmarried natural child, foster child, stepchild, legally adopted child or child under Subscriber's court appointed legal guardianship, residing with Subscriber or with Sub- scriber's present or former spouse in the Service Area who is (a) under nineteen (19) years of age, or (b) under twenty-five (25) years of age and primarily dependent on the Subscriber for financial support and attending an accredited college or university, trade or secondary school on a full-time basis, which has, in writing, verified said attendance or, A dependent unmarried natural child, foster child, stepchild, legally adopted child, or child under Subscriber's court appointed legal guardianship, residing with Subscriber or with Sub- scriber's present or former spouse in the Service area who is nineteen (19) years of age or older but incapable of self-sustaining employment because of mental retardation or physical handicap which commenced prior to age nineteen (19) (or commenced prior to age twenty- five (25) if such child was attending a recognized college or university, trade or secondary school on a full-time basis when such incapacity occurred), and primarily dependent upon the Subscriber for support and maintenance Such dependent child must have been a Member either prior to attaining nineteen (19) years of age or twenty-five (25) years of age under the conditions of the previous sentence Sub- scriber shall furnish Harris Health proof of such incapacity and dependency within thirty-one (31) days before the dependent child's attainment of the limiting age and from time to time thereafter as Harris Health deems appropriate, but not more frequently than annually Maternity care benefits will be extended to an unmarried Dependent Child If coverage is provided to the Dependent of the Subscriber, upon payment of the premium, benefits must be provided for any children of the Dependent if those children are Dependents of the Sub- scriber for federal income tax purposes 33 CHANGE IN GROUP ELIGIBILITY CRITERIA Requirements as defined by the Group for determining the eligibility for participating in Harris Health are material to the execution of this Agreement by Harris Health During the term of this Agree- ment no change in the Group definition of eligibility for participation shall be permitted to affect eligibil- ity or enrollment under this Agreement in any manner unless such change is approved in advance by mutual written agreement between Group and Harris Health 34 EFFECTIVE DATE FOR ELIGIBLE PERSONS 3 41 Open Enrollment Period An Eligible Person who applies for coverage in Harris Health by submitting an Application dur- ing an Open Enrollment Period shall become covered as a Subscriber on the Group Effective Date or such Effective Date specified as such for the Open Enrollment Period 3 4 2 On Acquiring Eligibility Status An Eligible Person who first meets the eligibility requirements other than during the Open Enrollment Period may enroll within thirty (30) days of meeting such requirements by submitting an Application Such person shall become covered under Harris Health as a Subscriber on the first day he became an Eligible Person provided that the premium applicable to the Subscriber has been received in accordance with this Agreement 35 EFFECTIVE DATE FOR ELIGIBLE DEPENDENTS 3 51 Open Enrollment Period An Eligible Dependent for whom the Subscriber has applied for coverage in Harris Health by submitting an Application during an Open Enrollment Period shall become covered as a Dependent on the Effective Date of the Subscriber 3 5 2 On Acquiring Eligibility Status A newly acquired Eligible Dependent, and an Eligible Dependent other than a newborn child who first meets the eligibility requirements of Group on other than during an Open Enrollment Period, may be enrolled by the Subscriber within thirty (30) days of meeting such requirements by submitting an Application Such Eligible Dependent shall become covered under Harris Health as a Dependent on the day he became an Eligible Dependent provided that the premium applicable to the Dependent has been received in accordance with this Agreement described in Section 51 Coverage for newly adopted children shall commence on the earlier of (a) the date upon which such child commences residence with the Subscriber or (b) when the adoption becomeq legal Adopted children and newborn children shall be covered under Harris Health for an initial period of thirty-one (31) days and shall continue to be so covered after that time only if, prior to the expiration of such thirty-one day period, an Application has been submitted and the premium applicable to the Dependent has been received in accordance with this Agreement described in Section 51 7 36 PERSONS NOT ELIGIBLE FOR COVERAGE Notwithstanding the foregoing provisions of this Section, persons not eligible for cover- age in Harris Health shall be as follows • Coverage Previously Terminated No person shall be eligible to become a Member who has had coverage terminated by Harris Health for cause, as described in Section 4 2 of this Agreement • Indebtedness No person shall be eligible to become a Member if such person has unpaid financial obligations arising from prior coverage in Harris Health 37 CONDITIONS OF ELIGIBILITY No Eligible Person or Eligible Dependent shall be refused enrollment by Harris Health because of health status, requirements for health services, or the existence of a Pre -Existing Condition on the Group Effective Date In addition, no Member's coverage shall be terminated by Harris Health due to his health status or his healthcare needs If an Eligible Person or Eligible Dependent applies for cover- age on a date other than Open Enrollment Period or more than thirty (30) days after becoming an Eligi- ble Person or Eligible Dependent, then such Eligible Person or Eligible Dependent shall have to document Evidence of Insurability as required by Harris Health 38 NOTIFICATION OF INELIGIBILITY A condition of participation in Harris Health is Subscriber's agreement to notify Harris Health of any changes in status that affect Subscriber or the ability of the Subscriber's Dependents to meet the eligibility criteria set forth in this Section 39 CLERICAL ERROR Eligibility under this Agreement shall in no event be invalidated by failure of the Group, due to clerical error, to record or report an Eligible Person or Eligible Dependent to Harris Health if an Appli- cation had been completed and submitted to Group as required under the terms of this Agreement by or on behalf of such Eligible Person or Eligible Dependent and that the premium applicable to such coverage had been received by Harris Health Section 4 0 GROUP AND MEMBER TERMINATION, CONTINUATION OF BENEFITS AND CONVERSION 41 TERMINATION OF GROUP 41 1 Default in Payment of Premium If Group fails to pay to Harris Health the premium payable hereunder on or before the thirty-first (31) calendar day after such payment is due, this Agreement may be terminated by Harris Health and all benefits and services shall cease at the end of such thirty-one (31) day grace period Group may be held liable for the cost of all benefits and services provided to Member by Harris Health during the grace period Group shall remain liable for all premiums (and any interest accrued thereon) not paid prior to termination Interest on late payments from the date such premiums were due may be charged at a rate equal to eighteen percent (18%) per year Unpaid interest shall be due and payable upon notice thereof to Group from Harris Health If Group remits its delinquent payments to Harris Health within fifteen (15) days of a termination date, Harris Health may reinstate Group without requiring a new Group Enrollment Agreement How- ever, Harris Health reserves the right to refuse to reinstate by refunding within five (5) business days all payments made by Group after the date of termination 41 2 Upon Notification This Agreement may be terminated by either Harris Health or Group upon written notice to the other party at least sixty (60) days prior to the end of the Contract Year Such termination shall occur at midnight on the day proceeding the end of the Contract Year In the event that Harris Health terminates this Agreement, any Member who is a registered bed patient in a Hospital on the date of termination shall receive coverage for all hospital services for that hospital confinement or until a determination is made by the Medical Director that inpatient care is no longer medically indicated, whichever occurs first 42 TERMINATION OF MEMBER — FOR CAUSE 4 21 Default in Payment of Copayments If any required Copayment is not paid timely by or on behalf of Member, pursuant to the terms of this Agreement, such Member's entitlement to benefits may be terminated not less than sixty-one (61) days written notice after the date such Copayment was due 4 2 2 Default in Payment of Premium If any premium contributions due from Member are not paid timely by or on behalf of Member, such Member's entitlement to benefits may be terminated not less than thirty-one (31) days after the date such premium was due 4 2 3 Misrepresentation If any Subscriber should make a fraudulent statement or provide any material misrepresenta- tion of fact by or on behalf of such Subscriber or Dependent on an Application or Evidence of Insura- bility form, Harris Health shall have the right to terminate the Member's coverage under this Agreement without any further liability or obligation to such Member Such Subscriber's entitlement to benefits may be terminated not less than sixty-one (61) days written notice after such misrepresentation If a Mem- ber corrects inaccurate information furnished to Harris Health, and Harris Health has not relied upon such incorrect information to its prejudice, the furnishing of incorrect information shall not constitute a basis for termination of the Member's coverage In the absence of fraud, all statements made by a Subscriber are considered representations and not warranties During the first two years, coverage can be voided 'for material misrepresentation contained in a written Application or Evidence of Insura- bility Form After two years, coverage can be voided only in the event of a fraudulent misstatement contained in the written Application or Evidence of Insurability form A copy of the written Application must have been furnished to the Subscriber if the terms of the Application or Evidence of Insurability form are to be applied 4 2 4 Misuse of Identification Card Possession of a Harris Health identification card in and of itself confers no rights to services or other benefits The holder of the card must be, in fact, a Member on whose behalf all applicable pre- miums under this Agreement have actually been paid Any person receiving services or other benefits to which he is not entitled pursuant to this Agreement shall be solely responsible for the full payment of any charges associated with the services received If any Member permits the use of the Member identification card by any other person, such card may be confiscated and Harris Health shall have the right to terminate the Member's coverage under this Agreement and, if a Subscriber, the coverage of his Dependents Such Member's entitlement to benefits may be terminated not less than fifteen (15) days written notice after such misuse of the identification card 4 2 5 Fraudulent Use of Benefits or Services Fraudulent use by Member of services, benefits, providers, facilities, or coverage will result in cancellation of coverage after not less than a fifteen (15) day written notice to Subscriber 4 2 6 Misconduct Misconduct by a Member detrimental to safe Health Plan operations and the delivery of service or treatment, or abuse of healthcare professionals, facilities, or Health Plan personnel may result in cancellation of coverage effective immediately 4 2 7 Untenable Patient/Physician Relationship If the Member and the Participating Physician fail to establish a satisfactory patient -physician relationship and if it is shown that Harris Health has, in good faith, provided the Member with the opportunity to select an alternative Participating Physician, the Member shall be notified in writing at least thirty (30) days in advance that Harris Health considers the patient -physician relationship to be unsatisfactory and specifies the changes that are necessary in order to avoid termination if Member fails to make such changes, coverage may be cancelled at the end of thirty (30) days For refusal by a Member to accept recommended procedures or treatment as described in Section 8 3 of this Agreement, the Member's coverage may be cancelled after not less than thirty (30) days written notice M 4 2 8 Termination Procedure Any Member terminated for cause pursuant to this Section shall be given written notice of ter- mination prior to the effective date of termination in accordance with notification requirements of Sec- tion 4 2 If Member receiving notice of termination initiates the Member Complaint Resolution Procedure described in Section 10 of this Agreement during the notification period to challenge the grounds for termination, the effective date of termination shall be postponed until Member Complaint Resolution Procedure is completed and a final decision regarding termination is provided If the Mem- ber, on his own behalf or on behalf of a minor child, fails to initiate the Member Complaint Resolution Procedure within the notification period, such failure shall constitute a waiver of said Member's right to challenge the termination 43 TERMINATION OF MEMBER — OTHER THAN FOR CAUSE 4 31 Subscriber No Longer Eligible Person If the Subscriber ceases to be an Eligible Person, coverage under this Agreement shall auto- matically terminate at midnight of the day on which such Subscriber ceased to be an Eligible Person, subject to continuation of coverage and conversion privilege provisions 4 3 2 Dependent No Longer Eligible Dependent If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall automatically terminate at midnight of the day on which such Dependent ceased to be an Eligible Dependent, subject to continuation of coverage and conversion privilege provisions 4 3 3 Service Area Resident If a Member ceases to be a resident of the Service Area as defined by Harris Health, eligibility to participate in Harris Health shall automatically terminate as of the date on which the Member ceased to be a resident of the Service Area, except as may be required by State and Federal regula- tions for COBRA participants Such Member shall be eligible to convert to an Individual Hospital and Surgical Expense Policy as specified in Section 4 6 2 44 LIABILITY UPON TERMINATION At the effective date of any termination of a Member's coverage under this Agreement any pay- ments received on account of such Member applicable to periods after the effective date of the termi- nation of coverage, plus amounts due to such Member for claims reimbursement, if any, less any amount due to Harris Health or which must be paid by Harris Health on behalf of such Member, shall be refunded to the appropriate party within thirty-one (31) days Harris Health and Group shall there- after have no further liability or responsibility to such Member except as may be specifically provided in Section 4 1 2 of this Agreement 45 CONTINUATION OF COVERAGE If a Member's coverage ends, such coverage may qualify to be continued in one of the follow- ing ways • it may be extended under the Extension of Medical Benefits provisions, if the Member is Hos- pital Confined when this Agreement terminates, or • it may be continued under the Optional Continuation of Coverage provisions, or • it may be converted to an individual plan of medical coverage as described in the Conver- sion provisions If, under the provisions of Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272 ("COBRA"), any Member is granted the right to continuation of coverage beyond the date his coverage would otherwise terminate, or, if COBRA is inapplicable and the provi- sions of an applicable state statute grants such Member similar rights to continuation of coverage, this Agreement shall be deemed to allow continuation of coverage to the extent necessary to comply with the provisions of the applicable statute Contact the employer for verification of eligibility and proce- dures to follow 4 5 1 Extension of Medical Benefits Harris Health shall continue to provide medical services if this Agreement terminates under 10 Section 41 2 while a Member is confined in a Hospital or Skilled Nursing Facility Services will be pro- vided only for the same injury or sickness which caused the Member to be confined This continued coverage will end on the earlier of (1) the date the confinement is no longer Medically Necessary, or (2) the date the Member reaches any limits under the Group Contract for the provisions of services, or (3) the date the Member becomes eligible for similar coverage under another plan 46 CONVERSION PRIVILEGE If a Member has been covered by this Agreement for at least three (3) consecutive months or covered as a newborn from the date of birth and meets the definition of a person eligible for conver- sion, Member may enroll in an individual plan with a defined Schedule of Benefits available to conver- sion Members only under the terms and conditions of this Agreement ELIGIBILITY TO CONVERT A Member whose coverage under this Agreement is terminated in accordance with the Termi- nation provisions may convert if the coverage is not ending for one of the following reasons • Termination of this Agreement, • Failure to pay any required copayment amounts, • Termination for cause, • Coverage under another individual or group health policy, plan or contract, • Eligibility for Medicare, • Eligibility or coverage for similar hospital, medical or surgical benefits under a state or federal law A covered Dependent whose coverage is terminated under this Agreement may also convert if the termination is due to • Legal separation or divorce, or • The Subscriber's death, or • The Dependent reaching the maximum Dependent age HOW TO CONVERT 4 6 1 Residence in Service Area The Member eligible for conversion may, without Evidence of Insurability, convert to an Individ- ual Health Care Agreement issued by Harris Health To obtain an individual enrollment, the Eligible Person must continue to reside in the Service Area, must submit a completed application for conver- sion within thirty-one (31) days after termination of coverage under this Agreement, and must submit the premium for such Individual Health Care Agreement as required from the effective date of termina- tion of coverage' under this Agreement 4 6 2 Residence Out of Service Area If the Member eligible for conversion does not reside in the Service Area, the Member may, without Evidence of Insurability, convert to an individual policy issued by and renewable at the option of the indemnity insurer making such conversion coverage available to Harris Health Section 5 0 PAYMENT REQUIREMENTS 51 PREMIUM PAYMENTS The initial rates for the benefits and services under this Agreement shall be due and payable in advance on or before the first (1) day of the month for which such payment is made or is to be made In accordance with the terms and provisions of Section 12 3 of this Agreement, Harris Health shall have the right to change the rate payable under this Agreement at any time when the extent or nature of this Agreement is changed by amendment or termination of any provision, or by reason of any pro- vision of law or any governmental program or regulation No proration of the rate shall be made with 11 respect to Members whose coverage under this Agreement commences after the first (1) day of the month A grace period of thirty-one (31) days shall be allowed for each payment payable hereunder, whether due from Group or a Member except for the first payment due The rate required for a newly acquired Eligible Dependent shall be payable initially when the required Application is submitted to Harris Health Thereafter, all payments with respect to such new Eligible Dependent shall be made as otherwise provided in this Agreement Any payments required for newborn children who meet the requirements of Section 3 5 2 of this Agreement shall be initially payable to Harris Health on or before the first day of the next month follow- ing the month in which the Application required under Section 3 5 2 is submitted to the Health Plan Thereafter, all payments with respect to such newborn child shall be made as otherwise required under this Agreement 5 1 1 Non -Contributory Coverage If the coverage basis hereunder is "Non -Contributory," the Group agrees to pay at the principal office of Harris Health, or to its authorized representative, on each payment due date, the sum of the Harris Health rate for the coverage then provided under this Agreement The Group premium for the coverage provided by Harris Health under this Agreement shall be determined by the applicable rate then in effect and the number of Members at the monthly intervals established by Harris Health 5 12 Contributory Coverage If the coverage basis hereunder is "Contributory," Group agrees to pay at the principal office of Harris Health, or to its authorized representative, on each payment due date, that part of the Harris Health rate for the coverage then provided under this Agreement Group shall permit Subscribers to pay their contributory portion of such rate through payroll deduction Procedures for implementing payroll deductions for the Subscriber's portion of such rate shall be the same as those utilized for any Alternative Health Benefit Plan If the Group does not have an Alternative Health Benefit Plan, the pro- cedures shall solely be those as agreed to, in writing, between Group and Harris Health The Group premiums for the coverage provided by Harris Health under this Agreement shall be determined by the applicable rate then in effect and the number of Members at the monthly intervals established by Harris Health Group shall offer Harris Health to all Subscribers of Group on terms no less favorable with respect to the Group contribution than those applicable to any Alternative Health Benefit Plan as may be available through the Group The Group contributions shall not be changed during the term of this Agreement unless such change is prior approved, in writing, by Harris Health If, however, Group con- tribution to the Alternative Health Benefit Plan as may be available through the Group is increased dur- ing the term of this Agreement, Group agrees to also increase contribution to Harris Health effective the first monthly payment due following such increase 52 NOTIFICATION BY GROUP Group shall forward completed Applications and any Evidence of Insurability form(s) to Harris Health within ten (10) business days of their receipt from Eligible Persons In the event Group fails to notify Harris Health of the ineligibility of any person for whom the Group has made the monthly prepay- ment required pursuant to this Agreement, then, such prepayment shall be credited to Group only if Harris Health has not made arrangements for or paid benefits for the ineligible person but in no event shall such prepayment be credited subsequent to thirty (30) days after the date such person became ineligible 53 COPAYMENTS All Copayments, as specified in the Schedule of Benefits, are due and payable at the time a service is provided The maximum amount of Copayment shall not exceed the maximum specified in the Schedule of Benefits It is the Subscriber's responsibility to retain receipts and to notify Harris Health upon attaining the Copayment limit so that additional services can be provided without a Copayment charge 12 Section 6 0 CLAIM PROVISIONS 61 CHARGES PAID BY MEMBERS It is not anticipated that a Member shall make payments, other than the Copayments as set forth in the Schedule of Benefits, for benefits and covered services under this Agreement However, if a payment is made by a Member then a written description of such services, accompanied by evi- dence of payment by the Member must be provided to Harris Health within sixty (60) days after the performance of the service Failure to furnish such proof within the required time shall not invalidate nor reduce any claim, if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible If the Member provides evidence that he has made such payment, payment shall be paid to the Member but without prejudice to Harris Health's right to seek recovery of any payment made by it before receipt of such evidence Benefits under this Agreement will be paid directly to the provider unless Member requests payment to be made to himself and submits to Harris Health proof of prior payment to the provider for covered services Claims for such services will be processed as follows A Fifteen (15) calendar days after receipt of claim, Harris Health will 1 Acknowledge receipt of claim, 2 Commence investigation of claim, 3 Request all information from claimant as deemed necessary by Harris Health Subse- quent additional requests may be necessary B No later than fifteen (15) business days after receipt of all items required by Harris Health, Harris Health will 1 Notify claimant of acceptance or rejection of claim, 2 Notify claimant of the reason(s) Harris Health needs additional time Harris Health shall accept or reject the claim no later than forty-five (45) calendar days following receipt of additional information C Upon notification from Harris Health that the claim will be paid, the claim will be paid no later than five (5) business days after such notification was made 62 MEDICAL EMERGENCY Medical Emergency services which are covered under this Agreement but are not received from Participating Providers shall be reimbursed subject to the Copayments in the Schedule of Bene- fits Harris Health reserves the right to deny a claim for reimbursement of services received from a Hospital emergency department or a Minor Emergency Center, if it is determined by Harris Health that such services were not obtained pursuant to the terms of this Agreement or if a Medical Emergency did not exist at the time services were received by the Member 63 ACTION ON CLAIM All claims for reimbursement shall be finalized by Harris Health within sixty (60) days of receipt of written documentation describing the occurrence, character and extent of the event for which the claim is mace, unless the Member is notified of the need for a longer time If a claim is denied, written notice to the Member will state the reason for the denial Member may obtain a review of the denial through the Member Complaint Resolution Procedure as described in Section 10 0 64 EXAMINATION OF MEMBER Harris Health, at its own expense, shall have the right to examine the Member whose sickness or injury is the basis of a claim when and so often as it may reasonably require during the pendency of any claim 65 LIMITATION PROVISIONS • No action at law or equity shall be brought under this Section against Harris Health prior to the expiration of the sixty (60) day period immediately following the date on which written proof of this charge or loss upon which the action is brought, in accordance with the provi- sions of this Section, has been furnished to Harris Health, or later than three (3) years after the expiration of the period of time in which such proof of charge or loss is required under this Section to be furnished to Harris Health 13 • No liability shall be imposed under Harris Health other than for the benefits and services cov- ered under this Agreement Section 7 0 COORDINATION AND SUBROGATION OF BENEFITS The Harris Health Coordination and Subrogation of Benefits provisions applies to all of the ben- efits provided under this Agreement The value of any benefits or services provided by Harris Health shall be coordinated with any group insurance plan or coverage under governmental programs, including Medicare, to assure that a Member receives coverage while avoiding double recovery It is, therefore, understood and agreed that should a Member be covered by or under a Coordinated Plan in addition to coverage under this Agreement, the provisions and rules as described in this Section shall determine whether Harris Health or the Coordinated Plan is primarily responsible for paying the costs of benefits and services provided to the Member • If a Member who has enrolled under this Health Plan is entitled to inpatient benefits under another contract or policy of insurance due to inpatient care which began while the Member was enrolled under a previously held policy, Harris Health will pay, subject to Copayments under this plan, the difference between entitlements under this Health Plan and entitlements under the other contract or policy of insurance • Benefits which are provided directly through a specified provider of an employer shall in all cases be provided before the benefits of this Health Plan • Services and benefits for military service connected disabilities for which a Member is legally entitled and for which facilities are reasonably available, shall in all cases be provided before the benefits of this Health Plan • All sums payable for services provided pursuant to worker's compensation shall not be reim- bursable under this Agreement 71 DEFINITIONS For purposes of this Section only, words and phrases shall have meanings as follows • ALLOWABLE EXPENSE shall mean any Usual and Customary expense of which at least a portion is covered under this Health Plan covering the Member for whom the claim is made When a Coordinated Plan provides benefits in the form of services rather than cash pay- ments, the Usual and Customary cash value of each service provided shall be deemed to be both an Allowable Expense and a benefit paid • CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding any portion of a calendar year occurring prior to the Effective Date • COORDINATED PLAN shall mean any of the following that provides benefits or services for, or by reason of, medical care or treatment — Coverage under governmental programs, including Medicare, required or provided by any statute unless coordination of benefits with any such program is forbidden by law — Group coverage or any other arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, including any prepayment coverage, group practice basis or individual practice coverage and any coverage for students which is sponsored by, or provided through, a school or other educational institution above the high school level 72 DETERMINATION OF BENEFITS This provision shall apply in determining the benefits payable for the Allowable Expenses incurred by a Member during a Claim Determination Period The term Coordinated Plan shall be construed separately with respect to each policy, contract, or other arrangement for benefits or services and separately with respect to that portion of any such policy, contract, or other arrangement which reserves the right to take the benefits or services of other Coordinated Plans into consideration in determining its benefits and that portion which does not 14 Whenever the sum of the benefits that would be payable under this Agreement in the absence of this provision; and the benefits that would be payable under all Coordinated Plans in the absence thereof or amendments of similar purpose to this provision would exceed the Allowable Expenses, then the following shall apply • The benefits that would be payable under this Agreement shall be reduced to the extent necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Expenses under all Coordinated Plans shall not exceed the total payable under this Agreement Benefits payable under a Coordinated Plan include the benefits that would have been payable had claim been duly made therefor • If a Coordinated Plan would, according to its rules, determine its benefits after the benefits payable under this agreement have been determined, and the rules as described in Section 7 3 would require payment under this Agreement to be determined before the Coordinated Plan, then the benefits of the Coordinated Plan shall not be included for the purpose of deter- mining the benefits under this Agreement 73 ORDER OF BENEFIT DETERMINATION The rules establishing the order of benefit determination shall be as follows • The benefits of a Coordinated Plan without a coordination of benefits provision (or a non - duplication provision of similar intent) shall be determined before the benefits of this Agreement • The benefits of a Coordinated Plan which covers the Member other than as a dependent shall be determined before the benefits of a Coordinated Plan which covers such person as a dependent • The benefits of a Coordinated Plan which covers the Member as a dependent child of a per- son whose date of birth, excluding year of birth, occurs earlier in a calendar year, shall be determined before the benefits of a plan which covers such person as a dependent of a per- son whose date of birth, excluding year of birth, occurs later in a calendar year If a Coordi- nated Plan does not have the provisions of this paragraph regarding dependents, which results either in each Coordinated Plan determining its benefits before the other or in each Coordinated Plan determining its benefits after the other, the provisions of this paragraph shallinot apply, and the rule set forth in the Coordinated Plan which does not have the provi- sions of this paragraph shall determine the order of benefit determination unless Section 7 31 shall apply • If the rules provided above or the rules provided in Section 7 3 1 do not establish an order of benefit determination, then the benefits of a Coordinated Plan which has covered the Mem- ber for whom the claim is made for the longer period of time shall be determined before the benefits of a Coordinated Plan which has covered such Member for the shorter period of times except as follows — The benefits of a Coordinated Plan covering the Member as a laid -off or retired employee or as l be Coordi- natedthe P ands ovveringtsufsuch ch personmasea Melmberdother than after the as lbenefits aid off or retired employee or dependent of such person — If a Coordinated Plan does not have a provision regarding laid -off or retired employees, and, as a result, such Coordinated Plan determines its benefits after the Coordinated Plan with this provision, then the provisions of the immediately preceeding paragraph shall not apply 7 31 ' Legal Separation or Divorce In the event of a legal separation or divorce, the following order of benefit determination shall apply • If there is a court decree that establishes financial responsibility for the healthcare expenses of the child, the benefits of a Coordinated Plan which covers the child as a dependent of the Cparent oordi- nated Pllth such an which nancial covers rthe childlllas a dependent determined of thebparentre the witbenefits such financial responsibility 15 • In the event of a legal separation or divorce in which the court decree does not establish financial responsibility for the healthcare expenses of the child then the following shall apply — If the parent with custody of the child has not remarried, the benefits of a Coordinated Plan which covers the child as a dependent of the parent with custody of the child shall be determined before the benefits of a Coordinated Plan which covers that child as a dependent of the parent without custody — If the parent with custody of the child has remarried, the benefits of a Coordinated Plan which covers the child as a dependent of the parent with custody shall be determined before the benefits of a Coordinated Plan which covers that child as a dependent of the stepparent, and the benefits of a Coordinated Plan which covers that child as a depen- dent of the stepparent shall be determined before the benefits of a Coordinated Plan which covers that child as a dependent of the parent without custody Thus, in the event of a legal separation or divorce, unless a court decree specifies otherwise, the order of benefit determination described above may be summarized as follows Separated or Divorced and not Remarried Separated or Divorced and Remarried (1) Parent with custody (1) Parent with custody (2) Parent without custody (2) Stepparent with custody (3) Parent without custody 74 MEDICARE For purposes of determining benefits provided for a Member who is eligible to enroll for Medi- care, but does not, Harris Health will assume the amount provided under Medicare to be the amount the Member would have received if he or she had enrolled for it A Member is considered to be eligible for Medicare on the earliest date coverage under Medi- care could become effective for the Member Except as described under TEFRA in Section 7 4, Medi- care shall be interpreted so as to be included in Section 7 1 for each Member as follows • Such Member must agree to enroll for both Parts A and B of Medicare and assign to Harris Health any Medicare benefits for services covered by Harris Health If such Member receives benefits from Harris Health that would have been paid or reimbursed by Medicare, but Member has failed to enroll for Medicare coverage, then Harris Health shall be entitled to receive from the Member the actual costs of the services provided The Member shall remain liable for payment of the Copayments as set forth in the Schedule of Benefits • When Allowable Expenses are incurred by such Member during any Claim Determination Period and include expenses for services, treatment, or supplies which are payable under Medicare, such Allowable Expenses shall be reduced by an amount equal to the benefits payable by Medicare before comuting the benefits payable under this Agreement 7 4 1 TEFRA Options for Employers with 20 or More Employees Actively working covered Employees and their covered spouses who are eligible for Medicare will be permitted to choose one of the following options if the Employee is age 65 or older and eligible for Medicare Option 1 — The service of the Group Agreement will be provided first and the benefits of Medicare will be provided second Option 2 — Medicare benefits only Subscriber and Dependents, if any, will not be covered by the Group Agreement The employer will provide Subscriber with a choice to elect one of these options at least one month before becoming age 65 All new Employees age 65 or older will be offered these options when hired If Option 1 is chosen, Subscriber's rights under this Agreement will be subject to the same requirements as for an Employee or Dependent who is under age 65 There are two categories of persons eligible for Medicare The calculation and payment of ben- efits by this Agreement differs for each category 16 Category 1 Medicare Eligibles are 1 Actively working covered Employees age 65 or older who choose Option 1, 2 The age 65 or older covered spouses of actively working covered Employees age 65 or older who choose Option 1, 3 Age 65 or older covered spouses of actively working covered Employees who are under age 65, 4 Actively working covered Employees of employers with 100 or more Employees and their Covered Dependents who are entitled to Medicare by reason of disability other than End Stage Renal Disease (ESRD), and 5 Covered individuals entitled to Medicare solely on the basis of ESRD during a period of up to 12 months after the individual has been determined eligible for ESRD benefits Categoryl2 Medicare Eligibles are 1 Retired employees and their spouses, 2 Covered Employees of employers with less than 100 Employees and their covered Depen- dents ,who are entitled to Medicare by reason of a disability other than ESRD, and 3 Covered individuals entitled to Medicare solely on the basis of ESRD for more than 12 months after the individual has been determined eligible for ESRD benefits Calculation and Provision of Services For Members in Category 1, services are provied by this Agreement without regard to any benefits provided by Medicare Medicare will then determine its benefits For Members in Category 2, services are provided by the Group Agreement Harris Health shall then have the right to recover the full amount of all Medicare benefits the Member is entitled to receive, whether or not the Member is actually enrolled for them The Member should authorize payment of Medicare benefits directly to Harris Health for services rendered If the Member does not authorize direct payment, he or she is responsible for Harris Health for the reasonable value of the services rendered The Member is also responsible to Harris Health for the reasonable value of all Group Agreement services reimbursable by Medicare if the Member is not enrolled for all benefits he or she is entitled to receive 75 RIGHT TO RECEIVE AND RELEASE INFORMATION For purposes of administering the provisions of this section, Harris Health may, without further consent of, or notice to any Member, release to or obtain from any healthcare plan, insurance com- pany or other person or organization, any information with respect to any Member which it deems to be reasonably necessary for such purposes, as permitted by law Any Member receiving services or claiming benefits under this Agreement shall furnish to Harris Health all information deemed necessary by Harris Health to implement this Section 7 0 76 FACILITY OF PAYMENT Whenever payments which should have been made by Harris Health in accordance with this Section have been made by a Coordinated Plan, Harris Health shall have the right, exercisable alone and in its sole discretion, to authorize payment to the Coordinated Plan making such payments any amounts Harris Health shall determine to be warranted in order to satisfy the intent of this Section, and amounts when so paid shall be deemed to be benefits under this Agreement, and, to the extent of such payments, i Harris Health shall be fully discharged from liability under this Agreement 77 RIGHT OF RECOVERY Whenever payments have been made by Harris Health with respect to Allowable Expenses in a total amount which is, at any time, in excess of the maximum amount of payment neccessary at that time to satisfy the intent of this Section, Harris Health shall have the right to recover such payments, to the extent of such excess, from one or more of the following, as Harris Health shall determine any per- son or persons to, or for, or with respect to whom such payments were made, any insurance company or companies, and any other organization or organizations which provided services, or to which such payments were made 17 78 DISCLOSURE Each Member agrees to disclose to Harris Health at the time of enrollment, at the time of receipt of services and benefits, and from time to time as requested by Harris Health, the existence of other health plan coverage, the identity of the carrier, and the group through which such coverage is provided 79 SUBROGATION Subrogation seeks to shift the expense for injuries suffered by Plan Members to those responsi- ble for causing them In return for Harris Health providing benefits for injuries, ailments, or diseases caused as a result of the negligence, omission or willful act of a third party, each Member agrees to execute any instrument which may be needed in order for the right of subrogation to be effective Each Member also agrees to assign to Harris Health the right of recovery against such third party to the extent of benefits received from or through Harris Health plus costs of legal suit including attorney fees At the time such benefits are provided or thereafter as Harris Health may request, Member agrees to comply with the following provisions • Execute a formal written injury report and assignment to Harris Health of right to recover the reasonable value of any benefits provided directly by Harris Health and the actual costs paid by Harris Health under this Agreement for injuries, ailments and diseases caused by a third party together with the costs of legal suit including attorney fees • Reimburse Harris Health for the reasonable value of any benefits and services provided by Harris Health and in an amount equal to the charges therefor together with the costs of legal suit, including attorney fees, but not in excess of monetary damages collected, immediately upon receipt of any monies paid by or on behalf of a third party in settlement of any claim arising out of injuries, ailments and diseases covered by such third party In determing the reasonable value of benefits and services provided by Harris Health, Harris Health shall con- sider charges for similar services being made by providers in the community which possess similar training or capability as well as unusual circumstances, or a medical complication requiring additional time, skill experience and/or facilities in connection with a particular ser- vice Harris Health shall have a lien on any recovery from such third party whether by judg- ment, settlement, compromise or reimbursement • Execute and deliver such papers and provide such reasonable help (including authorizing bringing suit against such third party in Member's name and making court appearances) as may be necessary to enable Harris Health to recover the reasonable value of benefits and services provided by Harris Health, together with costs of legal suit, including attorney fees Section 8 0 INDEPENDENT AGENTS/REFUSAL TO ACCEPT TREATMENT 81 INDEPENDENT AGENTS The relationships between Harris Health and contracting entities may be defined as follows • The relationship between Harris Health and Member Hospitals is that of independently con- tracting entities Member Hospitals are not agents or employees of Harris Health nor is Harris Health an agent of any Member Hospital Member Hospitals shall maintain the hospital - patient relationship with Members and shall be the only parties responsible to Members for the Hospital services that they provide • The relationship between Harris Health and Participating Providers is that of independent contracting entities Participating Providers are not agents or employees of Harris Health nor is Harris Health an employee or agent of any Participating Provider Participating Providers shall maintain the physician -patient or professional -patient relationship with Members and shall be the only parties responsible to Members for the services provided Neither Harris Health nor any employee of Harris Health shall be deemed to be engaged in the practice of medicine Harris Health shall in no way supervise the practice of medicine by any Participat- ing Provider hereunder, nor shall Harris Health in any manner supervise, regulate or interfere with the usual professional relationships between a Participating Provider and a Member f[7 The relationship between Harris Health, the Group and any Member is that of independent contracting entities Neither the Group nor any Member is the agent or employee of Harris Health, and Harris Health is not the employee or agent of the Group or any Member Neither the Group or any Member shall be liable for any acts or omissions of Harris Health, its agents or employees, any Physician, any Hospital, or any other person or organization in which Har- ris Health has made, or hereafter shall make arrangements for the performance of services under this Agreement 82 LIMITATION ON LIABILITY Harris Health does not guarantee by this Agreement that any Participating Provider shall per- form or properly perform such contracts, the only obligation of Harris Health in the event of breach of such contract'by any Participating Provider shall be, upon request, to use its best efforts to procure the needed services from another provider Harris Health shall not be liable to a Member for any act of omission or commission on the part of any Participating Provider 83 REFUSAL TO ACCEPT TREATMENT/EXCESSIVE TREATMENT Members may, for reasons personal to themselves, refuse to accept services or complete a Course of Treatment as recommended by a Participating Physician Participating Physicians shall use their best efforts to render all necessary and appropriate professional services in a manner compatible with the Member's wishes, insofar as this can be done consistently with such Participating Physician's judgment as to the requirements of proper medical practice If a Member refuses to complete a recommended Course of Treatment, and the Participating Physician believes that no professionally acceptable alternative exists, such member shall be so advised If upon being so advised, the Member still refuses to follow the recommended treatment or procedure, then the Member shall be given no further treatment for the condition, and neither the Par- ticipating Physician nor Harris Health shall have any further responsibility to provide care for such con- dition A Member may appeal a withdrawal of treatment under this provision through the Member Complaint Resolution Procedure as described in Section 10 0 of this Agreement If two (2) or more Participating Physicians who have rendered care to a Member inform Harris Health that the Member is receiving health services or prescription medications in a manner or in a quantity which is not medically necessary or not medically beneficial, the Member may be required by Harris Health to select a single Participating Primary Physician (hereafter referred to as a "Coordinat- ing Health Plan Physician") and a single Participating Pharmacy, if Pharmacy benefits are available to Member, for the provision and coordination of all future health services If the Member fails to voluntar- ily select a Coordinating Health Plan Physician and a single Participating Pharmacy within thirty (30) days of written notice by Harris Health of the need to do so, Harris Health shall designate a Coordinat- ing Health Plan Physician and/or a Participating Pharmacy for the Member Following selection or designation of a Coordinating Health Plan Physician for a Member, cov- erage of health services set forth on this Agreement shall be contingent upon each health service being provided by or through written referral to the Coordinating Health Plan Physician for that Member If, after sixty (60) days from initial notification by Harris Health, the Member is not in compliance with this Section, the Member may be terminated by Harris Health under Section 4 2 7 Section 9 0 EXCLUSIONS ON SERVICE RESPONSIBILITIES The rights of Members and obligations of Participating Providers under this Agreement are subject to the exclusions as specified below 91 MAJOR DISASTER OR EPIDEMIC In the event of any major disaster or epidemic that would severely limit the availability of Partici- pating Providers to provide healthcare services on a timely basis, Participating Providers shall, in good faith, use their[ best efforts to render the benefits and services covered insofar as practical according to their best judgment and within the limitation of such facilities and personnel as are then available If Harris Health and Participating Providers shall, in good faith, have used their best efforts to provide or ie1 make arrangements for the benefits and services, they shall have no further liability or obligation for delay or failure to provide such benefits and services due to a shortage of available facilities or per- sonnel resulting from such disaster or epidemic 92 CIRCUMSTANCES BEYOND CONTROL In the event that, due to circumstances not reasonably within the control of Harris Health or Participating Providers, such as the complete or partial destruction of facilities because of war, riot, civil insurrection, or the disability of a significant number of Participating Providers, the rendering of benefits and services covered hereunder is delayed or rendered impractical, neither Harris Health nor any Participating Provider shall have any liability or obligation on account of such delay or such failure to provide such benefits and services, if they shall, in good faith, have used their best efforts to pro- vide or make arrangements for the benefits and services covered insofar as practical according to their best judgment and within the limitations of such facilities and personnel as are then available Pre- mium payment shall be suspended for the duration of such time period for the Group 93 FRAUDULENTLY OBTAINED BENEFITS In the event a member fraudulently obtains healthcare services as a result of the improper or unauthorized use of a Harris Health identification card, such Member agrees and is solely responsible for the payment of all charges for services so obtained and for the payment of all reasonable costs of collection thereof, including court costs, collection fees and attorney fees 94 DISCONTINUANCE If Harris Health or Group determines it would be impractical to continue due to circumstances beyond the control of Harris Health or Group, Harris Health and Group may endeavor to agree to amendments and adjustments to this Agreement which relate to services and benefits to be discontin- ued If parties cannot agree on amendments and adjustments, Harris Health or Group may terminate this Agreement at the end of any month upon at least sixty (60) days written notice for Group In the event of such termination, neither Harris Health nor Participating Providers shall have any further liabil- ity or responsibility under this Agreement However, if any Participating Provider terminates their contract, then Harris Health shall be lia- ble for the continuance of services and benefits described in this Agreement Such services shall be rendered to Members by other Participating Providers Section 10 0 MEMBER COMPLAINT RESOLUTION PROCEDURE 101 COMPLAINT RESOLUTION PROCESS A Member may make an oral or written suggestion or indicate a complaint to any Harris Health employee or to any Participating Provider All oral suggestions and complaints shall be handled promptly by Harris Health If the Member is not satisfied with the response to an oral suggestion or complaint, the Member may file a written complaint by calling Harris Health or, at the Member's option the Member may file a written complaint by completing and forwarding a complaint form to Harris Health at the latest address provided on the front of this Agreement A Harris Health Member Service Representative shall contact the Member by telephone to verify details and resolve the problem imme- diately if possible Within fifteen (15) business days from the receipt of the oral or written complaint, Harris Health shall respond in writing to inform the Member of the progress or decision on the com- plaint In the event a decision cannot be reached within fifteen (15) business days, Harris Health shall notify the Member that a decision shall be provided as soon as possible, but not later than sixty (60) days after initial receipt of the complaint 10 1 1 Ad Hoc Review Committee If the Member is not satisfied with the resolution of the complaint by Harris Health, the Member may request a review by filing such a request, in writing, within fifteen (15) business days of receiving written notice of the resolution of the complaint This request shall be sent to Harris Health Upon receipt of this written request, Harris Health shall forward the request and any and all memoranda and notes made as a result of the original investigation of the complaint to the Medical Director and to Har- ris Health 20 After reviewing the complaint records, Harris Health shall convene an Ad Hoc Review Commit- tee composed of Harris Health, the Medical Director, and at least two other individuals not involved in the initial investigation of the complaint In the case of a complaint concerning medical treatment or services, medical personnel or facilities, such other individuals on the Ad Hoc Review Committee shall be Participating Physicians Within fifteen (15) business days of receipt of the request for a review, Harris Health shall respond, in writing, to inform the Member of the decision or resolution of the com- plaint by the Ad Hoc Review Committee 10 1 2 Notification By Review Committee If the original complaint involved a physician -patient relationship, the written response of the Ad Hoc Review Committee shall inform the Member that he has the option, at his discretion, to submit the complaint to they mediation service maintained by the Tarrant County Medical Society, and that such mediation shall usually be concluded within a thirty (30) day to sixty (60) day time period The notice shall inform the Member that participation in the mediation process is voluntary and that mediation rec- ommendations are non -binding on both parties As part of their contractual obligation to comply with the Health Plan rules and regulations, Participating Physicians must cooperate with the Tarrant County Medical Society mediation service 10 2 COMPLAINT RESOLUTION APPEAL PROCESS If a Member is not satisfied with the decision of the Ad Hoc Review Committee, or the Tarrant County Medical Society mediation service, the Member may request an additional review by Harris Health The Member must file a request for review within fifteen (15) business days of receipt of the decision of the Ad Hoc Review Committee or the mediation service Upon receipt of a request for a review, Harris Health shall forward the review request and a complete record of the complaint history to the Medical Director and to Harris Health After reviewing the complaint records, Harris Health shall convene an Ad Hoc Appeal Commit- tee composed of Harris Health, the Medical Director and at least two other individuals not involved in the initial investigation of the complaint In the case of a complaint concerning medical treatment or services, medical personnel or facilities, such other individuals on the Ad Hoc Appeal Committee shall be Participating Physicians Within fifteen (15) business days of receipt of the request for a review, Harris Health shall respond, in writing, to inform the Member of the decision or resolution of the complaint by the Ad Hoc Appeal Committee If all parties involved in the complaint agree, the complaint response of the Ad Hoc Appeal Committee shall be final and binding on all parties Section 110 HEALTH CARE SERVICES 11 1 Benefits and Services Harris Health agrees to arrange for the provision of the benefits and services in the Schedule of Benefits and/or, Riders, in accordance with the procedures and subject to the limitations and exclu- sions specified in such Schedule of Benefits and/or Riders and in this Agreement Unless referred in writing by a Participating Primary Physician (or by a Participating Specialist Physician), and except in cases of Medical Emergency, benefits and services set forth in the Limita- tions and Exclusions Section of the Schedule of Benefits or any Riders that are rendered by a Partici- pating Physician other than a Participating Primary Physician shall not be covered All hospital admissions must be authorized by Harris Health, and the Member's condition or required services must be such that treatment can be rendered only in a hospital setting Harris Health and the Participating Physician may decide to provide Medically Necessary services on an outpatient basis or in an outpatient surgery unit The use of alternative levels of care, such as outpatient hospital or home care, will be encouraged where possible based on Member condition and treatment Unless previously authorized in writing by a Participating Physician and by the Medical Director and except in cases of Medical Emergency, all benefits and services set forth in the Schedule of Ben- efits and any Riders shall be available and covered only when provided by a Participating Physician, Participating Hospital or by another Provider under contract with Harris Health to provide healthcare services to Members 21 All charges related to services and supplies incurred prior to the Member's effective date, or after the Member's termination date of coverage under this Agreement shall not be covered Section 12 0 TERM AND AMENDMENT OF AGREEMENT 121 TERM This Agreement shall remain in effect for the first Contract Year and thereafter for successive Contract Years unless sooner terminated as provided in Section 4 0 of this Agreement 122 AMENDMENT • Harris Health and Group may mutually alter or revise the terms of this Agreement and/or Schedule of Benefits and Riders attached hereto In the event of such alteration or revision, Harris Health shall provide Group with at least sixty (60) days written notice before effective date of Amendment Such notice shall be considered to have been provided when mailed to the Group at the latest address shown on the records of Harris Health • This Agreement may be amended at any time, according to any provision of this Agreement or by written agreement between Harris Health and Group, without the consent of the Mem- bers, or any other person having a beneficial interest in it Any such amendment shall be without prejudice to any claim arising prior to the effective date of such amendment 12 3 CHANGE OF RATES Harris Health shall have the right to change the rates and premiums payable hereunder (1) as of any Anniversary Date (in which case the Group shall be notified at least sixty (60) days prior to a change in rates) or (u) in accordance with Section 12 2 of this Agreement Section 13 0 MISCELLANEOUS PROVISIONS 131 USE OF WORDS Words used in the masculine shall apply to the feminine where applicable, and, wherever the context of this Agreement dictates, the plural shall be read as the singular and the singular as the plu- ral The words "hereof," "herein," "hereunder" and other similar compounds of the word "here" shall mean and refer to the entire Agreement and not to any particular Section or provison All references to Sections and provisions shall mean and refer to Sections and provisions contained in this Agreement unless otherwise indicated 13 2 RECORDS AND INFORMATION Harris Health shall conduct a review program for the healthcare services it provides hereunder and for that purpose may examine the records of each Member Information from medical records of Members and information received from Physicians or Hospitals incident to the Physician -patient or Hospital -patient relationship shall be kept confidential This information, except as reasonably neces- sary in connection with the administration of this Agreement or as required by law, shall not be dis- closed without the consent of the Member Harris Health shall, to the extent legally allowable and without further consent of or notice to any Member, release to or obtain from any insurance company or other organization or person any information, with respect to any person, which Harris Health deems to be necessary for such pur- poses Any person claiming benefits shall furnish to Harris Health such information as may be neces- sary to implement this Agreement 133 INFORMATION FROM GROUP Group shall periodically forward the information required by Harris Health in conjunction with the administration of this Agreement All records of Group which have a bearing on the coverage shall be open for inspection by Harris Health at any reasonable time Harris Health shall not be liable for the fulfillment of any obligation dependent upon such information prior to its receipt in a form satisfactory to Harris Health Incorrect information furnished may be corrected, if Harris Health shall not have acted to its prejudice by relying on it Harris Health shall have the right, at reasonable times, to examine 22 Group's records, including payroll records of employers having employees covered through Group, with respect to eligibility and monthly premiums under this Agreement 13 4 ASSIGNMENT The benefits to a Member under this agreement are specific to the Member and are not assignable or otherwise transferable 13 5 AUTHORITY Any alterations or revisions to this Agreement shall not be valid unless evidenced by a written whichamendment has been signed by Group and affected document No other person has the authority Health an officer of Harris attached and uthorityto change this Agreement or to waive any of is provisions 13 6 GOVERNING LAW This Agreement is executed and is to be performed in all respects in accordance with all fed- eral and Texasi state laws applicable to Health Maintenance Organizations and all other applicable Texas state laws or regulations 13 7 INCORPORATION BY REFERENCE The Schedule of Benefits, Group Enrollment Agreement, Applications, any optional Riders, any Attachments, and n his Agreement as f fully incorporated herein Any directrb conflict or aforegoing, mguityhof s t( Agreement shall e I he resolved under terms most favorable to the Member 13 8 ENTIRE AGREEMENT This Agreement constitutes the entire understanding between Harris Health and Group 13 9 INFORMATION TO MEMBER Upon execution of this Agreement, Harris Health shall provide to each Subscriber a copy of this Agreement and an Identification Card Such delivery shall be accomplished by mailing postage paid, to the latest address furnished to Harris Health or by delivery from a representative of Harris Health or Group to Subscriber 1310 UNIFORM RULES In the administration of Harris Health, this Agreement shall be applied uniformly to all Members similarly situated 1311 CALCULATION OF TIME In determining time periods within which an event or action is to take place for purposes of Harris Health, no fraction of a day shall be considered, and any act, the performance of which would fall on a Saturday, Sunday, holiday or other non -business day, may be performed on the next following business day 1312 EVIDENCE Evidence required of any Member of Harris Health may be by certificate, affidavit, document, or other information which the person acting on it considers pertinent and reliable, and signed, made or presented by the proper party or parties 1313 SEVERABILITY If any provision of this Agreement shall be held invalid or illegal, the rest of this Agreement shall remain in full force and effect and shall be construed in accordance with the intentions of the parties as manifested by all provisions hereof including those which shall have been held invalid and illegal Furthermore, in lieu of pofound to be illegal, ninvalid or there shall be added hereto arvision as similar n terms tossuch illegal, invalid or nnforceable provision as may be possible and be legal, valid and enforceable without materially changing the purpose and intent of this Agreement 23 1314 VENUE The parties hereby expressly agree that this Agreement is executed and shall be performable in Tarrant County, Texas, and venue of any disputes, claims, or lawsuits arising hereunder shall be in the said Tarrant County 1315 WAIVER OF NOTICE Any person entitled to notice under this Agreement may waive the notice 1316 HEADINGS The titles and headings of Sections or provisions are included for convenience of reference only and are not to be considered in construction of the Sections or provisions hereof 1317 NOTICE OF CERTAIN EVENTS If Group may be materially or adversely affected thereby, Harris Health shall, within a reasona- ble time, provide written notice to Group of any termination or breach of contract, or inability of any Participating Provider to provide the services and benefits as described in this Agreement 1318 NOTICE OF TERMINATION All Harris Health notices of termination of this Agreement or of any Member's rights will be in writing and shall state the cause of termination, with specific reference to the provision(s) of this Agree- ment giving rise to the right of termination 1319 NOTICE Any notice under this Agreement shall be in writing, and shall be given by United States mad, postage prepaid, addressed as follows Harris Health P O Box 90100 Arlington, Texas 76004-3100 Group The address specified on the executed Group Enrollment Agreement or the latest address provided, in writing, to Harris Health Subscriber The latest address provided by the Subscriber on Application form actually delivered to Harris Health The effective date of notice is two (2) business days after the date of deposit with the United States Post Office 24 HARRIS HEALTH SERVICE AREA The Harris Health Service Area includes six teen (16) counties and parts of four (4) court ties in North Central Texas The following sixteen (16) counties are in eluded in the Service Area Boscue Hood Commanche Johnson Dallas Limestone Denton Parker Erath Palo Pinto Freestone Somervell Hamilton Tarrant Hill Wise In the following four (4) counties zip codes are included as specified in the Service Area COUNTY ZIP CODES Coryell 76512 76525 76528 76538 76566 76580 Ellis 76064 76065 Montague 76230 76239 76251 76270 Navarro 75110 76639 75153 76679 76681 W} to r i ' Gib Montague , Lamar Coke = OraYgon Pinata a r 34 � nella f �4F 6k f Y Pdek Wise Collin Hum Napkins Denton M r an'll Ran., Parker larram Dallas ` @q�vPxito t r Kau man µdo 7andt Hood r Johnson Hlis Erath x<mkrson , :; Soap ae Hill Navarro Bosque Comanche A,Merson Freestone Hamilton Limestone r ' +. McLennm t M1gIUa Coryell uon i� Fplle a ^. 6gd �da � Lamt�+as Bell Robertw t _, SCHEDULE OF BENEFITS PREFERRED FLEX PLAN HARRIS METHODIST TEXAS HEALTH PLAN, INC. d/b/a HARRIS METHODIST HEALTH PLAN A FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATION FLEX 96 FLEX PREF Please contact Us whenever You have a problem, comment, or question. Harris Methodist Health Plan 611 Ryan Plaza Drive, Suite 900 Arlington, TX 76011-4009 (817) 462-7800 1-800-633-8598 FLEX 96 FLEX PREF TABLE OF CONTENTS OBTAINING HEALTH CARE SERVICES I SCHEDULE OF BENEFITS 3 PHYSICIAN SERVICES 4 EMERGENCY CARE SERVICES 6 INPATIENT FACILITY SERVICES 8 OUTPATIENT FACILITY SERVICES 9 MATERNITY SERVICES 10 FAMILY PLANNING SERVICES 1 I INFERTILITY SERVICES 12 MENTAL HEALTH SERVICES 13 CHEMICAL DEPENDENCY SERVICES 15 REHABILITATION SERVICES 16 CARDIAC REHABILITATION SERVICES 17 KIDNEY DIALYSIS SERVICES 18 AMBULANCE SERVICES 18 HOME HEALTH CARE SERVICES 19 SKILLED NURSING FACILITY SERVICES 20 PROSTHETIC MEDICAL APPLIANCES 21 DURABLE MEDICAL EQUIPMENT 22 OSTOMY SUPPLIES 24 ORGAN TRANSPLANT SERVICES 25 LIMITED DENTAL SERVICES 26 LIMITED VISION SERVICES 27 GENERAL LIMITATIONS AND EXCLUSIONS 28 FLEX 96 FLEX PREF OBTAINING Welcome to Harris Methodist Texas Health Plan, Inc doing business as Harris HEALTH CARE Methodist Health Plan (the Health Plan) We have prepared this Schedule of SERVICES Benefits to help explain the coverage provided by the Health Plan It explains how to obtain medical care, what health services are covered, and what portion of the health care cost You are required to pay You should refer to this information whenever You need medical services You may get additional assistance by calling the Health Plan's Customer Service Department at (817) 462-7800 or (800) 633-8598 The Health Plan coordinates a health care system to finance and deliver quality, cost-effective services to You The Health Plan does not provide services, equipment, or products You may choose to seek health care services outside the terms of this Schedule of Benefits However, the Health Plan will only provide coverage for services received according to the terns of this Schedule of Benefits Selecting a The Primary Care Physician is responsible for coordinating Your total health Primary Care care This includes initial care, routine care, home and office visits, and referrals Physician Upon enrollment, the Health Plan will provide You with a list, including addresses and telephone numbers, of the Primary Care Physicians that participate in the Health Plan You may choose a Primary Care Physician If You do not choose a Primary Care Physician, the Health Plan will select one for You, and notify You of that selection You may reject the Primary Care Physician that the Health Plan selects for You You may change Your Primary Care Physician by contacting the Health Plan's Customer Service Department The change becomes effective on the first day of the month following the request The Health Plan may limit a Member's request to change a Primary Care Physician to four changes in any twelve month period You may request health services by calling Your Primary Care Physician any time, day or night Your Primary Care Physician must coordinate all referrals to a Specialist, except for Mental Health Services and Obstetrical/Gynecological Services Each referral is valid only for the number of services and/or time specified on the referral form Obtaining the If a required specialty is not represented in the Health Plan, Your Primary Care Services of a Physician may request authorization for referral to a Non -Participating Provider Specialist for Covered Services All such non -emergency referrals must be authorized by Physician the Health Plan before services are obtained FLEX 96 1 FLEX PREF Mental Health You may access Mental Health and Chemical Dependency Services directly by and Chemical contacting Harris Mental Health Management Services at (817) 462-6677 or Dependency (800) 374-2129, or by requesting assistance from Your Primary Care Physician Services Obstetrical & A referral from Your Primary Care Physician is not required for obstetrical or Gynecological gynecological care provided by a Participating Obstetrician/Gynecologist You Services may directly access the Obstetrician/Gynecologist of Your choice from the list of Participating Physicians provided by the Health Plan Preauthonzation Preauthorization is the review of a requested service for medical necessity This and the process helps ensure that You are getting the most appropriate care available Utilization under this Schedule of Benefits Review Program Your Physician should contact the Health Plan before scheduling any service or admission requiring preauthorization Some services which require preauthonzation are ► Educational Services ► Inpatient or Outpatient Facility Services ► Maternity Service ► Infertility Services ► Mental Health Services ► Rehabilitation Services ► Cardiac Rehabilitation Services ► Non -emergency Care Ambulance Services ► Prosthetic Medical Appliances ► Durable Medical Equipment ► Organ Transplant Services Customer The Health Plan's Customer Service Department can help You any time You Service have a problem or question Call a representative at (817) 462-7800 or 1-800- Department 633-8598 if You ► Need to change Your Primary Care Physician ► Have a benefit question ► Cannot reach Your Primary Care Physician ► Need any replacement documents (Member Handbook, Schedule of Benefits, Certificate of Coverage, Provider Directory, etc ) ► Need to replace a lost or stolen ID Card ► Need to update Your name, address, or phone number ► Have a complaint, problem, or suggestion ► Have any other questions about Your health care coverage FLEX 96 2 FLEX PREF SCHEDULE OF BENEFITS Limitations and Exclusions Regarding Copayments Copayment Maximums You are entitled to receive benefits for the Covered Services described in this Schedule of Benefits All services and benefits are subject to the stated Copayment amounts, Limitations, Exclusions, and provisions of the Group Health Care Agreement/Subscriber Certificate of Coverage and this Schedule of Benefits Benefits may be added to this Schedule of Benefits by the addition of benefit Riders Limitations and Exclusions that apply to Your benefits are listed in the General Limitations and Exclusions Section of this Schedule of Benefits All benefits are subject to the stated Limitations and Exclusions This Schedule of Benefits shows different Copayments for different Covered Services When a Provider performs two or more Covered Services on the same day, You pay the higher Copayment only You would pay more than one Copayment for services on the same day if more than one Provider is involved, such as paying a Facility Copayment to the Hospital and a Physician Copayment to the doctor Copayments shown as a "Percentage of Total Charges" means You pay the percentage of the rate the Health Plan has negotiated with that Provider If there is not a negotiated rate, You pay the percentage of the rate charged by the Provider When the total Copayments applied to all Covered Services received by an individual Member reach the Per Member Copayment maximum, no Copayment will be taken on additional Covered Services provided to that Member in the same Calendar Year When the total Copayments applied to all Covered Services received by a family reach the Per Family Copayment maximum, no Copayment will be taken on additional Covered Services provided to any Member of that family in the same Calendar Year It is possible that a family could reach the Per Family maximum without any one of the Members first reaching the Per Member maximum Per Member Per Family $2,000 00 $4,000 00 FLEX 96 3 FLEX PREF BENEFITS AND FEESCHEDULE PHYSICIAN SERVICES Benefits and Primary Care Physician Office Visits $15 OONisit Required Including office surgery, adult health Copayments assessments, routine physical examinations, and well -child care for the diagnosis, care, and treatment of illness or Injury Specialist Physician Office Visits $20 00/Visit Annual Well -Woman Examinations $15 OONisit-Primary Care $20 OONisit-Specialist Home Visits $15 OONisit-Primary Care $20 OONisit-Specialist Physician visits outside of scheduled office hours $25 OONisit Immunizations administered in the office No Copayment Allergy testing $50 OONisit Allergy injections administered in the office No Copayment Therapeutic drugs administered $15 OONisit-Primary Care by any means, medications, dressings, $20 OONisit-Specialist splints, and re -application of casts Diagnostic tests, laboratory tests, x-rays, and No Copayment professional radiology or pathology services Physician services for surgery $50 00 per procedure or other procedure performed in an outpatient Facility Physician services while You are 20% of Total Charges hospitalized Diabetic Education Services No Copayment Physician services in an Emergency No Copayment FLEX 96 4 FLEX PREF Limitations Exclusions Physician Services Benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Covered educational services are limited to authorized programs for Diabetic Education A $600 00 per Calendar Year maximum benefit per Member applies Excluded services include, but are not limited to classes or training for • prepared childbirth, Lamaze, teen pregnancy, cesarean section, and vaginal birth after cesarean • parenting • breast-feeding • stress management Charges for Physician Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Reports, evaluations, or physical examinations not required for treatment of health conditions, or not directly related to medical treatment Examples include, but are not limited to services (including immunizations) for compliance with a court order, employment, insurance, camp, adoption, school, travel, or government licenses Allergy serum FLEX 96 5 FLEX PREF EMERGENCY CARE SERVICES Emergencies When faced with an emergency Illness or Injury, it is suggested You contact the local emergency service or proceed to the nearest emergency care Facility Upon arrival at the Facility, You or someone You designate must contact Your Primary Care Physician The Health Plan will pay for Emergency Care whether it is provided inside or outside the Health Plan's Service Area Emergency Care means bona fide emergency services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in • placing the patient's health in serious jeopardy • serious impairment to bodily functions, or • serious dysfunction of any bodily organ or part The Health Plan will pay for medical screening examinations or other evaluation provided to You in the Emergency Department necessary to determine whether an emergency medical condition exists The Health Plan will also pay for necessary emergency care services provided to You and services originating in a hospital emergency department following stabilization of an emergency medical condition The Health Plan must approve or deny coverage of post - stabilization care within the time frame appropriate to the circumstances, but in no case to exceed one hour Other Situations If the Illness or Injury is not an emergency, contact Your Primary Care Physician before seeking treatment Your Primary Care Physician will direct You to the most appropriate place of service Your Primary Care Physician, or someone he designates, is available 24 hours per day, seven days a week Notifying the You, or someone You designate, must notify the Health Plan within 24 hours of Health Plan any emergency care visit, or as soon as possible Please provide the following information • date of service • name of the Facility where You were treated • Your diagnosis, with accident details if accident related • whether Your Primary Care Physician directed You to this Facility • whether You were admitted to the inpatient portion of the Facility Non -participating Coverage for services by Non -participating Providers either inside or outside of Providers the Health Plan's Service Area is limited to the care required before You can, without medically harmful or injurious consequences, be transferred or treated by a Participating Provider All follow-up care must be authorized by the Health Plan or provided by a Participating Provider FLEX 96 6 FLEX PREF Inpatient Admission Benefits and Required Copayments Limitations Exclusions If You are admitted directly to an inpatient Facility from the emergency department of the same Facility, all Emergency Care charges will be subject to the appropriate inpatient Copayment Inside or outside the Health Plan's Service Area 20% of Total Charges Emergency Room Facility Services Urgent Care Center Services $25 OONisit Emergency Care Services benefits are limited as follows Benefits for Members temporarily residing outside the Service Area are limited to Emergency Care Service benefits The Member must return to the Service Area for all other services and follow-up care Charges for Emergency Care Services except as otherwise specified in this benefit section are excluded FLEX 96 7 FLEX PREF INPATIENT FACILITY SERVICES Benefits and Room, board, medications, and supplies 20% of Total Charges Required Copayments Limitations Inpatient Facility Services benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Inpatient diagnostic testing is limited to services directly related to the condition for which the hospitalization is authorized Exclusions Charges for Inpatient Facility Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Recreational or educational therapy FLEX 96 8 FLEX PREF OUTPATIENT FACILITY SERVICES Benefits and Required Copayments Limitations Exclusions Facility services for surgery or other $100 OONisit procedure Chemotherapy, Radiation therapy, 20% of Total Charges and Inhalation therapy Diagnostic tests, laboratory tests, and x-rays No Copayment Outpatient Facility Services benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Charges for Outpatient Facility Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Recreational or educational therapy FLEX 96 9 FLEX PREF MATERNITY SERVICES Benefits and Required Copayments Limitations Exclusions Physician Services for Obstetrical Care 20% of Total Charges Including pre -natal care, delivery, postpartum care, Hospital visits, and anesthesia Physician services to the Hospital for 20% of Total Charges care of an Eligible Newborn Inpatient Facility Charges 20% of Total Charges Maternity Services benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Coverage for Maternity services received outside the Service Area before week 37 of the pregnancy are limited to covered Emergency Care Services benefits or services preauthorized by the Health Plan You must have preauthorization from the Health Plan to travel outside the Service Area after week 36 of the pregnancy or services received outside the Service Area will not be covered Coverage for Maternity services by Non -participating Providers is limited to Members that become eligible with the Health Plan after week 31 of the pregnancy All services must be authorized by the Health Plan before charges are incurred All obstetrical/gynecological services provided after this initial covered pregnancy must be performed by a Participating Physician Charges related to Maternity Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Any procedure performed for sex determination of the fetus Examples include, but are not limited to ultrasound, amniocentesis, or any assisted reproductive technology procedure FLEX 96 10 FLEX PREF FAMILY PLANNING SERVICES Benefits and Required Copayments Limitations Exclusions Physician Office Visits Including testing, counseling, genetic counseling, Federal Drug Administration approved contraceptive injections, the fitting or dispensing of an IUD or diaphragm, removal of Norplant and office surgery $15 OONistt-Primary Care $20 OONistt-Specialist Family Planning Services benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Charges for Family Planning Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Reversal of sterilization Subsequent resterilization Insertion or supply ofNorplant or any similar device FLEX 96 11 FLEX PREF INFERTILITY SERVICES Benefits and Required Copayments Limitations Exclusions Physician Office Visits Laboratory tests, x-rays, and professional radiology or pathology services Endometrial biopsy, hysterosalpingography, and diagnostic laparoscopy Infertility Services benefits are limited as follows $15 00/Visit-Primary Care $20 OONisit-Specialist No Copayment 20% of Total Charges All services must be provided in relation to a covered diagnosis or procedure Coverage is limited to diagnostic services to determine the cause of infertility Charges related to Infertility Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Infertility treatment Infertility medications Reversal of sterilization Surrogate parenting Any assisted reproductive technology (ART) procedure that enhances a woman's ability to become pregnant Examples of ART procedures include, but are not limited to intra-uterine insemination, GIFT procedures, SIFT procedures, and in -vitro fertilization Any costs associated with the collection, storage, purchase, or processing of sperm for use in any assisted reproductive technology procedure FLEX 96 12 FLEX PREF MENTAL HEALTH SERVICES Benefits and Required Copayments Limitations Mental Health Benefits include Outpatient Care - Services for the evaluation and treatment of mental health conditions which do not require a program of daily treatment and for which services are provided on a per -visit basis Structured Sub -acute Care - A program of treatment for mental health conditions which do not require 24-hour-a-day supervision but require the intensity of daily treatment Residential Care for Children and Adolescents - A program of treatment for mental health conditions which require 24-hour-a-day supervision but do not require the more intensive medical monitoring of an acute inpatient hospitalization Inpatient Care - Services for the evaluation and treatment of mental health conditions which require 24-hour-a-day supervision and the intensive medical monitoring of an acute inpatient hospitalization Outpatient Care Covered Services except group therapy and home health visits Group therapy and home health visits Medication Management Psychological Testing Inpatient Care, Structured Sub -acute Care, or Residential Care for Children and Adolescents Maximum 30 visits/Year $20 OONisit $20 OONisit $15 OONisit-Primary Care $20 OONisit-Specialist Mental Health Services benefits are limited as follows 20% of Total Charges 20% of Total Charges All services must be provided in relation to a covered diagnosis or procedure Benefits are limited to evaluation, crisis intervention, and stabilization for the diagnosis and treatment of covered mental illnesses or disorders FLEX 96 13 FLEX PREF Limitations . Outpatient Care services are limited to a combined, maximum benefit of 30 Continued visits per Calendar Year, and may include individual, family, or group therapy, medication management, and home health visits Inpatient Care services, Structured Sub -acute Care services, and Residential Care for Children and Adolescents services are limited to a combined, maximum benefit of 30 days per Calendar Year For Structured Sub -acute Care services and Residential Care for Children and Adolescents services, each two days of treatment will be considered equal to one day of inpatient treatment in determining the combined, maximum benefit Exclusions Charges for Mental Health Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Services for psychiatric conditions that are chrome or organic in nature, or that will not substantially benefit from Short-term treatment Marriage, career, or financial counseling Treatment of mental retardation or mental deficiency Behavioral training Remedial education Evaluation and treatment of learning and developmental disabilities and minimal brain dysfunction Psychological testing or psychotherapy for the treatment of attention deficit disorders or related conditions Recreational or educational therapy Biofeedback FLEX 96 14 FLEX PREF CHEMICAL DEPENDENCY SERVICES Benefits and Required Copayments Limitations Exclusions You are entitled to coverage of necessary care and treatment for Chemical Dependency on the same basis as that provided for any physical illness Diagnosis and treatment for Chemical Dependency will include detoxification and/or rehabilitation on an inpatient or outpatient basis A series of treatments is a planned, structured, and organized program to promote chemical free status which may include different facilities or modalities and is complete when the Member • is discharged on medical advice, or • has completed a series of these treatments without a lapse in treatment, or • fails to materially comply with the treatment program for a period of 30 days Outpatient Care Inpatient Care or Structured Sub -acute Care $15 OONisit-Primary Care $20 OONisd-Specialist 20% of Total Charges Lifetime Maximum Benefit Three separate series of treatments Chemical Dependency Services benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Benefits are limited to a Lifetime Maximum benefit of three separate series of treatments for each Member Charges for Chemical Dependency Services except as otherwise specified in this benefit section are excluded FLEX 96 15 FLEX PREF REHABILITATION SERVICES Benefits and Required Copayments Limitations Exclusions Short-term rehabilitative services including occupational therapy, physical therapy, or speech therapy Outpatient $20 OONisit Inpatient 20% of Total Charges Maximum Benefit Two months per medical episode for services provided in an outpatient setting Rehabilitation Services benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Services are limited to a maximum of two months per medical episode for services provided in an outpatient setting • Services must prevent dysfunction, restore functional ability, or facilitate maximal adaptation to impairment • The services provided must be • directed and monitored by a Participating Physician, • for therapy provided by a Physician or by a licensed or certified physical, occupational, or speech therapist, • furnished to You by a Participating Facility or through a Participating Provider, • provided according to a specific written treatment plan that details the treatment, including frequency and duration, and provides for on -going reviews, and • expected to result in a significant improvement of the condition within a two month period The two month period commences with the first visit Short term is defined as two months or less Charges related to Rehabilitation Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to • Work hardening programs FLEX 96 16 FLEX PREF CARDIAC REHABILITATION SERVICES Benefits and Required Copayments Limitations Exclusions Outpatient Services $20 OONisit-Specialist Maximum Benefit 36 sessions within 12 consecutive weeks Cardiac Rehabilitation Services are limited as follows All services must be provided in relation to a covered diagnosis or procedure Services must be provided immediately following • a documented episode of Unstable Angina • Coronary Artery Bypass Graft surgery • a Coronary Angioplasty procedure Charges for Cardiac Rehabilitation Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Supervised exercise that is not EKG monitored FLEX 96 17 FLEX PREF KIDNEY DIALYSIS SERVICES Benefits and Required Copayments Limitations Exclusions AMBULANCE SERVICES Benefits and Required Copayments Limitations Exclusions Outpatient Services $20 OONisit Inpatient Services 20% of Total Charges Home Dialysis (Continuous Ambulatory Peritoneal Dialysis) $20 OONisrt Including equipment, training, solutions, coils, and drug and surgical supplies Kidney Dialysis Services benefits are limited as follows All services must be provided to relation to a covered diagnosis or procedure Charges for Kidney Dialysis Services except as otherwise specified in this benefit section are excluded Land and air ambulance services 20% of Total Charges Ambulance Services benefits are limited as follows • All services must be provided in relation to a covered diagnosis or procedure • Services must be provided to relation to covered Emergency Care Services Charges for Ambulance Services except as otherwise specified in this benefit section are excluded FLEX 96 18 FLEX PREF HOME HEALTH CARE SERVICES Benefits and Required Copayments Limitations Exclusions Home Health Services $15 OONisit Hospice (Home Health Service Only) $15 00/Day Home Health Care Services benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Coverage is limited to services provided only for • chemotherapy • radiation therapy • treatment of terminal illness • treatments determined by the Health Plan to be medically necessary and appropriate to be rendered in a home setting Physical, occupational, or speech therapy received in the home is provided under the Rehabilitation Services benefit Hospice care received outside the home is provided under the Inpatient Facility Services benefit Charges for Home Health Care Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Homemaker, chore, or similar services Services primarily for rest, Custodial, Domiciliary, or convalescent care Respite care FLEX 96 19 FLEX PREF SKILLED NURSING FACILITY SERVICES Benefits and Required Copayments Limitations Exclusions Room, board, medications, and supplies 20% of Total Charges Maximum Benefit 60 days/Calendar Year Skilled Nursing Facility Services are limited as follows • All services must be provided in relation to a covered diagnosis or procedure • The medical condition must be subject to significant clinical improvement Services must be provided instead of hospitalization, either to place of an admission or upon discharge from inpatient care • Services must be determined Medically Necessary by the Health Plan based on acuity of services and patient condition Charges for Skilled Nursing Facility Services except as otherwise specified in this benefit section are excluded FLEX 96 20 FLEX PHEF PROSTHETIC MEDICAL APPLIANCES Benefits and Required Copayments Limitations Exclusions Internal and external 20% of Total Charges prosthetic appliances and applicable hardware Maximum Benefit $5,000 00/Calendar Year Prosthetic Medical Appliances benefits are limited as follows • All services must be provided in relation to a covered diagnosis or procedure Appliance must serve a physiological purpose Appliance must be obtained from a participating prosthetic appliance provider Repair or replacement of external prostheses is covered only when required by marked physical changes, growth, or malfunction of the device as determined by the Health Plan The purchase of an external breast prosthesis and any associated garments is limited to purchase of the initial prosthesis and bra following mastectomy without reconstruction Charges related to Prosthetic Medical Appliances except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Aids, appliances, or supplies that possess features not required by the patients condition, are not primarily medical in nature, are self help devices, are primarily for the patients comfort or convenience, are for common household use, are research equipment, or are deemed Experimental by the Health Plan, including, but not limited to • corrective orthopedic shoes, arch supports, or foot orthotics • dentures • contact lenses • wigs or hair pieces Routine maintenance of any external device, appliance, equipment, or supply Repairs determined to be cosmetic by the Health Plan FLEX 96 21 FLEX PREF DURABLE MEDICAL EQUIPMENT Benefits and Required Copayment Limitations Rental or purchase of 20% of Total Charges medical equipment Maximum Benefit $5,000 00/Calendar Year Durable Medical Equipment (DME) benefits are limited as follows • All services must be provided in relation to a covered diagnosis or procedure • At its option, the Health Plan may rent or purchase approved equipment • Services for which the purchase price or total rental costs will exceed $200 00 require preauthorization by the Health Plan Equipment must be • obtained from a participating DME Provider • obtained on written referral to the DME Provider by the Primary Care Physician • able to withstand repeated use • primarily and customarily serve a medical purpose • not generally useful in the absence of illness or Injury • ordered by a Participating Physician • appropriate for use in the home • Replacement of Durable Medical Equipment is covered only when required by marked physical changes or growth • Breast pumps must be determined Medically Necessary by the Health Plan to be eligible for coverage • All TENS or electrical nerve stimulation devices require pre -authorization from the Health Plan FLEX 96 22 FLEX PREF Exclusions Charges related to Durable Medical Equipment except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to Aids, appliances, or supplies that possess features not required by the patient's condition, are not primarily medical in nature, are self-help devices, are primarily for the patient's comfort or convenience, are for common household use, are research equipment, or are deemed Experimental by the Health Plan, including, but not limited to • motor -driven wheel chairs and beds • bed boards, bathtub lifts, over -bed tables, adjustable beds, telephone arms, sauna or whirlpool baths, chairs, or elevators • stethoscopes, sphygmomanometers, or other blood pressure units • exercise equipment or enrollment to health or athletic clubs • corrective orthopedic shoes, arch supports, or foot orthotics • air purifiers, air conditioners, or water purifiers • hypo -allergenic pillows or mattresses, or water beds • cervical collars, slings, or traction apparatus • Repair or routine maintenance of any Durable Medical Equipment FLEX 96 23 FLEX PREF OSTOMY SUPPLIES Benefits and Required Copayments Limitations Exclusions Ostomy Supplies 20% of Total Charges Maximum Benefit $1,000 00/Calendar Year Ostomy Supplies benefits are limited to the following All services must be provided in relation to a covered diagnosis or procedure Coverage is limited to bags, stoma caps, skin cleanser, skin prep, paste, and powder Charges related to Ostomy Supplies except as otherwise specified in this benefit section are excluded FLEX 96 24 FLEX PREF ORGAN TRANSPLANT SERVICES Benefits and Required Copayments Limitations Exclusions If Medically Necessary and preauthonzed by the Health Plan Medical Director or his designee, the Health Plan will provide benefits only toward the following transplants ► kidney transplants ► cornea transplants ► liver transplants ► pancreas transplants ► bone marrow transplants heart transplant, ► lung transplants ► any combination of these covered transplants Room, board, medications, and supplies 20% of Total Charges Organ Transplants benefits are limited as follows ► All services must be provided in relation to a covered diagnosis or procedure Charges related to Organ Transplants except as otherwise specified in this section are excluded Exclusions include, but are not limited to ► Artificial Organ Transplants ► Cross -species whole organ transplants ► Organ donor transportation or lodging costs ► Services provided to any Member for the donation of any organ or element of the body to a non -Member recipient FLEX 96 25 FLEX PREF LIMITED DENTAL SERVICES Benefits and Limited Dental Services 20% of Total Charges Required Copayments Maximum Benefit $500 00/Calendar Year Limitations Limited Dental Services benefits are limited as follows • All services must be provided in relation to a covered diagnosis or procedure Treatment is limited to the repair of accidental, non -occupational Injury to Sound, Natural Teeth • Treatment must begin within 30 days of the accident Treatment must be completed within 180 days of the accident Exclusions Charges related to Limited Dental Services except as otherwise specified in this section are excluded Exclusions include, but are not limited to • Repair or replacement of any implant, pontic, bridge, or denture Routine orthodontia services • Appliances Splints Routine dental care, including but not limited to • fillings or other dental repair procedures • replacement of teeth, including fixed or removable prostheses • treatment for diseases of the teeth or gums • extraction of teeth, including wisdom teeth • treatment for malocclusion or malposition of the teeth orjaws (mandibular or maxillary hyperplasia or hypoplasia) • anesthesia or professional services related to or required for the sole purpose of providing dental care • Hospital care • inpatient or outpatient surgery required for any dental care • prescription drugs for dental treatment • x-rays FLEX 96 26 FLEX PREF LIMITED VISION SERVICES Benefits and Required Copayments Limitations Exclusions Limited Vision Services No Copayment Maximum Benefit $75/Calendar Year Limited Vision Services benefits are limited as follows All services must be provided in relation to a covered diagnosis or procedure Services are limited to the purchase and fitting of the • initial set of eyeglasses or • initial contact lens following • cataract surgery • repair of Congenital Anomaly or • as required by accidental Injury when the natural lens has not been replaced by an internal prosthetic lens Charges related to Limited Vision Services except as otherwise specified in this section are excluded Exclusions include, but are not limited to Radial keratotomy and other keratoplasties or keratotomies FLEX 96 27 FLEX PREF GENERAL The Limitations and Exclusions applying to Your benefits are listed in this LIMITATIONS General Limitations and Exclusions Section Limitations and Exclusions that AND normally occur in relation to one specific benefit have been listed in the EXCLUSIONS appropriate benefit section However, all benefits are subject to the stated Limitations and Exclusions Limitations 1 Coverage is limited to services provided in relation to a covered diagnosis or procedure 2 Coverage of services, supplies, or treatments not provided, referred, or authorized by Your Primary Care Physician or the Health Plan is limited to coverage under the Emergency Care Services benefit as described in this Schedule of Benefits 3 Coverage of services by Physicians, facilities, or other providers, who are not Participating Providers, is limited to coverage under the Emergency Care Services benefit as described in this Schedule of Benefits or to services preauthorized by the Health Plan 4 Reconstructive Surgery is limited to the reconstruction necessary to repair a dysfunction or disfigurement resulting from Injury, tumor, or Congenital Anomaly 5 Benefits for Members temporarily residing outside the Service Area are limited to Emergency Care Services benefits The Member must return to the Service Area for all other services and follow-up care 6 Charges submitted by a Hospital as part of an inpatient confinement are I mited to services related to the condition for which the confinement was approved 7 Pam control therapy is limited to services preauthorized by the Health Plan 8 Transportation or travel by means of any private or commercial carrier is limited to covered Ambulance Services 9 Coverage for treatment of the temporomandibular joint (TMJ) is limited to those services for which coverage is mandated by the State of Texas This includes only Medically Necessary diagnostic services and/or surgical treatment determined to be Medically Necessary by the Health Plan Medical Director or his designee All services must be provided by a Participating Provider Charges related to dental services or malocclusion are not covered 10 Coverage of services that are provided, paid for, or required by state or federal law is limited to those services for which benefits are available through Medicaid 11 Benefits for covered prescription and non-prescription drugs, medications, and pharmaceuticals are limited to those covered items purchased and administered in a clinical setting by the Provider Formulas necessary for the treatment of phenylketonuria (PKU) or other heritable diseases are covered to the same extent as for drugs available only on the orders of a Physician 12 Inpatient diagnostic testing is limited to services directly related to the condition for which the hospitalization is authorized FLEX 96 28 FLEX PHEF Limitations 13 Covered educational services are limited to authorized programs for Diabetic Continued Education A $600 00 per Calendar Year maximum benefit per Member applies Excluded services include, but are not limited to classes or training for • prepared childbirth, Lamaze, teen pregnancy, cesarean section, and vaginal birth after cesarean • parenting • breast-feeding • stress management 14 Coverage for Maternity services received outside the Service Area before week 37 of the pregnancy are limited to covered Emergency Care Services benefits or services preauthorized by the Health Plan 15 You must have preauthorization from the Health Plan to travel outside the Service Area after week 36 of the pregnancy or services received outside the Service Area will not be covered 16 Coverage for Maternity services by Non -participating Providers is limited to Members that become eligible with the Health Plan after week 31 of the pregnancy All services must be authorized by the Health Plan before charges are incurred All future obstetrical/gynecological services must be performed by a Participating Physician 17 Infertility Services benefits are limited to diagnostic services to determine the cause of infertility 18 Mental Health Services benefits are limited to evaluation, crisis intervention, and stabilization for the diagnosis and treatment of covered mental illnesses or disorders 19 Mental Health Services benefits for Outpatient Care services are limited to a combined, maximum benefit of 30 visits per Calendar Year, and may include individual, family or group therapy, medication management, and home health visits 20 Mental Health Services benefits for Inpatient Care services, Structured Sub- acute Care services, and Residential Care for Children and Adolescents services are limited to a combined, maximum benefit of 30 days per Calendar Year For Structured Sub -acute Care services and Residential Care for Children and Adolescents services, each two days of treatment will be considered equal to one day of inpatient treatment in determining the combined, maximum benefit 21 Chemical Dependency Services benefits are limited to a Lifetime Maximum benefit of three separate series of treatments for each Member A series of treatments is a planned, structured, and organized program that promotes a chemical -free status The program may include different facilities or modalities 22 Rehabilitation Services benefits are limited to a maximum two months per medical episode for services provided in an outpatient setting FLEX 96 29 FLEX PREF Limitations 23 Rehabilitation Services benefits are limited to services that Continued prevent dysfunction, restore functional ability, or facilitate maximal adaptation to impairment, • are directed and monitored by a Participating Physician, • are for therapy provided by a Physician or by a licensed or certified physical, occupational, or speech therapist, • are furnished to You by a Participating Facility or through a Participating Provider, • are provided according to a specific, written treatment plan that details the treatment, including frequency and duration, and provides for on -going reviews, and • is expected to result in a significant improvement of the condition within a two month period on an outpatient bans The two month period commences with the first visit Short term is defined as two months or less 24 Cardiac Rehabilitation Services benefits are limited to services provided immediately following • a documented episode of Unstable Angina • Coronary Artery Bypass Graft surgery • a Coronary Angioplasty procedure 25 Ambulance Services benefits are limited to • services provided in relation to covered Emergency Care Services • non -emergency services preauthorized by the Health Plan 26 Home Health Care Services benefits are limited to services provided only for • chemotherapy • radiation therapy • treatment of terminal illness • treatments determined by the Health Plan to be medically necessary and appropriate to be rendered in a home setting 27 Physical, occupational, or speech therapy received in the home is provided under the Rehabilitation Services benefit 28 Hospice care received outside the home is provided under the Inpatient Facility Services benefit 29 Skilled Nursing Facility Services benefits are limited to • medical conditions subject to significant clinical improvement • services provided instead of hospitalization, either in place of an admission or upon discharge from inpatient care • services determined Medically Necessary by the Health Plan based on acuity of services and patient condition 30 Prosthetic Medical Appliances benefits are limited to appliances that • serve a physiological purpose • are obtained from a participating prosthetic provider FLEX 96 30 FLEX PREF Limitations 31 Repair or replacement of external prostheses is covered only when required Continued by marked physical changes, growth, or malfunction of the device as determined by the Health Plan 32 The purchase of an external breast prosthesis and any associated garments is limited to purchase of the initial prosthesis and bra following mastectomy without reconstruction 33 Durable Medical Equipment benefits are limited to equipment that is • obtained from a participating DME Provider • obtained on written referral to the DME Provider by the Primary Care Physician • able to withstand repeated use • primarily and customarily serve a medical purpose • not generally useful in the absence of illness or Injury • ordered by a Participating Physician • appropriate for use in the home 34 Replacement of Durable Medical Equipment is covered only when required by marked physical changes or growth 35 Breast pumps must be determined Medically Necessary by the Health Plan to be eligible for coverage 36 All TENS or electrical nerve stimulation devices require pre -authorization from the Health Plan 37 Coverage of consumable or disposable supplies, dressings, syringes, sheaths, bags, or gloves is limited to the following ostomy supplies bags, stoma caps, skin cleanser, skin prep, paste, and powder 38 Organ Transplant Services benefits are limited to • kidney transplants • comea transplants • liver transplants • pancreas transplants • bone marrow transplants • heart transplants • lung transplants • any combination of these covered transplants when determined Medically Necessary and preauthorized by the Health Plan Medical Director or his designee 39 Limited Dental Services benefits are limited to treatment • for the repair of accidental, non -occupational Injury to Sound, Natural Teeth • begun within 30 days of the accident • completed within 180 days of the accident 40 Limited Vision Services benefits are limited to the purchase and fitting of the • initial set of eyeglasses or • initial contact lens following FLEX 96 31 FLEX PREF Limitations Continued • cataract surgery • repair of Congenital Anomaly or • as required by accidental Injury when the natural lens has not been replaced by an internal prosthetic lens FLEX 96 32 FLEX PHEF The following services are specifically excluded from coverage under this Schedule of Benefits Please check any Rider purchased with this Schedule of Benefits for possible coverage of these excluded services 1 Any service or treatment for which You would not legally be required to pay in the absence of coverage provided by this Schedule of Benefits, except for Medicaid 2 Care for conditions that state or local law requires be treated in a public Facility 3 Care for military service connected disabilities for which the Member is legally entitled to services and for which facilities are reasonably available to the Member 4 Services rendered by an immediate relative of the Member or by a person who resides in the Member's home An immediate relative is the spouse, child, parent, grandparent, or sibling of the Member and includes in-law and step -family relationships formed through a current or previous marriage 5 Any medical, surgical, or health care procedure or treatment held to be Experimental or Investigational at the time it is performed 6 Services or products not for the specific treatment of illness or Injury, including, but not limited to • personal, convenience, or comfort items • personal kits provided on admission to a Hospital • television • telephone • photographs • living accommodations or expenses, guest meals, or cots • finance charges • announcements 7 Private room accommodations 8 Private duty nursing in an inpatient Facility 9 Alternative methods of treatment including, but not limited to • acupuncture • naturopathy • psychosurgery • megavitamin therapy • nutritionally based alcoholism therapy • holistic or homeopathic care, including drugs • ecological or environmental medicine • hypnotherapy or hypnotic anesthesia • hippotherapy • sleep therapy 10 Services primarily for rest, Custodial, Domiciliary, or convalescent care I 1 Respite care 12 Blood and blood products FLEX 96 33 FLEX PREF Exclusions 13 Routine care and treatment of the exterior surfaces of the feet Excluded Continued services include, but are not limited to • removal or reduction of corns or calluses • trimming of nails • treatment of flat feet • arch supports or other orthotics • braces • splints 14 Treatment of obesity or complications of obesity treatment, regardless of associated medical or psychological condition including, but not limited to • intestinal or stomach bypass surgery • gastric stapling • wiring of the jaw • insertion of gastric balloons 15 Marriage, career, or financial counseling 16 Treatment of mental retardation or mental deficiency 17 Behavioral training 18 Remedial education 19 Evaluation and treatment of learning and developmental disabilities, and minimal brain dysfunction 20 Psychological testing or psychotherapy for the treatment of attention deficit disorders or related conditions 21 Services indicated primarily to improve Member's appearance, which will not result in significant functional improvement Exclusions include, but are not limited to • plastic surgery • surgical treatment of keloid formation • rhmoplasty • sear revision • revision or reformation of sagging skin on any part of the body described as relating to the eye lids, face, neck, abdomen, arms, legs, or buttocks • liposuction procedures • procedures performed in connection with the enlargement, reduction, implantation, or appearance of a part of the body described as relating to the breast, face, lips, jaw, chin, nose, ears, or genitals • hair replacement or transplantation • chemical applications or peels • abrasion of the skin • tattoo removal or camouflage • electrolysis depilation 22 Transsexual surgery, including medical or psychological counseling or hormonal therapy, in preparation for or subsequent to any such surgery 23 Hearing aids, batteries, and examinations for the fitting of hearing aids 24 Structural changes to a building or vehicle FLEX 96 34 FLEX PREF Exclusions Continued 25 Recreational or educational therapy 26 Drugs or substances not approved by the FDA, labeled "Caution - Limited by Federal Law to Investigational use," or considered Experimental 27 Aids, appliances, or supplies that possess features not required by the patient's condition, are not primarily medical in nature, are self-help devices, are primarily for the patient's comfort or convenience, are for copmon household use, are research equipment, or are deemed Experimental Toy the Health Plan, including, but not limited to • corrective orthopedic shoes, arch supports, or foot orthotics • dentures • contact lenses • wigs or hair pieces • motor -driven wheel chairs and beds • bed boards, bathtub lifts, over -bed tables, adjustable beds, telephone arms, sauna or whirlpool baths, chairs, or elevators • stethoscopes, sphygmomanometers, or other blood pressure units • exercise equipment or enrollment in health or athletic clubs • air purifiers, air conditioners, or water purifiers • hypo -allergenic pillows or mattresses, or water beds • elastic stockings, garter belts, or corsets • cervical collars, slings, or traction apparatus • home testing kits or supplies • diapers or incontinent supplies • over-the-counter medications 28 Reports, evaluations, or physical examinations not required for treatment of health conditions, or not directly related to medical treatment Examples include, but are not limited to services (including immunizations) for compliance with a court order, employment, insurance, camp, adoption, school, travel, or government licenses 29 Allergy serum 30 Any procedure performed for sex determination of the fetus Examples include, but are not limited to ultrasound, amniocentesis, or any assisted reproductive technology procedure 31 Reversal of sterilization 32 Subsequent resterilization 33 Insertion or supply of Norplant or any similar device 34 Infertility treatment 35 Infertility medications 36 Surrogate parenting 37 Any costs associated with the collection, storage, purchase, or processing of sperm for use in any assisted reproductive technology procedure FLEX 96 35 FLEX PREF 38 Any assisted reproductive technology (ART) procedure that enhances a woman's ability to become pregnant Examples of ART procedures include, but are not limited to intra-uterine insemination, GIFT procedures, SIFT procedures, and in -vitro fertilization 39 Services for psychiatric conditions that are chronic or organic in nature, or that will not substantially benefit from Short-term treatment 40 Biofeedback 41 Work hardening programs 42 Supervised exercise that is not EKG monitored 43 Homemaker, chore, or similar services 44 Routine maintenance of any external device, appliance, equipment, or supply 45 Repairs to Prosthetic Medical Appliances determined to be cosmetic by the Health Plan 46 Repair or routine maintenance of any Durable Medical Equipment 47 Artificial Organ Transplants 48 Cross -species whole organ transplants 49 Organ donor transportation or lodging costs 50 Services provided to any Member for the donation of any organ or element of the body to a non -Member recipient 51 Repair or replacement of any implant, pontic, bridge, or denture 52 Routine orthodontia services 53 Appliances or splints for conditions involving the teeth, jaws, or tongue 54 Routine dental care, including, but not limited to • fillings or other dental repair procedures • replacement of teeth, including fixed or removable prostheses • treatment for diseases of the teeth or gums • extraction of teeth, including wisdom teeth • treatment for malocclusion or malposition of the teeth or jaws (mandibular or maxillary hyperplasia or hypoplasia) • anesthesia or professional services related to or required for the sole purpose of providing dental care • Hospital care • inpatient or outpatient surgery required for any dental care • prescription drugs for dental treatment • x-rays 55 Radial keratotomy and other keratoplasties or keratotomies 56 Formulas, dietary supplements, or special diets FLEX 96 36 FLEX PREF OUTPATIENT PRESCRIPTION DRUG RIDER WITH MAIL ORDER FOR USE ONLY WITH THE GROUP HEALTH CARE AGREEMENT/SUBSCRIBER CERTIFICATE OF COVERAGE HARRIS METHODIST TEXAS HEALTH PLAN, INC. dba HARRIS METHODIST HEALTH PLAN A Federally Qualified Health Maintenance Organization 611 Ryan Plaza Drive, Suite 900 Arlington, Texas 76011-4009 (800) 633-8598 (817) 462-7000 Benefits are available to eligible members as identified in the agreement When you go to a participating pharmacy, present your prescription and your HMHP Identification card. You must be enrolled and eligible with Harris Health at the time your prescription is filled or refilled to receive the benefits as outlined This rider's benefits for outpatient 'prescription drugs are subject to the definitions, conditions, exclusions, and provisions of the Agreement Except for emergency care, benefits are available only if prescribed by a Participating Provider and dispensed by a Participating Pharmacy You will be provided with a list of Participating Providers and Pharmacies. This rider does not cover prescriptions that represent a replacement of a previous prescription that was lost, spilled, stolen, or otherwise misplaced All out-of-pocket Copayments for outpatient Prescription drugs will count toward your benefit out-of- pocket maximums. PDMF 696 1 PDM5 10/8 15/F Agreement is the application, schedule of benefits, certificate of coverage, any riders, and any other plan documents relating to the policies or benefits of HMHP. Billed Charge is the amount a pharmacy would charge the general public for a prescription Brand Name Drug is a Prescription that may or may not have a Generic equivalent Copayment is the amount you are required to pay the Participating Pharmacy for dispensing or refilling a Prescription. Cost is the contracted amount we will pay the Participating Pharmacy for the Prescription Drug Covered Drug is 1) a drug prescribed by a Participating Provider; 2) a drug that, under federal or state law, can only be dispensed according to a Prescription, or 3) disposable syringes, urine and blood glucose testing strips, and lancets. Drug Formulary is our pre -approved listing of drugs that are safe, efficient, and cost- effective. Your prescribed drug will not be covered if it does not appear on the Drug Formulary Generic Drug is a pharmaceutic and therapeutic equivalent to a brand -name drug. You will pay the lowest copayment for a generic prescription: ` Member is the subscriber or any dependents covered under the Agreement. Prescription Drug 1) is Medically Necessary for your condition, 2) is prescribed by a Participating Provider; 3) legally requires a prescription; and 4) is obtained from a Participating Pharmacy Heritable Disease is an inherited disease that could result in mental or physical handicap or death Participating Pharmacy is a Pharmacy that has contracted with us to provide services to you Participating Provider is a Physician or other provider that has contracted with us to provide services to you PKU (Phenylketonuria) is an inherited condition that could cause severe mental retardation if not treated PDMF 696 2 PDM6 10/8 151F The benefits for mad order Prescription Drugs provided under this Rider are available for maintenance drugs and medicines that are dispensed according to a Prescription for your outpatient use Mad -order Prescriptions must be prescribed by a Participating Provider and dispensed by a Participating mad order Pharmacy Schedule of Benefits The Participating Mad Order Pharmacy Provider will furnish up to a 90-day supply of a Covered Drug for a Copayment of. • $8 00 for each new Prescription and/or refill of a Generic Drug on our Drug Formulary, or • $115 00 for each new Prescription and/or refill of a Brand Name Drug on our Drug Formulary Exclusions In addition to the exclusions described in Section 8.0, the following exclusions apply to the Mad Order Pharmacy benefit: • Fluorides • Drugs requiring refrigeration Covered Quantities t I - Prescribed covered quantities include the lesser of the prescribed amount or a 90-day supply for each new covered Prescription or refill You must pay 100% for any amount iof a covered Prescription exceeding covered quantities, including lost or misplaced medications PDMF 696 5 PDM5 1018 15/F There is no benefit provided under this Rider for: • drugs not contained on the Health Plan's Drug Formulary; • contraceptive devices, • devices of any type, including but not limited to, artificial appliances, therapeutic or prosthetic devices, supports, or other non -medical products, • medical supplies except those specifically listed in this Rider as covered items; • immunization agents, allergy and biological sera, • compounded Prescription Drugs intended for parenteral use; • Prescription Drugs produced from blood, blood plasma, and blood products, derivatives, Hemofd M, Factor Vill, and synthetic blood products, • experimental or investigational drugs; • fertility medications, • appetite suppressants; • drugs that by federal and/or state law do not require a Prescription (except for insulin, PKU and other heritable disease supplements) and over-the-counter medications or their equivalents, even if written on a Prescription; • drugs consumed in an inpatient or other institutional care setting, • vitamins, nutritional, or dietary supplements, except when required by a Prescription, • drugs intended for use in a Participating Physician's office or clinical setting, • Prescription Drugs for cosmetic conditions not covered, including but not limited to, Retin-A (for patients over the age of 25) and Minoxldd; • smoking cessation patches, gum, and other such aids; • medications not used for an FDA -approved indication; • anabolic steroids, • drug infusion/metering devices; • growth hormones, • administration or injection of any drugs or medications, except as specified as a basic benefit in the Group Health Care Agreement/Subscriber Certificate of Coverage PDMF-696 6 PDM5 1018 15/F Prescription is the authorization for a Prescription Drug issued by a Participating Provider] who is licensed to prescribe in the ordinary course of his/her professional practice. Prescriptions can be authorized by non -Participating Physicians if we have approved the referral or in emergency cases In cases of an emergency, you will be reimbursed for Covered Drugs if • your life or health would have been endangered had purchasing the Covered Drug been delayed until it could be prescribed by a Participating Provider and/or obtained from a Participating Pharmacy, • the Covered Drug was purchased according to a Prescription or authorized by a'Provider, • you request, in writing, reimbursement from us and submit a receipt for the covered drug within 60 days of the date of purchase; and • the receipt from the pharmacy includes the National Drug Code (NDC) for the prescription drug dispensed. When we accept your proof ofpayment, you are entitled to 100% of the pharmacy's Billed Charge, minus your Copayment. Refills are covered if • allowed by law; • authorized by a Participating Provider, • dispensed by a Participating Pharmacy; • you remain eligible for the benefit; and • 75% of the medication has been consumed, based on the dosage instructions of the Physician Refills must be dispensed within 12 months of the original prescription date PDMF 696 3 PDM5 10/8-15/F The Participating Pharmacy will dispense up to a 30-day supply of a Covered Drug for a Copayment of • the lesser of $5.00 or Cost for each new prescription and/or refill for a Generic Drug on our Drug Formulary, or • the lesser of $10 00 or Cost for each new prescription and/or refill for a Brand - Name Drug on our Drug Formulary. If a Brand -Name Drug is dispensed at your request when a Generic Drug is available, you will pay the Generic Copayment and the cost difference between the Brand -Name Drug and the Generic Drug The cost difference that you pay will not apply toward the fulfillment of the per year maximum Member Copayment limit specified in the Agreement Covered quantities include up to a 30-day supply for each new covered prescription or refill You must pay 100% for any amount of a covered prescription exceeding covered quantities, including lost or misplaced medications. Limitations: • up to three (3) vials of insulin; • up to eight (8) fluid ounces of a liquid medication, except for liquid potassium supplement, • up to three (3) ounces net weight of ointment, cream, or gel except vaginal medication which will be limited to one tube, • up to two (2) standard packages of a nasal or oral inhaler, • one (1) vial containing up to 15 milliliters of any eye or ear medications; and • one month's supply of oral contraceptives. PDMF 696 4 PDM5 10/8 15/F