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1996-172 ORDINANCE NO ~ ~/7oq.- AN ORDINANCE ACCEPTING COMPETITIVE BIDS AND AWARDING i CONTRACT FOR THE PURCHASE OF MATERIALS, EQUIPMENT, SUPPLIES OR SERVICES, PROVIDING FOR THE EXPENDITURE OF FUNDS THEREFOR, AND PROVIDiNG FOR AN EFFECTIVE DATE WHEREAS, the City has solicited, received and tabulated competitive bids for the purchase of necessary matermls, equipment, supplies or services in accordance with the procedures of STATE law and City ordinances, and WHEREAS, the City Manager or a designated employee has reviewed and recommended that the hereto described bids are the lowest responsible bids for the materials, eqmpment, supplies or services as shown in the "Bid Proposals" submitted therefore, and WHEREAS, the City Council has provided in the City Budget for the appropriation of funds to be used for the purchase of the materials, equipment, supplies or services approved and accepted herein, NOW, THEREFORE, THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS SECTION I That the numbered items in the following numbered bids for materials, eqmpment, supplies, or services, shown in the "Bid Proposals" attached hereto, are hereby accepted and approved as being the lowest responsible bids for such gems BID ITEM NUMBER NO_ V~,NDOR AMOUNT 1869 ALL HARRIS METHODIST EXHIBIT "A" HEALTH PLAN 1911 ALL DYNA-PAK CORP $171,120 00 1920 1 PRIESTER $ 11,600 00 1920 2 TECHLINE $ 10,980 00 1920 3 WESCO $ 10,320 00 1921 ALL DARR EQUIPMENT $178,837 00 SEC. XiON2I That by the acceptance and approval of the above numbered items of the submitted bids, the City accepts the offer of the persons submitting the bids for such items and agrees to purchase the materials, equipment, supplies or services in accordance with the terms, specifications, standards, quantities and for the specified sums contained in the Bid Invitations, Bid Proposals, and related documents SECIION2II That should the City and persons submitting approved and accepted gems and of the submitted bids w~sh to enter into a formal written agreement as a result of the acceptance, approval, and awarding of the bids, the City Manager or his designated representative is hereby authorized to execute the written contract which shall be attached hereto, provided that the written contract Is in accordance w~th the terms, cond~ttons, specifications, standards, quantities and specified sums contmned in the Bid Proposal and related documents herein approved and accepted SECTION IV That the Mayor is hereby authorized to execute the Letter Agreement and contract with Hams Methodist for B~d//1869 SECTION V That by the acceptance and approval of the above numbered items of the submitted bids, the City Council hereby authorizes the expenditure of funds therefor m the mount and m accordance with the approved bids or pursuant to a written contract made pursuant thereto as authorized hereto SECTION VI That th~s ordinance shall become effectave ~mmedmtely upon its passage and approval APPROVED this the ~ day of ~, 1996 PASSED AND ATTEST JENNIFER WALTERS, CITY SECRETARY APPROVED AS TO LEGAL FORM HERBERT L PROUTY, CITY ATTORNEY DATE AUGUST 6, 1996 C~Y~I)IJ3LCII~I~pORT TO Mayor and Members of the City Councd FROM Ted Benavides, C~ty Manager SUBJECT BID #1869 - HEALTH INSURANCE RECOMMENDATION: We recommend this bid be awarded to the lowest responsible bidder, Harris Methodist Health Plan, at the listed rates (Exhibit A) for a one year contract renewable for two additional years at a maximum increase of 5% for 1998 and 9% for 1999 SUMMARY: Tbas bid IS for the Health Insurance Plan for City of Denton employees, retirees, and their dependent family The contract wdl be for the 1997 year renewable for 1998 and 1999 Rates for 1998 are guaranteed not to exceed a 5% increase and for 1999 a not to exceed a 9% increase Based upon current census data the expenditures for each year are hsted on the tabulation sheet attached (Exhibit B) Additional information was presented to Council for consideration during the work session of July 23, 1996 BACKGROIJ3~ Rate Schedule Exhibit A, Cost Comparison Exhibit B PROGRAMS, DEPARTMENTS OR GROIIPS AFFECIED, The Health Insurance Program covers all ehg~ble regular full-time and part time employees and their covered dependents ~n all city departments Also affected are those retirees participating ~n the Health Plan FJtS~,I~I~AC2~ The Health Insurance Plan is a participation program w~th the c~ty paying a set amount and the employee paying a set amount The rate quoted for 1997 reflects an approximate $37,824 00 savings over the 1995/96 budget and an approximate 4 1% decrease In the employees contribution amount Respectfully submitted Ted Benavtdes City Manager Approved Name Tom D Shaw, C P M Title Purchasing Agent 756 AGENDA DATE AUGUST 6, 1996 CITY COIJNCIL REPORT TO Mayor and Members of the City Cotmcfl FROM Ted Benawdes, C~ty Manager SUBJECT BID #1911 - REFUSE BAGS RECOMI~IENDATION: We recommend ttus bid be awarded to the low bidder, Dyna-Pak Corp, at the per umt price of 52 Bag Roll 2 81 per roll Regular Roll 30 Bag Roll 1 68 per roll Small Roll for an estimated annual total of $171,120 00 8UMMARYt Th~s bid is for an annual contract for the purchase of residential refuse bags to be stored tn the warehouse for use by the Sohd Waste Department The 52 bag rolls are &stnbuted to utility customers twine a year and the 30 bag rolls are handed out to new customers who sign up for utility service between the two distributions Four bid proposals were received tn response to ten bid packages mailed to prospective vendors ~ Tabulation Sheet PROGRAMS; DEPARTMENTS OR GROUPS AI?FECTEDI Warehouse Inventory, Residential Sohd Waste, Utility Customers of the City of Denton ~ Budgeted funds for 1996-97 for Warehouse Working Capital #710-043-0582 Respectfully submitted City Manager Prepared by Name Demse Harpool Title Semor Buyer Title Purchasing Agent 752 AGENDA DATE AUGUST 6, 1996 CIIYA7A)U~C.1L REPORT TO Mayor and Members of the City Council FROM Ted Benavldes, City Manager SUBJECT BID # 1920 - DISTRIBUTION TRANSFORMERS RECOMMENDATION: We recommend th~s bid be awarded to the low evaluated bidder as follows ITEM QUANTITY DESCRIPTION VENDOR PRICE 1 10 EACH 75 KVPM PRIESTER $ 1,160 00 EACH 2 3 EACH 150 KVPM TECHLINE $ 3,660 00 EACH 3 1 EACH 1000 KVPM WESCO $10,320 00 EACH for a total expenditure of $32,900 00 SUMMARY: Th~s bid is for the purchase of padmounted transformers for use at proposed developments and for mmntenance stock Transformers are evaluated using a load loss equation to assure lowest operating cost E~ght bid proposals were received m response to twenty-two bid packages mailed to vendors ~ Tabulation Sheet, Memorandum from Don McLaughhn dated 7-12-96 PROGRAMS, DEPARTMENTS OR GROUPS~AFFI_X2TED. Electric Distribution, Electric Utilities, Electric Customers of the City of Denton ][ISI2ALIMi~ACI~' Budgeted funds for 1996-97, Account #610-103-1031-5880-8925 Respectfully submitted Ted Benamdes City Manager Prepared by Name Denise Harpool Title Senior Buyer Name Tom D Shaw, C P M Title Purchasing Agent 751 AGENDA 96 JULI2 } 06 To Denise Marpool, Senior Buyer From Don McLaughlln, Senior Engineer Electric Engineering Date July 12, 1996 Sub3ect Evaluation of Quotation on bid # 1920 The 75 KVA 120/240 volt single phase pad-mounted, transformers could be used in the followIng project are for proposed developments at Loop 288 and Audra by the M + M Group, and a proposed development at Teasley Lane and Llllan Miller The utility staff recommends awarding the b~d to the low bidder Preferred Sales The 150 KVA 120/208 volt three phase pad-mounted, transformers are to maintain stock for maintenance and operation The utility staff recommends awardln§ the bzd to the low bidder Techl~ne The 1000 KVA 277/480 volt three phase pad-mounted, transformer zs to maintain stock for maintenance and operation The utility staff recommends awarding the bzd to the low bidder WESCO Sincerely, Donald L McLaughlln Attachments I Exhlblt I, Loss / Cost Evaluatzon II Exhzblt II, Total Cost EXHIBIT I FOR BID 1920 PAGE 1 ~tem 1 Loss / Cost Evaluation of Ten 75 KVA, 120/240 Volt Padmou nted Loop S~ngle Phase Transformer LL TL BID CAL DELIVERY MADE NL BIDDER BY LOSSES LOSSES LOSSES COST COST DAYS Cummins Supply 164 524 688 1530 8720 832 42 KBS Electrical 151 629 780 1190 7900 746 84 3referred ,3entral 192 455 647 1297 7879 134 56 8ESCO SESCO 220 800 1020 $1,707 $10,936 90 Techl~ne Howard 147 630 777 $1,270 $8,142 126 Temple GE 39 733 772 $1,649 $8,952 77 /ANTRAN VANTRAN 220 580 800 $1,792 $10,306 70 WESCO ABB 155 707 862 $1 198 $8 286 98 LOW BID $7,799 Item 2 Loss / Cost Evaluation of Three 150 KVA, 120/208 Volt Padmounted Loop Three Phase Transformer MADE NL LL TL BID CAL DELIVERY BIDDER BY LOSSES LOSSES LOSSES COST COST DAYS KBS Electncal 340 1230 1570 4125 21899 56 84 Preferred Central 283 1553 1836 3849 21837 37 70 =r~ester Cooper 340 1230 1570 4010 2151086 95 SESCO SESCO 520 2340 2860 4512 29331 64 90 VANTRAN VANTRAN 500 1600 2100 $3,993 $24,328 70 WESCO ABB 376 1275 1651 $3750 $21 119 70 LOW BID $20,299 Item 3 Loss / Cost Evaluation of One 1000 KVA, 277/480 Volt Padmounted Loop Three Phase Transformer MADE NL LL TL BID CAL DELIVERY BIDDER BY LOSSES LOSSES LOSSES COST COST DAYS 4BS Electrical 1322 8481 9803 10865 74590 81 84 Preferred ;entral 1044 7749 8793 9739 66151 70 Pr~ester Cooper 1322 8481 9803 10564 73573 43 9b SESCO SESCO 1800 10000 11800 $11 041 $83,978 90 Techl~ne ~oward 1322 8151 9473 $10406 $71 995 126 Temple GE 2020 11941 13961 $8,352 $82,868 77 VANTRAN VANTRAN 2080 6600 8680 $11,007 $75 431 70 LOW BID $64 594 12-Jul-96 02 45 PM H \HOME\E_ENG3\TRANX\B1920\B1920 WK3 EXHIBIT II FOR BID 1920 ITEM DESCRIPTION QUANTITY DISTRIBUTOR MANUFACTURER PRICE TOTAL ITEM I 175 KVA 120/240 1 Phase UG 10 Preferred Central $1 1601 $11,600I ITEM 2 1150 KVA 120/208 3 Phase UG 3 Techllne Howard $3,660 $10,980 ITEM 3 I1000 KVA 277/480 3 Phase UG 1 WESCO ABB $10,320 $10,320 Total Cost $$2,90u H \HOME\E ENG3\TRANX\B1920\B1920 WK3 11-Jul-96 02 59 PM DATE AUGUST 6, 1996 CITY COUNCIl. REPORT TO Mayor and Members of the City Council FROM Ted Benavldes, City Manager SUBJECT BID #1921 - ARTICULATED WHEEL LOADER RECOMMENDATION. We recommend this bid be awarded to the lowest bidder, Dart Equipment, in the amount of $178,837 00 SUMMARY. This bid is for the purchase of a 4 5 cubic yard, articulated frame, 4 wheel drive, rubber tire loader The loader will be utilized at the Wastewater Treatment Facility in the sludge/compost project This Caterpillar 960F loader replaces a smaller 1980 model loader The older loader has the engine "locked up" and is no longer economical to repair It will be sold at auction August 15, 1996 The bid price includes a 3 year or 5,000 hour extended warranty BACKGROUND. Tabulation Sheet pROGRAMS, DEPARTMENIS~)RJT~,OIJPS AFFECTED: Wastewater Treatment Facility, Sludge/Compost Project and Fleet Operations EISI2AI~I~CI~ Funds for this purchase are available in the 1995/96 budget accounts as follows Motor Pool Replacement #720-025-0584-9104 $108,968 00 Wastewater Plant Capital Expenditure #0470-9104 $ 69,869_00 $178,837 00 Respectfully submitted Ted Benavides City Manager Approved Name Tom D Shaw, C P M Title Purchasing Agent 755 AGENDA BID # 1921 BID NAME 'ARTICULATEDLoADERWHEEL DARREQPT FUTUREEQPT MEGAEQPT OPEN DATE 7-9-96 DE$CRIPTION VEND~O~ ~E~DOR VENlO6~ ~ENDOR_ I 4 5 CUBIC YARD ARTICULATED 4 WHEEL DRIVE LOADER $178,837 00 $193,473 00 NO BID MANUFACTURER CATERPILLAR CASE _ _ MODEL 960 F 921B Harris Methodist Health Insurance HARRIS METHODIST iqEALTH INSURANCE COMPANY GROUP ENROLLMENT APPLICATION Tbe Hams Metbodist Health Insurence Company, and City of Denton (Group), agree to be bound by the provlsiuns for henlth care service m aecordanco with this ~roup Enrollment Application, thc Coverage Agrecmant, the Listing of Benefits, and any amendments and riders Covel~e will be for eligible mamber~ of Oroapand their Depundants wh° enrolhn Hams Mefimdlat Heatth Insurance Company Eligible members of ~he Group are those persons who are uxemnt and work u mimimum of 30 h°urs ncr wank and who comply with the provistons of this ~mant. The Group agr~s that, after the on~nal enrollment period under the Coverage Agreement, each new emp.l~oyec will be given the opportunity to elect membership az procedure of ~mployment Effective date~ of Harris Methodist Health Insurenc, o Company Coverage of new Subscribers and of tormmanon of Coverage offered by Group will be (check appropriate box) Cover~e Effective Date Termination EffecUvc Date Date of hire XX Date Employment ends First of month following deto of hire __ End of month in which employment ends XX Other (specify), Other (specify) On the first day of each month, Prammms for that month are payable az follows XX In full for the complete month m which coverage begins or ends In full Ifc, overage begins on or before 15th of month or ends on or after the 16th of thc month Prorated according to the actual number of days covered Other (specify) The benefits selected by Group are az follows (Circle one) In Vitro Fcrtthzatlon Yes (~ This agreement will become effective January 1, ]997 The contract term IS 1~ months This agreement will automat~celly renew for anew, esslve twelve (12) month period unless terminated by Harris Methodist Health Insurance Company or the Group in accordance with the provisions for the Coverage Agreement This Agreement will be governed by the laws of the State of Texas All notices should be sent to these administrative addresses HARRIS METHOD~EAL.TI~' INSURANCE 0RQ,UP City of Dneton COMPANY ~ ~ B~..~ ]~'~'~-, Accepted by ,~ ~'~*--~_~-~-- Title Title t~xecutlveVmePr~stdent~ ~ Address 601EastHmkorv Address ~lams Methodist Health Insurance Comannv ~)$nton. Texas 76205 611 Rvan Plaza Drive. State 900 Arhn~n. Texas 76011-4009 The Hams Methodist Health Insurance Company and the C~oup agree that this agreement will not become effective unless at least n/a employees mitlefiy enroll In Hams Methodist Health Insurance Company Letter of Understanding C~ty of Denton B~d No. 1869 This Letter of Understandmg is between Harris Methodist Health Plan (HMHP) and the City of Denton (City) m connection w~th Bid No 1869 HMHP and City agree to the following 1 As City employees' needs for additional health care services ~n the Denton area expand, HMHP is committed to ongoing assessment of these needs and expansion of HMtiPs' current network through the recruitment of appropriately qualified providers to serve these needs 2 HMHP guarantees that it meets the minimum b~d requirement of having one Denton hospital in ItS provider network HMHP will maintain at least one Denton hospital in its network Should HMHP be unable to meet the minimum bid requirement of having one Denton hospital in its network, HMHP will pay the lesser of(l) 50% of the consulting contract which would be necessary to rebld City's health benefits program or 01) $30,000 Prowded however, nothing in this paragraph reheves HMHP from ItS obhgation to maintmn at least one Denton hospital in its network In addition, HMHP will exercise best efforts to enter into a mutually acceptable and commercially reasonable contract for hospital services for City's eligible employees and dependents with the other hospital located in the City 3 HMHP guarantees the 1997 total annual cost of its b~d will not exceed $2,573,320 as long as enrollment, plan option participation, plan designs, and blended rates remain exactly as set forth below for every month of the 1997 calendar year BLENDED RATES ACTIVE ~ TOTAL HMO Opt-out Plan EE Only 14 $220 07 EE & Spouse 5 $341 09 EE & Child 12 $294 88 EE & Family 14 $371 90 HMO Plan EE Only 355 $185 03 EE & Spouse 86 $287 59 EE & Child 150 $248 47 EE & Family 218 $312 59 HMO Opt-out Plan Retiree Only 0 $220 07 Retiree & Spouse 1 $341 09 Retiree & Child 0 $294 88 Retiree & Family 0 $371 90 Letter of Understanding Cay of Denton Bid No 1869 Page 2 of 2 HMO Plan Retlree Only 5 $185 03 Retiree & Spouse 3 $287 59 Retiree & Chdd 0 $248 47 Retu'ee & Famdy I $312 59 HMO Opt-out Plan Retu'ee Only I $220 07 Retiree &Spouso I $341 09 Retu'ee & Spouse (1 under 65) 0 $341 09 Retiree & Famdy (1 under 65) 0 $371 90 Retiree & Family 0 $371 90 HMO Plan Rearee Only 5 $185 03 Rearee & Spouse 1 $287 59 Retiree & Spouse (I under 65) 3 $287 59 Retu'ee & Family (1 under 65) 0 $312 59 Returee & Family 0 $312 59 City understands that the total annual cost of HMHP's bid may increase or decrease depen&ng on the number of eligible employees participating, any shift between plan options or tier, any retroactive terminations, or change in City's selection of non-blended or blended rates Further, HMHP guarantees that the quoted rates m its response to Bid No 1869 yell not increase more than 5% for plan year 1998 and yell not increase more than 9% for plan year 1999 HMHP understands and agrees that any increase in HMHP's bid shall be consistent vath the competatlVe bidding laws of the State of Texas 4 This Letter of Agreement shall become effective January 1, 1997 and shall be attached to and incorporated into the agreement of the parties authorized by City pursuant to the ordinance approved on the day of ., 1996, relating to the award of Bid No 1869 5 The terms and conditions of flus Letter of Understanding are binding conhactual obligations and not mere recitals and may be enforced by either party HMHP and City, through their respective duly authorized representatives, have executed this Letter of Understanding to be effective as of January 1, 1997 // Thomas Keenan ' ' --'-Jack Md~/ Title Executive Vice President/COO Mayor Wellness and Prevention Program Harris Health Plan, Inc w~ll prowde the following wellness and prevention program ~n conjunction wtth the C~ty of Denton's b~d #1869 · Modifiable Cl~um Audit ($2,000 value) No Charge · Health Pdsk Assessments for C~ty of Denton employees ($25 00 value per assessment) $10 00 per Assessment · Monthly Wellness Event ($50 value per event) No Charge · Mammography Screemng ($65 value per screemng) No Charge Note Th~s wellness program was developed as a value added benefit to our b~d gl 869 for the C~ty of Denton Hams Health Plan ~s underwriting a port~on of the cost as outhned above HARRIS METHODIST HEALTH INSURANCE COMPANY PREMIUM RATES 1997 Harris Methodist Health System Total Monthly Rates City of Denton Blended Employee Only $ 220.07 Blended Employee & Spouse $ 341.09 Blended Employee & Child(ren) $ 294.88 Blended F~mployee & Famdy $371.90 CERTIFICATE OF INSURANCE INSURANCE BOOKLET for Employees of: CITY OF DENTON (Called the Group) Insured by. Harris Methodist Health Insurance Company (Called HMHIC) Arlington, Texas 76011 The Harris Metbochst Health Insurance Company has tssued Group Pohcy No POS-GA-OO19 covering Employees of the Group Tlus booklet ts your certtficate of insurance when a sttcker ts attached to the mstde front cover The sticker w~ll show your name and the effecttve date of your msurance The benefits of the group pohcy are described in tins booklet Ftnal mterpretatton ts governed by flus Pohcy THE GROUP AGREEMENT UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM, Tins booklet ts your certtficate of msurance only when you are insured under the Pohcy Thru certificate describes the benefit under the Plan ~n effect as of January 1, 1997 for all employees. POS-CERg-92 3 IMPORTANT NOTICE AVISO IMPORTANTE To obtmn tnformation or make a complaint Para obtener mformacion o para someter una queja You may call Hams Methochst Health Usted puede llamar al nuthero de telefono Insurance Company's toll-free telephone gratis de Hams Methodist Health Insurance number for information or to make a Company's para lnformaclon o para someter complaint at una que3a al 1-800.633-8598 1-800-633-8598 You may contact the Texas Department of Puede comumcarse con el Departamento de Insurance to obtarn mformatton on Seguros de Texas para obtener reformation compames, coverages, rights or complmnts acerca de compamas, ooberturas, derechos o at quejas al 1-800-252-3439 1-800-252-3439 You may write the Texas Department of Puede escnblr al Departamento de Seguros Insurance de Texas P O Box 149104 P O Box 149104 Austin, TX 78714-9104 Austin, TX 787149-9104 FAX # (512) 475-1771 FAX # (512) 475-1771 PREMIUM OR CLAIM DISPUTES. DISPUTAS SOBRE PRIMAS O Should you have a chspute concerning your RECLAMOS: S1 tlene una dlsputa premium or about a clarrn you should concemlente a su prima o a un reclamo, contact the company first Ifthe dispute is debe comumcarse con la compama pnmero not resolved, you may contact the Texas Si no se resuelve la dlsputa, puede entonces Department of Insurance comumcarse con el departamento (TDI) ATTACH THIS NOTICE TO YOUR UNA ESTE AVISO A SU POLIZA: Este POLICY: Ttus notice is for information avlso es solo para proposlto de lnforrnacion only and does not become part or condition y no se conwerte en parte o conchcion del of the attached document documento adjunto ~ 4 TABLE OFCONTENTS BENEFIT DESCRIPTION GROUP AND AFFILIATED ORGANIZATIONS -' 7 ELIGIBILITY AND EFFECTIVE DATE TERMINATION, CONTINUATION OF BENEFITS, AND CONVERSION 12 PAYMENT REQUIREMENTS 17 CLAIMS INFORMATION 19 COORDINATION OF BENEFITS 21 INDEPENDENT AGENTS 27 GLOSSARY OF TERMS 28 TERM AND AMENDMENT OF AGREEMENT 39 MISCELLANEOUS PROVISIONS 40 ~ 5 ]}ENEFIT DESCRIPTION The benefits and prowsions of tlus Plan are descnbed m the attached Schedule of Beuefits prowded by Hams Metho&st Health Insurance Company (HMHIC) This Plan is m effect as of January 1,1997 Valldl~y of the policy shall not be contested except for nonpayment of premiums after it has been m force for two (2) years from m date of issue and that in the absence of fraud no statement made by any per.on covered by the policy relating to hs or her insurability shall be used m contesting the vahd~ty of the insurance with respect to which such statement was made after such insurance has been m force prior to the contest for a period of two (2) years dunng such person's hfetune nor unless it is contamed m a written instrument signed by hun or her, prowded, however, that no such provision shall preclude the assertion at any time of defenses based upon (a) provisions m the policy which relate to ehgibflity for coverage, (b) provision m group accident and health msuranco or chsabihty msuranee policies which relate to ovenusurance, (c) provision of &sabllity policies wluch relate to the relation of earnings to insurance, or (d) other sumlar provisions m such policies that lumt the amounts ofrecove~ from all sources to no more than one hundred (100%) percent of the total actual losses or expenses recurred, The ce~lificate of coverage, application, schedule of benefits, and group contract attached shall coustttute the entire contract between the parties and that m the absence of frand all statements made by the policyholder or person insured shall be deemed representations and not warranties, and that no such statement shall be used in any contest under the policy, unless a copy of the written mstrumant containing the statement is or has been furmshed to such person or in the event of death or incapacity of the msured person to the individual's beneficiary or personal representative Please see the attached Schedule of Benefits for Deductibles, Maximum Out-of-Pocket Limit, Exclusions, Llmitattons, and Covered Services ~ 6 GROUP AND AFFILIATED ORGANIZATIONS Or_~am~,stmns included under this A~eement The Group and its affiliated orgamzations are included under this Agreement Affiliated orgamzations ~nclude all orgamzaUons which are a subsidiary to or affihated with the Group ~hsnoe ofAffihated Or~amzations The Group shall notify HMHIC, in writing, when an affiliated orgamzation ceases to be a subsidiary of, or affiliated with, the Group When an organization ceases to be a subsidiary of, or affiliated w~th, the Group, it shall cease to be an included orgamzation Theref6~e, flus Agreement shall terminate on the date of such cessatwn w~th respect to all Eligible Persons of that orgamzatmn, except for those persons who on the next day are employees of another affiliated orgamzation and thus Eligible Persons under tlus Agreement Replacement of Former Policy If an individual is d~sabled on the effective date, the former policy is liable only to extent of its accrued habdmes and extensions of benefits Regardless of whether the group pohcyholder or other entity responsthle for malone payments to the career secures replacement coverage Any person covered under the prior plan on the termination date who is eligible for coverage in accordance voth the succeeding carrier's plan of benefits, in respect of classes eligible and actively at work and nonconfinement rules and who elect such coverage shall be covered under the succeechng career's on its effective date, provided that any person who would have been covered under the succeeding prowsions oftlus subsection but for the actively at work or nonconfinement rules shall become covered under the succeeding carnet plan when such person satisfies such actively at work and nonconfinement rules When replacing a prior earner's plan, the succeeding career's plan, in the case of a type of coverage for which Extension of Coverage reqmres an extension of benefits for a person who is totally disabled shall provide the lesser of (1) the extension of benefits which would have been required by the former policy, or (2) the extension of benefits required for the succeeding former plan, provided, any such benefits may be reduced by any benefits actually payable under the former policy If there is a preexisting condmon limitation, other than wmtmg period, included in the former plan, the level of benefits applicable to preexisting conditions of persons becoming covered in accordance w~th ttus section by the succeeding carrier's plan and who are covered under the prior plan dunng the period of time the limitation applies under the succeeding carrier's plan shall be the lesser of (1) the benefits of the succeeding carrier's plan determined w~thout application of the preexisting condmons limitations, or (2) the benefits of the prior plan The succeeding plan, in applying any wmtlng period in its plan, shall give credit for the satisfaction or partial satisfaction of same or similar provision under the prior plan is required by the succeeding carrier, the prior carrier shall, at the succeeding carrier's request, furnish a statement of the benefits available or pertinent mformat~on sufficient either to permit certification of the benefits available under the prior plan are deternuned in accordance w~th all of the definitions, conditions, and covered expenses provisions of the former and not the succeeding career's plan The benefit determination is made as if the prior plan had not been replaced bY the succeeding carrier ~ 7 ELIGIBILITY AND EFFECTIVE DATE To be ehg~ble to enroll as an Employee, you must sattsfy the following · Employment wath the Group, and/or · Ehg~ble under the ehg~blhty cntena estabhshed by the Group ELIGIBLE DEPENDENTS ~ To be eligible to enroll as a Dependent, you must be The legal spouse of a Employee, Detemumng the dependents or the beneficiaries of an insured, or both, prohibits a chsttnctton on the basis of the marital status or the lack of marital status between the tnsured and the other parent · (a) A dependent unmarned natural child, and legally adopted child regardless of residence, or (b) foster child, step child, or child under Employee's court appointed legal guardtansbap, resichng wath Employee or wath Employee's present or former spouse (1) under mneteen (19) years of age, or (2) under twenty-five (25) years of age and primarily dependent on the Employee for f'mancial support and attendmg an accredited college or umversity, trade or secondary school on a full-time basis, which has, m wntmg, verified smd attendance or, · (a) A dependent unmarried natural child, or legally adopted child regardless of residence, or (b) foster cluld, stepchild, or child under Employee's eonrt appointed legal gnarchanstup, residing wath Employee or wath Employee's present or former spouse who is mneteen (19) years of age or older but incapable of self-sustmnmg employment because of mental retardation or physical handmap which commenced prior to age mneteen (19) (or commenced prior to age twenty-five (25) if such child was attending a reeogmzed college or university, trade or secondary school on a full-time basis when such incapacity occurred), and primarily dependent upon the Employee for support and maintenance Such dependent child must have been a parampant either prior to attalmng mneteen (19) years of age or twenty-five (25) years of age under the condlhons of the previous sentence Employee shall furmsh HMHIC proof of such incapacity and dependency within thirty-one (31) days after the dependent child's attainment of the hmltlng age and from tune to time thereafter as HMHIC deems appropriate, but not more frequently than annually · Crrandchildren wall be eligible for coverage if the child is considered a dependent of the Employees for federal income tax purposes · Managing Conservator Coverage for a minor child who otherwase qualifies as a dependent of a person who is a member of the group may pay benefits on behalf of the child to the person who is not a member of the group ifa court order provl&ng for the ~ 8 managmg conservator of the child has been issued by a court of competent junschct~on m flus or any other state HMHIC is reqmred to pay benefits pursuant to the terms of the pohcy and as provided by flus amcle on comphance by the person who ~s not a member of the group with reqmrements of tins Agreement However, any reqmrements unposed on the managing conservator of the cluld shall not apply m the case of any unpmd mechcal bill for wluch a vahd asmgnment of benefits has been exercised m accordance with pohcy prowsions or otherwise, nor to clmms submitted by the group member where the group member has pard any pomon of a medical bill that would be covered under the terms of the pohcy Before a person who ~s not a member of a group ~s entitled to be paid benefits under the above mentioned paragraph, the person must submit to HMHIC with the'~lanns apphcaUon wntten not~ce that the person (1) is the managing conservator oftbe chid on whose behalf the clmms is made, and (2) subnut a certified copy of a court order estabhslung the person as managing conservator or other ewdence demgnated by role of the Texas Department of Insurance that the person quahfies to be prod the benefits as provided by tins section CHANGE IN GROUP ELIGIBILITY CRITERIA Reqmrements as defined by the Group for detenmmng the ehg~bfl~ty for participating m HMHIC are material to the execution of tins Agreement by HMHIC Dunng the term of flus Agreement no change m the Group defimt~on of ehg~bfl~ty participation shall be permxtted to affect ehg~bfllty or enrollment under flus Agreement ~n any manner unless such change ~s approved m advance by mutual written agreement between the Group and HMHIC EFFECTIVE DATE FOR YOU OPEN ENROLLMENT By subm~tUng an Apphcat~on during an Open Enrollment Period you shall become covered on the Group Effective Date or the Effectlve Date specified as such for the Open Enrollment Period ON ACQUIRING ELIGIBILITY STATUS If you first meet the ehg~bfl~ty reqmrements other than dnrlng the Open Enrollment Period you may enroll wiflun tlurty (30) days of meeting such reqmrements by submitting an Apphcat~on You will become covered under HMHIC on the first day you become an Ehg~ble Person prowded that the premium apphcable to you has been received in accordance with th~s Agreement EFFECTIVE DATE FOR YOUR DEPENDENTS OPEN ENROLLMENT Your Dependents, for whom you have apphed for coverage ~n HMHIC by submlmng an Apphcatton dunng an Open Enrollment Period, shall be covered as a Dependent on your Effectxve Date ON ACQUIRING ELIGIBILITY STATUS A newly acquired Eligible Dependent, other than a newborn child, and an Eligible Dependent who first meets the ehgiblhty reqtnrements of the Group, other than during an Open Enrollment Penod, may be enrolled by the Employee vathm tlurty (30) days of mectmg such reqmrements by subnu~ng an Apphcai~un Such Ehgible Dependent shall be covered under HMHIC as a Dependent on the day he became an Eligible Dependent prowded that the prenuum apphcable to the Dependent has been received m accordance vath tins Agreement descnbad m the PAYMENT REQUIREMENTS Section below Newborn children shall be covered under HlVIHIC for a penod of thirty-one (31) days from the date of hirth and shall continue to be covered after that time only if, pnor to the expn'ation of such thirty-one day penod, Notification has been submitted for such newborn child and the prennum applicable to the Dependent has been received m accordance vath this Agreement descnbed m the PAYMENT REQUIREMENTS Section Newly adopted children shall be covered under HMHIC as if they were newborn children The thirty-one (31) days grace period for submission of NotificaUon shall commence on the earlier of the date upon which such child commences residence vath you or when the adoption becomes legal PERSONS NOT ELIGIBLE FOR COVERAGE Notvathstandmg the foregoing provisions of tins Section, you will not be eligible for coverage in HMHIC if · Coverage Prewously Tenmnated You shall not be eligible for coverage if you have had previous coverage terminated by HMHIC for cause, as descnbed in Section TERMINATION, CONTINUATION OF BENEFITS AND CONVERSION of this Agreement · Indebtedness You shall not be eligible for coverage if you have unpmd financial obligations arising from pnor coverage in HMHIC CONDITIONS OF ELIGIBILITY You or your Eligible Dependent shall not be refused enrollment by HMHIC because of health status, requirements for health services, or the erastence of a Pre-Existing condition on the Group Effective Date In addition, your coverage shall not be terminated by HMHIC due to your health status or health care needs If you or your eligible Dependents apply for coverage on a date other than Open Enrollment Penod or more than thirty (30) days after becoming an eligible person or eligible Dependent, then you or your eligible Dependent shall be required to submit Evidence of Insurability as required by HMHIC NOTIFICATION OF INELIGIBILITY A conchtion of participation in HMHIC is your Agreement to notify HMHIC of any changes in status that affect you or the ability of the your dependents to meet the eligibility criteria set forth in this Section Eligibility under this Agreement shall m no event be invalidated by fmlure of the Group, due to clerical error, to record or report you or your eligible Dependent to I-LMHIC You shall be eligible If an Application has been completed and submitted to the Group as reqmred under the terms of this Agreement by or on behalf of you or your ehglble Dependent and the prermum applicable to such coverage had been received by HMHIC I'RE EXISTING CONDITIONS "Pre-existing Conditions" means any medical condition which diagnosis was made or treatment received within a six (6) months immediately preceding your effective date of c6verage under this Agreement A medical condition has been "diagnosed" If its existence has been ~dentified or recognized by a Physician or other Health Professional A medical condition has been "treated" If ally servleeS of a Physician or other Health Professional have been received with respect thereto, including but not lumted to office visits or consultations, hospital treatment, laboratory services, X-rays or the dispensing of prescnption medication or refills In no event shall the himtation of 50% additional Copayment apply to cost of treatment (which shall include all applicable Copayment as specified in the Schedule of Benefits) following the earlier of (a) the end of a continuous penod of twelve (12) months commencing on or after the effective date of the person's coverage dunng all of which the person has received no medical advice or treatment in connection with such disease or physical condmon and (b) the end of the two (2) year period commencing on the effective date of the person's coverage The maxunum amount of adchtional Copayment for a Pre-existtng Condition dunng a Calendar year will not exceed $2,000 00 for any such Covered Person or Dependent, or $4,000 00 total for such Covered Person and his Dependents TERMINATION. CONTINUATION OF BENEFITS AND TERMINATION OF GROUP DEFAULT IN PAYMENT OF PREMIUM If the Croup fails to pay to HIVIHIC the premium payable hereunder on or before the thn'ty-~t (31) calendar day after such payment is due, this Agreement may be ternunatad by HMHIC and all benefits shall cease at the end of such thuty-one (31) day grace period Croup may be held hable for the cost of all benefits pwvided to you by HMI-HC during the grace pe"nod Croup shall remain hable for all prermums (and any interest accrued thereon) not pad prior to termination Interest on late payments from the date such prermums were due may be charged at a rate equal to eighteen percent (18%) per year Unpaid interest shall be due and payable upon notice thereof to the Group from HMHIC If Group remits its delinquent payments to I-1MHIC vothm fifteen (15) days of termination date, HMHIC may reinstate Croup vothout reqtunng a new Croup Enrollment Agreement However, HMHIC reserves the right to refuse to reinstate by refunchng wtthm five (5) business days all payments made by Croup after the date of termination UPON NOTIFICATION This Agreement may be terminated by either I-IMHIC or the Group upon written notice to the other party at least sixty (60) days prior to the end of the Contract Year Such termination shall occur at ratdmght on the day prece&ng the end of the Contract Year In the event that HMHIC terminates tins Agreement, if you are Totally Disabled at the date of discontinuance of the group policy or contract, expenses for treatment wtll continue at least for the period of such total disability or for 90 days, wluchever is less For the purposes oftlus section, the terms "total disability" and "totally disabled" mean (1) w~th respect to an employce or other primary insured under the policy, the complete mabdity of the person to perform all of the substantial and material duties and functions of ins or her occupation and any other gainful occupation in wtuch such person earns substantially the same compensation earned prior to disability, and (b) w~th respect to any other person under the policy, confinement as a bed patient in a hospital TERMINATION - FOR CAUSE DEFAULT IN PAYMENT OF PREMIUM If any premmm contributions due from you are not paid timely by or on behalf of you, your entitlement to benefits may be tenmnated not less than thmy-one (31) days after the date such premium was due MISREPRESENTATION If you should make a fraudulent statement or provide any material misrepresentation of fact by or on behalf of you or your Dependent on a Application or Evidence of Insurability form, HMHIC shall have the right to terminate your coverage under this Agreement w~thout any further liability or obligation to you Your entitlement to benefits may be terminated not less then sixty-one (61) days after such misrepresentation If you correct inaccurate reformation furnished to HMHIC, ~ 12 and HMHIC has not relied upon such incorrect information to its prejudice, the furmshmg of incorrect reformation shall not constitute a basis for termination of your coverage In the absence of fraud, all statements made by you are considered representations and not warranties and such statements shall not void the coverage or reduce the benefits under tins Agreement two (2) years after your Effective Date MISUSE OF IDENTIFICATION CARD Possession cfa HMHIC ldant~fication card is and of itself confers no nghts to services or other benefits The holder of the card must be, m fact, you or an ehgible person on whose behalf all apphcable premiums under tins Agreement have actually been paid When receiving services or other benefits to winch you are not entitled pursuant to tins Agreement you shall'"oe solely responsible for the full peymant of any charges associated w~th the services received Ifyou penmt the use of the your ~dantification card by any other person, such card may be confiscated and HMHIC shall have the nght to terminate your coverage under this Agreement and the coverage of your Dependents Your entitlement to benefits may be terminated not less than fifteen (15) days wnttan notice after such rmsuse of the identification card FRAUDULENT USE OF BENEFITS OR SERVICES Fraudulent use by you of serwces, benefits, providers, facilities, or coverage will result m cancellation of coverage after not less than fifteen (15) day written notice to you TERMINATION OF COVERAGE EMPLOYEE NO LONGER ELIGIBLE PERSON If you cease to be ehglble, coverage under this Agreement shall automatically ternunate at mldmght of that day on which you cease to be eligible DEPENDENT NO LONGER ELIGIBLE DEPENDENT If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall automatically terminate at midmght of the day on which the Dependent ceases to be an Eligible Dependent LIABILITY UPON TERMINATION At the effective date of any termination of your coverage under this Agreement any payments received on your account, appheable to periods after the effective date of the termination of coverage, plus amounts due to you for claims reimbursement, if any, less any amount due to HMHIC or which must be paid by HMHIC on your behalf, shall be refunded to the appropriate party vathln thn'ty-one (31) days HMHIC and the Group shall thereafter have no further liability or responsibility to you except as may be specifically provided in Section UPON NOTIFICATION of tins Agreement (~ONTINUATION OF COVERAGE COBRA If, under the prowslons of Title X oftbe Consolidated Omnibus Budget Reconclhation Act of 1985, Public Law 99-272 ("COBRA"), you are granted the right to continuation of coverage beyond the date your coverage would otherwise ternunate, or, If COBRA Is inapplicable and the provision of an apphcable state statute grants you mmflar rights to continuation of coverage, this Agreement shall be deemed to allow contmuatious of coverage to the extent necessary to comply with the provlsiOus of the applicable statute No evidence of msurabdlty is reqmred If you are eligible for continuation under COBRA you must inform HMHIC of ehglhihty ~wthin 3 months of the effective date CONTINUATION OF COVERAGE Any employee, covered person, or dependent whose insurance under the group policy has been termmated for any reason except involuntary termination for cause, including discontinuance of the group policy m Its entirety or with respect to an insured class, and who has been continuously insured under the group policy and under any group policy providing sirmlar benefit which it replaces for at least three consecutive months lmmedmtely prior to termination shall be entitled to such conunuation pnvllages Involuntary termination for cause does not include terrmnation for any health related cause HMHIC shall not be required to issue a converted policy covering any person if (a) such person is or could be covered by Medicare, (b) such person is covered for sumlar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program, (c) such person is ehgible for similar benefits whether or not covered therefor under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, (d) sh'mlar benefits are provided for or available to such person, pursuant to or m accordance with the reqmrements of any state or federal law, or (e) the benefits provided under the sources herein enumerated, together vath the benefits provided by the continued policy, would result In overmsurance according to HMHIC's standards HMHIC's standards are the reasonable relationship between the actual health care costs In the area m which the covered person hves at the time of the continuation and must be filed voth the comnussloner of insurance prior to their use in denying coverage Contmnation of group coverage for employees or covered persons and tbeuc eligible dependents subject to the ellglbthty provisions Continuation of group coverage will not include dental, wslon care, or prescription drug benefits and must be requested in writing within twenty-one (21) days following the later of (a) the date the group coverage would otherwise terminate, or (b) the date the employee is given notice of the right of continuation by either the employer or the group pohcy holder In not event may the employee or the covered person elect continuation more than 31 days after the date of such termination An employee or covered person electtng continuation must pay to the group policyholder or the employer, on a monthly basis in advance, the amount of contribution required by the policyholder or employer, but not more than the group rate for the insurance being continued under the group pohcy on the due day of each payment Tbe employee% or tbe covered person's wnttan election of continuation, together w~th the first contribution reqmred to establish contributions on a monthly basxs in advance, must be g~ven to the policyholder or employer within thirty-one (31) days of the date coverage would otherwise terminate Contxnuation may not terminate until the earher of (a) s~x months after the date the election is made, (b) failure to make timely payments, (c) the date on which the group coverage terminated ~ 14 in its entirety, (d) or one of condmons specified in items listed above regardmg ineligible person's is met by the m&vidual FAMILY SEVERANCE If coverage ends due to severance of family relat~onstup, by virtue of family or dependent relatmnslup to a person who is a member or ehg~ble for the group for wlueh the health insurance policy, is provided to continue coverage with the group If (1) Prevmns ehglblhty for coverage under the health msuranee policy ceases because of the severance of the farmly relattonslup or the retarement or death of the me,abet of the group, and (2) The famaly member or dependent has been a member of the group for a period of at least one year or is an infant under one year of age (3) A person who exercises flus option, may not be required to take and pass a physical examination as a condition for contmmng coverage (4) A person who exercises flus option is entttled to coverage under the policy, and exclusions that were not mcluded m the policy may not be included in the group continuation coverage However, if the group pohcyholder replaces the health Insurance policy w~tlun the one-year provided, the person may obtain coverage Identical in scope to the coverage under the replacement group pohcy as provided by flus article (5) A person covered under group continuation coverage shall pay premiums for the coverage directly to the group policyholder, and the coverage shall prowde the person voth the option of paying the premiums m monthly installments The group pohcyholder may require the person to pay a fee of not more than $5 a month for adrmmstrat~ve costs (6) Upon lmUal severance of fanuly relatlonstup, you must inform HMHIC of the severance, upon receipt of the noUficatlon HMHIC will send the application to the severed family member Immediately (7) W~flun sixty (60) days from the severance of the family relationship or retirement or death of the member of the group, the dependent must give written notice to the group policyholder of the desire to exercme the option under item (1) of flus section or the option expires Coverage under the health Insurance policy remmns m effect during this sixty (60) day period prowded the policy premiums are paid (8) Any period of previous coverage under the health insurance pohcy Is to be used in full or partially satisfaction of any reqmred probationary or wmtmg periods provided m the contract for dependent coverage (9) If a health insurance policy provides to a group member continuation rights to cover the period between the Ume that the member retires and the time of ehglbfllty for coverage by Medicare, those same continuation rights shall be made avmlable to the group member's dependents (10) Ifa person exercises the conunuat~on option under item (1) of this section, coverage of that person continues w~thout interruption and may not be canceled or otherwme terminated until (a) the msured fails to make a premium payment m the time required to make that payment, (b) the insured becomes eligible for substantially similar coverage under another health Insurance pohcy, hospital, or medical service subscriber contract, medical practice or other prepayment plan, or by any other plan or program, or (c) a period of three years has elapsed since the severance of the family relationstup or the retirement or death of the member of the group ~os-c~- ~2 EXTENSION OF MEDICAL BENEFITS HMHIC shall continue to pro,ode medical services if this Agreement temunates wlule you are Totally D~bled at the date of d~scontmuance of the group policy or coniract at least for the penod of such total chsabllity or for 90 days, wluchever is less, for expense for treamient of the conchtion causing such total disability For the purposes of tius section, the terms "total d~sabthty" and "totally &sabled" mean (1) with respect to an employee or other pnmary insured under the pohcy, the complete mablhty of the person to perform all of the substanUal and material duties and functions of his or her occupation and any other g/unful occt~pation in wluch such person earns substantially the same compensation earned pnor to disability, and Co) with respect to any other person under the pol, cy, confinement as a bed patient m a hospital This continued coverage will end on the earlier of (1) the penod of "total chsablhty" is no longer meets the above defined statement, or (2) 90 days from the termination date, or (3) the date you become eligible for sumlar coverage under another plan PAYMENT REOUIREMENTS pREMIUM PAYMENTS The ~ual rates for the benefits and services under flus Agreement shall be due and payable in advance on or before the first (lst) day of the month for wluch such payment is made or is to be made In accordance wth the terms and provimons of the TERM AND AMENDMENT OF AGREEMENT Seet~on of flus Agreement, HMHIC shall have the right to change the rate payable under flus Agreement at any t~me when the extent or nature of tlus Agreement is changed by Amendment or tenmnat~on of any provision, or by reason of any provimon of law or governmental program or regulation Prenuums do not vary by age No proration of the rate shall be made w~th respect to your coverage under flus Agreement commencmg~tfter the first (lst) day of the month A grace period of thirty-one (31) days shall be allowed for each payment payable hereunder, whether due from Group or you The rate reqmred for a newly acqmred Ehgtble Dependent shall be payable nuttally when the reqmred Apphcat~on ts submitted to HMHIC Thereafter, alt payments w~th respect to such new Ehglble Dependent shall be made as otberw~se provided tn flus Agreement Any payments reqmred for newborn children who meet the requirement of the Section ELIGIBILITY AND EFFECTIVE DATE of flus Agreement shall be lmtially payable to HMHIC on or before the first day of the next month followang the month mn which the Notification reqmred under the above menttoned sectton Is subm:tted to HMHIC Thereafter, all payments voth respect to such newborn child shall be made as otherwise reqmred under flus Agreement NON-CONTRIBUTORY COVERAGE If the coverage basis hereunder is "Non-Contributory", the Group agrees to pay at the prmmpal office of HMHIC, or to its authorized representattve, on each payment due date, the sum of the HMHIC rate for the coverage under flus Agreement The Group premium for the coverage provided by ITMHIC under flus Agreement shall be determine by the applicable rate then m effect and the number of Members at the monthly intervals estabhsbed by HMHIC CONTRIBUTORY COVERAGE If the coverage basis hereunder ~s "Contributory", the Group agrees to pay at the pnnclpal office of HMHIC, or to its authorized representative, on each payment due date, the sum of the HMI-IIC rate for the coverage under flus Agreement Group shall permit you to pay your contributory portion of such rate through payroll deductmn Procedures for implementing payroll deduction for your portion of such rate shall be the same as those utilized for any Alternative Health Benefit Plan If the Group does not have an Alternative Health Benefit Plan, the procedures shall solely be those as agreed to, m wnUng, between Group and HMHIC The Group premiums for the coverage provided by HMHIC under flus Agreement shall be determined by the applicable rate than tn effect and the number of Members at the monthly intervals established by HMHIC Group shall offer HMHIC to all Employees of Group on terms no less favorable w~th respect to the Croup contrtbutmn than those applicable to any Alternative Health Benefit Plan as may be avmlable through the Group The Group contnbutmns shall not be changed dunng the term of thts Agreement unless such change is prior approved, m writing, by HMHIC If, however, the Group contributions to the Alternative Health Benefit Plan, as may be avatlable through the Croup, is increased dunng the term of tins Agreement, the Group agrees to also increase ~ 17 conmbut~ons to HMHIC effectsve the first monthly payment due following such increase NOTIFICATION BY OROUP Croup shall forward completed Apphcat~ons and any Evidence of Insurabd~ty form(s) to HMHIC within ten (10) bnslness days of their receipt from Ehg~ble Persons In the event Group fails to notify HMI-HC of the mehg~bthty of any person for whom the Group has made the monthly prepayment requn'ed pursuant to tins Agreement, then, such prepayment shall be credited to Croup only if HMHIC has not made arrangements for or prod benefits for the ~nehglble person but m no event will prepayment be crechted subsequent to tlnrty (30) days aider the date such person became ~nehg~ble. CLAIMS INFORMATION HOW TO PILE A CLAIM You must send your medical bills to HMHIC The claim office address can be found on the back of your I D card When you send your medical bills be sure to include your name, ad&ess, and social security number Wnttan notice of claim must be given to the insured w~thm twenty (20) days after the occurrence or commencement of any loss covered by the pohcy Failure to give notice wffiun such tune shall not invalidate or reduce any clann If it shall be shown not to have been reasonably possible to g~ve such notice and that notice was given as soon as was reasonably posslbl6l HMHIC will furmsh to the person malong claim or to be policyholder for delivery to such person such forms as are usually funushed by it for filing proof of loss If such forms are not funnshed before the expiration of fiftean (15) days at~er the insurer received notice of any claun under the policy, the person malong such clmms shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting vatinn the time frame fixed in the policy for filing proof of loss, written proof covenng the occurrence, character, and extent of the loss for winch claims is made HOW AND WHEN ARE CLAIMS PAID? In the case of claun for loss, wntten proof of such loss must be furnished to the insurer vathm the ninety (90) days after the commencement of the period for which the insurer is liable Failure to funush such proof witinn such tune shall not invalidate or reduce any claim if it was not reasonably possible to furnish such proof within such time, provided such proof is furmshed as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the tune proof is othervase required All benefits payable under the pohcy shall be payable not more than sixty (60) days after receipt of proof HMHIC shall have the right and opportunity to examine the person of the individual for whom claim is made when and so often as it may reasonably require during the pendency of claim under the pohcy and also the nght and opportunity to make an autopsy in case of death where it is not proinblted by law The Group policy shall provide payment to the Texas Department of Human Resources for the actual cost of medical expenses the department pays through medical assistance for a person insured by the contract if the Insured is entitled to payment for the medical expenses by the insurance contract All benefits paid on behalf of the cinld or cinl&en under the policy must be paid to the Texas Department of Human Servmes whenever the Texas Department of Human Services ~s paying benefits under the Haman Resources Code, Chapter 31, or Chapter 32, t e, financial and mechcal assistance service programs admlmstered pursuant to the Human resources code, and · the parent who is covered by the group policy has possession or access to the child pursuant to a court order, or is not entitled to access or possession of the child and Is required by the court to pay child support No action at law or m eqtuty shall be brought to recover on the policy pnor to the expiration of sixty (60) days after proof of loss has been filed m accordance with the reqmrements of the policy and that no such action shall be brought at all unless brought within three years from the expiration of the time witlun which proof of loss is reqmred by the policy, TIME LIMIT OF CERTArN DEFENSES Hams Methodist Health Insurance Company will not deny or reduce a claim because of a Pre- Existing Condition tfboth of the following conditions are met · The claim is for a loss that happened or a disability started after the insurance coverage for that person has been m effect for the earlier of (A) twelve (12) months, with no treatment in connections w~th such pre-emstmg condition, or (B) two (2) years, with any treatment for such pre-existing condition · The condition is not excluded from coverage by name or specific descnpt~on ~ 20 COORDINATION OF BENEFITS The HamsMethodist Health Insurance Company, Coordination of Benefit and Subrogation of Benefits provision apphes to all of the benefits provided under this Agreement The benefits provided by Hams Methodist Health Insurance Company shall be coordinated with any group insurance plan or coverage under governmental programs (exclu&ng Medmmd), mcludmg Medicare, to assure that you receive coverage wlule avoiding double recovery It is, therefore, understood and agreed that should you be covered by or under a Coordinated Plan m additmn to coverage under flus Agreement, the provisions and rules as described in flus Section shall determine whether HMHIC or the Coordinated Plan is pnmanly responsible for paying the cost of banefits,and services provided to you Services and benefits for military service connected chsabllltles for which you are legally enl~tled and for winch facihi~es are reasonably available, shall in all cases be provided before the benefits of this Plan For purposes of this Section only, words and phrases shall have meamng as follows ALLOWABLE EXPENSE shall mean any Usual and Customary expense of wluch at least a pomon is covered under flus Plan covenng you when a clmm is made When a Coordinated Plan provided benefits in the form of services rather than cash payments, the Usual and Customary cash value of each service provided shall be deemed to be both an Allowable Expense and a benefit prod · CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding any portion of a calendar year occumng pnur to the effective date · COORDINATED PLAN shall mean any of the following that provides benefits or services for, or by reason of, medical care or treatment · Coverage under governmental programs, including Medicare (excluding Medicaid), reqmred or provided by any statute unless coordination of benefits with any such program is forbidden by law · Group coverage or any other arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, including any prepayment coverage, group practice basis or individual practice coverage and any coverage for students which is sponsored by, or provided through, a school or other educational institution above the high school level DETERMINATION OF BENEFITS This provision shall apply in determwang the benefits payable for the Allowable Expenses incurred by you dunng a Clam Determination Period The term Coordinated Plan shall be construed separately w~th respect to each policy, contract, or other arrangement for benefits or serwces and separately w~th respect to that po~on of any such pohcy, contract, or other arrangement which reserves the n~ht to take the benefits or services of the other Coordinated Plans into consideraUon in determLmng its benefits and that portwn which does not Whenever the sum of the benefits that would be payable under flus Agreement m the absence of fins prowslon, and the benefits that would be payable under all Coordinated Plans m the absence thereof or amendments of sunllar purpose to flus provision would exceed the Allowable Expenses, then the following shall apply · The benefits that would be payable under flus Agreement shall be reduced to the extent necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Expenses under all Coordinated Plan include the benefits that would have been payable had ctmm been duly made therefor · If a Coordinated Plan would, according to its rules, determine its benefits at~er the benefits payable under flus Agreement have been determined, and the rules as described below would reqmre payment under this Agreement to be detenmned before the Coordinated Plan, then the benefits of the Coordinated Plans shall not be included for the purpose of detemumng the benefits under flus Agreement ORDER OF BENEFIT DETERMINATION The rules establishing the order of benefit determmaUon shall be as follows · The benefits of a Coordinated Plan wtthout a coordination of benefits promslon (or a non-dupllcatton prowsion of slnular intent) shall be determined before the benefits of flus Agreement · The benefits of a Coordinated Plan winch covers you other than as a Dependent shall be determined before the benefits of a CoorOanated Plan whleh covers you as a dependent The benefits of a Coordinated Plan which covers you as a dependent child of a person whose date of birth, excluding year of b~rth, occurs earlier in a calendar year, shall be deterunned before the benefits of a Plan which covers you as a dependent ora person whose date of b~rth, excluding year of birth, occurs later in the calendar year Ifa Coordinated Plan does not have the provisions of this paragraph regarding dependents, which results either m each Coorchnated Plan determlmng its benefits before the other or m each Coordinated Plan detenmmng its benefits after the other, the prowslons of flus paragraph shall not apply, and the rule set forth in the Coordinated Plan which does not have the provisions of this paragraph shall determine the order of benefit determlnat~on unless the Legal Separation or Divorce Section shall apply · If the rules provided above or the rules provided in the above section do not establish an order of benefit determination, then the benefits of a Coordinated Plan which covers you, when a clmm is made, for the longest period of time shall be determined before the benefits of a Coordinated Plan which covers you for the shorter period of Ume except as follows ~ 22 · The benefits of a Coordinated Plan cover you as a lmd-offpart- tune or rettred employee or as the dependent of such a person shall be determined after the benefits of a Coordinated Plan covenng you as a covered member other than as a lind-off or retued employee or dependent of such person · If a Coorchnated Plan does not have a provision regarding lind-off or rettred employees, and as a result, such Coordinated Plan determines its benefits afier the Coordinated Plan w~th tlus provision, then the prowmon of the immediately preceding paragraph shall not apply LEGAL SEPARATION OR DIVORCE In the event of a legal separation or chvorce, the following order of benefits detenmnation shall apply · If there Is a court decree that establishes f'mancial responsibility for the provision of health insurance coverage for the cluld, the benefits ora Coordinated Plan wtuch covers the ctuld as a dependent of the parent vnth such financial responsib~hty shall be determined before the benefits of a Coordinated Plan wluch covers the cluld as a dependent of the parent vothout such financial respons~blhty · In the event of a legal separation or chvorce in whtch the court decree does not establish financial responsibility for the health care expenses of the child then the following shall apply · If the parent vath custody of the cluld has not remanued, the benefits of a Coordinated Plan wtuch covers the cluld as a dependent of the parent with custody of the cluld shall be detemuned before the benefits of a Coordinated Plan wtuch covers that cluld as a dependent of the parent without custody · If the parent w~th custody of the cluld has remained, the benefits of a Coordinated Plan wluch covers the cluld as a dependent of the parent with custody shall be determined before the benefits of a Coordinated Plan which covers that ctuld as a dependent of the stepparent, and the benefits ora Coordinated Plan wluch covers that cluld as a dependent of the stepparent shall be determined before the benefits of a Coordinated Plan wi'ach covers that eluld as a dependent of the parent w~thout custody Thus, in the event of legal separation or divorce, unless a court decree specifies otherwise, the order of benefit determination described above may be summarized as follows Separated or Divorced and not Remamed (1) Parent voth Custody (2) Parent w~thout Custody Separated or Divorced and Remarned (1) Parent with custody (2) gtepparent with custody (3) Parent without custody For purposes of determining benefits provided for you, if you are ehglble to enroll for Medicare, but do not, HMHIC will assume the amount provided under Mechcare to be the amount you would have received if you had enrolled m it You are considered to be ehgible for Me(hcare on the earliest date coverage under Medicare could become effective for you Except as described TEFRA, Medicare benefit~'wfll be coordinated m accordance with the policy TEFRA Options for Groups with 20 or more Kmployees If you are actively worlong, you and your covered spouse who are eligible for Medicare will be penmtted to choose one of the following options if you, the Employee are age 65 or older and eligible for Medicare OPTION 1 - The service of the Group Agreement will be provided first and the benefits of Medicare vail be provided second OPTION 2 - Medicare benefits only You and your Dependents, if any, will not be covered by the Group Agreement The Group will prowde you, the employee, with a choice to elect one of these options at least one month before becoming age 65 All new Employees age 65 or older will be offered these options when lured If Option 1 is chosen, your rights under flus Agreement will be subject to the same requirements as for an Employee or Dependents who are under age 65 There are two diffarent categories of persous eligible for Medmare The calculation and payment of benefits by this Agreement differs from each category, Category 1 Medicare Ehglble are 1 Actively working covered Employees age 65 or older who choose Option 1, 2 Age 65 or older covered spouses of actively working employees age 65 or older who choose Option 1, 3 Age 65 or older covered spouses of actively working covered Employees who are under age 65, 4 Actively worlang covered Employees of groups with 100 or more employees and their covered dependents who are entitled to Medicare by reason of disability other than End Stage Renal Disease (ESRD), and 5 Covered individuals entitled to Medicare solely on the basis of pOS-CER9-92 24 ESRD durmg a period of up to 18 months al~er the tndtwdual has been determined ehgtble for ESRD benefits Category 2 Mechcare Ehglble are 1 Retu'ed employees and their spouses, 2 Covered Employees of groups w~th less than 100 employees and their covered Dependents who are entitled to Medicare by reason of a d~sabihty other than ESRD, and 3 Covered mchwduals entitled to Medicare solely on the basra of" ESRD for more than 12 months after the md~wdual has been deterrmned ehglble for ESRD benefits ]RIGHT TO IH~I~F, ASE INFORMATION For purposes of admmlstenng the provisions of this SecUon, HMHIC may, vothout further consent of, or notice to you, release to or obtmn from any health care plan, insurance company or other person or organization, any reformation w~th respect to you which ~t deems to be reasonably necessary for such purposes, as to facilitate coordination of benefits, as permitted by law When you receive serwces or clmm benefits under this Agreement you shall furmsh HMHIC all mformat~on deemed necessary by HMHIC to implement th~s Section (COORDINATION AND SUBROGATION OF BENEFITS) t~/kCILITY OF PAYMENT Whenever payment which should have been made by HMHIC m accordance w~th this Section has been made by a Coordinated Plan, HMHIC shall have the right, exercisable alone and m sole d~scretion, to authorize payment to the Coordinated Plan making such payments any amounts HMHIC shall determine to be warranted m order to satisfy the mtent of this Section, and amounts when so prod shall be deemed to be benefits under th~s Agreement, and, to the extent of such payments, HMHIC shall be fully d~scharged from habH~ty under flus Agreement RIGHT TO RECOVERY Whenever payments have been made by HMHIC voth respect to Allowable Expenses m total amount wluch ~s, at any time, ~n excess of the maxnnum amount of payment necessary at the tune to satisfy the mtent of flus Section, HMHIC shall have the right to recover such payments, to the extent of such excess, from one or more of the relieving, as HMHIC shall determine any person or persons to, or for, or vnth respect to whom such payments were made, any insurance company or compames, and orgamzation(s) to which such payments were made You agree to disclose to HMHIC at the time of enrollment, at the time of receipt of serwces and benefits, and from time to time as requested by HMHIC, the existence of other health plan coverage, the xdentity of the carrier, and the group through which such coverage ~s prowded pOS-CERg-92 2~ Subrogation seeks to shtft the expense for injuries suffered by you to those responsible for causing them In return for HMHIC pmwdmg benefits for injuries, mlments, or dtsease caused as a result of the neghgenee, onussion or wtllful act ora thtrd party, you agree to execute any ~nstmment whtch may be reqmred You also agree to assign to HMI-HC the nght of recovery against such thtrd party to the extent of benefits pard At the ume such benefits are provided or thereafter as HMHIC may request, you also agree to comply wtth the followng pmws~ons · Execute a formal written injury report and assignment to HMHIC of right to recover the actual benefits prod by HMHIC under tlus Agreement for ~njunes, mlments and disease caused by a tturd party Reimburse HMHIC for the actual benefits prod by HMHIC, but not in excess of monetary damages collected, ~mmedlately upon receipt of any momes pa~d by or on behalf of such tlurd party in settlement of any clmms arising out of ~njunes, adments and d~seases covered by HMHIC HMHIC shall have a hen on any actual recovery from such tlurd party whether by judgment, settlement, compromise or reunbursemant · Execute and dehver such papers and provtde such reasonable help 0nclud~ng authonzang bnng~ng su~t against such tturd party ~n your name and makdng court appearances) as may be necessary to enable HMHIC to recover the actual benefit paid by HMHIC ~ 26 INDEPENDENT AGENTS The relationship between HMHIC and the Group is that of Independent contracting entities Neither the Group nor you Is the a~ent or employee of HIVIHIC, and HMHIC is not the employee or agent of the Group or you POS-CERg-92 27 (These defirattons apply when the following terms are used in tlus Cemficate and the attached Schedule of Benefits ) Actively at work shall mean that the eligible employee must be performing the usual and customary duties of your regular employment dunng your usual worlong hours on your effective date of coverage, provided, however that if you are absent from work due to vac[ition, holiday, jury duty, or other similar circumstances, not caused by injury or illness, you shall be considered actively at work Agreement shall mean Entire Contract winch is defined as the Group Contract, Certaficate of Coverage, Group Enrollment Agreement, Schedule of Benefits, Applications, Attachments, RJders, Amendments hereto, if any Agreement shall consUtute the entare contract between the parties and that m the absence of fraud all statements made the policyholder or person insured shall be deemed representations and not warrant~es, and that no such statement shall be used in any contest under the policy, unless a copy of the written lnstmmant contmmng the statement is nor has been furmshed to such person or in the event of death or incapacity of the insured person to the individual's beneficiary or personal representative ALTERNATE HEALTH BENEFIT PLAN Alternate Health Benefit Plan shall mean the plan winch the Group designates as the alternative to tins Agreement ALLIED HEALTH PROFESSIONAL Allied Health Professional shall mean any health care provider/physician that provides benefits as set forth in tlus Agreement and described in the Schedule of Benefits Attachment ,~MBULATORY SURGICAL CENTER A specialized facility which is established, operated and staffed primarily for the purpose of performing surgical procedures and which fully meets one of the following two tests It is hcensed as an ambulatory surgical center by the regulatory authority having responslblhty for the hcensmg under the laws of the jurisdmtlon in which at is located · Where licensing is not required, it meets all of the following requirements · It is operated under the supervision of a licensed doctor of Medicine (M D ) or a doctor of osteopathy (D O ) who is devoted full time to supervision and permits a surgical procedure to be performed only by a duly qualified physician who, at the time the procedure is performed, is privileged to perform the procedure in at least one Hospital in the area ~ 28 · It reqmres m all cases, except those requlnng only local infiltration anesthetics, that a licensed anesthesiologist admlmster the anesthetic or supermse an anesthetist who is adrmmstenng the anesthetic and that the anesthesiologist or anesthetist remain present throughout the surgical procedure · It pro,odes at least one operating room and at least one post-anesthesia recovery room · It is eqmpped to perform &agnostic X-ray and laboratory examinations or has arrangement to obtain these services · It has trained personnel and necessary equipment to handle emergency situations · It has ~mmcdiate access to a blood bank or blood supphes · It provides the full tune services of one or more registered graduate nurses (R N ) for patient care in the operating rooms and m the post-anesthesm recovery room · It maintains an adequate medical record for each patient, the record to contain an admitting chagnosls mchichng for all patients except those undergoing a procedure under local anesthesia, a pre-operative exanunat~on report, medical history and laboratory tests and/or X-rays, an operative report, and a discharge summary A specialized facility which is primarily a place for dehvery of children following a normal uncomplicated pregnancy and which fully meets one of the following two tests · It is licensed by the regulatory authority having responslblhty for the licensing under the laws of the jurisdiction in which it is located · It meets all of the following reqmrements ·It is operated and eqmpped in accordance with any applicable state laws · It is equipped to perform routine diagnostic and laboratory examluatlons such as hematocnt and urlnalys~s for glucose, protein, bacteria, and specific gravity · It has avmlable to handle foreseeable emergencies, trmned personnel and necessary eqmpment, mcludmg but not limited to oxygen, positive pressure mask, suction, intravenous eqmpment, eqmpment for malntmmng infant temperature and ventilation, and blood expanders · It is operated under the full supervision of a licensed doctor of medicine (M D ) or registered graduate nurse (R N ) · It maintains a written agreement with at least one Hospital in the area for immediate acceptance of patients who develop _P..ql,lz_c,F.~:-.~ 29 comphcattons It nudul's,r,s an adequate medical record for each patient, the record to contain prenatal lnstory, prenatal exammaUon, any laboratory or dmgno~c tests and a postpartum summary ·It ~s expected to chscharge or transfer patients witlun 24 hours following delivery A period of one year beginning w~th .January 1 QHEMICAL DEPENDENCY TREATMENT CENTER Chemical Dependency Treatment Center shall mean a fac, hty wiuch provides a program for the treatment of chemical dependency pursuant to a written treatment plan approved and momtored by a physician and wiuch facility is also ( 1 ) afflhated with a hospital under a contractual agreement wth an established system for paUant referral, or (2) accredited as such a facility by the Joint commission on Accreditation of Hospitals, or (3) licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drag Abuse, or (4) licensed, certified, or approved as a chemical dependency treatment program or center by any other state agency hawng legal authority to so license, cerUfy, or approve COMPLICATIONS OF PREGNANCY Complications of Pregnancy is defined as condlUons, reqmnng hospital confinement (when the pregnancy is not terminated), whose diagnosis are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephnUs, nephrosis, cardiac decompression, missed abortion, and similar medical and surgical conchtions of comparable seventy, but shall not include false labor, occasional spotting, physician prescribed rest dunng the period of pregnancy, mormng sickness, hyperemesls gravidarum, pre-eclampsla, and similar conditions associated wth the management of a difficult pregnancy not constituting a nosologically distract complication of pregnancy, and non-elective cesarean section, termination of ectopic pregnancy, and spontaneous termination of pregnancy, occurring dunng a period of gestation m wluch a viable birth is not possible Contract year shall mean the period of twelve (12) months commencing on the Oroup effective date and each twelve (12) month period thereafter, unless terminated COORDINATED POLICY Coordinated Plan shall mean any of the following that provides benefits or services for, or by reason of, medical care or treatment ~ 3O Coverage under governmental progranm, (excluding Medicinal) including Medtcare, reqrlired or prowded by any statute unless coordination of benefits voth any such programs is forbidden by law Group coverage or any other arrangement of coverage for mdlwduals m a group, whether on an Insured or uninsured basis, ~n¢ludmg any prepayment coverage, group practice basis or mchvldnal practice coverage and any coverage for students which is sponsored by, or prowded through, a school or other educatmnal msttmuon above the lugh school level COURSE OF TREATMENT .~ Course of Trealment shall mean that period of time represented by an ~npaUent hospital admission and related discharge during winch time treatment has been received by you or your dependents or that period of time authorized by HMHIC as necessary to complete a cycle of treatment and subsequently prowde a medical release to you or your dependents Covered Expenses shall mean the serv~cas and supphes, detmled ~n the Schedule of Benefits Attachment, for wluch a payment ~s made COVERED FAMILY MEMBERS You and your vale or husband and Dependent cluldren who are covered under the Agreement CRISIS STABII,IZATION UNIT Cnms StablhzaUon Umt shall mean a twenty-four (24) hour residential program that is usually short-term m nature and that provtdes intensive superwmon and highly structured actlwtms to persons who are demonstrating an acute demonstrable psyetuatnc ens~s of moderate to severe proportions Custodml Care shall mean 1) that care wluch ~s marked by or given to watclung and protecting rather that seelong cure, or 2) care wluch ~s not a necessary part of medical treatment or recovery, or 3) care comprised of services and supplies that are primarily prowded to assist m the activmes of daily living DAY TREATMENT CENTER A psyeluatnc day treatment facthty shall mean a mental health faethty which prowdes treatment for mdlvtduals suffenng from aente, mental and nervous d~sorders m a structured psychiatric program utlhzmg lndlwdnahzed treatment plans w~th specific attainable goals and objecUves appropriate both to the pataent and the treatment modahty of the program and that ~s chmcally supervised by a doctor of mechcme who m certtfied m psychiatry by the American Board of Psyehmtry and Neurology Day treatment facd~ty may prowde coverage for not more than e~ght hours m a twenty-four (24) hour period, the attending physician certifies that such treatment ~s ~n heu of hosp~tahzatlon, and POS- C~R9- 92 31 the psycluatnc treatment facility Is accredited by the Program for psycluatnc Facilities, or its successor, of the $oints Commission on Accreditation of Hospitals Each full day of treatment in a psycluatno day treatment facility shall be considered equal to one- half of one,day oftreatmant of mental or emotional illness or disorder m a hospital Dependent shall mean an Eligible Dependent who has satisfied the eligibility and participation reqmrements specified m tlus Agreement Donuclhary Care shall mean that care prowded in the home, custodml m nature, for persons so d~sabled or reform as to be unable to live independently DURABLE Iv~DICAL EOUIPMENT Durable Mechcal Eqmpment must be able to vathstand repeated use, pnmanly and customanly serve a medical purpose, generally not be used in the absence of dlness or injury, reqmre a Physician's order and be appropnate for use in the home Effective Date shall mean the effective date of coverage for you and your Eligible Dependents pursuant to the terms of this Agreement ELIOIBI.E DEPENDENT Eligible Dependent shall mean an individual as defined m the ELIGIBILITY AND EFFECTIVE DATE Section of this Agreement Eligible Person shall mean an mchvldual as defined in the ELIGIBILITY AND EFFECTIVE DATE Scctaon of tins Agreement Emergency care shall mean bona fide emergency services prowded after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient seventy, ~ncluding severe pain, such that the absence of immediate mechcal attention could reasonably be expected to result in placing the patient's health m serious jeopardy, serious impairment or bodily functions, or senous dysfunction to any bodily organ or part See ELIGIBILITY AND EFFECTIVE DATE Section ]EVIDENCE OF INSURABILITY ~ 32 Evidence of Insurabthty shall mean the documentation o f health status as required by HMHIC for Eligible Persons and Ehgtble Dependents who do NOT meet the following requirements regarchng application for coverage (a) apply for coverage during an open enrollment period, or Co) apply for coverage within tinrty (30) days of quahfylng for coverage Such reformation shall be rewewed by HMHIC Notification will be sent to the Eligible Person or Ehglble Dependents regarding their ehgibthty for participation m HIVlBIC Exclusion shall mean those specific cund~tlons or causes for winch coverage by HMI-IIG is entirely excluded FAMILY DEDUCTIBLE The mammum your entire farmly will have to pay for Deductible in any year is the amount of Fannly Deductible shown m Schedule of Benefits Tins Family Deductible apphes no matter how large your fannly may be Only Covered Expenses which count toward a person's Indlmdual Deductible count toward this Deductible FDA shall mean the Food and Drug Adrmmstration, an agency of the Umted States Government Group shall mean collectively the contracting Group and all affiliated orgamzatlons of the Group, to winch tins Agreement is issued and through winch as an agent for you and your dependents become entffied to the benefits as set forth in the Schedule of Benefits QROUP EFFECTIVE DATE Group Effective Date shall mean the date specified as such in the Group Enrollment Agreement GROUP ENROLLMENT AGREEMENT Group Enrollment Agreement shall mean that agreement which is executed between HMHIC and the Group for the purpose of making available to Eligible Persons and Eligible Dependents of the Group those benefits winch are described m the cemficate of Insurance Such Group Enrollment Agreement shall identify the Group, Group Effective Date, eligibility requirements, rates, and covered benefits ]-IEALTH CARE PROVIDER/PHYSICIAN A licensed or certified provider whose services Harris Methodist Health Insurance Company must cover due to a state law requiring payment of services given w~tlun the scope of that provlder's hcense or certification A Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency, Laboratory, Dletatian, Minor Emergency Room Center, Chemical Dependency Treatment Center, Psycinatnc Day Treatment facility, Residential Treatment Center, or Crisis Stabilization Umt, or other provider or entity which provides services as set forth in this ~ 33 Agreement as described ~n the Schedule of Benefits Attachment POS-CER9-92 34 HOME bIEALTH AOENCY An agency or orgamTation wluch provides a program of home health care and wbach fully meets one of the following tests. It IS approved by Medicare · It IS established and operated m accordance with the applicable licensing and other laws · It meets the following tests It has the primary purpose of providing a home health care dehvery system bringing supportive services to the home It has a full-time adrmmstrator · It maintains written records of services provided to the patient Its staff includes at least one registered graduate nurse (R N ) or it has nursing care by a registered graduate nurse (R N ) available Its employees are bonded and it provides malpractice insurance An agency that provides counseling and incidental medical semces for a terminally fll individual Room and board may be provided The agency must meet all of the following tests · It IS approved under any requrred state or governmental Certificate of Need · It provides 24 hour-a-day, 7 day-a-week service · It has a nurse coordinator who is a registered graduate nurse (R N ) with four years of full-time chmcal expenence Two of these years must involve canng for terminally ill patients · It has a social-service coordinator who IS licensed in the area in which It IS located · The matn purpose of the agency is to provide Hospice services · It has a full-time administrator · It mmntmns written record of services given to the patient · Its employees are bonded · It provides malpractice and malplacement insurance · It xs established and operated in accordance w~th any applicable state laws ~ 35 Hospital shall mean an institution hcensed by the State of Texas and which ~s ( 1 )pnmanly engaged m providing diagnostic, medical, surg~cel, or mental health facdmes for the care and treatment of injured or swk persons, (2) operated under the medicel superviswn of a staff of legally quahfied and licensed physicians, (3) provides twenty-four (24) hour-a-day nursing service by or under the direct supervision of a Registered Nurse (R N ), (4) provides for ovenught care of patients, (5) manltzinlng clenoal and ancillary services necessary for the treaUnent of medical and surgical patients including but not lmuted to laboratory, X-ray, dietary and medical records library In no event shall the term "hospital" include a convalescent nursing home or any restitution or part thereof which is used pnnclpally as a convalescent facility, rest facdity, nursing facility, facdlty for the aged, extended care facility, intermediate'care facility, skilled nursing facility or facility primarily for rehabilitative services, the term hospital shall pursuant to Chapter 3, Texas Insurance Code, Article 3 72 included treatment in a residential treatment center for children and adolescents, treatment provided by a cnsis stabilization umt, psychiatnc,day treatment, or chenucal dependency unit IDENTIFICATION CARD A card that generally descnbes the benefits of a Plan, that in and of itself confers no nghts to semces or'other benefits The card is the sole property of HMHIC, and HlviHIC reserves the right of possession IlxIDIVIDUAL DEDUCTIBLE The Individual Deductible applies to all covered expenses The amount of the Individual Deductible is shown in Schedule of Benefits I~MMMOGRAPHY. LOW-DOSE Low Dose,Mammography shall mean the X-Ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one tad mldbreast, with two views for each breast Coverage for 35 year old females or older for an annual screening for the presence of occult breast cancer subject to the same dollar limits, deductibles, and co-insurance factors MEDICAL EMERGENCY Medical Emergency shall mean a medical condition so classified by the medical drrector and which manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient's health in serious jeopardy, or (b) serious impairment of bodily function, or (c) serious dysfunction to any bodily organ or part Examples of conditions which do not usually constitute medical emergencies are colds, influenzas, ordinary sprains, children's ear infections, or nausealand headaches Heart attacks, cardiovascular accidents, poisomng, loss of consciousness or respiration, convulsions, severe bleeding or broken bones are examples of true medical emergencies MEDICALLY NECESSARY Shall mean semces or supplies winch are (1) provided for the diagnostic care and treatment of a medical condition; (2) appropriate and necessary for the symptoms, diagnosis or treatment of a medical condition, (3) generally acceptable medical practice, (4) performed in the most cost effective and efficient manner appwpnate to treat you or your Eligible Dependent's medical condition, and (5) provided m accordance voth accepted medical standards Medicare shall mean Part A and Part B of Title XVIII of the Social Secunty Act and any amendments or regulations thereunder. MENTAL OR NERVOUS DISORDER Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotaonal disease or disorder of any land [ See SERIOUS IvIENTAL ILLNESS for defimtion of Serious Mental Illness ] NO-FAULT AUTOMOBILE INSURANCE LAW The basic reparations provision of a law providing for payment w~thout determnnng fault m connection w~th automobile accidents NURSE-PRACTITIONER A person who is licensed or certified to practice as a nurse-practmoner and fulfills both of these reqmrements · A person licensed by a board of nursing as a registered nurse · A person who has completed a program approved by the state for the preparation of nurse-practitioners OPEN ENROLLMENT PERIOD Open enrollment shall mean a period of at least thn'ty (30) days during each twelve (12) consecutive months when Eligible Persons may elect to change from the Alternative Health Benefit Plan to HMHIC or from HMHIC to the Altematlve Health Benefit Plan OTHER SERVICES AND SUPPLIES Services and supplies furmshed to the Individual and reqmred for treatment, other than the professional senaces of any Physician and any private duty or special nursing services (including intensive nursing care by whatever name called) PHYSICIAN/HEALTH CARE PROVIDER A licensed or certified provider whose services Harris Methodist Health Insurance Company must cover due to a state law requiring payment of services given within the scope of that provlder's hcense or certification ~ 37 A Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency, Laboratory, Dietitian, Minor Emergency Room Center, Chenucal Dependency Treatment Center, Psychiatric Day Treatment facility, Residential Treatment Center, or Cnsls Stahihzation Umt, or other provider or entity which provides sevaces as set forth m th~s Agreement,as descnbed m the Schedule of Benefits Attachment I~RE.EXISTING CONDITION Pre-ex~stmg Condmon shall mean a physical conchtion {hagnosed or treated w~thm sm months prior to the effective date of coverage Please see ELIGIBILITY AND EFFECTIVE DATE Section Provider shall mean any Physician, Hospital, Alhed Health Professmnal, Home Health Agency, Laboratory, Minor Emergency Room Center, Residential Treatment Center for children and adolescents, Cns~s stahilsmtion Umt, Chenncal De~ndancy Umt, Psychialnc Day Treatment facdlty or other provider or entity which provides services as set forth m this Agreement an descnbed ~n the Schedule of Benefits Attachment ltEASONABLE CHARGE An amount measured and detennmed by Hams Methodist Health Insurance Company by companng the actual charges for the semce or supply w~th the prevailing charges made for ~t Hams Metbochst Health Insurance Company detemunes the prevaflmg charge It takes ~nto account all pertanent factors mchidmg The compleraty of the service · The range of services provided · The prevadlng charge level m the geographic area where the provider ~s located and other geographic areas having snmlar medical cost experience RESIDENTIAL TREATMENT CENTER Residential Treatment Center for Children and Adolescents means a child-care restitution that provides residential care and treatment for emotionally disturbed children and adolescents and that ~s accredited as a residential treatment center by the Councd on Accreditation, the Joint Commission on Acered~taUon of Hospitals, or the American Assocmtion of Psychiatnc Semces for Children Room, board, general duty nursing, intensive care by whatever name called, and any other service regularly furnished by the hospital as a condition of occupancy of the class of accommodations occupied, but not ~ncludmg professional services of Phys~cmn nor spemal nursmg services rendered outside of an intensive care umt by whatever name called The term "s~ckness" will include a surgical procedure for stenhzat~on and related medical care and treatment and confinement vattnn 30 consecutive days from the procedure The term "sickness" will mclude comphcat~on of pregnancy (as described above) The term "s~ckness" used ~n cormect~on voth newborn children will mclude congemtal defects and bush abnormalmes, lnclu&ng premature births ~TT,T,ED NURSING FACILITY If the famhty Is approved by Medicare as a Skilled Nursing Fa~lhty then it is covered by th~s Agreement If not approved by Medicare, the facility may be covered if it meets the following tests · It is operated under the applicable hcensin§ and other laws · It is under the supervision of a ho~nsed Physician or registered graduate nurse (R N ) who Is devoting full time to supervis, on · It is r~gularly engaged m provid~ng room and board and continuously provides 24 hour a day skilled nursing care of sick and injured person's at the pauent's expense during convalescent stage of an mjury or s,¢knass · It mamtmns a daffy medical record of each patient who is under the care of a duly licensed Physician · It is anthonzcd to admimster medlcatmns to paUents on the order of a duly licensed Physician · It is not, other than incidentally, a home for the aged, the blind or the deaf, a hotel, a douncthary care home, a maternity home, or a home for aleohohcs or drug addicts or the mentally ill Total Disability and totally disabled shall mean (1) with respect to an employee or other primary msured under the policy, the complete inability of the person to perform all of the substantial and material duties and function of his or her occupation and any other gmnful occupation in wMch such person earns substantially the same compensation earned prior to disability, and (2) w~th respect to any other person/dependent under the policy, confinement as a bed patient in a hospital UTII.17.A. TION REVIEW DEPARTMENT Utthzataon Review Department shall mean a department of HMHIC which determines, in its discretion, if a service or supply is medically necessary for diagnosis or treatment of an accidental injury, illness or pregnancy A service or supply is not medically necessary if a less mtenslve or more appropriate d~agnostic or treatment alternative could be used in lieu of the services or supply given ~ 39 TERM AND AMENDMENT OF AGREEMENT This Agreement shall remain m effect for the first Con,'act Year and thereafter for successive Conm~ct Years unless sooner temunated as provided in Section TERMINATION of this Agreement HMHIC and Group may mutually alter or revise the terms of this Agreement and/or Schedule of Benefits and Riders bereto In the event of such alteration or revision, HMI-HC shall provide Group with at least sixty (60) days wntton noUce before effective date of Amendment Such notice shall be considered to have been provided when mmled to the Group at the latest date shown on the records of HMHIC · The Agreement may be amended at any time, according to any provisions of this Agreement or by written agreement between HMHIC and Group, without consent of you, or any other person having a beneficial interest in it Any such amendment shall be without prejudice to any clmm arising prior to the effective date of such amendment HMHIC shall have the right to change the rates and premiums payable hereunder (1) as of any Anniversary Date (m which case the Group shall be notified at least sixty (60) days prior to a change in rates) or (ii) in accordance with Section TERM AND AMENDMENT OF AGREEMENT of this Agreement ~ 4o ~MiSCV. i,I,~,NEOUS PROVISIONS Words usexl m the masculine shall apply to the feminine where apph~ble, and, wherever the context of tlns Agreement &crates, the plural shall be read as the singular and the singular as the plural The terms "you", "your", and "insured" shall refer to the employee "HMHIC" and ,,insurer,, shall refer to Hams Methodist Health Insurance Company The words "here°la', "hereto", "hereunder" and other sunllar compounds of the word "here" shall mean and refer to the entire Agreement and not to any particular Section or pwvlslon All references to Sections and provisions shall mean and refer to Sections and provisions contained in tins Agr.efment unless othewnse indicated RECORDS AND INFORMATION HMHIC shall, to the extent legally allowable and w~thout further consent of or not, ce to you, release to or obtmn from any insurance company or other orgamzat~on or person any mformat~on, vnth respei~t to you, winch HMHIC deems to be necessary for such purposes as Coordmatton of Benefits When o]aim,og benefits, you shall furmsh HMHIC mformat~on as may be necessary to implement tins Agreement INFORMATION FROM GROUP Group shall penoihcally forward the mformat~on required by HMHIC in conjunction w~th the admunstrat~on of the Agreement All records of Group winch have a beanng on the coverage shall be open for inspection by HMHIC at any reasonable time HMHIC shall not be liable for the fulfillment of any obhgat~on dependent upon such information prior to its receipt in a form satisfactory to HMHIC Incorrect lnformatton furmshed may be corrected, if HMHIC shall not have acted to its prejudice by relying on it HMHIC shall have the right, at reasonable times, to examine Group's records, including payroll records of the Croup hawng employees covered through tbas Agreement, w~th respect to ehgibthty and monthly premmms under tins Agreement Assignment shall mean the authonzat~on to pay benefits d~rectly to the party providing the benefit Tins may not be construed to (1) provide a coverage or benefit not otherv~se avmlable under the health ~nsurance policy, (2) allow assignment of a benefit payment to a person who ~s not legally entitled to receive such a direct payment, or (3) proinbit an insurer from verifying through the insurer's normal process the health care services provided to the covered person by the physic~an or health care provider If a written assignment of benefits payable for health care services is made by a covered person and ~s obtmnad by or delivered to the insured w~th the claim for benefits, the benefit payment shall be made by the insurer directly to the physician or other health care provider If a wntten assignment of benefits is made and dehvered or obtained as provided, the insurer is reheved of the obligation to pay and of/my habflity for paying the benefits for the health care ~ 41 services to the covered person The payment of benefits under an assignment does not reheved the covered person of any contractual realponslblhty for the payment of deductibles and copayments A physician or other health care provider may not waive copayments or deductibles by acceptance of an asmgnment Any alterations or rewslons to this Agreement shall not be valid unless evidenced by a written amendment winch has been signed by Oroup and by an officer of HMHIC and attached to the affected document No other person has the authority to change tins Agreement or to wmve any of its provis~ons Tins Agreement is executed and is to be performed in all respects in accordance w~th all federal and Texas state laws applicable to Health Insurance Compames and all other applicable Texas state laws or regulations IblCORPORATION BY REFERENCE The Schedule of Benefits, Group Enrollment Applications, any optional Raders, any Attactunants, and any amendments to any other forgoing, form a part of flus Agreement as if fully incorporated hereto Any dtrect conflict or amblgmty of flus Agreement shall be resolved under terms most favorable to you ENTIRE AGREEMENT Agreement shall mean Entire Contract winch is defined as the Group Contract, Certificate of Coverage, Group Enrollment Agreement, Schedule of Benefits, Apphcatlons, Attachments, Pdders, Amendments hereto, if any ]INFORMATION TO YOU Upon execution of flus Agreement, HMHIC shall provide to you a copy of thts Certtficate of Coverage,, and an Identification Card Such delivery shall be accomplished by mmhng postage prod, to the latest address furmshed to HMHIC or by delivery from a representative of HMHIC or Group to you In the admimstratlon of HMHIC, flus Agreement shall be applied umformly to all similarly mmated employees CALCULATION OF TIME In deternumng time periods vatinn an event or action is to take place for purposes of HMHIC, no fraction of a day shall be considered, and any act, the performance of which would fall on a Saturday, Sunday, holiday or other non-business day, may be performed on the next following business day, may be performed on the next business day ~ 42 Ewdence reqmred of you to HMHIC may be cemficate, affidavit, document, or other lnformaUon wluch when acting on it considered perUnent and reliable, and signed, made or presented by the proper party or parties If any provision of tlus Agreement shall be held mvahd or illegal, the rest of tlu~Agreement shall remmn m force and effect and shall be construed in accordance w~th the intentions of the parties as ranmfasted by all prowslons hereof including those wluch shall have been held invalid and illegal Furthermore, m heu of any pmvmon hereof wluch is found to be illegal, invalid or unenforceable prowslon as may be possible and be legal, valid and enforceable without materially changing the purpose and intent of this Agreement The titles and headings of Sections or prowslons are included for convemence of references only and are not be considered in construction of the Sections or prowslons hereof NOTICE OF TERMINATION All HMI-HC notices of termination oftlus Agreement or of your rights will be in writing and shall state the cause of terrmnation, v~th specific reference to the provision(s) of this Agreement giving rise to the right of temunatlon Any notice under this Agreement shall be in writing, and shall be given by United States marl, postage prepmd, addressed as follows HMHIC 611 Ryan Plaza Drive, Suite 900 Arhngton, Texas 76011-4009 Group The address specified on the executed Group Enrollment Agreement or the latest address provided, m writing, to HMHIC Employee The latest address provided by you on the Application form actually dehvered to HMHIC The effective date of notice is two (2) bus~ness days after the date of deposit wrth the Umted States Post Office ~ 43 SCHEDULE OF BENEFITS POS PREFERRED PLUS HARRIS METHODIST HEALTH INSURANCE COMPANY 601 Ryan Plaza Dr, ve, Su,te 211 Arhngton, Texas 76011 t -800-356-7522 (817)462-7800 POSLG$CH98 You and your Ehglble Dependents are entitled to receive the services and benefits set forth ~n this Schedule of Benefits which are Medically Necessary and obtained in accordance with the provisions of the Group Health Care Agreement/Subscnber Certificate of Coverage and/or Certificate of Insurance A The Uflhzat~on Rewew Department determines the Medical Necessity of services You are responsible for notifying the Ut~hzat~on Rewew Department (UR) for the serwces hsted below The UR phone number ~s (817)462-7800 or 1(800) 633-8598 Benefits which are not Medically Necessary will be denied The ultimate decision on your medical care must be made by you and your Physician The Ut~hzat~on Review Department only determines the Medical Necessity of a service, only servlcaS medically necessary ara pa~d for according to the Agreement benefits and prowslons Benefits are reduced ~fyou do not call UR pnor to receiving services as required The penalty for not calhng UR ~s a 50% reduction ~n benefit payment The penalty is applied to each confinement, surgical procedure, diagnostic procedure, or treatment plan Within five (5) working days before rece~wng the following servmes, you are required to call UR for authorization · Inpatient Admissions (~ncludlng pregnancy) · Outpatient surgery where the procedure raqulreS an operating room or surgical sethng (excephon endoscopes, stenhzatlon, and b~ops~es) · Inpatient Chemical Dependency Treatment · Home IV Therapy · Physical Therapy and Occupatmnal Therapy beyond SlX (6) visits · Durable Medical Equ~pment/Prosthehcs · Home Nursing Services · Heanng A~ds, ~f coverage ~s ~ncluded · Skilled Nursing Fac~hty · Outpatient Mental/Nervous disorder Other office procedures requlnng precertlficat~on are · Laser procedures, Thalhum stress tests, Cystoscop~es, Chonomc vllh samphng, Ammocentesls, LEEP/LETZ procedures, and D&C · Artenogram, Aortogram, Myelogram, and Lumbar Puncture B Benefits which are covered under Hams Health Plan, Inc d/b/a Hams Methodist Health Plan (HMHP)are not covered expenses under Hams Methodist Health Insurance Company (HMHIC) No Coord~nahon of Benefits are available between HMHP and HMHIC Benefits Emergency Care which does not meet HMHP's deflmt~on will be covered under HMHIC C You must submit your own claim forms for all medical bills for services received from Prowders The claim office address ~s P O Box 90100, Arlington, Texas 76004-3100 Benefits are based on the Reasonable and Customary charges as established by HMHIC The benefits will be POSLGSCH 96 2 sent ~n accordance w,th claims prowslons outlined in the Certificate of Coverage document An explanation of benefits (EOB) summary will be sent which explains the amount of benefits pa~d as well as the amount of payment which ~s your responsibility D All services and benefits are subJect to any stated Copayment or coinsurance amounts, hm~taflons, and exclusions described m th~s Schedule of Benefits E Any copayment expressed as a percentage of "Total Charges" or flat amount shall mean that portion of the Reasonable and Customary charges as established by HMHIC F Th~s Schedule of Benefits may be supplemented by adding benefit R~ders ~f included w~th th~s Group Health Care Agreement/Subscnber Cerfificate of Coverage, and/or Certificate of Insurance G The relationship between HMHIC and Group ~s that of ~ndependent contracting entities Providers are not agents or employees of HMHIC nor ~s HMHIC an employee or agent of any Prowder Prowders shall maintain the physician-patient or professional-patient relationship w~th you and shall be the only part~es responsible to you for the services prowded Neither HMHIC or any employee of HMHIC shall be deemed to be engaged ~n the practice of medicine HMHIC shall ~n no way supervise the practice of medicine by any Prowder, nor shall HMHIC ~n any manner superwse, regulate or ~nterfere w~th the usual professional relationships between a Prowder and you H The follow~ng Calendar Year Deducfible must be satisfied ~n full (100%) for all benefits and nders from January 1 through December 31 Maximum Calendar Year Deductible Per Member $500 00 Per Family $1,500 00 Any serwces which are I~m~ted ~n e~ther da~ly I~m~ts or dollar maximums under HMHP pohcy w~ll also be counted towards HMHIC's da~ly hm~t or dollar maximum POSLGSCH 96 3 The Calendar Year Deductible must be satisfied ~n full (100%) for all benefits and nders from January I through December 31 Only one Copayment w~ll be required for covered services performed or furmshed on same date of service by the same Provider Th~s Copayment w~ll be the h~gher of all hsted Copayments Benefits Required Copayment Physician office ws~ts $20 00 per ws~t Adult health assessments, routine physical 50% of Total Charges examinations, well child care, and health education for d~agnos~s, care and treatment of ~llness or ~njury prowded by a Physician Annual well woman examlnahon 50% of Total Charges Medically accepted Bone Mass Measurement for 50% of Total Charges Quahfled Ind~wduals for detection of Iow bone mass and to determine the person's nsk of osteoporos~s and fractures associated w~th osteoporos~s Physician office vis,ts after hours $25 00 per wslt Immun~zabons 50% of Total Charges Home ws~ts $20 00 per visit Allergy d~agnos~s and/or testing, serum is not covered $75 00 per wsit Administered drugs, medications, dressings, sphnts, $20 00 per visit and casts D~agnost~c services, laboratory tests, and x-rays 30% of Total Charges (Including Low-Dose Mammography, w~ll be covered as other x-rays) Ultrasound, MRI, CAT, and non-routine laboratory tests $100 00 per test Surgery and/or anesthesia performed ~n the $100 00 per procedure physician's office or outpatient setting POSLGSCH 96 4 All physician fees ~ncludmg anesthesia wh~le 30% of Total Charges the Insured ~s hospitalized Professional radiology and pathology fees 30% of Total Charges (Includ~nglLow-Dose Mammography) For maternity services, Covered Person shall be entitled to receive medical, surgical, and hospital care from physicians and other Prowders dunng the term of the pregnancy, upon dehvery, and dunng the postpartum penod for normal dehvery, for aborhon and m~scamages, and for complications of pregnancy Charges related to medical serv~cas connected w~th the home delivery of a newborn and services of m~d-w~ves, unless prowded as Emergency Care Services, w~ll not be covered Benefits Required Copayment Physlc~anl services for maternity care ~nclud~ng 30% of Total Charges delivery, hospital ws~ts, and anesthesia Physician' care in the hospital for care 30% of Total Charges of Eligible Newborn NOTE You must obtain authorization for most health care serwces (other than rouhne office v~s~ts) by calhng the Ut~hzaflon Rewew Department Inpabent admission to any health care fac~hty must always be precerhfled See Item "A" under "Obta~mng Health Care Services" for the complete I~st of other services and procedures which require Utilization Rewew precerfificat~on Failure to call Ut~hzat~on Rewew as directed w~ll result ~n a fifty percent (50%) reduction m benefit payment penalty POSLG$CHg6 5 The Calendar Year Deducttble must be satisfied ~n full (100%) for all benefits and nders from January 1 through December 31 You shall be entitled to receive Medically Necessary hospital services, subject to all defimhons, terms and cond~hons of th~s Agreement and Schedule of Benefits If you elect to remain ~n the hospital beyond the penod which ~s Med~celly Necessary (as determined by your Physician and HMHIC Uflhzat~on Rewew Department), you will be responsible for non Medically Necessary services d~rectly to the hospital You must not~fy the Utlhzahon Rewew department ~f your stay ~s extended beyond the authonzed t~me by the Ut~hzaflon Rewew Department Benefits Required Copayment INPATIENT HOSPITAL SERVICES 30% of Total Charges Sem~-pnvate room, private ~f Medically Necessary, and all services and medical supphes related to ~npabent treatment OUTPATIENT HOSPITAL SERVICES (Including Ambulatory Fac~ht~es) Surgery $100 00 per procedure Therapeutic rad~abon treatment 30% of Total Charges Inhalation therapy 30% of Total Charges D~agnoshc teshng, laboratory, and x-rays 30% of Total Charges Ultrasound, MRI, CAT, and non-roubne $100 00 per test laboratory tests NOTE You must obtain authorization for most health care services (other than routine office ws~ts) by calling the Ut~hzahon Rewew Department Inpabent admission to any health care facd~ty must always be precert~fied See item "A" under "Obtaining Health Care Services" for the complete hst of other services and procedures which require Ut~hzabon Review precert~ficat~on Failure to call Ut~hzabon Review as d~rected w~ll result ~n a fifty percent (50%) reducbon ~n benefit payment penalty POSLGSCH96 6 The Calendar Year Deductible must be satisfied ~n full (100%) for all benefits and riders from January 1 through December 31 In cases of a Medical Emergency, you are enhtled to the benefits and services set forth ~n th~s Schedule,of Benefits and m th~s Agreement At the time of a Medical Emergency which results ~n a hospital admission, you or someone acting on your behalf, shall notify the Ut~hzahon Review Department w~th~n twenty-four (24) hours or as soon as reasonably possible Upon notification, the Uflhzat~on Review Department w~ll evaluate the need for continuation of hospital services Benefits Requ,red Copayment Physician office v;s~ts 30% of Total Charges Phys;c~an office v~s~ts after hours 30% of Total Charges Hospital emergency room and urgent care center 30% of Total Charges services, including physician fees Follow-up care 30% of Total Charges POSLG$CH96 7 The Calendar Year Deductible must be satisfied ~n full (100%) for all benefits and nders from January 1 through December 31 Family Planning Services will be avadable to you on a voluntary bas~s Covered services will include h~story, physical examination, related laboratory tests, medical supervision ~n accordance with generally accepted medical practice, ~nformaflon and counsehng on contraception, ~ncludlng adwce or prescnpbon for a contraceptive method, educahon, including educabon on the prevention of venereal d~sease, and voluntary stenhzatlon after appropriate counsehng Benefits Reqmred Copayment Physician office ws~ts, ~ncludlng related testing, $20 00 per ws~t education and counsehng F~ttlng and d~spenslng of IUD and d~aphragms $20 00 per ws~t Tubal hgat~on $75 00 per procedure Vasectomy $75 00 per procedure NOTE You must obtain authorization for most health care services (other than routine office ws~ts) by calhng the Utilization Rewew Department Inpahent admission to any health care facility must always be precerflfied See Item "A" under "Obtaining Health Care Services" for the complete I~st of other services and procedures which require Utilization Review precert~ficatlon Failure to call Utilization Rewew as d~rected w~ll result ~n a fifty percent (50%) reduction ~n benefit payment penalty POSLGSCH 96 8 The Calendar Year Deductible must be sat[stied ~n full (100%) for all benefits and riders from January I through December 31 Infertd~ty services will be available to you on a voluntary bas~s Artificial insemination and d~agnost~c services to determine the cause of ~nfert~hty will be prowded Excluded from serwces to treat ~nfert~l~ty are thOSelServ~ces descnbed ~n "Exclusions" of th~s Schedule of Benefits Benefits Requtred Copayment Physician office ws~ts for d~agnosis, non-psychiatric $20 00 per ws~t counseling, artificial insemination, and sperm count Admlmstraflon of ~nfertlhty medications, tnferfllity $20 00 per ws~t medications not covered Endometnal b~opsy, hysterosalp~ngography and 30% of Total Charges d~agnost~c laparoscopy Sonogrem and/or ovulation k~t $75 00 per test or k~t NOTE You must obtain authonzaflon for most health care services (other than routine office ws~ts) by calhng the Utilization Review Department Inpatient admission to any health care facility must always be precert~fled See Item "A" under "Obta~mng Health Care Services" for the complete I~st of other services and procedures which require Uflhzatlon Review precerflficat~on Failure to call Utilization Rewew as directed will result ~n a fifty percent (50%) reduction ~n benefit payment penalty POSLGSCH 96 ~ The Calendar Year Deducbble must be satisfied ~n full (100%) for all benefits and nders from January 1 through December 31 You shall be entitled to all necessary care and treatment for chemical dependency on the same bas~s as that provided for any physical illness to a I~febme maximum of three (3) separate senes of treatments D~agnos~s and treatment for chemical dependency shall include detox~flcabon and/or rehabilitation on e~ther an inpatient or outpatient bas~s as determined to be Medically Necessary by a Physician All treatment ~s subJect to the same I~mltaflons, exclusions, and copayments as apphed to covered services of any other physical ~llness Note Inpatient Drug Treatment requires precert~flcaflon by the Utilization Rewew Department A senes of treatments ~s considered to be a planned, structured, and organized program to promote chemical free status which may ~nclude d~fferent fac~l~bes or modal~fies and ~s complete when [] You are d~scharged on medical adwce from ~npaflent detox~flcabon, inpatient rehab~htabon treatment, part~al hospitalization or ~ntenswe outpatient treatment, or [] You have received a senes of these levels of treatments w~thout a lapse m treatment, or [] You fa~l to matenally comply w~th the treatment program for a penod of thirty (30) days Benefits Required Copayment Office ws~ts $20 00 per ws~t Necessary care and treatment for detox~flcahon and/or $20 00 per ws~t rehab~htat;on from chemical dependency Intensive outpatient or parbal hosp~tahzat~on 30% of Total Charges NOTE You must obtain authonzat~on for most health care services (other than routine office ws~ts) by calling the Uhhzat~on Review Department Inpabent admission to any health care facility must always be precert~fied See Item "A" under "Obta~mng Health Care Services" for the complete hst of other services and procedures which require Ubl~zabon Review precert;ficaflon Failure to call Ut~hzaflon Rewew as directed w~ll result in a fifty percent (50%) reduct;on ~n benefit payment penalty NOTE Any serv~cas which are I~m~ted ~n e~ther da~ly hm~ts or dollar maximums under HMHP policy w~ll also be counted towards HMHIC's da~ly hm~t or dollar maximum POSLGSCH 96 10 The Calendar Year Deductible must be satisfied ~n full (100%) for all benefits and nders from January 1 through'December 31 OUTPATIENT MENTAL HEALTH SERVICES You shall be entitled to reca~ve up to twenty (20) office ws~ts per Calendar Year for evaluation, cns~s ~ntervenflon and stab~hzaflon, and for outpatient therapy m support of the evaluahon or cns~s ~ntervenflon The twenty (20) ws~ts maximum may ~nclude md~wdual treatment, couple, or family ws~ts Benefits Required Copayment Outpatient office ws~ts for cns~s ~ntervenflon and treatment $20 00 per ws~t Psychological testing 30% of Total Charges INPATIENT MENTAL HEALTH SERVICES When deierm~ned to be Medically Necessary by the Uflhzat~on Rewew Department, you shall be entitled to evaluation, crisis intervention, treatment or any combmahon thereof for acute cond~bons Only treatment at the most appropnate level of care as determined by the Ut~hzatmn Rewew Department w~ll be authorized Benefits, Required Copayment Inpatient hosp~tahzat~on for up to thirty (30) ~npat~ent 30% of Total Charges days per Calendar Year Psychlatnc Day Treatment Fac~hty or Cns~s Stablhzabon 30% of Total Charges Umt or Residential Treatment Center for Children and Adolescents for up to s~xty (60) days per Calendar Year Treatment ~n such faclhtms w~ll be hm~ted to sixty (60) days of care such that one (1) day of care ~n a psych~atnc day treatment fac~hty center shall be equal to one-half (%) days of hospital (mpabent) care NOTE You must obtain authonzaflon for most health care services (other than routine office ws~ts) by calhng the Uhhzat~on Rewew Department Inpatient admission to any health care fac~hty must always be precert~fled See Item "A" under "Obtaining Health Care Services" for the complete hst of other serwcas and procedures which require Ut~hzat~on Rewew precart~ficaflon Failure to call Utihzat~on Rewew as d~rected w~ll result m a fifty percent (50%) reduction ~n benefit payment penalty NOTE Any serwcas which ara hm~ted ~n e~ther da~ly hm~ts or dollar maximums under HMHP pohcy w~ll also be counted towards HMHIC's da~ly hm~t or dollar maximum POSLQSCH 96 11 The Calendar Year Deductible must be satisfied m full (100%) for all benefits and nders from January 1 through December 31 You shall be entitled to receive Inpahent or Outpahent physical, occupational, and speech therapy rehab~htaflon services d~rected and monitored by a Physician or by a hcensed or certified physical, occupational, or speech therapist All servmes must be prowded ~n relation to a covered d,agnosls or procedure and must prevent dysfunction, restore functional ab~hty, or fac~htate maximal adaptation to ~mpa~rment Services must be pmwded according to a specific written treatment plan that details the treatment, ~nclud~ng frequency and duration, and prowdes for ongoing rewews Services ara expected to result ~n s~gn~ficant ~mpmvement of the condition w~th~n a two (2) month penod The two (2) month penod commences w~th the first ws~t Short term is defined as two (2) months or less Treatment ~s I~m~ted to a maximum of s~xty (60) ws~ts per medical episode Rehab~htat~on services ara prowded whether you are ,n a Hospital, nursing fac~hty, or at home Occupational therapy shall mean those services designated to prevent dysfuncbon, restore functional ab~hty and fac~htate maximal adaptation to ~mpa~rment Coverage is provided for the treatment of loss or ~mpalrment of speech or heanng Benef,ts Requ,red Copayment Short-term rehab~htahve services including $20 00 per ws~t-Outpahent occupahonal therapy, physical therapy, or 30% of Total Inpahent Charges speech therapy Long-term or maintenance services Not Covered Long term/maintenance services are defined as ~nclud~ng Custod~al/Domic~hary Care and services which are not skilled ~n nature and not medically necessary Maxlmui~ Benefit Services are hm~ted to a maximum of two (2) months per medical episode for services prowded ~n an Outpabent setting NOTE You must obtain authonzahon for most health care services (other than routine office ws~ts) by calhng the Ut~hzahon Rewew Department Inpahent adm~ssmn to any health care fac~hty must always be precert~fled See Item '%" under "Obtaining Health Care Services" for the complete hst of other services and procedures which require Ufihzat~on Rewew precert~ficat~on Failure to call Uflhzat;on Rewew as d~rected w~ll result ~n a fifty percent (50%) reduchon m benefit payment penalty NOTE Any servrces which are I~m;ted ~n e;ther daily hm~ts or dollar maximums under HMHP pohcy w~ll also be counted towards HMHIC's da~ly hm~t or dollar maximum POSLGSCH 96 12 The Calendar Year Deductible must be satisfied ~n full (100%) for all benefits and riders from January I through December 31 You shall be entitled to services and benefits provided for k~dney d~alys~s upon pnor authorization from the Uflhzat~on Rewew Department and only ~f your Physician determines that such service represents the preferred method of treatment, and you satisfy the cntena for the service ~nvolved Coveragelw~ll be coordinated for you if you are eligible for available coverage under the Medicare prows~ons for End Stage Renal D~sease Benef,ts Requ,red Copayment Inpatient or outpatient hospital, or outpatient 50% of Total Charges k~dney d~alys~s center Home d~alys~s (continuous ambulatory pentoneal 50% of Total Charges d~alys~s) ~nclud~ng equipment, training, solutions, co~ls, drug and surgical supplies NOTE You must obtain authonzat~on for most health care services (other than routine office ws~ts) by calling the Utilization Rewew Department Inpatient admission to any health care fac~hty must always be precerhfled See Item "A" under "Obtaining Health Care Serwces" for the complete I~st of other services and procedures which require Utilization ~ Rewew precert~ficat~on Failure to call Utll~zahon Review as d~rected w~ll result ~n a fifty I percent (50%) reduction m benefit payment penalty The Calendar Year Deductible must be satisfied ~n full (100%) for all benefits and nders from January 1 through December 31 Benefits Requ,red Copayment You shall be entitled to both land and a~r 30% of Total Charges ambulance serwces for Medically Necessary Emergency Care Services POSLGSCH g$ 13 The Calendar Year Deduchble must be satisfied ~n full (100%) for all benefits and riders from January I through December 31 "Home health service" means the prows~on of a health service for payment or other consideration in a patient's residence under a plan of care estabhshed, approved ~n wntmg, and reviewed at least every two (2) months by the attending Physician and certified by the attending Physician as necessary for medical purposes You shall be entitled to receive home health care services according to a Treatment Plan approved by the Utd~zat~on Rewew Department Treatment w~ll be prowded for phys~cel, occupational, speech, or respiratory therapy Home health care services ~ncludes · Skilled nursing by a registered nurse (RN) or hcensed vocafional nurse (LVN) under the supervision of at least one registered nurse and at least one physician · The servtce of a home health a~de under the supervision of a registered nurse The furnishing of medical equipment and medical supphes other than drugs and medicines Home Health Servmes prowded under th~s section may not be reimbursed unless the attending Physician certified that hosp~tahzat~on or confinement ~n a Skdled Fac~hty would otherwise be raqu~red ~f a treatment plan for home health care was not provided The number of ws~ts for whmh benefits w~ll be payable are s~xty (60) v~s~ts ~n any Calendar Year for each covered person under th~s pohcy Excluded benefits include Custodial Care, benefits prowded by a person who resides ~n the covered person's home, or ~s the Insured of the covered person's famdy A ws~t by a Home Health Agency representative ~s considered one (1) home health care v~s~t Four hours of home health a~de servme is considered one (1) Home Health Care v~s~t If servmes extend beyond four hours, each four hours or port~on of that period ~s considered as one (1) Home Health Care ws~t Benefits Requ,red Copayment Skdled nursing care, physical, occupabonal, $20 00 per v~s~t speech or respiratory therapy, ~ntravenous solutmns, and home health a~d services Hospice (home health service only) $20 00 per ws~t NOTE You must obtain authonzahon for most health care serv~cas (other than routine office ws~ts) by calhng the Uhhzat~on Review Department Inpatient admission to any health care fac~hty must always be precert~fied See item "A" under "Obtaining Health Care Services" for the complete hst of other services and procedures which require Utd~zahon Review precertlficaflon Failure to call Uflhzat~on Rewew as d~rected w~ll result ~n a fifty percent (50%) reduction ~n benefit payment penalty NOTE Any services which are hm~ted ~n e~ther da~ly hm~ts or dollar maximums under HMHP pohcy w~ll also be counted towards HMHIC's da~ly hm~t or dollar maximum POSLGSCH 96 14 The Calendar Year Deductible must be satisfied ~n full (100%) for all benefits and nders from January 1 through December 31 You are entitled to reca~ve servmes m a Skilled Nursing Fac~hty for medical conditions whmh ~n the judgement~of the Utihzaflon Review Department are subject to s~gmficant chmcal ~mprovement and which require serv~cas which can only be prowded at that level of care Services ~n a Skilled Nursing Facility may be provided ~n heu of hosp~tahzat~on (e~ther ~n heu of admission or upon d~scharge from ~npat~ent care) as Medically Necessary based on acuity of services and patient condition, are hm~ted to s~xty (60) days per Calendar Year Benefits Required Copayment Room, Board, medications and supphes 30% of Total Charges wh~le confined ~n a Skilled Nursing Fac~hty as part of a short-term recovery or rehab~htat~on program Physician ws~ts while confined to Skilled 30% of Total Charges Nursing Facility NOTE You must obtain authonzaflon for most health care services (other than routine office visits) by calling the Ut~l~zation Rewew Department Inpatient admission to any health care fac~hty must always be precart~fled See Item "A" under "Obtaining Health Care Serv~cas" for the complete hst of other services and procedures which require Ut~hzaflon Rewew precertlficaflon Failure to call Ut~hzaflon Rewew as d~rected w~ll result m a fifty percent (50%) reduction ~n benefit payment penalty NOTE Any serv~cas which are I~m~ted ~n e~ther da~ly hm~ts or dollar maximums under HMHP pohcy ~ w~ll also be counted towards HMHIC's da~ly hm~t or dollar maximum POSLGSCH 96 15 The Calendar Year Deductible must be sabsfied m full (100%) for all benefits and riders from January I through December 31 You are entitled to prosthetic medical services or medical apphances ~f Medically Necessary, with authonzafion from the Ut~hzat~on Rewew Department While you are covered under th~s Agreement, ~mflal prostheses are prowded when required due to illness or ~njury Replacement ~s prowded only when marked physical changes occur which require replacement, and ~s not prowded for ~tems which wear out due to normal usage Benefits Required Copayment Internal prosthetic apphances ~nclud~ng 30% of Total Charges ~ntemal card~ac pacemakers, and m~nor dewces such as screws, w~re mesh, na~ls, and artificial joints Supply of or replacement of ~nternal breast prothesls covered only if In~t~al surgery was result of ~njury or d~sease External prosthetic apphances ~nclud~ng 30% of Total Charges artificial arms, legs, above or below knee or elbow prostheses, eyes, lenses, external card~ac pacemaker, terminal dewces such as hand or hook, rigid or sem~-ng~d ~mmob~l~z~ng devices such as arm, leg, neck or back braces, and ordinary sphnts, and crutches NOTE You must obtain authonzabon for most health care services (other than routine office ws~ts) by calhng the Uhhzat~on Rewew Department Inpabent admission to any health care faclhty must always be precert~fled See Item "A" under "Obta~mng Health Care Services" for the complete hst of other serwces and procedures which require Utilization Rewew precerflficat~on Failure to call Uflhzat~on Rewew as d~rected will result ~n a fifty percent (50%) reduchon ~n benefit payment penalty POSLGSCH96 16 The Calendar Year Deductible must be satisfied ~n full (100%) for all benefits and nders from January I through December 31 You are entitled to benefits for certain durable med~cel equipment as prescnbed by a physician, w~th pnor authonzaflon from the Uflhzat~on Rewew Department Durable medical equipment must be able to w~thstahd repeated use, pr~manly and customanly serve a medical purpose, generally not useful ~n the absence of ~llness or ~njury, require a physician's order, and be appropnate for use ~n the home At ~ts option, HMHIC may rant or purchase approved equipment HMHIC retains the nght of possession of equipment HMHIC shall have no hab~hty or respons~b~hty for repair or replacement of equipment lost or damaged Equipment not cens~dered durable med~cel equipment' ~s descnbed ~n "Exclusions", Section XIX, Number 31 of th~s Schedule of Benefits Benef,ts, Required Copayment Rental or purchase of medical equipment 30% of Total Charges NOTE You must obtain authorization for most health care serwces (other than routine office ws~ts) by calhng the Ut;hzaflon Rewew Department Inpatient adm~ssmn to any health care fac~hty must always be precert~fled See Item "A" under "Obta~mng Health Care Services" for the complete I~st of other services and procedures which require Ut~hzaflon Rewew precert~ficat~on Failure to call Ut~hzat~on Rewew as d~rected w~ll result ~n a fifty percent (50%) reduction ;n benefit payment penalty POSLGSCH ~6 17 The Calendar Year Deducbble must be sabsfied ~n full (100%) for all benefits and nders from January 1 through December 31 If Medically Necessary and authonzed by the Company, you are enbtled to K~dney transplants, corneal transplants, hver transplants for chddren w~th b~hary atras~a and other rare congemtal abnormahbes, and bone marrow transplants for Aplast~c Anemia, leukemia, lymphoma, Severe Combined Immunodefic~ency D~sease, and Wmcott-Aldnch Syndrome where traditional modahbes of medical therapy have been exhausted Benefits for covered transplants, as spec{fled ~n this secbon, are prowded to the extent that benefits are avadable under th~s pohcy w~th the follow~ng excepbons a medical costs associated w~th organ procurement (the removal of an organ for a covered transplant) when the recipient ~s a Covered Person, are hm~ted to a maximum benefit of $10,000 00 for the recipient and donor, b the donor's transportabon costs are not covered, c charges related to organ, bssue, or artificial organ transplants, except as specified ~n th~s section, are not covered d services prowded to a Covered Person acting as a donor for an organ or element of the body are not covered, and e reimbursement for medical expenses of a hve donor are prowded to the extent that benefits remain avadable after all benefits have been prowded on behalf of the Covered Person as the recipient LIMITED DENTAL SERVICES The Calendar Year Deductible must be satisfied in full (100%) for all benefits and nders from January 1 through December 31 You are entitled to services for the ~nltlal stablhzabon of acute accidental, non-occupabonal ~njury, to sound natural teeth with pnor authonzatlon by the Ubhzatlon Rewew Department, when prowded within thirty (30) days of the acc{dent on an outpabent bas~s only Limitations and exclusions for dental services are descnbed in this Schedule of Benefits Copayments wdl be the same as described for other Hiness or mJury services POSLGSCH 96 18 The maximum annual Copayments for covered benefits, under this Schedule of Benefits, will not exceed the follow~ng m a Calendar Year as described ~n GLOSSARY OF TERMS, of the Group Agreemer~t/Subscriber Certificate of Coverage Benefits Maximum Annual Copayments Per ~Member $4,000 00 Per IFam~ly $8,000 00 POSLGSCH 98 lg The following services are hm~ted as described below 1 The Ut~hzaflon Rewew Department determines the Medical Necessity of services You are responsible for notifying the Ut~hzabon Rewew Department (UR) for the services hsted below The UR phone number ~s (817) 878-5828 Benefits which are not Medically Necessary w~ll be den~ed The ultimate decision on your medical care must be made by you and your Physician The Utdlzat~on Rewew Department only determines the Medical Necessity of a service, only services medically necessary are pa~d for according to the Agreement benefits and prows~ons Benefits are reduced ~fyou do not call UR pnor to receiving services as required The penalty for not calhng UR ~s a 50% reduchon ~n benefit payment The penalty ~s applied to each confinement, surgical procedure, d~agnost~c procedure, or treatment plan Services which are provided under HMHP are not covered expenses under HMHIC 2 Care and treatment of the teeth or gums, except for oral surgery for tumors or ~njur~es to the jaw bone or surrounding tissue, is limited to the ~n~tial stabilization of acute, accidental, non- occupational ~njury to sound, natural teeth when prowded within thirty (30) days of the accident, on an outpatient basis only 3 Coverage for v~s~on examinations ~s hm~ted to conditions which require examination to d~agnose ~njury or ~llness, unless covered by R~der attached to th~s Agreement 4 The benefit for durable rned~cal equipment ~s hm~ted to e~ther the total rental cost or the purchase pnce of such equipment, whichever ~s less, as determined and authonzed ~n advance bythe HMHIC Medical D~rector or h~s designee HMHIC w~ll have no hab~hty or responslbd~ty for repair or replacement of equipment lost or damaged 5 Care and treatment prowded ~n hospital owned or operated by federal government is hm~ted to the care for the condition which the law raqu~res to be treated or prowded ~n a pubhc facility 6 The purchase or flthng of eye glasses or contact lens or adwce on their care ~s hm~ted to the m~flal set of eye glasses, contact lens, or lens ~mplant required following cataract surgery, repair of congenital defect or as required by an accidental injury to you 7 Coverage for reconstructive surgery ~s hm~ted to surgery necessary to repair a functional d~sorder resulhng from d~sease, inJury (except Congenital defect), Congemtal defect reconstructive surgery w~ll be covered Supply or replacement of ~nternal breast prothes~s ~s covered only ~f ~nlt~al surgery was a result of ~njury or d~sease POSLGSCH96 20 8 Coverage for temporomand~bular'(jaw or cramomand~bular) joint (TM J) ~s I~m~ted to Medically Nec'essary d~agnostlc serwces end/or surgical treatment as determined to be Medically Nec~essary Charges related to dental services for this condition are not covered 9 Pre. Exist~ng Condition means any d~sease or physical condition for which the Covered Person rec~ived medical advice or treatment for dunng the continuous s~x (6) month penod pnor to the effective date of coverage Pra-Ex~st~ng Conditions ara covered under the Pohcy beginning the earher of e~ther a the end of a continuous penod of twelve (12) months commencing on or after the effective date of the Covered Person's coverage dunng all of which the Covered Person has recewed no medical advice or treatment for m connection w~th such , d~sease or physical condition, or b the end of the two (2) year penod commencing on the effective date of the Covered Person's coverage Pre-exrstmg conditions are covered after the satisfactory completion of a wa~tlng penod However, the wa~tlng period w~ll not apply to a Covered Person who was covered under the Pohcyholder's Pnor Plan on the Effective Date of the Pohcy The Company g~ves the Covered Person credit for the time he/she was covered under the Pnor Plan, ~f the prewous coverage was continuous to a date not more that thirty (30) days pnor to the Effechve Date of the Pohcy coverage, exclusive of any apphcable wa~t~ng penod under the pohcy The maximum amount of additional copayment for a Pre-Ex~st~ng Condition during a calendar year w~ll not exceed $2,000 for any such covered Person or Dependent, or $4,000 total for such Covered Person and h~s/her Dependents If benefits are received under the HMHP policy, no benefits are payable under the HMHiC pohcy, therefore the Pre-Ex,sting condition clause does not apply to your coverage POSLGSCH 96 The following services and supphes, and the cost hereof, are excluded from coverage under th~s Agreement, unless specifically added by R~der to this Schedule of Benefits 1 Charges for services covered or prowded under the HMHP Contract 2 Charges related to any service or treatment which a Covered Person would not be legally rrequ~red to pay, except for Medicaid 3 Charges related to personal, convenience, or comfort ~tems such as personal k~ts prowded on admission to a hospital, telews~on, telephone, newborn infant photographs, guest meals, b~rth announcements, and other related articles which are not for the specific treatment of ~llness or ~njury 4 Charges related to transportatmn, except charges related to land and a~r ambulance services for Medically Necessary Emergency Care Services descnbed ~n th~s Agreement 5 Charges related to pnvate hospital room and/or private duty nursing unless determined to be medically necessary and authonzed by HMHIC Ut~hzahon Revmw 6 Charges related to services rendered by a person who resides ~n the Covered Person's home, or by an ~mmed~ate relative of the Covered Person 7 Charges related to services for m~htary or service connected conditions for which the Covered Person ~s legally entitled, and for which appropriate fac~hfies are reasonably available to the Covered Person 8 Charges related to occupatmnal ~njury or ~llness or conditions covered under Worker's Compensation or s~m~lar law 9 Charges for health care services pnmanly for rest, custodial, respite, dom~c~hary, or convalescent care 10 Charges related to reports, evaluations, or physical examinations not required for health reasons (not Medically Necessary) Excluded ~tems are reports for employment, insurance, camp, adoption, travel, or government hcenses 11 Charges related to drugs or medicines, prescnpt~on or non-prescnpt~on, prowded to the Covered Person wh~le he or she ~s not an ~npaflent, unless specifically prowded by a R~der to th~s Schedule of Benefits 12 Charges related to expenmental drugs or substances not approved by the FDA for other than FDA approved red,cations, and drugs labeled "Caution - I~m~ted by Federal Law to ~nvest~gaflonal use" 13 Charges related to formulas, d~etary supplements, or special d~ets prowded to the Covered Person on an outpatient bas~s POSLGSCH 96 22 14 Charges related to ws~on care Excluded services are, but not hm~ted to examination for eye glasses, refraction, d~spensmg, or fitting of eye glass frames and lenses, all types of contact lens, eye exercise and wsual tralmng, and orthopt~cs, except as otherwise spec~tied ~n th~s Schedule of Benefits 15 Charges related to red,al keretotomy or other radial keratoplast~es, and all costs associated w~th such surgery 16 Charges related to heanng rods, battenes, and examinations for fitting thereof unless added by Rider 17 Charges related to the care and treatment of the feet unless such serwces are Medically Necessary Exclusions include routine foot care, such as removal of corns, calluses, or the tnmm~ng of na~ls, treatment for fiat feet, orthot~cs, arch supports, or custom titted braces and splints 18 Charges related to dental care, except as otherwise specified ~n th~s Schedule of Benefits, ~nclud~ng services related to the care, fill~ngs, removal, or replacement of teeth, treatment of d~seases of the teeth or gums, extraction of w~sdom teeth, malocclusion or malpos~t~on of the teeth and jaws (mandibular hyperplas~a/hypoplas~a), professional services or anesthesia related to or required for the sole purpose to provide dental care, hospital care, ~npaflent or outpabent surgery required for any dental care, prescnpflon drugs for dental treatment, dental x-rays, dentures, and dental apphances or prostheses 19 Charges related to surgical procedures and other treatment associated w~th the treatment of obesity, regardless of associated medical or psychological conditions, including treatment of a compl~cahon of surgical treatment for obesity Excluded procedures include, but are not I~mited to intestinal or stomach bypass surgery, gastric stapling, wrong of the jaw, ~nsert~on of gastnc balloons, or s~m~lar procedures 20 Charges related to transsexual surgery, ~nclud~ng medical or psychological counsehng or hormonal therapy, ~n preparation for or subsequent to any such surgery 21 Charges related to services for cosmetic surgery or reconstructive surgery, except as otherwise specified as covered m th~s Schedule of Benefits Cosmetic surgery exclusions ~nclude, but are not I~m~ted to rh~noplasty, scar rews~ons, prosthetic pemle ~mplants, surgical rews~on or reformation of any sagging skin on any part of the body, descnbed as relating to the eye hds, face, neck, abdomen, arms, legs or buttocks, hposucbon procedures, any services performed ~n connechon w~th the enlargement, reduction, ~mplantaflon or appearance of any porhon of the body descnbed as the breast, face, hps, jaw, ch~n, nose, ears, or gent~les, hair transplantation, chem~cel face peels or abrasions of the skin, removal of tattoos, and electrolysis dep~lation Supply or replacement of ~ntemal breast prothes~s ~s covered only ~f ~mhal surgery was a result of ~njury or d~sease 22 Charges related to reduction mammoplasty, unless determined to be Medically Necessary by the HMHIC Medical D~ractor of h~s designee 23 Charges related to reversal of surgically performed stenl~zaflon or subsequent restenl~zaflon POSLGSCH 96 23 24 Cha~ges related to surrogate parenting, GIFT procedures, and any costs associated w~th the collection or storage of sperm for artificial msem~nabon including donor fees, and ~nfertlhty med~cahons unless specifically provided by a R~der 25 Charges related to amn~ocentes~s, ultrasound, or any other procedure performed solely for sex determ~nahon of the fetus 26 Charges related to mental health serwces for psych~atnc conditions which are determined by the HMHIC to be not Medically Necessary m nature and beyond the maximum days allowed by HMHIC 27 Charges related to court ordered teshng, and special reports not d~rectly related to medical treatment 28 Charges related to servmes for the treatment of mental retardabon and mental deficiency 29 Charges related to employment, vocational, or mamage counseling, behaworal training, remedial education, ~nclud~ng evaluation and treatment of learmng and developmental d~sab~ht~es and m~n~mal bra~n dysfunction, or attention deficit therapy Benefits for the necessary care and treatment of loss or ~mpalrment of speech or heanng are excluded thereof unless added by Rider 30 Charges related to services for chromc retractable pa~n provided by a pa~n control center, acupuncture, naturopathy, and hypnotherapy, hohst~c or homeopathic care, ~nclud~ng drugs, and ecological or enwronmental medicine 31 Charges related to durable medical equipment, unless descnbed m th~s Schedule of Benefits Excluded ~tems are, but not hm~ted to a deluxe equipment, such as motor dnven wheel chairs and beds, possessing features of an aesthetm nature or features of a medical nature which are not required by the patient's cond~bon, b items not pnmanly medical ~n nature or for the patient's comfort and convenience, such as bed boards, bathtub hfts, over-bed tables, adJust-a-bed, and telephone arms, c physm~an's equipment such as stethoscope and sphygmomanometer, d exercise equipment such as exercycles and enrollment ~n health or athlebc clubs, e self-help dewces not pnmanly medical ~n nature, such as sauna or whirlpool baths, chairs, and elevators, f corrective orthopedic shoes and arch supports, g supphes or equipment for common household use, such as but not hm~ted to, a~r purifiers, central or umt a~r conditioners, water punfiers, allergenic p~llows or mattresses, and water beds, and h research equipment or ~tems deemed to be expenmental as determined by the HMHIC HMHIC w~ll have no hab~hty or respons~b~hty for repair or replacement of equipment lost or damaged 32 Charges related to prosthetic medical apphances, except as specified ~n th~s Schedule of Benefits Excluded ~tems ~nclude, but are not hm~ted to a dentures, heanng a~ds unless specifically prowded by a R~der, and contact lens, POSLGSCH 96 24 b medical supphes suoh as elastic stockings, garter belts, arch supports, corsets, and corTecflve orthopedic shoes, c research dewces or ~tems deemed to be experimental as determined by HMHIC, and d replacement, repair, and routine maintenance of covered apphances or braces unless surgically ~mplanted, or replacement required due to a marked change ~n physical growth or physical requirements 33 Charges related to med~cel supplies, a~ds, and appliances except as otherwise specified as covered ~n th~s Schedule of Benefits Excluded ~terns ~nclude, but are not i~m~ted to consumables, d~sposable supplies, sheaths, bags, gloves, cervical collars, elastic stockings, stethoscopes, blood pressure un~ts, traction apparatus, shngs, TENS umts or electncal nerve stimulation dewces, w~gs or hair p~eces, dressings, testing supphes, syringes, home testing k~ts, d~sposable d~apers or incontinent supphes, and over-the-counter medications 34 Charges related to inpat~ent or outpatient long-term neuromuscular, physical, speech, or occupational therapy services or other rehab~htafion services 35 Charges related to recreational, educational, or sleep therapy, and any related d~agnost~c testing, except as prowded by the hospital as part of an approved ~npat~ent hosp~tahzat~on 36 Charges related to structural changes to a house or vehicle 37 Charges related to any med~cel, surgical, or health care procedure or treatment held to be expenmental or ~nveshgat~onal at the time the procedure or treatment ~s performed HMHIC w~ll utilize findings and assessments of national medical associations, professional societies and organizations, and any appropnate technological body established by any state or federal government or s~m~lar entities to determine coverage and/or effectiveness 38 Charges exceeding the Reasonable and Customary amounts as determined by HMHIC POSLGSCH 96 25 PRESCRIPTION DRUG RIDER FOR USE ONLY WITH HMHIC HEALTH CARE AGREEMENT lO In conslderatton for the t~mely payment of premiums, and all other terms and conditions of the Group Health Care Agreement, and/or Certificate of Insurance, it is agreed that the benefits oftlus Rider, together w~th the terms and con&taons oftlus Rider, shall be added to Agreement as issued if this Rider is accepted by the Group 2 0 DEFINITIONS Benefits for outpatient prescription drags provided through this Rider shall be subject to the provisions and definitions of Agreement to which this Rider is a part In addition, for the purpose ofttus Rider, the following defimtmn shall apply ® Prescrlpt~on Drugs shall mean only those drugs and medmlnes which are prescribed by a Physician and legally require the written prescription of a Physlman before it can be obtmned by the Covered Person 30 D~SKEI~ Benefits hnutatlon and Covered Person cost shall be as follows · 30% Copayment by Covered Person Federal Legend Drugs and compounds requiring a prescription 0ncludlng msuhn), except those specifically excluded Generic Substitutions are covered (1) IUD Devices (2) Therapeutic or Prosthetic devices, except those dispensed by durable medical provider (3) Appliances, Supports or other non-medical products (4) Medical Supplies except those listed as covered items (5) Contraceptive devices excluding Oral contraceptives (6) Insulin synnges and miscellaneous diabetic supplies, including unne and blood glucose strips (7) Injectable Medications, other than insulin (8) Blood, Blood Plasma and Blood Products, except those dispensed by outpatient faclhty (9) Experimental Drugs (10) Immumzatlon Agents, except those dispensed m the physician's office (11) Fertility Medications (12) Drugs not requlnng a prescription (OTC, V~tamlns, Cough Syrup, etc ) (13) Drugs to be consumed in an inpatient or other institutional care setting (14) Nicorette gum POS2RX896 COVERED OUANTITIES As prescribed up to a maximum of a 30 day supply for each covered prescription or refill Prescriptions shall not be refilled until approximately 75% of the previously dispensed quantity has been consumed, based on dosage instructions of the physmlan Covered Person must pay m full for any amounts exceeding covered quantities, including lost or misplaced mcd~cations A maximum of five (5) refills per prescription shall be covered if allowed by law and authorized by Physician, provided such refills are dispensed within six (6) months of the lmtlal prescription date 40 ~ Benefits under this Pdder are avmlable to the Employee and his Dependents (Covered Persons) as identified in this Agreement POS2RX896 Harris Methodist Health Plan HARRIS HEALTH PLAN, INC 611Ryan Plaza Dr Arlington, TX 76011-4009 (817) 462-7000 1-800-622-8598 GROUP ENROLLMENT AGREEMENT Application is hereby made to Harris Health Plan Inc hereinafter called "Harris Health" by the Applicant named below hereinafter called "Group" for the purpose of making available to Eligible Persons and their Eligible Dependents under a Group Health Care Agreement/Subscriber Certificate of Coverage hereinafter called "Agreement" lssued by Harris Health, certain prepaid health care services and benefits The arrangement of the provisions of such serwces and benefits shall be the subject of the Agreement between Harris Health and Group and shall be based on the statements and representations contained in th~s Group Enrollment Agreement, a copy of which shall be incorporated by reference and made a part of the Agreement 1 0 GROUP Group Name C~tv of Denton Address 601 East Hlckorv. Suite A C~ty Denton State TX Z~p Code 76205 2 0 GROUP EFFECTIVE DATE Th~s Group Enrollment Agreement shall be effective 12 01A M , Central Time on the day 1st of January 1997 3 0 ELIGIBILITY Any person or his/her dependents who meet the eligibility requirements for coverage under the Group's Alternative Health Benefits Plan shall be eligible for coverage under Agreement as specIfied in Section 3 1 and Section 3 2 of Agreement A Rules of eligibility Per the written Qu~del~nes Drowded bv the City of Denton. 4 0 HEALTH CARE SERVICES (BENEFITS) AND COPAYMENTS Eligible Persons and Eligible Dependents of Group are entitled to Health Care Serwces and Beneflts as follows A Basic Health Care Services X Covered Basic Health Care Serwces as described in the Schedule of Benefits B Prescription Drug X Accepted Not Accepted 5 0 COVERAGE BASIS X Contributory Non-Contributory 6 0 SCHEDULE OF RATES Total Monthly Rates Blended Employee Only $185 03 Blended Employee + Spouse $287 59 Blended Employee + Chlld(ren) $248 47 Blended Employee + Fam31y $312 59 This Group Enrollment Agreement shall be automatically renewed at the end of each Contract period unless terminated by Harris Health or Group as provided in Agreement The first Contract period shall commence as of the Group Effective Date and w~ll remain in effect for twelve (12) consecutive months unless terminated before th~s date by Harris Health or Group IN WITNESS WHEREOF the undersigned ha~ecasusedthe Group Enrollment~Agreement to be executed on the ~-L/~ day of--~,~- 19. ~ City of Denton Group HARRIS $~j~A~N ~~ By Authorized Representative Title T~tle Vice President of Sales Address 601 East Hlckorv, Suite A Denton. Texas 76205 Telephone 817-566-8269 PROVIDER GROUP/Renewal c CONTRACT CON/sw P Callan/D Blaine Letter of Understanding City of Denton Bid No. 1869 This Letter of Understanding is between Hams Methodist Health Plan (HMHP) and the C~ty of Denton (C~ty) m connection with Bid No 1869 HMHP and C~ty agree to the following 1 As C~ty employees' needs for additional health care serwces m the Denton area expand, HMHP ~s committed to ongoing assessment of these needs and expansion of HMHPs' current network through the recrmtment of appropriately quahfied prowders to serve these needs 2 HMHP guarantees that ~t meets the mlmmum b~d reqmrement of hawng one Denton hospital ~n its prowder network HMHP will mmntmn at least one Denton hospital ~n ~ts network Should HMHP be unable to meet the mlmmum b~d reqmrement of hawng one Denton hospital ~n ~ts network, HMHP will pay the lesser of (t) 50% of the consulting contract whmh would be necessary to rebtd C~ty's health benefits progran~ or (n) $30,000 Prowded however, nothing ~n th~s paragraph reheves HMHP from its obhgatlon to mmntmn at least one Denton hospital ~n ~ts network In addition, HMHP will exercise best efforts to enter ~nto a mutually acceptable and commercially reasonable contract for hospital serwces for C~ty's ehglble employees and dependents with the other hospital located in the C~ty 3 HMHP guarantees the 1997 total annual cost of ~ts b~d will not exceed $2,573,320 as long as enrollment, plan option pammpat~on, plan designs, and blended rates remmn exactly as set forth below for every month of the 1997 calendar year BLENDED RATES ACTIVE ENROLLMENT TOTAL HMO Opt-out Plan EE Only 14 $220 07 EE & Spouse 5 $341 09 EE & Chdd 12 $294 88 EE & Famdy 14 $371 90 HMO Plan EE Only 355 $185 03 EE & Spouse 86 $287 59 EE & Child 150 $248 47 EE & Family 218 $312 59 HMO Opt-out Plan Retiree Only 0 $220 07 Retiree & Spouse i $341 09 Retiree & Child 0 $294 88 Retiree & Family 0 $371 90 Letter of Understanding City of Denton Bid No 1869 Page 2 of 2 HMO Plan Retiree Only 5 $185 03 Rettree& Spouse 3 $287 59 Retiree & Chdd 0 $248 47 Rettree& Fatally 1 $312 59 HMO Opt-out Plan Rettreo Only 1 $220 07 Retiree & Spouse 1 $341 09 Retu'ee & Spouse (1 under 65 0 $341 09 Retiree & Family (1 under 65 0 $371 90 Retiree & Family 0 $371 90 HMO Plan Retiree Only 5 $185 03 Retiree & Spouse I $287 59 Retiree & Spouse (1 under 65) 3 $287 59 Retiree & Farmly (1 under 65) 0 $31259 Retiree & Family 0 $312 59 C~ty understands that the total annual cost of HMHP's b~d may increase or decrease depending on the number of ehg~ble employees participating, any sh~ft between plan options or tier, any retroactive terminations, or change in E~ty's seleet~on of non-blended or blended rates Further, HMHP guarantees that the quoted rates in ~ts response to B~d No 1869 veil not increase more than 5% for plan year 1998 and will not increase more than 9% for plan year 1999 HMHP understands and agrees that any ~nerease m HMHP's b~d shall be consistent w~th the competitive b~d&ng laws of the State of Texas 4 Th~s Letter of Agreement shall become effective January 1, 1997 and shall be attached to and incorporated into the agreement of the part,es anthor~zed by C~ty pursuant to the ordinance approved on the day of ,1996, relating to the award of BldNo 1869 5 The terms and conditaons of tlus Letter of Understanding are binding contractual obligations and not mere recitals and may be enforced by e~ther party HMHP and City, through their respective duly authorized representatives, have executed th~s Letter of Understanding to be effective as of January 1, 1997 Byg/~ ./~'t,~_; ,~ - ~ By ~ Thomas Keenan ~'"~Jack Mdle~/~ Title Executive Vice President/COO Mayor Wellness and Prevention Program Hams Health Plan, Inc will provide the following wellness and prevention program in conjunction wtth the Cxty of Denton's btd# 1869 · Mochfiable Claun Au&t ($2,000 value) No Charge · Health Pask Assessments for C~ty of Denton employees ($25 00 value per assessment) $10 00 per Assessment · Monthly Wellness Event ($50 value per event) No Charge · Mammography Screening ($65 value per screemng) No Charge Note This wellness program was developed as a value added benefit to our b~d #1869 for the City of Denton Hams Health Plan xs underwriting a portaon of the cost as outlined above Harris Methodist Health Plan GROUP HEALTH CARE AGREEMENT/ SUBSCRIBER CERTIFICATE OF COVERAGE HARRIS HEALTH PLAN, INC. PO Box 90100 Arhngton, Texas 76004-3100 817/462-7800 1-800/633-8598 GA 992 Harris Health Plan, Inc Health Mmntenance Organlzat on P O Box 90100 Arhngton, Texas 76004 3 I00 IMPORTANT NOTICE AVISO IMPORTANTE To obtmn Information or make a complaint Para obtener lnformaclon o para someter una queja You may call Harris Health Plan, Inc's toll-free telephone number for Information or to make a Usted puede llamar al numero de telefono gratis de complmnt at Harris Health Plan, Inc para lnformac~on o para 1-800-633-8598 someter una queja al You may contact the Texas Department of 1-800-633-8598 Insurance to obtain ~nformanon on compames, Puede comumcarse con el Departmento de Seguros coverages, rights or complaints at de Texas para obtener lnformaclon acerca de 1-800-252-3439 compamas, coberturas, derechos o quejas al You may write the Texas Department o1 1-800-252-3439 Insurance Puede escrlblr al Departmento de Seguros de PO Box 149104 Texas Austin, TX 78714-9104 FAX # (512) 475-1771 PO Box 149104 ATTACH THIS NOTICE TO YOUR POLICY Austxn, TX 78714-9104 Th~s not~ce ~s for Information only and does not FAX # (512) 475-1771 become a part or condition of the attached UNA ESTE AVISO A SU POLIZA Este awso es document solo para propos~to de ~nformac~on y no se conwerte en parte o cond~c~on del documento ad junto TABLE OF CONTENTS Page Page 1 0 General Definitions 2 8 0 independent Agents/Refusal to Accept Treatment 18 2 0 Group and Afflhated Organ~zabons 6 8 1 Independent Agents 18 2 1 Organizations Included Under This 8 2 L~mltabon on Llablhty 19 Agreement 6 8 3 Refusal to Accept Treatment/Excessive 2 2 Change of Afflhated Organizations 6 Treatment 19 3 0 Ehg~b~hty and Effective Date 6 9 0 Exclusions on Serwce Respons~bd~bes 19 3 1 Ehg~ble Persons 6 9 1 Major Dmaster or Epidemic 19 3 2 Ehg~ble Dependents 6 9 2 Circumstances Beyond Control 20 3 3 Change ~n Group Ehg~b~hty Criteria 7 9 3 Fraudulently Obtained Benefits 20 3 4 Effecbve Date for Ehg~ble Persons 7 9 4 D~scont~nuance 20 3 5 Effective Date for Ehglble Dependents 7 3 6 Persons Not Ehg~ble for Coverage 8 10 0 Member Complaint Resolubon Procedure 20 3 7 Cond~bons of'Ehglb~l~ty 8 10 1 Complaint Resolution Process 20 3 8 Not~flcabon of Inehg~blhty 8 10 2 Complaint Resolution Appeal Process 21 3 9 Clencal Error, 8 11 0 Health Care Serwces 21 4 0 Group and Member Termination, Continuation of Benefits and Conversion 8 t 1 1 Benefits and Serwces 21 4 1 Term~nabon of Group 8 12 0 Term and Amendment of Agreement 22 4 2 Termination of Member -- For Cause 9 12 1 Term 22 4 3 Term~nabon of Member -- Other Than for 12 2 Amendment 22 Cause 10 12 3 Change of Rates 22 4 4 L~ab~l~ty Upon Termination 10 4 5 Cont~nuat~onlof Coverage 10 13 0 M~scellaneous Prows~ons 22 4 6 Conversion Pnwlege 11 13 1 Use of Words 22 5 0 Payment Requirements 11 13 2 Records and Informabon 22 13 3 Informabon from Group 22 5 1 Premium Payments 11 13 4 Assignment 23 5 2 Nobflcat~on by Group 12 13 5 Authonty 23 5 3 Copayments 12 13 6 Govermng Law 23 6 0 Claim Prows~ons 13 13 7 Incorporabon by Reference 23 13 8 Enbre Agreement 23 6 1 Charges Pa¢ by Members 13 13 9 Information to Member 23 62 Medical Emergency 13 1310 Un~form Rules 23 6 3 Acbon on Claim 13 13 11 Calculabon of T~me 23 6 4 Examination' of Member 13 13 12 Ewdence 23 6 5 L~m~tat~on Prows~ons 13 13 13 Severab~hty 23 7 0 Coord~nabon and Subrogation of Benefits 14 13 14 Venue 24 13 15 Waiver of Nobce 24 7 1 Defln~bons 14 13 16 Headings 24 7 2 Determ~nabon of Benefits 14 13 17 Nobce of Certain Events 24 7 3 Order of Bepeflt Determ~nabon 15 13 18 Nobce of Termination 24 7 4 Medicare 16 13 19 Not~ce 24 7 5 R~ght to Receive and Release Informabon 17 7 6 Fac~hty of P,ayment 17 Attachment A Serwce Area Map and Descnptlon 7 7 R~ght of Recovery 17 7 8 D~sclosure 18 7 9 Subrogabon 18 Section 1 0 GENERAL DEFINITIONS 1 ACTIVELY AT WORK shall mean that the eligible employee must be performing the usual and cus- tomary duties of h~s regular employment during h~s usual working hours on h~s effecbve date of coverage, provided, however that ~f the ehg~ble employee ~s absent from work due to vacation, holiday, jury duty, or other s~m~lar c~rcumstances, not caused by ~njury or ~llness, such employee shall be considered acbvely at work 2 ACUTE shall mean a condition of sudden onset or severe symptomatology which mandates ~mme- dlate ~ntervent~on 3 AGREEMENT shall mean th~s Group Health Care Agreement/Subscriber Cert~hcate of Coverage, Group Enrollment Agreement, Applications, all Attachments, R~ders, Amendments hereto, ~f any 4 ALLIED HEALTH PROFESSIONAL shall mean a dentist, nurse, audiologist, optometrist, physician's assrstant, chn~cal psychologist, pharmacist, nutnhon~st, physical therapist, speech language pathologist, d~et~c~an, podiatrist, certified social worker (advanced clinical pract~boner) and other professionals engaged ~n the dehvery of health services who are hcensed, practice under an ~nst~- tut~onal I~cense, are certified, or practice under the authority of a Physician or legally constituted professional association, or other authority consistent w~th the laws of the State of Texas 5 ALTERNATIVE HEALTH BENEFIT PLAN shall mean the plan which the Group designates as the alternative to th~s Agreement 6 APPLICATION shall mean the form prescnbed by Harris Health which each Eligible Person shall on h~s/her own behalf and or, behalf of h~s/her Ehg~ble Dependents, be required to complete and submit to Harris Health for the purpose of enrolling himself/herself and such dependents for cover- age hereunder 7 CHEMICAL DEPENDENCY, means the abuse of or psychological or physical dependence on or addiction to alcohol or a controlled substance 8 CHEMICAL DEPENDENCE TREATMENT CENTER shall mean a facility which prowdes a program for the treatment of chemical dependence pursuant to a written treatment plan approved and monitored by a physician and which facility ~s also a afhhated w~th a hospital under a contract agreement w~th an estabhshed system for patient referral, or b accredited as such a facility by the Joint Commission on Accred~tabon of Health Care Organi- zations, or c licensed as a chemical dependency treatment program by the Texas Commission on Alcohol and Drug Abuse, or d hcensed, certified, or approved as a chemical dependency treatment program or center by any other state agency having legal authority to so license, certify or approve 9 COMPLICATIONS OF PREGNANCY shall mean those conditions, requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or caused by pregnancy, such as acute nephritis, nephros~s, card~ac decompensabon, missed abortion, and similar medical and surgical conditions of compa- rable severity Comphcat~ons or pregnancy shall not include false labor, occasional spotting, physi- cian prescnbed rest during the per~od of pregnancy, morning sickness, hyperemesls gravidarum, pre-eclampsla, and s~mllar conditions associated with the management of a difficult pregnancy not constituting a nosologlcally distinct compllcabon of pregnancy, non-elective cesarean section, ter- mination of ectoplc pregnancy, or spontaneous termmabon of pregnancy ocoumng during a period of gestabon ~n which a viable birth is not possible 10 CONTRACT YEAR shall mean the period of twelve (12) months commencing on the Group Effec- tive Date and each twelve (12) month period thereafter, unless otherwise terminated as hereinafter provided 11 CONTROLLED SUBSTANCE shall mean a toxic inhalant or a substance designated as a con- trolled substance ~n the Chapter 481, Health and Safety Code 2 12 COPAYMENT shall mean the fee as set forth ~n the Schedule of Benefits which ~s not covered by premiums payable hereunder, and which must be pa~d by Members d~rectly to the person or entity prowd~ng the serwce when the serwce as set forth ~n the Schedule of Benefits ~s received 13 COURSE OF TREATMENT shall mean that period of t~me represented by an ~npat~ent hospital admission and related d~scharge dunng which t~me treatment has been received by a Member or that penod of t~me authonzed by a Participating Physician and/or Harris Health as necessary to complete a cycle of treatment and subsequently prowde a medical release to the Member 14 CRISIS STABILIZATION UNIT shall mean a twenty-four (24) hour residential program, hcensed by Texas DepaCtment of Mental Health and Mental Retardation, that ~s usually short-term ~n nature and that prowdes ~ntens~ve superwslon and highly structured acbwtles to persons who are demon- strat~ng an acute demonstrable psych~atnc cns~s of moderate to severe proportions 15 CUSTODIAL CARE shall mean 1) that care which ~s marked by or g~ven to watching and protect- ~ng rather than seeking to cure, or 2) care which ~s not a necessary part of medical treatment or recovery, or 3) care comprised of services and supplies that are pnmanly provided to assist ~n the acbwt~es of cla~ly I~wng 16 DEPENDENT shall mean an Ehg~ble Dependent who has satisfied the eligibility and participation requirements spec[fled ~n th~s Agreement 17 DOMICILIARY CARE shall mean that care prowded for persons so d~sabled or ~nflrm as to be unable to I~ve Independently 18 EFFECTIVE DATE shall mean the effective date of coverage for Ehg~ble Persons and Ehg~bte Dependents pursuant to the terms of th~s Agreement 19 ELIGIBLE DEPENDENT shall mean an Ind~wdual as defined ~n Section 3 2 of th~s Agreement 20 ELIGIBLE PERSON shall mean an ~nd~wdual as defined ~n Secbon 3 1 of th~s Agreement 21 EMERGENCY CARE shall mean bona f~de emergency serwces prowded after the sudden onset of a medical condition manifesting ~tself by acute symptoms of sufficient severity, ~nclud~ng severe pa~n, such that the absence of ~mmed~ate medical attention could reasonably be expected to result ~n placing the patient's health ~n senous jeopardy, senous ~mpa~rment to boddy functions, or serious dysfunction to any bodily organ or part 22 EVIDENCE OF INSURABILITY shall mean that an Eligible Person or Ehg~ble Dependent ver~fles that they were enrolled for the preceedlng twelve (12) months in a group or ind~wdual plan provid- ing benefits for medical, surgical and hospital expenses, and completes the Ewdence of Insurabil- ity form and prowdes t~mely any additional documentation of health status as required by Harns Health Such ~nformat~on shall be rewewed by Harns Health and the Ehg~ble Person or Ehg~ble Dependent shall be not~fled regarding their eligibility for participation ~n Harns Health 23 EXCLUSION shall mean those specific conditions or causes for which coverage by Hams Health ~s entirely excluded 24 FDA shall mean the Food and Drug Administration, an agency of the Un~ted States government 25 GROUP shall mean collecbvely the contracting employer and all afflhated orgamzat~ons of the employer as set forth m Attachment A annexed hereto and made a part hereof, to which th~s Agreement ~s issued and through which as agent for Subscnber and not for Harns Health, Sub- scnber and Dependents become entitled to the benefits as set forth ~n the Schedule of Benefits 26 GROUP EFFECTIVE DATE shall mean the date specified as such ~n the Group Enrollment Agreement 27 GROUP ENROLLMENT AGREEMENT shall mean that agreement which ~s executed between Har- ns Health and Group for the purpose of making available to Ehg~ble Persons and Eligible Depen- dents of Group those benefits and serwoes which are described m the Group Health Care Agreement/Subscnber Cerbflcate of Coverage Such Group Enrollment Agreement shall identCy the Group, Group Effective Date, el~g~b~lity requirements, rates, and covered benefits 28 HARRIS HEALTH shall mean Harns Health Plan, Inc, a Texas not-for-profit corporabon orgamzed as a Health Maintenance Organ~zabon (HMO) and hcensed by the Texas Department of Insurance 29 HEALTH PLAN shall mean the Health Maintenance Organization operated by Hams Health d/b/a Hams Methodist Health Plan 30 HOSPITAL shall mean an ~nst~tut~on hcensed by the State of Texas and which ~s (1) primarily engaged rn prowd~ng d~agnosbc medical and surgical facd~bes for the care and treatment of Injured or sick persons, (2) operated under the medical superws~on of a staff of legally quahfled and hcensed physicians, (3) provides twenty-four (24) hour-a-day nursing serwce by or under the d~rect supervision of a Registered Nurse (R N ), (4) provides for overnight care of patients, (5) maintains clencal and ancillary services necessary for the treatment of medical and surgical patients ~nclud~ng but not I~m~ted to laboratory, X-ray, d~etary and medical records library In no event shall the term "hospital" ~nclude a convalescent nurs,ng home or any Inst~tut~on or part thereof which ~s used pnnc~pally as a convalescent facd~ty, rest facility, nursing fac~hty, facility for the aged, extended care facility, ~ntermedlate care facllrty, sMled nursing facility or facd~ty pnmanly for rehabd~tat~ve serwces, the term hospital shall, pursuant to Chapter 3, Texas Insurance Code, Article 3 72 ~nclude treatment ~n a residential treatment center for children and adolescents and treatment prowded by a cnsrs stabilization unit 31 INDIVIDUAL TREATMENT PLAN shall mean a treatment plan with specific attainable goals and objectives appropnate to both the patient and the treatment modahty of the program 32 KIDNEY DIALYSIS CENTER shall mean any facility licensed by the State of Texas, approved by Medicare to prowde outpatrent services and/or ,nstructlon in home k~dney d~alys~s treatments and which has contracted w~th Hams Health to provide care to Members 33 MEDICAL DIRECTOR shall mean the licensed Physician designated by Hams Health and/or such other Physicians as the Medical D~rector may designate with the prior approval of Hams Health Such physician shall be responsible for superws~ng the dehvery of medical serwces to Members and for mon~tonng the quahty of medical care rendered to Members 34 MEDICAL EMERGENCY shall mean a medical condition so classified by the medical d~rector and which manifests ~tself by acute symptoms of sufficient seventy 0nclud~ng severe pa~n) such that the absence of ~mmed~ate medical attention could reasonably be expected to result ~n (a) placing the patient's health in serious jeopardy, or (b) serious impairment to boddy functions, or (c) senous dysfunction to any bodily organ or part Examples of conditions which do not usually constitute medical emergencies are colds, ~nfluenzas, ordinary sprarns, ch,ldren's ear ~nfectlons, or nausea and headaches Heart attacks, cardiovascular accidents, poison,rigs, loss of consc,ousness or resp,rat~on, convulsions, severe bleed,ng or broken bones are examples of true medical emergencies 35 MEDICALLY NECESSARY shall mean services or supplies which are (1) prowded for the d~agno- s~s or care and treatment of a medical condition, (2) appropnate and necessary for the symptoms, dlagnos~s or treatment of a medical condition, (3) generally acceptable medical practice, (4) per- formed ~n the most cost effective and efficient manner appropnate to treat the plan Member's medical condition, and (5) prowded ~n accordance w~th accepted medical standards and Hams Health requirements as approved by the Health Plan's rewew committees for professional and technical practices and the Health Plan Medical D~rector 36 MEDICARE shall mean Part A and Part B of T~tle XVlII of the Social Secunty Act and any amend- ments or regulations thereunder 37 MEMBER shall mean any Subscnber and/or Dependent 38 MEMBER HOSPITAL shall mean any Hospital which has contracted w~th Harns Health to prowde to Members the serwces as set forth ~n the Schedule of Benefits and descnbed ~n th~s Agreement 39 NON-MEMBER HOSPITAL shall mean any Hospital which has not contracted with Harns Health to prowde to Members the services as set forth ~n the Schedule of Benefits and descnbed ~n th~s Agreement 40 MINOR EMERGENCY CENTER shall mean any I~censed facd~ty, not ~nclud~ng a Hospital, which prowdes Physician serwces for the immediate treatment only of an ~njury or d~sease 41 NON-PARTICIPATING PHYSICIAN shall mean a Physician who ~s not a Part~ctpat~ng Physician and to whom a Member ~s referred for oonsultatron or treatment by a Participating Physician only w~th 4 pnor written approval of Harns Health unless there ~s a Medical Emergency and a Participating Physician ~s not available 42 NON-PARTICIPATING PROVIDER shall mean any Physician, Hospital, Alhed Health Professional, Home Health Agency, Laboratory, M~nor Emergency Center, Residential Treatment Facility, Chem,- cai Dependency Treatment Center, or other hcensed healthcare professional or other prowder or entity which has not contracted w~th Harns Health to prowde to Members the serwces as set forth ~n the Schedule of Benefits and described ~n th~s Agreement 43 OPEN ENROLLMENT PERIOD shall mean a penod of at least thirty (30) days dunng each twelve (12) consecubve months when B~g~ble Persons may elect to change from the Alternative Health Benefit Plan to Hams Health or from Harns Health to the Alternabve Health Benefit Plan 44 PARTICIPATING PHYSICIAN shall mean any Physician who has contracted w~th Hams Health to provide to Members the serwces as set forth ~n the Schedule of Benefits and descnbed ~n th~s Agreement 45 PARTICIPATING PROVIDER shall mean any Physician, Hospital All~ed Health Professional, Home Health Agency, Laboratory, M~nor Emergency Center, Chemical Dependency Treatment Center, Psychiatric Day Treatment facdlty or other prowder or entity which has contracted w~th Harns Health to prowde to Members the serwces as set forth ~n the Schedule of Benefits and descnbed ~n th~s Agreement 46 PSYCHIATRIC DAY TREATMENT FACILITY shall mean a mental health facd~ty which prowdes treatment for ~nd~wduals suffenng from acute mental and nervous d~sorders ~n a structured psychl- atnc program utd~z~ng ~nd~wduahzed treatment plans w~th specific attainable goals and objectives appropnate both to the patient and the treatment modahty of the program and that ~s clinically superwsed by a Physician who ~s certified ~n Psychiatry by the Amencan Board of Psychiatry and Neurology The facility shall be hcensed by the State of Texas, accredited by the Program for Psy- ch~atnc Facilities, or ~ts successor, of the Joint Commission on Accreditation of Health Care Orga- nizations, and shall have contracted w~th Harns to provide to Members the mental health serwces as set forth ~n the Schedule of Benefits and described ~n th~s Agreement 47 PHYSICIAN,shall mean any ~nd~wdual (other than a hospital resident or ~ntern) who ~s fully hcensed and qualified to practice w~th~n the scope of the hcense under the law of the junsd~ct~on ~n which treatment ~s'rece~ved 48 PRIMARY PHYSICIAN shall mean, w~th respect to each Member, those Participating Physicians who are designated by Harns Health and ~dent~fled ~n wnt~ng to Members as Physicians hawng primary responsibility for coordinating such Member's medical care, prowd~ng ~n~tlal and pnmary care to Members, maintaining the continuity of such Member's care and ~n~t~at~ng referrals for spe- c~al~st care 49 RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS shall mean a child- care ~nst~tutlon that prowdes residential care and treatment for emotionally d~sturbed children and adolescents, I~censed by Texas Department of Mental Health and Mental Retardation, and that ~s accredited as a residential treatment center by the Councd on Accreditation, the Joint Commission on Accred~tabon of Health Care Organizations or the Amencan Association of Psychlatnc Serwces for Children 50 RIDER shall mean a Schedule prowded w~th th~s Agreement, and made a part hereof, which sets forth additional benefits and serwces made avadable by Hams Health by amending th~s Schedule of Benefits 51 SCHEDULE OF BENEFITS shall mean the schedule which sets forth the benefits and serwces that Harns Health shall make available to Members 52 SEMI-PRIVATE shall mean the charge made by a Member Hospital for a room containing two (2) or more beds 53 SERVICE AREA shall mean the geographic area as set forth and annexed hereto as Attachment A 54 SHORT TERM shall mean a course of treatment lasting thirty (30) days or less 5 55 SPECIALIST PHYSICIAN shall mean any Physician who has contracted w~th Harns Health to pro- vide speclal~st care to Members upon referral of a Pnmary Physician or upon referral of another Speclal~st Physician w~th the concurrence of the responsible Primary Phys,c~an 56 SKILLED NURSING FACILITY shall mean an ~nst~tut~on or part thereof, hcensed by state or local law that ~s accredited as an Extended Care Facd~ty by the Joint Commission on Accreditation of Health Care Organizations, or ~s recognized as a Skdled Nursing Facd~ty by the Department of Health and Human Serwces under Title XVlll of the Social Security Act (Medicare), as amended 57 SUBSCRIBER shall mean an Eligible Person who has satisfied the ehg~bd~ty and participation requirements specified ~n th~s Agreement 58 TOXIC INHALANT means a volatde chemical under Chapter 484, Health and Safety Code, or abusable glue or aerosol paint under Section 485 001, Health and Safety Code 59 USUAL, CUSTOMARY, AND REASONABLE CHARGES shall mean the charge ~s (1) the fee charged by a prowder ~n normal practice for a g~ven serwce, (2) w~th~n the range of usual charges by prowders for the same serwce ~n the geographic area where serwces are prowded to a Mem- ber, and (3) reasonable when taking ~nto consideration any unusual c~rcumstances or medical comphcat~ons requmng additional time, sMI and expenence in prowd~ng a specific treatment or service Section 2 0 GROUP AND AFFILIATED ORGANIZATIONS 2 1 ORGANIZATIONS INCLUDED UNDER THIS AGREEMENT The Group and Its afflhated organizations are included under th~s Agreement Afl,hated organi- zations ~nclude all those organ~zabons which are subsidiary to or afflhated w~th the Group and located within the Serwce Area of Harns Health 2 2 CHANGE OF AFFILIATED ORGANIZATIONS The Group shall nobfy Hams Health, ~n wntlng, when an affd~ated orgamzabon ceases to be a subsidiary of, or afflhated w~th, the Group When an organization ceases to be a subsidiary of, or affili- ated w~th, the Group, ~t shall cease to be an included organization Therefore, th~s Agreement shall ter- minate on the date of such cessation w~th respect to all Ehg~ble Persons of that organization, except for those persons who on the next day are employees of another afflhated organlzabon and thus Ehglble Persons under th~s Agreement Section 3 0 ELIGIBILITY AND EFFECTIVE DATE 3 1 ELIGIBLE PERSONS To be ehg~ble to enroll as a Subscnber, a person must reside ~n the Service Area and be an glble Person as follows · In the employment of the Group or a bona fide Member of the Group, and/or · Eligible under the ehglbdlty criteria estabhshed by the Group, and · Entitled on h~s or her behalf to participate ~n the medical and hospital care benefits arranged by the Group 3 2 ELIGIBLE DEPENDENTS To be ehg~ble to enroll as a Dependent, a person must reside ~n the Serwce Area and be · The legal spouse of a Subscriber, · A dependent unmarried natural ch,Id, foster child, stepchild, legally adopted chdd or child under Subscnber's court appointed legal guardianship, residing w~th Subscnber or w~th Sub- scnber's present or former spouse in the Serwce Area who ~s (a) under n~neteen (19) years of age, or (b) under twenty-five (25) years of age and pnmanly dependent on the Subscriber for financial support and attending an accredited college or university, trade or secondary school on a full-t~me basis, which has, in writing, verified said attendance or, 6 · A dependent unmarned natural child, foster child, stepchild, legally adopted child, or child under Subscnber's court appointed legal guardianship, residing w~th Subscnber or w~th Sub- scrlber's present or former spouse ~n the Service area who is nineteen (19) years of age or older but ~ncapable of self-susta~n~ng employment because of mental retardation or physical hand~cap which commenced pnor to age n~neteen (19) (or commenced pnor to age twenty- five (25) ~f such child was attending a recognized college or university, trade or secondary school on a full-bme bas~s when such ~noapac~ty occurred), and pnmanly dependent upon the Subscnber for support and maintenance Such dependent child must have been a Member e~ther pnor to attaining n~neteen (19) years of age or twenty-five (25) years of age under the conditions of the prewous sentence Sub- scnber shall furnish Harns Health proof of such ~ncapac~ty and dependency w~th~n thirty-one (31) days before the dependent child's attainment of the I~m~t~ng age and from bme to bme thereafter as Hams Health deems appropnate, but not more frequently than annually · Maternity care benefits w~ll be extended to an unmarned Dependent Child If coverage ~s prowded to the Dependent of the Subscriber, upon payment of the premium, benefits must be prowded for any children of the Dependent ~f those children are Dependents of the Sub~ scriber for federal ~ncome tax purposes 3 3 CHANGE IN GROUP ELIGIBILITY CRITERIA Requirements as defined by the Group for determining the ehg~b~hty for parbc~pat~ng ~n Hams Health are matenal to the execubon of th~s Agreement by Harns Health Dunng the term of th~s Agree- ment no change ~n the Group definition of eligibility for parbc~pat~on shall be permitted to affect ehg~b~l- ~ty or enrollment under th~s Agreement ~n any manner unless such change is approved ~n advance by mutual wntten agreement between Group and Harns Health 3 4 EFFECTIVE DATE FOR ELIGIBLE PERSONS 3 4 1 Open Enrollment Penod An Eligible Person who apphes for coverage ~n Harns Health by submitting an Apphcat~on dur- ing an Open Enrollment Penod shall become covered as a Subscnber on the Group Effective Date or such Effective Date specified as such for the Open Enrollment Period 3 4 2 On Acqu~nng El~g~bil~ty Status An Ehg~ble Person who first meets the ehg~b~hty requirements other than dunng the Open Enrollment Penod may enroll w~th~n thirty (30) days of meeting such requirements by submitting an Application Such person shall become covered under Harns Health as a Subscnber on the hrst day he became an Eligible Person prowded that the premium applicable to the Subscnber has been received in accordance with this Agreement 3 5 EFFECTIVE DATE FOR ELIGIBLE DEPENDENTS 3 5 1 Open Enrollment Penod An Ehg~ble Dependent for whom the Subscnber has apphed for coverage ~n Harns Health by submitting an Application dunng an Open Enrollment Penod shall become covered as a Dependent on the Effecbve Date of the Subscnber 3 5 2 On Acqu~nng Ehg~b~l~ty Status A newly acquired Eligible Dependent, and an Eligible Dependent other than a newborn child who first meets the eligibility requirements of Group on other than dunng an Open Enrollment Penod, may be enrolled by the Subscnber w~th~n thirty (30) days of meeting such requirements by subm~tbng an Application Such Ehg~ble Dependent shall become covered under Harns Health as a Dependent on the day he became an Eligible Dependent prowded that the premium applicable to the Dependent has been received ~n accordance w~th th~s Agreement descnbed in Section 5 1 Coverage for newly adopted children shall commence on the earher of (a) the date upon which such chdd commences residence w~th the Subscnber or (b) when the adoption becomes legal Adopted children and newborn children shall be covered under Harns Health for an ~mt~al penod of thirty-one (31) ~ays and shall continue to be so covered after that t~me only ~f, pnor to the expiration of such thirty-one day penod, an Apphcat~on has been submitted and the premium applicable to the Dependent has been received in accordance w~th th~s Agreement descnbed ~n Section 5 1 7 3 6 PERSONS NOT ELIGIBLE FOR COVERAGE Notwithstanding the foregoing prows~ons of th~s Section, persons not ehg~ble for cover- age ~n Hams Health shall be as follows · Coverage Prewously Terminated No person shall be ehg~ble to become a Member who has had coverage terminated by Hams Health for cause, as described ~n Section 4 2 of th~s Agreement · Indebtedness No person shall be ehg~ble to become a Member if such person has unpaid financial obhgat~ons ans~ng from pnor coverage ~n Harris Health 3 7 CONDITIONS OF ELIGIBILITY No Ehg~ble Person or Ehg~ble Dependent shall be refused enrollment by Hams Health because of health status, requirements for health services, or the existence of a Pre-Ex~st~ng Condition on the Group Effective Date In addition, no Member's coverage shall be termrnated by Harns Health due to h~s health status or h~s healthcare needs If an Ehg~ble Person or Ehg~ble Dependent applies for cover- age on a date other than Open Enrollment Penod or more than thirty (30) days after becoming an Ehg~- hie Person or Ehg~ble Dependent, then such Ehg~ble Person or Ehg~ble Dependent shall have to document Evidence of Insurabd~ty as required by Hams Health 3 8 NOTIFICATION OF INELIGIBILITY A condition of participation ~n Harns Health ~s Subscnber's agreement to not~fy Hams Health of any changes ~n status that affect Subscnber or the ab~hty of the Subscnber's Dependents to meet the ehg~b~hty cntena set forth ~n th~s Section 3 9 CLERICAL ERROR Ehg~blhty under th~s Agreement shall in no event be ~nvahdated by failure of the Group, due to clencal error, to record or report an Ehg~ble Person or Ehg~ble Dependent to Harns Health ~f an Apph- cat~on had been completed and submitted to Group as required under the terms of th~s Agreement by or on behalf of such Ehg~ble Person or Ehg~ble Dependent and that the premium apphcable to such coverage had been received by Harns Health Section 4 0 GROUP AND MEMBER TERMINATION, CONTINUATION OF BENEFITS AND CONVERSION 4 1 TERMINATION OF GROUP 4 1 1 Default ~n Payment of Premium If Group fa~ls to pay to Harns Health the premium payable hereunder on or before the thirty~first (31) calendar day after such payment ~s due, th~s Agreement may be terminated by Hams Health and all benefits and services shall cease at the end of such thirty-one (31) day grace penod Group may be held hable for the cost of all benefits and serwces prowded to Member by Harns Health during the grace penod Group shall remain hable for all premiums (and any interest accrued thereon) not pa~d pnor to termination Interest on late payments from the date such premiums were due may be charged at a rate equal to e~ghteen percent (18%) per year Unpaid ~nterest shall be due and payable upon not~ce thereof to Group from Harns Health If Group remits ~ts dehnquent payments to Hams Health with~n fifteen (15) days of a term~nabon date, Harns Health may reinstate Group without requmng a new Group Enrollment Agreement How- ever, Harns Health reserves the nght to refuse to reinstate by refunding w~th~n five (5) bus~ness days all payments made by Group after the date of termination 4 1 2 Upon Notification Th~s Agreement may be terminated by either Hams Health or Group upon wntten notice to the other party at least s~xty (60) days pnor to the end of the Contract Year Such termination shall occur at m~dn~ght on the day preceed~ng the end of the Contract Year In the event that Harns Health terminates th~s Agreement, any Member who ~s a registered bed patient ~n a Hospital on the date of termination shall receive coverage for all hospital servtces for that hospital confinement or until a determination ~s 8 made by the Medical D~rector that ~npabent care ~s no longer medically ~nd~cated, whichever occurs first 4 2 TERMINATION OF MEMBER -- FOR CAUSE 4 2 1 Befault m Payment of Copayments If any required Copayment ~s not pa~d timely by or on behalf of Member, pursuant to the terms of th~s Agreement, such Member's entitlement to benefits may be terminated not less than s~xty-one (61) days wntten nobce after the date such Copayment was due 4 2 2 Default ~n Payment of Premium If any premium contnbut~ons due from Member are not pa~d bmely by or on behalf of Member, such Member's entitlement to benefits may be terminated not less than thirty-one (31) days after the date such premium was due 4 2 3 M~srepresentat~on If any Subscnber should make a fraudulent statement or prowde any matenal m~srepresenta- t~on of fact by or on behalf of such Subscnber or Dependent on an Apphcabon or Ewdence of Insura- b~hty form, Hams Health shall have the nght to terminate the Member's coverage under th~s Agreement w~thout any further habhty or obhgat~on to such Member Such Subscnber's entitlement to benefits may be terminated not less than s~xty-one (61) days wntten not~ce after such m~srepresentat~on If a Mem- ber corrects ~naccurate ~nformat~on furnished to Hams Health, and Hams Health has not rehed upon such ~ncorrect ~nformat~on to Its prejudice, the furnishing of ~ncorrect ~nformat~on shall not constitute a bas~s for termination of the Member's coverage In the absence of fraud, all statements made by a Subscriber are considered representations and not warrant~es Dunng the first two years, coverage can be voided 'for matenal m~srepresentat~on contained ~n a wntten Apphcat~on or Ewdence of Insura- b~hty Form After two years, coverage can be voided only ~n the event of a fraudulent m~sstatement contained ~n the wntten Apphcat~on or Evidence of Insurab~hty form A copy of the wntten Apphcatlon must have been furnished to the Subscnber ~f the terms of the Apphcat~on or Ewdence of Insurab~hty form are to be apphed 4 2 4 M~suse of Identification Card Possession of a Hams Health ~dent~flcat~on card ~n and of ~tself confers no nghts to serwces or other benefits The holder of the card must be, ~n fact, a Member on whose behalf all apphcable pre- m~ums under th~s Agreement have actually been pa~d Any person receiving services or other benehts to which he ~s not entitled pursuant to th~s Agreement shall be solely responsible for the full payment of any charges associated w~th the serwces received If any Member permits the use of the Member ~dent~flcat~on card by any other person, such card may be confiscated and Hams Health shall have the nght to terminate the Member's coverage under th~s Agreement and, ~f a Subscriber, the coverage of h~s Dependents Such Member's entitlement to benefits may be terminated not less than fifteen (15) days written nobce after such m~suse of the ~denbflcat~on card 4 2 5 Fraudulent Use of Benefits or Services Fraudulent use by Member of serwces, benefits, providers, fac~ht~es, or coverage w~ll result ~n cancellation of coverage after not less than a fifteen (15) day wntten not~ce to Subscnber 4 2 6 M~sconduct M~sconduct by a Member detnmental to safe Health Plan operations and the dehvery of serwce or treatment, or abuse of healthcare professionals, fac~ht~es, or Health Plan personnel may result ~n cancellation of coverage effective ~mmed~ately 4 2 7 Untenable Patient/Physician Relationship If the Member and the Participating Physician fa~l to estabhsh a satisfactory patient-physician relationship and ~f it ~s shown that Harns Health has, ~n good faith, provided the Member w~th the opportunity to select an alternative Part~c~pabng Physician, the Member shall be nobfled ~n writing at least thirty (30) days ~n advance that Hams Health considers the pat~ent-phys~c~an relationship to be unsatisfactory ~nd specifies the changes that are necessary ~n order to avoid termination ~f Member fa~ls to make such changes, coverage may be cancelled at the end of thirty (30) days For refusal by a Member to accept recommended procedures or treatment as descnbed ~n Section 8 3 of this Agreement, the Member's coverage may be cancelled after not less than thirty (30) days wntten not~ce 9 4 2 8 Termination Procedure Any Member terminated for cause pursuant to th~s Section shall be g~ven wntten not~ce of ter- mination pnor to the effective date of term~nabon ~n accordance w~th notification requirements of Sec- t~on 4 2 If Member rece~wng not~ce of termination m~bates the Member Complaint Resolubon Procedure descnbed ~n Section 10 of th~s Agreement dunng the notification penod to challenge the grounds for termination, the effective date of termination shall be postponed until Member Complaint Resolution Procedure ~s completed and a final decision regarding termination ~s prowded If the Mem- ber, on h~s own behalf or on behalf of a m~nor child, fa~ls to ~n~t~ate the Member Complaint Resolution Procedure w~th~n the notification penod, such failure shall constitute a waiver of said Member's nght to challenge the term~nabon 4 3 TERMINATION OF MEMBER -- OTHER THAN FOR CAUSE 4 3 1 Subscnber No Longer Ehg~ble Person if the Subscnber ceases to be an Ehg~ble Person, coverage under th~s Agreement shall auto- mat~cally terminate at m~dn~ght of the day on which such Subscnber ceased to be an Ehg~ble Person, subject to continuation of coverage and conversion pnwlege provisions 4 3 2 Dependent No Longer Ehg~ble Dependent If a Dependent ceases to be an Ehg~ble Dependent, coverage under th~s Agreement shall automatically terminate at m~dn~ght of the day on which such Dependent ceased to be an Ehg~ble Dependent, subject to oonbnuat~on of coverage and conversion pnwlege prowsions 4 3 3 Service Area Resident If a Member ceases to be a resident of the Serwce Area as defined by Harns Health, ehglb~hty to parbc~pate ~n Hams Health shall automabcally terminate as of the date on which the Member ceased to be a resident of the Serwce Area, except as may be required by State and Federal regula- tions for COBRA participants Such Member shall be ehg~ble to convert to an Ind~wdual Hospital and Surgical Expense Pohcy as specified ~n Section 4 6 2 4 4 LIABILITY UPON TERMINATION At the effective date of any termination of a Member's coverage under this Agreement any pay- ments received on account of such Member applicable to penods after the effective date of the term~- nat~on of coverage, plus amounts due to such Member for claims reimbursement, ~f any, less any amount due to Hams Health or which must be pa~d by Hams Health on behalf of such Member, shall be refunded to the appropnate party w~th~n thirty-one (31) days Harris Health and Group shall there- after have no further hab~hty or respons~b~hty to such Member except as may be specifically prowded ~n Section 4 1 2 of th~s Agreement 4 5 CONTINUATION OF COVERAGE If a Member's coverage ends, such coverage may quahfy to be continued ~n one of the follow- ~ng ways · ~t may be extended under the Extension of Medical Benehts prows~ons, ~f the Member ~s Hos- pital Confined when th~s Agreement terminates, or · ~t may be conbnued under the Optional Continuation of Coverage prowslons, or · ~t may be converted to an ~nd~wdual plan of medical coverage as descnbed ~n the Conver* s~on prows~ons If, under the prows~ons of T~tle X of the Consohdated Omnibus Budget Reconc~hat~on Act of 1985, Pubhc Law 99-272 ("COBRA"), any Member ~s granted the nght to continuation of coverage beyond the date h~s coverage would otherwise terminate, or, ~f COBRA ~s inapphcable and the prow- slons of an apphcable state statute grants such Member s~m~lar nghts to cont~nuation of coverage, th~s Agreement shall be deemed to allow continuation of coverage to the extent necessary to comply w~th the prows~ons of the apphcable statute Contact the employer for venflcat~on of ehg~b~hty and proce- dures to follow 4 5 1 Extension of Medmal Benefits Harns Health shall continue to prowde medical serwces ~f th~s Agreement terminates under 10 Secbon 4 1 2 wh~le a Member ~s confined ~n a Hospital or Skdled Nursing Facd~ty Serwces wdl be pro- wded only for the same ~nlury or s~okness which caused the Member to be confined Th~s continued coverage wdl end on the earlier of (1) the date the confinement ~s no longer Medically Necessary, or (2) the date the Member reaches any I~m~ts under the Group Contract for the prows~ons of serwces, or (3) the date the Member becomes ehg~ble for s~mdar coverage under another plan 4 6 CONVERSION PRIVILEGE If a Me~ber has been covered by th~s Agreement for at least three (3) consecutive months or covered as a newborn from the date of b~rth and meets the defln~bon of a person eligible for conver- s~on, Member may enroll ~n an ~nd~wdual plan w~th a defined Schedule of Benefits avadable to conver~ s~on Members only under the terms and conditions of th~s Agreement ELIGIBILITY TO CONVERT A Member whose coverage under th~s Agreement ~s terminated ~n accordance w~th the Term~- nat~on prows~on~ may convert ~f the coverage ~s not ending for one of the following reasons · Termination of th~s Agreement, · Fadure to pay any required copayment amounts, · Termination for cause, · Coverage under another ~nd~wdual or group health policy, plan or contract, · El~g~bdlty for Medicare, · El~g~bdlty or coverage for s~mllar hospital, medical or surgical benefits under a state or federal law A covered Dependent whose coverage ~s terminated under th~s Agreement may also convert ~f the termination ~S due to · Legal separation or d~vorce, or · The Subscnber's death, or · The Dependent reaching the maximum Dependent age HOW TO CONVERT 4 6 1 Residence ~n Service Area The Member eligible for conversion may, without Evidence of Insurabd~ty, convert to an Indiv~d- ual Health Care Agreement ~ssued by Harns Health To obtain an ~nd~v~dual enrollment, the Ehglble Person must continue to reside in the Service Area, must submit a completed appllcabon for conver- sion with~n thirty-one (31) days after termination of coverage under this Agreement, and must submit the premium for such Ind~wdual Health Care Agreement as required from the effective date of termina- tion of coverage~ under this Agreement 4 6 2 Residence Out of Service Area If the Member eligible for conversion does not reside in the Service Area, the Member may, w~thout Evidence of Insurabdtty, convert to an ~nd~wdual pohcy ~ssued by and renewable at the option of the ~ndemn~ty ~nsurer making such conversion coverage available to Harns Health Section 5 0 PAYMENT REQUIREMENTS 5 1 PREMIUM PAYMENTS The m~b~l rates for the benefits and serwces under th~s Agreement shall be due and payable in advance on or before the first (1) day of the month for which such payment ~s made or ~s to be made In accordance with the terms and provisions of Section 12 3 of th~s Agreement, Harns Health shall have the nght to change the rate payable under th~s Agreement at any t~me when the extent or nature of th~s Agreement ~s changed by amendment or termination of any prows~on, or by reason of any pro- v~s~on of law or any governmental program or regulabon No proration of the rate shall be made w~th 11 respect to Members whose coverage under this Agreement commences after the first (1) day of the month A grace penod of thirty-one (31) days shall be allowed for each payment payable hereunder, whether due from Group or a Member except for the first payment due The rate required for a newly acquired Eligible Dependent shall be payable ~n~t~ally when the required Application ~s submitted to Hams Health Thereafter, all payments w~th respect to such new Eligible Dependent shall be made as otherwise provided ~n th~s Agreement Any payments required for newborn chddren who meet the requirements of Secbon 3 5 2 of th~s Agreement shall be ~n~t~ally payable to Hams Health on or before the first day of the next month follow- ~ng the month in which the Apphcatlon required under Section 3 5 2 ~s submitted to the Health Plan Thereafter, all payments w~th respect to such newborn child shall be made as otherwise required under th~s Agreement 5 1 1 Non-Contnbutory Coverage If the coverage bas~s hereunder ~s "Non-Contributory," the Group agrees to pay at the pnnc~pal office of Hams Health, or to ~ts authonzed representative, on each payment due date, the sum of the Hams Health rate for the coverage then prowded under th~s Agreement The Group premium for the coverage provided by Hams Health under th~s Agreement shall be determined by the applicable rate then ~n effect and the number of Members at the monthly ~ntervals establtshed by Hams Health 5 1 2 Contnbutory Coverage If the coverage bas~s hereunder ~s "Contributory," Group agrees to pay at the pnnc~pal off~ce of Harris Health, or to ~ts authonzed representative, on each payment due date, that part of the Hams Health rate for the coverage then prowded under th~s Agreement Group shall permit Subscnbers to pay their contnbutory port~on of such rate through payroll deduction Procedures for ~mplemenbng payroll deductions for the Subscriber's port~on of such rate shall be the same as those uttl~zed for any Alternative Health Benefit Plan If the Group does not have an Alternative Health Benefit Plan, the pro- cedures shall solely be those as agreed to, ~n wnt~ng, between Group and Hams Health The Group premiums for the coverage prowded by Hams Health under th~s Agreement shall be determined by the applicable rate then ~n effect and the number of Members at the monthly ~ntervals established by Hams Health Group shall offer Hams Health to all Subscnbers of Group on terms no less favorable w~th respect to the Group contnbut~on than those apphcable to any Alternative Health Benefit Plan as may be avadable through the Group The Group contnbut~ons shall not be changed dunng the term of th~s Agreement unless such change ts pnor approved, ~n wnt~ng, by Hams Health If, however, Group con- tnbut~on to the Alternative Health Benefit Plan as may be avadable through the Group ~s ~ncreased dur- ~ng the term of th~s Agreement, Group agrees to also ~ncrease contnbut~on to Hams Health effective the first monthly payment due following such ~ncrease 5 2 NOTIFICATION BY GROUP Group shall forward completed Applications and any Ewdence of Insurabd~ty form(s) to Hams Health w~th~n ten (10) bus~ness days of their receipt from Eligible Persons In the event Group fa~ls to nottfy Harns Health of the ~nel~g~bd~ty of any person for whom the Group has made the monthly prepay- ment required pursuant to th~s Agreement, then, such prepayment shall be credited to Group only ~f Harns Health has not made arrangements for or pa~d benefits for the ~nel~g~ble person but ~n no event shall such prepayment be credited subsequent to thirty (30) days after the date such person became ~nel~g~ble 5 3 COPAYMENTS All Copayments, as specified ~n the Schedule of Benefits, are due and payable at the t~me a serwce ~s provided The maximum amount of Copayment shall not exceed the maximum specified In the Schedule of Benefits It ~s the Subscriber's responsibility to retain receipts and to not~fy Harns Health upon atta~mng the Copayment hm~t so that additional serwces can be prowded w~thout a Copayment charge 12 Section 6 0 CLAIM PROVISIONS 6 1 CHARGES PAID BY MEMBERS It ~s not anticipated that a Member shall make payments, other than the Copayments as set forth ~n the Schedule of Benehts, for benehts and covered serwces under th~s Agreement However, ~f a payment ~s made by a Member then a written description of such serwces, accompanied by ew- dence of payment by the Member must be prowded to Hams Health w~th~n s~xty (60) days after the performance ~of the serwce Failure to furnish such proof w~th~n the required t~me shall not ~nvahdate nor reduce any claim, ~f ~t was not reasonably possible to g~ve proof w~th~n such t~me, prowded such proof ~s furnished as soon as reasonably possible If the Member provides ewdence that he has made such payment, payment shall be pa~d to the Member but w~thout prejudice to Harris Health's r~ght to seek recovery of any payment made by ~t before receipt of such ewdence Benefits under th~s Agreement w~ll be pa~d directly to the prowder unless Member requests payment to be made to h~mself and submits to Harris Health proof of prior payment to the prowder for covered services Claims for such serwces will be processed as follows A Rfteen (15) calendar days after receipt of claim, Hams Health w~ll 1 Acknowledge receipt of claim, 2 Commence ~nvest~gat~on of claim, 3 Request all information from claimant as deemed necessary by Hams Health Subse- quent additional requests may be necessary B No later than f~fteen (15) bus~ness days after receipt of all ~tems required by Hams Health, Harris Health w~ll 1 Not~fy claimant of acceptance or rejection of claim, 2 Not~fy claimant of the reason(s) Harns Health needs additional t~me Hams Health shall accept or reject the claim no later than forty-bye (45) calendar days follow{rig receipt of additional ~nformat~on C Upon not~hcat~on from Hams Health that the claim w~ll be pa~d, the claim w~ll be pa~d no later than hve (5) bus~ness days after such not~hcat~on was made 6 2 MEDICAL EMERGENCY Medical Emergency serwces which are covered under th~s Agreement but are not received from Participating Providers shall be reimbursed subject to the Copayments ~n the Schedule of Bene- hts Hams Health reserves the r~ght to deny a claim for reimbursement of serwces received from a Hospital emergency department or a M~nor Emergency Center, ~f ~t ~s determined by Hams Health that such services were not obtained pursuant to the terms of th~s Agreement or ~f a Medical Emergency d~d not ex~st at the t~me serwces were received by the Member 6 3 ACTION ON CLAIM All claims for reimbursement shall be hnahzed by Harns Health w~th~n s~xty (60) days of receipt of written documentation describing the occurrence, character and extent of the event for which the claim ~s made, unless the Member ~s not~hed of the need for a longer t~me If a claim ~s den~ed, written not~ce to the Member w~ll state the reason for the den~al Member may obtain a rewew of the den~al through theMember Complaint Resolution Procedure as described ~n Section 10 0 6 4 EXAMINATION OF MEMBER Harris Health, at ~ts own expense, shall have the r~ght to examine the Member whose s~ckness or ~njury ~s the bas~s of a claim when and so often as ~t may reasonably require during the pendency of any claim 6 5 LIMITATION PROVISIONS · No action at law or equity shall be brought under th~s Section against Hams Health pnor to the expiration of the s~xty (60) day per~od ~mmed~ately following the date on which written proof of th~s charge or loss upon which the action ~s brought, ~n accordance w~th the prow- s~ons of th~s Section, has been furnished to Hams Health, or later than three (3) years after the expiration of the per~od of t~me in which such proof of charge or loss ~s required under this Section to be furnished to Harris Health 13 · No I~ab~hty shall be imposed under Harns Health other than for the benefits and services cov- ered under th~s Agreement Section 7 0 COORDINATION AND SUBROGATION OF BENEFITS The Harris Health Coordination and Subrogation of Benefits provisions apphes to all of the ben- eflts provided under th~s Agreement The value of any benefits or serwces provided by Hams Health shall be coordinated w~th any group insurance plan or coverage under governmental programs, including Medicare, to assure that a Member receives coverage wh~le avoiding double recovery It ~s, therefore, understood and agreed that should a Member be covered by or under a Coordinated Plan ~n addition to coverage under th~s Agreement, the prows~ons and rules as descnbed ~n th~s Section shall determine whether Hams Health or the Coordinated Plan ~s pnmanly responsible for paying the costs of benefits and services prowded to the Member · If a Member who has enrolled under th~s Health Plan ~s enbtled to ~npat~ent benefits under another contract or pohcy of ~nsurance due to ~npat~ent care which began wh~le the Member was enrolled under a previously held pohcy, Hams Health w~ll pay, subject to Copayments under th~s plan, the d~fference between entitlements under th~s Health Plan and entitlements under the other contract or pohcy of ~nsurance · Benefits which are prowded d~rectly through a specified prowder of an employer shall ~n all cases be prowded before the benefits of th~s Health Plan · Serwces and benefits for m~htary service connected d~sabht~es for which a Member ~s legally entitled and for which fac~ht~es are reasonably available, shall ~n all cases be prowded before the benefits of th~s Health Plan · All sums payable for serwces prowded pursuant to worker's compensation shall not be reim- bursable under th~s Agreement 7 1 DEFINITIONS For purposes of th~s Section only, words and phrases shall have meanings as follows · ALLOWABLE EXPENSE shall mean any Usual and Customary expense of which at least a port,on ~s covered under th~s Health Plan covenng the Member for whom the claim ~s made When a Coordinated Plan prowdes benefits ~n the form of services rather than cash pay- ments, the Usual and Customary cash value of each serwce prowded shall be deemed to be both an Allowable Expense and a benefit pa~d · CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding any port,on of a calendar year occurnng pnor to the Effecbve Date · COORDINATED PLAN shall mean any of the follow~ng that provides benefits or serwces for, or by reason of, medical care or treatment -- Coverage under governmental programs, including Medicare, required or provided by any statute unless coordination of benefits w~th any such program ~s forbidden by law -- Group coverage or any other arrangement of coverage for ~nd~v~duals ~n a group, whether on an ~nsured or uninsured bas~s, ~nclud~ng any prepayment coverage, group practice bas~s or ~nd~wdual practice coverage and any coverage for students which ~s sponsored by, or prowded through, a school or other educational ~nst~tut~on above the h~gh school level 7 2 DETERMINATION OF BENEFITS Th~s provision shall apply ~n determining the benefits payable for the Allowable Expenses ~ncurred by a Member dunng a Claim Determ~nabon Penod The term Coordinated Plan shall be construed separately w~th respect to each pohcy, contract, or other arrangement for benefits or serwces and separately w~th respect to that port,on of any such policy, contract, or other arrangement which reserves the nght to take the benefits or services of other Coordinated Plans ~nto consideration ~n determining ~ts benefits and that port,on which does not 14 Whenever the sum of the benefits that would be payable under th~s Agreement ~n the absence of th~s prows~on~ and the benefits that would be payable under all Coordinated Plans ~n the absence thereof or amendments of s~m~lar purpose to th~s prows~on would exceed the Allowable Expenses, then the following sh~ll apply · The benefits that would be payable under th~s Agreement shall be reduced to the extent necessary so that the sum of such reduced benefits and all the benefits payable for such Allowable Expenses under all Coordinated Plans shall not exceed the total payable under th~s Agreement Benefits payable under a Coordinated Plan ~nclude the benefits that would have been payable had claim been duly made therefor · If a Coordinated Plan would, according to ~ts rules, determine ~ts benefits after the benefits payable under th~s agreement have been determined, and the rules as descnbed ~n Section 7 3 would require payment under th~s Agreement to be determined before the Coordinated Plan, then the benefits of the Coordinated Plan shall not be ~ncluded for the purpose of deter- m~n~ng the benefits under th~s Agreement 7 3 ORDER OF BENEFIT DETERMINATION The rules estabhsh~ng the order of benefit determination shall be as follows · The benefits of a Coordinated Plan w~thout a coordination of benefits prows~on (or a non- duphcat~on prows~on of s~m~lar ~ntent) shall be determined before the benefits of th~s Agreement · The benefits of a Coordinated Plan which covers the Member other than as a dependent shall be determined before the benefits of a Coordinated Plan which covers such person as a dependent · The benefits of a Coordinated Plan which covers the Member as a dependent child of a per- son whose date of birth, excluding year of b~rth, occurs earher ~n a calendar year, shall be determined before the benefits of a plan which covers such person as a dependent of a per- son whose date of b~rth, excluding year of b~rth, occurs later ~n a calendar year If a Coordi- nated Plan does not have the provisions of th~s paragraph regarding dependents, which results e~ther ~n each Coordinated Plan determining ~ts benefits before the other or ~n each Coordinated Plan determining ts benefits after the other, the prows~ons of th~s paragraph shalllnot apply, and the rule set forth ~n the Coordinated Plan which does not have the prov - s~on$ of th~$ paragraph shall determine the order of benefit determination unless Section 7 3 1 shall apply · if the rules provided above or the rules prowded ~n Section 7 3 1 do not establish an order of benefit determ~nabon, then the benefits of a Coordinated Plan which has covered the Mem- ber for whom the claim ~s made for the longer penod of t~me shall be determined before the benefits of a Coordinated Plan which has covered such Member for the shorter penod of t~me~ except as follows -- The benefits of a Coordinated Plan covenng the Member as a la,d-off or retired employee 6r as the dependent of such Member shall be determined after the benefits of a Coordi- nated Plan covenng such person as a Member other than as laid-off or retired employee or dependent of such person -- If a Coordinated Plan does not have a prowslon regarding laid-off or rebred employees, and, as a result, such Coordinated Plan determines ~ts benehts after the Coordinated Plan with this prows~on, then the provisions of the ~mmed~ately preceed~ng paragraph shall not apply 7 3 1 ' Legal Separation or D~vorce In the event of a legal separation or d~vorce, the following order of benefit determination shall apply · If there ts a court decree that establishes financial responsibility for the healthcare expenses of the child, the benefits of a Coordinated Plan which covers the child as a dependent of the parent w~th such financial responsibility shall be determined before the benefits of a Coordi- nated Plan which covers the child as a dependent of the parent w~thout such financial respons~b~llty 15 · In the event of a legal separation or d~vorce tn which the court decree does not establish financial responsibility for the healthcare expenses of the child then the following shall apply -- If the parent w~th custody of the child has not remarned, the benefits of a Coordinated Plan which covers the chdd as a dependent of the parent w~th custody of the chdd shall be determined before the benefits of a Coordinated Plan which covers that child as a dependent of the parent w~thout custody -- If the parent w~th custody of the child has remarned, the benefits of a Coordinated Plan which covers the chdd as a dependent of the parent w~th custody shall be determined before the benefits of a Coordinated Plan which covers that chdd as a dependent of the stepparent, and the benefits of a Coordinated Plan which covers that child as a depen- dent of the stepparent shall be determined before the benefits of a Coordinated Plan which covers that child as a dependent of the parent w~thout custody Thus, ~n the event of a legal separation or d~vorce, unless a court decree specifies otherwise, the order of benefit determination descnbed above may be summanzed as follows Separated or D~vorced and not Remained Separated or D~vorced and Remarned (1) Parent with custody (1) Parent w~th custody (2) Parent without custody (2) Stepparent w~th custody (3) Parent w~thout custody 7 4 MEDICARE For purposes of determining benefits prowded for a Member who ~s eligible to enroll for Med~- care, but does not, Harns Health wdl assume the amount prowded under Medicare to be the amount the Member would have received if he or she had enrolled for It A Member is considered to be eligible for Medicare on the earliest date coverage under Med~- care could become effectrve for the Member Except as descnbed under TEFRA in Secbon 7 4, Med,- care shall be ~nterpreted so as to be ~ncluded ~n Section 7 1 for each Member as follows · Such Member must agree to enroll for both Parts A and B of Medicare and assign to Harns Health any Medicare benefits for services covered by Harris Health If such Member receives benefits from Harris Health that would have been pa~d or reimbursed by Medicare, but Member has faded to enroll for Medicare coverage, then Harris Health shall be entitled to receive from the Member the actual costs of the serwoes prowded The Member shall remain I~able for payment of the Copayments as set forth in the Schedule of Benefits · When Allowable Expenses are ~ncurred by such Member dunng any Claim Determination Penod and ~nclude expenses for serwces, treatment, or supplies which are payable under Medicare, such Allowable Expenses shall be reduced by an amount equal to the benefits payable by Medicare before comut~ng the benefits payable under th~s Agreement 7 4 1 TEFRA Options for Employers w~th 20 or More Employees Acbvely work~ng covered Employees and their covered spouses who are el~g~bte for Medicare w~ll be permitted to choose one of the follow~ng options ~f the Employee ~s age 65 or older and eligible for Medicare Opbon 1 -- The serwce of the Group Agreement w~ll be prowded first and the benefits of Medicare w~ll be provided second Option 2 -- Medicare benefits only Subscnber and Dependents, ~f any, will not be covered by the Group Agreement The employer w~ll provide Subscnber w~th a choice to elect one of these options at least one month before becoming age 65 All new Employees age 65 or older w~ll be offered these options when h~red If Option 1 ~s chosen, Subscnber's r~ghts under th~s Agreement wdl be subject to the same requirements as for an Employee or Dependent who ~s under age 65 There are two categones of persons eligible for Medicare The calculation and payment of ben- eflts by th~s Agreement d~ffers for each category 16 Category 1 Medicare Eligibles are 1 Acbvely working covered Employees age 65 or older who choose Option 1, 2 The age 65 or older covered spouses of acbvely working covered Employees age 65 or older Who choose Option 1, 3 Age 65 or older covered spouses of actively working covered Employees who are under age 6,5, 4 Actively working covered Employees of employers w~th 100 or more Employees and their Covered Dependents who are entitled to Medicare by reason of d~sabd~ty other than End Stage Renal Disease (ESRD), and 5 Covered ~nd~v~duals entitled to Medicare solely on the bas~s of ESRD dunng a penod of up to 12 months after the ~nd~wdual has been determined eligible for ESRD benefits Categoryl2 Medicare Eligibles are 1 Retired employees and their spouses, 2 Covered Employees of employers w~th less than 100 Employees and their covered Depen- dents who are entitled to Medicare by reason of a d~sab~l~ty other than ESRD, and 3 Covered ~nd~wduals entitled to Medicare solely on the bas~s of ESRD for more than 12 months after the ~nd~wdual has been determined ehg~ble for ESRD benefits Calculation and Prows~on of Services For Members ~n Category 1, serwces are prowed by th~s Agreement w~thout regard to any benefits prowded by Medicare Medicare wdl then determine ~ts benefits For Members in Category 2, serwces are prowded by the Group Agreement Harns Health shall then have the nght to recover the full amount of all Medicare benefits the Member ~s entitled to receive, whether or not the Member ~s actually enrolled for them The Member should authorize payment of Medicare benefits d~rectly to Hams Health for serwces rendered If the Member does not authonze d~rect payment, he or she ~s responsible for Harns Health for the reasonable value of the services rendered The Member ~s also responsible to Harris Health for the reasonable value of all Group Agreement serwces reimbursable by Medicare ~f the Member ~s not enrolled for all benefits he or she ~s entitled to receive 7 5 RIGHT TO RECEIVE AND RELEASE INFORMATION For purposes of adm~n~stenng the prowslons of th~s secbon, Harns Health may, w~thout further consent of, or noboe to any Member, release to or obtain from any healthcare plan, ~nsurance com- pany or other person or orgamzat~on, any ~nformat~on w~th respect to any Member which ~t deems to be reasonably necessary for such purposes, as permitted by law Any Member rece~wng serwoes or cla~m~ng benefits under th~s Agreement shall furnish to Harns Health all informat~on deemed necessary by Harns Healthlto ~mplement th~s Section 7 0 7 6 FACILITY OF PAYMENT Whenever payments which should have been made by Hams Health ~n accordance w~th th~s Section have been made by a Coordinated Plan, Hams Health shall have the nght, exercisable alone and ~n ~ts sole d~scret~on, to authonze payment to the Coordinated Plan making such payments any amounts Harns Health shall determine to be warranted in order to satisfy the ~ntent of th~s Section, and amounts when so pa~d shall be deemed to be benefits under th~s Agreement, and, to the extent of such payments,~Harns Health shall be fully d~scharged from I~abd~ty under th~s Agreement 7 7 RIGHT (~F RECOVERY Whenever payments have been made by Hams Health w~th respect to Allowable Expenses ~n a total amount which ~s, at any t~me, ~n excess of the maximum amount of payment neccessary at that bme to sabsfy the ~ntent of th~s Secbon, Harns Health shall have the nght to recover such payments, to the extent of such excess, from one or more of the following, as Hams Health shall determine any per- son or persons to, or for, or w~th respect to whom such payments were made, any ~nsurance company or companies, and any other organization or organizations which provided services, or to which such payments were made 17 7 8 DISCLOSURE Each Member agrees to d~sclose to Hams Health at the t~me of enrollment, at the t~me of receipt of serwces and benefits, and from t~me to t~me as requested by Hams Health, the existence of other health plan coverage, the ~dent~ty of the career, and the group through which such coverage ~s prowded 7 9 SUBROGATION Subrogation seeks to shCt the expense for ~njunes suffered by Plan Members to those response- hie for causing them In return for Hams Health prowd~ng benefits for ~njur~es, adments, or d~seases caused as a result of the neghgence, omission or wdlful act of a third party, each Member agrees to execute any ~nstrument which may be needed ~n order for the nght of subrogation to be effective Each Member also agrees to assign to Hams Health the nght of recovery against such third party to the extent of benefits received from or through Hams Health plus costs of legal su~t ~nclud~ng attorney fees At the t~me such benefits are prowded or thereafter as Hams Health may request, Member agrees to comply w~th the following provisions · Execute a formal wntten ~njury report and assignment to Hams Health of nght to recover the reasonable value of any benefits prowded d~rectly by Harns Health and the actual costs pa~d by Harns Health under th~s Agreement for ~njunes, a~lments and d~seases caused by a third party together w~th the costs of legal su~t ~nclud~ng attorney fees · Reimburse Hams Health for the reasonable value of any benefits and serwces prowded by Hams Health and ~n an amount equal to the charges therefor together w~th the costs of legal su~t, ~nclud~ng attorney fees, but not ~n excess of monetary damages collected, ~mmed~ately upon receipt of any mon~es pa~d by or on behalf of a third party ~n settlement of any claim ans~ng out of ~njunes, adments and d~seases covered by such third party In determ~ng the reasonable value of benefits and serwces provided by Harns Health, Hams Health shall con~ s~der charges for s~m~lar serwces being made by prowders ~n the community which possess s~mdar training or capabd~ty as well as unusual c~rcumstances, or a medical comphcat~on requmng additional t~me, skdl expenence and/or facd~t~es ~n connection w~th a particular ser- vice Hams Health shall have a hen on any recovery from such third party whether by judg- ment, settlement, compromise or reimbursement · Execute and dehver such papers and prowde such reasonable help 0nclud~ng authonz~ng bnng~ng su~t against such third party ~n Member's name and making court appearances) as may be necessary to enable Hams Health to recover the reasonable value of benefits and serwces prowded by Hams Health, together w~th costs of legal su~t, ~nclud~ng attorney fees Section 8 0 INDEPENDENT AGENTS/REFUSAL TO ACCEPT TREATMENT 8 1 INDEPENDENT AGENTS The relationships between Harns Health and contracting ent~t~es may be defined as follows · The relabonsh~p between Harns Health and Member Hospitals ~s that of ~ndependently con- tract~ng ent~t~es Member Hospitals are not agents or employees of Hams Health nor ~s Harns Health an agent of any Member Hospital Member Hospitals shall maintain the hospltal- pabent relationship w~th Members and shall be the only parbes responsible to Members for the Hospital serwces that they prowde · The relabonsh~p between Harns Health and Parbc~pabng Prowders Is that of ~ndependent contracbng ent~bes Parbc~pabng Prowders are not agents or employees of Hams Health nor ~s Harns Health an employee or agent of any Parbc~pat~ng Prowder Parbc~pat~ng Prowders shall maintain the physician-patient or professional-patient relabonsh~p w~th Members and shall be the only part~es responsible to Members for the serwces prowded Neither Harris Health nor any employee of Harns Health shall be deemed to be engaged ~n the practice of medicine Harns Health shall ~n no way superwse the practice of medicine by any Participat- ing Prowder hereunder, nor shall Harns Health in any manner supervise, regulate or Interfere wtth the usual professional relationships between a Participating Prowder and a Member 18 · The relationship between Harns Health, the Group and any Member ~s that of ~ndependent contracting ent~bes Neither the Group nor any Member ~s the agent or employee of Harns Health, and Harns Health ~s not the employee or agent of the Group or any Member Neither the Group or any Member shall be hable for any acts or omissions of Harns Health, ~ts agents or employees, any Physician, any Hospital, or any other person or organization ~n which Har- ns Health has made, or hereafter shall make arrangements for the performance of services under th~s Agreement 8 2 LIMITATION ON LIABIL.,ITY Harns Health does not guarantee by this Agreement that any Participating Prowder shall per- form or properly perform such contracts, the only obhgat~on of Harns Health ~n the event of breach of such contract ~ by any Participating Prowder shall be, upon request, to use ~ts best efforts to procure the needed serwces from another prowder Hams Health shall not be hable to a Member for any act of omission or commission on the part of any Participating Prowder 8 3 REFUSAL TO ACCEPT TREATMENT/EXCESSIVE TREATMENT Members may, for reasons personal to themselves, refuse to accept serwoes or complete a Course of Treatment as recommended by a Participating Physician Participating Physicians shall use their best efforts to render all necessary and appropriate professional serwces ~n a manner compatible w~th the Member's w~shes, ~nsofar as th~s can be done consistently w~th such Participating Physician's judgment as to the requirements of proper medical practice If a Member refuses to complete a recommended Course of Treatment, and the Participating Physician believes that no professionally acceptable alternabve exists, such member shall be so adwsed If upon being so adwsed, the Member stdl refuses to follow the recommended treatment or procedure, then the Member shall be g~ven no further treatment for the condition, and neither the Par- t~c~pat~ng Physician nor Harns Health shall have any further respons~bd~ty to prowde care for such con- d~t~on A Member may appeal a w~thdrawal of treatment under th~s prows~on through the Member Complaint Resolution Procedure as descnbed ~n Section 10 0 of th~s Agreement If two (2) or more Participating Physicians who have rendered care to a Member ~nform Harns Health that the Member ~s rece~wng health serwces or prescnpt~on medications ~n a manner or ~n a quanbty which ~s not medically necessary or not medically beneficial, the Member may be required by Hams Health to select a s~ngle Parbc~pat~ng Pnmary Physician (hereafter referred to as a "Coord~nat- lng Health Plan Physician") and a s~ngle Part~c~pabng Pharmacy, ~f Pharmacy benefits are available to Member, for the prows~on and coordination of all future health serwces If the Member fads to voluntar- dy select a Coordinat~ng Health Plan Physician and a s~ngle Participating Pharmacy w~th~n thirty (30) days of wntten nottce by Harns Health of the need to do so, Harns Health shall designate a Coordinat- ing Health Plan Physician and/or a Participating Pharmacy for the Member Following select,on or designation of a Coordinating Health Plan Physician for a Member, cov- erage of health serwces set forth on th~s Agreement shall be contingent upon each health serwoe being prowded by or through written referral to the Coordinating Health Plan Physician for that Member If, after s~xty (60) days from ~n~t~al notification by Harns Health, the Member ~s not ~n comphance w~th th~s Section, the Member may be terminated by Harns Health under Section 4 2 7 Section 9 0 EXCLUSIONS ON SERVICE RESPONSIBILITIES The nghts of Members and obhgabons of Participating Providers under th~s Agreement are subject to the exclusions as specified below 9 t MAJOR DISASTER OR EPIDEMIC In the event of any major d~saster or epidemic that would severely hm~t the avadabd~ty of Partici- pating Providers to prowde healthcare services on a t~mely bas~s, Participating Providers shall, ~n good faith, use the~rr best efforts to render the benefits and serwces covered ~nsofar as practical according to their best judgment and w~thin the hm~tabon of such facd~t~es and personnel as are then avadable If Harns Health and Parbc~pat~ng Prowders shall, ~n good faith, have used their best efforts to prowde or 19 make arrangements for the benefits and serwces, they shall have no further hab~i~ty or obhgat~on for delay or fadure to prowde such benefits and serwces due to a shortage of avadable fac~hbes or per- sonnel resulting from such d~saster or epidemic 9 2 CIRCUMSTANCES BEYOND CONTROL In the event that, due to c~rcumstances not reasonably w~thm the control of Hams Health or Participating Prowders, such as the complete or part~al destruction of faod~t~es because of war, not, c~vd insurrection, or the d~sabd~ty of a s~gmflcant number of Parbclpat~ng Prowders, the rendenng of benefits and serwces covered hereunder ~s delayed or rendered ~mpract~cal, neither Harns Health nor any Parbc~pat~ng Prowder shall have any habd~ty or obhgatlon on account of such delay or such failure to prowde such benefits and serwces, ~f they shall, ~n good faith, have used their best efforts to pro~ wde or make arrangements for the benefits and serwces covered ~nsofar as practical according to their best judgment and w~th~n the hm~tat~ons of such facd~t~es and personnel as are then avadable Pre- m~um payment shall be suspended for the duration of such t~me penod for the Group 9 3 FRAUDULENTLY OBTAINED BENEFITS In the event a member fraudulently obtains healthcare serwces as a result of the ~mproper or unauthonzed use of a Harns Health identification card, such Member agrees and ~s solely responsible for the payment of all charges for serwces so obtained and for the payment of all reasonable costs of collection thereof, ~nclud~ng court costs, collecbon fees and attorney fees 9 4 DISCONTINUANCE If Harns Health or Group determines ~t would be ~mpraot~oal to continue due to o~rcumstances beyond the control of Harns Health or Group, Hams Health and Group may endeavor to agree to amendments and adjustments to th~s Agreement which relate to serwces and benefits to be d~sconbn- ued If part~es cannot agree on amendments and adjustments, Hams Health or Group may terminate th~s Agreement at the end of any month upon at least s~xty (60) days wntten not~ce for Group In the event of such termination, neither Harns Health nor Participating Prowders shall have any further habd- ~ty or respons~b~hty under th~s Agreement However, ~f any Participating Provider terminates their contract, then Hams Health shall be ha- ble for the continuance of serwces and benefits descnbed ~n th~s Agreement Such serwces shall be rendered to Members by other Participating Providers Section 10 0 MEMBER COMPLAINT RESOLUTION PROCEDURE 10 1 COMPLAINT RESOLUTION PROCESS A Member may make an oral or wntten suggestion or md~cate a complaint to any Harns Health employee or to any Participating Prowder All oral suggestions and complaints shall be handled promptly by Hams Health If the Member ~s not satisfied w~th the response to an oral suggestion or complaint, the Member may file a wntten complaint by calhng Harns Health or, at the Member's option the Member may file a wntten complaint by comCetmg and forwarding a complaint form to Hams Health at the latest address provided on the front of th~s Agreement A Harns Health Member Serwce Representatwe shall contact the Member by telephone to venfy detads and resolve the problem ~mme- d~ately ~f possible W~th~n fifteen (15) bus,ness days from the receipt of the oral or written complaint, Hams Health shall respond ~n wntmg to ~nform the Member of the progress or decision on the com- plaint In the event a decision cannot be reached w~th~n fifteen (15) bus~ness days, Harris Health shall not~fy the Member that a decision shall be prowded as soon as possible, but not later than s~xty (60) days after ~n~t~al receipt of the complaint 10 1 1 Ad Hoc Rewew Committee If the Member ~s not sabsfled w~th the resolution of the complaint by Hams Health, the Member may request a rewew by flhng such a request, in wntlng, within fifteen (15) bus~ness days of rece~wng wntten not,ce of the resolution of the complaint Th~s request shall be sent to Hams Health Upon receipt of th~s wntten request, Harns Health shall forward the request and any and alt memoranda and notes made as a result of the ong~nal ~nvest~gat~on of the complaint to the Medical D~rector and to Har- ns Health 20 After rewewlng the complaint records, Harns Health shall convene an Ad Hoc Rewew Comm~t- tee composed of Hams Health, the Medical D~rector, and at least two other ~nd~wduals not involved ~n the ~n~bal ~nvest~gat~on of the complaint In the case of a complaint concerning medical treatment or services, medical personnel or facd~t~es, such other ~nd~wduals on the Ad Hoc Rewew Committee shall be Participating Physicians W~th~n fifteen (15) bus~ness days of receipt of the request for a rewew, Harris Health shall respond, ~n writing, to ~nform the Member of the decision or resolution of the com- plaint by the Ad Hoc Rewew Committee 10 1 2 Not~flcabon By Rewew Committee If the onglnal complaint ~nvolved a physician-patient relationship, the wntten response of the Ad Hoc Review Committee shall ~nform the Member that he has the option, at h~s d~scret~on, to submit the complaint to the' mediation service maintained by the Tarrant County Medical Society, and that such mediation shall ~Jsually be concluded w~thln a thirty (30) day to s~xty (60) day t~me penod The notice shall ~nform the Member that participation ~n the mediation process ~s voluntary and that mediation rec- ommendations are non-binding on both part~es As part of their contractual obhgat~on to comply w~th the Health Plan rules and regulations, Participating Physicians must cooperate with the Tarrant County Medical Society mediation service 10 2 COMPLAINT RESOLUTION APPEAL PROCESS If a Member ~s not satisfied w~th the decision of the Ad Hoc Rewew Committee, or the Tarrant County Medical Society mediation service, the Member may request an additional rewew by Harns Health The Member must file a request for review w~th~n fifteen (15) bus~ness days of receipt of the decision of the Ad Hoc Rewew Committee or the mediation service Upon receipt of a request for a rewew, Harns Health shall forward the rewew request and a complete record of the complaint h~story to the Medical D~rector and to Hams Health After reviewing the complaint records, Harns Health shall convene an Ad Hoc Appeal Comm~t- tee composed of Harns Health, the Medical D~rector and at least two other ~nd~wduals not ~nvolved ~n the ~n~t~al investigation of the complaint In the case of a complaint concerning medical treatment or serwces, medical personnel or fac~ht~es, such other ~nd~wduals on the Ad Hoc Appeal Committee shall be Participating Physicians W~th~n fifteen (15) bus,ness days of receipt of the request for a review, Hams Health shall respond, in wnbng, to ~nform the Member of the decision or resolution of the complaint by the Ad Hoc Appeal Committee If all part~es ~nvolved ~n the complaint agree, the complaint response of the Ad Hoc Appeal Committee shall be final and binding on all part~es Section 11 0 HEALTH CARE SERVICES 11 1 Benefits and Serwces Hams Health agrees to arrange for the prows~on of the benefits and serwces ~n the Schedule of Benefits and/or, R~ders, ~n accordance w~th the procedures and subject to the hm~tabons and exclu- sions specified ~n such Schedule of Benefits and/or R~ders and ~n th~s Agreement Unless referred ~n writing by a Participating Pnmary Physician (or by a Parbc~pat~ng Spec~ahst Physician), and except ~n cases of Medical Emergency, benefits and serwces set forth ~n the L~m~ta- t~ons and Exclusions Section of the Schedule of Benefits or any R~ders that are rendered by a Partici- pating Physician other than a Participating Primary Physician shall not be covered All hospital admissions must be authonzed by Harns Health, and the Member's condition or required services must be such that treatment can be rendered only ~n a hospital setting Harns Health and the Participating Physician may dec~de to prowde Medically Necessary services on an outpatient bas~s or ~n an Outpatient surgery unit The use of alternative levels of care, such as outpatient hospital or home care, will be encouraged where possible based on Member condition and treatment Unless previously authorized in wnt~ng by a Participating Physician and by the Medical D~rector and except ~n cases of Medical Emergency, all benefits and services set forth ~n the Schedule of Ben- eflts and any Riders shall be available and covered only when prowded by a Participating Physician, Participating Hospital or by another Prowder under contract w~th Harns Health to provide healthcare services to Members 21 All charges related to serwces and supphes incurred pnor to the Member's effecbve date, or after the Member's term~nabon date of coverage under th~s Agreement shall not be covered Section 12 0 TERM AND AMENDMENT OF AGREEMENT 121 TERM Th~s Agreement shall remain ~n effect for the first Contract Year and thereafter for successive Contract Years unless sooner terminated as prowded in Section 4 0 of th~s Agreement 122 AMENDMENT · Harris Health and Group may mutually alter or rewse the terms of this Agreement and/or Schedule of Benefits and R~ders attached hereto In the event of such alterabon or rewslon, Harns Health shall prowde Group w~th at least s~xty (60) days wntten not~ce before effective date of Amendment Such not~ce shall be considered to have been provided when ma~led to the Group at the latest address shown on the records of Harris Health · Th~s Agreement may be amended at any ttme, according to any prowslon of th~s Agreement or by wntten agreement between Harris Health and Group, w~thout the consent of the Mem- bers, or any other person hawng a beneficial Interest ~n ~t Any such amendment shall be w~thout prejudice to any claim anslng pnor to the effecbve date of such amendment 123 CHANGE OF RATES Harns Health shall have the nght to change the rates and premiums payable hereunder O) as of any Anniversary Date 0n which case the Group shall be notified at least s~xty (60) days pnor to a change in rates) or (il) ~n accordance w~th Section 12 2 of this Agreement Section 13 0 MISCELLANEOUS PROVISIONS 13 1 USE OF WORDS Words used ~n the masculine shall apply to the femrmne where applicable, and, wherever the context of th~s Agreement d~ctates, the plural shall be read as the srngular and the srngular as the plu- ral The words "hereof," "here~n," "hereunder" and other srm~lar compounds of the word "here" shall mean and refer to the entire Agreement and not to any particular Secbon or prowson All references to Sectrons and prov~srons shall mean and refer to Sections and provisions contained in this Agreement unless otherwise indicated 132 RECORDS AND INFORMATION Harns Health shall conduct a review program for the healthcare services ~t prowdes hereunder and for that purpose may examine the records of each Member Information from medical records of Members and ~nformat~on received from Physicians or Hospitals ~nc~dent to the Physician-patient or Hospital-patient relabonsh~p shall be kept confidential Th~s ~nformat~on, except as reasonably neces- sary ~n connection w~th the administration of th~s Agreement or as required by law, shall not be d~s- closed w~thout the consent of the Member Harns Health shall, to the extent legally allowable and w~thout further consent of or not~ce to any Member, release to or obtain from any insurance company or other organization or person any ~nformat~on, w~th respect to any person, which Harris Health deems to be necessary for such pur- poses Any person cla~m~ng benefits shall furnish to Harns Health such informat~on as may be neces- sary to ~mplement th~s Agreement 13 3 INFORMATION FROM GROUP Group shall penodlcally forward the ~nformat~on required by Hams Health ~n conjunction w~th the administration of th~s Agreement All records of Group which have a beanng on the coverage shall be open for ~nspecbon by Harns Health at any reasonable bme Harns Health shall not be hable for the fulfillment of any obhgat~on dependent upon such ~nformabon pnor to its receipt in a form satisfactory to Harris Health Incorrect ~nformabon furnished may be corrected, if Harris Health shall not have acted to ~ts prejudice by relying on ~t Harns Health shall have the right, at reasonable t~mes, to examine 22 Group's records, ~ncludlng payroll records of employers hawng employees covered through Group, w~th respect to ehg~b~l,ty and monthly premiums under th~s Agreement 134 ASSIGNMENT The benefits to a Member under th~s agreement are spec~hc to the Member and are not assignable or otherwise transferable 135 AUTHORITY Any alterations or rews~ons to th~s Agreement shall not be vahd unless ewdenced by a wntten amendment which has been s~gned by Group and by an ofhcer of Harns Health and attached to the affected document No other person has the authority to change th~s Agreement or to waive any of ~ts provisions 136 GOVERNING LAW This Agreement is executed and ~s to be performed ~n all respects ~n accordance w~th all fed- eral and Texas state laws apphcable to Health Maintenance Organizations and all other apphcable Texas state laws or regulat ons 137 INCORPORATION BY REFERENCE The Schedule of Benefits, Group Enrollment Agreement, Apphcat~ons, any optional R~ders, any Attachments, ahd any amendments to any of the foregoing, form a part of th~s Agreement as ~f fully ~ncorporated here~n Any direct conflict or ambiguity of th~s Agreement shall be resolved under terms most favorable to the Member 138 ENTIRE AGREEMENT This Agreement constitutes the entire understanding between Harns Health and Group 13 9 INFORMATION TO MEMBER Upon execution of this Agreement, Harris Health shall provide to each Subscnber a copy of thts Agreement and an Identification Card Such delivery shall be accomphshed by ma~hng postage pa~d, to the latest address furnished to Harris Health or by dehvery from a representatwe of Harris Health or Group to Subscriber 1310 UNIFORM RULES In the administration of Harris Health, th~s Agreement shall be applied uniformly to all Members s~mdarly s~tuated 13 11 CALCULATION OF TIME In determining t~me penods w~th~n which an event or action ~s to take place for purposes of Harns Health, no fracbon of a day shall be considered, and any act, the performance of which would fall on a Saturday, Sunday, holiday or other non-bus,ness day, may be performed on the next following business day 13 12 EVIDENCE Ewdence required of any Member of Harris Health may be by certificate, affldawt, document, or other ~nformat~on which the person acting on ~t considers pertinent and rehable, and s~gned, made or presented by the proper party or part~es 13 13 SEVERABILITY If any prowslon of this Agreement shall be held ~nvahd or dlegal, the rest of th~s Agreement shall remain ~n full force and effect and shall be construed ~n accordance w~th the ~ntent~ons of the part~es as manifested by all prows~ons hereof ~nclud~ng those which shall have been held invalid and tllegal Furthermore, ~n I~eu of any provision hereof which ~s found to be illegal, ~nvahd or unenforceable, there shall be added hereto a provision as s~m~lar ~n terms to such dlegal, ~nvahd or unenforceable prows~on as may be possible and be legal, vahd and enforceable w~thout mater~ally changing the purpose and intent of this Agreement 28 13 14 VENUE The part~es hereby expressly agree that th~s Agreement ~s executed and shall be performable ~n Tarrant County, Texas, and venue of any d~sputes, claims, or lawsuits anslng hereunder shaJl be ~n the sa~d Tarrant County 13 15 WAIVER OF NOTICE Any person entitled to not,ce under th~s Agreement may waive the nobce 13 16 HEADINGS The t~tJes and head~ngs of Sections or prows~ons are ~ncluded for convenience of reference only and are not to be considered ~n construction of the Sections or prows~ons hereof 13 17 NOTICE OF CERTAIN EVENTS If Group may be matenally or adversely affected thereby, Harris Health shall, w~th~n a reasona- ble t~me, prowde wntten not,ce to Group of any termination or breach of contract, or ~nab~l~ty of any Parbc~pat~ng Prowder to prowde the serwces and benefits as descnbed in this Agreement 13 18 NOTICE OF TERMINATION All Harns Health nobces of termination of th~s Agreement or of any Member's r~ghts w~ll be ~n wntmg and shall state the cause of termination, w~th specific reference to the provision(s) of th~s Agree- ment g~v~ng nse to the r~ght of termination 13 19 NOTICE Any nobce under th~s Agreement shall be ~n wnt~ng, and shall be g~ven by Un,ted States ma~l, postage prepaid, addressed as follows Harns Health PO Box 90100 Arhngton, Texas 76004-3100 Group The address specified on the executed Group Enrollment Agreement or the latest address provided, ~n wnt~ng, to Hams Health Subscnber The latest address prowded by the Subscnber on Application form actually delivered to Harns Health The effective date of notice ~s two (2) bus,ness days after the date of deposit w~th the Un~ted States Post Off~ce 24 HARRIS HEALTH SERVICE AREA The Hams Health Serwce Area includes six teen (16) counties and parts of four (4) coun ties tn North Central Texas The following sixteen (16) counties are ii1 cluded in the Service Area Boscue Hood Commanche Johnson Dallas Limestone Denton Parker Erath Palo Pinto Freestone Somervell Hamdton Tarrant Hill Wise In the following four (4) counties zip codes are included as specified in the Service Area COUNTY ZIP CODES Coryell 76512 76525 76528 76538 76566 76580 Elhs 76064 76065 Montague 76230 76239 76251 76270 Navarro 75110 76639 75153 76679 76681 SCHEDULE OF BENEFITS PREFERRED FLEX PLAN HARRIS METHODIST TEXAS HEALTH PLAN, INC. d/b/a HARRIS METHODIST HEALTH PLAN A FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATION FLEX 96 FLEX PREF Please contact Us whenever You have a problem, comment, or question. Harris Methodist Health Plan 611 Ryan Plaza Drive, Suite 900 Arlington, TX 76011-4009 (817) 462-7800 1-800-633-8598 FLEX 96 FLEX PREF TABLE OF CONTENTS OBTAINING HEALTH CARE SERVICES 1 SCHEDULE OF BENEFITS 3 PHYSICIAN SERVICES 4 EMERGENCY CARE SERVICES 6 INPATIENT FACILITY SERVICES 8 OUTPATIENT FACILITY SERVICES 9 MATERNITY SERVICES 10 FAMILY PLANNING SERVICES 11 INFERTILITY SERVICES 12 MENTAL HEALTH SERVICES 13 CHEMICAL DEPENDENCY SERVICES 15 REHABILITATION SERVICES 16 CARDIAC REHABILITATION SERVICES 17 KIDNEY DIALYSIS SERVICES 18 AMBULANCE SERVICES 18 HOME HEALTH CARE SERVICES 19 SKILLED NURSING FACILITY SERVICES 20 PROSTHETIC MEDICAL APPLIANCES 21 DURABLE MEDICAL EQUIPMENT 22 OSTOMY SUPPLIES 24 ORGAN TRANSPLANT SERVICES 25 LIMITED DENTAL SERVICES 26 LIMITED VISION SERVICES 27 GENERAL LIMITATIONS AND EXCLUSIONS 28 FLEX 96 FLEX PREF OBTAINING Welcome to Harris Methodist Texas Health Plan, Inc doing business as Harris HEALTH CARE Methodist Health Plan (the Health Plan) We have prepared this Schedule of SERVICES Benefits to help explain the coverage provided by the Health Plan It explains how to obtain medical care, what health services are covered, and what portion of the health care cost You are required to pay You should refer to this information whenever You need medical services You may get additional assistance by calhng the Health Plan's Customer Service Department at (817) 462-7800 or (800) 633-8598 The Health Plan coordinates a health care system to finance and deliver quality, cost-effective services to You The Health Plan does not provide services, equipment, or products You may choose to seek health care services outside the terms of this Schedule of Benefits However, the Health Plan will only provide coverage for services received according to the terms of this Schedule of Benefits Selecting a The Primary Care Physician is responsible for coordinating Your total health Primary Care care This includes initial care, routine care, home and office visits, and referrals Physician Upon enrollment, the Health Plan will provide You with a list, including addresses and telephone numbers, of the Primary Care Physicians that participate in the Health Plan You may choose a Primary Care Physician If You do not choose a Primary Care Physician, the Health Plan will select one for You, and notify You of that selection You may re. leer the Primary Care Physician that the Health Plan selects for You You may change Your Primary Care Physician by contacting the Health Plan's Customer Service Department The change becomes effective on the first day of the month following the request The Health Plan may limit a Member's request to change a Primary Care Physician to four changes in any twelve month period You may request health services by calling Your Primary Care Physician any time, day or night Your Primary Care Physician must coot&narc all referrals to a Specialist, except for Mental Health Services and Obstetrical/Gynecological Services Each referral is valid only for the number of services and/or time specified on the referral form Obtaining the If a reqmrod specialty is not represented in the Health Plan, Your Primary Care Services of a Physician may request authorization for referral to a Non-Parhclpatmg Provider Specialist for Covered Services All such non-emergency referrals must be authorized by Physician the Health Plan before services are obtained FLEX 96 I FLEX PREF Mental Health You may access Mental Health and Chemical Dependency Services directly by and Chemical contacting Harris Mental Health Management Services at (817) 462-6577 or Dependency (800) 374-2129, or by requesting assistance from Your Primary Care Physician Services Obstetrical & A referral from Your Primary Care Physician is not required for obstetrical or Gynecological gynecological care provided by a Participating Obstetrician/Gynecologist You Services may directly access the Obstetrician/Gynecologist of Your choice from the list of Participating Physicians provided by the Health Plan Preauthor~zatlon Preanthorlzatlon is the review of a requested service for medical necessity This and the ~rocess helps ensure that You are getting the most appropriate care available Utlhzat~on under this Schedule of Benefits Review Program Your Physician should contact the Health Plan before scheduling any service or admission requiring preanthorlzatlon Some services which reqmre )reauthorlzatlon are · Educational Services Inpatient or Outpatient Faclhty Services · Matarnlty Service · Infertility Services · Mental Health Services · Rehabilitation Services · Cardiac Rehabilitation Services · Non-emergancy Care Ambulance Services · Prosthetic Medical Appliances · Durable Medical Equipment · Organ Transplant Services Customer The Health Plan's Customer Service Department can help You any time You Service have a problem or question Call a representative at (817) 462-7800 or 1-g00- Department 633-g$9g if You · Need to change Your Primary Care Physician · Have a benefit question · Cannot reach Your Primary Care Physician · Need any replacement documents (Member Handbook, Schedule of Benefits, Certificate of Coverage, Provider Directory, etc ) · Need to replace a lost or stolen ID Card · Need to update Your name, address, or phone number · Have a complaint, problem, or suggestion · Have any other questions about Your health care coverage FLEX 96 2 FLEX PREF SCHEDULE OF You are entitled to receive benefits for the Covered Services described in this BENEFITS Schedule of Benefits All services and benefits are subject to the stated Copayment amounts, Limitations, Exclusions, and provisions of the Group Health Care Agreement/Subscnbar Certificate of Covarage and this Schedule of Benefits Benefits may be added to this Schedule of Benefits by the addition of benefit Raders Limitations and Limitations and Exclusions that apply to Your benefits are listed in the General Exclusions Limitations and Exclusions Section of this Schedule of Benefits AIl benefits are subject to the stated Limitations and Exclusions Regarding This Schedule of Benefits shows different Copayments for different Covered Copayments Services When a Provider performs two or more Covered Services on the same day, You pay the higher Copayment only You would pay more than one Copayment for services on the same day if more than one Provider is ~nvolved, such as paying a Facility Copayment to the Hospital and a Physic~an Copayment to the doctor Copayments shown as a "Percentage of Total Charges" means You pay the percentage of the rate the Health Plan has negotiated w~th that Prowder Ifthere is not a negotiated rate, You pay the percentage of the rate charged by the Provider Copayment When the total Copayments applied to all Covered Services received by an Maximums indimdual Member reach the Per Member Copayment maximum, no Copayment will be taken on additional Covered Serwces prowded to that Member ~n the same Calendar Year When the total Copayments appbed to all Covered Services received by a family reach the Per Family Copayment maximum, no Copayment will be taken on additional Covered Services provided to any Member of that family in the same Calendar Year It is possible that a family could reach the Per Family maximum without any one of the Members first reaching the Per Member maximum Per Member $2,000 00 Per Family $4,000 00 FLEX 96 ~ FLEX PREF BENEFITS AND FEE SCHEDULE PHYSICIAN SERVICES Benefits and Primary Care Physician Office Visits $15 00/Visit Required Including office surgery, adult health Copayments assessments, routine physical examinations, and well-child care for the diagnosis, care, and treatment of illness or Injury Speciahst Physician Office Visits $20 00/Visit Annual Well-Woman Examinations $15 00/Visit-Primary Care $20 00/VIsit-Spec~ahst Home Visits $1 $ 00/Visit-Primary Care $20 00/VIsit-Speciahst Physician visits outside of scheduled office hours $25 00/Visit Immumzations administered in the office No Copayment Allergy testing $50 00/Visit Allergy m. lections administered m the office No Copayment Tharapeutlc drugs administered $1 $ 00/V~sit-Pnmary Care by any means, medications, dressings, $20 00/Vlsit-Speclahst splints, and re-application of casts Diagnostic tests, laboratory tests, x-rays, and No Copayment professional radiology or pathology services Physician services for surgery $:~0 00 per procedure or other procedure performed in an outpatient Facility Physician services while You are 20% of Total Charges hospitahzed Diabetic Education Services No Copayment Physician services in an Emergency No Copayment FLEX 96 4 FLEX PREF Limitations Physician Services Benefits are limited as follows · All services must be provided in relation to a covered diagnosis or procedure Covered educational services are limited to authorized programs for Diabetic Education A $600 00 per Calendar Year maximum benefit per Member applies Excluded services include, but are not hmlted to classes or tramlng for · prepared childbirth, Lamaze, teen pregnancy, cesarean section, and vagmal b~rth after cesarean · parenting · breast-feedmg · stress management Exclusions Charges for Physic~an Services except as otherwise specdied in th~s benefit section are excluded Exclusions include, but are not limited to · Reports, evaluations, or physical examinations not required for treatment of health condmons, or not directly related to medical treatment Examples include, but are not limited to services Onclud~ng lmmumzat~ons) for comphance with a court order, employment, insurance, camp, adoption, school, travel, or government licenses · Allergy serum FLEX 96 5 FLEX PREF EMERGENCY CARE SERVICES Emergencies When faced with an emergency Illness or Injury, it is suggested You contact the local emergency service or proceed to the nearest emergency care Faclhty Upon arrival at the Facility, You or someone You designate must contact Your Primary Care Physician The Health Plan will pay for Emergency Care whether it Is provided inside or outside the Health Plan's Service Area Emergency Care means bona fide emergency services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in · placing the patient's health in serious jeopardy · serious impairment to bodily functions, or · serious dysfunction of any bodily organ or part The Health Plan will pay for medical screening examinations or other evaluation provided to You in the Emergency Department necessary to determine whether an emergency medical condition exists The Health Plan will also pay for necessary emergency care services provided to You and services originating in a hospital emergency department following stabilization of an emergency medical condition The Health Plan must approve or deny coverage of post- stabilization care within the time frame appropriate to the circumstances, but in no case to exceed one hour Other Situations If the Illness or Injury is not an emergency, contact Your Primary Care Physician before seeking treatment Your Primary Care Physician will direct You to the most appropriate place of servlce Your Primary Care Physician, or someone he designates, is available 24 hours per day, seven days a week Notifying the You, or someone You designate, must notify the Health Plan within 24 hours of Health Plan any emergency care visit, or as soon as possible Please provide the following information · date of service · name of the Facility where You were treated · Your diagnosis, with accident details if accident related · whether Your Primary Care Physician directed You to this Facility · whether You were admitted to the inpatient portion of the Facility Non-participating Coverage for services by Non-participating Providers either inside or outside of Providers the Health Plan's Service Area is limited to the care required before You can, without medically harmful or injurious consequences, be transferred or treated by a Participating Provider All follow-up care must be authorized by the Health Plan or provided by a Participating Provider FLEX 96 6 FLEX PREF Inpatient If You are admitted d~rectly to an ~npatlent Facthty from the emergency Admission department of the same Fac~hty, all Emergency Care charges will be subject to the appropriate inpatient Copayment Benefits and Inside or outside the Health Plan's Service Area 20% of Total Charges Required Emergency Room Facility Services Copayments Urgent Care Center Services $25 Ltmitatlons Emergency Care Services benefits are hm~ted as follows · Benefits for Members temporarily residing outside the Service Area are limited to Emergency Care Service benefits The Member must return to the Service Area for all other services and follow-up care Exclusions Charges for Emergency Care Services except as otherwise specified in this benefit section are excluded FLEX 96 7 FLEX PREF INPATIENT FACILITY SERVICES Benefits and Room, board, medications, and supplies 20% of Total Charges Required Copayments Limitations Inpatient Facility Services benefits are limited as follows · Ali services must be provided in relation to a covered diagnosis or procedure · Inpatient d,agnostic testing is limited to services directly related to the condition for which the hospltahzation is authorized Exclusions Charges for Inpatient Facility Services except as otherwise specified ,n this benefit section are excluded Exclusions include, but are not hmlted to · Recreational or educational therapy FLEX 96 8 FLEX PREF OUTPATIENT FACILITY SERVICES Benefits and Facility services for surgery or other $100 00/Visit Required procedure Copayments Chemotherapy, Radiation therapy, 20% of Total Charges and Inhalation therapy Diagnostic tests, laboratory tests, and x-rays No Copayment Limitations Outpatient Facility Services benefits are hm~ted as follows · All servmes must be prowded in relation to a covered dmgnosts or procedure Exclusions Charges for Outpatient Facility Services except as otherwise specified in thms benefit section are excluded Exclusions mclude, but are not hmited to · Recreational or educational therapy FLEX 96 9 FLEX PREF MATERNITY SERVICES Benefits and Physician Services for Obstetrical Care 20% of Total Charges Required Including pre-natal care, delivery, Copayments postpartum care, Hospital VlSltS, and anesthesia Physician services In the Hospital for 20% of Total Charges care of an Eligible Newborn Inpatient Facility Charges 20% of Total Charges L~mltatlons Maternity Services benefits are limited as follows · All services must be provided in relation to a covered diagnosis or procedure · Coverage for Maternity services received outside the Service Area before week 37 of the pregnancy are limited to covered Emergency Care Services benefits or services preauthorized by the Health Plan · You must have preauthonzation from the Health Plan to travel outside the Service Area aRer week 36 of the pregnancy or services received outside the Service Area will not be covered · Coverage for Maternity services by Non-participating Providers is limited to Members that become eligible with the Health Plan after week 31 of the pregnancy All services must be authorized by the Health Plan before charges are incurred All obstetrical/gynecological services provided after this initial covered pregnancy must be performed by a Participating Physician Exclusions Charges related to Maternity Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to · Any procedure performed for sex determination of the fetus Examples include, but are not limited to ultrasound, ammocentesis, or any assisted reproductive technology procedure FLEX 96 10 FLEX PREF FAMILY PLANNING SERVICES Benefits and Physician Office Visits $1 $ 00/Visit-Primary Care Required Including testing, counseling, $20 00Nlslt-Speciahst Copayments genetic counseling, Federal Drug Administration approved contraceptive injections, the fitting or dispensing of an IUD or diaphragm, removal of Norplant and office surgery Limitations Family Plannmg Services benefits are hmitcd as follows * All services must be provided in relation to a covered diagnosis or procedure Exclusions Charges for Family Planning Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not hmited to · Reversal of sterilization · Subsequent resterihzat~on · Insertion or supply of Norplant or any s~mllar device FLEX 96 ]1 FLEX PREF INFERTILITY SERVICES Benefits and Physician Office Vislts $15 00/Visit-Primary Care Required $20 00Nisit-Speciahst Copayments Laboratory tests, x-rays, and professional No Copayment radiology or pathology services Endometnal biopsy, hysterosalpmgography, 20% of Total Charges and diagnostic laparoseopy Limitations Infertility Services benefits are limited as follows · All services must be provided in relation to a covered diagnosis or procedure · Coverage is limited to diagnostic services to determine the cause of infertility Exclusions Charges related to Infertility Services except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to · Infertility treatment · Infertility medications · Reversal of sterilization · Surrogate parenting · Any assisted reproductive technology (ART) procedure that enhances a woman's abthty to become pregnant Examples of ART procedures include, but are not limited to lntra-uterme insemination, GIFT procedures, SIFT procedures, and in-vitro fertilization · Any costs associated with the collection, storage, purchase, or processing of sperm for use in any assisted reproductive technology procedure FLEX 96 12 FLEX PREF MENTAL HEALTH SERVICES Benefits and Mental Health Benefits include Required Copayments * Outpatient Care - Services for the evaluation and treatment of mental health conditions which do not require a program of daily treatment and for which services are provided on a per-visit basis · Structured Sub-acuta Care - A program of treatment for mental health conditions which do not require 24-hour-a-day supervision but require the intensity of daily treatment · Residential Care for Chddren and Adolescents - A program of treatment for mental health conditions which require 24-hour-a-day supervision but do not require the more intensive medical momtormg of an acute ~npatient hospitalization · Inpatient Care - Services for the evaluation and treatment of mental health condit~ons which reqmre 24-hour-a-day supervis~on and the mtansive medical monitoring of an acute inpatient hosp~tahzat~on Outpatient Care Maximum 30 visits/Year Covered Services except group therapy $20 00/Visit and home health visits Group therapy and home health wsits $20 00/Visit Medication Management $15 00/V~s~t-Prlmary Care $20 00/V~sit-Speciahst Psychological Testing 20% of Total Charges Inpatient Care, Structured Sub-acute Care, 20% of Total Charges or Residential Care for Children and Adolescents Limitations Mental Health Services benefits are hmited as follows ~ All services must be provided in relation to a covered d~agnosls or procedure · Benefits are hmlted to evaluation, crisis intervention, and stabilization for the d~agnosls and treatment of covered mental illnesses or disorders FLEX 96 13 FLEX PREF Limitations · Outpatient Care services are limited to a combined, maximum benefit of 30 Continued visits per Calendar Year, and may include mdw~dual, family, or group therapy, medicatxon management, and home health wslts · Inpatient Care services, Structured Sub-acute Care services, and Resxdential Care for Children and Adolescents services are limited to a combined, maximum benefit of 30 days per Calendar Year For Structured Sub-acute Care services and Residential Care for Children and Adolescents services, each two days of treatment will be considered equal to one day of mpatmnt treatment m determining the combined, maximum benefit Exclusions Charges for Mental Health Services except as otherwise specified ~n this benefit section are excluded Exclusions include, but are not hmxted to Services for psychiatric conditions that are chronic or organic in nature, or that will not substantially benefit from Short-term treatment Marriage, career, or financial counsehng Treatment of mental retardation or mantal deficiency ·Behaworal training Remedial education · Evaluation and treatment of learning and developmental dlsabdities and minimal brain dysfunction Psychological testing or psychotherapy for the treatment of attention deficit disorders or related condltlons · Recreational or educational therapy · Biofeedback FLEX 96 14 FLEX PREF CHEMICAL You are entitled to coverage of necessary care and treatment for Chemical DEPENDENCY Dependency on the same bas~s as that provided for any physical illness SERVICES Diagnosis and treatment for Chemical Dependency will include detoxfficatlon and/or rehabdltatlon on an inpatient or outpatient basts A series of treatments is a planned, structured, and orgamzed program to promote chemical free status which may include different facilities or modahties and is complete when the Member ·is discharged on medical advtce, or · has completed a series of these treatments without a lapse m treatment, or · falls to materially comply with the treatment program for a per,od of 30 days Benefits and Outpatient Care $15 00/Vis,t-Primary Care Reqmred $20 00/Vis,t-Spec~ahst Copayments Inpatient Care or 20% of Total Charges Structured Sub-acute Care Llfet,me Maximum Benefit Three separate series of treatments Limttattons Chemical Dependency Servmes benefits are hmtted as follows · All services must be prov,ded in relation to a covered d,agnosis or procedure Benefits are limited to a L~fetime Mammum benefit of three separate series of treatments for each Member Exelustons Charges for Chemical Dependency Services except as otherwise spec,fled in th~s benefit section are excluded FLEX 96 15 FLEX PREF REHABILITATION SERVICES Benefits and Short-term rehabilitative services Outpatient $20 00Nlslt Reqmred mcludmg occupational therapy, Inpatient 20% of Total Charges Copayments physical therapy, or speech therapy Maximum Benefit Two months per medical episode for servmes prowded m an outpauent setting L~mltahons Rehabdltat~on Services benefits are hm~ted as follows · All services must be prowded m relatmn to a covered dmgnos~s or procedure · Services are hm~ted to a maximum of two months per medical episode for services prowded m an outpatient setting · Services must prevent dysfunctmn, restore functional abd~ty, or famhtate maxxmal adaptatmn to impairment · The services provided must be · directed and momtored by a Participating Physician, · for therapy prowded by a Physmmn or by a hcensed or certffied physteal, occupatmnal, or speech therapist, · furnished to You by a Participating Famhty or through a Participating Prowder, · prowded according to a spectfic written treatment plan that details the treatment, ~ncludlng frequency and duration, and prowdes for on~gomg rewews, and · expected to result ~n a slgmficant ~mprovement of the condition w~thm a two month period The two month period commences with the first ws~t Short term ~s defined as two months or less Exclusaons Charges related to Rehabilitation Services except as otherwise spemfied m this benefit section are excluded Exclusxons Include, but are not hmxted to · Work hardemng programs FLEX 96 16 FLEX PREF CARDIAC REHABILITATION SERVICES Benefits and Outpatient Services $20 00N~stt-Speclahst Reqmred Copayments Maximum Benefit 36 sessions w~thm 12 consecuttve weeks L~m~tat~ons Car&ac Rehabfl~tatmn Services are hm~ted as follows * All servxces must be prowded m relation to a covered diagnosis or procedure · Servmes must be prowded ~mmedmtely following · a documented episode of Unstable Angina · Coronary Artery Bypass Graft surgery · a Coronary Ang~oplasty procedure Exclusaons Charges for Cardiac Rehabilitation Services except as otherwise specified in th~s benefit section are excluded Exclusmns ~nclude, but are not hm~ted to · Superwsed exercise that ~s not EKG momtored FLEX 96 17 FLEX PREF KIDNEY DIALYSIS SERVICES Benefits and Outpatient Services $20 00/Visit Required Inpatient Services 20% of Total Charges Copayments Home Dialysis (Continuous Ambulatory Peritoneal Dialysis) $20 00NIslt Including equipment, training, solutions, coils, and drug and surgical supplies Limitations Kidney Dialysis Services benefits are limited as follows · All services must be provided In relation to a covered diagnosis or procedure Exclusions Charges for Kidney D,alysis Services except as otherwise specified in this benefit section are excluded AMBULANCE SERVICES Benefits and Land and air ambulance services 20% of Total Charges Required Copayments Limitations Ambulance Services benefits are limited as follows ~ Ail services must be provided in relation to a covered diagnosis or procedure · Services must be provided in relation to covered Emergency Care Services Exclusions Charges for Ambulance Services except as otherwise specified in this benefit section are excluded FLEX 96 18 FLEX PREF HOME HEALTH CARE SERVICES Benefits and Home Health Services $15 00/Vislt Required Copayments Hospice (Home Health Service Only) $15 00/Day Limttatlons Home Health Care Services benefits are limited as follows ~ All services must be provided in relation to a covered diagnosis or procedure · Coverage is limited to services provided only for · chemotherapy · radiation therapy · treatment of terminal illness · treatments determined by the Health Plan to be medically necessary and appropriate to be rendered in a home setting · Physmal, oecupatmnal, or speech therapy received m the home ~s provided under the Rehabthtatlon Servmes benefit · Hospme care received outside the home is provided under the Inpatient Famhty Services benefit Exclusions Charges for Home Health Care Services except as otherwise speeffied ~n th~s benefit section are excluded Exclusions ~nclude, but are not hmaed to · Homemaker, chore, or similar services · Services primarily for rest, Custodial, Dom~cflmry, or convalescent care · Respite care FLEX 96 19 FLEX PREF SKILLED NURSING FACILITY SERVICES Benefits and Room, board, medications, and supplies 20% of Total Charges Required Copayments Maximum Benefit 60 days/Calendar Year Limitations Skilled Nursing Faclhty Services are llmlted as follows All services must be provided in relation to a covered diagnosis or procedure · The medical condition must be subject to significant clinical improvement Services must be provided instead ofhospitahzatlon, either in place of an admission or upon discharge from inpatient care · Services must be determined Medically Necessary by the Health Plan based on acuity of services and patient condition Exclusions Charges for Skilled Nursing Facility Services except as otherwise specified in this benefit section are excluded FLEX 96 20 FLEX PREF PROSTHETIC MEDICAL APPLIANCES Benefits and Internal and external 20% of Total Charges Reqmred prosthetic appliances Copayments and applicable hardware Maximum Benefit $5,000 O0/Calendar Year L~mitatlons Prosthetic Medical Appliances benefits are limited as follows · Ail services must be provided m relation to a covered d~agnosls or procedure · Appliance must serve a physiological purpose · Appliance must be obtained from a participating prosthetm apphance provider · Repair or replacement of external prostheses ~s covered only when required by marked physical changes, growth, or malfunction of the devine as determined by the Health Plan · The purchase of an external breast prosthes~s and any associated garments Is limited to purchase of the lmt~al prosthes~s and bra following mastectomy without reconstruction Exclusions Charges related to Prosthetic Medmal Apphances except as otherwise spemfied in this benefit section are excluded Exclusions include, but are not hmlted to · Aids, apphances, or supphes that possess features not reqmred by the patient's condmon, are not pnmardy medmal m natare, are self help dewces, are primarily for the patient's comfort or convenience, are for common household use, are research eqmpment, or are deemed Experimental by the Health Plan, including, but not limited to · corrective orthopedic shoes, arch supports, or foot orthottcs · dentures · contact lenses · wigs or hair pieces · Routine maintenance of any external device, appliance, equipment, or supply · Repairs determined to be cosmetic by the Health Plan FLEX 96 21 FLEX PREF DURABLE MEDICAL EQUIPMENT Benefits and Rental or purchase of 20% of Total Charges Required medical eqmpment Copayment Maximum Benefit $5,000 00/Calendar Year L~m~tatlons Durable Medical Eqmpmant (DME) benefits are hm~ted as follows All services must be prowded in relation to a covered dtagnos~s or procedure At its option, the Health Plan may rent or purchase approved eqmpment · Services for which the purchase price or total rental costs wdl exceed $200 00 reqmre preauthonzatlon by the Health Plan · Equipment must be · obtatned from a partlmpatlng DME Provider · obtained on written referral to the DME Provtder by the Primary Care Physician ·able to wtthstand repeated use · primarily and customarily serve a medical purpose · not generally useful m the absence of illness or Injury · ordered by a Participating Physician · appropriate for use tn the home Replacement of Durable Medmal Equipment ~s covered only when required by marked physmal changes or growth · Breast pumps must be detenmned Medically Necessary by the Health Plan to be ehgtble for coverage · All TENS or electrical nerve mmulat~on devices require pre-authonzatmn from the Health Plan FLEX 96 22 FLEX PREF Exclusions Charges related to Durable Medical Equipment except as otherwise specified in this benefit section are excluded Exclusions include, but are not limited to · Aids, appliances, or supplies that possess features not required by the patient's condition, are not primarily medical In nature, are self-help devices, are primarily for the patient's comfort or convenience, are for common household use, are research equipment, or are deemed Experimental by the Health Plan, including, but not limited to · motor-driven wheel chairs and beds · bed boards, bathtub lffis, over-bed tables, adjustable beds, telephone arms, sauna or whirlpool baths, chairs, or elevators · stethoscopes, sphygmomanometers, or other blood pressure units · exercise equipment or enrollment In health or athletic clubs · corrective orthopedic shoes, arch supports, or foot orthotlcs · mr purifiers, mr conditioners, or water purifiers · hypo-allergenic pillows or mattresses, or water beds · cervical collars, slings, or traction apparatus · Repair or routine maintenance of any Durable Medical Eqmpment FLEX 96 23 FLEX PREF OSTOMY SUPPLIES Benefits and Ostomy Supplies 20% of Total Charges Required Copayments Maximum Benefit $1,000 00/Calendar Year Limitat~ons Ostomy Supplies benefits are limited to the following · All services must be provided in relation to a covered diagnosis or procedure Coverage is limited to bags, stoma caps, skin cleanser, skin prep, paste, and powder Exclusions Charges related to Ostomy Supplies except as otherwise specified in this benefit section are excluded FLEX 96 24 FLEX PREF ORGAN If Medically Necessary and preauthonzed by the Health Plan Medical D~rector TRANSPLANT or his designee, the Health Plan w~ll prowde benefits only toward the following SERVICES transplants · kidney transplants cornea transplants · hver transplants · pancreas transplants · bone marrow transplants · heart transplant, · lung transplants · any combination of these covered transplants Benefits and Room, board, medications, and supphes 20% of Total Charges Reqmred Copayments L~mttat[ons Organ Transplants benefits am hm~ted as follows · All services must be prowded m relation to a covered d~agnos~s or procedure Exclusions Charges related to Organ Transplants except as otherwise spectfied in th~s section are excluded Exclusions include, but are not hm~ted to · Art~ficml Organ Transplants · Cross-species whole organ transplants · Organ donor transportation or lodging costs · Services prowded to any Member for the donation of any organ or element of the body to a non-Member rec~plent FLEX 96 25 FLEX PREF LIMITED DENTAL SERVICES Benefits and Limited Dental Services 20% of Total Charges Required Copayments Maximum Benefit $500 00/Calendar Year Limitations Limited Dental Services benefits are hmlted as follows · All services must be provided in relation to a covered diagnosis or procedure · Treatment is limited to the repair of accidental, non-occupational Injury to Sound, Natural Teeth · Treatment must begin within 30 days of the accident · Treatment must be completed within 180 days of the accident Exclusions Charges related to Limited Dental Services except as otherwise specified in this section are excluded Exclusions include, but are not limited to · Repair or replacement of any implant, pontle, bridge, or denture · Routine orthodontia services · Appliances · Splints · Routine dental care, including but not limited to · fillings or other dental repair procedures · replacement of teeth, ~ncludmg fixed or removable prostheses · treatment for diseases of the teeth or gums · extraction of teeth, including wisdom teeth · treatment for malocclusion or malposition of the teeth or jaws (mandibular or maxillary hyperplasia or hypoplasia) · anesthesia or professional services related to or reqmred for the sole purpose of providing dental care · Hospital care · inpatient or outpatient surgery required for any dental care · prescription drugs for dental treatment · x-rays FLEX 96 26 FLEX PREF LIMITED VISION SERVICES Benefits and Limited Vision Services No Copayment Required Copayments Maximum Benefit $75/Calendar Year Limitations Limited Vision Services benefits are limited as follows · All services must be provided in mlatlon to a covered diagnosis or procedure · Services are limited to the purchase and fitting of the · imtial set of eyeglasses or · initial contact lens following · cataract surgery · repair of Congenital Anomaly or · as required by accidental Injury when the natural lens has not been replaced by an internal prosthetic lens Exclusions Charges related to Limited Vision Services except as otherwise specified in this section are excluded Exclusions include, but are not hmlted to · Radial keratotomy and other keratoplasties or keratotomies FLEX 96 27 FLEX PREF GENERAL The L~m~tahons and Exclusions applying to Your benefits are hsted ~n th~s LIMITATIONS General Lnmntat~ons and Exclusnons Section L~m~tatlons and Exclusions that AND normally occur in relation to one specific benefit have been lnsted m the EXCLUSIONS appropriate benefit sectnon However, all benefits are subject to the stated Limitations and Exclusnons L~m~tat~ons 1 Coverage xs limited to services provided in relation to a covered d~agnosls or procedure 2 Coverage of services, supplnes, or treatments not prowded, referred, or authorized by Your Primary Care Physician or the Health Plan ns lnmlted to coverage under the Emergency Care Services benefit as described m th~s Schedule of Benefits 3 Coverage of servnces by Phys~cnans, facdnt~es, or other providers, who are not Partnc~patnng Prowders, ~s hm~ted to coverage under the Emergency Care Services benefit as described m thns Schedule of Benefits or to services preauthorlzed by the Health Plan 4 Reconstructive Surgery ~s hm~ted to the reconstruction necessary to repair a dysfunction or d~sfigurement resulting from InJury, tumor, or Congemtal Anomaly 5 Benefits for Members temporarily residing outside the Service Area are hm~ted to Emergency Care Servnces benefits The Member must return to the Service Area for all other services and follow-up care 6 Charges submitted by a Hospital as part of an ~npat~ent confinement are hm~ted to services related to the condmon for which the confinement was approved 7 Para control therapy ~s Intuited to services preauthonzed by the Health Plan 8 Transportatnon or travel by means of any private or commercial carner ~s hmnted to covered Ambulance Services 9 Coverage for treatment of the temporomand~bularjomt (TMJ) ~s hmlted to those servnees for whnch coverage ~s mandated by the State of Texas Thns ~ncludes only Medically Necessary d~agnost~c services and/or surgical treatment detenmned to be Medncally Necessary by the Health Plan Medncal Dnrector or h~s designee All serwces must be prowded by a Part~c~patmg Prowder Charges related to dental services or malocclusion are not covered 10 Coverage of services that are prowded, prod for, or reqmred by state or federal law ns hmxted to those servnees for whtch benefits are avadable through Medicaid 11 Benefits for covered prescnptton and non-prescnptxon drugs, med~eatmns, and pharmaceuticals are hm~ted to those covered ~tems purchased and admtmstered m a clnmeal setting by the Prowder Formulas necessary for the treatment of phenylketonuna (PKU) or other heritable diseases are covered to the same extent as for drugs available only on the orders of a Physician 12 Inpatxent dmgnost~c testing ~s Intuited to services d~rectly related to the eondltmn for whnch the hospxtallzatnon is authorized FLEX 96 28 FLEX PREF L~m~tut~ons 13 Covered educational servmes are hmtted to authorized programs for Diabetic Continued Education A $600 00 per Calendar Year maximum benefit per Member applies Excluded services include, but are not limited to classes or training for · prepared childbirth, Lamaze, teen pregnancy, cesarean section, and vaginal birth after cesarean · parenting · breast-feeding · stress management 14 Coverage for Maternity services received outside the Service Area before week 37 of the pregnancy are limited to covered Emergency Care Services benefits or services preanthorlzed by the Health Plan 15 You must have preauthonzatmn from the Health Plan to travel outside the Service Area al/er week 36 of the pregnancy or services received outside the Service Area will not be covered 16 Coverage for Maternity services by Non-participating Prowders ~s hm~ted to Members that become eligible with the Health Plan after week 31 of the pregnancy All services must be authorized by the Health Plan before charges are recurred All future obstetrical/gynecological services must be performed by a Participating Physician 17 Infertlhty Services benefits are hmlted to dlagnostm servmes to determine the cause of infertthty 18 Mental Health Services benefits are hm~ted to evaluation, crisis intervention, and stabthzation for the diagnosis and treatment of covered mental illnesses or disorders 19 Mental Health Services benefits for Outpatient Care services are limited to a combined, maximum benefit of 30 wsKs per Calendar Year, and may ~nclude lndiwdual, family or group therapy, medication management, and home health visits 20 Mental Health Services benefits for Inpatient Care services, Structured Sub- acute Care services, and Residential Care for Children and Adolescents services are hmlted to a combined, maximum benefit of 30 days per Calendar Year For Structured Sub-acute Care services and Res~dential Care for Chddren and Adolescents services, each two days of treatment will be cons~derad equal to one day of inpatient treatment m determimng the combined, maximum benefit 21 Chemical Depandency Services benefits are hmited to a Lifetime Maximum benefit of three separate series of treatments for each Member A series of treatments is a planned, structured, and organized program that promotes a chemical-free status The program may include different facdmes or modahties 22 Rehablhtatlon Services benefits are hmlted to a maximum two months per medical episode for services provided in an outpatient setting FLEX 96 29 FLEX PREF Limitations 23 Rehabilitation Services benefits are limited to services that Continued * prevent dysfunction, restore functional ability, or facilitate maximal adaptation to impairment, · are directed and monitored by a Participating Physician, · are for therapy provided by a Physician or by a licensed or certified physical, occupational, or speech therapist, · arc furnished to You by a Participating Facility or through a Participating Provider, · are provided according to a specific, written treatment plan that details the treatment, including frequency and duration, and provides for on-going reviews, and · is expected to result In a significant Improvement of the condition within a two month period on an outpatient basis The two month period commences with the first visit Short term is defined as two months or less 24 Cardiac Rehabilitation Services benefits are limited to services provided Immediately following · a documented episode of Unstable Angina · Coronary Artery Bypass Graft surgery · a Coronary Angloplasty procedure 25 Ambulance Services benefits are hmlted to · services provided in relation to covered Emergency Care Services · non-emergency services preautborized by the Health Plan 26 Home Health Care Services benefits are limited to services provided only for · chemotherapy · radiation therapy · treatment of terminal illness · treatments determined by the Health Plan to be medically necessary and appropriate to be rendered in a home setting 27 Physical, occupational, or speech therapy received in the home Is provided under the Rehabilitation Services benefit 28 Hospice care received outside the home is provided under the Inpatient Facility Services benefit 29 Skilled Nursing Facility Services benefits are limited to · me&cai conditions subject to slgmficant clinical improvement · services provided instead ofhospltahzatlon, either in place of an admission or upon discharge from inpatient care · services determined Medically Necessary by the Health Plan based on acuity of services and patient condition 30 Prosthetic Medical Appliances benefits are limited to appliances that · serve a physiological purpose · are obtained from a participating prosthetic provider FLEX 96 30 FLEX PREF Limitations 31 Repair or replacement of external prostheses Is covered only when required Continued by marked physical changes, growth, or malfunction of the device as determined by the Health Plan 32 The purchase of an external breast prosthesis and any associated garments is limited to pumhase of the initial prosthesis and bm following mastectomy without reconstruction 33 Durable Medical Equipment benefits are limited to equipment that is · obtained from a participating DME Provider · obtained on written referral to the DME Provider by the Primary Care Physician · able to withstand repeated use · primarily and customarily serve a medical purpose · not generally useful in the absence of illness or InJury · ordered by a Participating Physician · appropriate for use tn the home 34 Replacement of Durable Medical Equipment m covered only when reqmred by marked physical changes or growth 35 Breast pumps must be detenmned Medically Necessary by the Health Plan to be eligible for coverage 36 All TENS or electrical nerve stimulation devices require pre-authorization from the Health Plan 37 Coverage of consumable or dmposable supphes, dressings, syringes, sheaths, bags, or gloves Is limited to the following ostomy supphes bags, stoma caps, skin cleanser, skin prep, paste, and powder 38 Organ Transplant Services benefits are limited to · kidney transplants · cornea transplants · liver transplants · pancreas transplants · bone marrow transplants · heart transplants · lung transplants · any combination of these covered transplants when determined Medically Necessary and preauthonzed by the Health Plan Medical Director or his designee 39 Limited Dental Services benefits are limited to treatment · for the repair of accidental, non-occupational Injury to Sound, Natural Teeth · begun within 30 days of the accident · completed within 180 days of the accident 40 Limited Vision Services benefits are limited to the purchase and fitting of the · Initial set of eyeglasses or · initial contact lens following FLEX 96 31 FLEX PREF Limitations · cataract surgery Continued · repair of Congemtal Anomaly or · as required by accidental Injury when the natural lens has not been replaced by an internal prosthetic lens FLEX 96 ~ FLEX PREF EXCLUSIONS The following services are specifically excluded from coverage under this Schedule of Benefits Please check any Rider purehased with thls Schedule of Benefits for possible coverage of these excluded services 1 Any service or treatment for which You would not legally be required to pay m the absence of coverage provided by this Schedule of Benefits, except for Medicaid 2 Care for conditions that state or local law requires be treated in a public Facility 3 Care for military service connected disabilities for which the Member is legally entitled to services and for which facilities are reasonably available to the Member 4 Services rendered by an immediate relative of the Member or by a person who resides in the Member's home An ~mmediate relative ~s the spouse, child, parent, grandparent, or slbhng of the Member and includes m-law and step-family relationships formed through a current or previous mamage 5 Any medical, surgmal, or health care procedure or treatment held to be Experimental or Investlgatlonal at the time ~t is performed Services or products not for the specific treatment of illness or Injury, including, but not limited to · personal, convenience, or comfort items · personal kits prowded on admlss~on to a Hospital · television · telephone · photographs · living accommodations or expenses, guest meals, or cots · finance charges 7 Private room accommodations 8 Private duty nursing in an inpatient Facility 9 Alternative methods of treatment including, but not limited to · acupuncture · naturopathy · psychosurgery · megavltamln therapy · nutritionally based alcoholism therapy · hohstlc or homeopathic care, including drugs · ecological or environmental medicine · hypnotherapy or hypnotic anesthesia · hlppotherapy · sleep therapy 10 Servlces pnmardy for rest, Custodial, Dommihary, or convalescent care I 1 Respite care 12 Blood and blood products FLEX 96 33 FLEX PREF Exclusions 13 Routine care and treatment of the exterior surfaces of the feet Excluded Continued services Include, but are not limited to * removal or reduction of corns or calluses · trimming of nails · treatment of fiat feet · arch supports or other orthotics · braces , splints 14 Treatment of obesity or comphcatlons of obesay treatment, regardless of assocmted medical or psychological eondmon including, but not hmlted to · intestinal or stomach bypass surgery · gastric stapling · w~rlng of the jaw · insertion of gastric balloons 15 Marriage, career, or financml counsehng 16 Treatment of mental retardatmn or mental deficiency 17 Behavioral traimng 18 Remedial education 19 Evaluation and treatment of learmng and developmental dlsablht~es, and minimal brain dysfunction 20 Psychological testing or psychotherapy for the treatment of attention deficit disorders or related eondltwns 21 Services w&eated primarily to improve Member's appearance, which wdl not result m s~gmficant functional improvement Exclusions include, but are not hmlted to · plastic surgery · surgical treatment of kelold formation · rhinoplasty · scar revision · revision or reformation of sagging skin on any part of the body described as relating to the eye lids, face, neck, abdomen, arms, legs, or buttocks · hposuction procedures · procedures performed in connection with the enlargement, reduction, implantation, or appearance of a part of the body described as relating to the breast, face, lips, jaw, chin, nose, ears, or genitals · hair replacement or transplantation · chemical apphcat~ons or peels · abrasion of the skin · tattoo removal or camouflage · electrolysis depilation 22 Transsexual surgery, ~ncludmg medwal or psychological counseling or hormonal therapy, m preparation for or subsequent to any such surgery 23Hearing aids, batteries, and examinations for the fitting of hearing aids 24Structural changes to a building or vehicle FLEX 96 34 FLEX PREF Exclusions 25 Recreational or educational therapy Continued 26 Drugs or substances not approved by the FDA, labeled "Caution - Limited by Federal Law to Investlgatlonal use," or considered Experimental 27 Aids, appliances, or supplies that possess features not required by the patlenfs condition, are not primarily medical in nature, are self-help devices, are primarily for the patient's comfort or convanlenee, are for common household use, are research equipment, or are deemed Experimental'by the Health Plan, including, but not limited to · corrective orthopedic shoes, arch supports, or foot orthottcs · dentures · contact lenses · wigs or hair pieces · motor-driven wheel chairs and beds · bed boards, bathtub lifts, over-bed tables, adjustable beds, telephone arms, sauna or whirlpool baths, chmrs, or elevators · stethoscopes, sphygmomanometers, or other blood pressure units · exercise equipment or enrollment In health or athletm clubs · mr purifiers, air conditioners, or water purifiers · hypo-allergenic pillows or mattresses, or water beds · elastic stockings, garter belts, or corsets · cervical collars, slings, or traction apparatus · home testing kits or supphes · diapers or ~neont~nent supplies · over-the-counter medications 28 Reports, evaluations, or physical examinations not required for treatment of health conditions, or not directly related to medical treatment Examples include, but are not limited to services 0nclud~ng ~mmumzatlons) for compliance with a court order, employment, insurance, camp, adoptmn, school, travel, or government licenses 29 Allergy serum 30 Any procedure performed for sex determination of the fetus Examples Include, but are not hmlted to ultrasound, amnlocentesls, or any assisted reproductive technology procedure 31 Reversal ofsterlhzation 32 Subsequent resterthzatlon 33 Insartmn or supply of Norplant or any similar device 34 Infertility treatment 35 Infertility medications 36 Surrogato parenting 37 Any costs associated with the collection, storage, purchase, or processing of sperm for use in any assisted reproductive technology procedure FLEX 96 35 FLEX PREF 38 Any assisted reproductive technology (ART) procedure that enhances a woman's abflay to become pregnant Examples of ART procedures include, but are not limited to lntra-uterme msemlnation, GIFT procedures, SIFT procedures, and m-varo fertilization 39 Services for psychiatric con&tlons that are chronic or organic m nature, or that will not substantially benefit from Short-term treatment 40 Biofeedback 41 Work hardening programs 42 Supervised exercise that is not EKG momtored 43 Homemaker, chore, or similar services 44 Routine maintenance of any external device, appliance, equipment, or supply 45 Repairs to Prosthetxc Medical Apphances determined to be cosmetic by the Health Plan 46 Repair or routme maintenance of any Durable Medical Equipment 47 Artlficml Organ Transplants 48 Cross-species whole organ transplants 49 Organ donor transportation or lodging costs 50 Services provided to any Member for the donation of any organ or element of the body to a non-Member recipient 51 Repair or replacement of any implant, pontic, bridge, or denture 52 Routine orthodontia services 53 Appliances or splints for con&t~ons involving the teeth, ,laws, or tongue 54 Routine dental care, including, but not hmlted to · fillings or other dental repair procedures · replacement of teeth, including fixed or removable prostheses · treatment for diseases of the teeth or gums · extraction of teeth, including wisdom teeth · treatment for malocclusion or malposition of the teeth or.laws (mandibular or maxillary hyperplasla or hypoplasla) · anesthesia or professional services related to or required for the sole purpose of providing dental care · Hospital care · ~npatient or outpatient surgery required for any dental care · prescription drugs for dental treatment · x-rays 55 Radial keratotomy and other keratoplastles or keratotomies 56 Formulas, d~etary supplements, or special diets 36 FLEX PREF OUTPATIENT PRESCRIPTION DRUG RIDER WITH MAIL ORDER FOR USE ONLY WITH THE GROUP HEALTH CARE AGREEMENT/SUBSCRIBER CERTIFICATE OF COVERAGE HARRIS METHODIST TEXAS HEALTH PLAN, INC. dba HARRIS METHODIST HEALTH PLAN A Federally Qualified Health Maintenance Organization 611 Ryan Plaza Dnve, Suite 900 Arhngton, Texas 76011-4009 {800) 633-8598 (817) 462-7000 Benefits are available to ehg~ble members as ~dent~fled ~n the agreement When you go to a partimpat, ng pharmacy, present your prescnpt~on and your HMHP Identification card. You must be enrolled and ehg~ble w~th Harns Health at the t~me your prescnptlon ~s filled or refilled to receive the benefits as outhned Th~s nder's benefits for outpat ant prescription c~rugs are subject to the deflmtlons, conditions, exclusions, and provis~ons of the Agreement Except for emergency care, benefits are available only If prescnbed by a Part~mpatmg Prowder and d~spensed by a Part~mpat~ng Pharmacy You will be prov.ded w~th a hst of Participating Prov.ders and Pharmames. Th~s nder does not cover prescnpt~ons that represent a replacement of a prewous prescnpt~on that was lost, sp~lled, stolen, or otherwise m~splaced All out-of-pocket Copayments for outpatient Prescription drugs will count toward your benefit out-of- pocket maximums. PDMF 696 1 PDM5 1018 1§IF Agreement is the apphcat~on, schedule of benefits, certificate of coverage, any r~ders, and any other plan documents relating to the policies or benefits of HMHP. B,Iled Charge is the amount a pharmacy would charge the general public for a prescription Brand Name Drug ~s a Prescription that may or may not have a Generic equivalent Copayment Is the amount you are required to pay the Participating Pharmacy for dispensing or refilling a Prescription. Cost Is the contracted amount we will pay the Partlmpat~ng Pharmacy for the Prescription Drug Covered Drug Is 1) a drug prescribed by a Participating Provider; 2) a drug that, under federal or state law, can only be dispensed according to a Prescription, or 3) d~sposable syringes, urine and blood glucose testing strips, and lancets. Drug Formulary ts our pre-approved hating of drugs that are safe, efficient, and cost- effective. Your prescribed drug will not be covered if it does not appear on the Drug Formulary * Generlo Drug is a pharmaceut.~o and therapeutlc~ equivalent. .,t° abra, n.d-name drug. You will pay the lowest copayment for a generic prescription. Member is the subscriber or any dependents covered under the Agreement. Prescription Drug 1) Is Medically Necessary for your condition, 2) is prescribed by a Participating Provider; 3) legally requires a prescription; and 4) is obtained from a Partlmpat~ng Pharmacy Heritable Disease is an inherited d~sease that could result in mental or physical handicap or death Participating Pharmacy is a Pharmacy that has contracted with us to provide services to you Partlc,patzng Prowder is a Physician or other prowder that has contracted with us to provide servmes to you PKU (Phenylketonurla} ~s an inherited condition that could cause severe mental retardation ~f not treated PDMF 696 2 PDM5 1018 15/F The benefits for ma,I order Prescription Drugs provided under this Rider are available for maintenance drugs and medmmes that are dispensed according to a Prescription for your outpatient use Mall-order Prescnptlons must be prescribed by a Partmlpat~ng Provider and d~spensed by a Partmlpat~ng ma~l order Pharmacy Schedule of Benefits The Partmlpatlng Mall Order Pharmacy Prowder w~ll furmsh up to a 90-day supply of a Covered Drug for a Copayment of. · $8 O0 for each new Prescription and/or refill of a Generic Drug on our Drug Formulary, or · $1~5 O0 for each new Prescription and/or refill of a Brand Name Drug on our Drug Formulary Exclusions In addition to the exclusions described in Section 8.0, the following exclusions apply to the Mall Order Pharmacy benefit: · Flaondes · Drugs requiring refrigeration Covered Quantities ~ , Prescribed covered quant~tms include the lesser of the prescribed amount or a 90-day supply for each new covered Prescription or refill You must pay 100% for any amount ~of a covered Prescription exceeding covered quantities, including lost or mmplaced medications PDMF 696 5 PDM5 1018 15/F There IS no benefit provided under th~s Rider for: · drugs not contained on the Health Plan's Drug Formulary; · contraceptive devices, · devices of any type, Including but not limited to, artlflCml appliances, therapeutic or prosthetic devices, supports, or other non-medical products, · medical supplies except those specifically listed in thru Rider as covered items; · Immumzatlon agents, allergy and b~olog~cal sera, · compounded Prescription Drugs Intended for parenterel use; · Prescription Drugs produced from blood, blood plasma, and blood products, derivatives, Hemofll M, Factor VIII, and synthetic blood products, · experimental or investlgatlonal drugs; · ferhhty medications, appetite suppressants; · drugs that by federal and/or state law do not require a Prescription (except for Insuhn, PKU and other hentable disease supplements) and over-the-counter medications or their equivalents, even If written on a Prescription; · drugs consumed in an inpatient or other Institutional care setting, · vitamins, nutritional, or dietary supplements, except when required by a Prescription, · drugs Intended for use in a Participating Physician's office or chmcal setting, · Prescription Drugs for cosmetic conditions not covered, including but not hmlted to, Retin-A (for patients over the age of 25) and MInoxldll; - · smoking cessation patches, gum, and other such aids; medmat~ons not used for an FDA-approved indication; · anabohc steroids, · drug Infuslon/metenng dewces; · growth hormones, · admimstratlon or InJection of any drugs or medications, except as specified as a basic benefit in the Group Health Care Agreement/Subscriber Certificate of Coverage PDMF-696 6 PDM5 10/8 15/F Prescription Is the authorization for a Prescription Drug ,ssued by a Part,mpatlng Prowderl who ~s hcensed to prescribe m the ord nary course of h s/her professional practice. Prescriptions can be authorized by non~Participating Phys~mans ~f we have approved the referral or ~n emergency cases In cases of an emergency, you w~ll be reimbursed for Covered Drugs ~f · your hfe or health would have been endangered had purchasing the Covered Drug been delayed until ~t could be prescribed by a Participating Provider and/or obtained from a Part~mpat~ng Pharmacy, · the Covered Drug was purchased according to a Prescription or authorized by a IProvlder, · you request, ~n writing, reimbursement from us and submit a receipt for the covered drug within 60 days of the date of purchase; and · the receipt from the pharmacy ~ncludes the National Drug Code (NDC) for the prescription drug dispensed. When we accept your proof of,payment, you are entitled to 100% of the pharmacy's B~lled Charge, minus your Copayment. Refills are covered ~f · allowed by law; · authorized by a Part~mpatlng Provider, · dispensed by a Partimpating Pharmacy; · you remain ehg~ble for the benef,t; and · 75% of the medication has been consumed, based on the dosage instructions of the Physic,an Refills must be d~spensed w~th~n 12 months of the original prescription date PDMF 696 3 PDM 5 1018-15IF The Participating Pharmacy w~ll d~spense up to s 30-day supply of a Covered Drug for a Copayment of the lesser of $5.00 or Cost for each new prescription and/or refill for a Gener, c Drug on our Drug Formulary, or · the lesser of $10 00 or Cost for each new prescription and/or refill for a Brand- Name Drug on our Drug Formulary. If a Brand-Name Drug is d~spensed at your request when a Generic Drug is available, you w~ll pay the Generic Copayment and the cost d~fference between the Brand-Name Drug and the Generic Drug The cost d~fference that you pay w~ll not apply toward the fulfillment of the per year maximum Member Copayment hmlt spemfled In the Agreement Covered quantities Include up to a 30-day supply for each new covered prescription or refill You must pay 100% for any amount of a covered prescr|ptlon exceeding covered quantities, ~ncludlng lost or m~spleced med,catlons. Limitations: · up to three (3) vials of insulin; · up to e~ght (8) fluid ounces of a liquid medication, except for liquid potassium supplement, · up to three (3) ounces net weight of ointment, cream, or gel except vaginal medication which w~ll be I~m~ted to one tube, · up to two (2) standard packages of a nasal or oral ~nhaler, · one (1) wal contalmng up to 15 m~ll,hters of any eye or ear medications; and · one month's supply of oral contraceptives. PDMF 696 4 PDM5 1018 151F