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