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HomeMy WebLinkAbout1989-144r AN ORDINANCE ACCEPTING THE PROPOSAL OF SANUS TEXAS HEALTH PLAN, INC FOR MEDICAL INSURANCE COVERAGE FOR CITY EMPLOYEES, AUTHORIZING THE EXPENDITURE OF FUNDS THEREFORE, AND DECLARING AN EFFECTIVE DATE WHEREAS, the City has solicited, received and tabulated competitive sealed proposals for the purchase of medical insurance coverage for city employees in accordance with the procedures of state law and City ordinances, and WHEREAS, the City Manager has reviewed and recommended that the proposal of Sanus Texas Health Plan, Inc is the lowest responsible proposal for services as shown in the "Bid Proposals" submitted therefor, and WHEREAS, the City Council has provided in the City Budget for the appropriation of funds to be used for the purchase of the services approved and accepted herein, NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS SEr=TION I That the proposal of Sanus Texas Health Plan, Inc for medical insurance coverage for city employees, a copy of which is attached hereto and incorporated by reference herein, is hereby accepted SECTION II That the City Council hereby authorizes the expenditure of funds in the manner and amount as specified in the agreement SECTION III That this ordinance immediately upon its passage and approval PASSED AND APPROVED this the l j--day shall become effective Ray S p ens, Mayor ATTEST. JENNIFER WALTERS, CITY SECRETARY BY MA APPR ED AS TO LEGAL FORM DEBRA ADAMI DRAYOVITCH, CITY ATTORNEY BY f 10/11/89 SANUS TEXAS HEALTH PLAN, INC 8600 Freeport Parkway, Suite 3040 Irving, Texas 75M Mstro 621.8143 or (214) 929.0376 GROUP MEMBERSHIP SERVICE AGREEMENT/ CERTIFICATE OF COVERAGE I DEFT ITION8 Except a expressly otherwise provided or unless the context otherwise requires the following words and phrases used in t Is Agreement shall have the following meanings 1 Actively at Work means that an Eligible Employee must be performing the usual and customary 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 Agreement' means this Group Membership Service Agreement the Schedule of Benefits all Applications all Attachments and Riders hereto, if any, and alt Amendments hereto if any 3 Alternative Health Benefits Plan means any health benefits plan other than this Plan which is offered by through or in Connection with the Group 4 Ambulatory Surgical Center means anon hospital center which provides ambulatory surgical services and which is properly Ik ensed as such by the State of Texas 5 Anniversary Date' means the annual anniversary of the Effective Date 8 Application n behalf of his Dependents prescribed beeequired to complete and submwhich it to SANUS TEXAS for the purpose of enroll f and o mg himself and such Dependents for coverage hereunder 7 Basic Plan Benefits' means those benefit covered by this Agreement and explained in the Schedule of Benefits but not including any Riders 8 Contract Year 'Means the period of twelve (12) months commencing on the Effective Date and each twelve (12) month [period thereafter, unless otherwise terminated as hereinafter provided 9 Copayment 'means the fee as set forth In the Schedule of Benefits and any Riders provided with this Agreement and made a part hereof which Is not covered by premiums payable hereunder to be paid by Members at the time offservice directly to Physicians Hospitals or other Health Professionals in connection with the services set forth in the Schedule of Benefits and Riders If any 10 Covered Services' means only the medical care services and supplies rendered under the folowing conditions a provided directed or authorized by the Member's Participating Primary Care Physician except in the case of a Medical Emergency as defined by the Plan b prescribed by a doctor or the therapeutic treatment of Injury sickness or pregnancy c doomed Medically Necessary and appropriate in type level setting and length of service by SANUS TEXAS d rendered in accordance with generally accepted medical practice and professionally recognized standards e not, generally considered to be experimental investigational, or which are performed or research purposes f services which are specifically Included and not excluded or limited or not specifically excluded by the Plan 11 Custodial Care means that care which 1s marked by or given to watching and protecting rather than seeking to cure or (2) care which is of a necessary part of medical treatment for recovery or (3) care comprised of ser vices and supplies that are provided primarily to assist in the activities of daily living 12 Deductible means the expense incurred or potion of such expense other than a Copayment which the Member Is required to pay directly to the Physicians Hospitals or other Health Care Providers in connection with Covered Services 13 Dependent means an Eligible Dependent who has been enrolled in the Plan by a Subscriber for whom the this Agreeemiumment and whments o contin es to meet the eligibility requirements received rent set ortTEXAS h In in 11 A(2) owith this Agrterms eementf 14 Domiclllary Care" means that care provided or persons so disabled or Infirm as to be unable to INS Independently 15 Effective Date means the effective date of coverage asset forth on the face page of this Agreement 18 Eligible Dependent" means an Eligible Employees spouse or child who meets the dependent eligibility re- quirements set forth in Section II A of this Agreement 17 Eligible Employee' means an Individual who meets the Subscriber eligibility requirements set forth in Section 11 A of this Agreement $ 18 Emergency Care' means bona fide emergency services provided after the sudden onset of a medical condition man testing Itself by acute symptoms of sufficient severity Including severe pain such that the absence of im mediate Imsdioal attention could reasonably be expected to result In a placing the patient's health in serious jeopardy b ssrigus impairment to bodily functions, or c serious dysfunction of any bodily organ or part GSA A"87D 1 1b Free Standing Surgic, enter shall have the same meaning as Art uory SurgicalCenter 20 Group means the employer labor union trust association partnership government agency or other organize lion to which this Agreement is Issued and through which as agent for Subscriber only and not also for SANUS TEXAS Subscriber and his Dependents become entitled to the coverage described in this Agreement 21 Group Enrollment Period means the period mutually agreed upon by SANUS TEXAS and the Group as set forth on the first page of this Agreement during which Eligible Employees and Eligible Dependents may elect to enroll under this Plan or terminate their enrollment in this Plan Such period shall be no less than fourteen (14) days in each Contract Year 22 Health Professional means dentists nurses audiologists podiatrists osteopaths optometrists physicians assistants clinical psychologists social workers pharmacists nutritionists physical therapists speech therapists and other professionals engaged in the delivery of health services who are licensed, practice under an mstitu tional 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 23 Hospital means a An institution which is operated pursuant to state law and is primarily engaged in providing on an inpatient basis for the medical care and treatment of sick and Injured persons through medical diagnostic and major surgical services all of which services must be provided on Its premises under the supervision of a staff of Physicians and with twenty four hour a day registered nursing service or b An institution not meeting all of the foregoing requirements but which meets state licensing requirements and is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals 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 or 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 Ina residential treatment center for children and adolescents and treatment provided by a crisis stabilization unit 24 Medical Director means the licensed physician In the full or part time employ of SANUS TEXAS and/or such other licensed physician as the Medical Director may designate who shall be responsible for monitoring the quail ty of medical care rendered to Members 25 Medical Emergency means 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 immedicate 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 of any bodily organ or part 26 Medically Necessary means medical or surgical treatment of an illness or Injury at the appropriate level of care in accordance with accepted medical standards and Plan requirements as approved by the Plan s review commit tees for professional and technical practice and the SANDS TEXAS Medical Director 27 Medicare means Title XVIII of the Social Security Act and regulations thereunder 28 Member means any Subscriber or Dependent 29 Non Participating Physician means a physician who is not a Participating Physician 30 Out Patient Emergency Care Center means a non hospital center which provides ambulatory medical surgical and/or emergency services 31 Participating Alcohol or Drug Dependency Treatment Facility" means a facility which provides a program for the treatment of alcohol or drug dependency pursuant to a written treatment plan approved and monitored by a Physician and which has contracted with SANDS TEXAS to provide such program to Members and which facility is also a affiliated with a Hospital under a contractual arrangement with an established system for patient referral or b accredited as such a facility by the Joint Commission on Accreditation of Hospitals or c licensed as an alcohol or drug treatment program or center by the Texas Commission on Alcohol and Drug Abuse or d licensed certified or approved as an alcohol or drug dependency treatment program or center by any other state agency having a legal authority to so license certify or approve 32 Participating Facility means those facilities properly licensed by the appropriate regulatory and licensing authorities of the State of Texas and contracted to provide services to SANDS TEXAS Members and which facilities shall include Hospitals Alcohol or Drug Dependency Treatment Facilities Out Patient Emergency Care Centers Am bulatory Surgical Centers and other facilities of similar purpose 33 Participating Hospital means a Hospital (as defined In subparagraph 23 of this Section) which has contracted with SANUS TEXAS to provide Members the Inpatient services set forth in Section II 8 (or if applicable Section IV B) of the Schedule of Benefits 34 Participating Out Patient Emergency Care Center means anon hospital center which has contracted to provide ambulatory medical surgical and/or emergency services to SANUS TEXAS Members 35 Participating Physician means any Physician who has contracted with SANUS TEXAS to provide care to Members covered under this Agreement 36 Participating Primary Care Physician means with respect to each Member, the Participating Physician engag- ed in the practice of family practice general medicine Internal medicine or pediatrics who is designated in aocor GSA AB-0987D 2 AAOO A dance with SANI'^ TEXAS policies as the Physician having prima esponsibillity for ' medical care p ding specialist and primary care to Members maintaining the continuity ofnsucch such acareand Initiating referral for specialist care 3� Participating Specialist Physician means any Physician who has contracted with SANUS TEXAS to provide specialist care to Members covered under this Agreement upon referral of a Participating Primary Care Physician ' (or upon referral of another Participating Specialist Physician with the Primary Care Physician) concurrence of the responsible Participating 38 "Participating Urgent Care Center' shall have the same meaning as Participating Out Patient Emergency Care Center I34 Physician" means anyone licensed by the State of Texas to practice as a Physician within the Scope of his license 40 'Plan is the plan of comprehensive healthcare services provided by SANDS TEXAS and covered by this Agreement 41 J 'Primarily Dependent means receiving more than fifty percent (50%) of his support from the Subscriber meeting i the requirements to be claimed as a dependent on the Subscriber a federal Income tax return and being a de tin dent unmarried child foster child stepchild legally adopted child or child under Subscriber s legal guardianship 42, Provider means any Health Professional Hospital Alcoholism or Drug Treatment Facility Out Patient Emergency Care Center or other facility which has contracted with SANUS TEXAS to provide services to Members covered ]under this Agreement 43 " Rider means a schedule provided with this Agreement and made a part hereof which sets forth changes in the benefits and services made available by SANUS TEXAS by modifying this Agreement and the Schedule of Benefits 44 SANUS TEXAS means SANUS TEXAS HEALTH PLAN INC a Texas corporation organized as a health maintenance organization and licensed by the Texas State Board of Insurance 45 � Schedule of Benefits means the schedule provided with this Agreement and made a part hereof which sets forth the benefits and services that SANUS TEXAS shall make available to Members 46 Schedule of Rates and Premiums means the schedule provided to the Group with this Agreement and made a part hereof, which seta forth the rates and premiums that are payable to SANUS TEXAS for the services and benefits that SANUS TEXAS shall provide or make available to Members 47 'Semi Private" means a room In a Hospital or Skilled Nursing Facility classified as semi private by such Hospital or Skilled Nursing Facility containing two (2) to four (4) beds and/or 48 Service Area" means that geographical area as defined by the Service Area map Included in the directory which contains a list of Participating Physicians and Providers 49 Skilled Nursing Facility' means 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 Hospitals or Is recognized as a skilled nursing facility by the Secretary of the Department of Heafih and Human Services under Title XVIII of the Social Security Act as amended 50 r 'Subscriber" means an Eligible Employee who has enrolled in the Plan and for whom the premium payments squired under this Agreement have been received by SANUS TEXAS in accordance with the terms of this Agreement 51 Termination Data,, means a for a Member the last date on which the Member is eligible for coverage or b 1 for the Group, the last date on which this Agreement is In force 62 urgent Care shall have the same meaning ae Medical Emergency 53 'urgent Care Center" shall have the same meaning ae Out Patient Emergency Care Center ,� . EFFECTIY DATE OP COYEtiAOE A Ellalbaltu o f f'a3�d SubsOrib"ef, aJ must reside In the Service Area and be E g oma perfnanen( empbyment Of the Group or a bona fide Member of the Group 0 nub Of =re to be eligible to enroll In the Grou a Prl twerlyr (20j hours pet We* whioMve► Cs greater and P s mary Health x b Eligible under such eligibility criteria established by the ad herein and Group and which is Supplemental to that describ- aeva o Eligible to enroll and receive benefits of alternate Health Benefit Plans offered by the Group and d Not be eligible for gage and/or covered under Extended Benefits coverage (or coverage similar thereto) of any other health plan 'To be eligible to enroll as is Dependent, a person must reside In the Service Area not bs eligible for coverage #rldlor covered under Extended Benefits (Or coverage similar thereto) of any other health plan and be The spouse of a Subscriber, MOLLerldent unmarrled natural oh1W foeler child stepchild legally adopted child or child under Subscriber a guardianship, residing with Subscriber or with Subscriber's present or former spouse in the Service 3 Area who is (a) under nineteen (19) years of age or (b) under Ndrily three (23) years of age Primarily Dependent on the Subscriber for financial support and attending a state accredited college or university, trade or secondary school on a full time basis which has In writing, verified said attendance or c A dependent unmarried natural child foster child stepchild legally adopted child or child under Subscriber a legal guardianship residing with Subscriber or with Subscriber a 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 commenced prior to age nineteen (19) (or commenced prior to age twenty three (23) it 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 three (23) years of age under the conditions of the previous sentence Subscriber shall furnish SANDS TEXAS proof of such incapacity and dependency within thirty-one (31) days before the dependent child a attainment of the limiting age and from time to time thereafter as SANDS TEXAS deems appropriate d Maternity care benefits will be extended to a Subscribers unmarried Dependent child No benefits are provided for the Infant child of the Subscriber a unmarried Dependent child unless the Infant child of the unmarried Dependent Is otherwise eligible for coverage by the Subscriber If such infant child is eligible for coverage by the Subscriber such coverage will be available as described in Section II A of this Agree• ment provided appropriate notices and premiums have been timely B When Subscriber Coverage Becomes Effective 1 During Group Enrollment Period Each Eligible Employee who applies for membership in the Plan by submit ting an Application during a Group Enrollment Period shall become covered under the Plan as a Subscriber on the Effective Date provided such Employee is Actively at Work on a full-time basis on that date otherwise it will begin the first day this requirement is met 2 Other Than During Group Enrollment Each Eligible Employee who first meets the eligibility requirements of Section II A other than during a Group Enrollment Period may enroll within thirty-one (31) days of meeting such requirements by submitting an Application Such employee shall become covered under the Plan as a Subscriber on the first day of the month following enrollment provided that the premium applicable to the Subscriber has been received in accordance with this Agreement and further provided that such Employee must be Actively at Work on such day otherwise coverage shall begin the first day this requirement Is met C When Dependent Coverage Becomes Effective 1 On Date Subscriber Becomes Covered An Eligible Dependent for whom the Subscriber has applied for member ship in the Plan by submitting an Application in accordance with Sections II A and II B shall become covered under the Plan as a Dependent on the Effective Date provided any Dependent confined at home in a Hospital or other medical Institution on the day that person would otherwise become covered will become covered on the first day such dependent is non -confined No Dependent can be covered before the date the Employee becomes covered If the Employee did not become covered solely because he did not meet the Actively at Work requirement stated in Section II B his Eligible Dependents who otherwise meet all requirements will become covered on the day the Employee becomes covered alter having met the Actively at Work requirement 2 Newly Acquired Dependents Dependents Flrst Becoming Eligible Other Than During Group Enrollment a A newly acquired Eligible Dependent other than a newborn child and an Eligible Dependent who first meets the eligibility requirements of Section 11 A other than during a Group Enrollment Period and has an Application submitted on his behalf within thirty-one (31) days of meeting such requirements shall be covered as of the first day on which he meets such requirements, provided any Dependent confined at home in a Hospital or other medical institution on the day that person would otherwise become covered will become covered on the first day such Dependent is non -confined b Newborn children of Subscriber and/or Subscriber s spouse shall be covered under the Plan for an initial period of thirty-one (31) days from the date of birth and shall continue to be so covered after that time only if prior to the expiration of such thirty-one (31) day period, Subscriber notifies SANUS TEXAS with an Application submitted for such newborn child and any premiums required are paid as of the first day of the month in which the new enrollment is effective, and in accordance with Section VI A c A newly adopted child including a newborn shall be covered under the Plan as If he were a newly so quired Eligible Dependent The thirty-one (31) day grace period for submission of an Application shall com- mence on the earlier of the date upon which such child commences residence with the Subscriber or when the adoption becomes legal and coverage shall begin on such earlier date provided the Application is submitted on a timely basis D Coverage on Effective Date In the event an employee or deper jnt has satisfied the eligibility conditions In Section II of this Agreement on the date that coverage under tr s Agreement becomes effective such person shall, as of that date, be covered under this Agreement SANUS TEXAS however shall not be required to cover arrange for, or other- wise be liable for services rendered prior to the Effective Date or for such confinement or services not covered under this Agreement including those services covered under Extended Benefits coverage of any other health plan as described in Section 11 A GSA AB-0987D • E Change of Group l bility Criteria The composition of the Group and requirements determining eligibility for membership in the Group and for participatlon in medical and hospital ogre benefits arranged by the Group are coneWerstione material to the gxeoutlon of this Agreement by SANDS TEXAS During the term of this Agreement no change In the Group a gllgibllity or participation requirements shell be permitted to affect e11gIbIltty or enrollment under this Agree mant in any mannar deemed adverse by SANUS TEXAS unless such change k+ effected by mutual written Agreement between the Group and SANDS TEXAS F Persons not Ellgible for Membership Notwithstanding the foregoing provisions of this Section II 1 Membership Previously Terminated No person shall become a Member who has had coverage terminated under any SANUS TEXAS prepaid health care plan for reasons described in Section III A(0 abcsort subparts 2 1 Indebtedness No person shall become a Member if such person has unpaid financial obligations to SANDS t TEXAS or any Participating Physician, Hospital or Provider arising from prior membership in a health plan care G Notification of Ineligibility A condition of participation in the Plan is Subscribers agreement to notify SANUS TEXAS of any changes In status that affect his Dependents' ability to most the eligibility criteria set forth in Section II A(2) H Clerical Error 1 Clerical error shall not deprive any individual of coverage under this Agreement provided that an Applica tlon has been completed and submitted to the Group within thirty-one (31) days from the date the employee or dependent was first eligible to enroll in the Plan and all appropriate premiums are paid to SANUS TEXAS 2 Failure to report the termination of coverage shall not continue such coverage beyond the date it Is scheduled to terminate according to the terms of this Agreement 3 1 Upon discovery of a clerical error, an appropriate adjustment shall be made However no such adjust ment In fees or coverage shall be granted by SANUS TEXAS to the Group for more than sixty (60) days Of coverage prior to the date SANUS TEXAS was notified of such clerical error I Eligible Employee No' Eligible Employee or Eligible Dependent will be refused enrollment or re -enrollment because of health status requirements for health services or the existence of a pre-existing physical or mental condition in cluding pregnancy at the time of his effective date of coverage so long as the conditions in Section II A of this Agreement are met and all applicable payments are made on a timely basis III TERMINATION A Termination of Member 1 No coverage will be prodded to any Member If the Group falls to pay the premium for the first month of this for the Agreement eecond or Subseq ertt moreement may nthstby theeted for end of the thirty (300) day grace period If so tremium if the erminatefalls to d a premiums a Termination Date shall be the last day for which premiums have been paid and the Member shall be liable for the cost of services received subsequent to the Termination Date 2 The coverage of any Member who ceases to be eligible under Section 11 A of this Agreement shall terminate on t e date such eligibility ceases This paragraph also applies to a Dependent of a Subscriber who lost his elig bility, for Whatever reason, Including the death of the Subscriber 3 For coverage purposes, a Subscriber's employment will be considered to terminate when the Subscriber is no longer actively engaged in work on a full-time basis for the Group 4 If the Member Is an inpatient on the Termination Date of this Agreement benefits will terminate for such Member at 12 01 a m on the day next following the Termination Date 5 Except as expressly provided below and elsewhere in this Agreement coverage for a Member may be ter mmated by SANUS TEXAS upon a sixty (W) day prior written notice 8 In the case of a Nonpayment of amounts due by the Member under this Agreement coverage may be cancelled after not less than a thirty (30) day written notice except no written notice will be required for failure to pay premium b Fraud or misrepresentation by Member except as described In this Agreement coverage may be cancell ad after not less than a fifteen (15) day written notice, provided that unless the misrepresentation made by a Member was fraudulent or unless It was material to the risk assumed by SANUS TEXAS and contain ed In an application, a copy of which has been given to Subscriber, the above provision will not be enforc ad after two (2) years from the time such Member a coverage becomes effective under this Agreement or GIRA.AB-0887D 5 c Fraud by a Member in the use of services or facilities coverage may be cancelled after not less than a fifteen (15) day written notice or d Failure of a Member to most eligibility requirements coverage may be cancelled immediately subject to the continuation of coverage and conversion provisions of this Agreement, or e Misconduct by a Member detrimental to safe plan operations and the delivery of services coverage may be cancelled immediately or f Failure of the Member and Participating Physician to establish a satisfactory Patient physician relation ship if it is shown that $ANUS TEXAS has in good faith provided the Member with the opportunity to select an alternative Participating Physician the Member is notified In writing at least thirty (30) days In advance that SANUS TEXAS considers the Patient physician relationship to be unsatisfactory and specifies the changes that are necessary in order to avoid termination and the Member has failed to make such changes coverage may be cancelled at the and of the thirty (30) days or g Refusal of a Member to accept recommended procedures or treatment as described in Section V A of this Agreement the Member a coverage may be cancelled after not less than a thirty (30) day written notice Termination of Group This Agreement may be terminated by either SANUS TEXAS or the Group upon written notice to the other party at least sixty (60) days prior to the Anniversary Date Such termination shall occur at midnight of the day preceding the Anniversary Date In the event no such notice is given this Agreement shall continue in effect for another Contract Year unless terminated pursuant to other provisions of this Agreement The Group may be terminated in the case of a Nonpayment of premium at the and of the thirty (30) day grace period and if so terminated all coverage will be cancelled as of the last day for which premium has been paid or b Fraud on the part of the Group all coverage may be cancelled after a fifteen (15) day written notice C Coverage Under Alternative Health Benefits Plan If the Subscriber becomes covered under an Alternative Health Benefits Plan his and his Dependent s coverage under this Agreement shall automatically terminate as of the date upon which his coverage becomes effective under the Alternative Health Benefits Plan D Notification of Members Ineligibility Group shall notify SANUS TEXAS within fifteen (15) days after Member ceases to be eligible for benefits under this Agreement Failure to do so will make the Group liable for any expenses incurred by the Plan whether or not paid due to the Group's failure to notify E Refunds/Credits If the coverage of a Member is terminated premium payments received on account of the terminated Member applicable to periods after the effective date of termination shall be refunded or credited to Group, at SANUS TEXAS sole option within thirty (30) days and neither SANUS TEXAS nor the Group shall have any further liability under this Agreement with respect to such Member The maximum refund or credit allowable Is equal to two (2) months of premium applicable to such terminated Member which shall include the month during which SANUS TEXAS is notified in writing of such termination and the next previous month, if applicable Any claim for refund or credit by Group must be made within sixty (60) days from the effective date of termination of the Member s coverage or otherwise such claims shall be deemed waived IV SPECIAL REQUIREMENTS FOR MEMBERS COVERED UNDER MEDICARE A SANUS TEXAS shall be primary insurer when a Subscriber age 85 or older Is enrolled in Medicare and is employed by the Group SANUS TEXAS shall be primary insurer for the spouse of a Subscriber who is employed by the Group when such spouse is a Dependent is enrolled in Medicare and is age 55 or older B SANUS TEXAS shall be primary insurer as compared to Medicare for a period of not less than nine (9) months and no greater than twelve (12) months for Members who have become entitled to Medicare solely on the basis of end stage renal disease Said twelve (12) month period begins with the earlier of (1) the month In which a regular course of dialysis is initiated or (2) in the case of an Individual who receives a kidney transplant the first month in which the individual became entitled to Medicare C When a Member is entitled in Part A and/or Part B of Medicare and Medicare is the primary insurer SANUS TEXAS shall pay on behalf of such Member all Medicare deductible and co-insurance payments for Services provided which meet the requirements set forth in this Agreement The Member shall remain liable, however for the Copayments and deductibles set troth in the SANUS TEXAS Schedule of Benefits and any Riders thereto If such Member is eligible for Medicare Part A and/or Pan S but has not elected such coverage, his claims shall be handl ed as though the Member had elected such Medicare coverage V REFUSAL TO ACCEPT TREATMENT, EXCESSIVE TREATMENT A Certain Members may for personal reasons refuse to accept procedures or treatment recommended by a Per ticipating Physician and/or Provider Participating Physician and/or Provider may regard such refusal to accept their recommendations as incompatible with the continuation of their Physician patient and/or Provider patient GSA AS-0987D 6 10 relationship and P- obstructing the provision of proper medical ca If a Member refuses to accept such recom mended treatme r procedure and the Participating Physician and/or Provider believes that no professionally acceptable alternative treatment or, procedure exists such Member shall be so advised It the Member still refuses to accept the recommended treatment or procedure then the Member may be terminated in accordance with Sec tion III A(6)(g) of this Agreement B If two (2) or more Perticlpating Physicians who have rendered care to a Member Inform SANUS TEXAS that the ttcipMember le receiving health services or preecriptlon medicatiorta In a manner or in a quantity which is not Medical Iy Necessary or not medically beneficial the Member may be required by SAND$ TEXAS to select a single Par ating Primary Care Phyetcian (hereafter referred to as a Coordinating Health Plan Physician ) and a singe Participating Pharmacy for the Provision and coordination of all future health services (withi If the Member fails to voluntarily select a Coordinating Health Plan Physician end a angle Participating Pharmacy in thirty (30) days of written notice by SANDS TEXAS of the need to do so SANUS TEXAS shall Pharmacy a Coordinating Health plan Physician and a Participating Pharmacy for the Member Following selection or designation of a Coordinating Health Plan Physician for a Member coverage for health Services Set forth in this Agreement shall be contingent upon each health service being provided by or through written referral of the Coordinating Health Plan Physician for that Member If after sixty (60) days from Initial notification by SANUS TEXAS the Member Is not In compliance with this Section V S the Member may be terminated by SANUS TEXAS VI PAYMENT REOUIREMENTS A Payments Due 1 I The is payments for the services and benefits made available hereunder are Set forth in the Schedule of Rates and Premiums and shall be due and payable In advance on or before the first day of the month for Which each such payment Is made or is to be made No proration of the payments will be made with respect ' i to Members whose coverage under this Agreement commences after the first day of a month 2 Imum COpaymerda are due and payable to the Physician and/or provider at the time a aervice Is delivered The in $1300}orany family w h only two for (2) MembersPlan ts In Or $ISM for a Subscriber and his Dependents provided y dar y $850 for any Member however, that no Copayment will exceed fifty percent (60%) of he cost of services paid to a Participating Physi clan iu Provider and that In no event will the maximum amount of Cops ment exceed two (2) times the annual Premium required to be paid by the Subscriber and Group for such Subscriber and his Dependents It is the ' Member S responsibility to retain receipts and to notify SANUS TEXAS upon attaining the Copayment limit i for so thach t additendar ional services will be provided without a Copayment charge Maximum amount of Copayment take Sint account anyrCopaym nits pertai iingg to any Rideed to the Basic Plan Benefits only and shall not I3 Any Payments required for newborn children who meet the requirements of Section 11 0(2)(b) of this Agree• ment shall be Initially payable to SANUS TEXAS on or before the first day of the month next following the month In which the Application required under Section 11 C(2)(b) Is submitted to the Plan Such initial I Payments shall be retroactive to the first day of the month in which such child s date of birth occurred Thereafter all payments with respect to such newborn child shall be made as otherwise required under this Agreement miums rom the date such 4 intheeMaximumon tallowable by law aw U paid Interest Premiums d e are due Will nd payablebuponanotticat a e thereof not to to Group from ANUS TEXAS $ Chaff ge of Rates SAN S TEXAS shall have the right to change the rates and premiums payable hereunder (1) as of any Anniver sary ate (In which case the Group will be notified at least Sixty (60) days prior to a change In rates) or (h) in accor dance with Section Vlll 8(2) of this Agreement VII IDENTIFICATION CARD8 A SANDS TEXAS shall Issue identification cards for the Members S P Ion of a $ANUS TEXAS identification card in and of Itself confers no rights to Services or other benefits The h (der of the card and the name on the card must be the same and the holder of the card must be in fact a Me bar on whose behalf all applicable hey person under this Agreement have actually been paid qn r�W ng services or other beneflte to whN h he fa not entitled pursuant to this A be TEXA Identification cant or otherwise, shell be chargeable therefor at the acirua�l coattof aervtes rend dUs a mbar Per 0 the use t ha SANUS TEXAS Identification card by any other erM invaI ated by SANUS TEXAS, and all rights of Such Member pursuant o this rouAguc reement may be termin fed in axOrdence with Section III A of this Agreement VIII TERM AND AMENDMENT OF AGREEMENT A Term This Agreement shall remain In effect for the first Contract Year and thereafter for successive Contract Years unless sooner terminated as provided herein B Amendment 1 This Agreement may be amended at any time without the consent of the Members or any other person hav, ing a beneficial interest in it upon written request made by the Group and agreed to by SANDS TEXAS Any such amendment shall be without prejudice to any claim arising prior to the date of such amendment 2 SANUS TEXAS may alter or revise the terms of this Agreement and/or any Schedule of Benefits or Riders attached hereto including the Schedule of Rates and Premiums In the event of such alteration or revision SANUS TEXAS shall give the Group at least sixty (00) days prior written notice which notice shall be con sidered to have been given when mailed to the Group at the address shown on the records of SANUS TEXAS The alteration or revision shall become effective on the date contained in the notice unless the Group pro- vides written notice within fifteen (15) days after the giving of notice by SANUS TEXAS of Its intention to ter mmate this Agreement IX HEALTH CARE SERVICES A Benefits and Services 1 SANUS TEXAS agrees to arrange for the provision of the benefits and services in the Schedule of Benefits and Riders in accordance with the procedures and subject to the limitations and exclusions sperified in such Schedule of Benefits and Riders and in this Agreement 2 Unless referred in writing by a Participating Primary Care Physician (or by a Participating Specialist Physician with the concurrence of the responsible Participating Primary Care Physician) and except In cases of Medical Emergency benefits and services set forth in Section If of the Schedule of Benefits and any Riders that are rendered by a Participating Physician other than a Participating Primary Care Physician shall not be covered 3 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 Section II of the Schedule of Benefits and any Riders shall be available and covered only when provided by a Participating Physician Participating Hospital or by another Provider under contract with SANUS TEXAS to provide health care services to Members 4 In cases of Medical Emergency Members shall be entitled to the benefits and services set forth in Section III of the Schedule of Benefits B Services Excluded from Coverage Members shall not be entitled to the services set forth in Section IV of the Schedule of Benefits unless specifically covered by a Rider to this Plan X LIMITATIONS The rights of Members and obligations of SANUS TEXAS Participating Physicians Participating Hospitals and Pro- Rders under this Agreement are subject to the following limitations A Major Disaster or Epidemic In the event of any major disaster or epidemic that would severely limn the ability of Participating Physicians Pro- viders and/or Hospitals to provide health care services on a timely basis Participating Physicians Participating Hospitals and Providers shall in good faith use their best efforts to render the benefits and services covered insofar as practical according to their best judgement and within the limitation of such facilities and personnel as are then available If SANUS TEXAS Participating Physicians Participating Hospitals and Providers shall have in good faith used their best efforts to render benefits and services in the aforesaid manner 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 personnel resulting from such disaster or epidemic B Circumstances Beyond SANUS TEXAS or Participating Physician or Provider Control In the event that due to circumstances not reasonably within the control of SANUS TEXAS Participating Physicians or 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 Physicians or Providers or similar causes the rendering of benefits and ser vices covered hereunder is delayed or rendered impractical neither SANUS TEXAS nor any Participating Physician or Provider shall have any liability or obligation on account of such delay or such failure to provide such benefits and services if they shall have in good faith used their best efforts to render the benefits and services covered insofar as practical according to their best judgement and within the limitation of such facilities and personnel as are then available C Limitations as Set Out in the Schedule of Benefits The benefits provided under this Agreement are also limited by the limitations and exclusions as set out in the Schedule of Benefits GSA A"987D a G D Non -Covered Servic, SANUS TEXAS shall not be responsible for the reimbursement for services or treatment of complications that result from r y ed nations d service, procedure or treatment SANDS TEXAS shall not be responsible for prescription drugs and/or Imedioatione related to any non -covered service procedure or treatment XI CLAIM PROVIAll A Relmibuhlement of Claims Paid by Members It Is not anticipated that a Member will make payment other than the Copayments and Deductibles required hereunder to any other person or institution providing benefits and services which are covered under this Agreement provided howevei that If the Member furnishes to SANUS TEXAS written proof that he has made payment to such or instit Lion with respect to benefits and services covered under this Agreement payment with re ices will be paid to the Member, but without prejudice to SANUS TEXAS right to seek recoveryof an person by it before receipt of such evidence Claims must be in writing but need not be in any particular form A letter accom to said sere panted by invoices describing the services Provided will normally be sufficient y payment made B Proof of Claim It a charge (other than as specified in paragraph C below) is made to a Member for any benefits and services which are cove ad under this Agreement, written proof of such charge must be furnished to SANDS TEXAS within six (6) months her the performance of the service C Pharmaceutical Services If this Agr"mem provides coverage for outpatient prescription drugs subject to certain deductibles It Is the Member s responsibility to retain receipts for covered drug payments Any claim for reimbursement must be made in writing to SAWS TEXAS and accompanied by relevant receipt within six (6) months following the end of the calendar year in which the covered expense Is Incurred D Emergency Care Services Payment or reimbursement of Emergency Care services (see Schedule of Benefits Section III for a description of covered Emergent: Care services) provided by Physicians, Hospitals or Health Professionals that have not contracted with SANU9 TVAS to provide services under the Plan whether Inside or outside the Service Area will be on a too -for service basis subject to a maximum allowable fee and Subject to Copayments Deductibles and exclusions set out in this Agreement as well as the following additional conditions 1 The Member and Provider must notify the Plan or his Participating Primary Care Physician of his condition and the se arrangements within forty-eight (46) houre after the onset of the Medical Emergency end receive authorize tion for continued services if indicated If the Member's physical condition does not permit such notification within the prescribed time, he must make the notification as soon as Ills reasonably poaslble to do so 2 The claim for reimbursement must be made in writing within sixty (60) days of the onset of the Medical Emergency for which payment Is requested, accompanied by Invoices or other appropriate evidence of payment E FailureItoFurnish Proof of Claim orarleduce ato udy claiProof if it within nofeeaeeou^ time established in paragraphs 8 and C of this Section shall not invalidate th soon rr rqyh time aeons ra Possible All such the will be possible to piaidProof wi n sixty (eoj days fproleceipt f suchhten proof covering the oCCurr 0 0 character and extent of the event for which claim I$ made unless the Member Is notified of the need for a longer tin purepant to paragraph 0 of this Section SANUS TEXAS, at it own expense, Shall have the right to examine the person whose sickness or injury is the basis Of a claim when and so often as It may reasonably require during the pendency of the claim Q Action on Claims Claims will be acted on within sixty (60) days unless the Member is notified of the need for a longer time If a claim k denied a Written notice will contain the reason for the denial N Review 0 a claim Is d riled a Subscriber may obtain a review of the denial through the Member Complaint Resolution Pro. ollqure (See I action XIV) 1 No so an at law or equity shall be brought under this Section against SANDS TEXAS (1) prior to the expiration of the sixty (80) daX period Immediately following the date on which written proof of the charge or loss upon * which the action is drought has, In accordance with the T I COO later than three (3) years after the expiratin of the provisions Period this timeISection, been furnished to SANDS er A required under this Section to be furnished to SANDTEXAS in which such proof of charge hheerllattlifty,eu dais shall be imposed upon SANUS TEXAS other than for the benefits and services specifically covered XII COORDINATION OF . /EFITS AND SUBROGATION It any benefits to which a Member is entitled under this Agreement are also covered under any other Health Care Plan the benefits payable under another Health Care Plan include the benefits that would have been payable had a claim been duly made therefor This provision does not apply to individual coverage or Medicaid A For purposes of this Section only the following words and phrases shall have the following meanings 1 Allowable Expenses means any necessary reasonable and customary Item of expense at least a portion of which is covered under at least one of the Health Care Plane covering the person for whom claim is made When a Health Care Plan (including this Plan) provides benefits in the form of services the reasonable cash value of each service rendered shall be deemed to be both an Allowable Expense and a benefit paid 2 Health Care Plan means any of the following (Including this Plan) which provide benefits or services for or by reason of medical care or treatment a Coverage under government programs including Medicare, required or provided by any statute unless coordination of benefits with any such program Is forbidden by law b Group coverage including automobile Insurance individual 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 The term Health Care Plan shall be construed separately with respect to (i) Each policy contract or other arrangement for benefits or services (li) That portion of any such policy contract or other arrangement which reserves the right to take the benefits of other Health Care Plans into consideration in determining its benefts and that portion which does not B SANUS TEXAS shall have the right to coordinate benefits between this Plan and any other Health Care Plan covering the Member The rules establishing the order of benefit determination between this Plan and any other Health Care Plan covering the Member on whose behalf a claim is made are as follows 1 The benefits of a Health Care Plan which does not have a coordination of benefits with other health plans provision shall In all cases be determined before the benefits of this Plan 2 If according to the rules set forth In Paragraph C of this Section the benefits of another Health Care Plan that contains a provision coordinating Its benefits with this Plan before the benefits of this Plan have been determined the benefits of such other Health Care Plan will be considered before the determination of benefits under this Plan C Rules establishing the order of benefit determination as to a Member's claim for the purposes of Paragraph B of this Section are as follows 1 The benefits of a plan which covers the person on whose expenses claim is based other than as a depen dent shall be determined before the benefits of a plan which covers such person as a dependent 2 The benefits of a plan which covers the person on whose expenses claim is based as a dependent of a person whose date of birth excluding year of birth occurs earlier in a calendar year shall be determin ad before the benefits of a plan which covers such person as a dependent of a person whose date of birth excluding year of birth occurs later in a calendar year If either plan does not have the provision of this paragraph regarding dependents which results either in each plan determining its benefits before the other or each plan determining Its benefits after the other the provisions of this paragraph shall not apply and the rule set forth in the plan which does not have the provisions of this paragraph shall deter mine the order of benefits except that in the case of a person for whom claim is made as a dependent child (t) When the parents are separated or divorced and the parent with custody of the child has not renter rigid the benefits of a plan which covers the child as a dependent of the parent with custody of the child will be determined before the benefits of a plan which covers the child as a dependent of the parent without custody (ii) When the parents are divorced and the parent with custody of the child has remarried the benefits of a plan which covers the child as a dependent of the parent with custody shall be determined before the benefits of a plan which covers that child as a dependent of the step-parent and the benefits of a plan which covers that child as a dependent of the step-parent will be determined before the benefits of a plan which covers the child as a dependent of the parent without custody (u) Notwithstanding Subparagraphs (i) and (ID of this Paragraph when the parents are divorced or separated and there Is a court decree which would otherwise establish financial responsibility for the medical dental, or other health care expenses with respect to the child, the benefits of a plan which covers the child as a dependent of the parent with such financial responsibility shall be deter mined before the benefits of any other plan which covers the child as a dependent child 3 When paragraphs (1) and (2) do not establish an order of benefits determination, the benefits of a plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a plan which has covered such person the shorter period of time, except that GSA A"870 10 (1) The benefits of a, , covering the person on whose expenses claim w ,,aired as a Is" or retired employee or u the dependent of such person shall be determined after the benefits of any other plan covering such person as an employee other than as a laid -off or retired employee or a dependent of such person and (I) if either plan does not have a provision regarding laid -off pr retired employees and, as a result each plan i determines its benefits after the other, then the provisions of subparagraph 0) of this paragraph do not apply D When any benefits are available as primary benefits to a Member under Medicare Medicare will be determined first and benefits available under this Plan If any will be reduced accordingly E If a Member who has enrolled under this 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 SANUO TEXAS will pay, subject to Copayments under this plan the difference between entitlements under this Plan and entitlements under the other contract or policy of Insurance F Benefits which are provided directly through a specified provider of an employer shall in all cases be provided before Ithe benefts of this Plan G 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 Plan H For purposes of this provision SANUS TEXAS may subject to applicable confidentiality requirements set forth in this Agreement release to or obtain from any Insurance company or other organization necessary information under this provision Any Member claiming benefits under this Agreement must furnish to SANUS TEXAS all in formation deemed necessary by it to Implement this provision 1 None of the above rules as to coordination of benefits will serve as a barrier to the Member first receiving direct health services arranged by SANUS TEXAS which are covered under this Plan except as specifically stated in Paragraph G of this Section J Whenever payments have been made by SANUS TEXAS with respect to Allowable Expenses in a total amount at any time in excess of 100%of the amount of payment necessary at that time to satisfy the Intent of this Section XII SA US TEXAS shall have the right to recover such payment to the extent of such excess from among one or more of the following as SANDS TEXAS shall determine any person or persons to or for or with respect to whom such payments were made any Insurance company or companies or any other organization or organize lions to which such payments were made K Worker s Compensation All sums payable for services provided pursuant to worker a compensation shall not be reimbursable under this Agreement L Member's Cooperation (Medicare) Each Member shall complete and submit to SANDS TEXAS such consents releases assignments and other documents as may be requested by SANDS TEXAS in order to obtain or assure reimbursement under Medicare Any Member who falls to enroll under Part 8 and if eligible Part A of the Medicare program will be liable for the amount of funds SANUS TEXAS would have received had Member so enrolled M Acts ofI Third Parties (Subrogation) Plan services shall be provided to a Member due to the act or omission of another person However if the Member is entitled to a recovery from any third party with respect to those services such Member shall agree in writing 1 To reimburse SANUS TEXAS to the extent of the usual and customary charge that would have been charged to �he injured Member for health care services hereunder If the Member were not covered under this Plan Su h reimbursement must be made immediatedly upon collection of damages for hospital or medical expenses by the Member whether by action at law settlement or otherwise 2 To provide SANUS TEXAS with a lien against any third parry recovery for hospital or medical expenses to the extent of the usual and customary charge that would have been charged to the Member for health care services In the absence of coverage under this Agreement Such lien may be filed with the person whose act caused the Injury such person a agent or the court i N Facilityiof Payment Whenlad r payments which should have been made under SANDS TEXAS coverage in accordance with this pro- visionve been meunder anyother Health CarePlan SANU3TEXASshell have the rightexercisable in Itssoliscretion, to payovertoan organizatiomakisuch other payments any amonts Ithall determinetobe wanted in order to eaUaty the Intent ofgtle Section XII Accounts so paid by SANU3TEXAS shall be deemed k,C tobe efilepaid underSANUSTEXAS coveraeand to the extent ofsuch paymentSANUSTEXASshall befullydharged from liability under this Plan , pisclosi re 'Each Member agrees to disclose to SANUS TEXAS at the time of enrollment at the time of receipt of services and benefits, and from time to time as requested by SANUS TEXAS Social Security number birthdate employ f Mont, and the existence of other Health Care Plan coverage, in regard to which the identity of the carrier and ` Me group through whom provided will be furnished by the Member 11 Xlll OPTION TO CONT14UE GROUP COVERAGE, CONVERSION PRIVILEGE AND TRANSFER A Continuation of Groin, %:overage If under the provisions of Title X of the Consoranted the lidated Omnibus Budget Reconciliation Act of 1985 Public Law W272 would otherwise terming eember is or If COBRA is Inapplicable and theht to tion of provisions ofgan beyond state statu e g ant 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 your employer for verifies tion of eligibility and procedures to follow B Conversion Privilege and Transfer 1 Conversion If the coverage of any Member terminates for any reason other than those set forth in Section III a(e) Subparts a b c e and f then such Member may convert his membership to individual membership without furnishing evidence of insurability No Member shall be allowed to convert if Member s termination results from the Group s withdrawal from this Plan or SANUS TEXAS termination of the Group In order to obtain Individual membership any Member eligible to convert his membership must continue to reside In the Service Area submit a completed application for conversion to SANDS TEXAS within thirty-one (31) days after the date of termination and submit premium payments required under such membership The effective date of such individual membership shall be the next day following the Termination Date of the Member a coverage under this Agreement 2 Transfer of Residence a Transfer within the SANUS TEXAS Service Area If a Subscriber changes his primary residence within the SANUS TEXAS service area he must notify SANUS TEXAS within thirty (30) days of such change b Transfer outside the SANUS TEXAS Service Area If a Subscriber changes his primary residence outside the SANUS TEXAS service area such change shall result in lose of eligibility and the Member will be eligible to convert without evidence of insurability to a non SANUS TEXAS Individual insurance policy upon making application and premium payment within thirty-one (31) days after date of termination XIV MEMBER COMPLAINT RESOLUTION PROCEDURE SANUS TEXAS agrees to investigate and endeavor to resolve any and all complaints received from Members with regard to the nature of professional services rendered Any inquiries or complaints shall be made to SANUS TEXAS In writing addressed as set forth in Section XV C of this Agreement or by calling SANUS TEXAS at the telephone number set forth in Section XV D of this Agreement SANUS TEXAS is committed to arranging for provision of high quality medical services in a convenient and accessi ble fashion to ensure Member satisfaction with all aspects of SANUS TEXAS On occasion Individual Members may find that They do not understand or agree with the policies procedures or operations of SANUS TEXAS or They are not satisfied with some part of their treatment by providers It is the intent of SANUS TEXAS to resolve any such complaint as expeditiously as possible preferably with the source of any such dissatisfaction In order to achieve SANUS TEXAS goal of ensuring Member satisfaction and to resolve any complaints that may occur SANUS TEXAS has implemented a Member Resolution Procedure The objectives of this Procedure are A To provide a clear procedure for complaint resolution that is easily understood by Members B To facilitate an expeditious resolution of all complaints, C To acquire feedback so that any recurring problems may be corrected and D To provide management Information so that Member satisfaction may be measured and compared to SANUS TEXAS service standards Members of the Plan are encouraged to communicate any question or concern directly to the Participating Physician Provider or staff member rendering service In order to immediately resolve the Issue Specifically the Member Complaint Resolution Procedure involves the following steps 1 An Informal Complaint An informal complaint is any complaint that cannot be resolved to the Member s satisfaction after speaking directly with the Participating Physician Provider or other concerned party A Member shall also have the right to contact the Quality Assurance Coordinator directly with any informal complaint at the address and telephone number of the SANUS administrative office as specified in Sections XV C and XV D A Member may lodge an Informal complaint over the telephone or in person When an Informal complaint is made the Quality Assurance Coordinator will attempt to resolve the complaint within thirty (30) days 2 A Formal Complaint Each Member has the right to submit a complaint or suggestion in writing no later than thirty-one (31) days i either from the decision regarding an informal complaint or from the date of the occurrence of the In- cident A written Member Complaint Form may be obtained from the administrative office either through the mail or by coming to the office of SANUS TEXAS The Quality Assurance Coordinator who has overall responsibility for administering the Member Complaint Resolution Procedure will con - GSA AB-0987D 12 aA Qf r C t: ; tact the Member I sting acknowledging receipt of the letter verifying the facts of the complaint and advis. ing the Member of when to expect a written response After Investigating the complaint and once a resolution has been reached the Quality Assurance Coordinator will draft a written response to the Member within thirty-one (31) days of receipt of the written complaint If edIn complaint itinignthas not that a decision on will be reacved in the hed within) another thirty day time frame the Member will be edvie days The resolution of a written complaint shall be considered binding unless the ne )Member seeks to appeal the deci lion The Member shall be advised in writing of his right to appeal the decision 3 Appeals Process If a Member is not satisfied with the decision obtained through the formal complaint procedure he may re- quest onwltMpnIn order to appeal a decision the Member must submit a written request to the Executive thirty (30) days after receipt of the written resolution The Committee shall m (30) days following receipt of the written appeal set within thirty The Committee will consist of the Executive Director the Director of Provider Relations the Medical Director the Quality Assurance Coordinator and one Physician from the advisory board The Member will be advised of the decision of the Committee in writing within fifteen (15) days attar the meeting Such decision shall be final and binding on the parties 4 Management Review ew each The the appropriateness of the actiontakenaken and the elimination of the prroble"ssuarter the complaint ) which led to he complaint rts in order to assure f The President and Board of Directors Shall likewise review the complaint reports not lees frequently than annually Allog shall be maintained by the Quality Assurance Coordinator of all written complaints and responses and shall be retained for a minimum of three (3) years The log shall clang each complaint by type and shall note the disposition of and total amount of time required to process each complaint XV MISCELLANEOUS_^_ A Pronouns Masculine pronouns used In this A r B Records and Information g eemant shall include both masculine and feminine genders 1 SANUS TEXAS shall have the right at reasonable times to examine the Group a records Including payroll records of employers having employes covered through the Group with r Payments under this Agreement aspect to eligibility and monthly Agreement 2 Information from medical records of Members and information received from Physicians or Providers or Facilities me dent to the Physician patient Provider patient or Facility patient relationship shall be kept confidential The intimation, except as reasonably necessary In connection with the administration of this Agreement or as required by law may not be disclosed without the consent of Members 3 For the purposes of administering this Plan (Including without limitation Section XII hereof) SANDS TEXAS may to the extent legally allowable and without further consent of or notice to any Member release to or obtain from son, which SANDS TEXAS deInsurance ems to be or necessary for such on or purposelrson y Any with respect benefits any per thislPlan shell famish to SANDS TEXAS such Information as may be necessary tto ImplementiSSection XII hereof r 4 The Application completed by Subscriber authorizes any Physician Health Professional or Facility to make such records photographs or information available to SANUS TEXAS as SANUS TEXAS may reasonably re- quest on behalf of Subscriber or his Dependents 5 Prior to admission as an inpatient for elective hospitalization or for same day surgery the Participating Primary Care Physician must obtain preadmission certification from SANUS TEXAS Notices Any notice under this Agreement may be given by United States Marl postage prepaid addressed as follows If to SANUS TEXAS SANUS TEXAS HEALTH PLAN 8600 Freeport Parkway, Suite 3o4o Irving Texas 75063 If to Group The latest address provided by the Group in writing to SANUS TEXAS If to Member The latest address provided by the Member on forms actually delivered to SANUS TEXAS Telephone The telephone number of SANUS TEXAS is (214) 82"376 Metro 6218143 Assignment The bone its to a Member under this Agreement are personal to the Member and are not assignable or otherwise Vanafere910 r 13 r oeverabllity The invalidity or nforceability of any term or condition hereof a in of any other ten r provision hereof no way affect the validity or enforceability , G Incorporation by Reference The Schedule of Benefits, the Schedule of Rates and Premiums, any optional Riders, the Application and any amendments to any of the foregoing attached hereto form a part of this Agreement as If full Incorporated herein Any direct conflict or ambiguity between itle Agr teement and the Schedule of Benefits and any Rider attached hereto will he resolved under terms most favorable to the Member y H Entire Agreement This Agreement the Schedule of Benefits the Schedule of Rates and Premiums Ame tional Riders and Application constitute the entireAndments, if any any op Agreement between SANUS TEXAS and the Group I Authority Any alteration or revision to this Agreement or the attached Schedule of Benefits and Riders must be in writing and signed by an officer of SANUS TEXAS to be valid No other person has the authority to change this Agree• ment or to waive any of Its provisions J Certificates of Coverage Upon execution of this Agreement SANUS TEXAS will deliver sufficient copies of this Agreement to the Group for delivery by the Group to each Subscriber Such copies shall serve as a Subscriber s Certificate of Coverage K List of Providers of Services Upon execution of this Agreement and from time to time thereafter SANUS TEXAS will provide to the Group for dissemination to Subscribers a list of Participating Physicians Participating Hospitals, Participating Alcohol or Drug Treatment Facilities and other Providers who have contracted with SANUS TEXAS to provide the aervices and benefits covered by this Agreement L Furnishing Information Any person claiming or who may claim benefits under this Plan shall facilitate the access of or furnish to SANUS TEXAS such information as may be necessary to implement this Agreement and SANUS TEXAS may release or obtain such information as needed to implement the provisions of this Agreement M Independent Agents 1 The relationship between SANUS TEXAS and Facilities is that of Independent contractors Facilities are not agents or employees of SANUS TEXAS no is SANUS TEXAS or any employee of SANUS TEXAS an employee or agent of any Facility Facilities shall maintain the FacilBy"tient relationship with Members and shall be the only parties responsible to Members for the services that they provide 2 The relationship between SANUS TEXAS and Physicians and other Health Professionals is that of Indepen dent contractors Physicians and Health Professionals are not agents or employees of SANUS TEXAS nor is SANUS TEXAS or any employee of SANUS TEXAS an em o fesaiot r Physicians and Health Professionals shall maintain Physior c en-patieent of n Cory Health Professional. Patient relationship with Members Neither the nor thereof Is he 9 be liable for any Group cts or Omfisss onerof SANUStTEXAS tits agents ore emplovs yees resentatl of any Physician any Provider or any other person or organization with which SANUS T EXAS a� neither shall for the Performance of services under this TEXAS has made o hereafter shall make arrangements ngements a4 GSA AB-0987D 14 x A GROUP APPLICATION To the extent herein defined and limited, this contract provides for comprehensive health care arranged through SANDS TEXAS HEALTH PLAN, INC (hereinafter referred to as "SANUS TEXAS"), a prepaid health care program Issued by SANUS TEXAS HEALTH PLAN, INC 8800 FREEPORT PARKWAY, SUITE 3040 IRVING, TEXAS 75063 METRO 021.8143 OR (214) 929.0376 A Corporation organized as a Health Maintenance Organization under the Laws of the State of Texas This AGREEMENT between (nereinatter referred to as the "Group") and SANUSi TEXAS entities the Subscriber and his enrolled Dependents, if any, to receive the benefits hereinafter set forth for the Contract Year, subject to the terms and condi- tions of this Agreement and upon payment of stipulated premium bType Cof verrage lanM All Subscribers and Dependents shall be entitled to receive the Agreement This Agreement consists of the terms of Sections I through XV, all Attttachments and Schedules to the Agreement, all Applications, all Amendments, If any, and the following Riders attached hereto Group Enrollment Period The Group Enrollment Period shall be from to Effective Date The Effective Date of this Agreement shall be at 12 01 a m on 12/01/89 OSAGA-0087 0 SHNUS TEXAS HEALTH Schedule of Rates and Premiums Monthly Premium Rates Effective From io/Di/a9 to 09/30/90 Subscriber Only Subscriber + Spouse + Children ( ) 3•Tier Subscriber Only Subscriber + t Dependent Subscriber + Spouse + Children (x) 4-Tler Subscriber Only $10000 Subscriber + Spouse Subscriber + Child(ren) '�gr47 Subscriber + Spouse + Children 255 42 P 05 IN WITNESS WHEREOF, the parties have caused this Agreement to be executed on this day of 19,_ SANDS TEXAS HEALTH PLAN, INC By Executive Director Citr of Den on roue By Authorized Representative SANDS TEXAS HEALTH PLAN has a maximum Member Copayment limit per calendar year which ap piles to any Copayments for services covered under the Basic Plan Benefits (excluding Riders) The Limits are specified In Section VI A(2) of this Agreement This means that any Copaymente paid by SANUS TEXAS Members for Participating Physician, Provider or Emergency services covered under the Basic Plan Benefits may be added together to reach the max imum Member Copayment limits Once reached, no other Copayments are required for the remainder of the calendar year (except Riders) OSAGA-0967D 2 e- i" U 15 49 SANUS TEXAS HEALTH P.02 GROUP APPLICATION To the extent herein defined and limited, this contract provides for comprehensive health care arranged through SANUS TEXAS HEALTH PLAN, INC (hereinafter referred to as "SANUS TEXAS"), a prepaid health care program Issued by SANUS TEXAS HEALTH PLAN, INC 8600 FREEPORT PARKWAY, SUITE 3040 IRVINQ, TEXAS 75063 METRO 821.8143 OR (214) 929.0376 A Corporation organized as a Health Maintenance Organization under the Laws of the State of Texas This AGREEMENT between and SANUS TEXAS entitles the Subscriber and his enrolledtDependents, Irred to as f any, to "Group") the benefits hereinafter set forth for the Contract Year, subject to the terms and condi- tions of this Agreement and upon payment of stipulated premium benef 8 of of Cov sage o �Atll Ss bscribers and Dependents shall be entitled to receive the Agreement- This Agreement consists of the terms of Sections I through XV, all Attachments and Schedules to the Agreement, all Applications, all Amendments, If any, and the following Riders attached hereto M (PRESCRIPTION DRUG - $50) A (IN 1TTFNT ME Ar m 5 (DURABLE MEDICAL EQUIPMENT RIDER) Group Enrollment Period The Group Enrollment Period shall be from to Effective Date The Effective Date of this Agreement shall be at 12 01 a m on TM1/89 QSAGA-M7-) ' L= r— S— S S0 T H U 1 S. S 0 SANDS TEXAS HEALTH P 03 4 Schedule of Rates and Premiums Monthly Premium Rates Effective From _ in/oi /Ae to 09/10/90 Subscriber Only Subscriber + Spouse + Children _ ( ) 3-Tier Subscriber Only Subscriber + 1 Dependent Subscriber + Spouse + Children Subscriber Only $o 25 Subscriber + Spouse 3aa.Ai. Subscriber + Child(ren) 219 68 Subscriber + Spouse + Children 402.62 IN WITNESS WHEREOF, the parties have caused this Agreement to be executed on this day of 1 g_ SANUS TEXAS HEALTH PLAN, INC By Executive Director Citv Denton roup By Authorized Representative SANUS TEXAS HEALTH PLAN has a maximum Member Copayment limit per calendar year which ap- piles to any Copayments for Services covered under the Basic Plan Benefits (excluding Riders) The Limits are Specified in Section VI A(2) of this Agreement This means that any Copayments paid by SANUS TEXAS Members for Participating Physician, Provider or Emergency services covered under the Basic Plan Benefits may be added together to reach the max imum Member Copsyment limits Once reached, no other Copayments are required for the remainder of the calendar year (except Riders) QSAQA•00e7-0 2 DESIGNED ESPECIALLY FOR City of Denton THESE MONTHLY PREMIUM RATES ARE GUARANTEED FOR A PERIOD OF 12 MONTHS, IF ACCEPTED FOR AN EFFECTIVE DATE OF_2"1 ia9 CATEGORY MONTHLY RATES Employee $231 73 Employee + Family 487 08 Option III Retiree Rates THE SANDS TEXAS ACCOUNT MMCIMVE- -- Hr. Yen DiBella TELEPHONE NUMBER 214ie21-814s BBNBWLEVEL 0 2f A S (FLIli-inured) DATE. Santember 29 1989 ftm o s-NN (FAR 4 v. DESIGNED ESPECIALLY FOR City of Denton THESE MONTHLY PREMIUM RATES ARE GUARANTEED FOR A PERIOD OF. 12 IF ACCEPTED FOR AN EFFECTIVE DATE Mom° �'T'EGORY MONTHLY Employe• RATES $171 52 Employee + Family 360.56 option I Retiree Ratee • • 11F. %MnvV TEXAS HEALTH A N ACCOUNTEXBDU7M Nr Pen DiBalla TBLBPHONE NUMBER 214/621-8149 DENIM Lou. N 5 Full insured) DAIS-- DESIGNED ESPECIALLY FOR City of Denton THESE MONTHLY PREMIUM RATES ARE GUARANTEED FOR A PERIOD OF 12 MONTHS, IF ACCEPTED FOR AN EFFECTIVE DATE OF 12/ol/89 CATEGORY MONTHLY RATES 1 on $ 81 23 2 on 162 46 1 on + 1 off 324 90 1 on + 1 off + family 484 66 2 on + family 322 21 THE SANDS TEXAS HEALTH PLAN ACCOUNT EXECUTIVE Mr Ken DiBella TELEPHONE NUMBER 2141621-8143 BENEFIT LEVEL Medicare Supplement (Q M A 5) DATE October 11, 1989 pnn a sr DESIGNED ESPECIALLY FOR City of Denton THESE MONTHLY PREMIUM RATES ARE GUARANTEED FOR A PERIOD OF 12 MONTHS, IF ACCEPTED FOR AN EFFECTIVE DATE OF 12/01/89 CATEGORY 1 on 2 on 1on+toff 1 on + 1 off + family 2 on + family MONTHLY RATES $ 61 89 123 78 247 56 369 27 245 49 THE SANDS TEXAS HEALTH PLAN ACCOUNT EXECUTIVE Mr Ken DiBella TELEPHONE NUMBER 214/621-8143 BENEFIT LEVEL Medicare Supplement (M 3 5) DATE October 11, 1989 SPt � SANUSPWS � BENEFITS PWAT6 PNYSM"'S 0111101106 •t Doer oR At a ooar ov: All office visits to pertkipeting physicians (primary care and splBcialist) for diagnosis and treatmentof IMesaorinJury lab x ray and other diagnoaticprocedUrsa $7perwsd Deductible PMENVA CARE SMWW498 Well babycareonphysician'srecommended schedule Routine immunizations Periodic health assessments on physicians recommended schedule NOCHARGE Not covered Annual well woman examination Routine vision speech and hearing screening (through 17 years of age) IN THE NOSWAL No limits on your covered hospital days as preauthorized All diagnostic services e g lab x ray etc Drugs, medications and radiotherapy Intensive and Coronary Care Units $275 Medical services per admission' Deductible (saml-gNate All necessary specialist care 20% care and consultations roan unleu Use of Operating and Recovery Rooms private room is Anesthesia Surgery Special Duty Nursing NO CHARGE' Deductible (onlywRen plus 50% meEkely (benef t Ilmn of neceteery $2500 per calendar year) PRwm GARB PWS10 N OR PREAUne0RRIZAT)ON SAN S TEXAS PROVIDERS RECUIRE REFERRAL By YOUR T SENSM laSTB WALL 09 DETERMINED 8r TAKING INTO ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANS Additional Benefits ►URABLE MEDICAL E UIPMENT RIDER provided at no charge when Medically Necessary, prescribed by a Participating he following will be p the SANUS TEXAS Medical Director nmary Care Physician and approved in advance by i A Initial placement of Durable Medical Equipment such as standard wheelchairs, crutches, walkers, hospital beds oxygen orthopedic tractions, etc Person ►n the absence of a "Durable Medical Equipment means equipmente allh isn w not ao apepeted use, is primarily an Y more than one person, and customarily used to serve a medical purpose.g � used by sickness or inJury is appropriate and used in the home may doesn t require an individual prescription for construction The following items are among those excluded, deluxe and in driven equipment, comfort items, disposable supplies, exercise equipmentprofessional instrumenacement or maintenance is excluded . ts, sauna baths, orthopedic shoes, arch supports, dentures, experimental or research items Repair, repl B Hearing Aids and Related Testing Physician, a SANUS TEXAS Participating rear, Diagnosis of hearing deficiencies when or bheanng aid device(s) one (1) audiogram pe Y including audiometry, imtial placement of necessary four (4) years if medically necessary if needed and replacement of the hearing aid device(s) every 4 a Additional Benef s PRESCRIPTION DRUGS - $SO Prescription Drugs are covered when prescribed or authorized by a participating Sanus Texas Physician or participating Sanus Texas Dentist for covered benefits and filled by a participating pharmacy Member Cost Source NO CHARGE (No Deductible) Mail Order Generically Equivalent Prescription Drugs $7' Brand Name Prescription Drugs • After a $50 calendar year deductible per person, maximum of 3 people per family need to meet this # deductible Maximum Dosage 30 day supply or 100 units (whichever is less) Exclusions Non-prescription, experimental or investigational drugs, blood, blood products, blood or untie testing devices, appetite suppresants or antismoking aids, uuectibles other than injecUble insulin, therapeutic devices or appliances, compounded medications not provided for an FDA approved indication, contraceptive devices (other than oral contraceptives and diaphragms), cosmetic medications including topical minoxidil and Retin A, Schedule V controlled substances including Robitussin, Guaiatussin and terpin hydrate with codeine, allergy sera, allergy testing materials, and prescriptions available without charge 11 a 11 4 11 1' a 11 SCHEDULE OF BENEFITS SANUS TEXAS Members are entitled to receive the services and benefits set forth in this Schedule of Benefits which are Medically Necessary and are provided ordered prescribed or authorized by a Participating Primary Care Physician subject to the limitations exclusions Copayments and deductibles specified I Routine Medical and Health Services when covered Except In the case of a Medical Emergency services are covered only C The Participating Primary Care Physician may make referrals under the following conditions only to Participating Physicians Participating Hospitals Par A Each Member must select a Participating Primary Care Physician At hul r Dru De ndency Treatment Facilities and from the directory who will be responsible for the Member s health needs including coordination of out -of area services and specialist referrals B To be covered under the Plan all services must be provided directed or authorized by the Participating Primary Care Physician at a Participating Facility When the Member requires care by ' another Physician Hospital Participating Alcohol or Drug Dependency Treatment Facility or other Health Professional the Participating Primary Care Physician will make a written referral to such Physician Hospital Participating Alcohol or Drug Dependency Treatment Facility or Health Professional The only exception is the well woman examination provided for in Section 11 B(1)(a) or as otherwise expressly provided The Plan will not pay for visits to any Physicians Hospitals Participating Alcohol or Drug Dependency Treatment Facilities or Health Professionals that have not been authorized in writing by the Participating Primary Care Physician and when appropriate approved in advance by SANUS TEXAS The Participating Primary Care Physician will be responsible for reviewing coordinating and following up on any specialty or hospital course of treatment B Qwralina fdariii-al Ranaflta Health RAnaf is and Coo A OUTPATIENT SERVICES 1 Office visits for diagnosis and treatment of illness or Injury a Laboratory services b Diagnostic and therapeutic radiological services In support of other covered benefits and services c Surgical procedures in Participating Physicians office (See Section II CHI) d Administered drugs medications injectibles biological$ fluids radioactive materials dressings splints caste braces and crutches The use of splints and braces except in case of emergency must be approved in advance by SANDS TEXAS (See Section IV X) i e Obstetrical care including prenatal and post natal services 2 Short term outpatient rehabilitation (1 a physical therapy) services for acute conditions which are Medically Necessary recommended by a Participating Primary Care Physician and approved in advance by SANUS TEXAS The acute condition must be subject to significant improvement through short term therapy Short term is defined as up to sixty (60) consecutive days per medical condition including treatment received as an Inpatient under Section II D(2) The total of out patient and inpatient rehabilitative services shall not exceed six ty (60) days per medical condition beginning with the first date of treatment 3 outpatient or same day inpatient surgery services Including anesthesia (See Section II C(11) 4 Services rendered in a Member a home 5 Allergy testing (Allergy injections and serum are not covered) 6 When approved in advance by SANDS TEXAS up to twenty (20) fifty (50) minute office waits per calendar year to a par ticipating psychiatrist psychologist or mental health professional for evaluation or crisis intervention mental health services (See Section IV 0) Sanue Texas Health Plan Inc A Health Maintenance Organization 8600 Freeport Parkway Suite 3040 Irving TX 7li0 Metro (214) 82121-0557 Senrassso ticipating co o g p- other Participating Health Professionals who have signed par ticipating provider agreements with SANUS TEXAS The Par ticipating Primary Care Physician may make referrals to Non Participating Physicians and Non Participating Hospitals and Health Professionals when such services cannot be provid ad by another Participating Provider Such referrals must be in writing and approved in advance by SANUS TEXAS Participating Specialist Physicians may make further referrals to other Physicians Hospitals Participating Alcohol or Drug Dependency Treatment Facilities and Health Professionals In each case they must receive the concurrence of the responsible Par ticipating Primary Care Physician and follow the same referral pro- cedures set out in paragraphs B and C above When a Participating Physician determines that a Member requires admission to a Participating Hospital the physician must obtain precertdication from SANUS TEXAS Length of stay will be carefully monitored to ensure that required treatment is provided In the most cost effective manner $15 per visit None in laboratory facility None in radiology facility (Office wart Copayment applies if laboratory or radiological services are performed in Participating Physicians office) $15 per visa $100 for each surgery in a hospital outpatient unit day surgery unit or Ambulatory Surgical Center $15 for each physician home visa $25 per testing visit $15 per visit (all others) $26 for each 50 minute visit TEXAS HEALTH PLAN, INC ol and treatment 7 for and rudr g dependency s provided nathetsame basis and is subject to the same limitations exclusions and ment mustts as treatment be p eauthorizedrby SANDS TEXAhysical Illness and generally11 carAll et must be provided by a Participating Facility 8 PREVENTIVE HEALTH SERVICES 1 Periodic health assessments pediatric well baby care and routine immunizations when dCare Pheemed Medically Necessary by the Participatinof such health Primary asa ssments shall Aon The schedule and be determined by the parent ticlpating Primary Care Physician Immunizations are given and covered in accordance with accepted medical practice for car tarn common communicable diseases including diptherla per tusis measles mumps rubella poliomyelitis and tetanus a Annual Well Woman Exam Female Members may elect to have a gynecological and related examination including Pap smear performed by any SANUS TEXAS Par ticipating Physician offering such examination NOTE No Participating Primary Care Physician referral Is needed for this exam However referrals are still required for other gynecological procedures b Routine vision speech and hearing screening through 17 years of age to determine the need for correction not to in clude retraction eye exams testing or fitting for hearing aids C FAMILY PLANNING 1 Family planning services on a voluntary basis to include history physical examination related laboratory tests and medical supervlsior in accordance with generally accepted medical prac tics information and counseling on contraception including ad vice on or prescription for a contraceptive method 2 Infertility services on a voluntary basis Diagnostic testing ser vices to determine the cause of Infertility are covered Artificial insemination (patients spouses sperm only) is covered All In- fertility services require precertification from SANUS TEXAS (See Section IV O) D INPATIENT SERVICES Inpatient Hospital Services for Medical Conditions Member is entitl. ed to receive the Inpatient hospital services set forth in this Sac tion subject to all definitions terms and conditions In this Agreement and its attachments Except as otherwise provided in Section III these services will be available only in the Service Area and only if performed prescribed arranged for directed or authorized by a Participating Primary Care Physician at a Per ticipating Facility All non emergency hospitalization must be ap- proved in advance by SANUS TEXAS 1 Inpatient hospital services are those provided by Participating Hospitals within the Service Area Inpatient hospital services for the specific treatment of illness or injury including but not limited to semi private room and board special diets when Medically Necessary use of operating room and related facilities special care unit and services x ray laboratory and other diagnostic tests drugs medications biologicals anesthesia and oxygen services physical therapy radiation therapy and inhalation therapy and administration of whole blood or blood products (See Section IV L) Special duty nursing shall be provided only when Medically Necessary (i a in the absence of an intensive care unit) when recommended by a Participating Primary Care Physician and approved In advance by SANUS TEXAS Private room coverage shall be provided on ly in cases of medical necessity (i a isolation due to infectious diseases) The Member may elect private room accommodations for other than the above stated reason In such cases the Member Is responsible for the direct payment of the difference to the Hospital NOTE Members electing to remain in the Hospital beyond authorized discharge time are responsible for direct payment to the Hospital SANUS TEXAS is not responsible or financially liable for such additional payments 2 Rehabilitation Services Short term Inpatient rehabilitation (I e physical therapy) services at a Participating Facility for acute conditions which are Medically Necessary recommended by a Participating Primary Care Physician and approved in advance by SANUS TEXAS This acute condition must be subject to significant Improvement through short term therapy Short term is defined as up to sixty (60) consecutive days per medical con cniincludesich es llot as an ptderSeltl A(2) Sch services shall nbe approved on an $15 per Wait (No C None /merit for aftercare maintenance visits) $15 per visit plus IUD $25 for insertion or removal Diaphragm $25 Vasectomy $25 Elective tubal ligation $25 (See Section II A131) $15 per visit 50% for each artificial insemination service Medical or Surgical $400 per admission Obstetrical (Including therapeutic abortions) Mother $400 Baby $400 $400 per admission aeM-0BaeD inpatient basis unless other acute medical care is to be provld ad The total of inpatient and outpatient rehabilitative services shall not exceed sixty (60) r 9cutive days per medical condl Non beginning with the firs a of treatment 3 Inpatienservices in a Participating Skilled Nursing Facility A Membershall be able to receive short term Inpatient treatment at a or Iclpatlrlg Skilled Nursing Facility when acute care hospital) cation Is not appropriate is recommended by a Par ficipating Physician and approved in advance by SANDS TEXAS NOTE killed nursing care Is not covered when provided for conditiorla of senile deterioration Alzhiemer a Disease mental retardation or mental Illness Private duty nursing services private room accomodations personal or comfort Items and other articles not specifically necessary for treatment of illness or injury pre excluded Short term is defined as up to sixty (00) consecutive days per medical condition 4 Alcohol and Drug Dependency Necessary inpatient treatment for Alcohol and Drug Dependency Is provided on the same basis and subject to the same limitations exclusions and Copaymente as treatment for physical Illness generally All treatment must be pre•authotized by SANDS TEXAS and all care must be provided by a Participating Facility E OTHER SERVICES 1 Home Health Care Services Home health care services are available only in the Service Area when provided by a SANDS TEXAS p rticipating home health care agency and are specificall limited to short term intermittent skilled visits Such services ust be Medically Necessary recommended by a Par Napaling Ikrimary Care Physician and approved in advance by SANUS TEXAS Short term is defined a$ up to sixty (50) con secutive days per medical condition beginning on the date when the first such visit occurs 2 Emergency Services a Hospital Emergency Room b Out Patient Emergency Care Center or physician offices operating alter hours or as emergency centers c Emergency ambulance service I Ambulance) Services Medically Necessary ambulance service to the nearest medical facility capable of providing Emergency Care or Medically Necessary non -emergency ambulance service when authorized in advance by SANUS TEXAS Prosthetic Devices Internal prosthetic devices (except organ transplant devices) are covered Initial external standard pro. sthetic medical appliances and limbs are coveretl when due to an acute illness or injury Internal prosthetic items covered are permanent eida and supports for defective part of the body such as the Star Edwards mitel valve the Internal pacemaker and minor device Such as screw nails sutures and wire mesh Ex ternal prost Ito appliances covered are artificial arms legs eyes or per anent lenses stove or below knee or elbow pro• stheses ext to cardiac pacemaker and terminal devices such as hand or hook All other prosthetic medical appliances to cludi itemo described in Section IV are excluded In ques. tions of medical necessity a second opinlon may be requested by the Plan and is binding See Section IV AA Administration of Blood and Blood Products Limited Dental Related Services Services which are authorized by a licensed nparrticipat participating deicipating ntista(D D S or D Mro Physician n0 ) and which are either treatment of a fractured or dislocated jaw or to repair damage to natural teeth resulting from nomoccupatlonal ac cidental injury provided such Injury occurred and services are POFfOrMed during P ov ded that the Member seeks treatment withinhereunder further and thirty (30)days of such accidental Injury Removal of cysts of the mouth are covered unless they are directly related to the teeth and their supporting structures Services IN GENERAL 1 Emergency Core services must be secured by the Member im medtatety afte the onset of the medical condition or ae soon thereafter ae I; possible but not later then twelve (12) hours alter the first Appearance of symptoms of illness or forty eight $25 per day $400 per admission $15 per visit $40 Copayment for each visit (Charge waived If admission occurs at the time of emergency room visit) $25 Copayment for each visit None None None None None (48) hours after an accident Heart attacks cardiovascular accidents poisoning loss of con sctousness or respiration convulsions severe bleeding and broken bones are examples of true Medical Emergencies 3 r- III Emergency and Urgent Servias Continued, 2 Emergency and urgent services are subject to SANUS TEXAS retrospective review for determination of whether an acute condition or incident requiring immediate emergency or urgent care existed If SANUS TEXAS determines that no need for emergency or urgent care existed the Member will be responsible for payment of all charges incurred for such care subject to the Member Complaint Resolution Procedure B WITHIN THE SERVICE AREA Inside the Service Arse the Member or someone acting on behalf of the Member is expected to contact the Participating Primary Care Physician for advice If it is not reasonably possible to contact the Participating Primary Care Physician at the time (such as that of a life threatening emergency) the Member or someone acting on behalf of the Member shall notify SANUS TEXAS within forty-eight (48) hours of the emergency or it not possible within forty-eight (48) hours as soon as it is reasonably possible Upon receipt of notifica lion SANUS TEXAS will coordinate the transfer of the patient to the care of the Participating Primary Care Physician when medically pru dent to do so Coverage for treatment for Medical Emergencies within the Service Area by non participating providers is limited to the care required before the Member can without medically harmful or injurious con sequences be treated by a Participating Physician or Participating Hospital C OUTSIDE THE SERVICE AREA Services are available while outside the Service Area provided that IV Limitations and Exclusions from Coverage The following services and supplies and the cost thereof are excluded from coverage under this Agreement unless specifically included by a supplemental rider A Private room accommodations and special duty nursing except as provided in Section II D(1) or unlimited hospital care except when deemed by SANUS TEXAS to be appropriate for an acute level of inpatient care a Services rendered by a Participating Specialist Physician or other Provider in non -emergency settings without referral by Member s Participating Primary Care Physician except for annual well woman examinations (see Section ll B[tjja)) C Any service given without a prior written referral from the Member s Participating Primary Care Physician except as otherwise permitted in Sections 1 II or III of this Schedule of Benefits D Treatment or evaluations required by thud persons including but not limited to those for school employment flight clearance summer camp insurance or court ordered E To the extent the Member does not comply with the SANUS TEXAS procedures for obtaining services SANUS TEXAS shall not pay for services and benefits for military service connected disabilities which are provided to the Member in governmental or military service con netted facilities which the Member chooses to use F Care which a Member receives from or through the United States Government or any of its corporations agencies or bureaus or from or through any Stale County City or any political subdivision thereof unless a charge is customarily made and services were pro• vided in accordance with the provisions of Sections It A II E G Cosmetic or surgical procedures are excluded except reconstructive surgery necessary to repair a functional disorder as a result of disease injury or congenital defect Such exclusions include but are not limited to surgical excision or reformation of any sagging skin on any part of the body including but not limited to the eyelids face neck abdomen arms jogs or buttocks any services perform ad in connection with the enlargement reduction implantation or change in appearance of a portion of the body including but not limited to the breasts face laps jaw chin nose ears or genitals hair transplantation chemical face peels or abrasion of the skin electrolysis dipalitation or any other surgical or non surgical pro• cedures which are primarily for cosmetic purposes SANUS TEXAS reserves the right to secure a second opinion by a physician of its own choosing with respect to any case involving cosmetic or reconstructive surgery H Dental services and dental prostheses including dentures are ex eluded except as covered in Section II E(6) Maxillary and man lobular osteotomies including any treatment for temporomandibular joint syndrome are excluded Hospitalization anesthesiology or other services relating to dental work are excluded I Custodial respite or Domiciliary Care such Services are of an emergency or urgent nature and cannot be postponed until the Member Is able to return to the Service Area to obtain treatment through a Participating Physician All continuing or follow up treatment shall be provided only within the Service Area subject to all the provisions of this Agreement To constitute a covered out of area service SANUS TEXAS must make the following determinations 1 onset of the acute illness or injury must have been sudden and units petted 2 the Member must not have been able to return to the Service Area to receive treatment from the Participating Primary Care Physician 3 the treatment must have been Medically Necessary SANUS TEXAS shall pay the Subscriber or arrange to pay the Non Participating Hospital(s) or Non Participating Physician(s) directly The payment shall be at the prevailing rate subject to any required Coperyments Covered services include ambulance transportation provided it is Medically Necessary and appropriate At the time of the emergency the Member or someone acting on behalf of the Member shall make every reasonable effort to notify SANUS TEXAS (and to obtain advice from the Participating Primary Care Physician) If it is not reasonable possible to notify SANUS TEXAS at that time the Member or someone acting on behalf of the Member shall notify SANUS TEXAS within forty-eight (48) hours or if not possible as soon as it is reasonably possible Upon notification SANUS TEXAS will coordinate the transfer of the patient to the care of the Participating Primary Care Physician within the Service Area when medically prudent to do so J Services and appliances for the correction of vision deficiencies in ctuding but not limited to special procedures such as orthophcs invasion training or radial keratotomy K Personal comfort and convenience items or services including but not limited to care kits provided on admission to a hospital TV a and telephones L Whole blood or blood components (blood replacement fees) M Surgery or other procedures or services for obesity including but not limited to gastric intestinal bypass surgery N Sex change surgery including medical or psychological counseling and hormonal therapy in preparation or subsequent to any such surgery O Reversal of voluntary sterilization gamete intra fallopian transfer any fees relating to donor sperm pergonal (menotropins) or related drug therapy surrogate parenting fees and In Vitro Fertilization P Acupuncture naturopathy and hypnotherapy 0 Inpatient mental health Treatment for mental retardation mental deficiency or other forms of senile deterioration such as Alzhiemer a Disease R Heart transplants bone marrow transplants (except autogemc) and all other organ transplants (except cornea kidney liver [for biliary attesae only)) All donor expenses are excluded S Any procedure or treatment that is deemed by the Plan to be ex penmental T Care for conditions that Federal state or local law requires to be treated in a public facility or while in the custody of legal authorities U Services payable under worker a compensation black lung benefits or a government program to the extent that such services are fully covered under worker s compensation or similar laws V Routine toot care such as hygienic care treatment for flat feel removal of toms or calluses and onhotics Corrective orthopedic shoes arch supports orthotics custom fitted braces or splints W All durable medical equipment X Outpatient patient purchased consumables or disposable supplies in eluding but not limited to sheaths bags elastic garments syringes needles blood or urine testing supplies ostomy bags home testing kits vitamins dietary supplements special food items non rigid ap• pliances and supplies Y Occupational and educational testing and therapy Z Long term rehabilitation therapy Long term means treatment in ex case of sixty (80) consecutive calendar days per illness or event AA Replacement repair or routine periodic maintenance of prosthetic devices Penile prostheses are excluded B 8 Speech and hearing therapy including hearing aids CC Outpatient prescription drugs and hospital discharge or take home drugs aeMABe&D 4 110111 71880 CITY OF DENTON RETIREES NAME BIRTHDATE M COVERAGE Buell, Dorothy 12-20-26 Female Single Fritz, George 05-15-21 Male Single Hale, Walker 04-23-21 Male Spouse Magana, Jose 10-15-24 Male Spouse Mendoza, Clarita 08-13-30 Female Single Ponce, Bruno 10-06-13 Male Single Steele, James 03-15-18 Male Spouse Jones, Jean (COBRA) 09-06-23 Female Single II CITY PLAN Allred, Clifton 05-18-13 Male Spouse Arnett, Charles 04-13-25 Male Spouse Castleberry, Carl 09-11-09 Male Spouse Johns, Crain 08-16-14 Male Spouse Vinson, Taylor 05-05-29 Male Spouse retirsan 092780 SANUS TEXAS HEALTH PLAN, INC 8600 Freeport Parkway, Suite 3040 Irving, Texas 75063 (214) 929-0376 or Metro (214) 621-8143 AMENDMENT TO GROUP MEMBERSHIP SERVICE AGREEMENT/ CERTIFICATE OF COVERAGE In accordance with Section VIII B(2) of the Group Membership Service Agreement/ Certificate of Coverage between SANDS TEXAS and the Group, the Agreement 1s hereby amended to reflect the changes indicated below All other terms and conditions of the Agreement are unchanged A Section II C is amended by adding the following paragraph before Section II C(1) For the purposes of this Section, the following words and phrases shall have the following meaning a "Confined in a Hospital or Other Medical Institution" means that a person is a patient and/or undergoing medical care or treatment in a hospital, nursing home, or other medical institution b "Confined at Home" means that a person is undergoing medical care or treatment in his home and/or has a condition, due to an illness, injury or congenital deformity, which restricts the patient's ability to leave his home without the aid of a supporting device, or monitoring equipment, or without the aid of another person B The first sentence of Section II C(1) is amended to read as follows 1 On Date Subscriber Becomes Covered An Eligible Dependent for whom the Subscriber has applied for membership in the Plan by submitting an application in accordance with Sections II A and II B shall become covered under the Plan as a Dependent on the effective date, provided that any Dependent Confined at Home or Confined in a Hospital or Other Medical Institution on the day that person would otherwise become covered will become covered on the first day such dependent is not confined C Section II C(2)(a) is amended to read as follows a A newly acquired Eligible Dependent other than a newborn child, and an Eligible Dependent who first meets the eligibility requirements of Section II A other than during a Group Enrollment Period and has an Application submitted on his behalf within thirty-one (31) days of meeting such requirements shall be covered as of the first day on which he meets such requirements, provided that any Dependent Confined at Home or Confined in a Hospital or Other Medical Institution on the day that person would otherwise become covered will become covered on the first day such Dependent is not confined Amendment to Group Membership Service Agreement/ Certificate of Coverage Page Two D Section III B(1) is amended by adding the following to the end of the paragraph 1 In the event no such notice is given, and this Agreement continues for another Contract Year, the premiums will not exceed 1227 of the previous Contract Year's premiums E Section VIII B(2) is amended by adding the following to the end of the paragraph 2 The reason for having the language in this Agreement is to permit Sanus Texas to change premium rates (1) on the Anniversary Date of the Plan, (2) if there are benefit changes mandated by state or federal law, and (3) if a group requests a change in benefits during the plan year Unless one of these events occurs, Sanus Texas will not increase Group's premiums F Section II is amended by adding paragraph J which shall read as follows 1 Sanus Texas agrees to provide coverage under this Plan for each of the Group's retirees who is covered by an Alternative Health Benefits Plan on the date immediately preceding the Effective Date of this Agreement 2 Sanus agrees to provide coverage to former employees and dependents who have exercised their rights under the COBRA "Act" for periods as specified under the "Act" and at the premiums specified by the "Act" G Section III is amended by adding paragraph F which shall read as follows At the end of the contract period, or upon termination of this Agreement as specified, Sanus Texas agrees to provide the City with an unlabeled, 1600 BPI computer tape of all claims data on employees and dependents by social security number, if permitted by law CITY OF DENTON, TEXAS RAY S EP ENS, MAYOR SANU TEXAS HEALTH PLAN, INC EXECUTIVE DIRECTOR A Additional Benef ,s if DURABLE MEDICAL EQUIPMENT RIDER 41 The following will be provided at no charge when Medically Necessary, prescribed by a Participating Primary Care Physician and approved in advance by the SANUS TEXAS Medical Director IA 11 11 I 11 11 11 L.__J 14 Initial placement of Durable Medical Equipment such as standard wheelchairs, crutches, walkers, hospital beds oxygen, orthopedic tractions, etc "Durable Medical Equipment means equipment which can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of a sickness or injury is appropriate and used in the home may be used by more than one person, and doesn t require an individual prescription for construction The following items are among those excluded, deluxe and motor driven equipment, comfort items disposable supplies, exercise equipment, professional instruments, sauna baths, orthopedic shoes, arch supports, dentures, experimental or research items Repair, replacement or maintenance is excluded B Hearing Aids and Related Testing Diagnosis of hearing deficiencies when ordered by a SANUS TEXAS Participating Physician including audiometry, initial placement of necessary hearing aid devtce(s) one (1) audtogram per year if needed, and replacement of the hearing aid device(s) every four (4) years if medically necessary Additional Benefitb INPATIENT MENTAL HEALTH Members shall be entitled to additional mental health care benefits for evaluation, crisis intervention, treatment or any combination thereof for acute conditions when such evaluation, crisis intervention or treatment is recommended by a Sanus Texas Participating Primary Care Physician, approved in advance by the Sanus Texas Medical Director and precertified by Sanus Texas A The total benefit is limited to any combination of the following, not to exceed thirty (30) treatment days per calendar year I As an inpatient in an authorized Sanus Texas participating psychiatric facility, one (1) inpatient day equals one (1) treatment day, or 2 As a daycare patient in an authorized Sanus Texas participating psychiatric facility, one (1) daycare equals one-half (1 /2) treatment day, or 3 As an inpatient in an authorized Sanus Texas particpating crisis stabilization unit or an authonzed Sanus Texas participating residential treatment center for ' children and adolescents, one (1) inpatient day equals one-half (1/2) treatment day Benefits in these facilities are available only for acute conditions which would otherwise necessitate confinement in an authorized Sanus Texas participating psychiatnc facility B Limitations and Exclusions ' 1 Mental health services for the following diagnosed conditions are excluded Chronic psychosis, Alzheimer's Disease, intractable personality disorders, mental retardation, psychiatric therapy on court order or as a condition of parole or probation, and chronic organic brain syndrome 2 The benefits described in the Rider are available when (a) the Member does not refuse to accept recommended procedures or treatment, and (b) they are provided in an authorized Sanus Texas participating psychiatric hospital, psychiatric facility, cnsis stabilization unit or residential treatment center for children and adolescents and by a Participating Provider, and (c) the Member continues to meet the Sanus Texas criteria for continued benefits under this Rider C Copayment 50% Additional Bene" Ys—�_ PRESCRIPTION DRUGS - $SO Prescription Drugs are covered when prescribed or authorized by a participating Sanus Texas Physician or ]participating Sanus Texas Dentist for covered benefits and filled by a participating pharmacy Member Cost Source NO CHARGE (No Deductible) Mail Order $2* Generically Equivalent Prescription Drugs $7* Brand Name Prescription Drugs ' After a $50 calendar year deductible per person, maximum of 3 people per family need to meet this deductible Maximum Dosage 30 day supply or 100 units (whichever is less) Exclusions Non-prescription, experimental or investigational drugs, blood, blood products, blood or unne testing devices, appetite suppresants or antismoking aids, irgectibles other than irgectible insulin, therapeutic devices or appliances, compounded medications not provided for an FDA approved indication, contraceptive devices (other than oral contraceptives and diaphragms), cosmetic medications including topical minoxidil and Retin A, Schedule V controlled substances including Robitussin, Gueiatussin and terpm hydrate with codeine, allergy sera, allergy testing materials, and prescriptions available without charge LI I I I r L_ I SMUSPWS BENEFITS 1 smug TII><„BNMOCOVO.GS:POO EOTEs Advance approval of Senor Tom required (Precentlleation) x Does not cover Wally mental retardation mental health condeons or Alzheimeh Diseases e Must notly Sarkis Am or Primary Care Physician wlthin rB hours alter coats of amelgamay The 011t d•POcket maximum does not Include comments for preealptbn drips Inpatient mental health and Omer Addltonal Bsnshts which may be Included es a rider option e The total of outpatient and inpatient physical therapy eWvkes may not exceed tip COnaeCgtva days Per medical oontlllkn $ANUS TEXAS HMO COVERAGE ODIWIAL LERTATNIN6 A ®fq.U8101M Unless otherwise covered as an Additional Benefit I g.nwAm does nos aww wabnsm a vvaWobwo require by twd-pereons misery service connected dbeGNtln. taro nalwd horn or through the federal a stale povernmma W arty Subdivision osreol SM eeatrnes'orfenlDaomrh• dibular joint (TMJ) syndronw oastaNSJ respite or domloawy can services are eppllances for the cerreollon Of view deMdances tlefAaeaes pnsonal comfort and oonventaas same whole Woad or blood ownporwaa surgery or cow prooldum or services or obes4 sex dwW surgery or related asperse reversal of voheaery sterilization fees related to donor aperm a esmagSts panning Aware fertbsalbn aapurwure nawmpaty Or hYP IWWW WIP"" mental health basement or nwnW melareatlon mental deacaroy Or odw one of tents dswbretlon AWnimeri Dine headtreneplaras o*wm n%WVoasdum ce fw' hda mequhedobstreatedmapwlofedNywoaws Compensation routine fad can correOUe ordapehlic alhoes arch supports will A custom lewd braces, or epees, durable roads.., egWpnwa, wrWedent p malwasd owwuneblss or d spos" supplies ooa9atlaW Ord sduealomW eras warm 9 pesaaplac meat few or maintenance, ofprostheticptetie devices. sPeach and how" VWWA hearing and slangy serum, and inisdicra, tpeeW gee" ere am sppy to Private roam accommodations special duly nursing services given Wit as Pica writer Marty ceamstk surgery do" services ard" Insemination services cane manner and W W, transplant, split and braces prosthetic deviow arc rehabikO n oeraPY Except In on d amwgsncy, as foepesegeto, end surgery must be approved In advance by Sa us Ante gads Tbxas tablab to Mwits for sarviwe wilt be settled In an worm of major d", W epidemic suer mkt Or otiwr odcumstmwes beyond Its owhbd THE F0110WM AM NOT COVERED By !ANUS TEXAS NMO: Antiseptics pOlat Mapases a veoGw (unleN W exposure proolit" WrM, NW me Gurn Ram or Mast Aaergy TML SANUB TEXAS NMO MJONIMTV: A be espeM to areas In Benue Axes HMO each POW ,kit roerdS In the Senw Am Service Am and mnser as other 00" aAede RBA$M FOR MOMATNM/ OF SANDS TEXAS HMO COVERAGE FOR SUBSCRIBDI Covarege may be terminated by Sa,ut Axes because of dslaua In payments or wpyamw to subscriber is no Weer eligible or deceased fraud or misrepresentation mwoomdid detrewram o sale plan a KMM fellin to establish e satmacay phymdmrpmom relationship refusal to accept trseInwn or M&W Of me Sane Am 10 Card NEW VORK UM MAJOR MEDICAL COVERAGE: GENERAL LEIUTATIONS • KXCLUMM Hospital sdmmssons under the Major Medical feature an subject to prior review spy CoMed our Major Medical Review Agency Failure a rewast tilt review can PC" In your having an adds ionm twit outof-pocket cost or hoePW 1 Street are proud , under a Group Major Medical Poky "mod by New York Lie to to Thates of The Insurance trxAvetry Team an form GRP Santis are ha cowed expenses which Include only wheal or Wevalling charges W neaeseary medical care or an Injury a soleness a mental dWordw or a pregnmwy. The New gust Lte policy does not cover occupational IN" or eoknses charges or Coe hxnklwd elf a government Wean' we 00r deice services WwAded w, dcreD�rNoluntary axaWt InrezeWnsare Daterow or accidental " Of she mtlm Charges or view care we covered only or tearooms of eocoent or hoses Spacial Imitations also apply to comWic surgery In amwn of jaw ON dleaders and body dstordon Own" hakuss trawl ymted to charges In ham W days of trip Conpee detees of to beneft including all benat mwbnams and wnmesans are 00MAkned In the Cere&ds Booklet which will be Issued to you This bodsse is for Nlanm,ew, ocy For a deWW and Pads, alaleswa d tie belle evewbw o YOU ao,plesd Panama, W to oo,WMpb *=M draw, ask your penan al department for s copy Of tw &vNw MAS tkheer/e Of guwlw ernd Grew Mernberstep gervla Agaern,NCsrmkse Of Coverage. a as SJ Npe TOM Ihxm a G•1ma 01199) 13 Foeaxe r LJ a Ll I I F I 4 11 SANUSPWS eorEFrrs PRESCRIPTION DRUGS •T Not covered Deductible plus 20% (up to $500 In covered expenses) See Additional Cove BenefltSA Benue SANDS NEWYORKUFE BENEFIT HMO MAJOR MEDICAL OVERVIEW BENEFITS BENEFITS Annual Deductible (par calendar year) None $400 per Individual" Coinsurance None 60%/20% (azGpl orcop ants on all covered listed above) expaneec (except as %icated above) Lifetime Maximum Benefit Unlimited Unlimited (except SW 000 for Mental Heaah) Outofpocket $650per individual • maximum $1300per family oftWo4 $5000 (percelendaryear) $1500perfamilXof per individual three or more plus deductible" HMO BENEFITS FOR SERVICES BY PARTICIPATING SANDS PROVIDERS REQUIRE REFERRAL By YOUR PRIMARY CARE PHYSICIAN OR PREAUTHORIZATION BY SANDS TEXAS t BENEFIT LIMITS WILL BE DETERMINED BY TAKING IWO ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANS FAMILY LIMIT IS THREE TIMES INDIVIDUAL AMOUNT � SANUSPWS � BENEFITS f PHYSICAL THERAPY HOOT" qt Mr A COST OR rwsr t�rl Outpatient services $7 per visit's Deductible plus 20'k Inpatient services $275 Deductible per admission's plus 20% ALLERGY Testing $25 per vies Deductible plus 20% All other visits $7 per visit Deductible (serum and plus 20% Injectioncovered) FAMILY PLANNING Voluntary Family Planning Services $7per visit IUD $25 oopayment Diaphragm $25 copayment Vasectomy $25copayment Not (plusappiicaoie covered wrperycopayment) Elective tuba) ligation $25copayment (Pluwrwry�ymeno dINFERTILITY SERVICES Diagnostic Testing Services $7 per visit' Artificial Insemination Services 50% copayment' covered d (Spourob Sperm) 4 dHMO BENEFIT$ FOR SERVICES BY PARTICIPATING SANUS TEXAS PROVIDERS REQUIRE REFERRAL BY YOUR PRIMARY CARE PHYSICIAN OR PREAUTHORIUTION BY SANUS TEXAS tBENEFIT LIMITS WILL BE DETERMINED BY TAKING INTO ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANS '� . o-Aet. Gw U 1/NfTt Paew.e L 1 H I t 11 F— L f I I 11 11 11 11 I I SANUSP wm=m�avk BENWITS SENEFITS AND SERVICES YOU CAN CHOOSE EITHER MENTAL HEALTH AT A owr apt a A � ,� In Your Physicians Private Office Up to 20 sessions of short term evaluation and crisis Intervention per calendar year $25 per visa' Deductible (50 minuiss plus 50% (up so bens0l limn In the Hospital Per wn) • As an inpatient up to thirty (30) days per calendar year 50% copaymersl Deductible plus 50% 'WITH SM 000 LIFETIME BENEFIT UNIT FOR MENTAL HEALTH ALCOHOL A DRUG DEPENDENCY REHABILITATION Outpatient visits Inpatient services CARE IN YOUR HOME Home health care services Home physician visits $7pervlas' Deductible plus 20% $275 pBr(LPB,aryeu per admission' iordngabuas servlcss in an e non TeRtlsnnsl arrorFrostl venrr,enl lXDgyarn)rem) $7pervlsal Deductible lmeaca�i m Wlbon plus 20% IMennXlers (UP to 100 visa skilled vlseal Per 12 morlMe) $7per visit Deductible plus 20% HMO BENEFITS FOR SERVICES BY PARTICIPATING SANUS TEXAS PROVIDERS REOUIRE REFERRAL BY YOUR PRIMARY CARE PHYSIOWI OR PREAUTHORWTION By SANUS TEXAS 1SENEFIT LIMITS WILL BE DETERMINED BY TAKING INTO ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANS n o 0./6I9 CAD (I 1/aa)•10 SMUSPUJS BENEFITS � **ggam�.. suRGERr �e�}a!, aI; 6t All medically necessary procedures Physician's office $7pervish' Deductible plus 20% Outpatient Hospital $50persurgery' Deductible plus 20% EXTENDED CARE IN A SKILL® NURSING FACILITY $25/day'R Deductible (up W eo plus 20% 001°"°W"" data (net 0o1+Ied after medial O day w in Wit hospuszotion) MATERNITY CARE In Your Physician's Private Offke Pre -natal and post natal visits $7per visit SERVICES In the Hospital FOR MOTHER All physician services for mother t Deductible Mother's hospital services { per admission' Plus 20% SERVICES Newborn nursery services FOR $275 NEWBORN Physician services for newborn peradmission' Deductible plus 20% N%ro out well baby an) AMID UMIQM3MIT CARE (24 hours a day, 7 d In case of accident or sudden and serious illness • Hospital Emergency Room • Emergency/Urgent Care Facility a $40 per visits (NO AddMUeA Deductible to Bw now") plus 20% $20 per visits HMO BENEFITS FOR SERVICES By PARTICIPATING 9ANUS TEXAS PROVIDERS REQUIRE REFERRAL BY YOUR PRIMARY CHIME PHySICW! OR PREAUrNOR1iATION BY SANUS TEXAS t BENEFIT LIMITS WILL BE OETE IMIMID By IMM W10 ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANE i 0.1010 CAD (Ila" P094006 I F Q 0