1993-214j:\wpdocs\ord\harris.o
NOTE: CONTRACTS ARE ATTACHED TO ORIGINAL ORDINANCE IN FILE.
ORDINANCE NO. 93 -o2l
AN ORDINANCE ACCEPTING COMPETITIVE BIDS AND PROVIDING FOR THE AWARD
OF CONTRACTS FOR THE PURCHASE OF EMPLOYEE GROUP HEALTH INSURANCE TO
HARRIS METHODIST HEALTH PLAN; PROVIDING FOR THE ADMINISTRATION OF
THE CONTRACT; PROVIDING FOR THE EXPENDITURE OF FUNDS THEREFOR; AND
PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the City has solicited, received and tabulated com-
petitive bids for the purchase of employee group health insurance
in accordance with the procedures of state law; and
WHEREAS, the City Manager, his designee, and the City's pro-
fessional insurance consultant, have received and recommended that
the bid described below is the lowest responsible bid for the
purchase of such insurance described in the Request for Bid No.
1523; and
WHEREAS, the City Council has provided in the City Budget for
the appropriation of funds to be used for the purchase of the
insurance policies and coverages approved and accepted herein;
NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS:
SECTION I. That the bid of Harris Methodist Health Plan, in
response to Request for Bid No. 1523 and providing for the purchase
of employee group health insurance, is hereby accepted and approved
as being the lowest responsible bid and the City Manager is
authorized to execute two (2) contracts on behalf of the City of
Denton with Harris Health Plan, Inc., one relating to the
"Preferred Plan", and the other relating to the "Preferred Plus
Network". The City Manager is also authorized to execute a "Group
Enrollment Application" on behalf of the City with Harris Methodist
Health Insurance Company. Copies of such documents are attached
hereto and incorporated by reference herein.
SECTION II. That the Director of Human Resources, or his
designee, is hereby authorized to administer these contracts in
behalf of the City of Denton.
SECTION III. That the City Council hereby authorizes the
expenditure of funds in the manner and amount as specified in the
contract.
SECTION IV. That this ordinance shall become effective immed-
iately upon its passage and approval.
PASSED AND APPROVED this the o?3_~day of ~ , 1993.
BOB CASTLEBERRY, MA
ATTEST:
JENNIFER WALTERS, CITY SECRETARY
BY: ~
APP VEDA TO LEGAL FORM:
DEBRA A. DRAYOVITCH, CITY ATTORNEY
BY: c QLf~-~2
Page 2
1
Harris Methodist
Health Plan
HARRIS HEALTH PLAN, INC.
1300 Summit Avenue
Fort Worth, TX 76102
(817) 878-5830
1-800-633-8598
GROUP ENROLLMENT AGREEMENT
Application is hereby made to Harris Health Plan, Inc., hereinafter called "Harris
Health" by the Applicant named below, hereinafter called "Group" for the purpose of making
available to Eligible Persons and their Eligible Dependents under a Group Health Care
Agreement/Subscriber certificate of Coverage, hereinafter called "Agreement" issued by Harris
Health, certain prepaid health care services and benefits. The arrangement of the provisions
of such services and benefits shall be the subject of the Agreement between Harris Health and
Group and shall be based on the statements and representations contained in this Group
Enrollment Agreement, a copy of which shall be incorporated by reference and made a part of
the Agreement.
.«d 1.0 GROUP
Group Name: City of Denton
Address: 324 East McKinney
City: Denton State: TX Zip Code: 76201
2.0 GROUP EFFECTIVE DATE
This Group Enrollment Agreement shall be effective 12:01 A.M., Central Time, on the
1st day of January 1994.
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 eligibility guidelines provided by the City of
4.0 HEALTH CARE SERVICES (BENEFITS) AND COPAYMENTS
Eligible Persons and Eligible Dependents of Group are entitled to Health Care Services
and Benefits as follows:
A. Basic Health Care services;
X Covered - Basic Health Care services as described in the
Schedule of Benefits.
B. Prescription Drug:
X Accepted
Not Accepted
5.0 COVERAGE BASIS
X Contributory
Non-Contributory
6.0 SCHEDULE OF RATES
Total Monthly
Rate
Active
Employee Only $188.50
Employee + Spouse $292.98
Employee + Child(ren) $253.13
Employee Family $318.45
Retirees Under 65
Retiree Only $255.34
Retiree and Spouse $493.35
Retiree and Child(ren) $398.71
Retiree and Family $604.26
Retirees 65 or Over (Medicare serves as Primar
Retiree Only
$ 94.25
2
on Medicare
$188.50
1
on, off
$384.54
1
on, 1 off + Family
$557.58
2
on + Family
$368.00
Group Enrollment Agreement shall be automatically renewed at the end of each
Contract period unless terminated by Harris Health or Group as provided in Agreement.
The first Contract period shall commence as of the Group Effective Date and will remain
in effect for twelve (12) consecutive months unless terminated before this date by
Harris Health or Group.
IN WITNESS WHEREOF, the undersigned have caused the Group Enrollment Agreement to be
executed on the g3 401
day of -72inr~-, 19. a-
City of Denton
Group i 11 . H AR HEALTH PLAN,
By: AR ZIUX~-
INC.
By:
Authorized Representative
Title:-
Address
Denton TX 76201
Telephone:
Title:Senior Vice President/Managed Care
Marketing
c:CONTRACT.lyaP51
AE:
Hams Methodist
Health Plan
(0
October 22, 1993
Mr. Thomas Klinck
Director of Human Resources
City of Denton
215 E. McKinney
Denton, Texas 76201
Re: City of Denton Health Plan Proposal
Dear Mr. Klinck:
Harris Methodist Health Plain is pleased to respond to the following issues as presented by
the City of Denton.
1) REQUEST FOR A MULTI-YEAR RATE GUARANTEE.
HMHP is prepared to provide a rate guarantee through the second and third plan
year for the Preferred HMO plan only. Our conditions for the 1995 and 1996 rate
guarantee is that the City of Denton contribution to the employee rate for our
Preferred HMO plan must be 100% and we will be the only carrier offered by the
City of Denton.
The Preferred HMO plan guarantee will be as follows:
"The years 1995 and 1996 combined maximum rate guarantee will not exceed a total
of 15%. The year 1995 will not exceed 9.9% of our 1994 rate."
2) EXPANSION OF THE DENTON AREA PROVIDER NETWORK TO PROVIDE
FOR THE CITY OF DENTON EMPLOYEES.
As the City of Denton employees expand the needs for additional health care services
in the Denton area, the HMHP is committed to ongoing assessment of these needs
and expansion of our current network through the recruitment of appropriately
qualified providers to serve these needs.
A member of
Harris Methodist Health System
1300 Summit Avenue / Suite 3001 P. 0. 13ox 901054 / Fort Worth, Texas 76101-2054 / 817-878-58001 Customer Service Telephone Number 817-878-5826
Ten additional Denton providers have been approved recently and will be added to =
the network as soon as contracts are executed. Your request for additional hospital
services through Denton Regional Medical Center will be given consideration for
future needs. this ongoing effort will continue as a part of our partnership with
employer groups that we serve in the Denton area.
3) COVERAGE FOR EMPLOYEES NOT ACTIVELY AT WORK.
HMHP considers actively at work to include anyone the new employer group
considers to be actively at work. This would include those employees that are off on
approved medical leaves of absences, vacation, holiday, jury duty, or other similar
circumstances.
We would be very pleased to add the City of Denton to our family of satisfied clients. Please
feel free to call me at 878-5836 should you have any questions regarding the Harris
Methodist Health Plan proposal.
Kindest Regards, .
Robe , Jt/
Director of ales
Managed Care Marketing
Harris Methodist
Health Plan
rI
GROUP HEALTH CARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
817/878-5826
1-800/633-8598
GA-992
"Iarris Health Plan, Inc.
Iealth Maintenance Organization
1300 Summit Avenue, Suite 300
rrt Worth, Texas 76102
IMPORTANT NOTICE
To obtain information or make a complaint:
:ou may call Harris Health Plan, Inc.'s toll-free
telephone number for information or to make a
Dmplaint at:
1-800-633-8598
.IOU may contact the Texas Department of
.nsurance to obtain information on companies,
coverages, rights or complaints at:
1.800-252-3439
You may write the Texas Department of
nsurance
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 475-1771
ATTACH THIS NOTICE TO YOUR POLICY:
this notice is for information only and does not
3ecome a part or condition of the attached
document.
AVISO IMPORTANTE
Para obtener informacion o para someter Una
queja:
Usted puede llamar al numero de telefono gratis de
Harris Health Plan, Inc. para informacion o para
someter Una queja al:
1-800-633-8598
Puede comunicarse con el Departmento de Seguros
de Texas para obtener informacion acerca de
companias, coberturas, derechos o quejas al:
1-800-252-3439
Puede escribir al Departmento de Seguros de
Texas
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 475-1771
UNA ESTE AVISO A SU POLIZA: Este aviso es
solo para proposito de informacion y no se
convierte en parte o condition del documento
adjunto.
TABLE OF CONTENTS
Page
Page
1.0 General Definitions
2
8.0 Independent Agents/Refusal to Accept
Treatment
.....18
2.0 Group and Affiliated Organizations
6
2.1 Organizations Included Under This
8.1 Independent Agents
8.2 Limitation on Liability
.....18
.....19
Agreement
6
8.3 Refusal to Accept Treatment/Excessive
2.2 Change of Affiliated Organizations
6
Treatment
.....19
3.0 Eligibility and Effective Date 6
3.1 Eligible Persons
6
3.2 Eligible Dependents
6
3.3 Change in Group Eligibility Criteria
7
3.4 Effective Date for Eligible Persons
7
3.5 Effective Date for Eligible Dependents
7
3.6 Persons Not Eligible for Coverage
8
3.7 Conditions of Eligibility
8
3.8 Notification of Ineligibility
8
3.9 Clerical Error
8
4.0 Group and Member Termination, Continuation of
Benefits and Conversion
8
9.0 Exclusions on Service Responsibilities ............19
9.1 Major Disaster or Epidemic ....................19
9.2 Circumstances Beyond Control ...............20
9.3 Fraudulently Obtained Benefits ...............20
9.4 Discontinuance ................................20
10.0 Member Complaint Resolution Procedure ........20
10.1 Complaint Resolution Process ...............20
10.2 Complaint Resolution Appeal Process ......21
11.0 Health Care Services ...............................21
11.1 Benefits and Services ........................21
4.1 Termination of Group
. 8
4.2 Termination of Member - For Cause
. 9
4.3 Termination of Member - Other Than for
Cause
.10
4.4 Liability Upon Termination
.10
4.5 Continuation of Coverage
.10
4.6 Conversion Privilege
.11
5.0 Payment Requirements .............................11
5.1 Premium Payments ............................11
5.2 Notification by Group ..........................12
5.3 Cbpayments ....................................12
6.0 Claim Provisions ....................................13
6.1 Charges Paid by Members ....................13
6.2 Medical Emergency ...........................13
6.3 Action on Claim ................................13
6.4 Examination of Member .......................13
6.5 Limitation Provisions ...........................13
7.0 Coordination and Subrogation of Benefits ........14
7.1
Definitions
..14
7.2
Determination of Benefits
..14
7.3
Order of Benefit Determination
..15
7.4
Medicare
..1 6
7.5
Right to Receive and Release Information .
..17
7.6
Facility of Payment
..17
7.7
Right of Recovery
..17
7.8
Disclosure
..18
7.9
Subrogation
..18
12.0 Term and Amendment of Agreement ..............22
12.1 Term .................................................22
12.2 Amendment .........................................22
12.3 Change of Rates ....................................22
13.0 Miscellaneous Provisions ..........................22
13.1
Use of Words
........22
13.2
Records and Information
........22
13.3
Information from Group
.........22
13.4
Assignment
.........23
13.5
Authority
.........23
13.6
Governing Law
.........23
13.7
Incorporation by Reference
.........23
13.8
Entire Agreement
.........23
13.9
Information to Member
.........23
13.10
Uniform Rules
.........23
13.11
Calculation of Time
.........23
13.12
Evidence
.........23
13.13
Severability
.........23
13.14
Venue
.........24
13.15
Waiver of Notice
.........24
13.16
Headings
.........24
13.17
Notice of Certain Events
.........24
13.18
Notice of Termination
.........24
13.19
Notice
.........24
Attachment A Service Area Map and Description
Section 1.0
GENERAL DEFINITIONS
1. ACTIVELY AT WORK shall mean that the eligible employee must be performing the usual and cus-
tomary duties of his regular employment during his usual working hours on his effective date of
coverage; provided, however that if the eligible employee is absent from work due to vacation,
holiday, jury duty, or other similar circumstances, not caused by injury or illness, such employee
shall be considered actively at work.
2. ACUTE shall mean a condition of sudden onset or severe symptomatology which mandates imme-
diate intervention.
3. AGREEMENT shall mean this Group Health Care Agreement/Subscriber Certificate of Coverage,
Group Enrollment Agreement, Applications, all Attachments, Riders, Amendments hereto, if any.
4. ALLIED HEALTH PROFESSIONAL shall mean a dentist, nurse, audiologist, optometrist, physician's
assistant, clinical psychologist, pharmacist, nutritionist, physical therapist, speech language
pathologist, dietician, podiatrist, certified social worker (advanced clinical practitioner) and other
professionals engaged in the delivery of health services who are licensed, practice under an insti-
tutional license, are certified, or practice under the authority of a Physician or legally constituted
professional association, or other authority consistent with the laws of the State of Texas.
5. ALTERNATIVE HEALTH BENEFIT PLAN shall mean the plan which the Group designates as the
alternative to this Agreement.
6. APPLICATION shall mean the form prescribed by Harris Health which each Eligible Person shall
on his/her own behalf and or, behalf of his/her Eligible Dependents, be required to complete and
submit to Harris Health for the purpose of enrolling himself/herself and such dependents for cover-
age hereunder.
7. CHEMICAL DEPENDENCY, means the abuse of or psychological or physical dependence on or
addiction to alcohol or a controlled substance.
8. CHEMICAL DEPENDENCE TREATMENT CENTER shall mean a facility which provides a program
for the treatment of chemical dependence pursuant to a written treatment plan approved and
monitored by a physician and which facility is also:
a. affiliated with a hospital under a contract agreement with an established system for patient
referral; or
b. accredited as such a facility by the Joint Commission on Accreditation of Health Care Organi-
zations; or
c. licensed as a chemical dependency treatment program by the Texas Commission on Alcohol
and Drug Abuse; or
d. licensed, certified, or approved as a chemical dependency treatment program or center by
any other state agency having legal authority to so license, certify or approve.
9. COMPLICATIONS OF PREGNANCY shall mean those conditions, requiring hospital confinement
(when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are
adversely affected by pregnancy or caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical and surgical conditions of compa-
rable severity. Complications or pregnancy shall not include false labor, occasional spotting, physi-
cian prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum,
pre-eclampsia, and similar conditions associated with the management of a difficult pregnancy not
constituting a nosologically distinct complication of pregnancy; non-elective cesarean section, ter-
mination of ectopic pregnancy, or spontaneous termination of pregnancy occurring during a
period of gestation in which a viable birth is not possible.
10. CONTRACT YEAR shall mean the period of twelve (12) months commencing on the Group Effec-
tive Date and each twelve (12) month period thereafter, unless otherwise terminated as hereinafter
provided.
11. CONTROLLED SUBSTANCE shall mean a toxic inhalant or a substance designated as a con-
trolled substance in the Chapter 481, Health and Safety Code.
12. COPAYMENT shall mean the fee as set forth in the Schedule of Benefits which is not covered by
premiums payable hereunder, and which must be paid by Members directly to the person or
entity providing the service when the service as set forth in the Schedule of Benefits is received.
13. COURSE OF TREATMENT shall mean that period of time represented by an inpatient hospital
admission and related discharge during which time treatment has been received by a Member or
that period of time authorized by a Participating Physician and/or Harris Health as necessary to
complete a cycle of treatment and subsequently provide a medical release to the Member.
14. CRISIS STABILIZATION UNIT shall mean a twenty-four (24) hour residential program, licensed by
Texas Department of Mental Health and Mental Retardation, that is usually short-term in nature
and that provides intensive supervision and highly structured activities to persons who are demon-
strating an acute demonstrable psychiatric crisis of moderate to severe proportions.
15. CUSTODIAL CARE shall mean 1) that care which is marked by or given to watching and protect-
ing rather than seeking to cure; or 2) care which is not a necessary part of medical treatment or
recovery; or 3) care comprised of services and supplies that are primarily provided to assist in the
activities of daily living.
16. DEPENDENT shall mean an Eligible Dependent who has satisfied the eligibility and participation
requirements specified in this Agreement.
17. DOMICILIARY CARE shall mean that care provided for persons so disabled or infirm as to be
unable to live independently.
18. EFFECTIVE DATE shall mean the effective date of coverage for Eligible Persons and Eligible
Dependents pursuant to the terms of this Agreement.
19. ELIGIBLE DEPENDENT shall mean an individual as defined in Section 3.2 of this Agreement.
20. ELIGIBLE PERSON shall mean an individual as defined in Section 3.1 of this Agreement.
21. EMERGENCY CARE shall mean bona fide emergency services provided after the sudden onset of
a medical condition manifesting itself by acute symptoms of sufficient severity, including severe
pain, such that the absence of immediate medical attention could reasonably be expected to
result in placing the patient's health in serious jeopardy; serious impairment to bodily functions; or
serious dysfunction to any bodily organ or part.
22. EVIDENCE OF INSURABILITY shall mean that an Eligible Person or Eligible Dependent verifies
that they were enrolled for the preceeding twelve (12) months in a group or individual plan provid-
ing benefits for medical, surgical and hospital expenses; and completes the Evidence of Insurabil-
ity form and provides timely any additional documentation of health status as required by Harris
Health. Such information shall be reviewed by Harris Health and the Eligible Person or Eligible
Dependent shall be notified regarding their eligibility for participation in Harris Health.
23. EXCLUSION shall mean those specific conditions or causes for which coverage by Harris Health
is entirely excluded.
24. FDA shall mean the Food and Drug Administration, an agency of the United States government.
25. GROUP shall mean collectively the contracting employer and all affiliated organizations of the
employer as set forth in Attachment A annexed hereto and made a part hereof, to which this
Agreement is issued and through which as agent for Subscriber and not for Harris Health, Sub-
scriber and Dependents become entitled to the benefits as set forth in the Schedule of Benefits.
26. GROUP EFFECTIVE DATE shall mean the date specified as such in the Group Enrollment
Agreement.
27. GROUP ENROLLMENT AGREEMENT shall mean that agreement which is executed between Har-
ris Health and Group for the purpose of making available to Eligible Persons and Eligible Depen-
dents of Group those benefits and services which are described in the Group Health Care
Agreement/ Subscriber Certificate of Coverage. Such Group Enrollment Agreement shall identify
the Group, Group Effective Date, eligibility requirements, rates, and covered benefits.
28. HARRIS HEALTH shall mean Harris Health Plan, Inc., a Texas not-for-profit corporation organized
as a Health Maintenance Organization (HMO) and licensed by the Texas Department of
Insurance.
29. HEALTH PLAN shall mean the Health Maintenance Organization operated by Harris Health d/b/a.
Harris Methodist Health Plan.
30. HOSPITAL shall mean an institution licensed by the State of Texas and which is (1) primarily
engaged in providing diagnostic, medical and surgical facilities for the care and treatment of
injured or sick persons, (2) operated under the medical supervision of a staff of legally qualified
and licensed physicians, (3) provides twenty-four (24) hour-a-day nursing service by or under the
direct supervision of a Registered Nurse (R.N.), (4) provides for overnight care of patients, (5)
maintains clerical and ancillary services necessary for the treatment of medical and surgical
patients including but not limited to laboratory, X-ray, dietary and medical records library. In no
event shall the term "hospital" include a convalescent nursing home or any institution or part
thereof which is used principally as a convalescent facility, rest facility, nursing facility, facility for
the aged, extended care facility, intermediate care facility, skilled nursing facility or facility primarily
for rehabilitative services; the term hospital shall, pursuant to Chapter 3, Texas Insurance Code,
Article 3.72 include treatment in a residential treatment center for children and adolescents and
treatment provided by a crisis stabilization unit.
31. INDIVIDUAL TREATMENT PLAN shall mean a treatment plan with specific attainable goals and
objectives appropriate to both the patient and the treatment modality of the program.
32. KIDNEY DIALYSIS CENTER shall mean any facility licensed by the State of Texas, approved by
Medicare to provide outpatient services and/or instruction in home kidney dialysis treatments and
which has contracted with Harris Health to provide care to Members.
33. MEDICAL DIRECTOR shall mean the licensed Physician designated by Harris Health and/or such
other Physicians as the Medical Director may designate with the prior approval of Harris Health.
Such physician shall be responsible for supervising the delivery of medical services to Members
and for monitoring the quality of medical care rendered to Members.
34. MEDICAL EMERGENCY shall mean a medical condition so classified by the medical director and
which manifests itself by acute symptoms of sufficient severity (including severe pain) such that
the absence of immediate medical attention could reasonably be expected to result in (a) placing
the patient's health in serious jeopardy; or (b) serious impairment to bodily functions; or (c) serious
dysfunction to any bodily organ or part. Examples of conditions which do not usually constitute
medical emergencies are colds, influenzas, ordinary sprains, children's ear infections, or nausea
and headaches. Heart attacks, cardiovascular accidents, poisonings, loss of consciousness or
respiration, convulsions, severe bleeding or broken bones are examples of true medical
emergencies.
35. MEDICALLY NECESSARY shall mean services or supplies which are (1) provided for the diagno-
sis or care and treatment of a medical condition; (2) appropriate and necessary for the symptoms,
diagnosis or treatment of a medical condition; (3) generally acceptable medical practice; (4) per-
formed in the most cost effective and efficient manner appropriate to treat the plan Member's
medical condition; and (5) provided in accordance with accepted medical standards and Harris
Health requirements as approved by the Health Plan's review committees for professional and
technical practices and the Health Plan Medical Director.
36. MEDICARE shall mean Part A and Part B of Title XVIII of the Social Security Act and any amend-
ments or regulations thereunder.
37. MEMBER shall mean any Subscriber and/or Dependent.
38. MEMBER HOSPITAL shall mean any Hospital which has contracted with Harris Health to provide
to Members the services as set forth in the Schedule of Benefits and described in this Agreement.
39. NON-MEMBER HOSPITAL shall mean any Hospital which has not contracted with Harris Health to
provide to Members the services as set forth in the Schedule of Benefits and described in this
Agreement.
40. MINOR EMERGENCY CENTER shall mean any licensed facility, not including a Hospital, which
provides Physician services for the immediate treatment only of an injury or disease.
41. NON-PARTICIPATING PHYSICIAN shall mean a Physician who is not a Participating Physician and
to whom a Member is referred for consultation or treatment by a Participating Physician only with
prior written approval of Harris Health unless there is a Medical Emergency and a Participating
Physician is not available.
42. NON-PARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professional,
Home Health Agency, Laboratory, Minor Emergency Center, Residential Treatment Facility, Chemi-
cal Dependency Treatment Center, or other licensed healthcare professional or other provider or
entity which has not contracted with Harris Health to provide to Members the services as set forth
in the Schedule of Benefits and described in this Agreement.
43. OPEN ENROLLMENT PERIOD shall mean a period of at least thirty (30) days during each twelve
(12) consecutive months when Eligible Persons may elect to change from the Alternative Health
Benefit Plan to Harris Health or from Harris Health to the Alternative Health Benefit Plan.
44. PARTICIPATING PHYSICIAN shall mean any Physician who has contracted with Harris Health to
provide to Members the services as set forth in the Schedule of Benefits and described in this
Agreement.
45. PARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professional, Home
Health Agency, Laboratory, Manor Emergency Center, Chemical Dependency Treatment Center,
Psychiatric Day Treatment facility or other provider or entity which has contracted with Harris
Health to provide to Members the services as set forth in the Schedule of Benefits and described
in this Agreement.
46. PSYCHIATRIC DAY TREATMENT FACILITY shall mean a mental health facility which provides
treatment for individuals suffering from acute mental and nervous disorders in a structured psychi-
atric program utilizing individualized treatment plans with specific attainable goals and objectives
appropriate both to the patient and the treatment modality of the program and that is clinically
supervised by a Physician who is certified in Psychiatry by the American Board of Psychiatry and
Neurology. The facility shall be licensed by the State of Texas, accredited by the Program for Psy-
chiatric Facilities, or its successor, of the Joint Commission on Accreditation of Health Care Orga-
nizations, and shall have contracted with Harris to provide to Members the mental health services
as set forth in the Schedule of Benefits and described in this Agreement.
47. PHYSICIAN shall mean any individual (other than a hospital resident or intern) who is fully licensed
and qualified to practice within the scope of the license under the law of the jurisdiction in which
treatment is received.
48. -PRIMARY PHYSICIAN shall mean, with respect to each Member, those Participating Physicians
who are designated by Harris Health and identified in writing to Members as Physicians having
primary responsibility for coordinating such Member's medical care, providing initial and primary
care to Members, maintaining the continuity of such Member's care and initiating referrals for spe-
cialist care.
49. RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS shall mean a child-
care institution that provides residential care and treatment for emotionally disturbed children and
adolescents, licensed by Texas Department of Mental Health and Mental Retardation, and that is
accredited as a residentiair treatment center by the Council on Accreditation, the Joint Commission
on Accreditation of Health Care Organizations or the American Association of Psychiatric Services
for Children.
50. RIDER shall mean a Schedule provided with this Agreement, and made a part hereof, which sets
forth additional benefits and services made available by Harris Health by amending this Schedule
of Benefits.
51. SCHEDULE OF BENEFITS shall mean the schedule which sets forth the benefits and services that
Harris Health shall make available to Members.
52. SEMI-PRIVATE shall mean the charge made by a Member Hospital for a room containing two (2)
or more beds.
53. SERVICE AREA shall mean the geographic area as set forth and annexed hereto as Attachment
A.
54. SHORT TERM shall mean a course of treatment lasting thirty (30) days or less.
55. SPECIALIST PHYSICIAN shall mean any Physician who has contracted with Harris Health to pro-
vide specialist care to Members upon referral of a Primary Physician or upon referral of another
Specialist Physician with the concurrence of the responsible Primary Physician.
56. SKILLED NURSING FACILITY shall mean an institution or part thereof, licensed by state or local
law, that is accredited as an Extended Care Facility by the Joint Commission on Accreditation of
Health Care Organizations, or is recognized as a Skilled Nursing Facility by the Department of
Health and Human Services under Title XVIII of the Social Security Act (Medicare), as amended.
57. SUBSCRIBER shall mean an Eligible Person who has satisfied the eligibility and participation
requirements specified in this Agreement.
58. TOXIC INHALANT means a volatile chemical under Chapter 484, Health and Safety Code, or
abusable glue or aerosol paint under Section 485.001, Health and Safety Code.
59. USUAL, CUSTOMARY, AND REASONABLE CHARGES shall mean the charge is (1) the fee
charged by a provider in normal practice for a given service; (2) within the range of usual charges
by providers for the same service in the geographic area where services are provided to a Mem-
ber; and (3) reasonable when taking into consideration any unusual circumstances or medical
complications requiring additional time, skill and experience in providing a specific treatment or
service.
Section 2.0
GROUP AND AFFILIATED ORGANIZATIONS
2.1 ORGANIZATIONS INCLUDED UNDER THIS AGREEMENT
The Group and its affiliated organizations are included under this Agreement. Affiliated organi-
zations include all those organizations which are subsidiary to or affiliated with the Group and located
within the Service Area of Harris Health.
2.2 CHANGE OF AFFILIATED ORGANIZATIONS
The Group shall notify Harris Health, in writing, when an affiliated organization ceases to be a
subsidiary of, or affiliated with, the Group. When an organization ceases to be a subsidiary of, or affili-
ated with, the Group, it shall cease to be an included organization. Therefore, this Agreement shall ter-
minate on the date of such cessation with respect to all Eligible Persons of that organization, except for
those persons who on the next day are employees of another affiliated organization and thus Eligible
Persons under this Agreement.
Section 3.0
ELIGIBILITY AND EFFECTIVE DATE
3.1 ELIGIBLE PERSONS
To be eligible to enroll as a Subscriber, a person must reside in the Service Area and be an Eli-
gible Person as follows:
• In the employment of the Group or a bona fide Member of the Group, and/or
Eligible under the eligibility criteria established by the Group; and
• Entitled on his or her behalf to participate in the medical and hospital care benefits arranged
by the Group.
3.2 ELIGIBLE DEPENDENTS
To be eligible to enroll as a Dependent, a person must reside in the Service Area and be:
The legal spouse of a Subscriber;
A' dependent unmarried natural child, foster child, stepchild, legally adopted child or child
under Subscriber's court appointed legal guardianship, residing with Subscriber or with Sub-
scriber's present or former spouse in the Service Area who is (a) under nineteen (19) years
of age, or (b) under twenty-five (25) years of age and primarily dependent on the Subscriber
for financial support and attending an accredited college or university, trade or secondary
school on a full-time basis, which has, in writing, verified said attendance or;
A dependent unmarried natural child, foster child, stepchild, legally adopted child, or child
under Subscriber's court appointed legal guardianship, residing with Subscriber or with Sub-
scriber's present or former spouse in the Service area who is nineteen (19) years of age or
older but incapable of self-sustaining employment because of mental retardation or physical
handicap which commenced prior to age nineteen (19) (or commenced prior to age twenty-
five (25) if such child was attending a recognized college or university, trade or secondary
school on a full-time basis when such incapacity occurred), and primarily dependent upon
the Subscriber for support and maintenance.
Such dependent child must have been a Member either prior to attaining nineteen (19) years
of age or twenty-five (25) years of age under the conditions of the previous sentence. Sub-
scriber shall furnish Harris Health proof of such incapacity and dependency within thirty-one
(31) days before the dependent child's attainment of the limiting age and from time to time
thereafter as Harris Health deems appropriate, but not more frequently than annually.
• Maternity care benefits will be extended to an unmarried Dependent Child. If coverage is
provided to the Dependent of the Subscriber, upon payment of the premium, benefits must
be provided for any children of the Dependent if those children are Dependents of the Sub-
scriber for federal income tax purposes.
3.3 CHANGE IN GROUP ELIGIBILITY CRITERIA
Requirements as defined by the Group for determining the eligibility for participating in Harris
Health are material to the execution of this Agreement by Harris Health. During the term of this Agree-
ment no change in the Group definition of eligibility for participation shall be permitted to affect eligibil-
ity or enrollment under this Agreement in any manner unless such change is approved in advance by
mutual written agreement between Group and Harris Health.
3.4 EFFECTIVE DATE FOR ELIGIBLE PERSONS
3.4.1 Open Enrollment Period
An Eligible Person who applies for coverage in Harris Health by submitting an Application dur-
ing an Open Enrollment Period shall become covered as a Subscriber on the Group Effective Date or
such Effective Date specified as such for the Open Enrollment Period.
3.4.2 On Acquiring Eligibility Status
An Eligible Person who first meets the eligibility requirements other than during the Open
Enrollment Period may enroll within thirty (30) days of meeting such requirements by submitting an
Application. Such person shall become covered under Harris Health as a Subscriber on the first day
he became an Eligible Person provided that the premium applicable to the Subscriber has been
received in accordance with this Agreement.
3.5 EFFECTIVE DATE FOR ELIGIBLE DEPENDENTS
3.5.1 Open Enrollment Period
An Eligible Dependent for whom the Subscriber has applied for coverage in Harris Health by
submitting an Application during an Open Enrollment Period shall become covered as a Dependent
on the Effective Date of the Subscriber.
3.5.2 On Acquiring Eligibility Status
A newly acquired Eligible Dependent, and an Eligible Dependent other than a newborn child
who first meets the eligibility requirements of Group on other than during an Open Enrollment Period,
may be enrolled by the Subscriber within thirty (30) days of meeting such requirements by submitting
an Application. Such Eligible Dependent shall become covered under Harris Health as a Dependent
on the day he became an Eligible Dependent provided that the premium applicable to the Dependent
has been received in accordance with this Agreement described in Section 5.1.
Coverage for newly adopted children shall commence on the earlier of (a) the date upon which
such child commences residence with the Subscriber or (b) when the adoption becomes legal.
Adopted children and newborn children shall be covered under Harris Health for an initial period of
thirty-one (31) days and shall continue to be so covered after that time only if, prior to the expiration of
such thirty-one day period, an Application has been submitted and the premium applicable to the
Dependent has been received in accordance with this Agreement described in Section 5.1.
3.6 PERSONS NOT ELIGIBLE FOR COVERAGE
Notwithstanding the foregoing provisions of this Section, persons not eligible for cover-
age in Harris Health shall be as follows:
Coverage Previously Terminated: No person shall be eligible to become a Member who has
had coverage terminated by Harris Health for cause, as described in Section 4.2 of this
Agreement.
Indebtedness: No person shall be eligible to become a Member if such person has unpaid
financial obligations arising from prior coverage in Harris Health.
3.7 CONDITIONS OF ELIGIBILITY
No Eligible Person or Eligible Dependent shall be refused enrollment by Harris Health because
of health status, requirements for health services, or the existence of a Pre-Existing Condition on the
Group Effective Date. In addition, no Member's coverage shall be terminated by Harris Health due to
his health status or his healthcare needs. If an Eligible Person or Eligible Dependent applies for cover-
age on a date other than Open Enrollment Period or more than thirty (30) days after becoming an Eligi-
ble Person or Eligible Dependent, then such Eligible Person or Eligible Dependent shall have to
document Evidence of Insurability as required by Harris Health.
3.8 NOTIFICATION OF INELIGIBILITY
A condition of participation in Harris Health is Subscriber's agreement to notify Harris Health of
any changes in status that affect Subscriber or the ability of the Subscriber's Dependents to meet the
eligibility criteria set forth in this Section.
3.9 CLERICAL ERROR
Eligibility under this Agreement shall in no event be invalidated by failure of the Group, due to
clerical error, to record or report an Eligible Person or Eligible Dependent to Harris Health if an Appli-
cation had been completed and submitted to Group as required under the terms of this Agreement by
or on behalf of such Eligible Person or Eligible Dependent and that the premium applicable to such
coverage had been received by Harris Health.
Section 4.0
GROUP AND MEMBER TERMINATION, CONTINUATION OF
BENEFITS AND CONVERSION
4.1 TERMINATION OF GROUP
41.1 Default in Payment of Premium
If Group fails to pay to Harris Health the premium payable hereunder on or before the thirty-first
(31) calendar day after such payment is due, this Agreement may be terminated by Harris Health and
all benefits and services shall cease at the end of such thirty-one (31) day grace period. Group may
be held liable for the cost of all benefits and services provided to Member by Harris Health during the
grace period. Group shall remain liable for all premiums (and any interest accrued thereon) not paid
prior to termination. Interest on late payments from the date such premiums were due may be charged
at a rate equal to eighteen percent (18%) per year. Unpaid interest shall be due and payable upon
notice thereof to Group from Harris Health.
If Group remits its delinquent payments to Harris Health within fifteen (15) days of a termination
date, Harris Health may reinstate Group without requiring a new Group Enrollment Agreement. How-
ever, Harris Health reserves the right to refuse to reinstate by refunding within five (5) business days all
payments made by Group after the date of termination.
4.1.2. Upon Notification
This Agreement may be terminated by either Harris Health or Group upon written notice to the
other party at least sixty (60) days prior to the end of the Contract Year. Such termination shall occur at
midnight on the day preceeding the end of the Contract Year. In the event that Harris Health terminates
this Agreement, any Member who is a registered bed patient in a Hospital on the date of termination
shall receive coverage for all hospital services for that hospital confinement or until a determination is
made by the Medical Director that inpatient care is no longer medically indicated, whichever occurs
first.
4.2 TERMINATION OF MEMBER - FOR CAUSE
4.2.1 Default in Payment of Copayments
If any required Copayment is not paid timely by or on behalf of Member, pursuant to the terms
of this Agreement, such Member's entitlement to benefits may be terminated not less than sixty-one
(61) days written notice after the date such Copayment was due.
4.2.2 Default in Payment of Premium
if any premium contributions due from Member are not paid timely by or on behalf of Member,
such Member's entitlement to benefits may be terminated not less than thirty-one (31) days after the
date such premium was due.
4.2.3 Misrepresentation
if any Subscriber should make a fraudulent statement or provide any material misrepresenta-
tion of fact by or on behalf of such Subscriber or Dependent on an Application or Evidence of Insura-
bility form, Harris Health shall have the right to terminate the Member's coverage under this Agreement
without any further liability or obligation to such Member. Such Subscriber's entitlement to benefits may
be terminated not less than sixty-one (61) days written notice after such misrepresentation. If a Mem-
ber corrects inaccurate information furnished to Harris Health, and Harris Health has not relied upon
such incorrect information to its prejudice, the furnishing of incorrect information shall not constitute a
basis for termination of the Member's coverage. In the absence of fraud, all statements made by a
Subscriber are considered representations and not warranties. During the first two years, coverage
can be voided for material misrepresentation contained in a written Application or Evidence of Insura-
bility Form. After two years, coverage can be voided only in the event of a fraudulent misstatement
contained in the written Application or Evidence of Insurabi!ity form. A copy of the written Application
must have been furnished to the Subscriber if the terms of the Application or Evidence of Insurability
form are to be applied.
4.2.4 Misuse of Identification Card
Possession of a Harris Health identification card in and of itself confers no rights to services or
other benefits. The holder of the card must be, in fact, a Member on whose behalf all applicable pre-
miums under this Agreement have actually been paid. Any person receiving services or other benefits
to which he is not entitled pursuant to this Agreement shall be solely responsible for the full payment of
any charges associated with the services received. If any Member permits the use of the Member
identification card by any other person, such card may be confiscated and Harris Health shall have
the right to terminate the Member's coverage under this Agreement and, if a Subscriber, the coverage
of his Dependents. Such Member's entitlement to benefits may be terminated not less than fifteen (15)
days written notice after such misuse of the identification card.
4.2.5 Fraudulent Use of Benefits or Services
Fraudulent use by Member of services, benefits, providers, facilities, or coverage will result in
cancellation of coverage after not less than a fifteen (15) day written notice to Subscriber.
4.2.6 Misconduct
Misconduct by a Member detrimental to safe Health Plan operations and the delivery of service
or treatment, or abuse of healthcare professionals, facilities, or Health Plan personnel may result in
cancellation of coverage effective immediately.
4.2.7 Untenable Patient/Physician Relationship
If the Member and the Participating Physician fail to establish a satisfactory patient-physician
relationship and if it is shown that Harris Health has, in good faith, provided the Member with the
opportunity to select an alternative Participating Physician, the Member shall be notified in writing at
least thirty (30) days in advance that Harris Health considers the patient-physician relationship to be
unsatisfactory and specifies the changes that are necessary in order to avoid termination if Member
fails to make such changes, coverage may be cancelled at the end of thirty (30) days.
For refusal by a Member to accept recommended procedures or treatment as described in
Section 8.3 of this Agreement, the Member's coverage may be cancelled after not less than thirty (30)
days written notice.
4.2.8 Termination Procedure
Any Member terminated for cause pursuant to this Section shall be given written notice of ter-
mination prior to the effective date of termination in accordance with notification requirements of Sec-
tion 4.2. If Member receiving notice of termination initiates the Member Complaint Resolution
Procedure described in Section 10 of this Agreement during the notification period to challenge the
grounds for termination; the effective date of termination shall be postponed until Member Complaint
Resolution Procedure is completed and a final decision regarding termination is provided. If the Mem-
ber, on his own behalf or on behalf of a minor child, fails to initiate the Member Complaint Resolution
Procedure within the notification period, such failure shall constitute a waiver of said Member's right to
challenge the termination.
4.3 TERMINATION OF MEMBER - OTHER THAN FOR CAUSE
4.3.1 Subscriber No Longer Eligible Person
If the Subscriber ceases to be an Eligible Person, coverage under this Agreement shall auto-
matically terminate at midnight of the day on which such Subscriber ceased to be an Eligible Person,
subject to continuation of coverage and conversion privilege provisions.
4.3.2 Dependent No Longer Eligible Dependent
If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall
automatically terminate at midnight of the day on which such Dependent ceased to be an Eligible
Dependent, subject to continuation of coverage and conversion privilege provisions.
4.3.3 Service Area Resident
If a Member ceases to be a resident of the Service Area as defined by Harris Health, eligibility
to participate in Harris Health shall. automatically terminate as of the date on which the Member
ceased to be a resident of the Service Area, except as may be required by State and Federal regula-
tions for COBRA participants. Such Member shall be eligible to convert to an Individual Hospital and
Surgical Expense Policy as specified in Section 4.6.2.
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 periods after the effective date of the termi-
nation of coverage, plus amounts due to such Member for claims reimbursement, if any, less any
amount due to Harris Health or which must be paid by Harris Health on behalf of such Member, shall
be refunded to the appropriate party within thirty-one (31) days. Harris Health and Group shall there-
after have no further liability or responsibility to such Member except as may be specifically provided
in Section 4.1.2 of this Agreement.
4.5 CONTINUATION OF COVERAGE
If a Member's coverage ends, such coverage may qualify to be continued in one of the follow-
ing ways:
• it may be extended under the Extension of Medical Benefits provisions, if the Member is Hos-
pital Confined when this Agreement terminates; or
• it may be continued under the Optional Continuation of Coverage provisions; or
• it may be converted to an individual plan of medical coverage as described in the Conver-
sion provisions.
If, under the provisions of Title X of the Consolidated Omnibus Budget Reconciliation Act of
1985, Public Law 99-272 ("COBRA"), any Member is granted the right to continuation of coverage
beyond the date his coverage would otherwise terminate, or, if COBRA is inapplicable and the provi-
sions of an applicable state statute grants such Member similar rights to continuation of coverage, this
Agreement shall be deemed to allow continuation of coverage to the extent necessary to comply with
the provisions of the applicable statute. Contact the employer for verification of eligibility and proce-
dures to follow.
4.5.1 Extension of Medical Benefits
Harris Health shall continue to provide medical services if this Agreement terminates under
10
Section 4.1.2 while a Member is confined in a Hospital or Skilled Nursing Facility. Services will be pro-
vided only for the same injury or sickness which caused the Member to be confined.
This continued coverage will end on the earlier of: (1) the date the confinement is no longer
Medically Necessary; or (2) the date the Member reaches any limits under the Group Contract for the
provisions of services; or (3) the date the Member becomes eligible for similar coverage under another
plan.
4.6 CONVERSION PRIVILEGE
If a Member has been covered by this Agreement for at least three (3) consecutive months or
covered as a newborn from the date of birth and meets the definition of a person eligible for conver-
sion, Member may enroll in an individual plan with a defined Schedule of Benefits available to conver-
sion Members only under the terms and conditions of this Agreement.
ELIGIBILITY TO CONVERT
A Member whose coverage under this Agreement is terminated in accordance with the Termi-
nation provisions may convert if the coverage is not ending for one of the following reasons:
• Termination of this Agreement;
• Failure to pay any required copayment amounts;
• Termination for cause;
• Coverage under another individual or group health policy, plan or contract;
• Eligibility for Medicare;
• Eligibility or coverage for similar hospital, medical or surgical benefits under a state or federal
law.
A covered Dependent whose coverage is terminated under this Agreement may also convert if
the termination is due to:
• Legal separation or divorce; or
• The Subscriber's death; or
• The Dependent reaching the maximum Dependent age.
HOW TO CONVERT
4.6.1 Residence in Service Area
The Member eligible for conversion may, without Evidence of Insurability, convert to an Individ-
ual Health Care Agreement issued by Harris Health. To obtain an individual enrollment, the Eligible
Person must continue to reside in the Service Area, must submit a completed application for conver-
sion within thirty-one (31) days after termination of coverage under this Agreement, and must submit
the premium for such Individual Health Care Agreement as required from the effective date of termina-
tion of coverage under this Agreement.
4.6.2 Residence Out of Service Area
If the Member eligible for conversion does not reside in the Service Area, the Member may,
without Evidence of Insurability, convert to an individual policy issued by and renewable at the option
of the indemnity insurer making such conversion coverage available to Harris Health.
Section 5.0
PAYMENT REQUIREMENTS
5.1 PREMIUM PAYMENTS
The initial rates for the benefits and services under this Agreement shall be due and payable in
advance on or before the first (1) day of the month for which such payment is made or is to be made.
In accordance with the terms and provisions of Section 12.3 of this Agreement, Harris Health shall
have the right to change the rate payable under this Agreement at any time when the extent or nature
of this Agreement is changed by amendment or termination of any provision, or by reason of any pro-
vision of law or any governmental program or regulation. No proration of the rate shall be made with
11
respect to Members whose coverage under this Agreement commences after the first (1) day of the
month. A grace period of thirty-one (31) days shall be allowed for each payment payable hereunder,
whether due from Group or a Member except for the first payment due.
The rate required for a newly acquired Eligible Dependent shall be payable initially when the
required Application is submitted to Harris Health. Thereafter, all payments with respect to such new
Eligible Dependent shall be made as otherwise provided in this Agreement.
Any payments required for newborn children who meet the requirements of Section 3.5.2 of this
Agreement shall be initially payable to Harris Health on or before the first day of the next month follow-
ing the month in which the Application required under Section 3.5.2 is submitted to the Health Plan.
Thereafter, all payments with respect to such newborn child shall be made as otherwise required
under this Agreement.
5.1.1 Non-Contributory Coverage
If the coverage basis hereunder is "Non-Contributory;" the Group agrees to pay at the principal
office of Harris Health, or to its authorized representative, on each payment due date, the sum of the
Harris Health rate for tho coverage then provided under this Agreement. The Group premium for the
coverage provided by Harris Health under this Agreement shall be determined by the applicable rate
then in effect and the number of Members at the monthly intervals established by Harris Health.
5.1.2 Contributory Coverage
If the coverage basis hereunder is "Contributory," Group agrees to pay at the principal office of
Harris Health, or to its authorized representative, on each payment due date, that part of the Harris
Health rate for the coverage then provided under this Agreement. Group shall permit Subscribers tc
pay their contributory portion of such rate through payroll deduction. Procedures for implementing
payroll deductions for the Subscriber's portion of such rate shall be the same as those utilized for any
Alternative Health Benefit Plan. If the Group does not have an Alternative Health Benefit Plan, the pro-
cedures shall solely be those as agreed to, in writing, between Group and Harris Health. The Group
premiums for the coverage provided by Harris Health under this Agreement shall be determined by
the applicable rate then in effect and the number of Members at the monthly intervals established by
Harris Health.
Group shall offer Harris Health to all Subscribers of Group on terms no less favorable with
respect to the Group contribution than those applicable to any Alternative Health Benefit Plan as may
be available through the Group. The Group contributions shall not be changed during the term of this
Agreement unless such change is prior approved, in writing, by Harris Health. If, however, Group con-
tribution to the Alternative Health Benefit Plan as may be available through the Group is increased dur-
ing the term of this Agreement, Group agrees to also increase contribution to Harris Health effective
the first monthly payment due following such increase.
5.2 NOTIFICATION BY GROUP
Group shall forward completed Applications and any Evidence of Insurability form(s) to Harris
Health within ten (10) business days of their receipt from Eligible Persons. In the event Group fails to
notify Harris Health of the ineligibility of any person for whom the Group has made the monthly prepay-
ment required pursuant to this Agreement, then, such prepayment shall be credited to Group only if
Harris Health has not made arrangements for or paid benefits for the ineligible person but in no event
shall such prepayment be credited subsequent to thirty (30) days after the date such person became
ineligible.
53 COPAYMENTS
All Copayments, as specified in the Schedule of Benefits, are due and payable at the time a
service is provided. The maximum amount of Copayment shall not exceed the maximum specified in
the Schedule of Benefits. It is the Subscriber's responsibility to retain receipts and to notify Harris
Health upon attaining the Copayment limit so that additional services can be provided without a
Copayment charge.
12
Section 6.0
CLAIM PROVISIONS
6.1 CHARGES PAID BY MEMBERS
It is not anticipated that a Member shall make payments, other than the Copayments as set
forth in the Schedule of Benefits, for benefits and covered services under this Agreement. However, if
a payment is made by a Member then a written description of such services, accompanied by evi-
dence of payment by the Member must be provided to Harris Health within sixty (60) days after the
performance of the service. Failure to furnish such proof within the required time shall not invalidate
nor reduce any claim, if it was not reasonably possible to give proof within such time, provided such
proof is furnished as soon as reasonably possible. If the Member provides evidence that he has made
such payment, payment shall be paid to the Member but without prejudice to Harris Health's right to
seek recovery of any payment made by it before receipt of such evidence.
Benefits under this Agreement will be paid directly to the provider unless Member requests
payment to be made to himself and submits to Harris Health proof of prior payment to the provider for
covered services. Claims for such services will be processed as follows:
A. Fifteen (15) calendar days after receipt of claim, Harris Health will:
1. Acknowledge receipt of claim;
2. Commence investigation of claim;
3. Request all information from claimant as deemed necessary by Harris Health. Subse-
quent additional requests may be necessary.
B. No later than fifteen (15) business days after receipt of all items required by Harris Health,
Harris Health will:
1. Notify claimant of acceptance or rejection of claim;
2. Notify claimant of the reason(s) Harris Health needs additional time.
Harris Health shall accept or reject the claim no later than forty-five (45) calendar days
following receipt of additional information.
C. Upon notification from Harris Health that the claim will be paid, the claim will be paid no
later than five (5) business days after such notification was made.
6.2 MEDICAL EMERGENCY
Medical Emergency services which are covered under this Agreement but are not received
fr6m Participating Providers shall be reimbursed subject to the Copayments in the Schedule of Bene-
fits. Harris Health reserves the right to deny a claim for reimbursement of services received from a
Hospital emergency department or a Minor Emergency Center, if it is determined by Harris Health that
such services were not obtained pursuant to the terms of this Agreement or if a Medical Emergency
did not exist at the time services were received by the Member.
6.3 ACTION ON CLAIM
All claims for reimbursement shall be finalized by Harris Health within sixty (60) days of receipt
of written documentation describing the occurrence, character and extent of the event for which the
claim is made, unless the Member is notified of the need for a longer time. If a claim is denied, written
notice to the Member will state the reason for the denial. Member may obtain a review of the denial
through the Member Complaint Resolution Procedure as described in Section 10.0.
6.4 EXAMINATION OF MEMBER
Harris Health, at its own expense, shall have the right to examine the Member whose sickness
or injury is the basis of a claim when and so often as it may reasonably require during the pendency of
any claim.
6.5 LIMITATION PROVISIONS
• No action at law or equity shall be brought under this Section against Harris Health prior to
the expiration of the sixty (60) day period immediately following the date on which written
proof of this charge or loss upon which the action is brought, in accordance with the provi-
sions of this Section, has been furnished to Harris Health; or later than three (3) years after
the expiration of the period of time in which such proof of charge or loss is required under
this Section to be furnished to Harris Health.
13
• No liability shall be imposed under Harris Health other than for the benefits and services cov-
ered under this Agreement.
Section 7.0
COORDINATION AND SUBROGATION OF BENEFITS
The Harris Health Coordination and Subrogation of Benefits provisions applies to all of the ben-
efits provided under this Agreement. The value of any benefits or services provided by Harris Health
shall be coordinated with any group insurance plan or coverage under governmental programs,
including Medicare, to assure that a Member receives coverage while avoiding double recovery. It is,
therefore, understood and agreed that should a Member be covered by or under a Coordinated Plan
in addition to coverage under this Agreement, the provisions and rules as described in this Section
shall determine whether Harris Health or the Coordinated Plan is primarily responsible for paying the
costs of benefits and services provided to the Member.
• If a Member who has enrolled under this Health Plan is entitled to inpatient benefits under
another contract or policy of insurance due to inpatient care which began while the Member
was enrolled under a previously held policy, Harris Health will pay, subject to Copayments
under this plan, the difference between entitlements under this Health Plan and entitlements
under the other contract or policy of insurance.
• Benefits which are provided directly through a specified provider of an employer shall in all
cases be provided before the benefits of this Health Plan.
• Services and benefits for military service connected disabilities for which a Member is legally
entitled and for which facilities are reasonably available, shall in all cases be provided before
the benefits of this Health Plan.
• All sums payable for services provided pursuant to worker's compensation shall not be reim
bursable under this Agreement.
7.1 DEFINITIONS
For purposes of this Section only, words and phrases shall have meanings as follows:
• ALLOWABLE EXPENSE shall mean any Usual and Customary expense of which at least a
portion is covered under this Health Plan covering the Member for whom the claim is made.
When a Coordinated Plan provides benefits in the form of services rather than cash pay-
ments, the Usual and Customary cash value of each service provided shall be deemed to
be both an Allowable Expense and a benefit paid.
CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding any portion of a
calendar year occurring prior to the Effective Date.
COORDINATED PLAN shall mean any of the following that provides benefits or services for,
or by reason of, medical care or treatment.
- Coverage under governmental programs, including Medicare, required or provided by
any statute unless coordination of benefits with any such program is forbidden by law.
- Group coverage or any other arrangement of coverage for individuals in a group,
whether on an insured or uninsured basis, including any prepayment coverage, group
practice basis or individual practice coverage and any coverage for students which is
sponsored by, or provided through, a school or other educational institution above the
high school level.
7.2 DETERMINATION OF BENEFITS
This provision shall apply in determining the benefits payable for the Allowable Expenses
incurred by a Member during a Claim Determination Period.
The term Coordinated Plan shall be construed separately with respect to each policy, contract,
or other arrangement for benefits or services and separately with respect to that portion of any such
policy, contract, or other arrangement which reserves the right to take the benefits or services of other
Coordinated Plans into consideration in determining its benefits and that portion which does not.
14
Whenever the sum of the benefits that would be payable under this Agreement in the absence
of this provision, and the benefits that would be payable under all Coordinated Plans in the absence
thereof or amendments of similar purpose to this provision would exceed the Allowable Expenses, then
the following shall apply:
• The benefits that would be payable under this Agreement shall be reduced to the extent
necessary so that the sum of such reduced benefits and all the benefits payable for such
Allowable Expenses under all Coordinated Plans shall not exceed the total payable under
this Agreement. Benefits payable under a Coordinated Plan include the benefits that would
have been payable had claim been duly made therefor.
• If a Coordinated Plan would, according to its rules, determine its benefits after the benefits
payable under this agreement have been determined, and the rules as described in Section
7.3 would require payment under this Agreement to be determined before the Coordinated
Plan, then the benefits of the Coordinated Plan shall not be included for the purpose of deter-
mining the benefits under this Agreement.
7.3 ORDER OF BENEFIT DETERMINATION
The rules establishing the order of benefit determination shall be as follows:
• The benefits of a Coordinated Plan without a coordination of benefits provision (or a non-
duplication provision of similar intent) shall be determined before the benefits of this
Agreement.
apply:
The benefits of a Coordinated Plan which covers the Member other than as a dependent
shall be determined before the benefits of a Coordinated Plan which covers such person as
a dependent.
The benefits of a Coordinated Plan which covers the Member as a dependent child of a per-
son whose date of birth, excluding year of birth, occurs earlier in a calendar year, shall be
determined before the benefits of a plan which covers such person as a dependent of a per-
son whose date of birth, excluding year of birth, occurs later in a calendar year. If a Coordi-
nated Plan does not have the provisions of this paragraph regarding dependents, which
results either in each Coordinated Plan determining its benefits before the other or in each
Coordinated Plan determining its benefits after the other, the provisions of this paragraph
shall not apply, and the rule set forth in the Coordinated Plan which does not have the provi-
sions of this paragraph shall determine the order of benefit determination unless Section
7.3.1 shall apply.
If the rules provided above or the rules provided in Section 7.3.1 do not establish an order of
benefit determination, then the benefits of a Coordinated Plan which has covered the Mem-
ber for whom the claim is made for the longer period of time shall be determined before the
benefits of a Coordinated Plan which has covered such Member for the shorter period of
time except as follows:
- The benefits of a Coordinated Plan covering the Member as a laid-off or retired employee
or as the dependent of such Member shall be determined after the benefits of a Coordi-
nated Plan covering 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 provision regarding laid-off or retired employees,
and, as a result, such Coordinated Plan determines its benefits after the Coordinated
Plan with this provision, then the provisions of the immediately preceeding paragraph
shall not apply.
7.3.1 Legal Separation or Divorce
In the event of a legal separation or divorce, the following order of benefit determination shall
• If there is a court decree that establishes financial responsibility for the healthcare expenses
of the child, the benefits of a Coordinated Plan which covers the child as a dependent of the
parent with such financial responsibility shall be determined before the benefits of a Coordi-
nated Plan which covers the child as a dependent of the parent without such financial
responsibility.
15
In the event of a legal separation or divorce in which the court decree does not establish
financial responsibility for the healthcare expenses of the child then the following shall apply:
- If the parent with custody of the child has not remarried, the benefits of a Coordinated
Plan which covers the child as a dependent of the parent with custody of the child shall
be determined before the benefits of a Coordinated Plan which covers that child as a
dependent of the child without custody.
- If the parent with custody of the child has remarried, the benefits of a Coordinated Plan
which covers the child as a dependent of the parent with custody shall be determined
before the benefits of a Coordinated Plan which covers that child as a dependent of the
stepparent; and the benefits of a Coordinated Plan which covers that child as a depen-
dent of the stepparent shall be determined before the benefits of a Coordinated Plan
which covers that child as a dependent of the parent without custody.
Thus, in the event of a legal separation or divorce, unless a court decree specifies otherwise,
the order of benefit determination described above may be summarized as follows:
Separated or Divorced and not Remarried:
(1) Parent with custody
(2) Parent without custody
Separated or Divorced and Remarried:
(1) Parent with custody
(2) Stepparent with custody
(3) Parent without custody
7.4 MEDICARE
For purposes of determining benefits provided for a Member who is eligible to enroll for Medi-
care, but does not, Harris Health will assume the amount provided under Medicare to be the amount
the Member would have received if he or she had enrolled for it.
A Member is considered to be eligible for Medicare on the earliest date coverage under Medi-
care could become effective for the Member. Except as described under TEFRA in Section 7.4, Medi-
care shall be interpreted so as to be included in Section 7.1 for each Member as follows:
• Such Member must agree to enroll for both Parts A and B of Medicare and assign to Harris
Health any Medicare benefits for services covered by Harris Health. If such Member
receives benefits from Harris Health that would have been paid or reimbursed by Medicare,
but Member has failed to enroll for Medicare coverage, then Harris Health shall be entitled to
receive from the Member the actual costs of the services provided. The Member shall remain
liable for payment of the Copayments as set forth in the Schedule of Benefits.
• When Allowable Expenses are incurred by such Member during any Claim Determination
Period and include expenses for services, treatment, or supplies which are payable under
Medicare, such Allowable Expenses shall be reduced by an amount equal to the benefits
payable by Medicare before comuting the benefits payable under this Agreement.
7.4.1 TEFRA Options for Employers with 20 or More Employees
Actively working covered Employees and their covered spouses who are eligible for Medicare
will be permitted to choose one of the following options if the Employee is age 65 or older and eligible
for Medicare:
Option 1 - The service of the Group Agreement will be provided first and the benefits of
Medicare will be provided second.
Option 2 - Medicare benefits only. Subscriber and Dependents, if any, will not be covered by
the Group Agreement.
The employer will provide Subscriber with a choice to elect one of these options at least one
month before becoming age 65. All new Employees age 65 or older will be offered these options when
hired. If Option 1 is chosen, Subscriber's rights under this Agreement will be subject to the same
requirements as for an Employee or Dependent who is under age 65.
There are two categories of persons eligible for Medicare. The calculation and payment of ben-
efits by this Agreement differs for each category.
16
Category 1 Medicare Eligibles are:
1. Actively working covered Employees age 65 or older who choose Option 1;
2. The age 65 or older covered spouses of actively working covered Employees age 65 or
older who choose Option 1;
3. Age 65 or older covered spouses of actively working covered Employees who are under
age 65;
4. Actively working covered Employees of employers with 100 or more Employees and their
Covered Dependents who are entitled to Medicare by reason of disability other than End
Stage Renal Disease (ESRD); and
5. Covered individuals entitled to Medicare solely on the basis of ESRD during a period of up
to 12 months after the individual has been determined eligible for ESRD benefits.
Category 2 Medicare Eligibles are:
1. Retired employees and their spouses;
2. Covered Employees of employers with less than 100 Employees and their covered Depen-
dents who are entitled to Medicare by reason of a disability other than ESRD; and
3. Covered individuals entitled to Medicare solely on the basis of ESRD for more than 12
months after the individual has been determined eligible for ESERD benefits.
Calculation and Provision of Services:
For Members in Category 1, services are provied by this Agreement without regard to
any benefits provided by Medicare. Medicare will then determine its benefits.
For Members in Category 2, services are provided by the Group Agreement. Harris
Health shall then have the right to recover the full amount of all Medicare benefits the Member
is entitled to receive, whether or not the Member is actually enrolled for them. The Member
should authorize payment of Medicare benefits directly to Harris Health for services rendered.
If the Member does not authorize direct payment, he or she is responsible for Harris Health for
the reasonable value of the services rendered. The Member is also responsible to Harris
Health for the reasonable value of all Group Agreement services reimbursable by Medicare if
- the Member is not enrolled for all benefits he or she is entitled to receive.
7.5 RIGHT TO RECEIVE AND RELEASE INFORMATION
For purposes of administering the provisions of this section, Harris Health may, without further
consent of, or notice to any Member, release to or obtain from any healthcare plan, insurance com-
pany or other person or organization, any information with respect to any Member which it deems to
be reasonably necessary for such purposes, as permitted by law. Any Member receiving services or
claiming benefits under this Agreement shall furnish to Harris Health all information deemed necessary
by Harris Health to implement this Section 7.0.
7.6 FACILITY OF PAYMENT
Whenever payments which should have been made by Harris Health in accordance with this
Section have been made by a Coordinated Plan, Harris Health shall have the right, exercisable alone
and in its sole discretion, to authorize payment to the Coordinated Plan making such payments any
amounts Harris Health shall determine to be warranted in order to satisfy the intent of this Section, and
amounts when so paid shall be deemed to be benefits under this Agreement, and, to the extent of
such payments, Harris Health shall be fully discharged from liability under this Agreement.
7.7 RIGHT OF RECOVERY
Whenever payments have been made by Harris Health with respect to Allowable Expenses in a
total amount which is, at any time, in excess of the maximum amount of payment neccessary at that
time to satisfy the intent of this Section, Harris Health shall have the right to recover such payments, to
the extent of such excess, from one or more of the following, as Harris Health shall determine: any per-
son or persons to, or for, or witH respect to whom such payments were made, any insurance company
or companies, and any other organization or organizations which provided services, or to which such
payments were made.
17
T8 DISCLOSURE
Each Member agrees to disclose to Harris Health at the time of enrollment, at the time of
receipt of services and benefits, and from time to time as requested by Harris Health, the existence of
other health plan coverage, the identity of the carrier, and the group through which such coverage is
provided.
7.9 SUBROGATION
Subrogation seeks to shift the expense for injuries suffered by Plan Members to those responsi-
ble for causing them.
In return for Harris Health providing benefits for injuries, ailments, or diseases caused as a
result of the negligence, omission or willful act of a third party, each Member agrees to execute any
instrument which may be needed in order for the right of subrogation to be effective. Each Member
also agrees to assign to Harris Health the right of recovery against such third party to the extent of
benefits received from or through Harris Health plus costs of legal suit including attorney fees. At the
time such benefits are provided or thereafter as Harris Health may request, Member agrees to comply
with the following provisions:
Execute a formal written injury report and assignment to Harris Health of right to recover the
reasonable value of any benefits provided directly by Harris Health and the actual costs paid
by Harris Health under this Agreement for injuries, ailments and diseases caused by a third
party together with the costs of legal suit including attorney fees.
Reimburse Harris Health for the reasonable value of any benefits and services provided by
Harris Health and in an amount equal to the charges therefor together with the costs of legal
suit, including attorney fees, but not in excess of monetary damages collected, immediately
upon receipt of any monies paid by or on behalf of a third party in settlement of any claim
arising out of injuries, ailments and diseases covered by such third party. In determing the
reasonable value of benefits and services provided by Harris Health, Harris Health shall con-
sider charges for similar services being made by providers in the community which possess
similar training or capability as well as unusual circumstances, or a medical complication
requiring additional time, skill experience and/or facilities in connection with a particular ser-
vice. Harris Health shall have a lien on any recovery from such third party whether by judg-
ment, settlement, compromise or reimbursement.
Execute and deliver such papers and provide such reasonable help (including authorizing
bringing suit against such third party in Member's name and making court appearances) as
may be necessary to enable Harris Health to recover the reasonable value of benefits and
services provided by Harris Health, together with costs of legal suit, including attorney fees.
Section 8.0
INDEPENDENT AGENTS/REFUSAL TO ACCEPT TREATMENT
8.1 INDEPENDENT AGENTS
The relationships between Harris Health and contracting entities may be defined as follows:
• The relationship between Harris Health and Member Hospitals is that of independently con-
tracting entities. Member Hospitals are not agents or employees of Harris Health nor is Harris
Health an agent of any Member Hospital. Member Hospitals shall maintain the hospital-
patient relationship with Members and shall be the only parties responsible to Members for
the Hospital services that they provide.
• The relationship between Harris Health and Participating Providers is that of independent
contracting entities. Participating Providers are not agents or employees of Harris Health nor
is Harris Health an employee or agent of any Participating Provider. Participating Providers
shall maintain the physician-patient or professional-patient relationship with Members and
shall be the only parties responsible to Members for the services provided. Neither Harris
Health nor any employee of Harris Health shall be deemed to be engaged in the practice of
medicine. Harris Health shall in no way supervise the practice of medicine by any Participat-
ing Provider hereunder, nor shall Harris Health in any manner supervise, regulate or interfere
with the usual professional relationships between a Participating Provider and a Member.
16
• The relationship between Harris Health, the Group and any Member is that of independent
contracting entities. Neither the Group nor any Member is the agent or employee of Harris
Health, and Harris Health is not the employee or agent of the Group or any Member. Neither
the Group or any Member shall be liable for any acts or omissions of Harris Health, its agents
or employees, any Physician, any Hospital, or any other person or organization in which Har-
ris Health has made, or hereafter shall make arrangements for the performance of services
under this Agreement.
8.2 LIMITATION ON LIABILITY
Harris Health does not guarantee by this Agreement that any Participating Provider shall per-
form or properly perform such contracts; the only obligation of Harris Health in the event of breach of
such contract by any Participating Provider shall be, upon request, to use its best efforts to procure
the needed services from another provider. Harris Health shall not be liable to a Member for any act of
omission or commission on the part of any Participating Provider.
8.3 REFUSAL TO ACCEPT TREATMENT/EXCESSIVE TREATMENT
Members may, for reasons personal to themselves, refuse to accept services or complete a
Course of Treatment as recommended by a Participating Physician. Participating Physicians shall use
their best efforts to render all necessary and appropriate professional services in a manner compatible
with the Member's wishes, insofar as this can be done consistently with such Participating Physician's
judgment as to the requirements of proper medical practice.
If a Member refuses to complete a recommended Course of Treatment, and the Participating
Physician believes that no professionally acceptable alternative exists, such member shall be so
advised. If upon being so advised, the Member still refuses to follow the recommended treatment or
procedure, then the Member shall be given no further treatment for the condition, and neither the Par-
ticipating Physician nor Harris Health shall have any further responsibility to provide care for such con-
dition. A Member may appeal a withdrawal of treatment under this provision through the Member
Complaint Resolution Procedure as described in Section 10.0 of this Agreement.
If two (2) or more Participating Physicians who have rendered care to a Member inform Harris
Health that the Member is receiving health services or prescription medications in a manner or in a
quantity which is not medically necessary or not medically beneficial, the Member may be required by
Harris Health to select a single Participating Primary Physician (hereafter referred to as a "Coordinat-
ing Health Plan Physician") and a single Participating Pharmacy, if Pharmacy benefits are available to
Member, for the provision and coordination of all future health services. If the Member fails to voluntar-
ily select a Coordinating Health Plan Physician and a single Participating Pharmacy within thirty (30)
days of written notice by Harris Health of the need to do so, Harris Health shall designate a Coordinat-
ing Health Plan Physician and/or a Participating Pharmacy for the Member.
Following selection or designation of a Coordinating Health Plan Physician for a Member, cov-
erage of health services set forth on this Agreement shall be contingent upon each health service
being provided by or through written referral to the Coordinating Health Plan Physician for that
Member.
If, after sixty (60) days from initial notification by Harris Health, the Member is not in compliance
with this Section, the Member may be terminated by Harris Health under Section 4.2.7.
Section 9.0
EXCLUSIONS ON SERVICE RESPONSIBILITIES
The rights of Members and obligations of Participating Providers under this Agreement are
subject to the exclusions as specified below.
9.1 MAJOR DISASTER OR EPIDEMIC
In the event of any major disaster or epidemic that would severely limit the availability of Partici-
pating Providers to provide healthcare services on a timely basis, Participating Providers shall, in good
faith, use their best efforts to render the benefits and services covered insofar as practical according
to their best judgment and within the limitation of such facilities and personnel as are then available. If
Harris Health and Participating Providers shall, in good faith, have used their best efforts to provide or
19
make arrangements for the benefits and services, they shall have no further liability or obligation for
delay or failure to provide such benefits and services due to a shortage of available facilities or per-
sonnel resulting from such disaster or epidemic.
9.2 CIRCUMSTANCES BEYOND CONTROL
In the event that, due to circumstances not reasonably within the control of Harris Health or
Participating Providers, such as the complete or partial destruction of facilities because of war, riot,
civil insurrection, or the disability of a significant number of Participating Providers, the rendering of
benefits and services covered hereunder is delayed or rendered impractical, neither Harris Health nor
any Participating Provider shall have any liability or obligation on account of such delay or such failure
to provide such benefits and services, if they shall, in good faith, have used their best efforts to pro-
vide or make arrangements for the benefits and services covered insofar as practical according to
their best judgment and within the limitations of such facilities and personnel as are then available. Pre-
mium payment shall be suspended for the duration of such time period for the Group.
9.3 FRAUDULENTLY OBTAINED BENEFITS
In the event a member fraudulently obtains healthcare services as a result of the improper or
unauthorized use of a Harris Health identification card, such Member agrees and is solely responsible
for the payment of all charges for services so obtained and for the payment of all reasonable costs of
collection thereof, including court costs, collection fees and attorney fees.
9.4 DISCONTINUANCE
If Harris Health or Group determines it would be impractical to continue due to circumstances
beyond the control of Harris Health or Group, Harris Health and Group may endeavor to agree to
amendments and adjustments to this Agreement which relate to services and benefits to be discontin-
ued. If parties cannot agree on amendments and adjustments, Harris Health or Group may terminate
this Agreement at the end of any month upon at least sixty (60) days written notice for Group. In.the
event of such termination, neither Harris Health nor Participating Providers shall have any further liabil-
ity or responsibility under this Agreement.
However, if any Participating Provider terminates their contract, then Harris Health shall be lia-
ble for the continuance of services and benefits described in this Agreement. Such services shall be
rendered to Members by other Participating Providers.
Section 10.0
MEMBER COMPLAINT RESOLUTION PROCEDURE
10.1 COMPLAINT RESOLUTION PROCESS
A Member may make an oral or written suggestion or indicate a complaint to any Harris Health
employee or to any Participating Provider. All oral suggestions and complaints shall be handled
promptly by Harris Health. If the Member is not satisfied with the response to an oral suggestion or
complaint, the Member may file a written complaint by calling Harris Health or, at the Member's option
the Member may file a written complaint by completing and forwarding a complaint form to Harris
Health at the latest address provided on the front of this Agreement. A Harris Health Member Service
Representative shall contact the Member by telephone to verify details and resolve the problem imme-
diately if possible. Within fifteen (15) business days from the receipt of the oral or written complaint,
Harris Health shall respond in writing to inform the Member of the progress or decision on the com-
plaint. In the event a decision cannot be reached within fifteen (15) business days, Harris Health shall
notify the Member that a decision shall be provided as soon as possible, but not later than sixty (60)
days after initial receipt of the complaint.
10.1.1 Ad Hoc Review Committee
If the Member is not satisfied with the resolution of the complaint by Harris Health, the Member
may request a review by filing such a request, in writing, within fifteen (15) business days of receiving
written notice of the resolution of the complaint. This request shall be sent to Harris Health. Upon
receipt of this written request, Harris Health shall forward the request and any and all memoranda and
notes made as a result of the original investigation of the complaint to the Medical Director and to Har-
ris Health.
20
After reviewing the complaint records, Harris Health shall convene an Ad Hoc Review Commit-
tee composed of Harris Health, the Medical Director, and at least two other individuals not involved in
the initial investigation of the complaint. In the case of a complaint concerning medical treatment or
services, medical personnel or facilities, such other individuals on the Ad Hoc Review Committee shall
be Participating Physicians. Within fifteen (15) business days of receipt of the request for a review,
Harris Health shall respond, in writing, to inform the Member of the decision or resolution of the com-
plaint by the Ad Hoc Review Committee.
10.1.2 Notification By Review Committee
If the original complaint involved a physician-patient relationship, the written response of the Ad
Hoc Review Committee shall inform the Member that he has the option, at his discretion, to submit the
complaint to the mediation service maintained by the Tarrant County Medical Society, and that such
mediation shall usually be concluded within a thirty (30) day to sixty (60) day time period. The notice
shall inform the Member that participation in the mediation process is voluntary and that mediation rec-
ommendations are non-binding on both parties. As part of their contractual obligation to comply with
the Health Plan rules and regulations, Participating Physicians must cooperate with the Tarrant County
Medical Society mediation service.
10.2 COMPLAINT RESOLUTION APPEAL PROCESS
If a Member is not satisfied with the decision of the Ad Hoc Review Committee, or the Tarrant
County Medical Society mediation service, the Member may request an additional review by Harris
Health. The Member must file a request for review within fifteen (15) business days of receipt of the
decision of the Ad Hoc Review Committee or the mediation service. Upon receipt of a request for a
review, Harris Health shall forward the review request and a complete record of the complaint history
to the Medical Director and to Harris Health.
After reviewing the complaint records, Harris Health shall convene an Ad Hoc Appeal Commit-
tee composed of Harris Health, the Medical Director and at least two other individuals not involved in
the initial investigation of the complaint. In the case of a complaint concerning medical treatment or
services, medical personnel or facilities, such other individuals on the Ad Hoc Appeal Committee shall
be Participating Physicians.
Within fifteen (15) business days of receipt of the request for a review, Harris Health shall
respond, in writing, to inform the Member of the decision or resolution of the complaint by the Ad Hoc
Appeal Committee. If all parties involved in the complaint agree, the complaint response of the Ad Hoc
Appeal Committee shall be final and binding on all parties.
Section 11.0
HEALTH CARE SERVICES
11.1 Benefits and Services
Harris Health agrees to arrange for the provision of the benefits and services in the Schedule of
Benefits and/or Riders, in accordance with the procedures and subject to the limitations and exclu-
sions specified in such Schedule of Benefits and/or Riders and in this Agreement.
Unless referred in writing by a Participating Primary Physician (or by a Participating Specialist
Physician), and except in cases of Medical Emergency, benefits and services set forth in the Limita-
tions and Exclusions Section of the Schedule of Benefits or any Riders that are rendered by a Partici-
pating Physician other than a Participating Primary Physician shall not be covered.
All hospital admissions must be authorized by Harris Health, and the Member's condition or
required services must be such that treatment can be rendered only in a hospital setting. Harris Health
and the Participating Physician may decide to provide Medically Necessary services on an outpatient
basis or in an outpatient surgery unit. The use of alternative levels of care, such as outpatient hospital
or home care, will be encouraged where possible based on Member condition and treatment.
Unless previously authorized in writing by a Participating Physician and by the Medical Director
and except in cases of Medical Emergency, all benefits and services set forth in the Schedule of Ben-
efits and any Riders shall be available and covered only when provided by a Participating Physician,
Participating Hospital or by another Provider under contract with Harris Health to provide healthcare
services to Members.
21
All charges related to services and supplies incurred prior to the Member's effective date, or
after the Member's termination date of coverage under this Agreement shall not be covered.
Section 12.0
TERM AND AMENDMENT OF AGREEMENT
12.1 TERM
This Agreement shall remain in effect for the first Contract Year and thereafter for successive
Contract Years unless sooner terminated as provided in Section 4.0 of this Agreement.
12.2 AMENDMENT
• Harris Health and Group may mutually alter or revise the terms of this Agreement and/or
Schedule of Benefits and Riders attached hereto. In the event of such alteration or revision,
Harris Health shall provide Group with at least sixty (60) days written notice before effective
date of Amendment. Such notice shall be considered to have been provided when mailed to
the Group at the latest address shown on the records of Harris Health.
• This Agreement may be amended at any time, according to any provision of this Agreement
or by written agreement between Harris Health and Group, without the consent of the Mem-
bers, or any other person having a beneficial interest in it. Any such amendment shall be
without prejudice to any claim arising prior to the effective date of such amendment.
12.3 CHANGE OF RATES
Harris Health shall have the right to change the rates and premiums payable hereunder (i) as
of any Anniversary Date (in which case the Group shall be notified at least sixty (60) days prior to a
change in rates) or (ii) in accordance with Section 12.2 of this Agreement.
Section 13.0
MISCELLANEOUS PROVISIONS
13.1 USE OF WORDS
Words used in the masculine shall apply to the feminine where applicable, and, wherever the
context of this Agreement dictates, the plural shall be read as the singular and the singular as the plu-
ral. The words "hereof;. "herein," "hereunder" and other similar compounds of the word "here" shall
mean and refer to the entire Agreement and not to any particular Section or provison. All references to
Sections and provisions shall mean and refer to Sections and provisions contained in this Agreement
unless otherwise indicated.
13.2 RECORDS AND INFORMATION
Harris Health shall conduct a review program for the healthcare services it provides hereunder
and for that purpose may examine the records of each Member. Information from medical records of
Members and information received from Physicians or Hospitals incident to the Physician-patient or
Hospital-patient relationship shall be kept confidential. This information, except as reasonably neces-
sary in connection with the administration of this Agreement or as required by law, shall not be dis-
closed without the consent of the Member.
Harris Health shall, to the extent legally allowable and without further consent of or notice to
any Member, release to or obtain from any insurance company or other organization or person any
information, with respect to any person, which Harris Health deems to be necessary for such pur-
poses. Any person claiming benefits shall furnish to Harris Health such information as may be neces-
sary to implement this Agreement.
13.3 INFORMATION FROM GROUP
Group shall periodically forward the information required by Harris Health in conjunction with
the administration of this Agreement. All records of Group which have a bearing on the coverage shall
be open for inspection by Harris Health at any reasonable time. Harris Health shall not be liable for the
fulfillment of any obligation dependent upon such information prior to its receipt in a form satisfactory
to Harris Health. Incorrect information furnished may be corrected, if Harris Health shall not have acted
to its prejudice by relying on it. Harris Health shall have the right, at reasonable times, to examine
22
Group's records, including payroll records of employers having employees covered through Group,
with respect to eligibiliity and monthly premiums under this Agreement.
13.4 ASSIGNMENT
The benefits to a Member under this agreement are specific to the Member and are not
assignable or otherwise transferable.
13.5 AUTHORITY
Any alterations or revisions to this Agreement shall not be valid unless evidenced by a written
amendment which has been signed by Group and by an officer of Harris Health and attached to the
affected document. No other person has the authority to change this Agreement or to waive any of its
provisions.
13.6 GOVERNING LAW
This Agreement is executed and is to be performed in all respects in accordance with all fed-
eral and Texas state laws applicable to Health Maintenance Organizations and all other applicable
Texas state laws or regulations.
13.7 INCORPORATION BY REFERENCE
The Schedule of Benefits, Group Enrollment Agreement, Applications, any optional Riders, any
Attachments, and any amendments to any of the foregoing, form a part of this Agreement as if fully
incorporated herein. Any direct conflict or ambiguity of this Agreement shall be resolved under terms
most favorable to the Member.
13.8 ENTIRE AGREEMENT
This Agreement constitutes the entire understanding between Harris Health and Group.
13.9 INFORMATION TO MEMBER
Upon execution of this Agreement, Harris Health shall provide to each Subscriber a copy of
this Agreement and an Identification Card. Such delivery shall be accomplished by mailing postage
paid, to the latest address furnished to Harris Health or by delivery from a representative of Harris
Health or Group to Subscriber.
13.10 UNIFORM RULES
In the administration of Harris Health, this Agreement shall be applied uniformly to all Members
similarly situated.
13.11 CALCULATION OF TIME
In determining time periods within which an event or action is to take place for purposes of
Harris Health, no fraction of a day shall be considered, and any act, the performance of which would
fall on a Saturday, Sunday, holiday or other non-business day, may be performed on the next following
business day.
13.12 EVIDENCE
Evidence required of any Member of Harris Health may be by certificate, affidavit, document,
or other information which the person acting on it considers pertinent and reliable, and signed, made
or presented by the proper party or parties.
13.13 SEVERABILITY
If any provision of this Agreement shall be held invalid or illegal, the rest of this Agreement shall
remain in full force and effect and shall be construed in accordance with the intentions of the parties
as manifested by all provisions hereof including those which shall have been held invalid and illegal.
Furthermore, in lieu of any provision hereof which is found to be illegal, invalid or unenforceable, there
shall be added hereto a provision as similar in terms to such illegal, invalid or uninforceable provision
as may be possible and be legal, valid and enforceable without materially changing the purpose and
intent of this Agreement.
23
13.14 VENUE
The parties hereby expressly agree that this Agreement is executed and shall be performable
in Tarrant County, Texas, and venue of any disputes, claims, or lawsuits arising hereunder shall be in
the said Tarrant County.
13.15 WAIVER OF NOTICE
Any person entitled to notice under this Agreement may waive the notice.
13.16 HEADINGS
The titles and headings of Sections or provisions are included for convenience of reference
only and are not to be considered in construction of the Sections or provisions hereof.
13.17 NOTICE OF CERTAIN EVENTS
If Group may be materially or adversely affected thereby, Harris Health shall, within a reasona-
ble time, provide written notice to Group of any termination or breach of contract, or inability of any
Participating Provider to provide the services and benefits as described in this Agreement.
13.18 NOTICE OF TERMINATION
All Harris Health notices of termination of this Agreement or of any Member's rights will be in
writing and shall state the cause of termination, with specific reference to the provision(s) of this Agree-
ment giving rise to the right of termination.
13.19 NOTICE
Any notice under this Agreement shall be
postage prepaid, addressed as follows:
Harris Health: 1300 Summit Avenue, Suite 300
Fort Worth, TX 76102
in writing, and shall be given by United States mail,
Group: The address specified on the executed Group Enrollment Agreement or the latest
address provided, in writing, to Harris Health.
Subscriber: The latest address provided by the Subscriber on Application form actually delivered
to Harris Health.
The effective date of notice is two (2) business days after the date of deposit with the United
States Post Office.
24
HARRIS HEALTH SERVICE AREA
The Harris Health Service Area includes six-
en (16) counties and parts of four (4) coun-
es in North Central Texas.
The following
sixteen (16) counties are in-
',uded in the Service Area:
;oscue
Hood
wmmanche
Johnson
Dallas
Limestone
7enton
Parker
?rath
Palo Pinto
areestone
Somervell
Hamilton
Tarrant
--fill
Wise
:n the following four (4) counties. zip codes
are included as specified in the Service Area:
COUNTY ZIP CODES
Coryell
76512
76525
76528
76538
76566
76580
Ellis
76064
76065
Montague
76230
76239
762,51
76270
Navarro
75110
76639
75153
76679
76681
1.
All Saints Cityview Hospital
2.
All Saints Episcopal Hospital
3.
Arlington Memorial Hospital
4.
Campbell Memorial Hospital
5.
Cook-Fort Worth Children's
Medical Center
6.
Decatur Community Hospital
7.
Denton Community Hospital
8.
Harris Methodist Erath County
9.
Harris Methodist Fort Worth
10.
Harris Methodist Glen Rose
11. Harris Methodist II-E-B
12. Harris Methodist HEB-Springwood
13. Harris Methodist Northwest
14. Harris Methodist Southwest
15. Hood General Hospital
16. Huguley Memorial Medical Center
17. Medical Plaza Hospital
18. Osteopathic Medical Center of Texas
19. Parkview Regional Hospital
20. St. Joseph Hospital
21. Walls Regional Hospital
SCHEDULE OF BENEFITS
PREFERRED PLAN
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
1-800/633-8598
(817) 878-5826
PREF-592
Each Subscriber and his Dependent Members are entitled to receive the services and benefits set
forth in this Schedule of Benefits which are Medically Necessary and obtained in accordance with the
provisions of the Group Health Care Agreement/Subscriber Certificate of Coverage.
A. Upon enrollment, each Member shall choose (or the Subscriber shall choose on behalf of his
Dependents) a Primary Care Physician, If the Member fails to choose a Primary Care Physi-
cian, Harris Health shall assign a Primary Care Physician for the Member. The names and ad-
dresses of the Primary Care Physician from which the Member may choose shall be provided
to each Subscriber upon enrollment. Services are provided or coverage arrangements are avail-
able twenty-four (24) hours per day, seven (7) days a week by calling the telephone number
provided for the Primary Care Physician.
B. A Member may change their Primary Care Physician by contacting the Harris Health Member
Services Department at the address or telephone number specified above. The change will be-
come effective on the first day of the month following the request.
C. All health care services, except those resulting from a Medical Emergency, are to be per-
formed, prescribed, arranged, directed or authorized by the Primary Care Physician selected by
the Member. When care by a Specialist Physician is necessary, the Primary Care Physician
shall coordinate the referral to a Participating Specialist Physician. No referral is necessary for
a female member to obtain obstetrical/gynecological services from a Harris Health participating
OB/Gyn Specialist. If a required specialty is not represented in Harris Health, a referral may be
made to a Non-Participating Provider. All such non-emergency referrals must be authorized by
the Harris Health before services are obtained. Any Member may obtain additional information
as to how medical services are obtained by contacting the Harris Health at the address speci-
fied above.
D. Except in cases of a Medical Emergency, or as a result of special prior approval by Harris
Health as specified above, only those services provided by a Participating Provider shall be
covered under this Schedule of Benefits.
E. All services and benefits are subject to any stated Copayment amounts, limitations, and exclu-
sions described in this Schedule of Benefits.
F. Any copayment expressed as a percentage of "Total Charges" shall mean the stated percent-
age of the medical provider's preferred rate which is the amount paid to the medical provider
by Harris Health.
G. This Schedule of Benefits may be supplemented by additional benefit Riders if included with
this Group Health Care Agreement/Subscriber Certificate of Coverage.
The relationship between Harris Health and Participating Providers is that of independent con-
tracting entities. Participating Providers are not agents or employees of Harris Health nor is
Harris Health an employee or agent of any Participating Provider. Participating Providers shall
maintain the physician-patient or professional-patient relationship with Members and shall be
the only parties responsible to Members for the services provided. Neither Harris Health nor
any employee of Harris Health shall be deemed to be engaged in the practice of medicine. Har-
ris Health shall in no way supervise the practice of medicine by any Participating Provider, nor
shall Harris Health in any manner supervise, regulate or interfere with the usual professional
relationships between a Participating Provider and a Member.
PREF-592
Only one Copayment will be required for covered services performed or furnished on same date of
service by the same Provider. This Copayment will be the higher of all listed Copayments.
Benefits
Required Copayment
Physician office visits, adult health assessments, routine
$15.OONisit-Primary Care
physical examinations, well child care, and health education
and treatment of illness or injury provided
i
s, care
for diagnos
by Primary Care Physician
Physician office visits from Specialist Physician
$20.OONisit-Specialist
Annual well woman examination
$15.OONisit-Primary Care
$20.OONisit-Specialist
Physician office visits after hours
$25.OONisit
Immunizations and injections
No Copayment
Home visits
$15.OONisit
Hearing, vision, and speech screening provided by Primary
$15.OONisit
Care Physician to determine the need for correction
Allergy diagnosis and/or testing; serum is not covered
$50.OONisit
Administered drugs, medications, dressings, splints, and
$20.OONisit-Primaa fst are
casts
Diagnostic services, laboratory tests, and x-rays
No Copayment
Ultrasound, MRI, CAT, and non-routine laboratory tests
$50.0011-est
Surgery and/or anesthesia performed in the physician's office
$50.00/Procedure (Phys.)
or outpatient setting
All physician fees including anesthesia while a member is
20% of Total Charges
hospitalized, except professional radiology and pathology fees
Professional radiology and pathology fees
No Copayment
Physician fee in an emergency room or urgent care center
20% of Total Charges
2
PREF-592
For maternity services within the Service Area, Member shall be entitled to receive medical, surgical,
and hospital care from Participating Physicians and other Providers during the term of the pregnancy,
upon delivery, and during the postpartum period for normal delivery; for abortion and miscarriages;
and for complications of pregnancy. Charges related to medical services connected with the home
delivery of a newborn and services of mid-wives, unless provided as Emergency Care Services, will
not be covered. Any normal delivery which occurs outside the Service Area within thirty (30) days of
the expected date of confinement as specified by a Participating Physician, will not qualify for
Emergency Care Services benefits, and will not be a covered benefit. Benefits for the child of an
unmarried Dependent Member will be provided if the child is considered to be a dependent of the
Subscriber for Federal income tax purposes, and upon payment of the applicable premium.
Benefits Required Copayment
Physician services for maternity care including delivery, 20% of Total Charges
hospital visits, and anesthesia
Physician care in the hospital for care of Eligible Newborn 20% of Total Charges
Member shall be entitled to receive Medically Necessary hospital services, subject to all definitions,
terms and conditions of this Agreement and Schedule of Benefits when performed, prescribed,
arranged for, directed or authorized by Participating Physicians and received at Participating
Hospitals. Members electing to remain in the hospital beyond the period which is Medically Necessary
will be responsible for direct payment to the hospital for any such time beyond the discharge time
authorized by the Participating Physician and/or the Harris Health Medical Director or his designee.
Benefits Required Copayment
INPATIENT HOSPITAL SERVICES: 20% of Total Charges
Semi-private room, private if Medically Necessary, and
all services and medical supplies related to inpatient
treatment.
OUTPATIENT HOSPITAL SERVICES (Including Ambulatory Facilities)
Surgery $100.00/Procedure (Facility)
Therapeutic radiation treatment 20% of Total Charges
Inhalation therapy 20% of Total Charges
Diagnostic testing, laboratory, and x-rays No Copayment
Ultrasound, MRI, CAT, and non-routine laboratory tests $50.00/Test
PREF-592
In cases of a Medical Emergency, Member is entitled to the benefits and services set forth in this
Schedule of Benefits and in this Agreement even if the services are not received from Participating
Providers. Member is entitled to receive these 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.
All treatment for such services will be reviewed retrospectively by the Harris Health Medical Director
or his designee to determine whether an acute condition or situation indicated immediate emergency
care to be appropriate. If upon review, the Harris Health Medical Director or his designee determines
that no need for emergency care existed, the Member will be responsible for payment of all charges
incurred for such care.
WITHIN THE SERVICE AREA Emergency Care Services must be obtained or authorized through the
Primary Care Physician who provides the Member with twenty-four (24) hours a day, seven (7) days
a week access to call coverage to assist the Member in obtaining Emergency Care Services. At the
time of a Medical Emergency, the Member or someone acting on behalf of the Member, shall make
every reasonable effort to contact the Member's Primary Care Physician for advice. If it is not
reasonably possible to contact the Primary Care Physician at the time (such as that of a life or limb
threatening emergency), the Member shall seek care from a Participating Hospital or Participating
Emergency Center.
At the time of a Medical Emergency which results in a hospital admission, the Member or someone
acting on behalf of the Member, shall notify Harris Health within twenty-four (24) hours or as soon as
reasonably possible. Upon notification, the Harris Health Medical Director or his designee may
coordinate transfer of the Member to the care of their Primary Care Physician or other designated
provider when medically prudent to do so.
Benefits (Within Service Area) Required Copayment
Physician office visits $15.00Nisit-Primary Care
$20.00Nisit-Specialist
Physician office visits after hours $25.OONisit
Hospital emergency room and urgent care center services, 20% of Total Charges
including physician fees
Follow-up care is covered from Primary Care Physician only, $15.OONisit-Primary Care
or upon referral from the Primary Care Physician $20.00Nisit-Specialist
PREF-592
OUTSIDE THE SERVICE AREA coverage for Emergency Care Services while outside the Service Area
are available provided that such Emergency Care Services cannot be reasonably delayed without risk
to Member until the Member is able to return to the Service Area to obtain treatment from
Participating Providers.
At the time of a Medical Emergency which results in a hospital admission, the Member or someone
acting on behalf of the Member, shall notify Harris Health within twenty-four (24) hours or as soon as
reasonably possible. Upon notification, the Harris Health Medical Director or his designee may
coordinate any transfer of management and control of the care to a Participating Provider or other
designated provider in the Service Area as soon as medically prudent to do so.
Continuing or follow-up treatment shall be provided within the Service Area. No claim for out-of-area
emergency services shall be allowed when procedures in this section are not complied with by the
Member.
Benefits (Outside the Service Area) Required Copayment
Physician office visits for stabilization and emergency care $15.00Nisit-Primary Care
services only $20.OONisit-Specialist
Physician office visits after hours $25.00Nisit
Hospital emergency room and urgent care center services for 20% of Total Charges
stabilization only, including physician fees
Follow-up care is covered from Primary Care Physician only, $15.OONisit-Primary Care
or upon referral from the Primary Care Physician $20.00Nisit-Specialist
Family Planning Services will be available to Members on a voluntary basis. Covered services are
limited to the use of Participating Providers and will include history, physical examination, related
laboratory tests; medical supervision in accordance with generally accepted medical practice;
information and counseling on contraception, including advice or prescription for a contraceptive
method; education, including education on the prevention of venereal disease; and voluntary
sterilization after appropriate counseling.
Benefits
Required Copayment
Physician office visits, including related testing, education and
counseling
$15.OONisit-Primary Care
$20.00/Visit-Specialist
Fitting and dispensing of IUD and diaphragms
$15.OONisit-Primary Care
$20.00Nisit-Specialist
Tubal ligation
$50.00/Procedure (Phys.)
Vasectomy
$50.00/Procedure (Phys.)
PREF-592
Infertility services will be available to Members on a voluntary basis.
Artificial insemination and
diagnostic services to determine the cause of infertility will be provided
from Participating Providers
and Participating Facilities. Excluded from services to treat infertility are those services described in
"Exclusions," Section XIX, Number 23 of this Schedule of Benefits.
Benefits
Required Copayment
Physician office visits for diagnosis, non-psychiatric
$15.00Nisit-Primary Care
counseling, artificial insemination, and sperm count
$20.OONisit-Specialist
Administration of infertility medications; infertility
$15.OONisit-Primary Care
medications not covered
$20.OONisit-Specialist
Endometrial biopsy, hysterosalpingography and diagnostic
20% of Total Charges
laparoscopy
Sonogram and/or ovulation kit $50.00/Test or Kit
Member shall be entitled to all necessary care and treatment for chemical dependency on the same
basis as that provided for any physical illness to a lifetime maximum of three (3) separate series of
treatments for the member. Diagnosis and treatment for chemical dependency shall include
detoxification and/or rehabilitation on either an inpatient or outpatient basis as determined to be
Medically Necessary by Participating Physicians. All treatment is subject to the same limitations,
exclusions, and copayments as applied to covered services of any other physical illness.
A series of treatments is considered to be a planned, structured, and organized program to promote
chemical free status which may include different facilities or modalities and is complete when:
The member is discharged on medical advice from inpatient detoxification, inpatient
rehabilitation treatment, partial hospitalization or intensive outpatient; or
The member has received a series of these levels of treatments without a lapse in treatment; or
The member fails to materially comply with the treatment program for a period of thirty (30)
days.
Benefits
Office visits
Necessary care and treatment for detoxification and/or
rehabilitation from chemical dependency
Intensive outpatient or partial hospitalization
Required Copayment
$15.OONisit-Primary Care
$20.OONisit-Specialist
$15.OONisit-Primary Care
$20.OONisit-Specialist
20% Total Inpatient Charges
20% Total Inpatient Charges
PREF-592
OUTPATIENT MENTAL HEALTH SERVICES:
Member shall be entitled to receive up to twenty (20) office visits per Calendar Year for evaluation,
crisis intervention and stabilization, and for outpatient therapy in support of the evaluation or crisis
intervention. Member must be referred by the Primary Care Physician or by the Harris Health
designee to Participating Specialist. Services must represent treatment for conditions which in the
judgment of Participating Providers can substantially benefit from short-term treatment. The twenty
(20) visits maximum may include individual treatment, couple, or family visits.
Benefits Required Copayment
Outpatient office visits for crisis intervention and treatment $20.OONisit
Psychological testing 20% of Total Charges
INPATIENT MENTAL HEALTH SERVICES:
When determined to be Medically Necessary by Participating Physician or by the Harris Health
designee, the Member shall be entitled to evaluation, crisis intervention, treatment or any
combination thereof for acute conditions at a Participating Facility. Services must represent treatment
for conditions which in the judgment of Participating Providers can substantially benefit from
treatment, and requires inpatient treatment.
Only treatment at the most appropriate level of care as determined by Participating Providers or by
the Harris Health designee will be authorized by Harris Health.
Chronic mental health conditions and long-term treatment are not covered.
Benefits
Inpatient hospitalization for up to thirty (30) inpatient days per
Calendar Year.
Psychiatric Day Treatment Facility, Crisis Stabilization Unit or
Residential Treatment Center for Children and Adolescents for
up to sixty (60) days per Calendar Year. Treatment in such
facilities will be limited to sixty (60) days of care such that one
(1) day of care shall be equal to one-half (1/2) day of inpatient
care.
Required Copayment
20% of Total Charges
20% of Total Charges
PREF-592
Member shall be entitled to receive short-term physical or occupational therapy rehabilitation services
from a Participating Provider for conditions which in the judgment of Participating Physicians are
Medically Necessary, subject to significant improvement through short-term treatment, and
authorized by Harris Health before services are obtained. Short-term treatment is defined as up to
sixty (60) consecutive days or twenty-five (25) visits per condition, whichever is greater, and shall be
provided on an outpatient basis only. Short-term rehabilitation services on an inpatient basis or in a
skilled nursing facility will be authorized only if other non-rehabilitation medical services are required
by the Member.
Occupational therapy shall mean those services designed to prevent dysfunction, restore functional
ability and facilitate maximal adaptation to impairment.
Benefits
Hospital, home health agency, or other provider for restorative
treatment subject to short-term clinical improvement, and
limited to sixty (60) consecutive days or twenty-five (25) visits
per condition, whichever is greater. Long-term or maintenance
services are not covered.
Required Copayment
$15.OONisit-Primary Care
$20.OONisit-Specialist
20% Total Inpatient Charges
Member shall be entitled to services and benefits provided within the Service Area for kidney dialysis
upon prior authorization from Harris Health and by referral to Participating Providers, only if
Participating Physician determines that such service represents the preferred method of treatment,
and the Member satisfies criteria for the service involved. Coverage will be coordinated for any
Member eligible for available coverage under the Medicare provisions for End Stage Renal Disease.
Benefits
Inpatient or outpatient hospital, or outpatient kidney dialysis
center
Home dialysis (continuous ambulatory peritoneal dialysis)
including equipment, training, solutions, coils, drug and
surgical supplies
Benefits
Member shall be entitled to both land and air ambulance
services for Medically Necessary Emergency Care Services
Required Copayment
$20.00Nisit-Outpatient
20% Total Inpatient Charges
$20.OONisit
Required Copayment
20% of Total Charges
PREF-592
Member shall be entitled to receive home health care services from a Participating Provider according
to a treatment Plan approved by the Participating Physician, and with prior authorization from Harris
Health. Treatment will be provided only for those medical conditions subject to clinical improvement
through short-term treatment; for recovery or rehabilitation of illness or injury; or for treatment of
terminal illness.
Benefits Required Copayment
Skilled nursing care; physical, occupational; or respiratory $15.OONisit
therapy; intravenous solutions; and home health aid services
Hospice (home health service only) $15.OONisit
Member is entitled to receive services in a Participating Skilled Nursing Facility for medical conditions
which in the judgment of a Participating Physician is subject to significant clinical improvement and
which require services which can only be provided at that level of care. Services in a Skilled Nursing
Facility may be provided in lieu of hospitalization (either in lieu of admission or upon discharge from
inpatient care) as Medically Necessary based on acuity of services and patient condition, are limited
to sixty (60) days per Calendar Year, and include Participating Physician services only.
Benefits Required Copayment
Room, board, medications and supplies while confined in a 20% of Total Charges
Skilled Nursing Facility as part of a short-term recovery or
rehabilitation program
Participating physician visits while confined to Skilled Nursing 20% of Total Charges
Facility
Member shall be entitled to prosthetic medical services or medical appliances if Medically Necessary,
with authorization from Harris Health, and received from Participating Providers. While the Member is
covered under this Agreement, initial prostheses are provided when required due to illness or injury.
Replacement is provided only when marked physical changes occur which require replacement, and is
not provided for items which wear out due to normal usage.
Benefits Required Copayment
Internal prosthetic appliances including internal cardiac 20% of Total Charges
pacemakers, and minor devices such as screws, wire mesh,
nails, and artificial joints. Supply of or replacement of internal
breast prothesis covered only if initial surgery was result of
injury or disease.
PREF-592
Benefits Required Copayment
External prosthetic appliances including artificial arms, legs, 20% of Total Charges
above or below knee or elbow prostheses; eyes, lenses,
external cardiac pacemaker; terminal devices such as hand or
hook; rigid or semirigid immobilizing devices such as arm,
leg, neck or back braces; and ordinary splints, and crutches
Member shall be entitled to benefits received from a Participating Provider for certain durable medical
equipment, as ordered by a Participating Physician, and with prior authorization from Harris Health.
Durable medical equipment must be able to withstand repeated use, primarily and customarily serve a
medical purpose, generally not be useful in the absence of illness or injury, require a Participating
may rent or
Phsician's order, and be purchase approved equipment. Harrise Hfor ealth sretains the right of possession of equipment.
Harris Health shall have no liability or responsibility for repair or replacement of equipment lost or
damaged. Equipment not considered durable medical equipment is described in ''Exclusions'',
Section XIX, Number 31 of this Schedule of Benefits.
Benefits
Rental or purchase of medical equipment
Required Copayment
20% of Total Charges
The Member shall be entitled to services for the initial stabilization of acute accidental, non-
occupational injury, to sound natural teeth with prior authorization by Harris Health, when provided
within thirty (30) days of the accident on an outpatient basis only.
While Member is covered under this Agreement coverage is limited to treatment of fractured or
dislocated jaw, or to repair damage to sound natural teeth. Limitations and exclusions for dental
services are described in Section XVIII, Number 3 and Section XIX, Number 17 of this Schedule of
Benefits. Copayments will be the same as described for other illness or injury services.
The maximum annual Copayments for covered benefits, under this Schedule of Benefits, shall not
exceed the following in a Calendar Year as described in Section 5.3, of the Group Health Care
Agreement/Subscriber Certificate of Coverage.
Benefits Maximum Annual Copayments
Per Member $2,000.00
P
Per Family $4,000.00
P
10
PREF-592
The following services are limited as described below:
1. Any service, supply, or treatment which is not provided, ordered, performed, prescribed,
directed, referred, arranged, authorized or approved by the Member's Primary Care Physician,
or the Harris Health Medical Director or his designee, will not be covered; except for
Emergency Care Services as described in this Schedule of Benefits.
2. Services by physicians, facilities or other providers, who are not Participating Providers, will
not be covered; except for Emergency Care Services as described in this Schedule of Benefits,
or those services authorized in advance in writing by the Harris Health Medical Director or his
designee.
3. Care and treatment of the teeth or gums, except for oral surgery for tumors or injuries to the
jaw bone or surrounding tissue, is limited to the initial stabilization of acute, accidental non
occupational injury to sound, natural teeth when provided within thirty (30) days of the
accident on an outpatient basis only.
4. Coverage for vision examinations is limited to conditions which require examination to
diagnose injury or illness, unless covered by Rider attached to this Agreement.
5. The benefit for durable medical equipment is limited to either the total rental cost or the
purchase price of such equipment, whichever is less, as determined and authorized in advance
by the Harris Health Medical Director or his designee. Harris Health shall have no liability or
responsibility for repair or replacement of equipment lost or damaged.
6. Care and treatment provided in non-participating hospital owned or operated by federal, state,
county or city government is limited to the care for the condition which the law requires to be
treated or provided in a public facility.
7. The purchase or fitting of eye glasses or contact lens or advice on their care is limited to the
initial set of eye glasses, contact lens, or lens implant required following cataract surgery,
repair of congenital defect or as required by an accidental injury to the Member.
8. Coverage for reconstructive surgery is limited to surgery necessary to repair a functional
disorder resulting from disease, injury, or congenital defect. Supply or replacement of internal
breast prothesis is covered only if initial surgery was a result of injury or disease.
9. Any normal delivery for the Member which occurs outside the Service Area, and is within thirty
(30) days of the expected date of confinement, as specified by a Participating Physician, will
not qualify as Emergency Care Services benefits described in this Schedule of Benefits.
10. Benefits for Dependents who are students temporarily residing outside the Service Area, are
limited to Emergency Care Services only outside the Service Area. The Dependent must return
to the Service Area for all other services.
11. Coverage for treatment of the tempo romandibular (jaw or craniomandibular) joint is limited to
Medically Necessary diagnostic services and/or surgical treatment as determined to be
Medically Necessary by the Harris Health Medical Director or his designee. All services must
be provided by a Participating Provider. Charges related to dental services for this condition
are not covered.
PREF-592 11
12. If Medically Necessary and authorized by the Harris Health Medical Director or designee, Harris
Health will cover kidney transplants, corneal transplants, liver transplants for children with
congenital biliary atresia, and bone marrow transplants for Aplastic Anemia; Leukemia;
Lymphoma; Severe Combined Immunodeficiency Disease; or Wiskott-Aldrich Syndrome where
traditional modalities of traditional medical therapy have been exhausted. Medical costs for
organ procurement associated with the removal of an organ for a covered transplant when the
recipient is a Member are limited to a maximum benefit of $10,000. Charges related to organ,
tissue, or artificial organ transplants except as otherwise specified in this section are excluded.
The donor's transportation costs are not covered. Services provided to any Member for the
donation of any organ or element of the body are not covered.
13. Benefits for the
and upon
considered to be ~afdependentoof the Subscriber DforeFederalvinlcome provided Ipu poses, the
payment of the applicable premium.
PREF-592
12
The following services and supplies, and the cost thereof, are excluded from coverage under this
Agreement, unless specifically added by Rider to this Schedule of Benefits.
1. Charges related to any service or treatment which a Member would not be legally required to
pay in the absence of this Agreement.
2. Charges related to personal, convenience, or comfort items such as personal kits provided on
admission to a hospital, television, telephone, newborn infant photographs, guest meals, birth
announcements, and other related articles which are not for the specific treatment of illness or
injury.
3. Charges related to transportation, except charges related to land and air ambulance services
for Medically Necessary Emergency Care Services described in Section XI of this Agreement.
4. Charges related to private hospital room and/or private duty nursing.
5. Charges related to services rendered by a person who resides in a Member's home, or by an
immediate relative of the Member.
6. Charges related to services for military or service connected conditions for which the Member
is legally entitled, and for which appropriate facilities are reasonably available to the Member.
7. Charges related to occupational injury or illness or conditions covered under Worker's
Compensation.
8. Charges related to homemaker, chore or similar services; and health care services primarily for
rest, custodial, respite, domiciliary, or convalescent care.
9. Charges related to reports, evaluations, or physical examinations not required for health
reasons (not Medically Necessary). Excluded items are: reports for employment, insurance,
camp, adoption, travel, or government licenses.
10. Charges related to drugs or medicines, prescription or non-prescription, provided to the
Member while he or she is not an inpatient, unless added by Rider to this Schedule of
Benefits.
11. Charges related to experimental drugs or substances not approved by the FDA for other than
FDA approved indications; and drugs labeled "Caution - limited by Federal Law to
investigational use."
12. Charges related to formulas, dietary supplements, or special diets provided to the Member on
an outpatient basis.
13. Charges related to vision care. Excluded services are: examination for eye glasses; refraction,
dispensing, or fitting of eye glass frames and lenses; all types of contact lens; eye exercise and
visual training; and orthoptics; except as otherwise specified in Section XVIII, Number 4 of this
Schedule of Benefits.
14. Charges related to radial keratotomy or other radial keratoplasties, and all costs associated
with such surgery.
PREF-592
13
15. Charges related to hearing aids, batteries, and examinations for fitting thereof unless added by
Rider to this Schedule of Benefits.
16. Charges related to the care and treatment of the feet unless such services are Medically
Necessary. Exclusions include routine foot care, such as removal of corns, calluses, or the
trimming of nails; treatment for flat feet; orthotics; arch supports; or custom fitted braces and
splints.
17. Charges related to dental care, except as otherwise specified in Section XVI of this Schedule of
Benefits, including services related to the care, fillings, removal, or replacement of teeth;
treatment of diseases of the teeth or gums; extraction of wisdom teeth; malocclusion or
malposition of the teeth and jaws (mandibular hyperplasia/hypoplasia); professional services or
anesthesia related to or required for the sole purpose to provide dental care; hospital care;
inpatient or outpatient surgery required for any dental care; prescription drugs for dental
treatment; dental x-rays; dentures; and dental appliances or prostheses.
18. Charges related to surgical procedures and other treatment associated with the treatment of
obesity, regardless of associated medical or psychological conditions, including treatment of a
complication of surgical treatment for obesity. Excluded procedures are: intestinal or stomach
bypass surgery, gastric stapling, wiring of the jaw, insertion of gastric balloons, or similar
procedures.
19. Charges related to transsexual surgery, including medical or psychological counseling or
hormonal therapy, in preparation for or subsequent to any such surgery.
20. Charges related to services for cosmetic surgery or reconstructive surgery, except as
otherwise specified as covered in this Schedule of Benefits. Cosmetic surgery exclusions are:
rhinoplasty; scar revisions; prosthetic penile implants; surgical revision or reformation of any
sagging skin on any part of the body, described as relating to the eye lids, face, neck,
abdomen, arms, legs or buttocks; liposuction procedures; any services performed in
connection with the enlargement, reduction, implantation or appearance of a portion of the
body described as the breast, face, lips, jaw, chin, nose, ears, or genitals; hair transplantation;
chemical face peels or abrasions of the skin; removal of tatoos; and electrolysis depilation.
Supply or replacement of internal breast prothesis is covered only if initial surgery was a result
of injury or disease.
21. Charges related to reduction mammoplasty, unless determined to be Medically Necessary by
the Harris Health Medical Director or his designee.
22. Charges related to reversal of surgically performed sterilization or subsequent resterilization.
23. Charges related to surrogate parenting; in-vitro fertilization; GIFT procedures; and any costs
associated with the collection or storage of sperm for artificial insemination including donor
fees; and infertility medications unless added by Rider to this Schedule of Benefits.
24. Charges related to amniocentesis, ultrasound, or any other procedure performed solely for sex
determination of the fetus.
25. Charges related to medical and hospital care for an infant of an unmarried Dependent Member,
unless the infant is considered to be a dependent of the Subscriber for Federal income tax
purposes, and applicable premium payment has been made.
26. Charges related to mental health services for psychiatric conditions which are determined by
the Harris Health Medical Director or his designee, to be chronic or organic in nature, and
which will not substantially benefit from short-term evaluation, crisis intervention and
stabilization, or short-term treatment.
PREF-592 14
27. Charges related to court ordered testing, and special reports not directly related to medical
treatment.
28. Charges related to services for the treatment of mental retardation and mental deficiency.
29. Charges related to employment, vocational, or marriage counseling; behavioral training;
remedial education, including evaluation and treatment of learning and developmental
disabilities and minimal brain dysfunction; or attention deficit therapy.
30. Charges related to services for chronic intractable pain provided by a pain control center;
acupuncture, naturopathy, and hypnotherapy; holistic or homeopathic care, including drugs;
and ecological or environmental medicine.
31. Charges related to durable medical equipment, unless described in this Schedule of Benefits.
Excluded items are: (a) equipment, such as motor driven wheel chairs and beds, possessing
features of an aesthetic nature or features of a medical nature which are not required by the
patient's condition; (b) items not primarily medical in nature or for the patient's comfort and
convenience, such as bed boards, bathtub lifts, over-bed tables, adjust-a-bed, and telephone
arms; (c) physician's equipment such as stethoscope and sphygmomanometer; (d) exercise
equipment such as exercycles and enrollment in health or athletic clubs; (e) self-help devices
not primarily medical in nature, such as sauna or whirlpool baths, chairs, and elevators; (f)
corrective orthopedic shoes and arch supports; (g) supplies or equipment for common
household use, such as but not limited to, air purifiers, central or unit air conditioners, water
purifiers, allergenic pillows or mattresses, and water beds; and (h) research equipment or
items deemed to be experimental as determined by the Harris Health. Harris Health shall have
no liability or responsibility for repair or replacement of equipment lost or damaged.
32. Charges related to prosthetic medical appliances, except as specified in Section XIV of this
Schedule of Benefits. Excluded items include: (a) dentures, hearing aids unless provided by
Rider, and contact lens; (b) medical supplies such as elastic stockings, garter belts, arch
supports, corsets, and corrective orthopedic shoes; (c) research devices or items deemed to
be experimental as determined by Harris Health; and (d) replacement, repair, and routine
maintenance of covered appliances or braces unless surgically implanted, or replacement
required due to a marked change in physical growth or physical requirements.
33. Charges related to medical supplies, aids, and appliances except as otherwise specified as
covered in this Schedule of Benefits. Excluded items are: consumables, disposable supplies,
sheaths, bags, gloves, cervical collars, elastic stockings, stethoscopes, blood pressure units,
traction apparatus, slings, TENS or electrical nerve stimulation devices, wigs or hair pieces,
dressings, testing supplies, syringes, home testing kits, disposable diapers or incontinent
supplies, and over-the-counter medications.
34. Charges related to inpatient or outpatient long-term neuromuscular, or occupational therapy
services or other rehabilitation services in excess of sixty (60) days per condition or twenty-
five (25) outpatient visits, whichever is greater.
35. Charges related to recreational or educational therapy, and any related diagnostic testing,
except as provided by the hospital as part of an approved inpatient hospitalization.
36. Charges related to structural changes to a house or vehicle.
37. Charges related to any medical, surgical, or health care procedure or treatment held to be
experimental or investigational at the time the procedure or treatment is performed. Harris
Health will utilize findings and assessments of national medical associations, professional
societies and organizations, and any appropriate technological body established by any state or
federal government or similar entities to determine coverage and/or effectiveness.
PREF-592 15
PRESCRIPTION DRUG RIDER
FORIUSE ONLY WITH GROUP HEALTH CARE AGREEMENT/SUBSCRIBER
CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance organization
1300 mmit Avenue, Suite 300
FSuort Worth, Texas 76102
800/633-8598
1.0 INTRODUCT
In consideration for the timely payment of premiums, and all other terms
and conditions of the Group Health Care Agreement/Subscriber Certificate
of Coverage ("Agreement"), it is agreed that the benefits of this Rider,
togetherjwith the terms and conditions of this Rider, shall be added to
Agreement as issued if this Rider is accepted by the Group.
2.0 DEFINITIONS
Benefits'i for outpatient prescription drugs provided through this Rider
shall bei subject to the provisions and definitions of Agreement to which
this Rider is a part.
Prescription Drugs shall mean only those drugs and medicines which are
prescribed by a Participating Physician, and legally require the written
prescription of a Physician before they can be obtained by the Member.
Heritable disease shall mean an inherited disease that may result in
mental or physical retardation or death.
Phenylketonuria (PKU) shall mean an inherited condition that may cause
severe mental retardation if not treated.
3.0 BENEFITS
For the purpose of this Rider, benefits for covered outpatient
prescription drugs shall include only those drugs and medicines which are
written', by Participating Physician, and obtained from a Participating
fllal III... I..
Benefit limitations and Member cost shall be as follows:
o $10.00 per new prescription or refill for each thirty-four (34) day
supply or fraction thereof.
0 $240.00 per Norplant device.
1
PDMIO-892
6.0 EXCLUSIONS (Continued)
o Drugs not requiring a prescription (OTC, Vitamins, Cough Syrup,
etc.), except PKU and other heritable diseases supplements
o Drugs to be consumed in an inpatient or other institutional care
setting
o Drugs requiring parenteral use or subcutaneous use
o Charges for cost difference in a brand name product when generic
drugs are prescribed or permitted by physician
0 Nutritional or dietary supplement, or formulas other than
prescription required vitamins
o Prescription written by nonparticipating physicians
o Medications dispensed by physician offices
o Prescriptions Drugs for cosmetic conditions not covered in the
Schedule of Benefits (such as Retin-A, Minoxidil, etc.)
PDMIO-892
4
SERIOUS MENTALIIEALTII RIDER
FOR USE ONLY WITH GROUP HEALTH CARE AGREEMENT/SUBSCRIBER
CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Ave, Suite 300
Fort Worth, Texas 76102
800/633-8598
1.0 INTRODUCTION
In consideration for the timely payment of premiums, and all other terms and conditions of the Group
Health Care Agreement/Subscriber Certificate of Coverage ("Agreement") , it is agreed that the
benefits of this Rider, together with the terms and conditions of this Rider, shall be added to
Agreement as issued if this Rider is accepted by the Group.
2.0 DEFINITIONS
Benefits for Serious Mental Health provided through this Rider shall be subject to the provisions and
definitions of the Agreement to which this Rider is a part.
Serious Mental Illness shall mean the following psychiatric illnesses as defined by the American
Psychiatric Association in the Diagnostic and Statistical Manual (DSM) III-R:
1. Schizophrenia;
2. Paranoid and other psychotic disorders;
3. Bipolar disorders (mixed, manic, and depressive);
4. Major depressive disorders (single episode or recurrent); and
5. Schizo-affective disorders (bipolar or depressive).
3.0 BENEFITS
For the purpose of this Rider, benefits for Serious Mental Illness care shall include only those
services obtained from Participating Providers.
Copayment by Member:
Mental health services provided for Serious Mental Illness shall be provided
subject to the same limitations, exclusions, and copayments as applied to
covered services of any other physical illness.
SMI-292
4.0 ELIGIBILTTY
Benefits under this Rider are available to the Subscriber and Dependents (Members) as identified in
Agreement.
Benefits provide no conversion privileges or benefit continuity for Members when such persons are
no longer entitled to Group benefits as set forth in Agreement to which this Rider is attached.
5.0 EXCLUSIONS
Charges related to mental health services for psychiatric conditions determined by the Harris
Medical Director or his designee, as not qualifying for coverage under this Rider will be
subject to the same limitations, exclusions, and copayments as applied to mental health
services listed in the Schedule of Benefits of which this Rider is a part.
Services must be obtained in accordance with Harris Health utilization review
guidelines.
2
SMI-292
SERIOUS MENTAL HEALTH RIDER
FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
ACCEPTED:
Group
By:
Audic
Date:
REJECTED:
Group
By:
Authorized Representative
HARRIS HEALTH PLAN, INC.
By:
Senior Vic President, Managed Care Marketing
1300 Sununit Avenue, Suite 200
Fort Worth, TX 76102
(817) 878-5830
Date: t i 4 (7 .
Date:
IN-VITRO FERTILIZATION RIDER
FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
800/633-8598
1.0
In consideration for the timely paymentof premiums, and all other terms and conditions of the Group
Healthcare Agreement/Subscriber Certificate of Coverage ("Agreement"), it is agreed that the benefits
of this Rider, together with the terms and conditions of this Rider, shall be added to Agreement as
issued if this Rider is accepted by the Group.
2.0 BENEFITS
For the purpose of this Rider, outpatient expenses arising from in-vitro fertilization procedures for
the Subscriber or the Subscriber's spouse, the following conditions shall apply:
The fertilization or attempt at fertilization of the Member's oocytes is made only with
Member's spouse's sperm.
The Member and the Member's spouse have a history of infertility of at least five
continuous years duration; or the infertility is associated with one or more of the
following medical conditions:
a. endometriosis;
b. exposure in utero to diethylstilbestrol (DES);
c. blockage of, or surgical removal of, one or both fallopian tubes (non-voluntary); or
d. oligospermia.
The Member has been unable to attain a successful pregnancy through any less costly
applicable infertility treatments for which benefits are available under the Plan.
The in-vitro fertilization procedures are performed at a medical facility that conforms
to the American College of Obstetric and Gynecology guidelines for in-vitro fertilization
clinics or to the American Fertility Society minimal standards for programs of in-vitro
fertilization.
Benefits for in-vitro fertilization procedures shall be provided to the same extent as
the benefits for other pregnancy-related procedures under the Plan.
NP188
3.0 ELIGIBILITY
Benefits under this Rider are available to the Subscriber and the Subscriber's spouse. Benefits
provide no conversion privileges or benefit continuity for Members when such persons are no
longer entitled to Group benefits as set forth in Agreement to which this Rider is issued.
4.0 LIMITATIONS
Benefits shall be provided only if recommended by a Harris Health Primary or Harris Health
Specialty Physician and have received prior written approval from the Harris Medical Director of his
designee.
IVFl88 2
IN-VITRO FERTILIZATION RIDER
FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
By: L i >2x~
Senior Vice resident, Managed Care Marketing
1300 Summit Avenue, Suite 200
Fort Worth, TX 76102
(817) 878-5830 z
Date: I I a' /
REJECTED:
C6&
Group V// 4/ 1 A
By:
Date:
Harris Methodist
Health Insurance
Preferred Plus
Non-network
HARRIS METHODIST HEALTH INSURANCE COMPANY
GROUP ENROLLMENT APPLICATION
The Harris Methodist Health Insurance Company, and City of Denton (Group), agree to be bound by the provisions for health
care service in accordance with this Group Enrollment Application, the Coverage Agreement, the Listing of Benefits, and any
amendments and riders. Coverage will be for eligible members of Group and their Dependents who enroll in Harris Methodist
Health Insurance Company. Eligible members of the Group are those persons who are exempt employees and work at least
(30) hours per week and who comply with the provisions of this agreement.
The Group agrees that, after the original enrollment period under the Coverage Agreement, each new employee will be given
the opportunity to elect membership as procedure of employment.
Effective dates of Harris Methodist Health Insurance Company Coverage of new Subscribers and of termination of Coverage
offered by Group will be (check appropriate box):
Coverage Effective Date
XX Date of hire
First of month from date of hire
Other (specify)
On the first day of each month, Premiums for that month are payable as follows:
Termination Effective Date
Date Employment ends
End of month in which employment ends
Other (specify)
In full for the complete month in which coverage begins or ends.
XX In full if coverage begins on or before 15th of month or ends on or after the 16th of the month.
Prorated according to the actual number of days covered.
Other (specify)
The benefits selected by Group are as follows:
Preferred Plus
Prescription Rider
(Circle o
In Vitro Fertilization Yes No
This agreement will become effective January 1 , 19 94 . The contract term is 12 months. This agreement will
automatically renew for successive twelve (12) month period unless terminated by Harris Methodist Health Insurance Company
or the Group in accordance with the provisions for the Coverage Agreement.
This Agreement will be governed by the laws of the State of Texas.
All notices should be sent to these administrative addresses:
HARRIS METHODI HEALTH I dSURANCE
COMPANY
Accepted by:~
Title:Senior Vice President, Insurance
& Managed Care Initiatives
Address:l300 Summit Avenue, Suite 800 _
Fort Worth TX 76102
GROUP:... Citv oCDentic
By: '
Title'
Address: 324 East McKinne
Denton. TX 76201
The Harris Methodist Health Insurance Company and the Group agree that this agreement will not become effective unless at
least N/A employees initially enroll in Harris Methodist Health Insurance Company.
P08-OA-7/20/92
HARRIS METHODIST HEALTH INSURANCE COMPANY
PREMIUM RATES
1994
The City of Denton
Total Monthly Rates
ACTIVE EMPLOYEE
QCTIRGGC IINIr1GR RF
Point of Service
Retiree Only
$295.03
Retiree and Spouse
$568.47
Retiree + Child(ren)
$459.69
Retiree and Family
$698.43
RETIREES UNDER 65 OR OVER
(MEDICARE SERVES AS PRIMARY)
Point=,of Service
Retiree Only
_$108.90
12 on Medicare
$217.80
1 on, off
$444.31
1 on, 1 off + Family
$644.25
12 on + Family
$425.21
CERTIFICATE OF INSURANCE
INSURANCE BOOKLET
for Employees of:
CITY OF DENTON
(Called the Group)
Insured by:
Harris Methodist Health Insurance Company
(Called HMHIC)
Fort Worth, Texas 76102
The Harris Methodist Health Insurance Company has issued Group Policy No. POS-GA-0019
covering Employees of the Group.
This booklet is your certificate of insurance when a sticker is attached to the inside front cover.
The sticker will show your name and the effective date of your insurance.
The benefits of the group policy are described in this booklet. Final interpretation is governed
by this Policy.
THE GROUP AGREEMENT UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT
A POLICY OF WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT
YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A
SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM.
This booklet is your certificate of insurance only when you are insured under the Policy.
This certificate describes the benefit under the Plan in effect as of January 1, 1994 for all
Employees.
POS-CER9-92
IMPORTANT NOTICE
To obtain information or make a complaint:
You may call Harris Methodist Health
Insurance Company's toll-free telephone
number for information or to make a
complaint at
1-800-633-8598
You may contact the Texas Department of
Insurance to obtain information on
companies, coverages, rights or complaints
at
1-800-252-3439
You may write the Texas Department of
Insurance
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 475-1771
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your
premium or about a claim you should
contact the company first. If the dispute is
not resolved, you may contact the Texas
Department of Insurance.
ATTACH THIS NOTICE TO YOUR
POLICY: This notice is for information
only and does not become part or condition
of the attached document.
AVISO IMPORTANTE
Para obtener informacion o para someter
una queja:
Usted puede llamar al numero de telefono
gratis de Harris Methodist Health Insurance
Company's Para informacion o para someter
una queja al
1-800-633-8598
Puede comunicarse con el Departamento de
Seguros de Texas para obtener informacion
acerca de companias, coberturas, derechos
o quejas al
1-800-252-3439
Puede escribir al Departamento de Seguros
de Texas
P.O. Box 149104
Austin, TX 787149-9104
FAX # (512) 475-1771
DISPUTAS SOBRE PRIMAS O
RECLAMOS: Si tiene una disputa
concerniente a su prima o a un reclamo,
debe comunicarse con la compania primero.
Si no se resuelve la disputa, puede entonces
comunicarse con el departamento (TDI).
UNA ESTE AVISO A SU POLIZA: Este
aviso es solo para proposito de informacion
y no se convierte en parte o condicion del
documento adjunto.
POS-CER9-92 2
TABLE OF CONTENTS
BENEFIT DESCRIPTION
.......................4
GROUP AND AFFILIATED ORGANIZATION
5
ELIGIBILITY AND EFFECTIVE DATE
6
TERMINATION, CONTINUATION OF BENEFITS,
AND CONVERSION 11
PAYMENT REQUIREMENT
......................16
CLAIMS INFORMATION
......................18
COORDINATION OF BENEFITS
20
INDEPENDENT AGENTS
.......................27
GLOSSARY OF TERMS
.......................28
TERM AND AMENDMENT OF AGREEMENT
42
MISCELLANEOUS PROVISIONS
.......................43
POS-CER9-92 3
BENEFIT DESCRIPTION
The benefits and provisions of this Plan are described in the attached Schedule of Benefits
provided by Harris Methodist Health Insurance Company (HMHIC). This Plan is in effect as
of January 1, 1994.
This policy is an additional benefit plan to the Harris Methodist Health Plan, Inc. HMO Product.
Any services which are provided under the Harris HMO will not be covered benefits under this
HMHIC Agreement. The patient has a choice to choose benefits under HMHIC or Harris
HMO, there are no coordination of benefits between the two plans.
Validity of the policy shall not be contested except for nonpayment of premiums after it has been
in force for two (2) years from its date of issue and that in the absence of fraud no statement
made by any person covered by the policy relating to his or her insurability shall be used in
contesting the validity of the insurance with respect to which such statement was made after such
insurance has been in force prior to the contest for a period of two (2) years during such
person's lifetime nor unless it is contained in a written instrument signed by him or her;
provided, however, that no such provision shall preclude the assertion at any time of defenses
based upon: (a) provisions in the policy which relate to eligibility for coverage; (b) provision
in group accident and health insurance or disability insurance policies which relate to
overinsurance; (c) provision of disability policies which relate to the relation of earnings to
insurance; or (d) other similar provisions in such policies that limit the amounts of recovery
from all sources to no more than one hundred (100%) percent of the total actual losses or
expenses incurred;
The certificate of coverage, application, schedule of benefits, and group contract attached shall
constitute the entire contract between the parties and that in the absence of fraud all statements
made by the policyholder or person insured shall be deemed representations and not warranties,
and that no such statement shall be used in any contest under the policy, unless a copy of the
written instrument containing the statement is or has been furnished to such person or in the
event of death or incapacity of the insured person to the individual's beneficiary or personal
representative;
Please see the attached Schedule of Benefits for Deductibles, Maximum Out-of-Pocket Limit,
Exclusions, Limitations, and Covered Services.
POS-CER9-92 4
GROUP AND AFFILIATED ORGANIZATIONS
Organizations included undf°r this Agreement
The Group and its affiliated organizations are included under this Agreement. Affiliated
organizations include all organizations which are a subsidiary to or affiliated with the Group.
Change of Affiliated Organizations
The Group shall notify HN1HIC, in writing, when an affiliated organization ceases to be a
subsidiary of, or affiliated with, the Group. When an organization ceases to be a subsidiary of,
or affiliated with, the Group, it shall cease to be an included organization. Therefore, this
Agreement shall terminate on the date of such cessation with respect to all Eligible Persons of
that organization, except for those persons who on the next day are employees of another
affiliated organization and thus Eligible Persons under this Agreement.
Replacement of Former Poles
if an individual is disabled on the effective date the former policy is liable only to the extent of
its accrued liabilities and extensions of benefits. Regardless of whether the group policyholder
or other entity responsible for making payments to the carrier's plan of benefits, in respect of
classes eligible and actively at work and non-confinement rules and who elect such coverage
shall be covered under the succeeding provisions of the subsection but for the actively at work
or non-confinement rules shall become covered under the succeeding carrier plan when such
person satisfies such actively at work and non-confinement rules. When replacing a prior
carrier's plan, the succeeding carrier's plan, in the case of a type of coverage for which
Extension of Coverage requires an extension of benefits for a person who is totally disabled shall
provide the lesser of (1) the extension of benefits which would have been required by the former
policy, or (2) the extension of benefits required for the succeeding former plan; provided, any
such benefits may be reduced by any benefits actually payable under the former policy.
If there is a preexisting condition limitation, other than a waiting period, included in the former
plan, the level of benefits applicable to preexisting conditions of persons becoming covered in
accordance with this section by the succeeding carrier's plan and who are covered under the
prior plan during the period of time the limitation applies under the succeeding carrier's plan
shall be the less of: (1) the benefits of the succeeding carrier's plan determined without
application of the preexisting conditions limitations' or (2) the benefits of the prior plan.
The succeeding plan, in applying any waiting period in its plan, shall give credit for the
satisfaction or partial satisfaction of same or similar provision under the prior plan providing
similar benefits. If a determination of benefits of the prior plan is required by the succeeding
carrier, the prior carrier shall, at the succeeding carrier's request, furnish a statement of the
benefits available or pertinent information sufficient either to permit certification of the benefits
available under the prior plan are determined in accordance with all of the definitions,
conditions, and covered expenses provisions of the former plan and not the succeeding carrier's
plan. The benefit determination is made as if the prior plan had not been replaced by the
succeeding carrier.
POs-cER9-92 5
ELIGIBILITY AND EFFECTIVE DATE
ELIGIBLE PERSONS
To be eligible to enroll as an Employee, you must be covered under Harris HMO as the
Employee.
ELIGIBLE DEPENDENTS
To be eligible to enroll as a Dependent, you must be covered under Harris HMO as a
Dependent, by satisfying the following:
• The legal spouse of a Employee;
• Determining the dependents or the beneficiaries of an insured, or both, prohibits a
distinction on the basis of the marital status or the lack of marital status between the
insured and the other parent.
• (a) A dependent unmarried natural child, and legally adopted child regardless of
residence; or (b) foster child, step child, or child under Employee's court appointed legal
guardianship, residing with Employee or with Employee's present or former spouse: (1)
under nineteen (19) years of age, or (2) under twenty-five (25) years of age and primarily
dependent on the Employee for financial support and attending an accredited college or
university, trade or secondary school on a full-time basis, which has, in writing, verified
said attendance or;
• (a) A dependent unmarried natural child, or legally adopted child regardless of residence;
or (b) foster child, stepchild, or child under Employee's court appointed legal
guardianship, residing with Employee or with Employee's present or former spouse:
who is nineteen (19) years of age or older but incapable of self-sustaining employment
because of mental retardation or physical handicap which commenced prior to age
nineteen (19) (or commenced prior to age twenty-five (25) if such child was attending
a recognized college or university, trade or secondary school on a full-time basis when
such incapacity occurred), and primarily dependent upon the Employee for support and
maintenance.
Such dependent child must have been a participant either prior to attaining nineteen (19)
years of age or twenty-five (25) years of age under the conditions of the previous
sentence. Employee shall furnish HMHIC proof of such incapacity and dependency
within thirty-one (31) days after the dependent child's attainment of the limiting age and
from time to time thereafter as HMHIC deems appropriate, but not more frequently than
annually,
POS-CER9-92
• Grandchildren will be eligible for coverage if the child is considered a dependent of the
Employees for federal income tax purposes.
• Managing Conservator: Coverage for a minor child who otherwise qualifies as a
dependent of a person who is a member of the group may pay benefits on behalf of the
child to the person who is not a member of the group if a court order providing for the
managing conservator of the child has been issued by a court of competent jurisdiction
in this or any other state. HMHIC is required to pay benefits pursuant to the terms of
the policy and as provided by this article on compliance by the person who is not a
member of the group with requirements of this Agreement. However, any requirements
imposed on the managing conservator of the child shall not apply in the case of any
unpaid medical bill for which a valid assignment of benefits has been exercised in
accordance with policy provisions or otherwise, nor to claims submitted by the group
member where the group member has paid any portion of a medical bill that would be
covered under the terms of the policy.
Before a person who is not a member of a group is entitled to be paid benefits under the
above mentioned paragraph, the person must submit to HMHIC with the claims
application written notice that the person:
(1) is the managing conservator of the child on whose behalf the claims is made; and
(2) submit a certified copy of a court order establishing the person as managing
conservator or other evidence designated by rule of the Texas Department of
Insurance that the person qualifies to be paid the benefits as provided by this
section.
CHANGE IN GROUP ELIGIBILITY CRITERIA
Requirements as defined by the Group for determining the eligibility for participating in HMHIC
are material to the execution of this Agreement by HMHIC. During the term of this Agreement
no change in the Group definition of eligibility participation shall be permitted to affect
eligibility or enrollment under this Agreement in any manner unless such change is approved in
advance by mutual written agreement between the Group and HMHIC.
POs-cER9-92 7
EFFECTIVE DATE FOR YOU
OPEN ENROLLMENT
Harris HMO's Open Enrollment Period, and election of this rider, you shall become covered
on the Group Effective Date or the Effective Date specified as such for the Open Enrollment
Period.
ON ACQUIRING ELIGIBILITY STATUS
If you first meet the eligibility requirements other than during Harris HMO's Open Enrollment
Period you may enroll within thirty (30) days of meeting such requirements by submitting an
Application. You will become covered under HMHIC on the first day you become an Eligible
Person provided that the premium applicable to you has, been received in accordance with this
Agreement.
EFFECTIVE DATE FOR YOUR DEPENDENTS
OPEN ENROLLMENT
Your Dependents, for whom you have applied for coverage in HMHIC by submitting an
Application during Harris HMO's Open Enrollment Period, shall be covered as a Dependent on
your Effective Date.
ON ACQUIRING ELIGIBILITY STATUS
A newly acquired Eligible Dependent, other than a newborn child, and an Eligible Dependent
who first meets the eligibility requirements of the Group, other than during Harris HMO's Open
Enrollment Period, may be enrolled by the Employee within thirty (30) days of meeting such
requirements by submitting an Application to Harris HMO and election of this Rider. Such
Eligible Dependent shall be covered under HMHIC as a Dependent on the day he became an
Eligible Dependent provided that the premium applicable to the Dependent has been received
in accordance with this Agreement described in the PAYMENT REQUIREMENTS Section
below. Newborn children shall be covered for a period of thirty-one (31) days from the date
of birth and shall continue to be covered after that time only if, prior to the expiration of such
thirty-one day period, Notification has been submitted to Harris HMO for such newborn child
and the premium applicable to the Dependent has been received in accordance with this
Agreement described in the PAYMENT REQUIREMENTS Section.
Newly adopted children shall be covered as if they were newborn children. The thirty-one (31)
days grace period for submission of Notification to Harris HMO shall commence on the earlier
of the date upon which such child commences residence with you or when the adoption becomes
legal.
POS-CER9-92 8
PERSONS NOT ELIGIBLE FOR COVERAGE
Notwithstanding the foregoing provisions of this Section, you will not be eligible for coverage
in HMHIC if:
• Coverage Previously Terminated: You shall not be eligible for
coverage if you have had previous coverage terminated by HMHIC
or Harris HMO for cause, as described in Section
TERMINATION, CONTINUATION OF BENEFITS AND
CONVERSION of this Agreement.
a Indebtedness: You shall not be eligible for coverage if you have
unpaid financial obligations arising from prior coverage in HMHIC
or Harris HMO.
CONDITIONS OF ELIGIBILITY
You or your Eligible Dependent shall not be refused enrollment by Harris HMO or HMHIC
because of health status, requirements for health services, or the existence of a Pre-Existing
condition on the Group Effective Date. In addition, your coverage shall not be terminated due
to your health status or health care needs. If you or your eligible Dependents apply for coverage
on a date other than Open Enrollment Period or more than thirty (30) days after becoming an
eligible person or eligible Dependent, then you or your eligible Dependent shall be required to
submit Evidence of Insurability as required by HMHIC.
NOTIFICATION OF INELIGIBILITY
A condition of participation in HMHIC is your Agreement to notify Harris HMO and 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.
CLERICAL ERRORS
Eligibility under this Agreement shall in no event be invalidated by failure of the Group, due
to clerical error, to record or report you or your eligible Dependent to Harris HMO or HMHIC.
You shall be eligible if an Application has been completed and submitted to the Group as
required under the terns of the Harris HMO Agreement by or on behalf of you or your eligible
Dependent and the premium applicable to such coverage had been received by Harris HMO and
forwarded to HMHIC for payment of this Rider.
POS-CER9-92 9
PRE EXISTING CONDITIONS
"Pre-existing Conditions means any medical condition which diagnosis was made or treatment
received within the six (6) months immediately preceding your effective date of coverage under
this Agreement. A medical condition has been "diagnosed" if its existence has been identified
or recognized by a Physician or other Health Professional. A medical condition has been
"treated" if any services of a Physician or other Health Professional have been received with
respect thereto, including but not limited to office visits or consultations, hospital treatment,
laboratory services, X-rays or the dispensing of prescription medication or refills.
In no event shall the limitation of 50% additional Copayment apply to cost of treatment (which
shall include all applicable Copayment as specified in the Schedule of Benefits) following the
earlier of: (a) the end of a continuous period of twelve (12) months commencing on or after the
effective date of the person's coverage during all of which the person has received no medical
advice or treatment in connection with such disease or physical condition; and (b) the end of the
two (2) year period commencing on the effective date of the person's coverage.
The maximum amount of additional Copayment for a Pre-existing Condition during a Calendar
year will not exceed $2,000.00 for any such Covered Person or Dependent, or $4,000.00 total
for such Covered Person and his Dependents.
If benefits are received under the Harris HMO policy, no benefits are available under HMHIC,
therefore the Pre-existing condition clause does not apply to your coverage.
POS-CER9-92 10
TERMINATION CONTINUATION OF BENEFITS AND
CONVERSION
TERMINATION OF GROUP
DEFAULT IN PAYMENT OF PREMIUM
If the Group fails to pay to Harris HMO, on behalf of HMHIC, the premium payable for this
coverage, hereunder on or before the thirty-first (31) calendar day after such payment is due,
this Agreement may be terminated by HMHIC and all benefits shall cease at the end of such
thirty-one (31) day grace period. Group may be held liable for the cost of all benefits provided
to you by HMHIC during the grace period. Group shall remain liable for all premiums (and any
interest accrued thereon) not paid prior to termination. Interest on late payments from the date
such premiums were due may be charged at a rate equal to eighteen percent (18%) per year.
Unpaid interest shall be due and payable upon notice thereof to the Group from HMHIC.
If Group remits its delinquent payments to Harris HMO for HMHIC within fifteen (15) days of
termination date, HMHIC may reinstate Group without requiring a new Group Enrollment
Agreement. However, HMHIC reserves the right to refuse to reinstate by refunding within five
(5) business days all payments made by Group after the date of termination.
UPON NOTIFICATION
This Agreement may be terminated by either HMHIC or the Group upon written notice to the
other party at least sixty (60) days prior to the end of the Contract Year. Such termination shall
occur at midnight on the day preceding the end of the Contract Year. In the event that HMHIC
terminates this Agreement, if you are Totally Disabled at the date of discontinuance of the group
policy or contact, expenses for treatment will continue at least for the period of such total
disability or for 90 days, whichever is less. For the purposes of this section, the terms "total
disability" and "totally disabled" mean (1) with respect to an employee or other primary insured
under the policy, the complete inability of the person to perform all of the substantial and
material duties and functions of his or her occupation and any other gainful occupation in which
such person earns substantially the same compensation earned prior to disability, and (b) with
respect to any other person under the policy, confinement as a bed patient in a hospital.
TERMINATION - FOR CAUSE
DEFAULT IN PAYMENT OF PREMIUM
If any premium contributions due from you are not paid timely by or on behalf of you, your
entitlement to benefits may be terminated not less than thirty-one (31) days after the date such
premium was due.
POS-CER9-92 11
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 for Harris HMO or Evidence of
Insurability form, HMHIC shall have the right to terminate your coverage under this Agreement
without any further liability or obligation to you. Your entitlement to benefits may be
terminated not less then sixty-one (61) days after such misrepresentation. If you correct
inaccurate information furnished to Harris HMO, and HMHIC has not relied upon such incorrect
information to its prejudice, the furnishing of incorrect information shall not constitute a basis
for termination of your coverage. In the absence of fraud, all statements made by you are
considered representations and not warranties and such statements shall not void the coverage
or reduce the benefits under this Agreement two (2) years after your Effective Date.
MISUSE OF IDENTIFICATION CARD
Possession of a HMHIC identification card is and of itself confers no rights to services or other
benefits. The holder of the card must be, in fact, you or an eligible person on whose behalf all
applicable premiums under this Agreement have actually been paid. When receiving services
or other benefits to which you are not entitled pursuant to this Agreement you shall be solely
responsible for the full payment of any charges associated with the services received. If you
permit the use of the your identification card by any other person, such card may be confiscated
and HMHIC shall have the right to terminate your coverage under this Agreement and the
coverage of your Dependents. Your entitlement to benefits may be terminated not less than
fifteen (15) days written notice after such misuse of the identification card.
FRAUDULENT USE OF BENEFITS OR SERVICES
Fraudulent use by you of services, benefits, providers, facilities, or coverage will result in
cancellation of coverage after not less than fifteen (15) day written notice to you.
TERMINATION OF COVERAGE
EMPLOYEE NO LONGER ELIGIBLE PERSON
If you cease to be eligible, coverage under this Agreement shall automatically terminate at
midnight of that day on which you cease to be eligible.
DEPENDENT NO LONGER ELIGIBLE DEPENDENT
If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall
automatically terminate at midnight of the day on which the Dependent ceases to be an Eligible
Dependent.
POS-CER9-92 12
LIABILITY UPON TERMINATION
At the effective date of any termination of your coverage under this Agreement any payments
received on your account, applicable to periods after the effective date of the termination of
coverage, plus amounts due to you for claims reimbursement, if any, less any amount due to
HMHIC or which must be paid by HMHIC on your behalf, shall be refunded to the appropriate
party within thirty-one (31) days. HMHIC and the Group shall thereafter have no further
liability or responsibility to you except as may be specifically provided in Section UPON
NOTIFICATION of this Agreement.
CONTINUATION OF COVERAGE
COBRA
If, under the provisions of Title X of the Consolidated Omnibus Budget Reconciliation Act of
1985, Public Law 99-272 ("COBRA"), you are granted the right to continuation of coverage
beyond the date your coverage would otherwise terminate, or, if COBRA is inapplicable and the
provision of an applicable state statute grants you similar rights to continuation of coverage, this
Agreement shall be deemed to allow continuations of coverage to the extent necessary to comply
with the provisions of the applicable statute. No evidence of insurability is required. If you
are eligible for continuation under COBRA you must inform HMHIC of eligibility within 3
months of the effective date.
CONTINUATION OF COVERAGE
Any employee, covered person, or dependent whose insurance under the group policy has been
terminated for any reason except involuntary termination for cause, including discontinuance of
the group policy in its entirety or with respect to an insured class, and who has been
continuously insured under the group policy and under any group policy providing similar
benefit which it replaces for at least three consecutive months immediately prior to termination
shall be entitled to such continuation privileges. Involuntary termination for cause does not
include termination for any health related cause. HMHIC shall not be required to issue a
converted policy covering any person if: (a) such person is or could be covered by Medicare;
(b) such person is covered for similar benefits by another hospital, surgical, medical, or major
medical expense insurance policy or hospital or medical service subscriber contract or medical
practice or other prepayment plan or by any other plan or program; (c) such person is eligible
for similar benefits whether or not covered therefor under any arrangement of coverage for
individuals in a group, whether on an insured or uninsured basis; (d) similar benefits are
provided for or available to such person, pursuant to or in accordance with the requirements of
any state or federal law; or (e) the benefits provided under the sources herein enumerated,
together with the benefits provided by the continued policy, would result in overinsurance
according to HMHIC's standards. HMHIC's standards are the reasonable relationship between
the actual health care costs in the area in which the covered person lives at the time of the
continuation and must be filed with the commissioner of insurance prior to their use in denying
coverage. Continuation of group coverage for employees or covered persons and their eligible
dependents subject to the eligibility provisions. Continuation of group coverage will not include
dental, vision care, or prescription drug benefits and must be requested in writing within twenty-
POS-CER9-92 13
one (21) days following the later of (a) the date the group coverage would otherwise terminate;
or (b) the date the employee is given notice of the right of continuation by either the employer
or the group policy holder. In not event may the employee or the covered person elect
continuation more than 31 days after the date of such termination. An employee or covered
person electing continuation must pay to the group policyholder or the employer, on a monthly
basis in advance, the amount of contribution required by the policyholder or employer, but not
more than the group rate for the insurance being continued under the group policy on the due
day of each payment. The employee's or the covered person's written election of continuation,
together with the first contribution required to establish contributions on a monthly basis in
advance, must be given to the policyholder or employer within thirty-one (31) days of the date
coverage would otherwise terminate. Continuation may not terminate until the earlier of: (a) six
months after the date the election is made; (b) failure to make timely payments; (c) the date on
which the group coverage terminated in its entirety; (d) or one of conditions specified in items
listed above regarding ineligible person's is met by the individual.
SEVERANCE OF FAMILY RELATIONSHIP
If coverage ends due to severance of family relationship, by virtue of family or dependent
relationship to a person who is a member or eligible for the group for which the health insurance
policy, is provided to continue coverage with the group if:
(1) Previous eligibility for coverage under the health insurance policy ceases because of the
severance of the family relationship or the retirement or death of the member of the
group; and
(2) The family member or dependent has been a member of the group for a period of at least
one year or is an infant under one year of age.
(3) A person who exercises this option, may not be required to take and pass a physical
examination as a condition for continuing coverage.
(4) A person who exercises this option is entitled to coverage under the policy, and
exclusions that were not included in the policy may not be included in the group
continuation coverage. However, if the group policyholder replaces the health insurance
policy within the one-year provided, the person may obtain coverage identical in scope
to the coverage under the replacement group policy as provided by this article.
(5) A person covered under group continuation coverage shall pay premiums for the
coverage directly to the group policyholder, and the coverage shall provide the person
with the option of paying the premiums in monthly installments. The group policyholder
may require the person to pay a fee of not more than $5 a month for administrative
costs.
POS-CER9-92 14
(6) Upon initial severance of family relationship, you must inform HMHIC of the severance,
upon receipt of the notification HMHIC will send the application to the severed family
member immediately.
(7) Within sixty (60) days from the severance of the family relationship or retirement or
death of the member of the group, the dependent must give written notice to the group
policyholder of the desire to exercise the option under item (1) of this section or the
option expires. Coverage under the health insurance policy remains in effect during this
sixty (60) day period provided the policy premiums are paid.
(8) Any period of previous coverage under the health insurance policy is to be used in full
or partially satisfaction of any required probationary or waiting periods provided in the
contract for dependent coverage.
(9) If a health insurance policy provides to a group member continuation rights to cover the
period between the time that the member retires and the time of eligibility for coverage
by Medicare, those same continuation rights shall be made available to the group
member's dependents.
(10) If a person exercises the continuation option under item (1) of this section, coverage of
that person continues without interruption and may not be canceled or otherwise
terminated until:
(a) the insured fails to make a premium payment in the time required to make that
payment;
(b) the insured becomes eligible for substantially similar coverage under another
health insurance policy, hospital, or medical service subscriber contract, medical
practice or other prepayment plan, or by any other plan or program; or
(c) a period of three years has elapsed since the severance of the family relationship
or the retirement or death of the member of the group.
EXTENSION OF MEDICAL BENEFITS
HMHICshall continue to provide medical services if this Agreement terminates while you are
Totally Disabled at the date of discontinuance of the group policy or contact at least for the
period of such total disability or for 90 days, whichever is less, for expense for treatment of the
condition causing such total disability. For the purposes of this section, the terms "total
disability" and "totally disabled" mean (1) with respect to an employee or other primary insured
under the policy, the complete inability of the person to perform all of the substantial and
material duties and functions of his or her occupation and any other gainful occupation in which
such person eams substantially the same compensation earned prior to disability, and (b) with
respect to any other person under the policy, confinement as a bed patient in a hospital.
This continued coverage will end on the earlier of: (1) the period of "total disability" is no
longer meets the above defined statement; or (2) 90 days from the termination date; or (3) the
date you become eligible for similar coverage under another plan.
POS-CER9-92 15
PAYMENT REQUIREMENTS
PREMIUM PAYMENTS
The initial rates for the benefits and services under this Agreement shall be due and payable in
advance on or before the first (1st) day of the month for which such payment is made or is to
be made. In accordance with the terms and provisions of the TERM AND AMENDMENT OF
AGREEMENT Section of this Agreement, HMHIC shall have the right to change the rate
payable under this Agreement at any time when the extent or nature of this Agreement is
changed by Amendment or termination of any provision, or by reason of any provision of law
or governmental program or regulation. Premiums do not vary by age. No proration of the rate
shall be made with respect to your coverage under this Agreement commencing after the first
(1st) day of the month. A grace period of thirty-one (31) days shall be allowed for each
payment payable hereunder, whether due from Group or you.
The rate required for a newly acquired Eligible Dependent shall be payable initially when the
required Notification is submitted to Harris HMO for coverage under HMHIC. Thereafter, all
payments with respect to such new Eligible Dependent shall be made as otherwise provided in
this Agreement.
Any payments required for newborn children who meet the requirement of the Section
ELIGIBILITY AND EFFECTIVE DATE of this Agreement shall be initially payable to Harris
HMO on behalf of HMHIC on or before the first day of the next month following the month in
which the Notification required under the above mentioned section is submitted to Harris HMO
for coverage under HMHIC. Thereafter, all payments with respect to such newborn child shall
be made as otherwise required under this Agreement.
NON-CONTRIBUTORY COVERAGE
If the coverage basis hereunder is "Non-Contributory", the Group agrees to pay at the principal
office of Harris HMO on behalf of HMHIC, or to its authorized representative, on each payment
due date, the sum of the HMHIC rate for the coverage under this Agreement. The Group
premium for the coverage provided by HMHIC under this Agreement shall be determine by the
applicable rate then in effect and the number of Members at the monthly intervals established
by HMHIC.
CONTRIBUTORY COVERAGE
If the coverage basis hereunder is "Contributory", the Group agrees to pay at the principal office
of Harris HMO on behalf of HMHIC, or to its authorized representative, on each payment due
date, the sum of the HMHIC rate for the coverage under this Agreement. Group shall permit
you to pay your contributory portion of such rate through payroll deduction. Procedures for
implementing payroll deduction for your portion of such rate shall be the same as those utilized
for any Alternative Health Benefit Plan. If the Group does not have an Alternative Health
Benefit Plan, the procedures shall solely be those as agreed to, in writing, between Group and
HMHIC. The Group premiums for the coverage provided by HMHIC under this Agreement
POS-CER9-92 16
shall be determined by the applicable rate than in effect and the number of Members at the
monthly intervals established by HMHIC.
Group shall offer HMHIC to all Employees of Group on terms no less favorable with respect
to the Group contribution than those applicable to any Alternative Health Benefit Plan as may
be available through the Group. The Group contributions shall not be changed during the term
of this Agreement unless such change is prior approved, in writing, by HMHIC. If, however,
the Group contributions to the Alternative Health Benefit Plan, as may be available through the
Group, is increased during the term of this Agreement, the Group agrees to also increase
contributions to HMHIC effective the first monthly payment due following such increase.
NOTIFICATION BY GROUP
Group shall forward completed Applications and any Evidence of Insurability form(s) to Harris
HMO for coverage under HMHIC within ten (10) business days of their receipt from Eligible
Persons. In the event Group fails to notify HMHIC of the ineligibility of any person for whom
the Group has made the monthly prepayment required pursuant to this Agreement, then, such
prepayment shall be credited to Group only if HMHIC has not made arrangements for or paid
benefits for the ineligible person but in no event will prepayment be credited subsequent to thirty
(30) days after the date such person became ineligible.
POS-CER9-92 17
CLAIMS INFORMATION
HOW TO FILE A CLAIM
You must send your medical bills to HMHIC. The claim office address can be found on the
back of your I.D. card. When you send your medical bills be sure to include your name,
address, and social security number.
Written notice of claim must be given to the insured within twenty (20) days after the occurrence
or commencement of any loss covered by the policy. Failure to give notice within such time
shall not invalidate or reduce any claim if it shall be shown not to have been reasonably possible
to give such notice and that notice was given as soon as was reasonably possible;
HMHIC will furnish to the person making claim or to be policyholder for delivery to such
person such forms as are usually furnished by it for filing proof of loss. If such forms are not
furnished before the expiration of fifteen (15) days after the insurer received notice of any claim
under the policy, the person making such claims shall be deemed to have complied with the
requirements of the policy as to proof of loss upon submitting within the time frame fixed in the
policy for filing proof of loss, written proof covering the occurrence, character, and extent of
the loss for which claims is made.
No benefits will be paid for services rendered under the Harris HMO policy.
HOW AND WHEN ARE CLAIMS PAID?
In the case of claim for loss, written proof of such loss must be furnished to the insurer within
the ninety (90) days after the commencement of the period for which the insurer is liable.
Failure to furnish such proof within such time shall not invalidate or reduce any claim if it was
not reasonably possible to furnish such proof within such time, provided such proof is furnished
as soon as reasonably possible and in no event, except in the absence of legal capacity of the
claimant, later than one year form the time proof is otherwise required.
All benefits payable under the policy shall be payable not more than sixty (60) days after receipt
of proof.
HMHIC shall have the right and opportunity to examine the person of the individual for whom
claim is made when and so often as it may reasonably require during the pendency of claim
under the policy and also the right and opportunity to make an autopsy in case of death where
it is not prohibited by law.
POS-CER9-92 18
PAYMENT TO STATE
The Group policy shall provide payment to the Texas Department of Human Resources for the
actual cost of medical expenses the department pays through medical assistance for a person
insured by the contract if the insured is entitled to payment for the medical expenses by the
insurance contract.
All benefits paid on behalf of the child or children under the policy must be paid to the Texas
Department of Human Services whenever:
• the Texas Department of Human Services is paying benefits under the Human Resources
Code, Chapter 31, or Chapter 32, i.e., financial and medical assistance service programs
administered 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.
LEGAL ACTION
No action at law or in equity shall be brought to recover on the policy prior to the expiration
of sixty (60) days after proof of loss has been filed in accordance with the requirements of the
policy and that no such action shall be brought at all unless brought within three years form the
expiration of the time within which proof of loss is required by the policy;
TIME LIMIT OF CERTAIN DEFENSES
Harris Methodist Health Insurance Company will not deny or reduce a claim because of a Pre-
Existing Condition if both of the following conditions are met:
• The claim is for a loss that happened or a disability started after the insurance
coverage for that person has been in effect for the earlier of: (A) twelve (12)
months, with no treatment in connections with such pre-existing condition; or (B)
two (2) years, with any treatment for such pre-existing condition.
• The condition is not excluded from coverage by name or specific description.
POS-CER9-92 19
COORDINATION OF BENEFITS
The Harris Methodist Health Insurance Company, Coordination of Benefit and Subrogation of
Benefits provision applies to all of the benefits provided under this Agreement, excluding
services rendered under Harris HMO. The benefits provided by Harris Methodist Health
Insurance Company shall be coordinated with any group insurance plan or coverage under
governmental programs (excluding Medicaid), including Medicare, to assure that you receive
coverage while avoiding double recovery. It is, therefore, understood and agreed that should
you be covered by or under a Coordinated Plan in addition to coverage under this Agreement,
the provisions and rules as described in this Section shall determine whether HMHIC or the
Coordinated Plan is primarily responsible for paying the cost of benefits and services provided
to you.
• Services and benefits for military service connected disabilities for which you are
legally entitled and for which facilities are reasonably available, shall in all cases
be provided before the benefits of this Plan.
DEFINITIONS
For purposes of this Section only, words and phrases shall have meaning as follows:
• ALLOWABLE EXPENSE shall mean any Usual and Customary expense of
which at least a portion is covered under this Plan covering you when a claim is
made. When a Coordinated Plan provided benefits in the form of services rather
than cash payments, the Usual and Customary cash value of each service provided
shall be deemed to be both an Allowable Expense and a benefit paid.
• CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding
any portion of a calendar year occurring prior to the effective date.
• COORDINATED PLAN shall mean any of the following that provides benefits
or services for, or by reason of, medical care or treatment:
Coverage under governmental programs, including Medicare
(excluding Medicaid), required or provided by any statute unless
coordination of benefits with any such program is forbidden by
law.
• Group coverage or any other arrangement of coverage for
individuals in a group, whether on an insured or uninsured basis,
including any prepayment coverage, group practice basis or
individual practice coverage and any coverage for students which
is sponsored by, or provided through, a school or other educational
institution above the high school level, excluding Harris HMO.
POS-CER9-92 20
DETERMINATION OF BENEFITS
This provision shall apply in determining the benefits payable for the Allowable Expenses
incurred by you during a Claim Determination Period.
The term Coordinated Plan shall be construed separately with respect to each policy, contract,
or other arrangement for benefits or services and separately with respect to that portion of any
such policy, contract, or other arrangement which reserves the right to take the benefits or
services of the other Coordinated Plans into consideration in determining its benefits and that
portion which does not.
Whenever the sum of the benefits that would be payable under this Agreement in the absence
of this provision, and the benefits that would be payable under all Coordinated Plans in the
absence thereof or amendments of similar purpose to this provision would exceed the Allowable
Expenses, then the following shall apply:
• The benefits that would be payable under this Agreement shall be reduced to the
extent necessary so that the sum of such reduced benefits and all the benefits
payable for such Allowable Expenses under all Coordinated Plan include the
benefits that would have been payable had claim been duly made therefor.
• If a Coordinated Plan would, according to its rules, determine its benefits after
the benefits payable under this Agreement have been determined, and the rules
as described below would require payment under this Agreement to be determined
before the Coordinated Plan, then the benefits of the Coordinated Plans shall not
be included for the purpose of determining the benefits under this Agreement.
ORDER OF BENEFIT DETERMINATION
The rules establishing the order of benefit determination shall be as follows:
• The benefits of a Coordinated Plan without a coordination of benefits provision
(or a non-duplication provision of similar intent) shall be determined before the
benefits of this Agreement.
• The benefits of a Coordinated Plan which covers you other than as a Dependent
shall be determined before the benefits of a Coordinated Plan which covers you
as a dependent.
• The benefits of a Coordinated Plan which covers you as a dependent child of a
person whose date of birth, excluding year of birth, occurs earlier in a calendar
year, shall be determined before the benefits of a Plan which covers you as a
dependent of a person whose date of birth, excluding year of birth, occurs later
in the calendar year. If a Coordinated Plan does not have the provisions of this
paragraph regarding dependents, which results either in each Coordinated Plan
determining its benefits before the other or in each Coordinated Plan determining
its benefits after the other, the provisions of this paragraph shall not apply, and
POS-CER9-92 21
the rule set forth in the Coordinated Plan which does not have the provisions of
this paragraph shall determine the order of benefit determination unless the Legal
Separation or Divorce Section shall apply.
• If the rules provided above or the rules provided in the above section do not
establish an order of benefit determination, then the benefits of a Coordinated
Plan which covers you, when a claim is made, for the longest period of time shall
be determined before the benefits of a Coordinated Plan which covers you for the
shorter period of time except as follows:
• The benefits of a Coordinated Plan cover you as a laid-off part-
time or retired employee or as the dependent of such a person shall
be determined after the benefits of a Coordinated Plan covering
you as a covered member other than as a laid-off or retired
employee or dependent of such person.
• If a Coordinated Plan does not have a provision regarding laid-off
or retired employees, and as a result, such Coordinated Plan
determines its benefits after the Coordinated Plan with this
provision, then the provision of the immediately preceding
paragraph shall not apply.
LEGAL SEPARATION OR DIVORCE
In the event of a legal separation or divorce, the following order of benefits determination shall
apply:
• If there is a court decree that establishes financial responsibility for the provision
of health insurance coverage for the child, the benefits of a Coordinated Plan
which covers the child as a dependent of the parent with such financial
responsibility shall be determined before the benefits of a Coordinated Plan which
covers the child as a dependent of the parent without such financial responsibility.
• In the event of a legal separation or divorce in which the court decree does not
establish financial responsibility for the health care expenses of the child then the
following shall apply:
• If the parent with custody of the child has not remarried, the
benefits of a Coordinated Plan which covers the child as a
dependent of the parent with custody of the child shall be
determined before the benefits of a Coordinated Plan which covers
that child as a dependent of the parent without custody.
• If the parent with custody of the child has remarried, the benefits
of a Coordinated Plan which covers the child as a dependent of the
parent with custody shall be determined before the benefits of a
Coordinated Plan which covers that child as a dependent of the
POS-CER9-92 22
stepparent; and the benefits of a Coordinated Plan which covers
that child as a dependent of the stepparent shall be determined
before the benefits of a Coordinated Plan which covers that child
as a dependent of the parent without custody.
Thus, in the event of legal separation or divorce, unless a court decree specifies otherwise, the
order of benefit determination described above may be summarized as follows:
Separated or Divorced and not Remarried:
(1)
Parent with Custody
(2)
Parent without Custody
Separated or Divorced and Remarried
(1)
Parent with custody
(2)
Stepparent with custody
(3)
Parent without custody
Medicare
For purposes of determining benefits provided for you, if you are eligible to enroll for
Medicare, but do not, HMHIC will assume the amount provided under Medicare to be the
amount you would have received if you had enrolled in it.
You are considered to be eligible for Medicare on the earliest date coverage under Medicare
could become effective for you. Except as described TEFRA, Medicare benefits will be
coordinated in accordance with the policy.
TEFRA Options for Groups with 20 or more Employees
If you are actively working, you and your covered spouse who are eligible for Medicare will
be permitted to choose one of the following options if you, the Employee are age 65 or older
and eligible for Medicare:
OPTION 1 - The service of the Group Agreement will be provided first and the
benefits of Medicare will be provided second.
OPTION 2 - Medicare benefits only. You and your Dependents, if any, will
not be covered by the Group Agreement.
The Group will provide you, the employee, with a choice to elect one of these options at least
one month before becoming age 65. All new Employees age 65 or older will be offered these
options when hired. If Option 1 is chosen, your rights under this Agreement will be subject to
the same requirements as for an Employee or Dependents who are under age 65.
POS-CER9-92 23
There are two different categories of persons eligible for Medicare. The calculation and
payment of benefits by this Agreement differs from each category,
Category 1 Medicare Eligible are:
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 working covered Employees of groups with 100 or more
employees and their covered dependents who are entitled to
Medicare by reason of disability other than End Stage Renal
Disease (ESRD); and
5. Covered individuals entitled to Medicare solely on the basis of
ESRD during a period of up to 18 months after the individual has
been determined eligible for ESRD benefits.
Category 2 Medicare Eligible are:
i. Retired employees and their spouses;
2. Covered Employees of groups with less than 100 employees and
their covered Dependents who are entitled to Medicare by reason
of a disability other than ESRD; and
3. Covered individuals entitled to Medicare solely on the basis of
ESRD for more than 12 months after the individual has been
determined eligible for ESRD benefits.
RIGHT TO RELEASE INFORMATION
For purposes of administering the provisions of this Section, HMHIC may, without further
consent of, or notice to you, release to or obtain from any health care plan, insurance company
or other person or organization, any information with respect to you which it deems to be
reasonably necessary for such purposes, as to facilitate coordination of benefits, as permitted by
law. When you receive services or claim benefits under this Agreement you shall furnish
HMHIC all information deemed necessary by HMHIC to implement this Section
(COORDINATION AND SUBROGATION OF BENEFITS)
POS-CER9-92 24
FACILITY OF PAYMENT
Whenever payment which should have been made by HMHIC in accordance with this Section
has been made by a Coordinated Plan, HMHIC shall have the right, exercisable alone and in
its sole discretion, to authorize payment to the Coordinated Plan making such payments any
amounts HMHIC shall determine to be warranted in order to satisfy the intent of this Section,
and amounts when so paid shall be deemed to be benefits under this Agreement, and, to the
extent of such payments, HMHIC shall be fully discharged from liability under this Agreement.
RIGHT TO RECOVERY
Whenever payments have been made by HMHIC with respect to Allowable Expenses in total
amount which is, at any time, in excess of the maximum amount of payment necessary at the
time to satisfy the intent of this Coordination of Benefits Section, HMHIC shall have the right
to recover such payments, to the extent of such excess, from one or more of the following, as
HMHIC shall determine: any person or persons to, or for, or with respect to whom such
payments were made, any insurance company or companies, and organization(s) to which such
payments were made.
DISCLOSURE
You agree to disclose to HMHIC at the time of enrollment, at the time of receipt of services and
benefits, and from time to time as requested by HMHIC, the existence of other health plan
coverage, the identity of the carrier, and the group through which such coverage is provided.
SUBROGATION
Subrogation seeks to shift the expense for injuries suffered by you to those responsible for
causing them.
In return for HMHIC providing benefits for injuries, ailments, or disease caused as a result of
the negligence, omission or willful act of a third party, you agree to execute any instrument
which may be required. You also agree to assign to HMHIC the right of recovery against such
third party to the extent of benefits paid. At the time such benefits are provided or thereafter
as HMHIC may request, you also agree to comply with the following provisions:
• Execute a formal written injury report and assignment to HMHIC
of right to recover the actual benefits paid by HMHIC under this
Agreement for injuries, ailments and disease caused by a third
party.
o Reimburse HMHIC for the actual benefits paid by HMHIC, but
not in excess of monetary damages collected, immediately upon
receipt of any monies paid by or on behalf of such third party in
settlement of any claims arising out of injuries, ailments and
diseases covered by HMHIC. HMHIC shall have a lien on any
POS-CER9-92 25
actual recovery from such third party whether by judgment,
settlement, compromise or reimbursement.
Execute and deliver such papers and provide such reasonable help
(including authorizing bringing suit against such third party in your
name and making court appearances) as may be necessary to
enable HMHIC to recover the actual benefit paid by HMHIC.
POS-CER9-92 26
INDEPENDENT AGENTS
The relationship between HMHIC, and the Group is that of independent contracting entities.
Neither the Group nor you is the agent or employee of HMHIC, and HMHIC is not the
employee or agent of the Group or you. Harris HMO and HMHIC are not representation of
each other.
POS-CER9-92 27
GLOSSARY
(These definitions apply when the following terms are used in this Certificate and the attached
Schedule of Benefits.)
ACTIVELY AT WORK
Actively at work shall mean that the eligible employee must be performing the usual and
customary duties of your regular employment during your usual working hours on your effective
date of coverage; provided, however that if you are absent from work due to vacation, holiday,
jury duty, or other similar circumstances, not caused by injury or illness, you shall be
considered actively at work.
AGREEMENT
Agreement shall mean Entire Contract which is defined as the Group Contract, Certificate of
Coverage, Group Enrollment Agreement, Schedule of Benefits, Applications, Attachments,
Riders, Amendments hereto, if any. Agreement shall constitute the entire contract between the
parties and that in the absence of fraud all statements made the policyholder or person insured
shall be deemed representations and not warranties, and that no such statement shall be used in
any contest under the policy, unless a copy of the written instrument containing the statement
is nor has been furnished to such person or in the event of death or incapacity of the insured
person to the individual's beneficiary or personal representative.
ALTERNATE HEALTH BENEFIT PLAN
Alternate Health Benefit Plan shall mean the plan which the Group designates as the alternative
to this Agreement.
ALLIED HEALTH PROFESSIONAL
Allied Health Professional shall mean any health care provider/physician that provides benefits
as set forth in this Agreement and described in the Schedule of Benefits Attachment.
AMBULATORY SURGICAL CENTER
A specialized facility which is established, operated and staffed primarily for the purpose of
performing surgical procedures and which fully meets one of the following two tests:
• It is licensed as an ambulatory surgical center by the regulatory authority having
responsibility for the licensing under the laws of the jurisdiction in which it is located.
POS-CER9-92 28
• 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.
• It requires in all cases, except those requiring only local infiltration
anesthetics, that a licensed anesthesiologist administer the anesthetic or
supervise an anesthetist who is administering the anesthetic and that the
anesthesiologist or anesthetist remain present throughout the surgical
procedure.
• It provides at least one operating room and at least one post-anesthesia
recovery room.
• It is equipped to perform diagnostic X-ray and laboratory examinations or
has arrangement to obtain these services.
• It has trained personnel and necessary equipment to handle emergency
situations.
• It has immediate access to a blood bank or blood supplies.
• It provides the full time services of one or more registered graduate nurses
(R.N.) for patient care in the operating rooms and in the post-anesthesia
recovery room.
• It maintains an adequate medical record for each patient, the record to
contain an admitting diagnosis including for all patients except those
undergoing a procedure under local anesthesia, a pre-operative
examination report, medical history and laboratory tests and/or X-rays, an
operative report, and a discharge summary.
BIRTH CENTER
A specialized facility which is primarily a place for delivery 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 responsibility for the licensing
under the laws of the jurisdiction in which it is located.
• It meets all of the following requirements:
• It is operated and equipped in accordance with any applicable state
laws.
POS-CER9-92 29
• It is equipped to perform routine diagnostic and laboratory
examinations such as hematocrit and urinalysis for glucose,
protein, bacteria, and specific gravity.
• It has available to handle foreseeable emergencies, trained
personnel and necessary equipment, including but not limited to
oxygen, positive pressure mask, suction, intravenous equipment,
equipment for maintaining infant temperature and ventilation, and
blood expanders.
• It is operated under the full supervision of a licensed doctor of
medicine (M.D.) or registered graduate nurse (R.N.).
• It maintains a written agreement with at least one Hospital in the
area for immediate acceptance of patients who develop
complications.
0 It maintains an adequate medical record for each patient, the
record to contain prenatal history, prenatal examination, any
laboratory or diagnostic tests and a postpartum summary.
• It is expected to discharge or transfer patients within 24 hours
following delivery.
CALENDAR YEAR
A period of one year beginning with January 1.
CHEMICAL DEPENDENCY TREATMENT CENTER
Chemical Dependency Treatment Center shall mean a facility which provides a program for the
treatment of chemical dependency pursuant to a written treatment plan approved and monitored
by a physician and which facility is also:
(1) affiliated with a hospital under a contractual agreement with an established system for
patient referral; or
(2) accredited as such a facility by the Joint commission on Accreditation of Hospitals; or
(3) licensed as a chemical dependency treatment program by the Texas Commission on
Alcohol and Drug Abuse; or
(4) licensed, certified, or approved as a chemical dependency treatment program or center
by any other state agency having legal authority to so license, certify, or approve.
COMPLICATIONS OF PREGNANCY
Complications of Pregnancy is defined as: conditions, requiring hospital confinement (when the
pregnancy is not terminated), whose diagnosis are distinct from pregnancy but are adversely
affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac
POS-CER9-92 30
decompression, missed abortion, and similar medical and surgical conditions of comparable
severity, but shall not include false labor, occasional spotting, physician prescribed rest during
the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia, and similar
conditions associated with the management of a difficult pregnancy not constituting a
nosologically distinct complication of pregnancy; and non-elective cesarean section, termination
of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of
gestation in which a viable birth is not possible.
CONTRACT YEAR
Contract year shall mean the period of twelve (12) months commencing on the Group effective
date and each twelve (12) month period thereafter, unless terminated.
COORDINATED POLICY
Coordinated Plan shall mean any of the following that provides benefits or services for, or by
reason of, medical care or treatment:
Coverage under governmental programs, (excluding Medicaid) including Medicare,
required or provided by any statute unless coordination of benefits with any such
programs is forbidden by law.
Group coverage or any other arrangement of coverage for individuals in a group,
whether on an insured or uninsured basis, including any prepayment coverage, group
practice basis or individual practice coverage and any coverage for students which is
sponsored by, or provided through, a school or other educational institution above the
high school level.
COURSE OF TREATMENT
Course of Treatment shall mean that period of time represented by an inpatient hospital
admission and related discharge during which time treatment has been received by you or your
dependents or that period of time authorized by HMHIC as necessary to complete a cycle of
treatment and subsequently provide a medical release to you or your dependents.
COVERED EXPENSE
Covered Expenses shall mean the services and supplies, detailed in the Schedule of Benefits
Attachment, for which a payment is made.
COVERED FAMILY MEMBERS
You and your wife or husband and Dependent children who are covered under the Agreement.
POS-CER9-92 31
CRISIS STABILIZATION UNIT
Crisis Stabilization Unit shall mean a twenty-four (24) hour residential program that is usually
short-term in nature and that provides intensive supervision and highly structured activities to
persons who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe
proportions.
CUSTODIAL CARE
Custodial Care shall mean 1). that care which is marked by or given to watching and protecting
rather that seeking cure; or 2). care which is not a necessary part of medical treatment or
recovery; or 3). care comprised of services and supplies that are primarily provided to assist in
the activities of daily living.
DAY TREATMENT CENTER
A psychiatric day treatment facility shall mean a mental health facility which provides treatment
for individuals suffering from acute, mental and nervous disorders in a structured psychiatric
program utilizing individualized treatment plans with specific attainable goals and objectives
appropriate both to the patient and the treatment modality of the program and that is clinically
supervised by a doctor of medicine who is certified in psychiatry by the American Board of
Psychiatry and Neurology.
Day treatment facility may provide coverage for not more than eight hours in a twenty-four (24)
hour period, the attending physician certifies that such treatment is in lieu of hospitalization, and
the psychiatric treatment facility is accredited by the Program for psychiatric Facilities, or its
successor, of the Joints Commission on Accreditation of Hospitals.
Each full day of treatment in a psychiatric day treatment facility shall be considered equal to
one-half of one day of treatment of mental or emotional illness or disorder in a hospital.
DEPENDENT
Dependent shall mean an Eligible Dependent who has satisfied the eligibility and participation
requirements specified in this Agreement.
DOMICILIARY CARE
Domiciliary Care shall mean that care provided in the home, custodial in nature, for persons so
disabled or inform as to be unable to live independently.
DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment must be able to withstand repeated use, primarily and customarily
POS-CER9-92 32
serve a medical purpose, generally not be used in the absence of illness or injury, require a
Physician's order and be appropriate for use in the home.
EFFECTIVE DATE
Effective Date shall mean the effective date of coverage for you and your Eligible Dependents
pursuant to the terms of this Agreement.
ELIGIBLE DEPENDENT
Eligible Dependent shall mean an individual as defined in the ELIGIBILITY AND EFFECTIVE
DATE Section of this Agreement.
ELIGIBLE PERSON
Eligible Person shall mean an individual as defined in the ELIGIBILITY AND EFFECTIVE
DATE Section of this Agreement.
EMERGENCY CARE
Emergency care shall mean bona fide emergency services provided after the sudden onset of a
medical condition manifesting itself by acute symptoms of sufficient severity, including severe
pain, such that the absence of immediate medical attention could reasonably be expected to result
in placing the patient's health in serious jeopardy; serious impairment or bodily functions; or
serious dysfunction to any bodily organ or part.
EMPLOYEE
See ELIGIBILITY AND EFFECTIVE DATE Section.
POS-CER9-92 33
EVIDENCE OF INSURABILITY
Evidence of Insurability shall mean the documentation of health status as required by HMHIC
for Eligible Persons and Eligible Dependents who do NOT meet the following requirements
regarding application for coverage: (a) apply for coverage during an open enrollment period; or
(b) apply for coverage within thirty (30) days of qualifying for coverage. Such information shall
be reviewed by HMHIC. Notification will be sent to the Eligible Person or Eligible Dependents
regarding their eligibility for participation in HMHIC.
EXCLUSION
Exclusion shall mean those specific conditions or causes for which coverage by HMHIC is
entirely excluded.
FAMILY DEDUCTIBLE
The maximum your entire family will have to pay for Deductible in any year is the amount of
Family Deductible shown in Schedule of Benefits. This Family Deductible applies no matter
how large your family may be. Only Covered Expenses which count toward a person's
Individual Deductible count toward this Deductible.
FDA
FDA shall mean the Food and Drug Administration, an agency of the United States Government.
GROUP
Group shall mean collectively the contracting Group and all affiliated organizations of the
Group, to which this Agreement is issued and through which as an agent for you and your
dependents become entitled to the benefits as set forth in the Schedule of Benefits.
GROUP EFFECTIVE DATE
Group Effective Date shall mean the date specified as such in the Group Enrollment Agreement.
GROUP ENROLLMENT AGREEMENT
Group Enrollment Agreement shall mean that agreement which is executed between HMHIC and
the Group for the purpose of making available to Eligible Persons and Eligible Dependents of
the Group those benefits which are described in the Certificate of Insurance. Such Group
Enrollment Agreement shall identify the Group, Group Effective Date, eligibility requirements,
rates, and covered benefits.
POS-CER9-92 34
HARRIS HMO
Harris HMO shall mean Harris Health Plan, Inc., a Texas not-for-profit corporation organized
as a Health Maintenance Organization (HMO) and licensed by the Texas Department of
Insurance.
HEALTH 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 within the scope of that
provider's license or certification.
A Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health
Agency, Laboratory, Dietitian, Minor Emergency Room Center, Chemical Dependency
Treatment Center, Psychiatric Day Treatment facility, Crisis Stabilization or Residential
Treatment Facility or other provider or entity which provides services as set forth in this
Agreement as described in the Schedule of Benefits Attachment.
HOME HEALTH AGENCY
An agency or organization which provides a program of home health care and which fully meets
one of the following tests:
• It is approved by Medicare.
• It is established and operated in accordance with the applicable licensing and
other laws.
• It meets the following tests:
0 It has the primary purpose of providing a home health care
delivery system bringing supportive services to the home.
0 It has a full-time administrator
0 It maintains written records of services provided to the patient.
0 Its staff includes at least one registered graduate nurse (R.N.) or
it has nursing care by a registered graduate nurse (R.N.) available.
0 Its employees are bonded and it provides malpractice insurance.
POS-CER9-92 35
HOSPICE
An agency that provides counseling and incidental medical services for a terminally ill
individual. Room and board may be provided. The agency must meet all of the following tests:
• It is approved under any required state or governmental Certificate of Need.
• It provides 24 hour-a-day, 7 day-a-week service
• It has a nurse coordinator who is a registered graduate nurse (R.N.) with four
years of full-time clinical experience. Two of these years must involve caring for
terminally ill patients.
• It has a social-service coordinator who is licensed in the area in which it is
located.
• The main purpose of the agency is to provide Hospice services.
• It has a full-time administrator.
• It maintains written record of services given to the patient.
• Its employees are bonded.
• It provides malpractice and malplacement insurance.
• It is established and operated in accordance with any applicable state laws.
HOSPITAL
Hospital shall mean an institution licensed by the State of Texas and which is (1.) primarily
engaged in providing diagnostic, medical, surgical, or mental health facilities for the care and
treatment of injured or sick persons, (2.) operated under the medical supervision of a staff of
legally qualified and licensed physicians, (3.) provides twenty-four (24) hour-a-day nursing
service by or tinder the direct supervision of a Registered Nurse (R.N.), (4.) provides for
overnight care of patients, (5.) maintaining clerical and ancillary services necessary for the
treatment of medical and surgical patients including but not limited to laboratory, X-ray, dietary
and medical records library. In no event shall the tern "hospital" include a convalescent nursing
home or any institution or part thereof which is used principally as a convalescent facility, rest
facility, nursing facility, facility for the aged, extended care facility, intermediate care facility,
skilled nursing facility or facility primarily for rehabilitative services; the tern hospital shall
pursuant to Chapter 3, Texas Insurance Code, Article 3.72 included treatment in a residential
treatment center for children and adolescents, treatment provided by a crisis stabilization unit,
psychiatric day treatment, or chemical dependency unit.
POS-CER9-92 36
IDENTIFICATION CARD
A card that generally describes the benefits of a Plan, that in and of itself confers no rights to
services or other benefits. The card is the sole property of HMHIC, and HMHIC reserves the
right of possession.
INDIVIDUAL DEDUCTIBLE
The Individual Deductible applies to all covered expenses. The amount of the Individual
Deductible is shown in Schedule of Benefits.
MAMMOGRAPHY. 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 rad
midbreast, with two views for each breast. Coverage for 35 year old females or older for an
annual screening for the presence of occult breast cancer subject to the same dollar limits,
deductibles, and co-insurance factors.
MEDICAL EMERGENCY
Medical Emergency shall mean a medical condition so classified by the medical director and
which manifests itself by acute symptoms of sufficient severity (including severe pain) such that
the absence of immediate medical attention could reasonably be expected to result in (a) placing
the patient's health in serious jeopardy; or (b) serious impairment of bodily function; or (c)
serious dysfunction to any bodily organ or part. Examples of conditions which do not usually
constitute medical emergencies are colds, influenzas, ordinary sprains, children's ear infections,
or nausea and headaches. Heart attacks, cardiovascular accidents, poisoning, loss of
consciousness or respiration, convulsions, severe bleeding or broken bones are examples of true
medical emergencies.
MEDICALLY NECESSARY
Shall mean services or supplies which 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 appropriate to treat you or your Eligible Dependent's medical
condition; and (5.) provided in accordance with accepted medical standards.
POS-CER9-92 37
MEDICARE
Medicare shall mean Part A and Part B of Title XVIII of the Social Security Act and any
amendments or regulations thereunder.
MENTAL OR NERVOUS DISORDER
Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder
of any kind. [ See SERIOUS MENTAL ILLNESS for definition of Serious Mental Illness.
NO-FAULT AUTOMOBILE INSURANCE LAW
The basic reparations provision of a law providing for payment without determining fault in
connection with automobile accidents.
NURSE-PRACTITIONER
A person who is licensed or certified to practice as a nurse-practitioner and fulfills both of these
requirements:
• A person licensed by a board of nursing as a registered nurse.
• A person who has completed a program approved by the state for the preparation
of nurse-practitioners.
POS-CER9-92 38
OPEN ENROLLMENT PERIOD
Open enrollment shall mean a period of at least thirty (30) days during each twelve (12)
consecutive months when Eligible Persons may elect to change from the Alternative Health
Benefit Plan to HMHIC or from HMHIC to the Alternative Health Benefit Plan.
OTHER SERVICES AND SUPPLIES
Services and supplies furnished to the individual and required for treatment, other than the
professional services of any Physician and any private duty or special nursing services (including
intensive nursing care by whatever name called).
PHYSICIANIHEALTH 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
provider's license or certification.
A Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health
Agency, Laboratory, Dietitian, Minor Emergency Room Center, Chemical Dependency
Treatment Center, Psychiatric Day Treatment facility, Crisis Stabilization Unit, or Residential
Treatment Facility or other provider or entity which provides services as set forth in this
Agreement as described in the Schedule of Benefits Attachment.
PRE-EXISTING CONDITION
Pre-existing Condition shall mean a physical condition diagnosed or treated within six months
prior to the effective date of coverage. Please see ELIGIBILITY AND EFFECTIVE DATE
Section.
PROVIDERS
Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency,
Laboratory, Minor Emergency Room Center, Residential Treatment Center for children and
adolescents, Crisis stabilization Unit, Chemical Dependency Unit, Psychiatric Day Treatment
facility or other provider or entity which provides services as set forth in this Agreement an
described in the Schedule of Benefits Attachment.
POS-CER9-92 39
REASONABLE CHARGE
An amount measured and determined by Harris Methodist Health Insurance Company by
comparing the actual charges for the service or supply with the prevailing charges made for it.
Harris Methodist Health Insurance Company determines the prevailing charge. It takes into
account all pertinent factors including:
• The complexity of the service.
• The range of services provided.
0 The prevailing charge level in the geographic area where the provider is located
and other geographic areas having similar medical cost experience.
RESIDENTIAL TREATMENT CENTER
Residential Treatment Center for Children and Adolescents means a child-care institution that
provides residential care and treatment for emotionally disturbed children and adolescents and
that is accredited as a residential treatment center by the Council on Accreditation, the Joint
Commission on Accreditation of Hospitals, or the American Association of Psychiatric Services
for Children.
ROOM AND BOARD
Room, board, general duty nursing, intensive care by whatever name called, and any other
service regularly furnished by the hospital as a condition of occupancy of the class of
accommodations occupied, but not including professional services of Physician nor special
nursing services rendered outside of an intensive care unit by whatever name called.
SICKNESS
The term "sickness" will include a surgical procedure for sterilization and related medical care
and treatment and confinement within 30 consecutive days from the procedure.
The term "sickness" will include complications of pregnancy as defined above.
The term "sickness" used in connection with newborn children will include congenital defects
and birth abnormalities, including premature births.
SKILLED NURSING FACILITY
If the facility is approved by Medicare as a Skilled Nursing Facility then it is covered by this
Agreement.
If not approved by Medicare, the facility may be covered if it meets the following tests:
POS-CER9-92 40
• It is operated tinder the applicable licensing and other laws.
• It is under the supervision of a licensed Physician or registered graduate nurse
(R.N.) who is devoting full time to supervision.
• It is regularly engaged in providing room and board and continuously provides
24 hour a day skilled nursing care of sick and injured person's at the patient's
expense during convalescent stage of an injury or sickness.
• It maintains a daily medical record of each patient who is under the care of a duly
licensed Physician.
• It is authorized to administer medications to patients on the order of a duly
licensed Physician.
• It is not, other than incidentally, a home for the aged, the blind or the deaf, a
hotel, a domiciliary care home, a maternity home, or a home for alcoholics or
drug addicts or the mentally ill.
TOTAL DISABILITY
Total Disability and totally disabled shall mean (1) with respect to an employee or other primary
insured under the policy, the complete inability of the person to perform all of the substantial
and material duties and function of his or her occupation and any other gainful occupation in
which such person earns substantially the same compensation earned prior to disability, and (2)
with respect to any other person/dependent under the policy, confinement as a bed patient in a
hospital.
UTILIZATION REVIEW DEPARTMENT
Utilization Review Department shall mean a department of HMHIC which determines, in its
discretion, if a service or supply is medically necessary for diagnosis or treatment of an
accidental injury, illness or pregnancy. A service or supply is not medically necessary if a less
intensive or more appropriate diagnostic or treatment alternative could be used in lieu of the
services or supply given.
POS-CER9-92 41
TERM AND AMENDMENT Or AGREEMENT
TERM
This Agreement shall remain in effect for the first Contract Year and thereafter for successive
Contract Years unless sooner terminated as provided in Section TERMINATION of this
Agreement.
AMENDMENT
• HMHIC and Group may mutually alter or revise the terns of this Agreement
and/or Schedule of Benefits and Riders hereto. In the event of such alteration or
revision, HMHIC shall provide Group with at least sixty (60) days written notice
before effective date of Amendment. Such notice shall be considered to have
been provided when mailed to the Group at the latest date shown on the records
of HMHIC.
• The Agreement may be amended at any time, according to any provisions of this
Agreement or by written agreement between HMHIC and Group, without consent
of you, or any other person having a beneficial interest in it. Any such
amendment shall be without prejudice to any claim arising prior to the effective
date of such amendment.
CHANGE OF RATES
HMHIC shall have the right to change the rates and premiums payable hereunder (i) as of any
Anniversary Date (in which case the Group shall be notified at least sixty (60) days prior to a
change in rates) or (ii) in accordance with Section TERM AND AMENDMENT OF
AGREEMENT of this Agreement.
POS-CER9-92 42
MISCELLANEOUS PROVISIONS
USE OF WORDS
Words used in the masculine shall apply to the feminine where applicable, and, wherever the
context of this Agreement dictates, the plural shall be read as the singular and the singular as
the plural. The terns "you", "your", and "insured" shall refer to the employee. "HMHIC" and
"insurer" shall refer to Harris Methodist Health Insurance Company. The words "hereof",
"herein", "hereunder" and other similar compounds of the word "here" shall mean and refer to
the entire Agreement and not to any particular Section or provision. All references to Sections
and provisions shall mean and refer to Sections and provisions contained in this Agreement
unless otherwise indicated.
RECORDS AND INFORMATION
HMHIC shall, to the extent legally allowable and without further consent of or notice to you,
release to or obtain from any insurance company or other organization or person any
information, with respect to you, which HMHIC deems to be necessary for such purposes as
Coordination of Benefits. When claiming benefits, you shall furnish HMHIC information as
may be necessary to implement this Agreement.
INFORMATION FROM GROUP
Group shall periodically forward the information required by HMHIC in conjunction with the
administration of the Agreement. All records of Group which have a bearing on the coverage
shall be open for inspection by HMHIC at any reasonable time. HMHIC shall not be liable for
the fulfillment of any obligation dependent upon such information prior to its receipt in a form
satisfactory to HMHIC. Incorrect information furnished may be corrected, if HMHIC shall not
have acted to its prejudice by relying on it. HMHIC shall have the right, at reasonable times,
to examine Group's records, including payroll records of the Group having employees covered
through this Agreement, with respect to eligibility and monthly premiums under this Agreement.
ASSIGNMENT
Assignment shall mean the authorization to pay benefits directly to the party providing the
benefit. This may not be construed to:
(1) provide a coverage or benefit not otherwise available tinder the health insurance policy;
(2) allow assignment of a benefit of a benefit payment to a person who is not legally entitled
to receive such a direct payment; or
(3) prohibit an insurer from verifying through the insurer's normal process the health care
services provided to the covered person by the physician or health care provider.
POS-CER9-92 43
If a written assignment of benefits payable for health care services is made by a covered person
and is obtained by or delivered to the insured with the claim for benefits, the benefit payment
shall be made by the insurer directly to the physician or other health care provider.
If a written assignment of benefits is made and delivered or obtained as provided, the insurer
is relieved of the obligation to pay and of any liability for paying the benefits for the health care
services to the covered person.
The payment of benefits under an assignment does not relieved the covered person of any
contractual responsibility for the payment of deductibles and copayments. A physician or other
health care provider may not waive copayments or deductibles by acceptance of an assignment.
AUTHORITY
Any alterations or revisions to this Agreement shall not be valid unless evidenced by a written
amendment which has been signed by Group and by an officer of HMHIC and attached to the
affected document. No other person has the authority to change this Agreement or to waive any
of its provisions.
GOVERNING LAW
This Agreement is executed and is to be performed in all respects in accordance with all federal
and Texas state laws applicable to Health Insurance Companies and all other applicable Texas
state laws or regulations.
INCORPORATION BY REFERENCE
The Schedule of Benefits, Group Enrollment Applications, any optional Riders, any
Attachments, and any amendments to any other forgoing, form a part of this Agreement as if
fully incorporated herein. Any direct conflict or ambiguity of this Agreement shall be resolved
under terns most favorable to you.
ENTIRE AGREEMENT
Agreement shall mean Entire Contract which is defined as the Group Contract, Certificate of
Coverage, Group Enrollment Agreement, Schedule of Benefits, Applications, Attachments,
Riders, Amendments hereto, if any. Agreement shall constitute the entire contract between the
parties and that in the absence of fraud all statements made the policyholder or person insured
shall be deemed representations and not warranties, and that no such statement shall be used in
any contest under the policy, unless a copy of the written instrument containing the statement
is nor has been furnished to such person or in the event of death or incapacity of the insured
person to the individual's beneficiary or personal representative.
POS-CER9-92 44
INFORMATION TO YOU
Upon execution of this Agreement, HMHIC shall provide to you a copy of this Certificate of
Coverage, and an Identification Card. Such delivery shall be accomplished by mailing postage
paid, to the latest address furnished to HMHIC or by delivery from a representative of HMHIC
or Group to you.
UNIFORM RULES
In the administration of HMHIC, this Agreement shall be applied uniformly to all similarly
situated employees.
CALCULATION OF TIME
In determining time periods within an event or action is to take place for purposes of HMHIC,
no fraction of a day shall be considered, and any act, the performance of which would fall on
a Saturday, Sunday, holiday or other non-business day, may be performed on the next following
business day, may be performed on the next business day.
EVIDENCE
Evidence required of you to HMHIC may be certificate, affidavit, document, or other
information which when acting on it considered pertinent and reliable, and signed, made or
presented by the proper party or parties.
SEVERABILITY
If any provision of this Agreement shall be held invalid or illegal, the rest of this Agreement
shall remain in force and effect and shall be construed in accordance with the intentions of the
parties as manifested by all provisions hereof including those which shall have been held invalid
and illegal. Furthermore, in lieu of any provision hereof which is found to be illegal, invalid
or unenforceable provision as may be possible and be legal, valid and enforceable without
materially changing the purpose and intent of this Agreement.
HEADINGS
The titles and headings of Sections or provisions are included for convenience of references only
and are not be considered in constriction of the Sections or provisions hereof.
NOTICE OF TERMINATION
All HMHIC notices of termination of this Agreement or of your rights will be in writing and
shall state the cause of termination, with specific reference to the provision(s) of this Agreement
giving rise to the right of termination.
POS-CER9-92 45
NOTICE
Any notice under this Agreement shall be in writing, and shall be given by United States mail,
postage prepaid, addressed as follows:
HMHIC: 1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
Group: The address specified on the executed Group Enrollment Agreement or the
latest address provided, in writing, to HMHIC.
Employee: The latest address provided by you on the Application form actually
delivered to HMHIC.
The effective date of notice is two (2) business days after the date of deposit with the United
States Post Office.
POS-CER9-92 46
SCHEDULE OF BENEFITS
Preferred PLUS
HARRIS METHODIST HEALTH INSURANCE COMPANY
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
1-800/633-8598
(817) 878-5826
POS-SCH9-92
1
You and your Eligible Dependents are entitled to receive the services and benefits set forth in this
Schedule of Benefits which are Medically Necessary and obtained in accordance with the provisions of Lj
the Group Health Care Agreement/Subscriber Certificate of Coverage and/or Certificate of Insurance.
A.
,
i
B. Benefits which are covered under Harris HMO are not covered expenses under HMHIC. No
Coordination of Benefits are available between Harris HMO and HMHIC benefits. Emergency Care
which does not meet Harris HMO's definition will be covered under HMHIC. To receive HMO ben-
efits for ER services the condition must conform to the following definition, and if time permits
you must notify your Primary Care Physician prior to receiving benefits. Harris HMO's definition
of Emergency Care shall mean bona fide emergency services provided after the sudden onset of a -
medical condition manifesting itself by acute symptoms of sufficient severity, including severe
pain that the absence of immediate medical attention could reasonably be expected to result in j '
(1) placing the patient's health in serious jeopardy; (2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part. If an Emergency Care situation exists follow
the procedure outlined in Harris HMO policy.
POS-SCH9-92 2
i
C. You must submit your own claim forms for all medical bills for services received from Providers.
The claim office address is P.O. Box 901054, Fort Worth, Texas 76101-2054. Benefits are based
on the Reasonable and Customary charges as established by HMHIC. The benefits will be sent in
accordance with claims provisions outlined in the Certificate of Coverage document. An explana-
tion of benefits (EOB) summary will be sent which explains the amount of benefits paid as well as
the amount of payment which is your responsibility.
0. All services and benefits are subject to any stated Copayment amounts, limitations, and exclu-
sions described in this Schedule of Benefits.
E. Any copayment expressed as a percentage of "Total Charges" or flat amount shall mean that por-
tion of the Reasonable and Customary charges as established by HMHIC.
This Schedule of Benefits may be supplemented by additional benefit Riders if included with this
Group Health Care Agreement/Subscriber Certificate of Coverage, and/or Certificate of Insurance.
G. The relationship between HMHIC and Group is that of independent contracting entities. Providers
are not agents or employees of HMHIC nor is HMHIC an employee or agent of any Provider.
Providers shall maintain the physician-patient or professional-patient relationship with you and
shall be the only parties responsible to you for the services provided. Neither HMHIC or any
employee of HMHIC shall be deemed to be engaged in the practice of medicine. HMHIC shall in
no way supervise the practice of medicine by any Provider, nor shall HMHIC in any manner
supervise, regulate or interfere with the usual professional relationships between a Provider and
you.
H.
POS-SCH9-92
Any services which are limited in either daily limits or dollar maximums under Harris HMO policy
will also be counted towards HMHIC's daily limit or dollar maximum.
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
Only one Copayment will be required for covered services performed or furnished on same date of ser-
vice by the same provider. This Copayment will be the higher of all listed Copayments.
Benefits
Required Copayment
Physician office visits
$20.00 per visit
Adult health assessments, routine physical examinations,
50% of Total Charges
well child care, and health education for diagnosis,
care and treatment of illness or injury provided by a Physician
Annual well woman examination
50% of Total Charges
Physician office visits after hours
$25.00 per visit
Immunizations
50% of Total Charges
Home visits
$20.00 per visit
Allergy diagnosis and/or testing; serum is not covered
$75.00 per visit
Administered drugs, medications, dressings, splints, and
$20.00 per visit
casts
Diagnostic services, laboratory tests, and x-rays 30% of Total Charges
(Including Low-Dose Mammography, will be covered as
other x-rays)
Ultrasound, MRI, CAT, and non-routine laboratory tests $100.00 per test
Surgery and/or anesthesia performed in the physician's office $100.00 per procedure
or outpatient setting
POS-SCH9-92
All physician fees including anesthesia while a member is 30% of Total Charges
hospitalized, except professional radiology and pathology fees
Professional radiology and pathology fees 30% of Total Charges
(Including Low-Dose Mammography, will be covered as
other x-rays, one examination per year for females
age 35 and older)
For maternity services, Covered Person shall be entitled to receive medical, surgical, and hospital care
from Physicians and other Providers during the term of the pregnancy, upon delivery, and during the
postpartum period for normal delivery; for abortion and miscarriages; and for complications of preg-
nancy. Charges related to medical services connected with the home delivery of a newborn and services
of mid-wives, unless provided as Emergency Care Services, will not be covered. Benefits for the child of
an unmarried Dependent covered person will be provided if maternity benefits are provided to the
dependent mother. The child of an unmarried dependent will be considered an eligible dependent of the
Subscriber if child is considered a dependent for Federal income tax purposes, and upon payment of the
applicable premium.
Benefits Required Copayment
Physician services for maternity care including delivery, 30% of Total Charges
hospital visits, and anesthesia
Physician care in the hospital for care of Eligible Newborn 30% of Total Charges
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
POS-SCH9-92
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You shall be entitled to receive Medically Necessary (See Page 2 item A for definition) hospital services,
subject to all definitions, terms and conditions of this Agreement and Schedule of Benefits. If you elect
to remain in the hospital beyond the period which is Medically Necessary (as determined by your
Physician and HMHIC Utilization Review Department), you will be responsible for non Medically
Necessary services directly to the hospital. You must notify the Utilization Review department if your
stay is extended beyond the authorized time by the Utilization Review Department.
Benefits
INPATIENT HOSPITAL SERVICES:
Semi-private room, private if Medically Necessary, and
all services and medical supplies related to inpatient
treatment.
OUTPATIENT HOSPITAL SERVICES (Including Ambulatory Facilities)
Surgery
Therapeutic radiation treatment
Inhalation therapy
Diagnostic testing, laboratory, and x-rays
Ultrasound, MRI, CAT, and non-routine laboratory tests
Required Copayment
30% of Total Charges
$100.00 per procedure
30% of Total Charges
30% of Total Charges
30% of Total Charges
$100.00 per test
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
POS-SCH9-92
Benefits which are covered under Harris HMO are not covered expenses under HMHIC. No coordination
of benefits are available between Harris HMO and HMHIC. Emergency care which does not meet Harris
HMO's definition will be covered under HMHIC. To receive HMO benefits for Emergency Services the
condition must conform to the following definition, and if time permits you must notify your Primary
Care Physician prior to receiving benefits. Harris HMO's definition of Emergency Care shall mean these
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 your health in serious jeopardy, seri-
ous impairment to bodily functions or serious dysfunction of any bodily organ or part.
In cases of a Medical Emergency, you are entitled to the benefits and services set forth in this Schedule
of Benefits and in this Agreement if the condition does not meet Harris HMO's definition of a Medical
Emergency. If the condition meets Harris HMO's definition, benefits will be paid by Harris Methodist
Health Plan. If the condition does not meet Harris HMO's definition, benefits will be paid by HMHIC. At
the time of a Medical Emergency, you or someone acting on your behalf, should make every reasonable
effort to contact the Utilization Review Department. If it is not reasonably possible to contact the
Utilization Review Department at the time (such as that of a life or limb threatening emergency), you
may seek care immediately.
Benefits
Physician office visits
Physician office visits after hours
Hospital emergency room and urgent care center services,
including physician fees
Follow-up care
Required Copayment
30% of Total Charges
30% of Total Charges
30% of Total Charges
30% of Total Charges
POS-SCH9-92
At the time of a Medical Emergency which results in a hospital admission, you or someone acting on
your behalf, shall notify the Utilization Review Department within twenty-four (24) hours or as soon as
reasonably possible. Upon notification, the Utilization Review Department will evaluate the need for con-
tinuation of hospital services.
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
Family Planning Services will be available to you on a voluntary basis. Covered services will include his-
tory, physical examination, related laboratory tests; medical supervision in accordance with generally
accepted medical practice; information and counseling on contraception, including advice or prescrip-
tion for a contraceptive method; education, including education on the prevention of venereal disease;
and voluntary sterilization after appropriate counseling.
Benefits Required Copayment
Physician office visits, including related testing, education $20.00 per visit
and counseling
Fitting and dispensing of IUD and diaphragms $20.00 per visit
Tubal ligation $75.00 per procedure
Vasectomy $75.00 per procedure
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
POS-SCH9-92
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
Infertility services will be available to you on a voluntary basis. Artificial insemination and diagnostic
services to determine the cause of infertility will be provided. Excluded from services to treat infertility
are those services described in "Exclusions," Section XIV, Number 23 of this Schedule of Benefits.
Benefits Required Copayment
Physician office visits for diagnosis, non-psychiatric $20.00 per visit
counseling, artificial insemination, and sperm count
Administration of infertility medications; infertility $20.00 per visit
medications not covered
Endometrial biopsy, hysterosalpingography and diagnostic 30% of Total Charges
laparoscopy
Sonogram and/or ovulation kit $75.00 per test or kit
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
POS-SCH9-92
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You shall be entitled to all necessary care and treatment for chemical dependency on the same basis as
that provided for any physical illness to a lifetime maximum of three (3) separate series of treatments.
Diagnosis and treatment for chemical dependency shall include detoxification and/or rehabilitation on
either an inpatient or outpatient basis as determined to be Medically Necessary by a Physician. All treat-
ment is subject to the same limitations, exclusions, and copayments as applied to covered services of
any other physical illness.
Note: Inpatient Drug Treatment required precertification by the Utilization Review Department.
A series of treatments is considered to be a planned, structured, and organized program to promote
chemical free status which may include different facilities or modalities and is complete when:
You are discharged on medical advice from inpatient detoxification, inpatient rehabilitation treatment,
partial hospitalization or intensive outpatient; or
You have received a series of these levels of treatments without a lapse in treatment; or
You fail to materially comply with the treatment program for a period of thirty (30) days.
Benefits Required Copayment
Office visits $20.00 per visit
Necessary care and treatment for detoxification and/or $20.00 per visit
rehabilitation from chemical dependency
Intensive outpatient or partial hospitalization 30% of Total Charges
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
NOTE: Any services which are limited in either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
POS-SCH9-92 10
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
OUTPATIENT MENTAL HEALTH SERVICES:
You shall be entitled to receive up to twenty (20) office visits per Calendar Year for evaluation, crisis
intervention and stabilization, and outpatient therapy in support of the evaluation or crisis intervention.
The twenty (20) visits maximum may include individual treatment, couple, or family visits.
Benefits Required Copayment
Outpatient office visits for crisis intervention and treatment $20.00 per visit
Psychological testing 30% of Total Charges
INPATIENT MENTAL HEALTH SERVICES:
When determined to be Medically Necessary by the Utilization Review Department, you shall be entitled
to evaluation, crisis intervention, treatment or any combination thereof for acute conditions.
Only treatment at the most appropriate level of care as determined by the Utilization Review Department
will be authorized.
Benefits Required Copayment
Inpatient hospitalization for up to thirty (30) inpatient 30% of Total Charges
days per Calendar Year.
Psychiatric Day Treatment Facility, Crisis Stabilization Unit 30% of Total Charges
or Residential Treatment Center for Children and Adolescents
for up to sixty (60) days per Calendar Year. Treatment in
such facilities will be limited to sixty (60) days of care
such that one (1) day of care shall be equal to one-half
(1/2) days of inpatient care.
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
NOTE: Any services which are limited in either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
POS-SCH9-92 11
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You shall be entitled to receive short-term physical or occupational therapy rehabilitation services for
conditions which are Medically Necessary, subject to significant improvement through short-term treat-
ment, and authorized by the Utilization Review Department before services are obtained. Treatment is
defined as up to sixty (60) visits per twelve (12) month period, per condition, and shall be provided on
an outpatient basis only. Rehabilitation services on an inpatient basis, or in a skilled nursing facility, will
be authorized only if other non-rehabilitation medical services are required by you.
Occupational therapy shall mean those services designated to prevent dysfunction, restore functional
ability and facilitate maximal adaptation to impairment.
Benefits
Required Copayment
Hospital, or other provider for restorative $20.00 per visit
treatment subject to clinical improvement,
and limited to sixty (60) visits per twelve (12)
month calendar year per condition.
Long-term or maintenance services.
Not Covered
Long term/maintenance services are defined as including Custodial/Domiciliary Care and services which
are not skilled in nature and not medically necessary.
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
NOTE: Any services which are limited in either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
POS-SCH9-92 12
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You shall be entitled to services and benefits provided for kidney dialysis upon prior authorization from
the Utilization Review Department and only if your Physician determines that such service represents
the preferred method of treatment, and you satisfy the criteria for the service involved. Coverage will be
coordinated for you if you are eligible for available coverage under the Medicare provisions for End
Stage Renal Disease.
Benefits
Required Copayment
Inpatient or outpatient Hospital, or outpatient Kidney dialysis 50% of Total Charges
center
Home dialysis (continuous ambulatory peritoneal dialysis) 50% of Total Charges
including equipment, training, solutions, coils, drug and
surgical supplies
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
POS-SCI9-92 13
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
Benefits
Required Copayment
You shall be entitled to both land and air ambulance 30% of Total Charges
services for Medically Necessary Emergency Care Services
POS-SCH9-92 14
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You shall be entitled to receive home health care services according to a Treatment Plan approved by
the Utilization Review Department. Treatment will be provided only for those medical conditions subject
to clinical improvement through short-term treatment; for recovery or rehabilitation of illness or injury;
or for treatment of terminal illness.
Short-term treatment is defined as: a plan of care established, approved in writing, and reviewed at least
every two (2) months by the attending physician and certified by the attending physician as necessary
for medical purposes. The number of visits for which benefits will be payable are sixty (60) visits in any
calendar year for each covered person under this policy. Excluded benefits include custodial care, bene-
fits provided by a person who resides in the covered person's home, or is a member of the covered per-
son's family. A visit by a Home Health Agency representative is considered one (1) home health visit.
Four hours of home health aid service is considered one (1) home health visit.
Benefits
Required Capayment
Skilled nursing care; physical, occupational; or respiratory $20.00 per visit
therapy; intravenous solutions; and home health aid services
Hospice (home health service only)
$20.00 per visit
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
NOTE: Any services which are limited in either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
POS-SCH9-92 15
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You are entitled to receive services in a Skilled Nursing Facility for medical conditions which in the
judgement of the Utilization Review Department are subject to significant clinical improvement and
which require services which can only be provided at that level of care. Services in a Skilled Nursing
Facility may be provided in lieu of hospitalization (either in lieu of admission or upon discharge from
inpatient care) as Medically Necessary based on acuity of services and patient condition, are limited to
sixty (60) days per Calendar Year.
Benefits Required Copayment
Room, Board, medications and supplies while confined in a 30% of Total Charges
Skilled Nursing Facility as part of a short-term recovery or
rehabilitation program
Physician visits while confined to Skilled 30% of Total Charges
Nursing Facility
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
NOTE: Any services which are limited in either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
POS-SCH9-92 16
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You are entitled to prosthetic medical services or medical appliances if Medically Necessary, with autho-
rization from the Utilization Review Department. While you are covered under this Agreement, initial
prostheses are provided when required due to illness or injury. Replacement is provided only when
marked physical changes occur which require replacement, and is not provided for items which wear
out due to normal usage.
Benefits
Required Copayment
Internal prosthetic appliances including internal cardiac 30% of Total Charges
pacemakers, and minor devices such as screws, wire mesh,
nails, and artificial joints. Supply of or replacement of
internal breast prosthesis covered only if initial surgery
was result of injury or disease.
External prosthetic appliances including artificial arms, 30% of Total Charges
legs, above or below knee or elbow prostheses; eyes,
lenses, external cardiac pacemaker; terminal devices such
as hand or hook; rigid or semi-rigid immobilizing devices
such as arm, leg, neck or back braces; and ordinary splints,
and crutches
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
POS-SCH9-92 17
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You are entitled to benefits for certain durable medical equipment as prescribed by a physician, with
prior authorization from the Utilization Review Department. Durable medical equipment must be able to
withstand repeated use, primarily and customarily serve a medical purpose, generally not useful in the
absence of illness or injury, require a physician's order, and be appropriate for use in the home. At its
option, HMHIC may rent or purchase approved equipment. HMHIC retains the right of possession of
equipment.
HMHIC shall have no liability or responsibility for repair or replacement of equipment lost or damaged.
Equipment not considered durable medical equipment is described in "Exclusions", Section XIV,
Number 31 of this Schedule of Benefits.
Benefits
Required Copayment
Rental or purchase of medical equipment 30% of Total Charges
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
POS-SCI9-92 18
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders from January 1
through December 31.
You are entitled to services for the initial stabilization of acute accidental, non-occupational injury, to
sound natural teeth with prior authorization by the Utilization Review Department, when provided within
thirty (30) days of the accident on an outpatient basis only.
While you are covered under this Agreement coverage is limited to treatment of fractured or dislocated
jaw, or to repair damage to sound natural teeth. Limitations and exclusions for dental services are
described in Section XVIII, Number 2 and Section XIV, Number 16 of this Schedule of Benefits.
Copayments will be the same as described for other illness or injury services.
POS-SCH9-92 19
The maximum annual Copayments for covered benefits, under this Schedule of Benefits, shall not
exceed the following in a Calendar Year as described in GLOSSARY OF TERMS, of the Group
Agreement/Subscriber Certificate of Coverage.
Benefits Maximum Annual Copayments
Per Member $4,000.00
Per Family $8,000.00
POS-SCI9-92 20
The following services are limited as described below:
The Utilization Review Department determines the Medical Necessity of services. You are respon-
sible for notifying the Utilization Review Department (UR) for the services listed below. The UR
phone number is (817) 878-5828. Benefits which are not Medically Necessary will be denied. The
ultimate decision on your medical care must be made by you and your Physician. The Utilization
Review Department only determines the Medical Necessity of a service, only services medically
necessary are paid for according to the Agreement benefits and provisions.
Benefits are reduced if you do not call UR prior to receiving services as required. The penalty for
not calling UR is a 50% reduction in benefit payment. The penalty is applied to each confinement,
surgical procedure, diagnostic procedure, or treatment plan.
Services which are provided under Harris HMO are not covered expenses under HMHIC.
Emergency Care which does not meet Harris HMO's definition will be covered under HMHIC.
Harris HMO's definition of Emergency Care shall mean bona fide emergency services provided
after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient
severity, including severe pain that the absence of immediate medical attention could reasonably
be expected to result in (1) placing the patient's health in serious jeopardy; (2) serious impair-
ment to bodily functions; or (3) serious dysfunction of any bodily organ or part. If an Emergency
Care situation exists follow the procedure outline in Harris HMO policy.
2. Care and treatment of the teeth or gums, except for oral surgery for tumors or injuries to the jaw
bone or surrounding tissue, is limited to the initial stabilization of acute, accidental non-occupa-
tional injury to sound, natural teeth when provided within thirty (30) days of the accident on an
outpatient basis only.
3. Coverage for vision examinations is limited to conditions which require examination to diagnose
injury or illness, unless covered by Rider attached to this Agreement.
4. The benefit for durable medical equipment is limited to either the total rental cost or the purchase
price of such equipment, whichever is less, as determined and authorized in advance by the
HMHIC Medical Director or his designee. HMHIC shall have no liability or responsibility for repair
or replacement of equipment lost or damaged.
5. Care and treatment provided in hospital owned or operated by federal government is limited to
the care for the condition which the law requires to be treated or provided in a public facility.
6. The purchase or fitting of eye glasses or contact lens or advice on their care is limited to the ini-
tial set of eye glasses, contact lens, or lens implant required following cataract surgery, repair of
congenital defect or as required by an accidental injury to you.
Coverage for reconstructive surgery is limited to surgery necessary to repair a functional disor-
der resulting from disease, injury (except Congenital defect); Congenital defect reconstructive
surgery will be covered. Supply or replacement of internal breast prosthesis is covered only if ini-
tial surgery was a result of injury or disease.
POS-SCH9-92 21
8. Coverage for treatment of the temporomandibular (jaw or craniomandibular) joint is limited to
Medically Necessary diagnostic services and/or surgical treatment as determined to be Medically
Necessary. Charges related to dental services for this condition are not covered.
9. If Medically Necessary and authorized by HMHIC, HMHIC will cover kidney transplants, corneal
transplants, liver transplants for children with congenital biliary atresia, and bone marrow trans-
plants for Aplastic Anemia; Leukemia; Lymphoma; Severe Combined immunodeficiency Disease;
or Waistcoat-Aldrich Syndrome where traditional modalities of traditional medical therapy have
been exhausted. Medical costs for organ procurement associated with the removal of an organ
for a covered transplant when the recipient is a Covered Person are limited to a maximum benefit
of $10,000.00. Charges related to organ, tissue, or artificial organ transplants except as other-
wise specified in this section are excluded. The donor's transportation costs are not covered.
Services provided to any Covered Person for the donation of any organ or element of the body
are not covered.
10. Benefits for grandchildren will be provided only if the child is considered to be a dependent of the
Subscriber for Federal income tax purposes, and upon payment of the applicable premium.
11. "Pre-existing Conditions" means any medical condition treated or diagnosed within the six (6)
months immediately preceding your effective date of coverage under this Agreement. A medical
condition has been "diagnosed" if its existence has been identified or recognized by a Physician
or other Health Professional. A medical condition has been "treated" if any services of a
Physician or other Health Professional have been received with respect thereto, including but not
limited to office visits or consultations, hospital treatment, laboratory services, X-rays or the dis-
pensing of prescription medication or refills.
Additional exclusions or limitations, if any, applicable under the policy with respect to a disease
or physical condition of a person, not otherwise excluded from the person's coverage by name of
specific description effective on the date of the person's loss, which existed prior to the effective
date of the person's coverage. In no event shall the limitation of 50% additional Copayment apply
to cost of treatment (which shall include all applicable Copayment as specified in the Schedule of
Benefits) commencing after the earlier of: (a) the end of a continuous period of twelve (12)
months commencing on or after the effective date of the person's coverage during all of which
the person has received no medical advice or treatment in connection with such disease or physi-
cal condition; and (b) the end of the two (2) year period commencing on the effective date of the
person's coverage.
The maximum amount of additional Copayment for a Pre-existing Condition during the period of
either one year or two year regardless of treatment, 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.
POS-SCH9-92 22
The following services and supplies, and the cost hereof, are excluded from coverage under this
Agreement, unless specifically added by Rider to this Schedule of Benefits.
Charges for services covered or provided under the Harris HMO Contract; including Emergency
Care Services (as defined by Harris HMO).
2. Charges related to any service or treatment which a Covered Person would not be legally required
to pay.
3. Charges related to personal, convenience or comfort items such as personal kits provided on
admission to a hospital, television, telephone, newborn infant photographs, guest meals, birth
announcements, and other related articles which are not for the specific treatment of illness or
injury.
4. Charges related to transportation, except charges related to land and air ambulance services for
Medically Necessary Emergency Care Services described in Section XI of this Agreement.
5. Charges related to private hospital room and/or private duty nursing unless determined to be
medically necessary and authorized by HMHIC Utilization Review.
6. Charges related to services rendered by a person who resides in the Covered Person's home, or
by an immediate relative of the Covered Person.
Charges related to services for military or service connected conditions for which the Covered
Person is legally entitled, and for which appropriate facilities are reasonably available to the
Covered Person.
8. Charges related to occupational injury or illness or conditions covered under Worker's
Compensation or similar law.
9. Charges for health care services primarily for rest, custodial, respite, domiciliary, or convalescent
care.
10. Charges related to reports, evaluations, or physical examinations not required for health reasons
(not Medically Necessary). Excluded items are: reports for employment, insurance, camp, adop-
tion, travel, or government licenses.
11. Charges related to drugs or medicines, prescription or non-prescription, provided to the Covered
Person while he or she is not an inpatient, unless specifically provided by a Rider to this
Schedule of Benefits.
12. Charges related to experimental drugs or substances not approved by the FDA for other than FDA
approved indications; and drugs labeled "Caution - limited by Federal Law to investigational use."
13. Charges related to formulas, dietary supplements, or special diets provided to the Covered
Person on an outpatient basis.
14. Charges related to vision care. Excluded services are: examination for eye glasses; refraction, dis-
pensing, or fitting of eye glass frames and lenses; all types of contact lens; eye exercise and visu-
al training; and orthoptics; except as otherwise specified in Section XVIII, Number 6 of this
POS-SCH9-92 23
Schedule of Benefits.
15. Charges related to radial keratotomy or other radial keratoplasties, and all costs associated with
such surgery.
16. Charges related to hearing aids, batteries, and examinations for fitting thereof unless added by
Rider to this Schedule of Benefits.
17. Charges related to the care and treatment of the feet unless such services are Medically
Necessary. Exclusions include routine foot care, such as removal of corns, calluses, or the trim-
ming of nails; treatment for flat feet; orthotics; arch supports; or custom fitted braces and splints.
18. Charges related to dental care, except as otherwise specified in Section XVI of this Schedule of
Benefits, including services related to the care, fillings, removal, or replacement of teeth; treat-
ment of diseases of the teeth or gums; extraction of wisdom teeth; malocclusion or malposition
of the teeth and jaws (mandibular hyperplasia/hypoplasia); professional services or anesthesia
related to or required for the sole purpose to provide dental care; hospital care; inpatient or out-
patient surgery required for any dental care; prescription drugs for dental treatment; dental x-
rays; dentures; and dental appliances or prostheses.
19. Charges related to surgical procedures and other treatment associated with the treatment of obe-
sity, regardless of associated medical or psychological conditions, including treatment of a com-
plication of surgical treatment for obesity. Excluded procedures are: intestinal or stomach bypass
surgery, gastric stapling, wiring of the jaw, insertion of gastric balloons, or similar procedures.
20. Charges related to transsexual surgery, including medical or psychological counseling or hor-
monal therapy, in preparation for or subsequent to any such surgery.
21. Charges related to services for cosmetic surgery or reconstructive surgery, except as otherwise
specified as covered in this Schedule of Benefits. Cosmetic surgery exclusions are: rhinoplasty;
scar revisions; prosthetic penile implants; surgical revision or reformation of any sagging skin on
any part of the body, described as relating to the eye lids, face, neck, abdomen, arms, legs or but-
tocks; liposuction procedures; any services performed in connection with the enlargement,
reduction, implantation or appearance of any portion of the body described as the breast, face,
lips, jaw, chin, nose, ears, or gentiles; hair transplantation; chemical face peels or abrasions of
the skin; removal of tatoos; and electrolysis depilation. Supply or replacement of internal breast
prosthesis is covered only if initial surgery was a result of injury or disease.
22. Charges related to reduction mammoplasty, unless determined to be Medically Necessary by the
HMHIC Medical Director of his designee.
23. Charges related to reversal of surgically performed sterilization or subsequent resterilization.
24. Charges related to surrogate parenting; GIFT procedures; and any costs associated with the col-
lection or storage of sperm for artificial insemination including donor fees; and infertility medica-
tions unless specifically provided by a Rider to this Schedule of Benefits.
25. Charges related to amniocentesis, ultrasound, or any other procedure preformed solely for sex
determination of the fetus.
POS-SCH9-92 24
26. Charges related to mental health services for psychiatric conditions which are determined by the
HMHIC to be not Medically Necessary in nature and beyond the maximum days allowed by
HMHIC.
27. Charges related to court ordered testing, and special reports not directly related to medical
treatment.
28. Charges related to services for the treatment of mental retardation and mental deficiency
29. Charges related to employment, vocational, or marriage counseling; behavioral training; remedial
education, including evaluation and treatment of learning and developmental disabilities and min-
imal brain dysfunction; or attention deficit therapy.
30. Charges related to services for chronic intractable pain provided by a pain control center;
acupuncture, naturopathy, and hypnotherapy; holistic or homeopathic care, including drugs; and
ecological or environmental medicine.
31. Charges related to durable medical equipment, unless described in this Schedule of Benefits.
Excluded items are: (a) deluxe equipment, such as motor driven wheel chairs and beds, possess-
ing features of an aesthetic nature or features of a medical nature which are not required by the
patient's condition; (b) items not primarily medical in nature or for the patient's comfort and con-
venience, such as bed boards, bathtub lifts, over-bed tables, adjust-a-bed, and telephone arms;
(c) physician's equipment such as stethoscope and sphygmomanometer; (d) exercise equipment
such as exercycles and enrollment in health or athletic clubs; (e) self-help devices not primarily
medical in nature, such as sauna or whirlpool baths, chairs, and elevators; (f) corrective orthope-
dic shoes and arch supports; (g) supplies or equipment for common household use, such as but
not limited to, air purifiers, central or unit air conditioners, water purifiers, allergenic pillows or
mattresses, and water beds; and (h) research equipment or items deemed to be experimental as
determined by the HMHIC. HMHIC shall have no liability or responsibility for repair or replace-
ment of equipment lost or damaged.
32. Charges related to prosthetic medical appliances, except as specified in Section XIV of this
Schedule of Benefits. Excluded items include: (a) dentures, hearing aids unless specifically pro-
vided by a Rider, and contact lens; (b) medical supplies such as elastic stockings, garter belts,
arch supports, corsets, and corrective orthopedic shoes; (c) research devices or items deemed to
be experimental as determined by HMHIC; and (d) replacement, repair, and routine maintenance
of covered appliances or braces unless surgically implanted, or replacement required due to a
marked change in physical growth or physical requirements.
33. Charges related to medical supplies, aids, and appliances except as otherwise specified as cov-
ered in this Schedule of Benefits. Excluded items are: consumables, disposable supplies,
sheaths, bags, gloves, cervical collars, elastic stockings, stethoscopes, blood pressure units,
traction apparatus, slings, TENS units or electrical nerve stimulation devices, wigs or hair pieces,
dressings, testing supplies, syringes, home testing kits, disposable diapers or incontinent sup-
plies, and over-the-counter medications.
34. Charges related to inpatient or outpatient long-term neuromuscular, or occupational therapy ser-
vices or other rehabilitation services in excess of sixty (60) visits per twelve (12) month period,
per condition, are not a covered benefit.
35. Charges related to recreational, educational, or sleep therapy, and any related diagnostic testing,
except as provided by the hospital as part of an approved inpatient hospitalization.
POS-SCH9-92 25
36. Charges related to structural changes to a house or vehicle.
37. Charges related to any medical, surgical, or health care procedure or treatment held to be experi-
mental or investigational at the time the procedure or treatment is performed. HMHIC will utilize
findings and assessments of national medical associations, professional societies and organiza-
tions, and any appropriate technological body established by any state or federal government or
similar entities to determine coverage and/or effectiveness.
38. Charges exceeding the Reasonable and Customary amounts as determined by HMHIC.
POS-SCH9-92 26
PRESCRIPTION DRUG RIDER
FOR USE ONLY WITH HMHIC HEALTH CARE AGREEMENT
1.0
2.0
INTRODUCTION
In consideration for the timely payment of premiums, and all other terms and conditions of the
Group Health Care Agreement, and/or Certificate of Insurance, it is agreed that the benefits of this
Rider, together with the terms and conditions of this Rider, shall be added to Agreement as
issued if this Rider is accepted by the Group.
DEFINITIONS
Benefits for outpatient prescription drugs provided through this Rider shall be subject to the pro-
visions and definitions of Agreement to which this Rider is a part.
In addition, for the purpose of this Rider, the following definition shall apply:
Prescription Drugs shall mean only those drugs and medicines which are prescribed by a
Physician and legally require the written prescription of a Physician before it can be
obtained by the Covered Person.
3.0 BENEFITS
Benefits limitation and Covered Person cost shall be as follows:
30% Copayment by Covered Person
COVERED ITEMS
Federal Legend Drugs and compounds requiring a prescription (including insulin), except those
specifically excluded. Generic Substitutions are covered.
EXCLUSIONS
(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 syringes and miscellaneous diabetic supplies, including urine and blood glucose
strips
(7) Injectable Medications, other than insulin
(8) Blood, Blood Plasma and Blood Products, except those dispensed by outpatient facility
(9) Experimental Drugs
(10) Immunization Agents, except those dispensed in the physician's office
(11) Fertility Medications
(12) Drugs not requiring a prescription (OTC, Vitamins, Cough Syrup, etc.)
(13) Drugs to be consumed in an inpatient or other institutional care setting
(14) Nicorette gum
POS-SCH9-92 27
(15) Drugs requiring parenteral use or subcutaneous use
(16) Charges for cost difference in a brand name product when generic drugs are prescribed or
permitted by physician
(17) Nutritional or dietary supplement, or formulas other than prescription required vitamins
(PKU formula, including other heritable diseases are covered as other prescription drugs)
(18) Medications dispensed by physician offices
(19) Prescription Drugs for cosmetic conditions not covered in the Schedule of Benefits (such
as Retin-A, Minoxidil, etc.)
COVERED QUANTITIES
As prescribed, up to a maximum of a 30 day supply for each covered prescription or refill.
Prescriptions shall not be refilled until approximately 75% of the previously dispensed quantity
has been consumed, based on dosage instructions of the physician. Covered Person must pay in
full for any amounts exceeding covered quantities, including lost or misplaced medications.
COVERED REFILLS
A maximum of five (5) refills per prescription shall be covered if allowed by law and authorized
by Physician, provided such refills are dispensed within six (6) months of the initial prescription
date.
4.0 ELIGIBILITY
Benefits under this Rider are available to the Employee and his Dependents (Covered Persons) as
identified in Agreement.
Benefits provide no conversion privileges or benefit continuity for Covered Persons when such
persons are no longer entitled to Group benefits as set forth in Agreement to which this Rider is
issued.
POS-SCH9-92
28
HARRIS HEALTH PLAN, INC.
1300 Summit Avenue
Fort Worth, TX 76102
(817) 878-5830
1-800-633-8598
GROUP ENROLLMENT AGREEMENT
Application is hereby made to Harris Health Plan, Inc., hereinafter called "Harris
Health" by the Applicant named below, hereinafter called "Group" for the purpose of making
available to Eligible Persons and their Eligible Dependents under a Group Health Care
Agreement/ Subscriber Certificate of Coverage, hereinafter called "Agreement" issued by Harris
Health, certain prepaid health care services and benefits. The arrangement of the provisions
of such services and benefits shall be the subject of the Agreement between Harris Health and
Group and shall be based on the statements and representations contained in this Group
Enrollment Agreement, a copy of which shall be incorporated by reference and made a part of
the Agreement.
1.0 GROUP
Group Name: City of Denton
Address: 324 East McKinney
City: Denton State: TX Zip Code: 76201
2.0 GROUP EFFECTIVE DATE
This Group Enrollment Agreement shall be effective 12:01 A.M., Central Time, on the
let day of January 1994.
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 eligibility guidelines provided by the City of
4.0 HEALTH CARE SERVICES (BENEFITS) AND COPAYMENTS
Eligible Persons and Eligible Dependents of Group are entitled to Health Care Services
and Benefits as follows:
A. Basic Health Care Services:
X Covered - Basic Health Care Services as described in the
schedule of Benefits.
B. Prescription Drug:
X Accepted
Not Accepted
5.0 COVERAGE BASIS
X Contributory
Non-Contributory
6.0 SCHEDULE OF RATES
Total Monthly
Rate
Active
Employee
Only
$217.80
Employee
+ Spouse
$337.59
Employee
+ Child(ren)
$291.85
Employee
+ Family
$368.08
Retirees Under 65
Retiree
only
$295.03
Retiree
and Spouse
$568.47
Retiree
and Child(ren)
$459.69
Retiree
and Family
$698.43
Retirees 65 or over (Medicare serves as Primar
Retiree Only
$108.90
2
on Medicare
$217.80
1
on, off
$444.31
1
on, 1 off + Family
$644.25
2
on + Family
$425.21
Group Enrollment Agreement shall be automatically renewed at the end of each
Contract period unless terminated by Harris Health or Group as provided in Agreement.
The first Contract period shall commence as of the Group Effective Date and will remain
in effect for twelve (12) consecutive months unless terminated before this date by
Harris Health or Group.
IN WITNESS WHEREOF, the undersigned have caused the Group Enrollment Agreement to be
executed on the 0~ly day of~~
City of Denton
Group
By:
Authorized
Title:_
Address:
Denton TX 76201
Telephones
HARRIS HEALTH LAN, INC.
By. Title:Senior Vice President/Managed Care
Marketing
C:CONTRACT.lyaP51
AE:
Harris Methodist
Health Plan
M
GROUP HEALTH CARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
817/878-5826
1-800/633-8598
GA-992
Harris Health Plan, Inc.
Health Maintenance Organization
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
IMPORTANT NOTICE
To obtain information or make a complaint:
You may call Harris Health Plan, Inc.'s toll-free
telephone number for information or to make a
complaint at:
1-800-633-8598
You may contact the Texas Department of
Insurance to obtain information on companies,
coverages, rights or complaints at:
1-800-252-3439
You may write the Texas Department of
Insurance
P.O. Box 149104
Austin, TX 78714-9104
FAX (512) 475-1771
ATTACH THIS NOTICE TO YOUR POLICY:
This notice is for information only and does not
become a part or condition of the attached
document.
AVISO IMPORTANTE
Para obtener information o para someter una
queja:
Usted puede Ilamar al numero de telefono gratis de
Harris Health Plan, Inc. para informacion o para
someter una queja al:
1-800-633-8598
Puede comunicarse con el Departmento de Seguros
de Texas para obtener informacion acerca de
companias, coberturas, derechos o quejas al:
1-800-252-3439
Puede escribir al Departmento de Seguros de
Texas
P.O. Box 149104
Austin, TX 78714-9104
FAX # (512) 475-1771
UNA ESTE AVISO A SU POLIZA: Este aviso es
solo para proposito de informacion y no se
convierte en parte o condition del documento
adjunto.
TABLE OF CONTENTS
Page Page
1.0 General Definitions 2 8.0 Independent Agents/Refusal to Accept
18
2.0 Group and Affiliated Organizations
6
2.1 Organizations Included Under This
Agreement
6
2.2 Change of Affiliated Organizations
6
3.0 Eligibility and Effective Date
6
3.1 Eligible Persons
6
3.2 Eligible Dependents
6
3.3 Change in Group Eligibility Criteria
7
3.4 Effective Date for Eligible Persons
7
3.5 Effective Date for Eligible Dependents
7
3.6 Persons Not Eligible for Coverage
8
3.7 Conditions of Eligibility
8
3.8 Notification of Ineligibility
8
3.9 Clerical Error
8
4.0 Group and Member Termination, Continuation of
Benefits and Conversion
8
4.1 Termination of Group
8
4.2 Termination of Member - For Cause
9
4.3 Termination of Meniber - Other Than for
Cause
10
4.4 Liability Upon Termination
.10
4.5 Continuation of Coverage
.10
4.6 Conversion Privilege
.11
5.0 Payment Requirements
.11
5.1 Premium Payments
.11
5.2 Notification by Group
.12
5.3 Cbpayments
.12
6.0 Claim Provisions
.13
6.1 Charges Paid by Members
..13
6.2 Medical Emergency
..13
6.3 Action on Claim
..13
6.4 Examination of Member
..13
6.5 Limitation Provisions
..13
7.0 Coordinationand Subrogation of Benefits
..14
7.1 Definitions
..14
7.2 Determination of Benefits
..14
7.3 Order of Benefit Determination
..15
7.4 Medicare
..16
7.5 Right to Receive and Release Information
...17
7.6 Facility of Payment
...17
7.7 Right of Recovery
...17
7.6 Disclosure
...18
7.9 Subrogation
...18
Treatment
8.1 Independent Agents
.....18
8.2 Limitation on Liability
.....19
8.3 Refusal to Accept Treatment/Excessive
Treatment
.....19
9.0
Exclusions on Service Responsibilities
.....19
9.1 Major Disaster or Epidemic
.....19
9.2 Circumstances Beyond Control
......20
9.3 Fraudulently Obtained Benefits
......20
9.4 Discontinuance
......20
10.0
Member Complaint Resolution Procedure
......20
10.1 Complaint Resolution Process
.....20
10.2 Complaint Resolution Appeal Process
......21
11.0
Health Care Services
.....21
11.1 Benefits and Services
......21
12.0
Term and Amendment of Agreement
.......22
12.1
Term
.......22
12.2
Amendment
.......22
12.3
Change of Rates
.......22
13.0
Miscellaneous Provisions
.......22
13.1 Use of Words
.......22
13.2 Records and Information
.......22
13.3 Information from Group
.......22
13.4 Assignment
.......23
13.5 Authority
........23
13.6 Governing Law
........23
13.7 Incorporation by Reference
........23
13.8 Entire Agreement
........23
13.9 Information to Member
........23
13.10 Uniform Rules
........23
13.11 Calculation of Time
........23
13.12 Evidence
........23
13.13 Severability
........23
13.14 Venue
........24
13.15 Waiver of Notice
.........24
13.16 Headings
.........24
13.17 Notice of Certain Events
.........24
13.18 Notice of Termination
.........24
13.19 Notice
.........24
Attachment A Service Area Map and Description
1
Section 1.0
GENERAL DEFINITIONS
1. ACTIVELY AT WORK shall mean that the eligible employee must be performing the usual and cus-
tomary duties of his regular employment during his usual working hours on his effective date of
coverage; provided, however that if the eligible employee is absent from work due to vacation,
holiday, jury duty, or other similar circumstances, not caused by injury or illness, such employee
shall be considered actively at work.
2. ACUTE shall mean a condition of sudden onset or severe symptomatology which mandates imme-
diate intervention.
3. AGREEMENT shall mean this Group Health Care Agreement/Subscriber Certificate of Coverage,
Group. Enrollment Agreement, Applications, all Attachments, Riders, Amendments hereto, if any.
4. ALLIED HEALTH PROFESSIONAL shall mean a dentist, nurse, audiologist, optometrist, physician's
assistant, clinical psychologist, pharmacist, nutritionist, physical therapist, speech language
pathologist, dietician, podiatrist, certified social worker (advanced clinical practitioner) and other
professionals engaged in the delivery of health services who are licensed, practice under an insti-
tutional license, are certified, or practice under the authority of a Physician or legally constituted
professional association, or other authority consistent with the laws of the State of Texas.
5. ALTERNATIVE HEALTH BENEFIT PLAN shall mean the plan which the Group designates as the
alternative to this Agreement.
6. APPLICATION shall mean the form prescribed by Harris Health which each Eligible Person shall
on his/her own behalf and or, behalf of his/her Eligible Dependents, be required to complete and
submit to Harris Health for the purpose of enrolling himself/herself and such dependents for cover-
age hereunder.
7. CHEMICAL DEPENDENCY, means the abuse of or psychological or physical dependence on or
addiction to alcohol or a controlled substance.
8. CHEMICAL DEPENDENCE TREATMENT CENTER shall mean a facility which provides a program
for the treatment of chemical dependence pursuant to a written treatment plan approved and
monitored by a physician and which facility is also:
a. affiliated with a hospital under a contract agreement with an established system for patient
referral; or
b. accredited as such a facility by the Joint Commission on Accreditation of Health Care Organi-
zations; or
c. licensed as a chemical dependency treatment program by the Texas Commission on Alcohol
and Drug Abuse; or
d. licensed, certified, or approved as a chemical dependency treatment program or center by
any other state agency having legal authority to so license, certify or approve.
9. COMPLICATIONS OF PREGNANCY shall mean those conditions, requiring hospital confinement
(when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are
adversely affected by pregnancy or caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical and surgical conditions of compa-
rable severity. Complications or pregnancy shall not include false labor, occasional spotting, physi-
cian prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum,
pre-eclampsia, and similar conditions associated with the management of a difficult pregnancy not
constituting a nosologically distinct complication of pregnancy; non-elective cesarean section, ter-
mination of ectopic pregnancy, or spontaneous termination of pregnancy occurring during a
period of gestation in which a viable birth is not possible.
10. CONTRACT YEAR shall mean the period of twelve (12) months commencing on the Group Effec-
tive Date and each twelve (12) month period thereafter, unless otherwise terminated as hereinafter
provided.
11. CONTROLLED SUBSTANCE shall mean a toxic inhalant or a substance designated as a con-
trolled substance in the Chapter 481, Health and Safety Code.
12. COPAYMENT shall mean the fee as set forth in the Schedule of Benefits which is not covered by
premiums payable hereunder, and which must be paid by Members directly to the person or
entity providing the service when the service as set forth in the Schedule of Benefits is received.
13. COURSE OF TREATMENT shall mean that period of time represented by an inpatient hospital
admission and related discharge during which time treatment has been received by a Member or
that period of time authorized by a Participating Physician and/or Harris Health as necessary to
complete a cycle of treatment and subsequently provide a medical release to.the Member.
14. CRISIS STABILIZATION UNIT shall mean a twenty-four (24) hour residential program, licensed by
Texas Department of Mental Health and Mental Retardation, that is usually short-term in nature
and that provides intensive supervision and highly structured activities to persons who are demon-
strating an acute demonstrable psychiatric crisis of moderate to severe proportions.
15. CUSTODIAL CARE shall mean 1) that care which is marked by or given to watching and protect-
ing rather than seeking to cure; or 2) care which is not a necessary part of medical treatment or
recovery; or 3) care comprised of services and supplies that are primarily provided to assist in the
activities of daily living.
16. DEPENDENT shall mean an Eligible Dependent who has satisfied the eligibility and participation
requirements specified in this Agreement.
17. DOMICILIARY CARE shall mean that care provided for persons so disabled or infirm as to be
unable to live independently.
18. EFFECTIVE DATE shall mean the effective date of coverage for Eligible Persons and Eligible
Dependents pursuant to the terms of this Agreement.
19. ELIGIBLE DEPENDENT shall mean an individual as defined in Section 3.2 of this Agreement.
20. ELIGIBLE PERSON shall mean an individual as defined in Section 3.1 of this Agreement.
21. EMERGENCY CARE shall mean bona fide emergency services provided after the sudden onset of
a medical condition manifesting itself by acute symptoms of sufficient severity, including severe
pain, such that the absence of immediate medical attention could reasonably be expected to
result in placing the patient's health in serious jeopardy; serious impairment to bodily functions; or
serious dysfunction to any bodily organ or part.
22. EVIDENCE OF INSURABILITY shall mean that an Eligible Person or Eligible Dependent verifies
that they were enrolled for the preceeding twelve (12) months in a group or individual plan provid-
ing benefits for medical, surgical and hospital expenses; and completes the Evidence of Insurabil-
ity form and provides timely any additional documentation of health status as required by Harris
Health. Such information shall be reviewed by Harris Health and the Eligible Person or Eligible
Dependent shall be notified regarding their eligibility for participation in Harris Health.
23. EXCLUSION shall mean those specific conditions or causes for which coverage by Harris Health
is entirely excluded.
24. FDA shall mean the Food and Drug Administration, an agency of the United States government.
25. GROUP shall mean collectively the contracting employer and all affiliated organizations of the
employer as set forth in Attachment A annexed hereto and made a part hereof, to which this
Agreement is issued and through which as agent for Subscriber and not for Harris Health, Sub-
scriber and Dependents become entitled to the benefits as set forth in the Schedule of Benefits.
26. GROUP EFFECTIVE DATE shall mean the date specified as such in the Group Enrollment
Agreement.
27. GROUP ENROLLMENT AGREEMENT shall mean that agreement which is executed between Har-
ris Health and Group for the purpose of making available to Eligible Persons and Eligible Depen-
dentsof Group those benefits and services which are described in the Group Health Care
Agreement/ Subscriber Certificate of Coverage. Such Group Enrollment Agreement shall identify
the Group, Group Effective Date, eligibility requirements, rates, and covered benefits.
28. HARRIS HEALTH shall mean Harris Health Plan, Inc., a Texas not-for-profit corporation organized
as a Health Maintenance Organization (HMO) and licensed by the Texas Department of
Insurance.
29. HEALTH PLAN shall mean the Health Maintenance Organization operated by Harris Health d/b/a.
Harris Methodist Health Plan.
30. HOSPITAL shall mean an institution licensed by the State of Texas and which is (1) primarily
engaged in providing diagnostic, medical and surgical facilities for the care and treatment of
injured or sick persons, (2) operated under the medical supervision of a staff of legally qualified
and licensed physicians, (3) provides twenty-four (24) hour-a-day nursing service by or under the
direct supervision of a Registered Nurse (R.N.), (4) provides for overnight care of patients, (5)
maintains clerical and ancillary services necessary for the treatment of medical and surgical
patients including but not limited to laboratory, X-ray, dietary and medical records library. In no
event shall the term "hospital" include a convalescent nursing home or any institution or part
thereof which is used principally as a convalescent facility, rest facility, nursing facility, facility for
the aged, extended care facility, intermediate care facility, skilled nursing facility or facility primarily
for rehabilitative services; the term hospital shall, pursuant to Chapter 3, Texas Insurance Code,
Article 3.72 include treatment in a residential treatment center for children and adolescents and
treatment provided by a crisis stabilization unit.
31. INDIVIDUAL TREATMENT PLAN shall mean a treatment plan with specific attainab;e goals and
objectives appropriate to both the patient and the treatment modality of the program.
32. KIDNEY DIALYSIS CENTER shall mean any facility licensed by the State of Texas, approved by
Medicare to provide outpatient services and/or instruction in home kidney dialysis treatments arid,
which has contracted with Harris Health to provide care to Members.
33. MEDICAL DIRECTOR shall mean the licensed Physician designated by Harris Health and/or such
other Physicians as the Medical Director may designate with the prior approval of Harris Health.
Such physician Shall be responsible for supervising the delivery of medical services to Members
and for monitoring the quality of medical care rendered to Members.
34. MEDICAL EMERGENCY shall mean a medical condition so classified by the medical director and
which manifests itself by acute symptoms of sufficient severity (including severe pain) such that
the absence of immediate medical attention could reasonably be expected to result in (a) placing
the patient's health in serious jeopardy; or (b) serious impairment to bodily functions; or (c) serious
dysfunction to any bodily organ or part. Examples of conditions which do not usually constitute
medical emergencies are colds, influenzas, ordinary sprains, children's ear infections, or nausea
and headaches. Heart attacks, cardiovascular accidents, poisonings, loss of consciousness or
respiration, convulsions, severe bleeding or broken bones are examples of true medical
emergencies.
35. MEDICALLY NECESSARY shall mean services or supplies which are (1) provided for the diagno-
sis or care and treatment of a medical condition; (2) appropriate and necessary for the symptoms,
diagnosis or treatment of a medical condition; (3) generally acceptable medical practice; (4) per-
formed in the most cost effective and efficient manner appropriate to treat the plan Members
medical condition; and (5) provided in accordance with accepted medical standards and Harris
Health requirements as approved by the Health Plan's review committees for professional and
technical practices and the Health Plan Medical Director.
36. MEDICARE shall mean Part A and Part B of Title XVIII of the Social Security Act and any amend-
ments or regulations thereunder.
37. MEMBER shall mean any Subscriber and/or Dependent.
38. MEMBER HOSPITAL shall mean any Hospital which has contracted with Harris Health to provide
to Members the services as set forth in the Schedule of Benefits and described in this Agreement.
39. NON-MEMBER HOSPITAL shall mean any Hospital which has not contracted with Harris Health to
provide to Members the services as set forth in the Schedule of Benefits and described in this
Agreement.
40. MINOR EMERGENCY CENTER shall mean any licensed facility, not including a Hospital, which
provides Physician services for the immediate treatment only of an injury or disease.
41. NON-PARTICIPATING PHYSICIAN shall mean a Physician who is not a Participating Physician and
to whom a Member is referred for consultation or treatment by a Participating Physician only with
prior written approval of Harris Health unless there is a Medical Emergency and a Participating
Physician is not available.
42. NON-PARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professional,
Home Health Agency, Laboratory, Minor Emergency Center, Residential Treatment Facility, Chemi-
cal Dependency Treatment Center, or other licensed healthcare professional or other provider or
entity which has not contracted with Harris Health to provide to Members the services as set forth
in the Schedule of Benefits and described in this Agreement.
43. OPEN ENROLLMENT PERIOD shall mean a period of at least thirty (30) days during each twelve
(12) consecutive months when Eligible Persons may elect to change from the Alternative Health
Benefit Plan to Harris Health or from Harris Health to the Alternative Health Benefit Plan.
44. PARTICIPATING PHYSICIAN shall mean any Physician who has contracted with Harris Health to
provide to Members the services as set forth in the Schedule of Benefits and described in this
Agreement.
45. PARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professional, Home
Health Agency, Laboratory, Minor Emergency Center, Chemical Dependency Treatment Center,
Psychiatric Day Treatment facility or other provider or entity which has contracted with Harris
Health to provide to Members the services as set forth in the Schedule of Benefits and described
in this Agreement.
46. PSYCHIATRIC DAY TREATMENT FACILITY shall mean a mental health facility which provides
treatment for individuals suffering from acute mental and nervous disorders in a structured psychi-
atric program utilizing individualized treatment plans with specific attainable goals and objectives
appropriate both to the patient and the treatment modality of the program and that is clinically
supervised by a Physician who is certified in Psychiatry by the American Board of Psychiatry and
Neurology. The facility shall be licensed by the State of Texas, accredited by the Program for Psy-
chiatric Facilities, or its successor, of the Joint Commission on Accreditation of Health Care Orga-
nizations, and shall have contracted with Harris to provide to Members the mental health services
as set forth in the Schedule of Benefits and described in this Agreement.
47. PHYSICIAN shall mean any individual (other than a hospital resident or intern) who is fully licensed
and qualified to practice within the scope of the license under the law of the jurisdiction in which
treatment is received.
48. -PRIMARY PHYSICIAN shall mean, with respect to each Member, those Participating Physicians
who are designated by Harris Health and identified in writing to Members as Physicians having
primary responsibility for coordinating such Member's medical care, providing initial and primary
care to Members, maintaining the continuity of such Members care and initiating referrals for spe-
cialist care.
49. RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS shall mean a child-
care institution that provides residential care and treatment for emotionally disturbed children and
adolescents, licensed by Texas Department of Mental Health and Mental Retardation, and that is
accredited as a residential- treatment center by the Council on Accreditation, the Joint Commission
on Accreditation of Health Care Organizations or the American Association of Psychiatric Services
for Children.
50. RIDER shall mean a Schedule provided with this Agreement, and made a part hereof, which sets
forth additional benefits and services made available by Harris Health by amending this Schedule
of Benefits.
51. SCHEDULE OF BENEFITS shall mean the schedule which sets forth the benefits and services that
Harris Health shall make available to Members.
52. SEMI-PRIVATE shall mean the charge made by a Member Hospital for a room containing two (2)
or more beds.
53. SERVICE AREA shall mean the geographic area as set forth and annexed hereto as Attachment
A.
54. SHORT TERM shall mean a course of treatment lasting thirty (30) days or less.
55. SPECIALIST PHYSICIAN shall mean any Physician who has contracted with Harris Health to pro-
vide specialist care to Members upon referral of a Primary Physician or upon referral of another
Specialist Physician with the concurrence of the responsible Primary Physician.
56. SKILLED NURSING FACILITY shall mean an institution or part thereof, licensed by state or local
law, that is accredited as an Extended Care Facility by the Joint Commission on Accreditation of
Health Care Organizations, or is recognized as a Skilled Nursing Facility by the Department of
Health and Human Services under Title XVIII of the Social Security Act (Medicare), as amended.
57. SUBSCRIBER shall mean an Eligible Person who has satisfied the eligibility and participation
requirements specified in this Agreement.
58. TOXIC INHALANT means a volatile chemical under Chapter 484, Health and Safety Code, or
abusable glue or aerosol paint under Section 485.001, Health and Safety Code.
59. USUAL, CUSTOMARY, AND REASONABLE CHARGES shall mean the charge is (1) the fee
charged by a provider in normal practice for a given service; (2) within the range of usual charges
by providers for the same service in the geographic area where services are provided to a Mem-
ber; and (3) reasonable when taking into consideration any unusual circumstances or medical
complications requiring additional time, skill and experience in providing a specific treatment or
service.
Section 2.0
GROUP AND AFFILIATED ORGANIZATIONS
2.1 ORGANIZATIONS INCLUDED UNDER THIS AGREEMENT
The Group and its affiliated organizations are included under this Agreement. Affiliated organi-
zations include all those organizations which are subsidiary to or affiliated with the Group and located
within the Service Area of Harris Health.
2.2 CHANGE OF AFFILIATED ORGANIZATIONS
The Group shall notify Harris Health, in writing, when an affiliated organization ceases to be a
subsidiary of, or affiliated with, the Group. When an organization ceases to be a subsidiary of, or affili-
ated with, the Group, it shall cease to be an included organization. Therefore, this Agreement shall ter-
minate on the date of such cessation with respect to all Eligible Persons of that organization, except for
those persons who on the next day are employees of another affiliated organization and thus Eligible
Persons under this Agreement.
Section 3.0
ELIGIBILITY AND EFFECTIVE DATE
3.1 ELIGIBLE PERSONS
To be eligible to enroll as a Subscriber, a person must reside in the Service Area and be an Eli-
gible Person as follows:
• In the employment of the Group or a bona fide Member of the Group, and/or
• Eligible under the eligibility criteria established by the Group; and
• Entitled on his or her behalf to participate in the medical and hospital care benefits arranged
by the Group.
3.2 ELIGIBLE DEPENDENTS
To be eligible to enroll as a Dependent, a person must reside in the Service Area and be:
• The legal spouse of a Subscriber;
• A dependent unmarried natural child, foster child, stepchild, legally adopted child or child
under Subscriber's court appointed legal guardianship, residing with Subscriber or with Sub-
scribers present or former spouse in the Service Area who is (a) under nineteen (19) years
of age, or (b) under twenty-five (25) years of age and primarily dependent on the Subscriber
for financial support and attending an accredited college or university, trade or secondary
school on a full-time basis, which has, in writing, verified said attendance or;
A dependent unmarried natural child, foster child, stepchild, legally adopted child, or child
under Subscriber's court appointed legal guardianship, residing with Subscriber or with Sub-
scriber's present or former spouse in the Service area who is nineteen (19) years of age or
older but incapable of self-sustaining employment because of mental retardation or physical
handicap which commenced prior to age nineteen (19) (or commenced prior to age twenty-
five (25) if such child was attending a recognized college or university, trade or secondary
school on a full-time basis when such incapacity occurred), and primarily dependent upon
the Subscriber for support and maintenance.
Such dependent child must have been a Member either prior to attaining nineteen (19) years
of age or twenty-five (25) years of age under the conditions of the previous sentence. Sub-
scriber shall furnish Harris Health proof of such incapacity and dependency within thirty-one
(31) days before the dependent child's attainment of the limiting age and from time to time
thereafter as Harris Health deems appropriate, but not more frequently than annually.
Maternity care benefits will be extended to an unmarried Dependent Child. If coverage is
provided to the Dependent of the Subscriber, upon payment of the premium, benefits must
be provided for any children of the Dependent if those children are Dependents of the Sub-
scriber for federal income tax purposes.
3.3 CHANGE IN GROUP ELIGIBILITY CRITERIA
Requirements as defined by the Group for determining the eligibility for participating in Harris
Health are material to the execution of this Agreement by Harris Health. During the tern of this Agree-
ment no change in the Group definition of eligibility for participation shall be permitted to affect eligibil-
ity or enrollment under this Agreement in any manner unless such change is approved in advance by
mutual written agreement between Group and Harris Health.
3.4 EFFECTIVE DATE FOR ELIGIBLE PERSONS
3.4.1 Open Enrollment Period
An Eligible Person who applies for coverage in Harris Health by submitting an Application dur-
ing an Open Enrollment Period shall become covered as a Subscriber on the Group Effective Date or
such Effective Date specified as such for the Open Enrollment Period.
3.4.2 On Acquiring Eligibility Status
An Eligible Person who first meets the eligibility requirements other than during the Open
Enrollment Period may enroll within thirty (30) days of meeting such requirements by submitting an
Application. Such person shall become covered under Harris Health as a Subscriber on the first day
he became an Eligible Person provided that the premium applicable to the Subscriber has been
received in accordance with this Agreement.
3.5 EFFECTIVE DATE FOR ELIGIBLE DEPENDENTS
3.5.1 Open Enrollment Period
An Eligible Dependent for whom the Subscriber has applied for coverage in Harris Health by
submitting an Application during an Open Enrollment Period shall become covered as a Dependent
on the Effective Date of the Subscriber.
3.5.2 On Acquiring Eligibility Status
A newly acquired Eligible Dependent, and an Eligible Dependent other than a newborn child
who first meets the eligibility requirements of Group on other than during an Open Enrollment Period,
may be enrolled by the Subscriber within thirty (30) days of meeting such requirements by submitting
an Application. Such Eligible Dependent shall become covered under Harris Health as a Dependent
on the day he became an Eligible Dependent provided that the premium applicable to the Dependent
has been received in accordance with this Agreement described in Section 5.1.
Coverage for newly adopted children shall commence on the earlier of (a) the date upon which
such child commences residence with the Subscriber or (b) when the adoption becomes legal.
Adopted children and newborn children. shall be covered under Harris Health for an initial period of
thirty-one (31) days and shall continue to be so covered after that time only if, prior to the expiration of
such thirty-one day period, an Application has been submitted and the premium applicable to the
Dependent has been received in accordance with this Agreement described in Section 5.1.
3.6 PERSONS NOT ELIGIBLE FOR COVERAGE
Notwithstanding the foregoing provisions of this Section, persons not eligible for cover-
age in Harris Health shall be as follows:
Coverage Previously Terminated: No person shall be eligible to become a Member who has
had coverage terminated by Harris Health for cause, as described in Section 4.2 of this
Agreement.
Indebtedness: No person shall be eligible to become a Member if such person has unpaid
financial obligations arising from prior coverage in Harris Health.
3.7 CONDITIONS OF ELIGIBILITY
No Eligible Person or Eligible Dependent shall be refused enrollment by Harris Health because
of health status, requirements for health services, or the existence of a Pre-Existing Condition on the
Group Effective Date. In addition, no Member's coverage shall be terminated by Harris Health due to
his health status or his healthcare needs. If an Eligible Person or Eligible Dependent applies for cover-
age on a date other than Open Enrollment Period or more than thirty (30) days after becoming an Eligi-
ble Person or Eligible Dependent, then such Eligible Person-or Eligible Dependent shall have to
document Evidence of Insurability as required by Harris Health.
3.8 NOTIFICATION OF INELIGIBILITY
A condition of participation in Harris Health is Subscriber's agreement to notify Harris Health of
any changes in status that affect Subscriber or the ability of the Subscriber's Dependents to meet the
eligibility criteria set forth in this Section.
3.9 CLERICAL ERROR
Eligibility under this Agreement shall in no event be invalidated by failure of the Group, due to
clerical error, to record or report an Eligible Person or Eligible Dependent to Harris Health if an Appli-
cation had been completed and submitted to Group as required under the terms of this Agreement by
or on behalf of such Eligible Person or Eligible Dependent and that the premium applicable to such
coverage had been received by Harris Health.
Section 4.0
GROUP AND MEMBER TERMINATION, CONTINUATION OF
BENEFITS AND CONVERSION
4.1 TERMINATION OF GROUP
4.1.1 Default in Payment of Premium
If Group fails to pay to Harris Health the premium payable hereunder on or before the thirty-first
(31) calendar day after such payment is due, this Agreement may be terminated by Harris Health and
all benefits and services shall cease at the end of such thirty-one (31) day grace period. Group may
be held liable for the cost of all benefits and services provided to Member by Harris Health during the
grace period. Group shall remain liable for all premiums (and any interest accrued thereon) not paid
prior to termination. Interest on late payments from the date such premiums were due may be charged
at a rate equal to eighteen percent (18%) per year. Unpaid interest shall be due and payable upon
notice thereof to Group from Harris Health.
If Group remits its delinquent payments to Harris Health within fifteen (15) days of a termination
date, Harris Health may reinstate Group without requiring a new Group Enrollment Agreement. How-
ever, Harris Health reserves the right to refuse to reinstate by refunding within five (5) business days all
payments made by Group after the date of termination.
4.1.2. Upon Notification
This Agreement may be terminated by either Harris Health or Group upon written notice to the
other party at least sixty (60) days prior to the end of the Contract Year. Such termination shall occur at
midnight on the day preceeding the end of the Contract Year. In the event that Harris Health terminates
this Agreement, any Member who is a registered bed patient in a Hospital on the date of termination
shall receive coverage for all hospital services for that hospital confinement or until a determination is
made by the Medical Director that inpatient care is no longer medically indicated, whichever occurs
first.
4.2 TERMINATION OF MEMBER - FOR CAUSE
4.2.1 Default in Payment of Copayments
If any required Copayment is not paid timely by or on behalf of Member, pursuant to the terms
of this Agreement, such Member's entitlement to benefits may be terminated not less than sixty-one
(61) days written notice after the date such Copayment was due.
4.2.2 Default in Payment of Premium
if any premium contributions due from Member are not paid timely by or on behalf of Member,
such Member's entitlement to benefits may be terminated not less than thirty-one (31) days after the
date such premium was due.
4.2.3 Misrepresentation
if any Subscriber should make a fraudulent statement or provide any material misrepresenta-
tion of fact by or on behalf of such Subscriber or Dependent on an Application or Evidence of Insura-
bility form, Harris Health shall have the right to terminate the Member's coverage under this Agreement
without any further liability or obligation to such Member. Such Subscribers entitlement to benefits may
be terminated not less than sixty-one (61) days written notice after such misrepresentation. If a Mem
ber corrects inaccurate information furnished to Harris Health, and Harris Health has not relied upon
such incorrect information to its prejudice, the furnishing of incorrect information shall not constitute a
basis for termination of the Member's coverage. In the absence of fraud, all statements made by a
Subscriber are considered representations and not warranties. During the first two years, coverage
can be voided for material misrepresentation contained in a written Application or Evidence of Insura-
bility Form. After two years, coverage can be voided only in the event of a fraudulent misstatement
contained in the written Application or Evidence of Insurability form. A copy of the written Application
must have been furnished to the Subscriber if the terms of the Application or Evidence of Insurability
form are to be applied.
424 Misuse of Identification Card
Possession of a Harris Health identification card in and of itself confers no rights to services or
other benefits. The holder of the card must be, in fact, a Member on whose behalf all applicable pre-
miums under this Agreement have actually been paid. Any person receiving services or other benefits
to which he is not entitled pursuant to this Agreement shall be solely responsible for the full payment of
any charges associated with the services received. If any Member permits the use of the Member
identification card by any other person, such card may be confiscated and Harris Health shall have
the right to terminate the Member's coverage under this Agreement and, if a Subscriber, the coverage
of his Dependents. Such Member's entitlement to benefits may be terminated not less than fifteen (15)
days written notice after such misuse of the identification card.
4.2.5 Fraudulent Use of Benefits or Services
Fraudulent use by Member of services, benefits, providers, facilities, or coverage will result in
cancellation of coverage after not less than a fifteen (15) day written notice to Subscriber.
4.2.6 Misconduct
Misconduct by a Member detrimental to safe Health Plan operations and the delivery of service
or treatment, or abuse of healthcare professionals, facilities, or Health Plan personnel may result in
cancellation of coverage effective immediately.
4.2.7 Untenable Patient/Physician Relationship
If the Member and the Participating Physician fail to establish a satisfactory patient-physician
relationship and if it is shown that Harris Health has, in good faith, provided the Member with the
opportunity to select an alternative Participating Physician, the Member shall be notified in writing at
least thirty (30) days in advance that Harris Health considers the patient-physician relationship to be
unsatisfactory and specifies the changes that are necessary in order to avoid termination if Member
fails to make such changes, coverage may be cancelled at the end of thirty (30) days.
For refusal by a Member to accept recommended procedures or treatment as described in
Section 8.3 of this Agreement, the Member's coverage may be cancelled after not less than thirty (30)
days written notice.
4.2.8 Termination Procedure
Any Member terminated for cause pursuant to this Section shall be given written notice of ter-
mination prior to the effective date of termination in accordance with notification requirements of Sec-
tion 4.2. If Member receiving notice of termination initiates the Member Complaint Resolution
Procedure described in Section 10 of this Agreement during the notification period to challenge the
grounds for termination, the effective date of termination shall be postponed until Member Complaint
Resolution Procedure is completed and a final decision regarding termination is provided. If the Mem-
ber, on his own behalf or on behalf of a minor child, fails to initiate the Member Complaint Resolution
Procedure within the notification period, such failure shall constitute a waiver of said Member's right to
challenge the termination.
4.3 TERMINATION OF MEMBER - OTHER THAN FOR CAUSE
4.3.1 Subscriber No Longer Eligible Person
If the Subscriber ceases to be an Eligible Person, coverage under this Agreement shall auto-
matically terminate at midnight of the day on which such Subscriber ceased to be an Eligible Person,
subject to continuation of coverage and conversion privilege provisions.
4.3.2 Dependent No Longer Eligible Dependent
If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall -
automatically terminate at midnight of the day on which such Dependent ceased to be an Eligible
Dependent, subject to continuation of coverage and conversion privilege provisions.
4.3.3 Service Area Resident
If a Member ceases to be a resident of the Service Area as defined by Harris Health, eligibility
to participate in Harris Health shall automatically terminate as of the date on which the Member
ceased to be a resident of the Service Area, except as may be required by State and Federal regula-
tions for COBRA participants. Such Member shall be eligible to convert to an Individual Hospital and
Surgical Expense Policy as specified in Section 4.6.2.
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 periods after the effective date of the termi-
nation of coverage, plus amounts due to such Member for claims reimbursement, if any, less any
amount due to Harris Health or which must be paid by Harris Health on behalf of such Member, shall
be refunded to the appropriate party within thirty-one (31) days. Harris Health and Group shall there-
after have no further liability or responsibility to such Member except as may be specifically provided
in Section 4.1.2 of this Agreement.
4.5 CONTINUATION OF COVERAGE
If a Member's coverage ends, such coverage may quality to be continued in one of the follow-
ing ways:
• it may be extended under the Extension of Medical Benefits provisions, if the Member is Hos-
pital Confined when this Agreement terminates; or
• it may be continued under the Optional Continuation of Coverage provisions; or
• it may be converted to an individual plan of medical coverage as described in the Conver-
sion provisions.
If, under the provisions of Title X of the Consolidated Omnibus Budget Reconciliation Act of
1985, Public Law 99-272 ("COBRA"), any Member is granted the right to continuation of coverage
beyond the date his coverage would otherwise terminate, or, if COBRA is inapplicable and the provi-
sions of an applicable state statute grants such Member similar rights to continuation of coverage, this
Agreement shall be deemed to allow continuation of coverage to the extent necessary to comply with
the provisions of the applicable statute. Contact the employer for verification of eligibility and proce-
dures to follow.
4.5.1 Extension of Medical Benefits
Harris Health shall continue to provide medical services if this Agreement terminates under
10
Section 4.1.2 while a Member is confined in a I lospital or Skilled Nursing Facility. Services will be pro-
vided only for the same injury or sickness which caused the Member to be confined.
This continued coverage will end on the earlier of: (1) the date the confinement is no longer
Medically Necessary; or (2) the date the Member reaches any limits under the Group Contract for the
provisions of services; or (3) the date the Member becomes eligible for similar coverage under another
plan.
4.6 CONVERSION PRIVILEGE
If a Member has been covered by this Agreement for at least three (3) consecutive months or
covered as a newborn from the date of birth and meets the definition of a person eligible for conver-
sion, Member may enroll in an individual plan with a defined Schedule of Benefits available to conver-
sion Members only under the terms and conditions of this Agreement.
ELIGIBILITY TO CONVERT
A Member whose coverage under this Agreement is terminated in accordance with the Termi-
nation provisions may convert if the coverage is not ending for one of the following reasons:
• Termination of this Agreement;
• Failure to pay any required copayment amounts;
• Termination for cause;
• Coverage under another individual or group health policy, plan or contract;
• Eligibility for Medicare;
• Eligibility or doverage for similar hospital, medical or surgical benefits under a state or federal
law.
A covered Dependent whose coverage is terminated under this Agreement may also convert if
the termination is due to:
• Legal separation or divorce; or
• The Subscriber's death; or
• The Dependent reaching the maximum Dependent age.
HOW TO CONVERT
4.6.1 Residence in Service Area
The Member eligible for conversion may, without Evidence of Insurability, convert to an Individ-
ual Health Care Agreement issued by Harris Health. To obtain an individual enrollment, the Eligible
Person must continue to reside in the Service Area, must submit a completed application for conver-
sion within thirty-one (31) days after termination of coverage under this Agreement, and must submit
the premium for such Individual Health Care Agreement as required from the effective date of termina-
tion of coverage under this Agreement.
4.6.2 Residence Out of Service Area
If the Member eligible for conversion does not reside in the Service Area, the Member may,
without Evidence of Insurability, convert to an individual policy issued by and renewable at the option
of the indemnity insurer making such conversion coverage available to Harris Health.
Section 5.0
PAYMENT REQUIREMENTS
5.1 PREMIUM PAYMENTS
The initial rates for the benefits and services under this Agreement shall be due and payable in
advance on or before the first (1) day of the month for which such payment is made or is to be made.
In accordance with the terms and provisions of Section 12.3 of this Agreement, Harris Health shall
have the right to change the rate payable under this Agreement at any time when the extent or nature
of this Agreement is changed by amendment or termination of any provision, or by reason of any pro-
vision of law or any governmental program or regulation. No proration of the rate shall be made with
11
respect to Members whose coverage under this Agreement commences alter the first (1) day of the
month. A grace period of thirty-one (31) days shall be allowed for each payment payable hereunder,
whether due from Group or a Member except for the first payment due.
The rate required for a newly acquired Eligible Dependent shall be payable initially when the
required Application is submitted to Harris Health. Thereafter, all payments with respect to such new
Eligible Dependent shall be made as otherwise provided in this Agreement.
Any payments required for newborn children who meet the requirements of Section 3.5.2 of this
Agreement shall be initially payable to Harris Health on or before the first day of the next month follow-
ing the month in which the Application required under Section 3.5.2 is submitted to the Health Plan.
Thereafter, all payments with respect to such newborn child shall be made as otherwise required
under this Agreement.
5.1.1 Non-Contributory Coverage
If the coverage basis hereunder is "Non-Contributory;" the Group agrees to pay at the principal
office of Harris Health, or to its authorized representative, on each payment due date, the sum of the
Harris Health rate for the coverage then provided under this Agreement. The Group premium for the
coverage provided by Harris Health under this Agreement shall be determined by the applicable rate
then in effect and the number of Members at the monthly intervals established by Harris Health.
5.1.2 Contributory Coverage
If the coverage basis hereunder is "Contributory;" Group agrees to pay at the principal office of
Harris Health, or to its authorized representative, on each payment due date, that part of the Harris
Health rate for the coverage then provided under this Agreement. Group shall permit Subscribers to
pay their contributory portion of such rate through payroll deduction. Procedures for implementing
payroll deductions for the Subscriber's portion of such rate shall be the same as those utilized for any
Alternative Health Benefit Plan. If the Group does not have an Alternative Health Benefit Plan, the pro-
cedures shall solely be those as agreed to, in writing, between Group and Harris Health. The Group
premiums for the coverage provided by Harris Health under this Agreement shall be determined by
the applicable rate then in effect and the number of Members at the monthly intervals established by
Harris Health.
Group shall offer Harris Health to all Subscribers of Group on terms no less favorable with
respect to the Group contribution than those applicable to any Alternative Health Benefit Plan as may
be available through the Group. The Group contributions shall not be changed during the term of this
Agreement unless such change is prior approved, in writing, by Harris Health. If, however, Group con-
tribution to the Alternative Health Benefit Plan as may be available through the Group is increased dur-
ing the term of this Agreement, Group agrees to also increase contribution to Harris Health effective
the first monthly payment due following such increase.
5.2 NOTIFICATION BY GROUP
Group shall forward completed Applications and any Evidence of Insurability form(s) to Harris
Health within ten (10) business days of their receipt from Eligible Persons. In the event Group fails to
notify Harris Health of the ineligibility of any person for whom the Group has made the monthly prepay-
ment required pursuant to this. Agreement, then, such prepayment shall be credited to Group only if
Harris Health has not made arrangements for or paid benefits for the ineligible person but in no event
shall such prepayment be credited subsequent to thirty (30) days after the date such person became
ineligible.
5.3 COPAYMENTS
All Copayments, as specified in the Schedule of Benefits, are due and payable at the time a
service is provided. The maximum amount of Copayment shall not exceed the maximum specified in
the Schedule of Benefits. It is the Subscriber's responsibility to retain receipts and to notify Harris
Health upon attaining the Copayment limit so that additional services can be provided without a
Copayment charge.
12
Section 6.0
CLAIM PROVISIONS
6.1 CHARGES PAID BY MEMBERS
It is not anticipated that a Member shall make payments, other than the Copayments as set
forth in the Schedule of Benefits, for benefits and covered services under this Agreement. However, if
a payment is made by a Member then a written description of such services, accompanied by evi-
dence of payment by the Member must be provided to Harris Health within sixty (60) days after the
performance of the service. Failure to furnish such proof within the required time shall not invalidate
nor reduce any claim, if it was not reasonably possible to give proof within such time, provided such
proof is furnished as soon as reasonably possible. If the Member provides evidence that he has made
such payment, payment shall be paid to the Member but without prejudice to Harris Health's right to
seek recovery of any payment made by it before receipt of such evidence.
Benefits under this Agreement will be paid directly to the provider unless Member requests
payment to be made to himself and submits to Harris Health proof of prior payment to the provider for
covered services. Claims for such services will be processed as follows:
A. Fifteen (15) calendar days after receipt of claim, Harris Health will:
1. Acknowledge receipt of claim;
2. Commence investigation of claim;
3. Request all information from claimant as deemed necessary by Harris Health. Subse-
quent additional requests may be necessary.
B. No later than fifteen (15) business days after receipt of all items required by Harris Health,
Harris Health will:
1. Notify claimant of acceptance or rejection of claim;
2. Notify claimant of the reason(s) Harris Health needs additional time.
Harris Health shall accept or reject the claim no later than forty-five (45) calendar days
following receipt of additional information.
C. Upon notification from Harris Health that the claim will be paid, the claim will be paid no
later than five (5) business days after such notification was made.
6.2 MEDICAL EMERGENCY
Medical Emergency services which are covered under this Agreement but are not received
fr6m Participating Providers shall be reimbursed subject to the Copayments in the Schedule of Bene-
fits. Harris Health reserves the right to deny a claim for reimbursement of services received from a
Hospital emergency department or a Minor Emergency Center, if it is determined by Harris Health that
such services were not obtained pursuant to the terms of this Agreement or if a Medical Emergency
did not exist at the time services were received by the Member.
6.3 ACTION ON CLAIM
All claims for reimbursement shall be finalized by Harris Health within sixty (60) days of receipt
of written documentation describing the occurrence, character and extent of the event for which the
claim is made, unless the Member is notified of the need for a longer time. If a claim is denied, written
notice to the Member will state the reason for the denial. Member may obtain a review of the denial
through the Member Complaint Resolution Procedure as described in Section 10.0.
6.4 EXAMINATION OF MEMBER
Harris Health, at its own expense, shall have the right to examine the Member whose sickness
or injury is the basis of a claim when and so often as it may reasonably require during the pendency of
any claim.
6.5 LIMITATION PROVISIONS
• No action at law or equity shall be brought under this Section against Harris Health prior to
the expiration of the sixty (60) day period immediately following the date on which written
proof of this charge or loss upon which the action is brought, in accordance with the provi-
sions of this Section, has been furnished to Harris Health; or later than three (3) years after
the expiration of the period of time in which such proof of charge or loss is required under
this Section to be furnished to Harris Health.
13
• No liability shall be imposed under Harris Health other than for the benefits and services cov-
ered under this Agreement.
Section 7.0
COORDINATION AND SUBROGATION OF BENEFITS
The Harris Health Coordination and Subrogation of Benefits provisions applies to all of the ben-
efits provided under this Agreement. The value of any benefits or services provided by Harris Health
shall be coordinated with any group insurance plan or coverage under governmental programs,
including Medicare, to assure that a Member receives coverage while avoiding double recovery. It is,
therefore, understood and agreed that should a Member be covered by or under a Coordinated Plan
in addition to coverage under this Agreement, the provisions and rules as described in this Section
shall determine whether Harris Health or the Coordinated Plan is primarily responsible for paying the
costs of benefits and services provided to the Member.
• If a Member who has enrolled under this Health Plan is entitled to inpatient benefits under
another contract or policy of insurance due to inpatient care which began while the Member
was enrolled under a previously held policy, Harris Health will pay, subject to Copayments
under this plan, the difference between entitlements under this Health Plan and entitlements
under the other contract or policy of insurance.
• Benefits which are provided directly through a specified provider of an employer shall in all
cases be provided before the benefits of this Health Plan.
• Services and benefits for military service connected disabilities for which a Member is legally
entitled and for which facilities are reasonably available, shall in all cases be provided before
the benefits of this Health Plan.
• All sums payable for services provided pursuant to worker's compensation shall not be reim-
bursable under this Agreement.
7.1 DEFINITIONS
For purposes of this Section only, words and phrases shall have meanings as follows:
• ALLOWABLE EXPENSE shall mean any Usual and Customary expense of which at least a
portion is covered under this Health Plan covering the Member for whom the claim is made.
When a Coordinated Plan provides benefits in the form of services rather than cash pay-
ments, the Usual and Customary cash value of each service provided shall be deemed to
be both an Allowable Expense and a benefit paid.
• CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding any portion of a
calendar year occurring prior to the Effective Date.
• COORDINATED PLAN shall mean any of the following that provides benefits or services for,
or by reason of, medical care or treatment.
- Coverage under governmental programs, including Medicare, required or provided by
any statute unless coordination of benefits with any such program is forbidden by law.
- Group coverage or any other arrangement of coverage for individuals in a group,
whether on an insured or uninsured basis, including any prepayment coverage, group
practice basis or individual practice coverage and any coverage for students which is
sponsored by, or provided through, a school or other educational institution above the
high school level.
7.2 DETERMINATION OF BENEFITS
This provision shall apply in determining the benefits payable for the Allowable Expenses
incurred by a Member. during a Claim Determination Period.
The term Coordinated Plan shall be.construed separately with respect to each policy, contract,
or other arrangement for benefits or services and separately with respect to that portion of any such
policy, contract, or other arrangement which reserves the right to take the benefits or services of other
Coordinated Plans into consideration in determining its benefits and that portion which does not.
14
Whenever the sum of the benefits that would be payable under this Agreement in the absence
of this provision, and the benefits that would be payable under all Coordinated Plans in the absence
thereof or amendments of similar purpose to this provision would exceed the Allowable Expenses, then
the following shall apply:
• The benefits that would be payable under this Agreement shall be reduced to the extent
necessary so that the sum of such reduced benefits and all the benefits payable for such
Allowable Expenses under all Coordinated Plans shall not exceed the total payable under
this Agreement. Benefits payable under a Coordinated Plan include the benefits that would
have been payable had claim been duly made therefor.
• If a Coordinated Plan would, according to its rules, determine its benefits after the benefits
payable under this agreement have been determined, and the rules as described in Section
7.3 would require payment under this Agreement to be determined before the Coordinated
Plan, then the benefits of the Coordinated Plan shall not be included for the purpose of deter-
mining the benefits under this Agreement.
7.3 ORDER OF BENEFIT DETERMINATION
The rules establishing the order of benefit determination shall be as follows:
The benefits
duplication
Agreement.
- The benefits of a Coordinated Plan covering the Member as a laid-off or retired employee
or as the dependent of such Member shall be determined after the benefits of a Coordi-
nated Plan covering 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 provision regarding laid-off or retired employees,
and, as a result, such Coordinated Plan determines its benefits after the Coordinated
Plan with this provision, then the provisions of the immediately proceeding paragraph
shall not apply.
of a Coordinated Plan without a coordination of benefits provision (or a non-
provision of similar intent) shall be determined before the benefits of this
The benefits of a Coordinated Plan which covers the Member other than as a dependent
shall be determined before the benefits of a Coordinated Plan which covers such person as
a dependent.
The benefits of a Coordinated Plan which covers the Member as a dependent child of a per-
son whose date of birth, excluding year of birth, occurs earlier in a calendar year, shall be
determined before the benefits of a plan which covers such person as a dependent of a per-
son whose date of birth, excluding year of birth, occurs later in a calendar year. If a Coordi-
nated Plan does not have the provisions of this paragraph regarding dependents, which
results either in each Coordinated Plan determining its benefits before the other or in each
Coordinated Plan determining its benefits after the other, the provisions of this paragraph
shall not apply, and the rule set forth in the Coordinated Plan which does not have the provi-
sions of this paragraph shall determine the order of benefit determination unless Section
7.3.1 shall apply.
If the rules provided above or the rules provided in Section 7.3.1 do not establish an order of
benefit determination, then the benefits of a Coordinated Plan which has covered the Mem-
ber for whom the claim is made for the longer period of time shall be determined before the
benefits of a Coordinated Plan which has covered such Member for the shorter period of
time except as follows:
In the event of a legal separation or divorce, the following order of benefit determination shall
7.3.1 Legal Separation or Divorce
apply:
• If there is a court decree that establishes financial responsibility for the healthcare expenses
of the child, the benefits of a Coordinated Plan which covers the child as a dependent of the
parent with such financial responsibility shall be determined before the benefits of a Coordi-
nated Plan which covers the child as a dependent of the parent without such financial
responsibility.
Sri
In the event of a legal separation or divorce in which tfre court decree does not establish
financial responsibility for the healthcare expenses of the child then the following shali apply:
- If the parent with custody of the child has not remarried, the benefits of a Coordinated
Plan which covers the child as a dependent of the parent with custody of the child shall
be determined before the benefits of a Coordinated Plan which covers that child as a
dependent of the child without custody.
- If the parent with custody of the child has remarried, the benefits of a Coordinated Plan
which covers the child as a dependent of the parent with custody shall be determined
before the benefits of a Coordinated Plan which covers that child as a dependent of the
stepparent; and the benefits of a Coordinated Plan which covers that child as a depen-
dent of the stepparent shall be determined before the benefits of a Coordinated Plan
which covers that child as a dependent of the parent without custody.
Thus, in the event of a legal separation or divorce, unless a court decree specifies otherwise,
the order of benefit determination described above may be summarized as follows:
Separated or Divorced and not Remarried:
(1) Parent with custody
(2) Parent without custody
Separated or Divorced and Remarried:
(1) Parent with custody
(2) Stepparent with custody
(3) Parent without custody
7A MEDICARE
For purposes of determining benefits provided for a Member who is eligible to enroll for Medi-
care, but does not, Harris Health will assume the amount provided under Medicare to be the amount
the Member would have received if he or she had enrolled for it.
A Member is considered to be eligible for Medicare on the earliest date coverage under Medi-
care could become effective for the Member. Except as described under TETRA in Section 7.4, Medi-
care shall be interpreted so as to be included in Section 7.1 for each Member as follows:
• Such Member must agree to enroll for both Parts A and B of Medicare and assign to Harris
Health any Medicare benefits for services covered by Harris Health. If such Member
receives benefits from Harris Health that would have been paid or reimbursed by Medicare,
but Member has failed to enroll for Medicare coverage, then Harris Health shall be entitled to
receive from the Member the actual costs of the services provided. The Member shall remain
liable for payment of the Copayments as set forth in the Schedule of Benefits.
• When Allowable Expenses are incurred by such Member during any Claim Determination
Period and include expenses for services, treatment, or supplies which are payable under
Medicare, such Allowable Expenses shall be reduced by an amount equal to the benefits
payable by Medicare before comuting the benefits payable under this Agreement.
7.4.1 TEFRA Options for Employers with 20 or More Employees
Actively working covered Employees and their covered spouses who are eligible for Medicare
will be permitted to choose one of the following options if the Employee is age 65 or older and eligible
for Medicare:
Option 1 - The service of the Group Agreement will be provided first and the benefits of
Medicare will be provided second.
Option 2 - Medicare benefits only. Subscriber and Dependents, if any, will not be covered by
the Group Agreement.
The employer will provide Subscriber with a choice to elect one of these options at least one
month before becoming age 65. All new Employees age 65 or older will be offered these options when
hired. If Option 1 is chosen, Subscriber's rights under this Agreement will be subject to the same
requirements as for an Employee or Dependent who is under age 65.
There are two categories of persons eligible for Medicare. The calculation and payment of ben-
efits by this Agreement differs for each category.
16
Category 1 Medicare Eligibles are:
1. Actively working covered Employees age 65 or older who choose option 1;
2. The age 65 or older covered spouses of actively working covered Employees age 65 or
older who choose Option 1;
3. Age 65 or older covered spouses of actively working covered Employees who are under
age 65;
4. Actively working covered Employees of employers with 100 or more Employees and their
Covered Dependents who are entitled to Medicare by reason of disability other than End
Stage Renal Disease (ESRD); and
5. Covered individuals entitled to Medicare solely on the basis of ESRD during a period of up
to 12 months after the individual has been determined eligible for ESRD benefits.
Category 2 Medicare Eligibles are:
1. Retired employees and their spouses;
2. Covered Employees of employers with less than 100 Employees and their covered Depen-
dents who are entitled to Medicare by reason of a disability other than ESRD; and
3. Covered individuals entitled to Medicare solely on the basis of ESRD for more than 12
months after the individual has been determined eligible for ESERD benefits.
Calculation and Provision of Services:
For Members in Category 1, services are provied by this Agreement without regard to
any benefits provided by Medicare. Medicare will then determine its benefits.
For Members in Category 2, services are provided by the Group Agreement. Harris
Health shall then have the right to recover the full amount of all Medicare benefits the Member
is entitled to receive, whether or not the Member is actually enrolled for them. The Member
should authorize payment of Medicare benefits directly to Harris Health for services rendered.
If the Member does not authorize direct payment, he or she is responsible for Harris Health for
the reasonable value of the services rendered. The Member is also responsible to Harris
Health for the reasonable value of all Group Agreement services reimbursable by Medicare if
- the Member is not enrolled for all benefits he or she is entitled to receive.
7.5 RIGHT TO RECEIVE AND RELEASE INFORMATION
For purposes of administering the provisions of this section, Harris Health may, without further
consent of, or notice to any Member, release to or obtain from any healthcare plan, insurance com-
pany or other person or organization, any information with respect to any Member which it deems to
be reasonably necessary for such purposes, as permitted by law. Any Member receiving services or
claiming benefits under this Agreement shall furnish to Harris Health all information deemed necessary
by Harris Health to implement this Section 7.0.
7.6 FACILITY OF PAYMENT
Whenever payments which should have been made by Harris Health in accordance with this
Section have been made by a Coordinated Plan, Harris Health shall have the right, exercisable alone
and in its sole discretion, to authorize payment to the Coordinated Plan making such payments any
amounts Harris Health shall determine to be warranted in order to satisfy the intent of this Section, and
amounts when so paid shall be deemed to be benefits under this Agreement, and, to the extent of
such payments, Harris Health shall be fully discharged from liability under this Agreement.
7.7 RIGHT OF RECOVERY
Whenever payments have been made by Harris Health with respect to Allowable Expenses in a
total amount which is, at any time, in excess of the maximum amount of payment neccessary at that
time to satisfy the intent of this Section, Harris Health shall have the right to recover such payments, to
the extent of such excess, from one or more of the following, as Harris Health shall determine: any per-
son or persons to, or for, or with respect to whom such payments were made, any insurance company
or companies, and any other organization or organizations which provided services, or to which such
payments were made.
17
7.8 DISCLOSURE
Each Member agrees to disclose to Harris Health at the time of enrollment, at the time of
receipt of services and benefits, and from time to time as requested by Harris Health, the existence of
other health plan coverage, the identity of the carrier, and the group through which such coverage is
provided.
7.9 SUBROGATION
Subrogation seeks to shift the expense for injuries suffered by Plan Members to those responsi-
ble for causing them.
In return for Harris Health providing benefits for injuries, ailments, or diseases caused as a
result of the negligence, omission or willful act of a third party, each Member agrees to execute any
instrument which may be needed in order for the right of subrogation to be effective. Each Member
also agrees to assign to Harris Health the right of recovery against such third party to the extent of
benefits received from or through Harris Health plus costs of legal suit including attorney fees. At the
time such benefits are provided or thereafter as Harris Health may request, Member agrees to comply
with the following provisions:
• Execute a formal written injury report and assignment to Harris Health of right to recover the
reasonable value of any benefits provided directly by Harris Health and the actual costs paid
by Harris Health under this Agreement for injuries, ailments and diseases caused by a third .
parry together with the costs of legal suit including attorney fees.
• Reimburse Harris Health for the reasonable value of any benefits and services provided by
Harris Health and in an amount equal to the charges therefor together with the costs of legal
suit, including attorney fees, but not in excess of monetary damages collected, immediately
upon receipt of any monies paid by or on behalf of a third party in settlement of any claim
arising out of injuries, ailments and diseases covered by such third party. In determing the
reasonable value of benefits and services provided by Harris Health, Harris Health shall con-
sider charges for similar services being made by providers in the community which possess
similar training or capability as well as unusual circumstances, or a medical complication
requiring additional time, skill experience and/or facilities in connection with a particular ser-
vice. Harris Health shall have a lien on any recovery from such third party whether by judg-
ment, settlement, compromise or reimbursement.
• Execute and deliver such papers and provide such reasonable help (including authorizing
bringing suit against such third party in Member's name and making court appearances) as
may be necessary to enable Harris Health to recover the reasonable value of benefits and
services provided by Harris Health, together with costs of legal suit, including attorney fees.
Section 8.0
INDEPENDENT AGENTS/REFUSAL TO ACCEPT TREATMENT
8.1 INDEPENDENT AGENTS
The relationships between Harris Health and contracting entities may be defined as follows:
• The relationship between Harris Health and Member Hospitals is that of independently con-
tracting entities. Member Hospitals are not agents or employees of Harris Health nor is Harris
Health an agent of any Member Hospital. Member Hospitals shall maintain the hospital-
patient relationship with Members and shall be the only parties responsible to Members for
the Hospital services that they provide.
• The relationship between Harris Health and Participating Providers is that of independent
contracting entities. Participating Providers are not agents or employees of Harris Health nor
is Harris Health an employee or agent of any Participating Provider. Participating Providers
shall maintain the physician-patient or professional-patient relationship with Members and
shall be the only parties responsible to Members for the services provided. Neither Harris
Health nor any employee of Harris Health shall be deemed to be engaged in the practice of
medicine. Harris Health shall in no way supervise the practice of medicine by any Participat-
ing Provider hereunder, nor shall Harris Health in any manner supervise, regulate or interfere
with the usual professional relationships between a Participating Provider and a Member.
18
The relationship between Harris Health, the Group and any Member is that of independent
contracting entities. Neither the Group nor any Member is the agent or employee of Harris
Health, and Harris Health is not the employee or agent of the Group or any Member. Neither
the Group or any Member shall be liable for any acts or omissions of Harris Health, its agents
or employees, any Physician, any Hospital, or any other person or organization in which Flar-
ris Health has made, or hereafter shall make arrangements for the performance of services
under this Agreement.
8.2 LIMITATION ON LIABILITY
Harris Health does not guarantee by this Agreement that any Participating Provider shall per-
form or properly perform such contracts; the only obligation of Harris Health in the event of breach of
such contract by any Participating Provider shall be, upon request, to use its best efforts to procure
the needed services from another provider. Harris Health shall not be liable to a Member for any act of
omission or commission on the part of any Participating Provider.
8.3 REFUSAL TO ACCEPT TREATMENT/EXCESSIVE TREATMENT
Members may, for reasons personal to themselves, refuse to accept services or complete a
Course of Treatment as recommended by a Participating Physician. Participating Physicians shall use
their best efforts to render all necessary and appropriate professional services in a manner compatible
with the Member's wishes, insofar as this can be done consistently with such Participating Physician's
judgment as to the requirements of proper medical practice.
If a Member refuses to complete a recommended Course of Treatment, and the Participating
Physician believes that no professionally acceptable alternative exists, such member shall be so
advised. If upon being so advised, the Member still refuses to follow the recommended treatment or
procedure, then the Member shall be given no further treatment for the condition, and neither the Par-
ticipating Physician nor Harris Health shall have any further responsibility to provide care for such con-
dition. A Member may appeal a withdrawal of treatment under this provision through the Member
Complaint Resolution Procedure as described in Section 10.0 of this Agreement.
If two (2) or more Participating Physicians who have rendered care to a Member inform Harris
Health that the Member is receiving health services or prescription medications in a manner or in a
quantity which is not medically necessary or not medically beneficial, the Member may be required by
Harris Health to select a single Participating Primary Physician (hereafter referred to as a "Coordinat-
ing Health Plan Physician") and a single: Participating Pharmacy, if Pharmacy benefits are available to
Member, for the provision and coordination of all future health services. If the Member fails to voluntar-
ily select a Coordinating Health Plan Physician and a single Participating Pharmacy within thirty (30)
days of written notice by Harris Health of the need to do so, Harris Health shall designate a Coordinat-
ing Health Plan Physician and/or a Participating Pharmacy for the Member.
Following selection or designation of a Coordinating Health Plan Physician for a Member, cov-
erage of health services set forth on this Agreement shall be contingent upon each health service
being provided by or through written referral to the Coordinating Health Plan Physician for that
Member.
If, after sixty (60) days from initial notification by Harris Health, the Member is not in compliance
with this Section, the Member may be terminated by Harris Health under Section 4.2.7.
Section 9.0
EXCLUSIONS ON SERVICE RESPONSIBILITIES
The rights of Members and obligations of Participating Providers under this Agreement are
subject to the exclusions as specified below.
9.1 MAJOR DISASTER OR EPIDEMIC
In the event of any major disaster or epidemic that would severely limit the availability of Partici-
pating Providers to provide healthcare services on a timely basis, Participating Providers shall, in good
faith, use their best efforts to render the benefits and services covered insofar as practical according
to their best judgment and within the limitation of such facilities and personnel as are then available. If
Harris Health and Participating Providers shall, in good faith, have used their best efforts to provide or
19
make arrangements for the benefits and services, they shall have no further liability or obligation for
delay or failure to provide such benefits and services due to a shortage of available facilities or per-
sonnel resulting from such disaster or epidemic.
9.2 CIRCUMSTANCES BEYOND CONTROL
In the event that, due to circumstances not reasonably within the control of Harris Health or
Participating Providers, such as the complete or partial destruction of facilities because of war, riot,
civil insurrection, or the disability of a significant number of Participating Providers, the rendering of
benefits and services covered hereunder is delayed or rendered impractical, neither Harris Health nor
any Participating Provider shall have any liability or obligation on account of such delay or such failure
to provide such benefits and services, if they shall, in good faith, have used their best efforts to pro-
vide or make arrangements for the benefits and services covered insofar as practical according to
their best judgment and within the limitations of such facilities and personnel as are then available. Pre-
mium payment shall be suspended for the duration of such time period for the Group.
9.3 FRAUDULENTLY OBTAINED BENEFITS
In the event a member fraudulently obtains healthcare services as a result of the improper or
unauthorized use of a Harris Health identification card, such Member agrees and is solely responsible
for the payment of all charges for services so obtained and for the payment of all reasonable costs of
collection thereof, including court costs, collection fees and attorney fees.
9.4 DISCONTINUANCE
If Harris Health or Group determines it would be impractical to continue due to circumstances
beyond the control of Harris Health or Group, Harris Health and Group may endeavor to agree to
amendments and adjustments to this Agreement which relate to services and benefits to be discontin-
ued. If parties cannot agree on amendments and adjustments, Harris Health or Group may terminate
this Agreement at the end of any month upon at least sixty (60) days written notice for Group. In the
event of such termination, neither Harris Health nor Participating Providers shall have any further liabil-
ity or responsibility under this Agreement.
However, if any Participating Provider terminates their contract, then Harris Health shall be lia-
ble for the continuance of services and benefits described in this Agreement. Such services shall be
rendered to Members by other Participating Providers.
Section 10.0
MEMBER COMPLAINT RESOLUTION PROCEDURE
10.1 COMPLAINT RESOLUTION PROCESS
A Member may make an oral or written suggestion or indicate a complaint to any Harris Health
employee or to any Participating Provider. All oral suggestions and complaints shall be handled
promptly by Harris Health. If the Member is not satisfied with the response to an oral suggestion or
complaint, the Member may file a written complaint by calling Harris Health or, at the Member's option
the Member may file a written complaint by completing and forwarding a complaint form to Harris
Health at the latest address provided on the front of this Agreement. A Harris Health Member Service
Representative shall contact the Member by telephone to verify details and resolve the problem imme-
diately if possible. Within fifteen (15) business days from the receipt of the oral or written complaint,
Harris Health shall respond in writing to inform the Member of the progress or decision on the com-
plaint. In the event a decision cannot be reached within fifteen (15) business days, Harris Health shall
notify the Member that a decision shall be provided as soon as possible, but not later than sixty (60)
days after initial receipt of the complaint.
10.1.1 Ad Hoc Review Committee
If the Member is not satisfied with the resolution of the complaint by Harris Health, the Member
may request a review by filing such a request, in writing, within fifteen (15) business days of receiving
written notice of the resolution of the complaint. This request shall be sent to Harris Health. Upon
receipt of this written request, Harris Health shall forward the request and any and all memoranda and
notes made as a result of the original investigation of the complaint to the Medical Director and to Har-
ris Health.
20
After reviewing the complaint records, Harris Health shall convene an Ad Hoc Review Commit-
tee composed of Harris Health, the Medical Director, and at least two other individuals not involved in
the initial investigation of the complaint. In the case of a complaint concerning medical treatment or
services, medical personnel or facilities, such other individuals on the Ad Hoc Review Committee shall
be Participating Physicians. Within fifteen (15) business days of receipt of the request for a review,
Harris Health shall respond, in writing, to inform the Member of the decision or resolution of the com-
plaint by the Ad Hoc Review Committee.
10.1.2 Notification By Review Committee
If the original complaint involved a physician-patient relationship, the written response of the Ad
Hoc Review Committee shall inform the Member that he has the option, at his discretion, to submit the
complaint to the mediation service maintained by the Tarrant County Medical Society, and that such
mediation shall usually be concluded within a thirty (30) day to sixty (60) day time period. The notice
shall inform the Member that participation in the mediation process is voluntary and that mediation rec-
ommendations are non-binding on both parties. As part of their contractual obligation to comply with
the Health Plan rules and regulations, Participating Physicians must cooperate with the Tarrant County
Medical Society mediation service.
10.2 COMPLAINT RESOLUTION APPEAL PROCESS
If a Member is not satisfied with the decision of the Ad Hoc Review Committee, or the Tarrant,
County Medical Society mediation service, the Member may request an additional review by Harris
Health. The Member must file a request for review within fifteen (15) business days of receipt of the
decision of the Ad Hoc Review Committee or the mediation service. Upon receipt of a request for a
review, Harris Health shall forward the review request and a complete record of the complaint history
to the Medical Director and to Harris Health.
After reviewing the complaint records, Harris Health shall convene an Ad Hoc Appeal Commit-
tee composed of Harris Health, the Medical Director and at least two other individuals not involved in
the initial investigation of the complaint. In the case of a complaint concerning medical treatment or
services, medical personnel or facilities, such other individuals on the Ad Hoc Appeal Committee shall
be Participating Physicians.
Within fifteen (15) business days of receipt of the request for a review, Harris Health shall
respond, in writing, to inform the Member of the decision or resolution of the complaint by the Ad Hoc
Appeal Committee. If all parties involved in the complaint agree, the complaint response of the Ad Hoc
Appeal Committee shall be final and binding on all parties.
Section 11.0
HEALTH CARE SERVICES
11.1 Benefits and Services
Harris Health agrees to arrange for the provision of the benefits and services in the Schedule of
Benefits and/or Riders, in accordance with the procedures and subject to the limitations and exclu-
sions specified in such Schedule of Benefits and/or Riders and in this Agreement.
Unless referred in writing by a Participating Primary Physician (or by a Participating Specialist
Physician), and except in cases of Medical Emergency, benefits and services set forth in the Limita-
tions and Exclusions Section of the Schedule of Benefits or any Riders that are rendered by a Partici-
pating Physician other than a Participating Primary Physician shall not be covered.
All hospital admissions must be authorized by Harris Health, and the Member's condition or
required services must be such that treatment can be rendered only in a hospital setting. Harris Health
and the Participating Physician may decide to provide Medically Necessary services on an outpatient
basis or in an outpatient surgery unit. The use of alternative levels of care, such as outpatient hospital
or home care, will be encouraged where possible based on Member condition and treatment.
Unless previously authorized in writing by a Participating Physician and by the Medical Director
and except in cases of Medical Emergency, all benefits and services set forth in the Schedule of Ben-
efits and any Riders shall be available and covered only when provided by a Participating Physician,
Participating Hospital or by another Provider under contract with Harris Health to provide healthcare
services to Members.
21
All charges related to services and supplies incurred prior to the Member's effective date, or
after the Member's termination date of coverage under this Agreement shall not be covered.
Section 12.0
TERM AND AMENDMENT OF AGREEMENT
12.1 TERM
This Agreement shall remain in effect for the first Contract Year and thereafter for successive
Contract Years unless sooner terminated as provided in Section 4.0 of this Agreement.
12.2 AMENDMENT
• Harris Health and Group may mutually alter or revise the terms of this Agreement and/or
Schedule of Benefits and Riders attached hereto. In the event of such alteration or revision,
Harris Health shall provide Group with at least sixty (60) days written notice before effective
date of Amendment. Such notice shall be considered to have been provided when mailed to
the Group at the latest address shown on the records of Harris Health.
• This.Agreement may be amended at any time, according to any provision of this Agreement
or by written agreement between Harris Health and Group, without the consent of the Mem-
bers, or any other person having a beneficial interest in it. Any such amendment shall be.
without prejudice to any claim arising prior to the effective date of such amendment.
12.3 CHANGE OF RATES
Harris Health shall have the right to change the rates and premiums payable hereunder (i) as
of any Anniversary Date (in which case the Group shall be notified at least sixty (60) days prior to a
change in rates) or (ii) in accordance with Section 12.2 of this Agreement.
Section 13.0
MISCELLANEOUS PROVISIONS
13.1 USE OF WORDS
Words used in the masculine shall apply to the feminine where applicable, and, wherever the
context of this Agreement dictates, the plural shall be read as the singular and the singular as the plu-
ral. The words "hereof," "herein," "hereunder" and other similar compounds of the word "here" shall
mean and refer to the entire Agreement and not to any particular Section or provison. All references to
Sections and provisions shall mean and refer to Sections and provisions contained in this Agreement
unless otherwise indicated.
13.2 RECORDS AND INFORMATION
Harris Health shall conduct a review program for the healthcare services it provides hereunder
and for that purpose may examine the records of each Member. Information from medical records of
Members and information received from Physicians or Hospitals incident to the Physician-patient or
Hospital-patient relationship shall be kept confidential. This information, except as reasonably neces-
sary in connection with the administration of this Agreement or as required by law, shall not be dis-
closed without the consent of the Member.
Harris Health shall, to the extent legally allowable and without further consent of or notice to
any Member, release to or obtain from any insurance company or other organization or person any
information, with respect to any person, which Harris Health deems to be necessary for such pur-
poses. Any person claiming benefits shall furnish to Harris Health such information as may be neces-
sary to implement this Agreement.
13.3 INFORMATION FROM GROUP
Group shall periodically forward the information required by Harris Health in conjunction with
the administration of this Agreement. All records of Group which have a bearing on the coverage shall
be open for inspection by Harris Health at any reasonable time. Harris Health shall not be liable for the
fulfillment of any obligation dependent upon such information prior to its receipt in a form satisfactory
to Harris Health. Incorrect information furnished may be corrected, if Harris Health shall not have acted
to its prejudice by relying on it. Harris Health shall have the right, at reasonable times, to examine
22
Group's records, including payroll records of employers having ernployees covered through Group,
with respect to eligibiliity and monthly premiums under this Agreement.
13.4 ASSIGNMENT
The benefits to a Member under this agreement are specific to the Member and are not
assignable or otherwise transferable.
13.5 AUTHORITY
Any alterations or revisions to this Agreement shall not be valid unless evidenced by a written
amendment which has been signed by Group and by an officer of Harris Health and attached to the
affected document. No other person has the authority to change this Agreement or to waive any of its
provisions.
13.6 GOVERNING LAW
This Agreement is executed and is to be performed in all respects in accordance with all fed-
eral and Texas state laws applicable to Health Maintenance Organizations and all other applicable
Texas state laws or regulations.
13.7 INCORPORATION BY REFERENCE
The Schedule of Benefits, Group Enrollment Agreement, Applications, any optional Riders, any
Attachments, and any amendments to any of the foregoing, form a part of this Agreement as if fully
incorporated herein. Any direct conflict or ambiguity of this Agreement shall be resolved under terms
most favorable to the Member.
13.8 ENTIRE AGREEMENT
This Agreement constitutes the entire understanding between Harris Health and Group.
13.9 INFORMATION TO MEMBER
Upon execution of this Agreement, Harris Health shall provide to each Subscriber a copy of
this Agreement and an Identification Card. Such delivery shall be accomplished by mailing postage
paid, to the latest address furnished to Harris Health or by delivery from a representative of Harris
Health or Group to Subscriber.
13.10 UNIFORM RULES
In the administration of Harris Health, this Agreement shall be applied uniformly to all Members
similarly situated.
13.11 CALCULATION OF TIME
In determining time periods within which an event or action is to take place for purposes of
Harris Health, no fraction of a day shall be considered, and any act, the performance of which would
fall on a Saturday, Sunday, holiday or other non-business day, may be performed on the next following
business day.
13.12 EVIDENCE
Evidence required of any Member of Harris Health may be by certificate, affidavit, document,
or other information which the person acting on it considers pertinent and reliable, and signed, made
or presented by the proper party or parties.
13.13 SEVERABILITY
If any provision of this Agreement shall be held invalid or illegal, the rest of this Agreement shall
remain in full force and effect and shall be construed in accordance with the intentions of the parties
as manifested by all provisions hereof including those which shall have been held invalid and illegal.
Furthermore, in lieu of any provision hereof which is found to be illegal, invalid or unenforceable, there
shall be added hereto a provision as similar in terms to such illegal, invalid or uninforceable provision
as may be possible and be legal, valid and enforceable without materially changing the purpose and
intent of this Agreement.
23
13.14 VENUE
The parties hereby expressly agree that this Agreement is executed and shall be performable
in Tarrant County, Texas, and venue of any disputes, claims, or lawsuits arising hereunder shall be in
the said Tarrant County.
13.15 WAIVER OF NOTICE
Any person entitled to notice under this Agreement may waive the notice.
13.16 HEADINGS
The titles and headings of Sections or provisions are included for convenience of reference
only and are not to be considered in construction of the Sections or provisions hereof.
13.17 NOTICE OF CERTAIN EVENTS
If Group may be materially or adversely affected thereby, Harris Health shall, within a reasona-
ble time, provide written notice to Group of any termination or breach of contract, or inability of any
Participating Provider to provide the services and benefits as described in this Agreement.
13.18 NOTICE OF TERMINATION
All Harris Health notices of termination of this Agreement or of any Member's rights will be in
writing and shall state the cause of termination, with specific reference to the provision(s) of this Agree-
ment giving rise to the right of termination.
13.19 NOTICE
Any notice under this Agreement shall be in writing, and shall be given by United States mail,
postage prepaid, addressed as follows:
Harris Health: 1300 Summit Avenue, Suite 300
Fort Worth, TX 76102
Group: The address specified on the executed Group Enrollment Agreement or the latest
address provided, in writing, to Harris Health.
Subscriber: The latest address provided by the Subscriber on Application form actually delivered
to Harris Health.
The effective date of notice is two (2) business days after the date of deposit with the United
States Post Office.
24
HARRIS HEALTH SERVICE AREA
The Harris Health Service Area includes six-
:een (16) counties and parts of four (4) coun-
ties in North Central Texas.
The following sixteen (16) counties are in-
cluded in the Service Area:
Boscue
Cornmanche
Dallas
Denton
Erath
Freestone
Hamilton
Hill
Hood
Johnson
Limestone
Parker
Palo Pinto
Somervell
Tarrant
Wise
In the following four (4) counties zip codes
are included as specified in the Service Area:
COUNTY
ZIP CODES
Coryell
76512
76525
76528
76538
76566
76580
Ellis
76064
76065
Montague
76230
76239
76251
76270
Navarro
75110
76639
75153
76679
76681
1.
All Saints Cityview Hospital
2.
All Saints Episcopal Hospital
3.
Arlington Memorial Hospital
4.
Campbell Memorial Hospital
5.
Cook-Fort Worth Children's
Medical Center
6.
Decatur Community Hospital
7.
Denton Community Hospital
8.
Harris Methodist Erath County
9.
Harris Methodist Fort Worth
10.
Harris Methodist Glen Rose
11. Harris Methodist H-E-B
12. Harris Methodist HEB-Springwood
13. Harris Methodist Northwest
14. Harris Methodist Southwest
15. Hood General Hospital
16. Huguley Memorial Medical Center
17. Medical Plaza Hospital
18. Osteopathic Medical Center of Texas
19. Parkview Regional Hospital
20. St. Joseph Hospital
21. Walls Regional Hospital
PRESCRIPTION DRUG RIDER
FOR USE ONLY WITH GROUP HEALTH CARE AGREEMENT/SUBSCRIBER
CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
800/633-8598
1.0
In consideration for the timely payment of premiums, and all other terms
and conditions of the Group Health Care Agreement/Subscriber Certificate
of Coverage ("Agreement"), it is agreed that the benefits of this Rider,
together with the terms and conditions of this Rider, shall be added to
Agreement as issued if this Rider is accepted by the Group.
2.0 DEFINITIONS
Benefits for outpatient prescription drugs provided through this Rider
shall be subject to the provisions and definitions of Agreement to which
this Rider is a part.
Prescription Drugs shall mean only those drugs and medicines which are
,prescribed by a Participating Physician, and legally require the written
prescription of a Physician before they can be obtained by the Member.
Heritable disease shall mean an inherited disease that may result in
mental or physical retardation or death.
Phenylketonuria (PKU) shall mean an inherited condition that may cause
severe mental retardation if not treated.
3.0 !,BENEFITS
For the purpose of this Rider, benefits for covered outpatient
prescription drugs shall include only those drugs and medicines which are
written by Participating Physician, and obtained from a Participating
Pharmacy.
Benefits limitations and Member cost shall be as follows:
Cooayment by Member
e
e
PDM16-892
$10.00 per new prescription or refill for each thirty-four (34) day
supply or fraction thereof.
$240.00 per Norplant device.
1
6.0 EXCLUSIONS (Continued)
o Drugs not requiring a prescription (OTC, Vitamins, Cough Syrup,
etc.), except PKU and other heritable diseases supplements
o Drugs to be consumed in an inpatient or other institutional care
setting
o Drugs requiring parenteral use or subcutaneous use
o Charges for cost difference in a brand name product when generic
drugs are prescribed or permitted by physician
o Nutritional or dietary supplement, or formulas other than
prescription required vitamins
o Prescription written by nonparticipating physicians
o Medications dispensed by physician offices
o Prescriptions Drugs for cosmetic conditions not covered in the
Schedule of Benefits (such as Retin-A, Minoxidil, etc.)
PDMIO-892 4
SCHEDULE OF BENEFITS
Preferred PLUS
NETWORK
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
1-800/633-8598
817/878-5826
PREF-592
MAN KALTN
Each Subscriber and his Dependent Members are entitled to receive the services and benefits set
forth in this Schedule of Benefits which are Medically Necessary and obtained in accordance with the IIII
provisions of the Group Health Care Agreement/Subscriber Certificate of Coverage.
A. Upon enrollment, each Member shall choose (or the Subscriber shall choose on behalf of his
Dependents) a Primary Care Physician. If the Member fails to choose a Primary Care Physi-
cian, Harris Health shall assign a Primary Care Physician for the Member. The names and ad-
dresses of the Primary Care Physician from which the Member may choose shall be provided
to each Subscriber upon enrollment. Services are provided or coverage arrangements are avail-
able twenty-four (24) hours per day, seven (7) days a week by calling the telephone number
provided for the Primary Care Physician.
B. A Member may change their Primary Care Physician by contacting the Harris Health Member
Services Department at the address or telephone number specified above. The change will be-
come effective on the first day of the month following the request.
C. All health care services, except those resulting from a Medical Emergency, are to be per-
formed, prescribed, arranged, directed or authorized by the Primary Care Physician selected by
the Member. When care by a Specialist Physician is necessary, the Primary Care Physician
shall coordinate the referral to a Participating Specialist Physician. No referral is necessary for
a female member to obtain obstetrical/gynecological services from a Harris Health participating
OB/Gyn Specialist. If a required specialty is not represented in Harris Health, a referral may be
made to a Non-Participating Provider. All such non-emergency referrals must be authorized by
the Harris Health before services are obtained. Any Member may obtain additional information
as to how medical services are obtained by contacting the Harris Health at the address speci-
fied above.
D. Except in cases of a Medical Emergency, or as a result of special prior approval by Harris
Health as specified above, only those services provided by a Participating Provider shall be
covered under this Schedule of Benefits.
E. All services and benefits are subject to any stated Copayment amounts, limitations, and exclu-
sions described in this Schedule of Benefits. J
F. Any copayment expressed as a percentage of "Total Charges" shall mean the stated percent-
age of the medical provider's preferred rate which is the amount paid to the medical provider
by Harris Health.
G. This Schedule of Benefits may be supplemented by additional benefit Riders if included with this Group Health Care Agreement/Subscriber Certificate of Coverage.
H. The relationship between Harris Health and Participating Providers is that of independent con-
tracting entities. Participating Providers are not agents or employees of Harris Health nor is
Harris Health an employee or agent of any Participating Provider. Participating Providers shall
maintain the physician-patient or professional-patient relationship with Members and shall be
the only parties responsible to Members for the services provided. Neither Harris Health nor
any employee of Harris Health shall be deemed to be engaged in the practice of medicine. Har-
ris Health shall in no way supervise the practice of medicine by any Participating Provider, nor
shall Harris Health in any manner supervise, regulate or interfere with the usual professional
relationships between a Participating Provider and a Member.
PREF-592
1
PRESCRIPTION DRUG RIDER
FOR USE ONLY WITH GROUP HEALTH CARE AGREEMENT/SUBSCRIBER
CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance organization
_.___I
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
800/633-8598
1.0 INTRODUCTION
In consideration for the timely payment of premiums, and all other terms
and conditions of the Group Health Care Agreement/Subscriber Certificate
of Coverage ("Agreement"), it is agreed that the benefits of this Rider,
together with the terms and conditions of this Rider, shall be added to
Agreement as issued if this Rider is accepted by the Group.
2.0 DEFINITIONS
Benefits for outpatient prescription drugs provided through this Rider
shall be subject to the provisions and definitions of Agreement to which
this Rider is a part.
Prescription Drugs shall mean only those drugs and medicines which are
prescribed by a Participating Physician, and legally require the written
prescription of a Physician before they can be obtained by the Member.
Heritable disease shall mean an inherited disease that may result in
mental or physical retardation or death.
Phenylketonuria (PKU) shall mean an inherited condition that may cause
severe mental retardation if not treated.
3.0 BENEFITS
For the purpose of this Rider, benefits for covered outpatient
prescription drugs shall include only those drugs and medicines which are
written by Participating Physician, and obtained from a Participating
Pharmacy.
Benefits limitations and Member cost shall be as follows:
CoDayment by Member
0 $10.00 per new prescription or refill for each thirty-four (34) day
supply or fraction thereof.
o $240.00 per Norplant device.
PDMIO-892 1
3.0 BENEFITS (Continued)
COVERED ITEMS
When prescribed by a Participating Physician and dispensed at a
Participating Pharmacy, coverage will include:
o Any Federal Legend Drugs
o Any medicinal substance which includes the legend "Caution, federal
law prohibits dispensing without prescription."
o Any medicinal substance which may be dispensed by prescription only
according to state law.
o Any medicinal substance which has at least one ingredient that is
Federal legend or State restricted in a therapeutic amount.
o Oral contraceptives.
o Injectable insulin, insulin syringes and miscellaneous diabetic
supplies, including urine and blood glucose strips.
o PKU and other heritable diseases supplements.
o Nicorette gum and nicotine patches limited to one (1) course of
treatment per lifetime.
COVERED OUANTITIES
As prescribed, up to a maximum of a thirty-four (34) day supply for each
new covered prescription or refill. Prescriptions shall not be refilled
until approximately 75% of the previously dispensed quantity has been
consumed, based on dosage instructions of the physician. Members must pay
in full for any amounts exceeding covered quantities, including lost or
misplaced medications.
COVERED REFILLS
A maximum of five (5) refills per prescription shall be covered if allowed
by law and authorized by Physician, provided such refills are dispensed
within six (6) months of the initial prescription date.
USE OF GENERIC DRUGS
Whenever Possible, Participating Physicians will write prescriptions which
permit substitutions of a generic product. If generic product is
prescribed or permitted, only the generic cost will be covered.
4.0 MAIL ORDER PHARMACY BENEFITS
For the purpose of this Rider, benefits for mail order outpatient
maintenance prescription drugs shall include only those maintenance drugs
and medicines which are obtained from a Participating Mail Order Pharmacy
Provider.
Benefit limitations and Member cost shall be as follows:
o Copayment by Member - $10.00 per new prescription or refill for each
ninety (90) day supply or fraction thereof.
PDM10-892
2
4.0 MAIL ORDER PHARMACY BENEFITS (Continued)
COVERED ITEMS/EXCEPTIONS
Same' as described
exceptions:
o Anorexic drugs
o Fluorides
o Drugs requiring
under Section 3.0
refrigeration
"Benefits" with the following
COVERED QUANTITIES
As prescribed, up to a maximum of a ninety (90) day supply for each
covered maintenance drug prescription or refill. Prescriptions shall not of the refilled
consumed, based on approximately o previously of the physician. quantity
has been con
or misplaced for any tionounts exceeding covered quantities, including
must pay in lost
COVERED ~S
A maximum of four (4) refills shall be covered if allowed by law and
date, are ndspthee Member iin twelve
authorized by Physician, provided vi prescription refills
(12) months of the initial remains
eligible for such benefit.
EXCLUSIONS
Same as described under Section 6.0 "Exclusions", and including exceptions
listed above under "Covered Items/Exceptions" in this Section.
5.0 ELIGIBILITY
Benefits under this Rider are available to the Subscriber and Dependents
(Members) as identified in Agreement.
Benefits provide no conversion privileges or benefit continuity for
Members wpsthis Rider is entitled attached. Group benefits as set
forth in Agreement to which
6.0 EXCLUSIONS
o
o
IUD Devices
Therapeutic or Prosthetic devices
other non-medical products
o
Appliances, Supports or
Medical Supplies except those
listed as covered items
o
o
Injectable Medications, other
roduced
s
d
than insulin
from blood, blood plasma
o
p
rug
Prescription
products
o
Experimental Drugs
o
Immunization Agents
o
Fertility Medications
and blood
PDM10-892
6.0 EXCLUSIONS (Continued)
o Drugs not requiring a prescription (OTC, Vitamins, Cough Syrup,
etc.), except PKU and other heritable diseases supplements
o Drugs to be consumed in an inpatient or other institutional care
setting
o Drugs requiring parenteral use or subcutaneous use
o Charges for cost difference in a brand name product when generic
drugs are prescribed or permitted by physician
o Nutritional or dietary supplement, or formulas other than
o Prescription writtend by vitamins physicians
o Medications dispensed by physician offices
o Prescriptions Drugs for cosmetic conditions not covered in the
Schedule of Benefits (such as Retin-A, Minoxidil, etc.)
PDMIO-892
Benefits
OONisit-Primary Care
$15
Physician office visits, adult health assessments, routine
and health education
ell child care
.
,
physical examinations, w
nd treatment of illness or injury provided
for diagnosis, care a
by Primary Care Physician
office visits from Specialist Physician
i
i
$20.OoNisit-Specialist
an
c
Phys
$15.OONisit-Primary Care
Annual well woman examination
$20.00Nisit-Specialist
$25.OONisit
Physician office visits after hours
No Copayment
immunizations and injections
$15.OONisit
Home visits
Primary
o
screening
Hearing
$15.OONisit
,
correction
need for
Physician to determine the
Ca
re
Allergy diagnosis and/or testing; serum is not covered
$50.00/Visit
Administered drugs, medications, dressings, splints, and
5.OONisit-Primary Care
$1 $20.OONisit-Specialist
casts
No Copayment
Diagnostic services, laboratory tests, and x-rays
Ultrasound, MRI, CAT, and non-routine laboratory tests
$50.00/Test
Surgery and/or anesthesia performed in the physician's office
$50.00/Procedure (Phys.)
or outpatient setting
All physician fees including anesthesia while a member is
nal radiology and pathology fees
i
f
20% of Total Charges
o
ess
hospitalized, except pro
Professional radiology and pathology fees
No Copayment
Physician fee in an emergency room or urgent care center
20% of Total Charges
2
PREF-592
Onl furnished on sservi enbyCtheasametProvlider.rTh slrCopaym nt willll bertheehigher orf all listed Copaymentssame date of
Required Copayment
For maternity services within the Service Area, Member shall be entitled to receive medical, surgical,
and hospital care from Participating Physicians and other Providers during the term of the pregnancy,
upon delivery, and during the postpartum period for normal delivery; for abortion and miscarriages;
and for complications of pregnancy. Charges related to medical services connected with the home
delivery of a newborn and services of mid-wives, unless provided as Emergency Care Services, will
not be covered. Any normal delivery which occurs outside the Service Area within thirty (30) days of
the expected date of confinement as specified by a Participating Physician, will not qualify for
Emergency Care Services benefits, and will not be a covered benefit. Benefits for the child of an
unmarried Dependent Member will be provided if the child is considered to be a dependent of the
Subscriber for Federal income tax purposes, and upon payment of the applicable premium.
Benefits
Required Copayment
Physician services for maternity care including delivery, 20% of Total Charges
hospital visits, and anesthesia
Physician care in the hospital for care of Eligible Newborn 20% of Total Charges
Member shall be entitled to receive Medically Necessary hospital services, subject to all definitions,
terms and conditions of this Agreement and Schedule of Benefits when performed, prescribed,
arranged for, directed or authorized by Participating Physicians and received at Participating
Hospitals. Members electing to remain in the hospital beyond the period which is Medically Necessary
will be responsible for direct payment to the hospital for any such time beyond the discharge time
authorized by the Participating Physician and/or the Harris Health Medical Director or his designee.
Benefits
INPATIENT HOSPITAL SERVICES: Required Copayment
20% of Total Charges
Semi-private room, private if Medically Necessary, and
all services and medical supplies related to inpatient
treatment.
OUTPATIENT HOSPITAL SERVICES (Including Ambulatory Facilities)
Surgery
$100.00/Procedure (Facility)
Therapeutic radiation treatment
20% of Total Charges
Inhalation therapy
20% of Total Charges
Diagnostic testing, laboratory, and x-rays
No Copayment
Ultrasound, MRI, CAT, and non-routine laboratory tests
$50.00/Test
PREF-592
In cases of a Medical Emergency, Member is entitled to the benefits and services set forth in this
Schedule of Benefits and in this Agreement even if the services are not received from Participating
Providers. Member is entitled to receive these 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.
All treatment for such services will be reviewed retrospectively by the Harris Health Medical Director
o
r his designee to determine whether an acute condition or situation indicated immediate emergency
care to
that no b need for ermergency care existed, the aMe Member twill bel responDirector or his designee sible ble for payment of all determines charges
incurred for such care.
WITHIN THE SERVICE AREA Emergency Care Services must be obtained or authorized through the
Primary Care Physician who provides the Member with twenty-four (24) hours a day, seven (7) days
a week access to call coverage to assist the Member in obtaining Emergency Care Services. At the
time of a Medical Emergency, the Member or someone acting on behalf of the Member, shall make
every reasonable effort to contact the Member's Primary Care Physician for advice. If it is not
reasonably possible to contact the Primary Care Physician at the time (such as that of a life or limb
threatening emergency), the Member shall seek care from a Participating Hospital or Participating
Emergency Center.
At the acting on time
of the Member, shall notify Harris Hin a ealth witthinl twadmission, the enty-four (24)nhours eoroasssoonoas
reasonably possible. Upon notification, the Harris Health Medical Director or his designee may
coordinate transfer of the Member to the care of their Primary Care Physician or other designated
provider when medically prudent to do so.
Benefits (Within Service Area) Required Copayment
Physician office visits $15.00/Visit-Primary Care
$20.00Nisit-Specialist
Physician office visits after hours
Hospital emergency room and urgent care center services,
including phys'cian fees
Follow-up care is covered from Primary Care Physician only,
or upon referral from the Primary Care Physician
$25.00/Visit
20% of Total Charges
$15.OONisit-Primary Care
$20.OONisit-Specialist
PREF-592
OUTSIDE THE SERVICE AREA coverage for Emergency Care Services while outside the Service Area
are available provided that such Emergency Care Services cannot be reasonably delayed without risk
to Member until the Member is able to return to the Service Area to obtain treatment from
Participating Providers.
At the time of a Medical Emergency which results in a hospital admission, the Member or someone
acting on behalf of the Member, shall notify Harris Health within twenty-four (24) hours or as soon as
reasonably possible. Upon notification, the Harris Health Medical Director or his designee may
coordinate any transfer of management and control of the care to a Participating Provider or other
designated provider in the Service Area as soon as medically prudent to do so.
emergency sor follow-u ervices shpall be allowed when procedures in this section are not comclaim plied by the
Member.
Required Copayment
Benefits (Outside the Service Area)
Physician office visits for stabilization and emergency care $20.OONisit Sp ecaiaryst Care
services only
Physician office visits after hours $25.00Nisit
20% of Total Charges
Hospital emergency room and urgent care center services for
stabilization only, including physician fees
Follow-up care is covered from Primary Care Physician only, $15.00Nisit-Primary Care
$20.00Nisit-Specialist
or upon referral from the primary Care Physician
Family Planning Services will be available to Members on a voluntary basis. Covered services are
limited to the use of Participating Providers and will include history, physical examination, related
laboratory tests; medical supervision in accordance with generally accepted medical practice;
information and counseling on contraception, including advice or prescription for a contraceptive
method; education, including education on the prevention of venereal disease; and voluntary
sterilization after appropriate counseling.
Benefits
Physician office visits, including related testing, education and
counseling
Fitting and dispensing of IUD and diaphragms
Tubal ligation
Vasectomy
Required Copayment
$15.OONisit- Primary Care
$20.00/Visit-Specialist
$15.OONisit-Primary Care
$20.OONisit-Specialist
$50.00/Procedure (Phys.)
$50.00/Procedure (Phys.)
PREF-592
Infertility services will be available to Members on a voluntary basis. Artificial insemination and
diagnostic services to determine the cause of infertility will be provided from Participating Providers
and Participating Facilities. Excluded from services to treat infertility are those services described in
"Exclusions," Section XIX, Number 23 of this Schedule of Benefits.
Benefits Required Copayment
Physician office visits for diagnosis, non-psychiatric $15.OONisit-Primary Care
counseling, artificial insemination, and sperm count $20.OONisit-Specialist
Administration of infertility medications; infertility $15.OONisit-Primary Care
medications not covered $20.OONisit-Specialist
Endometrial biopsy, hysterosalpingography and diagnostic 20% of Total Charges
laparoscopy
Sonogram and/or ovulation kit $50.00/Test or Kit
Member shall be entitled to all necessary care and treatment for chemical dependency on the same
basis as that provided for any physical illness to a lifetime maximum of three (3) separate series of
treatments for the member. Diagnosis and treatment for chemical dependency shall include
detoxification and/or rehabilitation on either an inpatient or outpatient basis as determined to be
Medically Necessary by Participating Physicians. All treatment is subject to the same limitations,
exclusions, and copayments as applied to covered services of any other physical illness.
A series of treatments is considered to be a planned, structured, and organized program to promote
chemical free status which may include different facilities or modalities and is complete when:
The member is discharged on medical advice from inpatient detoxification, inpatient
rehabilitation treatment, partial hospitalization or intensive outpatient; or
The member has received a series of these levels of treatments without a lapse in treatment; or
The member fails to materially comply with the treatment program for a period of thirty (30)
days.
Benefits
Office visits
Necessary care and treatment for detoxification and/or
rehabilitation from chemical dependency
Intensive outpatient or partial hospitalization
Required Copayment
$15.OONisit-Primary Care
$20.OONisit-Specialist
$15,0ONisit-Primary Care
$20.OONisit-Specialist
20% Total Inpatient Charges
20% Total Inpatient Charges
PREF-592
OUTPATIENT MENTAL HEALTH SERVICES:
Member shall be entitled to receive up to twenty (20) office visits per Calendar Year for evaluation,
crisis intervention and stabilization, and for outpatient therapy in support of the evaluation or crisis
intervention. Member must be referred by the Primary Care Physician or by the Harris Health
designee to Participating Specialist. Services must represent treatment for conditions which in the
judgment of Participating Providers can substantially benefit from short-term treatment. The twenty
(20) visits maximum may include individual treatment, couple, or family visits.
Benefits Required Copayment
Outpatient office visits for crisis intervention and treatment $20.00Nisit
Psychological testing 20% of Total Charges
INPATIENT MENTAL HEALTH SERVICES:
When determined to be Medically Necessary by Participating Physician or by the Harris Health
designee, the Member shall be entitled to evaluation, crisis intervention, treatment or any
combination thereof for acute conditions at a Participating Facility. Services must represent treatment
for conditions which in the judgment of Participating Providers can substantially benefit from
treatment, and requires inpatient treatment.
Only treatment at the most appropriate level of care as determined by 'Participating Providers or by
the Harris Health designee will be authorized by Harris Health.
Chronic mental health conditions and long-term treatment are not covered.
Benefits
Inpatient hospitalization for up to thirty (30) inpatient days per
Calendar Year.
Psychiatric Day Treatment Facility, Crisis Stabilization Unit or
Residential Treatment Center for Children and Adolescents for
up to sixty (60) days per Calendar Year. Treatment in such
facilities will be limited to sixty (60) days of care such that one
(1) day of care shall be equal to one-half (1/2) day of inpatient
care.
Required Copayment
20% of Total Charges
20% of Total Charges
PREF-592
Member shall be entitled to receive short-term physical or occupational therapy rehabilitation services
from a Participating Provider for conditions which in the judgment of Participating Physicians are
Medically Necessary, subject to significant improvement through short-term treatment, and
authorized by Harris Health before services are obtained. Short-term treatment is defined as up to
sixty (60) consecutive days or twenty-five (25) visits per condition, whichever is greater, and shall be
provided on an outpatient basis only. Short-term rehabilitation services on an inpatient basis or in a
skilled nursing facility will be authorized only if other non-rehabilitation medical services are required
by the Member.
Occupational therapy shall mean those services designed to prevent dysfunction, restore functional
ability and facilitate maximal adaptation to impairment.
Benefits Required Copayment
Hospital, home health agency, or other provider for restorative $15.OONisit-Primary Care
treatment subject to short-term clinical improvement, and $20.OONisit-Specialist
limited to sixty (60) consecutive days or twenty-five (25) visits 20% Total Inpatient Charges
per condition, whichever is greater. Long-term or maintenance
services are not covered.
Member shall be entitled to services and benefits provided within the Service Area for kidney dialysis
upon prior authorization from Harris Health and by referral to Participating Providers, only if
Participating Physician determines that such service represents the preferred method of treatment,
and the Member satisfies criteria for the service involved. Coverage will be coordinated for any
Member eligible for available coverage under the Medicare provisions for End Stage Renal Disease.
Benefits
Inpatient or outpatient hospital, or outpatient kidney dialysis
center
Home dialysis (continuous ambulatory peritoneal dialysis)
including equipment, training, solutions, coils, drug and
surgical supplies
Benefits
Member shall be entitled to both land and air ambulance
services for Medically Necessary Emergency Care Services
Required Copayment
$20.00N1s1t-0 utpatie nt
20% Total Inpatient Charges
$20.OONisit
Required Copayment
20% of Total Charges
PREF-592
Benefits
Skilled nursing care; physical, occupational; or respiratory
therapy; intravenous solutions; and home health aid services
Required Copayment
$15.OONisit
Member is entitled to receive services in a Participating Skilled Nursing Facility for medical conditions
which in the judgment of a Participating Physician is subject to significant clinical improvement and
which require services which can only be provided at that level of care. Services in a Skilled Nursing
Facility may be provided in lieu of hospitalization (either in lieu of admission or upon discharge from
inpatient care) as Medically Necessary based on acuity of services and patient condition, are limited
to sixty (60) days per Calendar Year, and include Participating Physician services only.
Benefits Required Copayment
20% of Total Charges
Room, board, medications and supplies while confined in a
Skilled Nursing Facility as part of a short-term recovery or
rehabilitation program
20% of Total Charges
Participating physician visits while confined to Skilled Nursing
Facility
Benefits
internal prosthetic appliances including internal cardiac
pacemakers, and minor devices such as screws, wire mesh,
nails, and artificial joints. Supply of or replacement of internal
breast prothesis covered only if initial surgery was result of
injury or disease.
PREF-592
Required Copayment
20% of Total Charges
Member shall be entitled to receive home health care services from a Participating Provider according
to a treatment Plan approved by the Participating Physician, and with prior authorization from Harris
Health. Treatment will be provided only for those medical conditions subject to clinical improvement
through short-term treatment; for recovery or rehabilitation of illness or injury; or for treatment of
terminal illness.
$15.OONisit
Hospice (home health service only)
Member shall be entitled to prosthetic medical services or medical appliances if Medically Necessary,
with authorization from Harris Health, and received from Participating Providers. While the Member is
covered under this Agreement, initial prostheses are provided when required due to illness or injury.
al changes occur which require replacement, and is
Replacement
provided f is provided which only when e marked to physical
not
Benefits
External prosthetic appliances including artificial arms, legs,
above or below knee or elbow prostheses; eyes, lenses,
external cardiac pacemaker; terminal devices such as hand or
hook; rigid or semi-rigid immobilizing devices such as arm,
leg, neck or back braces; and ordinary splints, and crutches
Required Copayment
20% of Total Charges
Member shall be entitled to benefits received from a Participating Provider for certain durable medical
equipment, as ordered by a Participating Physician, and with prior authorization from Harris Health.
Durable medical equipment must be able to withstand repeated use, primarily and customarily serve a
medical purpose, generally not be useful in the absence of illness or injury, require a Participating
Physician's order, and be appropriate for use in the home. At its option, Harris Health may rent or
purchase approved equipment. Harris Health retains the right of possession of equipment.
Harris Health shall have no liability or responsibility for repair or replacement of equipment lost or
damaged. Equipment not considered durable medical equipment is described in "Exclusions'',
Section XIX, Number 31 of this Schedule of Benefits.
Benefits
Rental or purchase of medical equipment
Required Copayment
20% of Total Charges
The Member shall be entitled to services for the initial stabilization of acute accidental, non-
occupational injury, to sound natural teeth with prior authorization by Harris Health, when provided
within thirty (30) days of the accident on an outpatient basis only.
While Member is covered under this Agreement coverage is limited to treatment of fractured or
dislocated jaw, or to repair damage to sound natural teeth. Limitations and exclusions for dental
services are described in Section XVIII, Number 3 and Section XIX, Number 17 of this Schedule of
Benefits. Copayments will be the same as described for other illness or injury services.
The maximum annual Copayments for covered benefits, under this Schedule of Benefits, shall not
exceed the following in a Calendar Year as described in Section 5.3, of the Group Health Care
Agreement/Subscriber Certificate of Coverage.
Benefits Maximum Annual Copayments
Per Member $2,000.00
Per Family $4,000.00
PREF-592 10
The following services are limited as described below:
Any service, supply, or treatment which is not provided, ordered, performed, prescribed,
directed, referred, arranged, authorized or approved by the Member's Primary Care Physician,
or the Harris Health Medical Director or his designee, will not be covered; except for
Emergency Care Services as described in this Schedule of Benefits.
2. Services by physicians, facilities or other providers, who are not Participating Providers, will
not be covered; except for Emergency Care Services as described in this Schedule of Benefits,
or those services authorized in advance in writing by the Harris Health Medical Director or his
designee.
3. Care and treatment of, the teeth or gums, except for oral surgery for tumors or injuries to the
jaw bone or surrgiindfrig tissue, is limited to the initial stabilization of acute, accidental non-
occupational injury-to sound, natural teeth when provided within thirty (30) days of the
accident on an outpatient basis only.
4. Coverage for vision examinations is limited to conditions which require examination to
diagnose injury or illness, unless covered by Rider attached to this Agreement.
5. The benefit for durable medical equipment is limited to either the total rental cost or the
purchase price of such equipment, whichever is less, as determined and authorized in advance
by the Harris Health Medical Director or his designee. Harris Health shall have no liability or
responsibility for repair or replacement of equipment lost or damaged.
Care and treatment provided in non-participating hospital owned or operated by federal, state,
county or city government is limited to the care for the condition which the law requires to be
treated or provided in a public facility.
The purchase or fitting of eye glasses or contact lens or advice on their care is limited to the
initial set of eye glasses, contact lens, or lens implant required following cataract surgery,
repair of congenital defect or as required by an accidental injury to the Member.
Coverage for reconstructive surgery is limited to surgery necessary to repair a functional
disorder resulting from disease, injury, or congenital defect. Supply or replacement of internal
breast prothesis is covered only if initial surgery was a result of injury or disease.
9. Any normal delivery for the Member which occurs outside the Service Area, and is within thirty
(30) days of the expected date of confinement, as specified by a Participating Physician, will
not qualify as Emergency Care Services benefits described in this Schedule of Benefits.
10. Benefits for Dependents who are students temporarily residing outside the Service Area, are
limited to Emergency Care Services only outside the Service Area. The Dependent must return
to the Service Area for all other services.
11. Coverage for treatment of the temporomandibular (jaw or craniomandibular) joint is limited to
Medically Necessary diagnostic services and/or surgical treatment as determined to be
Medically Necessary by the Harris Health Medical Director or his designee. All services must
be provided by a Participating Provider. Charges related to dental services for this condition
are not covered.
PREF-592 11
12. If Medically Necessary and authorized by the Harris Health Medical Director or designee, Harris
Health will cover kidney transplants, corneal transplants, liver transplants for children with
congenital biliary atresia, and bone marrow transplants for Aplastic Anemia; Leukemia;
Lymphoma; Severe Combined Immunodeficiency Disease; or Wiskott-Aldrich Syndrome where
traditional modalities of traditional medical therapy have been exhausted. Medical costs for
organ procurement associated with the removal of an organ for a covered transplant when the
recipient is a Member are limited to a maximum benefit of $10,000. Charges related to organ,
tissue, or artificial organ transplants except as otherwise specified in this section are excluded.
The donor's transportation costs are not covered. Services provided to any Member for the
donation of any organ or element of the body are not covered.
13. Benefits for the infant child of an unmarried Dependent will be provided if the infant is
considered to be a dependent of the Subscriber for Federal income tax purposes, and upon
payment of the applicable premium.
PREF-592 12
The following services and supplies, and the cost thereof, are excluded from coverage under this
Agreement, unless specifically added by Rider to this Schedule of Benefits.
1. Charges related to any service or treatment which a Member would not be legally required to
pay in the absence of this Agreement.
2. Charges related to personal, convenience, or comfort items such as personal kits provided on
admission to a hospital, television, telephone, newborn infant photographs, guest meals, birth
announcements, and other related articles which are not for the specific treatment of illness or
injury.
3. Charges related to transportation, except charges related to land and air ambulance services
for Medically Necessary Emergency Care Services described in Section XI of this Agreement.
4. Charges related to private hospital room and/or private duty nursing.
5. Charges related to services rendered by a person who resides in a Member's home, or by an
immediate relative of the Member.
6. Charges related to services for military or service connected conditions for which the Member
is legally entitled, and for which appropriate facilities are reasonably available to the Member.
7. Charges related to occupational injury or illness or conditions covered under Worker's
Compensation.
8. Charges related to homemaker, chore or similar services; and health care services primarily for
rest, custodial, respite, domiciliary, or convalescent care.
9. Charges related to reports, evaluations, or physical examinations not required for health
reasons (not Medically Necessary). Excluded items are: reports for employment, insurance,
camp, adoption, travel, or government licenses.
10. Charges related to drugs or medicines, prescription or non-prescription, provided to the
Member while he or she is not an inpatient, unless added by Rider to this Schedule of
Benefits.
11. Charges related to experimental drugs or substances not approved by the FDA for other than
FDA approved indications; and drugs labeled "Caution - limited by Federal Law to
investigational use."
12. Charges related to formulas, dietary supplements, or special diets provided to the Member on
an outpatient basis.
13. Charges related to vision care. Excluded services are: examination for eye glasses; refraction,
dispensing, or fitting of eye glass frames and lenses; all types of contact lens; eye exercise and
visual training; and orthoptics; except as otherwise specified in Section XVIII, Number 4 of this
Schedule of Benefits.
14. Charges related to radial keratotomy or other radial keratoplasties, and all costs associated
with such surgery.
PREF-592 13
15. Charges related to hearing aids, batteries, and examinations for fitting thereof unless added by
Rider to this Schedule of Benefits.
16. Charges related to the care and treatment of the feet unless such services are Medically
Necessary. Exclusions include routine foot care, such as removal of corns, calluses, or the
trimming of nails; treatment for flat feet; orthotics; arch supports; or custom fitted braces and
splints.
17. Charges related to dental care, except as otherwise specified in Section XVI of this Schedule of
Benefits, including services related to the care, fillings, removal, or replacement of teeth;
treatment of diseases of the teeth or gums; extraction of wisdom teeth; malocclusion or
malposition of the teeth and jaws (mandibular hype rplasia/hypoplasia); professional services or
anesthesia related to or required for the sole purpose to provide dental care; hospital care;
inpatient or outpatient surgery required for any dental care; prescription drugs for dental
treatment; dental x-rays; dentures; and dental appliances or prostheses.
18. Charges related to surgical procedures and other treatment associated with the treatment of
obesity, regardless of associated medical or psychological conditions, including treatment of a
complication of surgical treatment for obesity. Excluded procedures are: intestinal or stomach
bypass surgery, gastric stapling, wiring of the jaw, insertion of gastric balloons, or similar
procedures.
19. Charges related to transsexual surgery, including medical or psychological counseling or
hormonal therapy, in preparation for or subsequent to any such surgery.
20. Charges related to services for cosmetic surgery or reconstructive surgery, except as
otherwise specified as covered in this Schedule of Benefits. Cosmetic surgery exclusions are:
rhinoplasty; scar revisions; prosthetic penile implants; surgical revision or reformation of any
sagging skin on any part of the body, described as relating to the eye lids, face, neck,
abdomen, arms, legs or buttocks; liposuction procedures; any services performed in
connection with the enlargement, reduction, implantation or appearance of a portion of the
body described as the breast, face, lips, jaw, chin, nose, ears, or genitals; hair transplantation;
chemical face peels or abrasions of the skin; removal of tatoos; and electrolysis depilation.
Supply or replacement of internal breast prothesis is covered only if initial surgery was a result
of injury or disease.
21. Charges related to reduction mammoplasty, unless determined to be Medically Necessary by
the Harris Health Medical Director or his designee.
22. Charges related to reversal of surgically performed sterilization or subsequent resterilization.
23. Charges related to surrogate parenting; in-vitro fertilization; GIFT procedures; and any costs
associated with the collection or storage of sperm for artificial insemination including donor
fees; and infertility medications unless added by Rider to this Schedule of Benefits.
24. Charges related to amniocentesis, ultrasound, or any other procedure performed solely for sex
determination of the fetus.
25. Charges related to medical and hospital care for an infant of an unmarried Dependent Member,
unless the infant is considered to be a dependent of the Subscriber for Federal income tax
purposes, and applicable premium payment has been made.
26. Charges related to mental health services for psychiatric conditions which are determined by
the Harris Health Medical Director or his designee, to be chronic or organic in nature, and
which will not substantially benefit from short-term evaluation, crisis intervention and
stabilization, or short-term treatment.
PREF-592 14
27. Charges related to court ordered testing, and special reports not directly related to medical
treatment.
28. Charges related to services for the treatment of mental retardation and mental deficiency.
29. Charges related to employment, vocational, or marriage counseling; behavioral training;
remedial education, including evaluation and treatment of learning and developmental
disabilities and minimal brain dysfunction; or attention deficit therapy.
30. Charges related to services for chronic intractable pain provided by a pain control center;
acupuncture, naturopathy, and hypnotherapy; holistic or homeopathic care, including drugs;
and ecological or environmental medicine.
31. Charges related to durable medical equipment, unless described in this Schedule of Benefits.
Excluded items are: (a) equipment, such as motor driven wheel chairs and beds, possessing
features of an aesthetic nature or features of a medical nature which are not required by the
patient's condition; (b) items not primarily medical in nature or for the patient's comfort and
convenience, such as bed boards, bathtub lifts, over-bed tables, adjust-a-bed, and telephone
arms; (c) physician's equipment such as stethoscope and sphygmomanometer; (d) exercise
equipment such as exercycles and enrollment in health or athletic clubs; (e) self-help devices
not primarily medical in nature, such as sauna or whirlpool baths, chairs, and elevators; (f)
corrective orthopedic shoes and arch supports; (g) supplies or equipment for common
household use, such as but not limited to, air purifiers, central or unit air conditioners, water
purifiers, allergenic pillows or mattresses, and water beds; and (h) research equipment or
items deemed to be experimental as determined by the Harris Health. Harris Health shall have
no liability or responsibility for repair or replacement of equipment lost or damaged.
32. Charges related to prosthetic medical appliances, except as specified in Section XIV of this
Schedule of Benefits. Excluded items include: (a) dentures, hearing aids unless provided by
Rider, and contact lens; (b) medical supplies such as elastic stockings, garter belts, arch
supports, corsets, and corrective orthopedic shoes; (c) research devices or items deemed to
be experimental as determined by Harris Health; and (d) replacement, repair, and routine
maintenance of covered appliances or braces unless surgically implanted, or replacement
required due to a marked change in physical growth or physical requirements.
33. Charges related to medical supplies, aids, and appliances except as otherwise specified as
covered in this Schedule of Benefits. Excluded items are: consumables, disposable supplies,
sheaths, bags, gloves, cervical collars, elastic stockings, stethoscopes, blood pressure units,
traction apparatus, slings, TENS or electrical nerve stimulation devices, wigs or hair pieces,
dressings, testing supplies, syringes, home testing kits, disposable diapers or incontinent
supplies, and over-the-counter medications.
34. Charges related to inpatient or outpatient long-term neuromuscular, or occupational therapy
services or other rehabilitation services in excess of sixty (60) days per condition or twenty-
five (25) outpatient visits, whichever is greater.
35. Charges related to recreational or educational therapy, and any related diagnostic testing,
except as provided by the hospital as part of an approved inpatient hospitalization.
36. Charges related to structural changes to a house or vehicle.
37. Charges related to any medical, surgical, or health care procedure or treatment held to be
experimental or investigational at the time the procedure or treatment is performed. Harris
Health will utilize findings and assessments of national medical associations, professional
societies and organizations, and any appropriate technological body established by any state or
federal government or similar entities to determine coverage and/or effectiveness.
PREF-592 15
SERIOUS MENTALHEALTH RIDER
FOR USE ONLY WITH GROUP HEALTH CARE AGREEMENT/SUBSCRIBER
CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance Organim ion
1300 Summit Ave, Suite 300
Fort Worth, Texas 76102
8001633-8598
1.0 INTRODUCTION
In consideration for the timely payment of premiums, and all other terms and conditions of the Group
Health Care Agreement/Subscriber Certificate of Coverage ("Agreement") , it is agreed that the
benefits of this Rider, together with the terms and conditions of this Rider, shall be added to
Agreement as issued if this Rider is accepted by the Group.
2.0 DEFINITIONS
Benefits for Serious Mental Health provided through this Rider shall be subject to the provisions and
definitions of the Agreement to which this Rider is a part.
Serious Mental Illness shall mean the following psychiatric illnesses as defined by the American
Psychiatric Association in the Diagnostic and Statistical Manual (DSM) III-R:
1. Schizophrenia;
2. Paranoid and other psychotic disorders;
3. Bipolar disorders (mixed, manic, and depressive);
4. Major depressive disorders (single episode or recurrent); and
5. Schizo-affective disorders (bipolar or depressive).
3.0 BENEFITS
For the purpose of this Rider, benefits for Serious Mental Illness care shall include only those
services obtained from Participating Providers.
Copayment by Member:
Mental health services provided for Serious Mental Illness shall be provided
subject to the same limitations, exclusions, and copayments as applied to
covered services of any other physical illness.
SMI-292 )
4.0 ELIGIBILITY
Benefits under this Rider are available to the Subscriber and Dependents (Members) as identified in
Agreement.
Benefits provide no conversion privileges or benefit continuity for Members when such persons are
no longer entitled to Group benefits as set forth in Agreement to which this Rider is attached.
5.0
• Charges related to mental health services for psychiatric conditions determined by the Harris
Medical Director or his designee, as not qualifying for coverage under this Rider will be
subject to the same limitations, exclusions, and copayments as applied to mental health
services listed in the Schedule of Benefits of which this Rider is a part.
• Services must be obtained in accordance with Harris Health utilization review
guidelines.
SMI-292 2
SERIOUS MENTAL HEALTH RIDER
FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
ACCEPTED:
t L&
Group
By:
Awlu
Date:
REJECTED:
Group
By: _
Authorized Representative
HARRIS HEALTH PLAN, INC.
Senio4V.ee dent,Managed Carc MarAeling
1300 Summit Avenue, Suite 200
Fort Worth, TX 76102
(817) 878-5830
Date: I (.ll zCz 3
Date:
IN-VITRO FERTILIZATION RIDER
FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
800/633-8598
1.0 INTRODUCTION
In consideration for the timely paymentof premiums, and all other terms and conditions of the Group
Healthcare Agreement/Subscriber Certificate of Coverage ("Agreement"), it is agreed that the benefits
of this Rider, together with the terms and conditions of this Rider, shall be added to Agreement as
issued if this Rider is accepted by the Group.
2.0 BENEFITS
For the purpose of this Rider, outpatient expenses arising from in-vitro fertilization procedures for
the Subscriber or the Subscriber's spouse, the following conditions shall apply:
The fertilization or attempt at fertilization of the Member's oocytes is made only with
Member's spouse's sperm.
The Member and the Member's spouse have a history of infertility of at least five
continuous years duration; or the infertility is associated with one or more of the
following medical conditions:
a. endometriosis;
b. exposure in utero to diethylstilbestrol (DES);
c. blockage of, or surgical removal of, one or both fallopian tubes (non-voluntary); or
d. oligospermia.
The Member has been unable to attain a successful pregnancy through any less costly
applicable infertility treatments for which benefits are available under the Plan.
The in-vitro fertilization procedures are performed at a medical facility that conforms
to the American College of Obstetric and Gynecology guidelines for in-vitro fertilization
clinics or to the American Fertility Society minimal standards for programs of in-vitro
fertilization.
Benefits for in-vitro fertilization procedures shall be provided to the same extent as
the benefits for other pregnancy-related procedures under the Plan.
NF188
3.0 ELIGHHLrFV
Benefits under this Rider are available to the Subscriber and the Subscriber's spouse. Bents
provide no conversion privileges or benefit continuity for Members when such persons are no
longer entitled to Group benefits as set forth in Agreement to which this Rider is issued.
4.0 LIMITATIONS
Benefits shall be provided only if recommended by a Harris Health Primary or Harris Health
Specialty Physician and have received prior written approval from the Harris Medical Director of his
designee.
IVF188 2
IN-VITRO FERTILIZATION RIDER
FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
By. /2' ij
Senior Vice resident, Managed Care Marketing
1300 Summit Avenue, Suite 200
Fort Worth, TX 76102
(817) 878-5830
Date: l / % /1'
REJECTED:
Group
By:
Authorized Representative
Date:
CITY OF DENTON
REQUEST FOR BID
BID NO. 1523
Health Insurance Program
Due: September 24, 1993
Prepared: 06/28/93
CITY OF DENTON
Request for Bid for Group Medical
TABLE OF CONTENTS
Page
Background and General Information . . . . . .
Scope of Specifications and Instructions . . .
Plan Assumptions (Exhibit I) . . . . . . . . .
Bid Submission Form (Exhibit II) . . . . . . .
2
6
Current schedule of Benefits (Exhibit III) . . . . .
Plan Experience (Exhibit IV) . . . . . . . . . . . .
Carrier/Underwriter Profile (Exhibit V) . . . . . . .
Census Data (Exhibit VI) . . . . . . . . . . . . . .
. . . . 12
. . . . 16
. . . . 21
. . . . 22
AAA01836
BACKGROUND AND GENERAL INFORMATION
The City of Denton is a city of 68,000 population and was
incorporated in 1866.
Denton is located approximately 40 miles north of Dallas and
Fort Worth. It sits at the apex of a triangle that encompasses the
Dallas-Fort Worth metropolitan area. Although it benefits from the
forward thrust and continuous expansion of the largest Consolidated
Metropolitan Statistical Area in the state, Denton and its economy
stand proudly independent.
The City of Denton has a work force of approximately 850 employees.
The city has had an effective safety and risk management program
since 1970.
The services the City provide consist of law enforcement, fire
safety, paramedics/ rescue, refuse collection, sanitary landfill,
electric, water, sanitary sewer, storm sewer, animal control,
parks/ recreation, library and airport. In general, we are a
full-service city; however, there is no city hospital or rest home.
Two major universities University of North Texas and Texas
Woman's University along with a fully accredited public school
system, allow local citizens every educational advantage possible
and a rich blend of cultures.
The eastern and western branches of Interstate Highway 35 meet in
Denton, making it conveniently accessible to everything in Dallas
and Fort Worth.
Denton offers worlds of opportunities to the prospective developer,
business person or industrialist. Texas Instruments has a plant
here and other industries are expanding.
Any questions regarding the City's current health plan or this bid
should be directed to Ike Obi at (817) 566-8340. Questions
concerning the bid submittal should be directed to Tom Shaw at
(817) 383-7100.
AAA01836 -1-
SCOPE OF SPECIFICATIONS & INSTRUCTIONS
The City will entertain proposals on fully insured managed care
plan basis. The specifications contained herein will encompass
Network Only and Non-Network Plans. since we are presently
evaluating options to reduce our cost, we are seeking optional
quotes on plans designed to achieve this. We, in essence, urge
innovative approaches to health care coverage.
The City of Denton is seeking an insurance policy/ agreement to
become effective January 1, 1994, for a minimum of one (1) year.
The policy shall provide, if not cancelled prior to December 31,
1994 in accordance with the terms of the policy/agreement, bid
submission form, and/or request for bidders, for the renewal of
this policy for two (2) successive twelve (12) month periods,
thereafter subject to the renegotiation of the terms of this
policy, if City Manager and insurance company agree, without the
necessity of rebidding this insurance proposal as long as the cost
of insurance during either the first or second twelve (12) month
successive period does not increase more than 30% and the plan
design benefits do not decrease more than 30%. However, this
proposal may be terminated if insurance company and City are unable
to agree in writing to a mutually agreeable plan design and
insurance cost no later than seventy-five (75) days prior to the
end of the preceding period.
The City is interested in a fully insured managed care proposal.
The instructions contained herein apply to all sections; otherwise,
each section can stand alone, or be a part of a partial or total
package. Although the City is interested in packaging these
coverages, for a number of reasons, it is understood that all
coverages contained within these specifications cannot necessarily
be incorporated into a single policy, either because of Texas law,
or because some of the coverages do not lend themselves to that
procedure. The City is allowing for the possibility that some
agencies or underwriters would prefer not, or be unable, to quote
all coverages in these specifications and will not place packaging
over another alternative which is clearly beneficial to the City
and the taxpayers.
The City will also accept and encourage innovative and alternative
methods of pricing and coverage of risks so long as they do not
violate Texas law; however, exceptions must be noted and made in
addition to the specifications, which should be adhered to for the
purpose of proper comparison, and all such variations must be
clearly detailed, including advantages claimed to be gained
thereby. Please review the entire scope of specifications,
instructions, and the specification package carefully before
submitting quotations.
AAA01836 -2-
Scope of Specifications & Instructions
Conflicts Between Request for Bid and Bid
Should a conflict arise between the terms and provisions of this
request for bid and the bid of the insurance company (which
includes insurance policies, insurance agreement, etc.) the terms
and provisions of this request for bid will prevail.
Incontestability Provisions Are Inapplicable
City and Bidders agree that if a conflict arises relating to an
interpretation or meaning of the terms and provisions of City's
request for bid and the bid of the insurance company (which
includes insurance policy and insurance agreement, etc.t such
conflict will not be resolved through arbitration or be waived by
the parties, but will be resolved by judicial review in the courts
in Denton County, Texas.
Duty of Carrier
in order for bids to be compared on an identical basis, it is
necessary that all portions of the document, including requests for
specific information about coverage, ratings, services, forms and
general information regarding the carrier, be completed and adhered
to.
Carriers participating in this process must guarantee that these
specifications will be used in their presentations to their
underwriters without modification. For purposes of comparison, it
is important that quotations be submitted on this bid form (see
Exhibit II). Any amendments or innovations must be submitted by
addendum to this specific package and so noted. Sample
insurance policies and insurance agreements, including
endorsements, must be submitted with all quotations. Commitments
in writing from underwriters and re-insurers are also required as
a part of the quotations.
Any carrier which is unable or unwilling to meet the specifications
shall so state (with a full explanation) and detail the coverages
affected, whether or not adversely, in a supplementary letter to be
attached to the submitted quotation, specifically noted and made a
part thereof.
Underwriters' Oualifications
All carriers must be licensed to do business in the State of Texas
and maintain a BEST's Insurance Guide rating of at least A
(excellent). Exhibit V must also be completed.
Caveat
Although every effort has been' made to provide accurate and
up-to-date information, companies supplying quotations should
contact the City for any questions that you might have.
AAA01836 -3-
Scope of Specifications & Instructions
contract stipulation
Any carrier chosen by the City of Denton will be required to cover
all eligible employees of the City that are currently covered
regardless of whether they are actively at work or not.
Additionally, the carrier must provide coverage equal to the
coverage supplied existing employees, to both former employees and
deceased employees and their families as required by law, and
including, but not limited to, Texas Senate Bills 97 and 404 passed
during the 1993 legislative session. The City is subject to the
provisions of the Consolidated OMNIBUS Budget Reconciliation Act of
1986 (COBRA). Proposals must conform to this law.
Administration
The successful bidder will be required to perform all necessary
administrative functions in order to effectively manage the benefit
plans and to comply with prevailing laws and regulations. These
functions include, but are not limited to, the issuing of booklets,
Certificates of Insurance, I.D. cards and master policies as well
as providing for claims auditing and processing, computer-
generated experience reporting at least quarterly, enrollment
materials, claim forms, and conversion forms. All costs associated
with the provision of such services must be included in the rates
and reflected within the retention illustration. The City alsc
desires representatives from the selected carrier to be available
to conduct large group meetings if deemed necessary.
Criteria for Bid selection
The award of the contract will not be based on cost alone. The
City will evaluate the bids on rates as well as the following:
1. Claims processing capabilities
2. Contractual requirement (i.e., billing etc.)
3. Ability or willingness to make a timely, accurate and
inexpensive transition with current carrier.
4. Ability to service contracts.
5. Bidder's financial stability.
6. Ability to provide claims data in the forms necessary to track
the performance of the plan.
7. Full text of insurance policy and insurance agreement you are
bidding.
Times and Locations for Filing Ouotations
Quotations shall be considered irrevocable for ninety (90) days,
and the City of Denton reserves the right to accept or reject any
or all quotations and waive any informalities in any quotation.
Note: Bidder should provide an'explanation for all items giving
as much information as possible, including a transition
plan samples of claims reports, and other information.
AAA01836 -4-
Scope of Specifications & Instructions
Request for detailed specifications, loss experiences, and
questions should be directed to Ike Obi, City of Denton at (817)
566-8340. All quotations must be submitted with two copies (in a
sealed envelope, clearly marked "Insurance Quotations for the City
of Denton, Texas") on or before September 24, 1993, at 2:00 p.m.
to:
Mr. Tom Shaw
Purchasing Department
service center
901 B Texas Street
Denton, Texas 76201
AAA01836 -5-
The following exhibits and instructions are pertinent to the
completion of this bid.
EXHIBITS
INSTRUCTION/COMMENTS
I. Plan Assumption
II. Bid Submission Form
III. Schedule of Benefits
IV. Plan Experience
V. Carrier/Underwriter Profile
vi. Census Data
See Exhibit I
Please do not rather submit your
standard bid,
complete the bid form.
Details of benefits provided
under the current plan
Exhibit III.
Basic information on carrier
and/or underwriter must be
completed.
AAA01836 _6
EXHIBIT I
ASSUMPTION
1. Plan Year January 1, 1994 - December 31, 1994
2. Contract Multi-year contract as the City of
Denton is interested in a long term
association with carrier. The City
requires a rebid of its health
insurance program every three years.
3. Plan Design Two Basic Plan Designs (Exhibit III)
A. Network Provider
B. Non-Network Provider
Miscellaneous provisions for excep-
tions such as services outside
service areas, emergency service
outside service areas.
Bidders must agree to include at
least one of the two local hospitals
in the Network Provider List.
A fully-insured proposal.
4. Funding Fully-insured managed care plan.
The plan will be net of commission.
5. Claims History See Exhibit VI.
AAA01836 -7-
EXHIBIT II
CITY OF DENTON
BID SUBMISSION FORM
FOR FULLY-INSURED Managed Care BID
Carrier/Vendor:
Date:
Completed By:
Phone Number:
1. Premium Rate for the Health Plan, net of commissions:
(Name & Title)
Monthl
y Cost
Active
Current Benefits
Proposed
Benefits
a. Employee Only
5
$
b. Employee & Spouse
$
S
C. Employee & Child
$
S
d. Employee & Family
e. How long are rates guaranteed?
$
mo/yr
S
mo/yr
Retirees Under 65
a. Retiree Only
$
S
b. Retiree and Spouse
S
$
C. Retiree and Children
S
5
d. Retiree and Family
S
S
Retirees 65 or over (on Medicare
l
a. Retiree Only
$
$
b. 2 on Medicare
$
5
C. 1 on, 1 off
$
S
d. 1 on, 1 off + Family
$
5
e. 2 on + Family
$
$
f. How long are retiree rates
mo/yr
mo/yr
guaranteed?
2. Are there any other fees in additi
on
to the Premium Rates?
If yes,
identify and state the amount.
PURPOSE
AMOUNT
Identification Card
$
Medical Conversion
$
Large Claim Management
S
Bank Reconciliation
5
5
5
S
S
AAA01836 -8-
Exhibit II
3. a. What claim payment software do you use?
b. Where are your claims processed?
4. Is a software system or vendor change planned for the period 01/01/94-
12/31/94? If so, to what system/vendor?
5. Assuming that the contract for the City of Denton plan will be effective
January 1, 1994, provide a detailed implementation plan for the transition
on a separate sheet of paper. Be specific concerning your capabilities to
load detailed coverage and claims history information.
6. Claim payment software features:
Which of the following features are inherent to your current claim payment
software?
Yes No
a. Hard coded plan design -
b. Direct eligibility interface -
C. Deductible applied and calculated -
d. Out-of-pocket applied and calculated -
e. Duplicate payment audit -
f. Pooled claim accounting -
g. Interface to pre-certification service -
7. What percent of claims are subject $
to internal claim office audit?
8. What is your claims processing accuracy rate?
a. Transaction a
b. Dollar Value 8
9. Please provide the most recent internal audit report (within the last
year), verifying your claims processing accuracy levels.
Yes No
10. Will your claim system facilitate a future -
PPO plan design, either as a per diem based,
or reduced charge, of higher coinsurance
percentage, etc.?
Yes No
11. can the City of Denton Human Resources -
Department access their claim files
electronically and directly via an
on-site modem?
$One-Time SRecurrinc
If so, what are costs (one-time and recurring?)
AAA01836 -9-
Exhibit II
12. Do you offer the following Utilization Review services? If so, please
identify the services provided and describe your billing structure and
estimated costs for each of the areas previously mentioned; i.e.: initial
setup fees, monthly fees/employee or fees/service, minimum fees, etc.
Per Service Setup No
Yes No EE Mo. Fees Fees Fees
HOSPITALIZATION
Pre-certification Reviews:
Continued Stay Reviews:
Concurrent Stay Reviews:
SURGERY
Second Surgical Opinion
Reviews:
Outpatient Surgery Reviews:
LARGE CASE MANAGEMENT
Research of Catastrophic
Cases:
AIDS Case Management:
Mental Health Case
Management:
OTHER SERVICES
Bill review G Claim
Audits:
DRG Validations:
Ancillary Service
Evaluations:
* Analysis Reports:
TOTAL FEES
13. Fund Balance Statement
(Recap of Check Register
showing fund balances with
interest earned, when
deposits were made, etc.)
14. Hospital Utilization
Reporting (Frequency
and bed days)
15. Please provide a list of 3 client references, and a list of 3 former
clients who have discontinued your services within the last two years.
16. Please provide a sample specimen of all agreements/contracts, etc. for all
the above listed services.
*Contact Ike Obi for sample of Claims Management Reports at (817) 566-8340.
AAA01836 -10-
Exhibit II
17. Please provide the most recent audited financial statement or a "Statement
of Condition" if an audited financial statement is not applicable, for
your firm.
18. If any insurance is quoted on a retention basis, please explain the
reserves that will be established, the methodology for determining the
amounts, and the disposition of the reserves upon termination of the
contract.
19. Please explain the COBRA administration offered by your organization and
any additional costs for these services.
20. Does your bid require that you provide all of the insurance and/or
services specified in this bid, or will you "unbundle" the services
quoted?
21. Please provide your recommended plan designs based upon the network vs.
non-network point of service option.
22. Please provide sample plan management reports including profit and lose
sample reports.
AAA01836 -11-
EXHIBIT III
CURRENT SCHEDULE OF BENEFITS
CITY OF DENTON
SERVICE NETWORK NON-NETWORK
PHYSICIAN'S OFFICE VISIT $15 per visit. $50 Deductible plus 408 of
copay for diagnostic schedule plus any amount
services (1) over schedule (2)
PREVENTIVE CARE
Well Baby
(Recommended
Schedule)
Routine
Immunizations
Annual Health
Assessment
Employee/Covered
spouse 35 years or
older. Includes:
Chest X-Ray,
Urinalysis, EKG,
Blood testing.
WELL WOMAN EXAM
Annual (once every
12 months)
$15 per visit. $50
copay for diagnostic
services (1)
$15 per visit. $50
copay for diagnostic
services (1)
$15 per visit. $50
copay for diagnostic
services (1)
$15 per visit. $50
copay for diagnostic
services (1)
Not covered.
Not covered.
Not covered.
Not covered.
ROUTINE VISION, SPEECH,
HEARING SCREENING
0 through age 17
$15 per visit. $50
copay for diagnostic
services (1)
Not covered.
IN-HOSPITAL SERVICES (4)
No limits on
medically necessary
days
Must be pre-
certified by
Intracorp
Semi-private room
All necessary
hospital services
$500 deductible, 1008
$300 per admission
deductible plus the non-
network deductible plus
408.
AAA01836 -12-
Exhibit III
SERVIC NETWORK NON-NETWORK
OUTPATIENT HOSPITAL
SERVICES
Surgery or Treatment $75 per visit, 1008 Deductible plus 408 of
eligible charges.
MATERNITY CARE
Physicians Visits $15 per visit. $50 Deductible plus 408 of
copay for diagnostic schedule plus any amount
services (1) over schedule.
In-Hospital Services $500 deductible, 1008 $300 per admission
deductible plus non-
network deductible plus
408 of eligible charges.
Newborn Nursery (3) No additional copay 408 of eligible charges.
Physicians Services covered Not covered.
for Newborn
EMERGENCY OR URGENT CARE
(In case of Accident or
Sudden and Serious
Illness)
Hospital Emergency $75 per visit, 1008 $75 per visit, 1008
Room or Urgent Care
Facility (4)
Physician's Office $15 per visit. $50 $15 per visit plus $50
(4) copay for diagnostic copay for other
services (1) services, if any (1)
MENTAL HEALTH/SUBSTANCE
ABUSE (Serious mental
illness or Substance
abuse)
Physician's office
$15 per visit. $50
Deductible plus 408 of
(5)
copay for diagnostic
schedule plus amount in
services (1)
excess of schedule.
In the Hospital (5)
$500 deductible, 1008
$300 per admission
deductible plus the non-
network plus 408 of
eligible charges.
PHYSICAL THERAPY (6)
$15 per visit. $50
Deductible plus 408 of
copay for diagnostic
eligible charges.
services (1)
FAMILY PLANNING
Based on Service
Not covered.
provided
INFERTILITY SERVICES
$15 per visit. $50
Not covered.
copay for diagnostic
services (1),
AAA01836 -13-
Exhibit III
SERVICE
NETWORK
NON-NETWORX
DETECTION & CORRECTION
OF BODY DISTORTION (7)
PRESCRIPTION DRUGS (8)
MAINTENANCE DRUGS
ALL OTHER ELIGIBLE
SERVICES
ANNUAL DEDUCTIBLE*
COINSURANCE*
INDIVIDUAL LIFETIME
MAXIMUM*
$15 per visit. $50
copay for diagnostic
services (1)
$150 deductible; $5
copay, generic; $15
copay, brand
Up to 100 days Supply;
one copay
Deductible plus 408 of
eligible charges.
Not covered.
Not covered.
Deductible plus 208 (4)
$500 plus a $150 drug
deductible per calendar
year, 3 per family (2)
$1,000
$2,000 (not including
$15 office visit copay)
$1M
408 up to $6,000 plus
amount in excess of per
diems & schedules.
$1M
*Family Limit is three (3) times individual maximum.
Out-of-Service Area Residents
For covered persons who reside outside service are (50-mile radius of City of
Denton) plan of benefits is $500 deductible plus 808 of eligible charges up to
a $2,000 out-of-pocket maximum.
Important Notes:
(1) This is a maximum copay which applies to diagnostic work done in
conjunction with the specific provider visit whether the diagnostic service
is performed at that provider's office or another diagnostic service
office/laboratory. $50 copay is applied toward the Annual Deductible.
(2) Eligible charge is the per diem or schedule offered by Network Hospital.
Amounts in excess of that per diem or schedule do not apply to out-of-
pocket maximum.
(3) No additional copayments are necessary while mother and child are confined
at same time.
(4) An additional $500 deductible will be applied if a hospital stay is not
pre-certified by Intracorp. No benefits are available for days which are
not determined to be medically necessary. If patient is admitted to
hospital from emergency room, the Emergency Room Copay will apply towards
the inpatient deductible.
(5) An employee must pre-certify mental health and/or substance abuse treatment
with IBH before beginning any treatment plan (see page 8).
(6) Physical Therapy services are limited to sixty (60) visits per medical
condition.
(7) Detection and Correction of Body Distortion benefits are subject to a
maximum benefit of $500 per calendar year.
AAA01836 -14-
Exhibit III
(8) AESTAT: If your physician permits or orders a generic drug and you decide
to purchase brand, the cost will be generic copay plus the entire
difference price between generic and brand.
AAA01836 -15-
EXHIBIT IV
PLAN EXPERIENCE
AAA01836 -16-
EXHIBIT IV
CITY OF DENTON PLAN EXPERIENCE
JANUARY 1992 THROUGH MAY 1993
PLAN DEMOGRAPHICS/PREMIUMS, 1993
Employee
Monthly
Employees'
City's
*coverage
Count
premiums
cost
cost
Employee
Only
370
$201.25
$11.50
$189.75
Employee
+ Spouse
83
312.80
123.05
189.75
Employee
+ Children 176
270.25
80.50
189.75
Employee
+ Family
178
340.00
201.25
189.75
807
* Call Ike Obi at (817) 566-8340 for current Retiree Rates
1992 PLAN YEAR
Month
Premiums
Medical Claims
Prescription Drug
Jan
$ 171,754
$ 0
$ 4,096
Feb
202,728
41,119
8,808
Mar
190,711
186,623
9,569
Apr
196,377
229,068
13,979
May
195,177
144,166
16,679
Jun
195,962
308,488
17,636
Jul
194,517
182,947
18,010
Aug
184,223
217,513
17,132
Sep
186,393
210,015
20,603
Oct
191,259
153,004
21,876
Nov
196,389
102,160
22,561
Dec
194.858
156,375
26.754
TOTAL
$2,300,348
$1,931,478
$197,703
1993 PLAN YEAR
miums
P
Prescription Druv
Month
re
Jan
$ 221,104
$ 143,968
$ 36,575
Feb
245,914
115,086
2,643
Mar
209,785
174,315
13,329
Apr
225,452
147,887
13,404
May
223,098
149,775
14.621
TOTAL
$1,125,353
$ 731,031
$ 80,572
AAA01836 -17-
EXHIBIT IV (continued)
CLAIMS BY TYPE OF PROVIDER
Jan. 1, 1992 to Dec. 31, 1992
PROVIDER GROUP PAID
HOSPITAL PROVIDER $ 845,771
Inpatient 514,670
Room
Ancillary 11,686
Outpatient 290,537
Emergency Room 28,806
Others 71
PHYSICIAN PROVIDER
11040,207
Nonsurgical
76,858
M. D. Inpatient Surgery
103,002
M. D. Outpatient Surgery
201,363
M. D. Maternity
93,018
M. D. All others (Lab., X-ray, etc.)
565,967
PRESCRIPTION DRUGS
197,703
OTHERS
55,996
TOTAL CLAIMS COST $2,139.677
AAA01836 -18-
EXHIBIT IV (continued)
CLAIMS BY TYPE OF PROVIDER
Jan. 1, 1993 to June 30, 1993*
PROVIDER GROUP PAID
HOSPITAL PROVIDER
Inpatient
Room
Ancillary
Outpatient
Emergency Room
Others
PHYSICIAN PROVIDER
Nonsurgical
M. D. Inpatient
M. D. Outpatient
M. D. Maternity
M. D. All others (Lab., X-ray, etc.)
PRESCRIPTION DRUGS
OTHERS
TOTAL CLAIMS COST
* For claims data for the period shown above, please contact
Ike obi at (817) 566-8340.
AAA01836 -19-
EXHIBIT IV (continued)
HIGH CLAIM REPORT - $10,000 AND OVER
JANUARY 1, 1992 TO MAY 31, 1993
DIAGNOSIS AMOUNT PAID
Neoplasms (Tumors)
$43,495
002
41
Neoplasms (Tumors)
,
593
39
Digestive Systems
,
206
38
Perinatal Conditions
,
37,598
Neoplasms
Circulatory System
30,864
Genitourinary System
28,005
360
26
Circulatory System
,
378
21
Circulatory System
,
708
20
Digestive System
,
680
18
Musculoskeletal System
,
17,912
Mental Disorders
857
17
Genitourinary System
,
16,754
Mental Disorders
15,624
Respiratory
581
14
Mental Disorders
,
13,647
Neoplasms
Musculoskeletal System
11,983
Genitourinary System
10,568
10,337
Digestive System
10,000
Mental Disorders
10,000
Mental Disorders
AAA01836 -20-
EXHIBIT V
1. Name of Firm
Address
2. Name of Principal
3. ownership of Firm
4. Date Firm Was First Formed
5. other Locations (City and state)
6. Location of Headquarters (City and State)
7. Location of Claims processing office
Tel.
8. Fidelity Bond $
(Submit Copy of Face Page of policy or Certificate)
9. References:
1.
2.
3.
4.
CARRIER/UNDERWRITER PROFILE
City/State Name of Contact Tel.
AAA01836 -21
EXHIBIT VI
CENSUS DATA
AAA01836 -22-
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CITY OF DENTON
BID SUBMISSION FORM
FOR FULLY-INSURED Managed Care BID
CarrierNendor: Harris Methodist Health Plan
Date: September 24 1993
Completed By: Robert I Hurst Jr ./Director of Sales (Name & Title)
Phone Number: (817) 878-5830
1. Premium Rate for the Health Plan, net of commissions:
Monthly Cost
Preferred Plan w/$10.00
Prescription Rider and
Active
Current Benefits
Serious Mental Health Rider
a.
Employee Only
$ N/A *
$188.50
b.
Employee + Spouse
$ N/A
$292.98
C.
Employee + Child
$ N/A
$253.13
d.
Employee + Family
$ N/A
$318.45
e.
How long are rates guaranteed? N/A mo/yr
1 Year
Retirees Under 65
A. Retiree Only $ N/A $255.34
b. Retiree and Spouse $ N/A $493.35
C. Retiree and Children $ N/A $398.71
d. Retiree and Family $ N/A $604.26
Retirees 65 or Over (Medicare serves as Primary)
a.
Retiree Only
$ N/A
$ 94.25
b.
2 on Medicare
$ N/A
$188.50
C.
1 on, off
$ N/A
$384.54
d.
I on, I off + Family
$ N/A
$557.58
e.
2 on + Family
$ N/A
$368.00
f.
How long are retiree rates
guaranteed?
N/A mo/yr
1 Year
* Not Applicable
I
CITY OF DENTON
BID SUBMISSION FORM
FOR FULLY-INSURED Managed Care BID
Carrier/Vendor: Harris Methodist Health Plan
Date: September 24 1993
Completed By: Robert 1 Hurst ]r /Director of Sales (Name & Title)
Phone Number: (817) 878-5830
-
1. Premium Rate for the Health Plan, net of commissions:
Monthly Cost
Plan 10 w/$10.00
Prescription Rider and
Active
Serious Mental Health Rider
a.
Employee Only
$ N/A *
$199.60
b.
Employee + Spouse
$ N/A
$310.28
C.
Employee + Child
$ N/A
$268.08
d.
Employee + Family
$ N/A
$337.27
e.
How long are rates guaranteed? N/A mo/yr
I Year
etirees Under 65
a. Retiree Only
$ N/A
$270.38
b. Retiree and Spouse
$ N/A
$522.48
C. Retiree and Children
$ N/A
$422.25
d. Retiree and Family
$ N/A
$639.97
Retirees 65 or Over (Medicare serves as Primary)
a.
Retiree Only
$ N/A
$ 99.80
b.
2 on Medicare
$ N/A
$199.60
C.
1 on, off
$ N/A
$407.18
d.
1 on, 1 off + Family
$ N/A
$590.42
e.
2 on + Family
$ N/A
$389.68
f.
How long are retiree rates
guaranteed?
N/A mo/yr
I Year
* Not Applicable
CITY OF DENTON
BID SUBMISSION FORM
FOR FULLY-INSURED Managed Care BID
Carrier/Vendor: Harris Methodist Health Plan
Date: September 24 1993
Completed By: Robert 1 Hurst Jr, /Director of Sales (Name & Title)
Phone Number: (817) 878-5830
1. Premium Rate for the Health Plan, net of commissions:
Monthly Cost
Preferred Plus w/
Prescription Rider and
Active
Current Benefits
Serious Mental Health Rider
a.
Employee Only
$ N/A*
$217.80
b.
Employee + Spouse
$ N/A
$337.59
C.
Employee + Child
$ N/A
$291.85
d.
Employee + Family
$ N/A
$368.08
e,
How long are rates guaranteed? N/A mo/yr
l Year
Retirees Under 65
a. Retiree Only $ N/A $295.03
b. Retiree and Spouse $ N/A $568.47
C. Retiree and Children $ N/A $459.69
d. Retiree and Family $ N/A $698.43
Retirees 65 or Over (Medicare serves as Primary)
a.
Retiree Only
$ N/A
b.
2 on Medicare
$ N/A
C.
1 on, off
$ N/A
d.
1 on, 1 off + Family
$ N/A
e.
2 on + Family
$ N/A
f.
How long are retiree rates
guaranteed?
N/A mo/yr
* Not Applicable
$108.90
$217.80
$444.31
$644.25
$425.21
1 Year
3
2. Are there any other fees in addition to the Premium Rates? If yes, identify and state the amount.
Purpose Amount
Identification Card
$
-0-
Medical Conversion
$
-0-
Large Claim Management
$
-0-
Bank Reconciliation
$
-0-
3. a. What claim payment software do you use?
Response: Model 204, internally developed in 1986.
b. Where are your claims processed?
Response: Harris Methodist Health Plan
1300 Summit, Suite 300
Fort Worth, TX 76102
4. Is a software system or vendor change planned for the period 01/01/94 - 12/31/94? If so, to what
systemlvendor?
Response: No
5. Assuming that the contract for the City of Denton plan will be effective January 1, 1994, provide a
detailed implementation plan for the transition on a separate sheet of paper. Be specific concerning your
capabilities to load detailed coverage and claims history information.
Response: Harris Methodist Health Plan is prepared to work in partnership with the City of
Denton in order to plan and provide a smooth transition. Our intent is to develop
with the City of Denton specific time frames and activities. Please refer to the
"Implementation Timeline" exhibit for activities suggested but not limited to.
Our system has the following alternatives for new employer groups with respect to
loading detailed coverage and claims history information:
1. Harris Methodist Health Plan can enter manually from explanations of
benefits submitted by the employee, or from a report provided by the
employer/previous administrator.
2. Employer/Previous administrator may provide information in tape or
diskette format.
The determination of what is entered into the system is based on the amount and
types of data captured by the prior administrator. We also have the ability to enter
prior claims history.
6. Claim payment software features:
Which of the following features are inherent to your current claim payment software?
Yes No
a. Hard coded plan design _ X
b. Direct eligibility interface X
C. Deductible applied and calculated X
it. Out-of-pocket applied and calculated X _
e. Duplicate payment audit X _
f. Pooled claim accounting X -
g. Interface to pre-certification service X -
7. What percent of claims are subject to internal claim office audit? 4 %
8. What is your claims processing accuracy rate?
a. Transaction 98 %
b. Dollar Value
9. Please provide the most recent internal audit report (within the last year), verifying your claims
processing accuracy levels.
Response: Please refer to "Internal Audit" Exhibit
Yes No
10. Will you claim system facilitate and future PPO X
plan design, either as a per diem based, or reduced
charge, of higher coinsurance percentage, etc?
Yes No
11. Can the City of Denton Human Resources _ X
Department access their claim files
electronically and directly via an
on-site modem?
$One-Time $Recurring
If so, what are costs (one-time and recurring?)
12. Do you offer the following Utilization Review services? If so, please identify the services provided and
describe your billing structure and estimated costs for each of the areas previously mentioned; i.e.=
initial setup fees, monthly fees/employee or fees/service, minimum fees, etc.
Per Service Setup No
Yes No EE/Mo. Fees Fees Fees
HOSPITALIZATION
Pre-certification Reviews:
Continued Stay Reviews:
Concurrent Stay Reviews: / ✓
SURGERY
Second Surgical Opinion
Reviews:
Outpatient Surgery Reviews:
LARGE CASE MANAGEMENT
Research of Catastrophic
Cases:
AIDS Case Management:
Mental Health Case
Management:
OTHER SERVICES
Bill review & Claim
Audits:
DRG Validations:
Ancillary Service
Evaluations:
Analysis Reports:
TOTAL FEES
13. Fund Balance Statement (Recap
of Check Register showing fund
balances with interest earned,
when deposits were made, etc.)
V
-
-
-
V
V
-0-
-0-
-0-
Response: Not Applicable as Harris Methodist
Health Plan is proposing fully insured
plan designs.
14. Hospital Utilization Reporting
(Frequency and bed days) Response: Please refer to "Utilization Reports"
6 Exhibit
15.
16.
17.
18.
19.
20.
Please provide a list of 3 client references, and a list of 3 former clients who have discontinued your
services within the last two years.
Response: Please refer to "Client Reference" Exhibit
Please provide a sample specimen of all agreements/contracts, etc. for all the above listed services.
Response: The functions described in Question #12 are performed internally within the Harris
Methodist Health Plan. No contracts are in place for these
services as Harris Methodist Health Plan employees perform these functions.
Please provide the most recent audited financial statement or a "Statement of Condition" if an audited
financial statement is not applicable, for your firm.
Response: Please refer to "Financial Statement" Exhibit
If any insurance is quoted on a retention basis, please explain the reserves that will be established, the
methodology for determining the amounts, and the disposition of the reserves upon termination of the
contract.
Response: Not Applicable as Harris Methodist Health Plan is proposing fully insured plan
designs.
Please explain the COBRA administration offered by your organization and any additional costs for
these services.
Response: Harris Methodist Health Plan can provide COBRA rates in addition to a separate
billing for COBRA participants. Also, Harris Methodist Health Plan will assist with
the development of COBRA documents. These services are available at no cost to the
City of Denton.
Does your bid require that you provide all of the insurance and/or services specified in this bid, or will
you "unbundle" the services quoted?
Response: Harris Methodist Health Plan will provide any of the following plan designs:
1) A Network Provider plan design through our HMO plan (Preferred Plan or Plan
10).
2) A Point-of Service (Preferred Plus) plan design providing a choice of accessing at
the time of service either a Network Provider or Non-Network Provider.
3) A Point-of-Enrollment plan design providing a choice at the time of enrollment
either a HMO plan or Point-of-Service plan.
21
Please provide your recommended plan designs based upon the network vs. non-network point of service
option.
Response: Please refer to the following Exhibits:
"Preferred" Exhibit
"Plan 10" Exhibit
"Preferred Plan" Exhibit
"Point-of-Enrollment Exhibit
22.
Please provide sample plan management reports including profit and loss sample reports.
Response: Please refer to "Utilization Reports" Exhibit
j:\wpdoce\ord\harris.o
NOTE: CONTRACTS ARE ATTACHED TO ORIGINAL IN PILE.
ORDINANCE NO. 3'o2 /
AN ORDINANCE ACCEPTING COMPETITIVE BIDS AND PROVIDING FOR THE AWARD
OF CONTRACTS FOR THE PURCHASE OF EMPLOYEE GROUP HEALTH INSURANCE TO
HARRIS METHODIST HEALTH PLAN; PROVIDING FOR THE ADMINISTRATION OF
THE CONTRACT; PROVIDING FOR THE EXPENDITURE OF FUNDS THEREFOR; AND
PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the City has solicited, received and tabulated com-
petitive bids for the purchase of employee group health insurance
in accordance with the procedures of state law; and
WHEREAS, the City Manager, his designee, and the City's pro-
fessional insurance consultant, have received and recommended that
the bid described below is the lowest responsible bid for the
purchase of such insurance described in the Request for Bid No.
1523; and
WHEREAS, the City Council has provided in the City Budget for
the appropriation of funds to be used for the purchase of the
insurance policies and coverages approved and accepted herein;
NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS:
SECTION I. That the bid of Harris Methodist Health Plan, in
response to Request for Bid No. 1523 and providing for the purchase
of employee group, health insurance, is hereby accepted and approved
as being the lowest responsible bid and the City Manager is
authorized to execute two (2) contracts on behalf of the City of
Denton with Harris Health Plan, Inc., one relating to the
"Preferred Plan", and the other relating to the "Preferred Plus
Network". The City Manager is also authorized to execute a "Group
Enrollment Application" on behalf of the City with Harris Methodist
Health Insurance Company. Copies of such documents are attached
hereto and incorporated by reference herein.
SECTION II. That the Director of Human Resources, or his
designee, is hereby authorized to administer these contracts in
behalf of the City of Denton.
SECTION III. That the City Council hereby authorizes the
expenditure of funds in the manner and amount as specified in the
contract.
SECTION IV. That this ordinance shall become effective immed-
iately upon its passage and approval.
PASSED AND APPROVED this the"J" day of -AftkX14dA,., 1993.
BOB CASTLEBERRY, MAYOR
ATTEST:
JENNIFER WALTERS, CITY SECRETARY
BY: C (i'C[--ICI
APP OVED AS TO LEGAL FORM:
DEBRA A. DRAYOVITCH, CITY ATTORNEY
BY: A 6/Z 41 Page 2