1989-144NO 8 9 - Z~
AN ORDINANCE ACCEPTING THE PROPOSAL OF SANUS TEXAS HEALTH PLAN,
INC FOR MEDICAL INSURANCE COVERAGE FOR CITY EMPLOYEES, AUTHORIZING
THE EXPENDITURE OF FUNDS THEREFORE, AND DECLARING AN EFFECTIVE
DATE
WHEREAS, the City has solicited, received and tabulated
competitive sealed proposals for the purchase of medical insurance
coverage for city employees in accordance with the procedures of
state law and City ordinances, and
WHEREAS, the City Manager has reviewed and recommended that
the proposal of Sanus Texas Health Plan, Inc is the lowest
responsible proposal for services as shown in the "Bid Proposals"
submitted therefor, and
WHEREAS, the City Council has provided in the City Budget for
the appropriation of funds to be used for the purchase of the
services approved and accepted herein, NOW THEREFORE,
THE CITY COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS
SEr=TION I That the proposal of Sanus Texas Health Plan, Inc
for medical insurance coverage for city employees, a copy of which
is attached hereto and incorporated by reference herein, is hereby
accepted
SECTION II That the City Council hereby authorizes the
expenditure of funds in the manner and amount as specified in the
agreement
SECTION III That this ordinance
immediately upon its passage and approval
PASSED AND APPROVED this the l j--day
shall become effective
of00,444ay , 1989
jo-~
Ray S p ens, /Mayor
ATTEST.
JENNIFER WALTERS, CITY SECRETARY
BY 1
APPR ED AS TO LEGAL FORM
DEBRA ADAMI DRAYOVITCH, CITY ATTORNEY
BY f
10/11/89
SANUS TEXAS HEALTH PLAN, INC
8800 Freeport Parkway, Suite 9040
Irving, Texas 78089
Metre 8218149 or (214) 029-0978
GROUP MEMBERSHIP SERVICE AGREEMENT/
CERTIFICATE OF COVERAGE
I DEFT ITION8
Except a expressly otherwise provided or unless the context otherwise requires the following words and phrases
used in t Is Agreement shall have the following meanings
1 Actively at Work means that an Eligible Employee must be performing the usual and customary duties of his
regular employment during his usual working hours on his Effective Date of coverage provided however that
if the Eligible Employee is absent from work due to vacation holiday jury duty or other similar circumstances
not caused by Injury or Illness such employee shall be considered Actively at Work
2 Agreement' means this Group Membership Service Agreement the Schedule of Benefits all Applications all
Attachments and Riders hereto, if any, and alt Amendments hereto if any
3 Alternative Health Benefits Plan means any health benefits plan other than this Plan which is offered by through
or in Connection with the Group
4 Ambulatory Surgical Center means anon hospital center which provides ambulatory surgical services and which
is properly Ik ensed as such by the State of Texas
5 Anniversary Date' means the annual anniversary of the Effective Date
and o
8 Application prescribed behalf of his Dependents be required to cSANUS TEXAS which each omplete and submit to SANUS TEXAS for the purpose of enroll
f
mg himself and such Dependents for coverage hereunder
7 Basic Plan Benefits' means those benefit covered by this Agreement and explained in the Schedule of Benefits
but not including any Riders
8 Contract Year 'Means the period of twelve (12) months commencing on the Effective Date and each twelve (12)
month [period thereafter, unless otherwise terminated as hereinafter provided
9 Copayment 'means the fee as set forth In the Schedule of Benefits and any Riders provided with this Agreement
and made a part hereof which Is not covered by premiums payable hereunder to be paid by Members at the
time offservice directly to Physicians Hospitals or other Health Professionals in connection with the services set
forth in the Schedule of Benefits and Riders If any
10 Covered Services' means only the medical care services and supplies rendered under the folowing conditions
a provided directed or authorized by the Member's Participating Primary Care Physician except in the
can of a Medical Emergency as defined by the Plan
b prescribed by a doctor or the therapeutic treatment of Injury sickness or pregnancy
c doomed Medically Necessary and appropriate in type level setting and length of service by SANUS TEXAS
d rendered in accordance with generally accepted medical practice and professionally recognized standards
e not, generally considered to be experimental investigational, or which are performed or research purposes
f services which are specifically Included and not excluded or limited or not specifically excluded by the Plan
11 Custodial Care means that care which 1s marked by or given to watching and protecting rather than seeking
to cure or (2) care which is of a necessary part of medical treatment for recovery or (3) care comprised of ser
vices and supplies that are provided primarily to assist in the activities of daily living
12 Deductible means the expense incurred or potion of such expense other than a Copayment which the Member
is required to pay directly to the Physicians Hospitals or other Health Care Providers in connection with Covered
Services
13 Dependent means an Eligible Dependent who has been enrolled in the Plan by a Subscriber for whom the
this Agre men and who continues to meet the eligibility requirements l set forth In Section 11 A(2) of this Agreement
14 Domiclllary Care" means that care provided or persons so disabled or Infirm as to be unable to INS Independently
15 Effective Date means the effective date of coverage asset forth on the face page of this Agreement
18 Eligible Dependent" means an Eligible Employees spouse or child who meets the dependent eligibility re-
quirements set forth in Section II A of this Agreement
17 Eligible Employee' means an Individual who meets the Subscriber eligibility requirements set forth in Section
11 A of this Agreement
$ 18 Emergency Care' means bona fide emergency services provided after the sudden onset of a medical condition
man testing Itself by acute symptoms of sufficient severity Including severe pain such that the absence of im
mediate Imed cal attention could reasonably be expected to result In
a placing the patient's health in serious jeopardy
b serious impairment to bodily functions, or
c serious dysfunction of any bodily organ or part
GSA A"87D 1
1b Free Standing Surgic, enter shall have the same meaning as Art uory SurgicalCenter
20 Group means the employer labor union trust association partnership government agency or other organize
lion to which this Agreement Is Issued and through which as agent for Subscriber only and not also for SANUS
TEXAS Subscriber and his Dependents become entitled to the coverage described in this Agreement
21 Group Enrollment Period means the period mutually agreed upon by SANUS TEXAS and the Group as set
forth on the first page of this Agreement during which Eligible Employees and Eligible Dependents may elect to
enroll under this Plan or terminate their enrollment in this Plan Such period shall be no less than fourteen (14)
days in each Contract Year
22 Health Professional means dentists nurses audiologists podiatrists osteopaths optometrists physicians
assistants clinical psychologists social workers pharmacists nutritionists physical therapists speech therapists
and other professionals engaged in the delivery of health services who are licensed, practice under an mstitu
bonal license are certified or practice under the authority of a Physician or legally constituted professional association
or other authority consistent with the laws of the State of Texas
23 Hospital means
a An institution which is operated pursuant to state law and is primarily engaged in providing on an inpatient
basis for the medical care and treatment of sick and Injured persons through medical diagnostic and major
surgical services all of which services must be provided on Its premises under the supervision of a staff of
Physicians and with twenty four hour a day registered nursing service or
b An institution not meeting all of the foregoing requirements but which meets state licensing requirements and
is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals
In no event shall the term Hospital include a convalescent nursing home or any Institution or part thereof which
is used principally as a convalescent facility rest facility nursing facility facility for the aged or extended care
facility intermediate care facility skilled nursing facility or facility primarily for rehabilitative services the term
Hospital shall pursuant to Chapter 3 Texas Insurance Code Article 3 72 include treatment Ina residential
treatment center for children and adolescents and treatment provided by a crisis stabilization unit
24 Medical Director means the licensed physician In the full or part time employ of SANUS TEXAS and/or such
other licensed physician as the Medical Director may designate who shall be responsible for monitoring the quail
ty of medical care rendered to Members
25 Medical Emergency means a medical condition so classified by the Medical Director and which manifests itself
by acute symptoms of sufficient severity (including severe pain) such that the absence of immedicate medical
attention could reasonably be expected to result in (a) placing the patient s health in serious jeopardy or (b) serious
impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part
26 Medically Necessary means medical or surgical treatment of an illness or Injury at the appropriate level of care
in accordance with accepted medical standards and Plan requirements as approved by the Plan s review commit
tees for professional and technical practice and the SANDS TEXAS Medical Director
27 Medicare means rills XVIII of the Social Security Act and regulations thereunder
28 Member means any Subscriber or Dependent
29 Non Participating Physician means a physician who is not a Participating Physician
30 Out Patient Emergency Care Center means a non hospital center which provides ambulatory medical surgical
and/or emergency services
31 Participating Alcohol or Drug Dependency Treatment Facility" means a facility which provides a program for
the treatment of alcohol or drug dependency pursuant to a written treatment plan approved and monitored by
a Physician and which has contracted with SANDS TEXAS to provide such program to Members and which facility
is also
a affiliated with a Hospital under a contractual arrangement with an established system for patient referral or
b accredited as such a facility by the Joint Commission on Accreditation of Hospitals or
c licensed as an alcohol or drug treatment program or center by the Texas Commission on Alcohol and Drug
Abuse or
d licensed certified or approved as an alcohol or drug dependency treatment program or center by any other
state agency having a legal authority to so license certify or approve
32 Participating Facility means those facilities properly licensed by the appropriate regulatory and licensing authorities
of the State of Texas and contracted to provide services to SANDS TEXAS Members and which facilities shall
include Hospitals Alcohol or Drug Dependency Treatment Facilities Out Patient Emergency Care Centers Am
bulatory Surgical Centers and other facilities of similar purpose
33 Participating Hospital means a Hospital (as defined In subparagraph 23 of this Section) which has contracted
with SANUS TEXAS to provide Members the Inpatient services set forth in Section 11 8 (or if applicable Section
IV B) of the Schedule of Benefits
34 Participating Out Patient Emergency Care Center means anon hospital center which has contracted to provide
ambulatory medical surgical and/or emergency services to SANUS TEXAS Members
35 Participating Physician means any Physician who has contracted with SANUS TEXAS to provide care to Members
covered under this Agreement
36 Participating Primary Care Physician means with respect to each Member, the Participating Physician engag-
ed in the practice of family practice general medicine internal medicine or pediatrics who is designated in aocor
GSA AB-0987D 2 A-AOO
dance with SANI'^ TEXAS policies as the Physician having prima esponsibillity for ' coordinating care p ding Initial and primary care
and Initiating referral for specialist we to Members maintaining the ccontinuityofnsucch such Member acare
3~ Participating Specialist Physician means any Physician who has contracted with SANUS TEXAS to provide
specialist care to Members covered under this Agreement upon referral of a Participating Primary Care Physician
' (or upon referral of another Participating Specialist Physician with the concurrence of the responsible Participating
Primary Care Physician)
3S "Participating Urgent Care Center' shall have the same meaning as Participating Out Patient Emergency Care
Center
I 34 Physician" means anyone licensed by the State of Texas to practice as a Physician within the scope of his license
40 'Plan is the plan of comprehensive health care services provided by SANDS TEXAS and covered by this
Agreement
41 J 'Primarily Dependent means receiving more than fifty percent (50%) of his support from the Subscriber meeting
i the requirements to be claimed as a dependent on the Subscriber a federal Income tax return and being a depen
dent unmarried child foster child stepchild legally adopted child or child under Subscriber s legal guardianship
42, Provider means any Health Professional Hospital Alcoholism or Drug Treatment Facility Out Patient Emergency
Care Center or other facility which has contracted with SANUS TEXAS to provide services to Members covered
]under this Agreement
43 " Rider means a schedule provided with this Agreement and made a part hereof which sets forth changes in
the benefits and services made available by SANUS TEXAS by modifying this Agreement and the Schedule of
Benefits
44 SANUS TEXAS means SANUS TEXAS HEALTH PLAN INC a Texas corporation organized as a health
maintenance organization and licensed by the Texas State Board of Insurance
45 ~ Schedule of Benefits means the schedule provided with this Agreement and made a part hereof which sets
forth the benefits and services that SANUS TEXAS shall make available to Members
46 Schedule of Rates and Premiums means the schedule provided to the Group with this Agreement and made
a part hereof, which sets forth the rates and premiums that are payable to SANDS TEXAS for the services and
benefits that SANUS TEXAS shall provide or make available to Members
47 'Semi Private" means a room In a Hospital or Skilled Nursing Facility containing two (2) to four (4) beds and/or
classified as semi private by such Hospital or Skilled Nursing Facility
48 Service Area" means that geographical area as defined by the Service Area map Included in the directory which
contains a list of Participating Physicians and Providers
49 Skilled Nursing Facility ' means an institution or part thereof licensed by state or local law that Is accredited
as an extended care facility by the Joint Commission on Accreditation of Hospitals or Is recognized as a skilled
nursing facility by the Secretary of the Department of Heafih and Human Services under Title XVIII of the Social
Security Act as amended
50 r ' Subscriber" means an Eligible Employee who has enrolled in the Plan and for whom the premium payments
squired under this Agreement have been received by SANUS TEXAS in accordance with the terms of this
Agreement
51 Termination Date" means
a for a Member the last date on which the Member is eligible for coverage or
b 1 for the Group, the last date on which this Agreement Is In force
62 urgent Care shall have the same meaning as Medical Emergency
53 'urgent Care Center" shall have the same meaning as Out Patient Emergency Care Center
~ _ .
EFFECTIV DATE OP COVERAGE
A Ellalbilltu
A
o f f'a3~d Subtgrib"ef, aJP~reosn must reside In the Service Area and be
ma perfnanen( empbyment of the Group or a bona fide Member of the Group
E g o 0 nub Of =re necessary to be eligible to enroll In the Grou a Prl
(2% hours pet We* whWovef Cs greater and p s mary Health
x b Eligible under such eligibility criteria established by the Group and which is Supplemental to that describ-
aeoa ed herein and
o Eligible to enroll and receive benefits of alternate Health Benefit Plans Offered by the Group and
d Not be eligible for gage and/or covered under Extended Benefits coverage (or coverage similar thereto)
borre of any other health plan
Jo be eligible to enroll as is Dependent, a person must reside in the Service Area not be eligible for coverage
✓Mdlor covered under Extended Benefits (Or coverage similar thereto) of any other health plan and be
The epouae of a Subscriber,
ertdent unmarried cultural child foster child stepchild legally adopted child or child under Subscriber a
ONTO MOLL
guardianship, residing with Subscriber or with Subscriber's present or former spouse in the Service
3
Area who is (a) under nineteen (19) years of age or (b) under Ndrily three (23) years of age Primarily
Dependent on the Subscriber for financial support and attending a state accredited college or university,
trade or secondary school on a full time basis which has In writing, verified said attendance or
c A dependent unmarried natural child foster child stepchild legally adopted child or child under Subscriber a
legal guardianship residing with Subscriber or with Subscriber a present or former spouse in the Service
Area who is nineteen (19) years of age or older but Incapable of self sustaining employment because of
mental retardation or physical handicap commenced prior to age nineteen (19) (or commenced prior to
age twenty three (23) it such child was attending a recognized college or university trade or secondary
school on a full time basis when such incapacity occurred) and Primarily Dependent upon the Subscriber
for support and maintenance Such dependent child must have been a Member either prior to attaining
nineteen (19) years of age or twenty three (23) years of age under the conditions of the previous sentence
Subscriber shall furnish SANDS TEXAS proof of such incapacity and dependency within thirty-one (31)
days before the dependent child a attainment of the limiting age and from time to time thereafter as SANDS
TEXAS deems appropriate
d Maternity care benefits will be extended to a Subscribers unmarried Dependent child No benefits are
provided for the Infant child of the Subscriber a unmarried Dependent child unless the Infant child of the
unmarried Dependent Is otherwise eligible for coverage by the Subscriber If such infant child is eligible
for coverage by the Subscriber such coverage will be available as described in Section II A of this Agree•
ment provided appropriate notices and premiums have been timely
B When Subscriber Coverage Becomes Effective
1 During Group Enrollment Period Each Eligible Employee who applies for membership in the Plan by submit
ting an Application during a Group Enrollment Period shall become covered under the Plan as a Subscriber
on the Effective Date provided such Employee Is Actively at Work on a full-time basis on that date otherwise
it will begin the first day this requirement is met
2 Other Than During Group Enrollment Each Eligible Employee who first meets the eligibility requirements of
Section II A other than during a Group Enrollment Period may enroll within thirty-one (31) days of meeting
such requirements by submitting an Application Such employee shall become covered under the Plan as
a Subscriber on the first day of the month following enrollment provided that the premium applicable to the
Subscriber has been received in accordance with this Agreement and further provided that such Employee
must be Actively at Work on such day otherwise coverage shall begin the first day this requirement Is met
C When Dependent Coverage Becomes Effective
1 On Date Subscriber Becomes Covered An Eligible Dependent for whom the Subscriber has applied for member
ship in the Plan by submitting an Application in accordance with Sections II A and 11 8 shall become covered
under the Plan as a Dependent on the Effective Date provided any Dependent confined at home in a Hospital
or other medical Institution on the day that person would otherwise become covered will become covered on
the first day such dependent is non-confined No Dependent can be covered before the date the Employee
becomes covered If the Employee did not become covered solely because he did not meet the Actively W
Work requirement stated in Section II B his Eligible Dependents who otherwise meet all requirements will
become covered on the day the Employee becomes covered alter having met the Actively at Work requirement
2 Newly Acquired Dependents Dependents Flrst Becoming Eligible Other Than During Group Enrollment
a A newly acquired Eligible Dependent other than a newborn child and an Eligible Dependent who first
meets the eligibility requirements of Section 11 A other than during a Group Enrollment Period and has
an Application submitted on his behalf within thirty-one (31) days of meeting such requirements shall be
covered as of the first day on which he meets such requirements, provided any Dependent confined at
home in a Hospital or other medical institution on the day that person would otherwise become covered
will become covered on the first day such Dependent is non-confined
b Newborn children of Subscriber and/or Subscriber s spouse shall be covered under the Plan for an initial
period of thirty-one (31) days from the date of birth and shall continue to be so covered after that time
only if prior to the expiration of such thirty-one (31) day period, Subscriber notifies SANUS TEXAS with
an Application submitted for such newborn child and any premiums required are paid as of the first day
of the month in which the new enrollment is effective, and in accordance with Section VI A
c A newly adopted child including a newborn shall be covered under the Plan as If he were a newly so
quired Eligible Dependent The thirty-one (31) day grace period for submission of an Application shall com-
mence on the earlier of the date upon which such child commences residence with the Subscriber or
when the adoption becomes legal and coverage shall begin on such earlier date provided the Application
is submitted on a timely basis
D Coverage on Effective Date
In the event an employee or deper jnt has satisfied the eligibility conditions In Section II of this Agreement
on the date that coverage under tr s Agreement becomes effective such person shall, as of that date, be
covered under this Agreement SANUS TEXAS however shall not be required to cover arrange for, or other-
wise be liable for services rendered prior to the Effective Date or for such confinement or services not covered
under this Agreement including those services covered under Extended Benefits coverage of any other health
plan as described in Section 11 A
GSA AB-0987D
•
E Change of Group l bility Criteria
The composition of the Group and requirements determining eligibility for membership in the Group and for
panicipatbn in medical and hospital ogre benefits arranged by the Group are coneWerstione material to the
gxeoutlon of this Agreement b
SANDS TEXAS Duri
th
y
ng
e term of this Agreement no change In the Group a
gllgibllityor participation requirements shell be permitted to affect e11gIbIltty or enrollment under this Agree
mant in any mannar deemed adverse by SANUS TEXAS unless such
h
b
ff
c
ange
e
ected by mutual written
Agreement between the Group and SANDS TEXAS
F Persons not Eligible for Membership
Notwithstanding the foregoing provisions of this Section II
1 Membership Previously Terminated No person shall become a Member who has had coverage terminated
under any SANDS TEXAS prepaid health care plan for reasons described in Section III A(8) sub
parts
abcsort
21 Indebtedness No person shall become a Member if such person has unpaid financial obligations to SANDS
t TEXAS or any Participating Physician, Hospital or Provider arising from prior membershi
in a health
p
care
plan
G Notification of Ineligibility
A condition of participation in the Plan is Subscribers agreement to notify SANUS TEXAS of any changes
Inistatus that affect his Dependents' ability to most the eligibility criteria set forth in Section 11 A(2)
H Clerical Error
1 Clerical error shall not deprive any individual of coverage under this Agreement provided that an Applica
tlon has been completed and submitted to the Group within thirty-one (31) days from the date the employee
or dependent was first eligible to enroll in the Plan and all appropriate premiums are paid to SANUS TEXAS
2 Failure to report the termination of coverage shall not continue such coverage beyond the date it Is scheduled
to terminate according to the terms of this Agreement
3 1 Upon discovery of a clerical error, an appropriate adjustment shall be made However no such adjust
ment In fees or coverage shall be granted by SANUS TEXAS to the Group for more than sixty (80) days
of coverage prior to the date SANUS TEXAS was notified of such clerical error
I Eligible Employee
No' Eligible Employee or Eligible Dependent will be refused enrollment or re-enrollment because of health
status requirements for health services or the existence of a preexisting physical or mental condition in
cluding pregnancy at the time of his effective date of coverage so long as the conditions in Section 11 A of
this Agreement are met and all applicable payments are made on a timely basis
III TERMINATION
A Termination of Member
1 No coverage will be prodded to any Member If the Group falls to pay the premium for the first month of this
for the Agreement
eecond or subsea ertt months tby the of the thirty (30) day grace period If so terminated a Memberr a
Termination Date shall be the last day for which premiums have been paid and the Member shall be liable
for the cost of services received subsequent to the Termination Date
2 The coverage of any Member who ceases to be eligible under Section 11 A of this Agreement shall terminate
on t e date such eligibility ceases This paragraph also applies to a Dependent of a Subscriber who lost his
elig bility, for whatever reason, including the death of the Subscriber
3 For coverage purposes, a Subscriber's employment will be considered to terminate when the Subscriber is
no longer actively engaged in work on a full-time basis for the Group
4 If the Member is an inpatient on the Termination Date of this Agreement benefits will terminate for such Member
at 12 01 a m on the day next following the Termination Date
5 Except as expressly provided below and elsewhere in this Agreement coverage for a Member may be ter
mmated by SANUS TEXAS upon a sixty (00) day prior written notice
5 In the case of
a Nonpayment of amounts due by the Member under this Agreement coverage may be cancelled after not
~ than a thirty (30) day written notice except no written notice will be required for failure to pay premium
b Fraud or misrepresentation by Member except as described In this Agreement coverage may be cancell
ad after not less than a fifteen (15) day written notice, provided that unless the misrepresentation made
by a Member was fraudulent or unless It was material to the risk assumed by SANUS TEXAS and contain
ad in an application, a copy of which has been given to Subscriber, the above provision will not be enforc
ad after two (2) years from the time such Member a coverage becomes effective under this Agreement or
GIRA.AS-0887D 5
c Fraud by a Member in the use of services or facilities coverage may be cancelled after not less than
a fifteen (15) day written notice or
d Failure of a Member to most eligibility requirements coverage may be cancelled immediately subject
to the continuation of coverage and conversion provisions of this Agreement, or
e Misconduct by a Member detrimental to safe plan operations and the delivery of services coverage may
be cancelled immediately or
f Failure of the Member and Participating Physician to establish a satisfactory Patient physician relation
ship if it is shown that SANUS TEXAS has in good faith provided the Member with the opportunity to
select an alternative Participating Physician the Member is notified in writing at least thirty (30) days in
advance that SANUS TEXAS considers the Patient physician relationship to be unsatisfactory and specifies
the changes that are necessary in order to avoid termination and the Member has failed to make such
changes coverage may be cancelled at the and of the thirty (30) days or
g Refusal of a Member to accept recommended procedures or treatment as described in Section V A of
this Agreement the Member a coverage may be cancelled after not less than a thirty (30) day written notice
Termination of Group
This Agreement may be terminated by either SANUS TEXAS or the Group upon written notice to the other
party at least sixty (80) days prior to the Anniversary Date Such termination shall occur at midnight of the
day preceding the Anniversary Date In the event no such notice is given this Agreement shall continue in
effect for another Contract Year unless terminated pursuant to other provisions of this Agreement
The Group may be terminated in the case of
a Nonpayment of premium at the and of the thirty (30) day grace period and if so terminated all coverage
will be cancelled as of the last day for which premium has been paid or
b Fraud on the part of the Group all coverage may be cancelled after a fifteen (15) day written notice
C Coverage Under Alternative Health Benefits Plan
If the Subscriber becomes covered under an Alternative Health Benefits Plan his and his Dependent s coverage
under this Agreement shall automatically terminate as of the date upon which his coverage becomes effective
under the Alternative Health Benefits Plan
D Notification of Members Ineligibility
Group shall notify SANUS TEXAS within fifteen (15) days after Member ceases to be eligible for benefits under
this Agreement Failure to do so will make the Group liable for any expenses incurred by the Plan whether or
not paid due to the Group's failure to notify
E Refunds/Credits
If the coverage of a Member is terminated premium payments received on account of the terminated Member
applicable to periods after the effective date of termination shall be refunded or credited to Group, at SANUS TEXAS
sole option within thirty (30) days and neither SANUS TEXAS nor the Group shall have any further liability under
this Agreement with respect to such Member The maximum refund or credit allowable Is equal to two (2) months
of premium applicable to such terminated Member which shall include the month during which SANUS TEXAS
is notified in writing of such termination and the next previous month, if applicable Any claim for refund or credit
by Group must be made within sixty (80) days from the effective date of termination of the Member s coverage
or otherwise such claims shall be deemed waived
IV SPECIAL REQUIREMENTS FOR MEMBERS COVERED UNDER MEDICARE
A SANUS TEXAS shall be primary insurer when a Subscriber age 85 or older Is enrolled in Medicare and is employed
by the Group SANUS TEXAS shall be primary insurer for the spouse of a Subscriber who is employed by the
Group when such spouse is a Dependent is enrolled in Medicare and is age 85 or older
B SANUS TEXAS shall be primary insurer as compared to Medicare for a period of not less than nine (9) months
and no greater than twelve (12) months for Members who have become entitled to Medicare solely on the basis
of end stage renal disease Said twelve (12) month period begins with the earlier of (1) the month In which a regular
course of dialysis is initiated or (2) in the case of an Individual who receives a kidney transplant the first month
in which the individual became entitled to Medicare
C When a Member is entitled in Part A and/or Part B of Medicare and Medicare is the primary insurer SANUS TEXAS
shall pay on behalf of such Member all Medicare deductible and co-insurance payments for Services provided
which meet the requirements set forth in this Agreement The Member shall remain liable, however for the
Copayments and deductibles set troth in the SANUS TEXAS Schedule of Benefits and any Riders thereto If such
Member is eligible for Medicare Part A and/or Pan S but has not elected such coverage, his claims shall be handl
ed as though the Member had elected such Medicare coverage
V REFUSAL TO ACCEPT TREATMENT, EXCESSIVE TREATMENT
A Certain Members may for personal reasons refuse to accept procedures or treatment recommended by a Per
ticipating Physician and/or Provider Participating Physician and/or Provider may regard such refusal to accept
their recommendations as incompatible with the continuation of their Physician patient and/or Provider patient
GSA AS-0987D 6 0
relationship and v- obstructing the provision of proper medical ca If a Member refuses to accept such recom
mended treatme r procedure and the Participating Physician and/or Provider believes that no professionally
acceptable alternative treatment or, procedure exists such Member shall be so advised It the Member still refuses
to accept the recommended treatment or procedure then the Member may be terminated in accordance with Sec
tion III A(6)(9) of this Agreement
B If two (2) or more Participating Physicians who have rendered care to a Member Inform SANUS TEXAS that the
Member le receiving health services or preecriptlon medicatiorts In a manner or in a quantity which is not Medical
Iy Necessary or not medically beneficial the Member may be required by SANUS TEXAS to select single Par
ttcipating Primary Care Physician (hereafter referred to as a Coordinating Health Plan Physician )and aa amge
Participating Pharmacy for the provision and coordlnatton of all future health services
i If the Member fails to voluntarily select a Coordinating Health Plan Physician end a angle Participating Pharmacy
(within thirty (30) days of written notice by SANDS TEXAS of the need to do so SANUS TEXArm
a Coordinating Health plan Physician and a Participating Pharmacy for the Member S shall designate
Ph
cy
Following selection or designation of a Coordinating Health Plan Physician for a Member coverage for health
Services set forth in this Agreement shall be contingent upon each health service being provided by or through
written referral of the Coordinating Health Plan Physician for that Member
If after sixty (60) days from Initial notification by SANUS TEXAS the Member Is not In compliance with this Section
V 8 the Member may be terminated by SANUS TEXAS
VI PAYMENT REOUIREMENTS
A Payments Due
1 The is
of quired payments for the services and benefits made available hereunder are set forth in the Schedule
Rates and Premiums and shall be due and payable In advance on or before the first day of the month for
which each such payment Is made or is to be made No proration of the payments will be made with respect
' i to Members whose coverage under this Agreement commences after the first day of a month
2 Comments are due and payable to the Physician and/or provider at the time a service IS delivered The max
Imurn
any cadar y $850 for any Member
$1300}orany family w h only ttwol(2) Members Or $1500 for a Subscriber and his Dependents provided
however, that no Copayment will exceed fifty percent (60%) of the cost of services paid to a Participating Physi
clan or Provider and that In no event will the maximum amount of Cope ment exceed two (2) times the annual
premium required to be paid by the Subscriber and Group for such Subscriber and his Dependents It Is the
' Member a responsibility to retain receipts and to notify SANUS TEXAS upon attaining the Copayment limit
so that additional services will be provided without a Copayment charge Maximum amount of Copayment
for endar
is determ
Copayments
relat take Sint account anyrCopaym nits pertai iingg to any Rideed to the Basic Plan Benefits only and shall not
I 3 Any payments required for newborn children who meet the requirements of Section 11 C(2)(b) of this Agree.
ment shall be Initially payable to SANUS TEXAS on or before the first day of the month next following the
month In which the Application required under Section 11 C(2)(b) Is submitted to the Plan Such initial
I payments
shall be retroactive to the first day of the month in which such child s date of birth occurred Thereafter all
payments with respect to such newborn child shall be made as otherwise required under this Agreement miums
the
such
e due
will 4 heemaximumtallowable byt law U paid Interest will ibe d e arnd payab ebucharged
on a nottice thereof to Group freed at a rat not to ANUS TEXAS
8 Chaff ge of Rates
SAN S TEXAS shall have the right to change the rates and premiums payable hereunder (I) as of any Anmver
sary ate (In which case the Group will be notified at least sixty (60) days prior to a change In rates) or (h) in accor
dance with Section VIII 8(2) of this Agreement
VII IDENTIFICATION CARD8
A SANDS TEXAS shall issue identification cards for the Members
a P Ion of as SANUS TEXAS identification card in and of Itself confers no rights to services or other benefits
y person
The It (der of the card and the name on the card must be the same and the holder of the card must r in tact
a Me ber o n whos e behalf all appli cable cha rges und er th is eve actuall p
y bee
n aid An
ces or other beneflte to whN h he Its not entitled pur sua t o this A
r~W ng serv i nt herwise
TEXA Identiatio n ca or , shell be chargeable h Agre nt ere for at t ment he his
a mbar Per 0 the use ott his SANUS TEXAS Identifica I It
acirua~l coattof aervtes rend dUs
card by any other
termin t and "c vaI ated by SANUS TEXAS, and all rights of such Member pursuant to this on It car
ad in in axOrdence with Section III A of this Agreement
Agreement may be
VIII TERM AND AMENDMENT OF AGREEMENT
A Term
This Agreement shall remain in effect for the first Contract Year and thereafter for successive Contract Years unless
sooner terminated as provided herein
B Amendment
1 This Agreement may be amended at any time without the consent of the Members or any other person hav,
ing a beneficial interest in it upon written request made by the Group and agreed to by SANDS TEXAS Any
such amendment shall be without prejudice to any claim arising prior to the date of such amendment
2 SANUS TEXAS may alter or revise the terms of this Agreement and/or any Schedule of Benefits or Riders
attached hereto including the Schedule of Rates and Premiums In the event of such alteration or revision
SANDS TEXAS shall give the Group at least sixty (80) days prior written notice which notice shall be con
sidered to have been given when mailed to the Group at the address shown on the records of SANUS TEXAS
The alteration or revision shall become effective on the date contained in the notice unless the Group pro-
vides written notice within fifteen (15) days after the giving of notice by SANUS TEXAS of its intention to ter
mmate this Agreement
IX HEALTH CARE SERVICES
A Benefits and Services
1 SANUS TEXAS agrees to arrange for the provision of the benefits and services in the Schedule of Benefits
and Riders in accordance with the procedures and subject to the limitations and exclusions sperified in such
Schedule of Benefits and Riders and in this Agreement
2 Unless referred in writing by a Participating Primary Care Physician (or by a Participating Specialist Physician
with the concurrence of the responsible Participating Primary Care Physician) and except In cases of Medical
Emergency benefits and services set forth in Section If of the Schedule of Benefits and any Riders that are
rendered by a Participating Physician other than a Participating Primary Care Physician shall not be covered
3 Unless previously authorized in writing by a Participating Physician and by the Medical Director and except
in cases of Medical Emergency all benefits and services set forth in Section II of the Schedule of Benefits
and any Riders shall be available and covered only when provided by a Participating Physician Participating
Hospital or by another Provider under contract with SANDS TEXAS to provide health care services to Members
4 In cases of Medical Emergency Members shall be entitled to the benefits and services set forth in Section
III of the Schedule of Benefits
B Services Excluded from Coverage
Members shall not be entitled to the services set forth in Section IV of the Schedule of Benefits unless specifically
covered by a Rider to this Plan
X LIMITATIONS
The rights of Members and obligations of SANUS TEXAS Participating Physicians Participating Hospitals and Pro-
wders under this Agreement are subject to the following limitations
A Major Disaster or Epidemic
In the event of any major disaster or epidemic that would severely limit the ability of Participating Physicians Pro-
viders and/or Hospitals to provide health care services on a timely basis Participating Physicians Participating Hospitals
and Providers shall in good faith use their best efforts to render the benefits and services covered insofar as practical
according to their best judgement and within the limitation of such facilities and personnel as are then available If
SANDS TEXAS Participating Physicians Participating Hospitals and Providers shall have in good faith used their
best efforts to render benefits and services in the aforesaid manner they shall have no further liability or obligation
for delay or failure to provide such benefits and services due to a shortage of available facilities or personnel resulting
from such disaster or epidemic
B Circumstances Beyond SANUS TEXAS or Participating Physician or Provider Control
In the event that due to circumstances not reasonably within the control of SANDS TEXAS Participating Physicians
or Providers such as the complete or partial destruction of facilities because of war riot, civil Insurrection or the disability
of a significant number of Participating Physicians or Providers or similar causes the rendering of benefits and ser
vices covered hereunder is delayed or rendered impractical neither SANUS TEXAS nor any Participating Physician
or Provider shall have any liability or obligation on account of such delay or such failure to provide such benefits and
services if they shall have in good faith used their best efforts to render the benefits and services covered insofar
as practical according to their best judgement and within the limitation of such facilities and personnel as are then
available
C Limitations as Set Out in the Schedule of Benefits
The benefits provided under this Agreement are also limited by the limitations and exclusions as set out in the Schedule
of Benefits
GSA A"987D
D Non-Covered Servic,
SANUS TEXAS Shall not be responsible for the reimbursement far services or treatment of complications that drags
from all noncovered service, procnynortedurercor ovaratreatmdent SANDS TEXAS shall not be responsible for prescription result
and/or (medications related to a service procedure or treatment
XI CLAIM PROVISIM
G
A Re butsement of Claims Paid by Members
It Is not anticipated that a Member will make payment other than the Copayments and Deductibles required hereunder
to any other person or institution providing benefits and services which are covered under this Agreement provided
howeve~ that if the Member furnishes to SANUS TEXAS written proof that he has made payment to such
or merit lion with respect to benefits and services covered underSANDSthisTEXASAgreementseek recovery
ces will be paid to the Member, but without prejudice to person
right payment with re
to
by it before receipt of such evidence Claims must be in writing but need not be in any particular form aped letter said sere
panted by invoices describing the services provided will normally be sufficient of any payment made
A letter
accom
B Proof of Claim
if a charge (other than as specified in paragraph C below) is made to a Member for any benefits and services which
are cove ltd under this Agreement, written proof of such charge must be furnished to SANUS TEXAS within six (6)
months her the performance of the service
C Pharmaceutical Services
If this Agr"mem provides coverage for outpatient prescription drugs subject to certain deductibles It is the Member a
responsibility to retain receipts for covered drug payments Any claim for reimbursement must be made In writing
to SAWS TEXAS and accompanied by relevant receipt within six (6) months following the end of the calendar year
in which the covered expense Is Incurred
D Emergency Care Services
Payment or reimbursement of Emergency Care services (see Schedule of Benefits Section III for a description of covered
Emergent: Care services) provided by Physicians, Hospitals or Health Professionals that have not contracted with
SANU9 TVAS to provide services under the Plan whether Inside or outside the Service Area will be on a too-for
service basis subject to a maximum allowable fee and subject to Copayments Deductibles and exclusions set out
in this Agreement as well as the following additional conditions
1 The Member and Provider must notify the Plan or his Participating Primary Care Physician of his condition and
the se arrangements within forty-eight (46) houre after the onset of the Medical Emergency and receive authorize
tion for continued services if indicated If the Member's physical condition does not permit such notification within
the prescribed time, he must make the notification as soon as ilia reasonably possible to do so
2 The claim for reimbursement must be made in writing within sixty (60) days of the onset of the Medical Emergency
for which payment Is requested, accompanied by Invoices or other appropriate evidence of payment
E Failure Ito Furnish Proof of Claim
o enure to au~y sh claim r if it within was the reequu^ed time established in paragraphs 8 and C of this Section shall not invalidate
reduce as soon as r asonably possible All such cha possible will be paidpwin sixty (60) days Provided such
receipt of written proof covert g
the occurrence character and extent of the event for which claim is made unless the Member Is notified of the need
for a longertime purspant to paragraph 0 of this Section
SANUS TEXAS, at it own expense, Shall have the right to examine the person whose sickness or Injury is the basis
of a claim when and ad often as It may reasonably require during the pendency of the claim
Q Action on Claims
Claims will be acted on within sixty (60) days unless the Member is notified of the need for a longer time if a claim
k denied a Written notice will contain the reason for the denial
H Review
0 a Claim Is d riled a Subscriber may obtain a review of the denial through the Member Complaint Resolution Pro.
ollqure (See action XIV)
I No ac an at law or equity shall be brought under title Section against SANDS TEXAS (1) prior to the expiration
of the sixty (60) daX period Immediately following the date on which written proof of the charge or loss upon
* which the action 18 rought has, In accordance with the
TEYA I c► PI) later than three (3) years after the expiration of thea ri this time in, been furnished to SANDS
Or 10111 N required under this Section to be furnished to SANDS TEXASime in which such proof of charge
hheerlau Illy shall be imposed upon 8ANU8 TEXAS other than for the benefits and services specifically covered
M
XII COORDINATION OF . /EFITS AND SUBROGATION
It any benefits to which a Member is entitled under this Agreement are also covered under any other Health Care
Plan the benefits payable under another Health Care Plan include the benefits that would have been payable had
a claim been duly made therefor This provision does not apply to individual coverage or Medicaid
A For purposes of this Section only the following words and phrases shall have the following meanings
1 Allowable Expenses means any necessary reasonable and customary Item of expense at least a portion
of which is covered under at least one of the Health Care Plane covering the person for whom claim is made
When a Health Care Plan (including this Plan) provides benefits in the form of services the reasonable cash
value of each service rendered shall be deemed to be both an Allowable Expense and a benefit paid
2 Health Care Plan means any of the following (Including this Plan) which provide benefits or services for
or by reason of medical care or treatment
a Coverage under government programs including Medicare, required or provided by any statute unless
coordination of benefits with any such program is forbidden by law
b Group coverage including automobile insurance individual coverage or any other arrangement of coverage
for individuals in a group whether on an insured or uninsured basis including any prepayment coverage
group practice basis or individual practice coverage and any coverage for students which is sponsored
by or provided through a school or other educational Institution above the high school level
The term Health Care Plan shall be construed separately with respect to
(i) Each policy contract or other arrangement for benefits or services
(Ii) That portion of any such policy contract or other arrangement which reserves the right to take the benefits
of other Health Care Plans into consideration in determining its benefts and that portion which does not
B SANUS TEXAS shall have the right to coordinate benefits between this Plan and any other Health Care Plan
covering the Member
The rules establishing the order of benefit determination between this Plan and any other Health Care Plan
covering the Member on whose behalf a claim is made are as follows
1 The benefits of a Health Care Plan which does not have a coordination of benefits with other health plans
provision shall In all cases be determined before the benefits of this Plan
2 If according to the rules set forth in Paragraph C of this Section the benefits of another Health Care
Plan that contains a provision coordinating Its benefits with this Plan before the benefits of this Plan have
been determined the benefits of such other Health Care Plan will be considered before the determination
of benefits under this Plan
C Rules establishing the order of benefit determination as to a Member's claim for the purposes of Paragraph
B of this Section are as follows
1 The benefits of a plan which covers the person on whose expenses claim is based other than as a depen
dent shall be determined before the benefits of a plan which covers such person as a dependent
2 The benefits of a plan which covers the person on whose expenses claim is based as a dependent of
a person whose date of birth excluding year of birth occurs earlier in a calendar year shall be determm
ad before the benefits of a plan which covers such person as a dependent of a person whose date of
birth excluding year of birth occurs later in a calendar year If either plan does not have the provision
of this paragraph regarding dependents which results either in each plan determining its benefits before
the other or each plan determining Its benefits after the other the provisions of this paragraph shall not
apply and the rule set forth in the plan which does not have the provisions of this paragraph shall deter
mine the order of benefits except that in the case of a person for whom claim is made as a dependent child
(t) When the parents are separated or divorced and the parent with custody of the child has not renter
rigid the benefits of a plan which covers the child as a dependent of the parent with custody of
the child will be determined before the benefits of a plan which covers the child as a dependent
of the parent without custody
(ii) When the parents are divorced and the parent with custody of the child has remarried the benefits
of a plan which covers the child as a dependent of the parent with custody shall be determined
before the benefits of a plan which covers that child as a dependent of the step-parent and the
benefits of a plan which covers that child as a dependent of the step-parent will be determined before
the benefits of a plan which covers the child as a dependent of the parent without custody
(w) Notwithstanding Subparagraphs (i) and (ID of this Paragraph when the parents are divorced or
separated and there Is a court decree which would otherwise establish financial responsibility for
the medical dental, or other health care expenses with respect to the child, the benefits of a plan
which covers the child as a dependent of the parent with such financial responsibility shall be deter
mined before the benefits of any other plan which covers the child as a dependent child
3 When paragraphs (1) and (2) do not establish an order of benefits determination, the benefits of a plan which
has covered the person on whose expenses claim is based for the longer period of time shall be determined
before the benefits of a plan which has covered such person the shorter period of time, except that
GSA A"87D 10
(1) The benefits of a, , covering the person on whose expenses claim w weed as a Is" or retired employee
or as the dependent of such person shall be determined after the benefits of any other plan covering such
person as an employee other than as a laid-off or retired employee or a dependent of such person and
(I) if either plan does not have a provision regarding laid-off pr retired employees and, as a result each plan
i determines its benefits after the other, then the provisions of subparagraph 0) of this paragraph do not apply
D When any benefits are available as primary benefits to a Member under Medicare Medicare will be determined
first and benefits available under this Plan If any will be reduced accordingly
E If a Member who has enrolled under this Plan is entitled to inpatient benefits under another contract or policy
of Insurance due to inpatient care which began while the Member was enrolled under a previously held policy
SANUO TEXAS will pay, subject to Copayments under this plan the difference between entitlements under this
Plan and entitlements under the other contract or policy of Insurance
F Benefits which are provided directly through a specified provider of an employer shall in all cases be provided
before Ithe benefts of this Plan
G Services and benefits for military service connected disabilities for which a Member is legally entitled and for which
facilities are reasonably available shall In all cases be provided before the benefits of this Plan
H For purposes of this provision SANUS TEXAS may subject to applicable confidentiality requirements set forth
in this Agreement release to or obtain from any Insurance company or other organization necessary information
under this provision Any Member claiming benefits under this Agreement must furnish to SANUS TEXAS all in
formation deemed necessary by it to Implement this provision
1 None of the above rules as to coordination of benefits will serve as a barrier to the Member first receiving direct
health services arranged by SANUS TEXAS which are covered under this Plan except as specifically stated in
Paragraph G of this Section
J Whenever payments have been made by SANUS TEXAS with respect to Allowable Expenses in a total amount
at any time in excess of 100% of the amount of payment necessary at that time to satisfy the Intent of this Section
XII SA US TEXAS shall have the right to recover such payment to the extent of such excess from among one
or more of the following as SANDS TEXAS shall determine any person or persons to or for or with respect to
whom such payments were made any insurance company or companies or any other organization or organize
lions to which such payments were made
K Worker s Compensation
All sums payable for services provided pursuant to worker a compensation shall not be reimbursable under this
Agreement
L Member's Cooperation (Medicare)
Each Member shall complete and submit to SANDS TEXAS such consents releases assignments and other
documents as may be requested by SANDS TEXAS in order to obtain or assure reimbursement under Medicare
Any Member who falls to enroll under Part 8 and if eligible Part A of the Medicare program will be liable for
the amount of funds SANUS TEXAS would have received had Member so enrolled
M Acts ofI Third Parties (Subrogation)
Plan services shall be provided to a Member due to the act or omission of another person However If the Member
is entitled to a recovery from any third party with respect to those services such Member shall agree in writing
1 To reimburse SANUS TEXAS to the extent of the usual and customary charge that would have been charged
to ~he Injured Member for health care services hereunder If the Member were not covered under this Plan
Su h reimbursement must be made immediatedly upon collection of damages for hospital or medical expenses
by the Member whether by action at law settlement or otherwise
2 To provide SANUS TEXAS with a lien against any third parry recovery for hospital or medical expenses to
the extent of the usual and customary charge that would have been charged to the Member for health care
services In the absence of coverage under this Agreement Such lien may be filed with the person whose
act caused the injury such person a agent or the court
i N Facilityiof Payment
WhenladIaa vi ion r payments whi ch should have n made under SANDS TEXAS coverage in accordance with this pro-
vbeen me undany othr Hre Plan NU3 TES shell have the ht exercisable in
Its solscretionto pay over to an onizatiomakisuch other pyments any amonts It hall determine
to be w nted in rder to eaUaty the Itent of gtle ion XII Accounts so paid by SANU3 TEhall bdeemed
to be efile paid under SANUS TES coverae and to the extent of such payment SAUS TEXAS shall be
fully dharged from liability under this Plan
k,C , pisclosi re
'Each Member agrees to disclose to SANUS TEXAS at the time of enrollment at the time of receipt of services
and benefits, and from time to time as requested by SANUS TEXAS Social Security number birthdate employ
f Mont, and the existence of other Health Care Plan coverage, in regard to which the identity of the carrier and
'1111119 group through whom provided will be furnished by the Member
11
Xlll OPTION TO CONT14UE GROUP COVERAGE, CONVERSION PRIVILEGE AND TRANSFER
A Continuation of Groin, %:overage
If under the provisions of Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985 Public Law W272
otherwise terminate e or If COBRA Is Inapplicable and the provisions ofgan beyond state stahis tute would
uch
Member similar rights to continuation of coverage this Agreement shall be deemed to allow continuation of coverage
to the extent necessary to comply with the provisions of the applicable statute Contact your employer for verifies
tion of eligibility and procedures to follow
B Conversion Privilege and Transfer
1 Conversion
If the coverage of any Member terminates for any reason other than those set forth in Section III a(8) Subparts
a b c e and f then such Member may convert his membership to individual membership without furnishing evidence
of insurability No Member shall be allowed to convert if Member s termination results from the Group s withdrawal
from this Plan or SANUS TEXAS termination of the Group In order to obtain Individual membership any Member
eligible to convert his membership must continue to reside In the Service Area submit a completed application
for conversion to SANDS TEXAS within thirty-one (31) days after the date of termination and submit premium
payments required under such membership The effective date of such individual membership shall be the next
day following the Termination Date of the Member a coverage under this Agreement
2 Transfer of Residence
a Transfer within the SANUS TEXAS Service Area If a Subscriber changes his primary residence within
the SANUS TEXAS service area he must notify SANUS TEXAS within thirty (30) days of such change
b Transfer outside the SANUS TEXAS Service Area If a Subscriber changes his primary residence outside
the SANUS TEXAS service area such change shall result in lose of eligibility and the Member will be
eligible to convert without evidence of insurability to a non SANUS TEXAS Individual Insurance policy
upon making application and premium payment within thirty-one (31) days after date of termination
XIV MEMBER COMPLAINT RESOLUTION PROCEDURE
SANUS TEXAS agrees to investigate and endeavor to resolve any and all complaints received from Members with
regard to the nature of professional services rendered Any inquiries or complaints shall be made to SANUS TEXAS
In writing addressed as set forth in Section XV C of this Agreement or by calling SANUS TEXAS at the telephone
number set forth in Section XV D of this Agreement
SANUS TEXAS is committed to arranging for provision of high quality medical services in a convenient and accessi
ble fashion to ensure Member satisfaction with all aspects of SANUS TEXAS On occasion Individual Members may
find that
They do not understand or agree with the policies procedures or operations of SANUS TEXAS or
They are not satisfied with some part of their treatment by providers
It is the intent of SANUS TEXAS to resolve any such complaint as expeditiously as possible preferably with the source
of any such dissatisfaction
In order to achieve SANUS TEXAS goal of ensuring Member satisfaction and to resolve any complaints that may
occur SANUS TEXAS has implemented a Member Resolution Procedure The objectives of this Procedure are
A To provide a clear procedure for complaint resolution that is easily understood by Members
B To facilitate an expeditious resolution of all complaints,
C To acquire feedback so that any recurring problems may be corrected and
D To provide management Information so that Member satisfaction may be measured and compared to SANUS
TEXAS service standards
Members of the Plan are encouraged to communicate any question or concern directly to the Participating Physician
Provider or staff member rendering service in order to immediately resolve the Issue
Specifically the Member Complaint Resolution Procedure involves the following steps
1 An Informal Complaint
An informal complaint is any complaint that cannot be resolved to the Member s satisfaction after speaking
directly with the Participating Physician Provider or other concerned party A Member shall also have the
right to contact the Quality Assurance Coordinator directly with any informal complaint at the address and
telephone number of the SANUS administrative office as specified in Sections XV C and XV D A Member
may lodge an Informal complaint over the telephone or in person When an Informal complaint is made the
Quality Assurance Coordinator will attempt to resolve the complaint within thirty (30) days
2 A Formal Complaint
Each Member has the right to submit a complaint or suggestion in writing no later than thirty-one (31) days i
either from the decision regarding an informal complaint or from the date of the occurrence of the In-
cident A written Member Complaint Form may be obtained from the administrative office either through the
mail or by coming to the office of SANUS TEXAS The Quality Assurance Coordinator who has
overall responsibility for administering the Member Complaint Resolution Procedure will con-
GSA AB-0987D 12 aA Qf
tact the Member I sting acknowledging receipt of the letter verifying the facts of the complaint and advis.
ing the Member of when to expect a written response
After Investigating the complaint and once a resolution has been reached the Quality Assurance Coordinator
will draft a written response to the Member within thirty-999 (31) days of receipt of the written complint If has
not
a
with
n the tehdeicoW p'atthat a deceel on w/l be reached within) another thirty-one day time frame the Member will be advis
The resolution of a written complaint shall be considered binding unless the(31)Member seeks to appeal the deci
lion The Member shall be advised in writing of his right to appeal the decision
3 Appeals Process
If a Member is not satisfied with the decision obtained through the formal complaint procedure he may re-
questonwltMpnl In order to appeal a decision the Member must submit a written request to the Executive
thirty (30) days after receipt of the written resolution The Committee shall meet within thirty
(30) days following receipt of the written appeal
The Committee will consist of the Executive Director the Director of Provider Relations the Medical Director
the Quality Assurance Coordinator and one Physician from the advisory board
The Member will be advised of the decision of the Committee in writing within fifteen (15) days after the meeting
Such decision shall be final and binding on the parties
4 Management Review
of the Executive Director shall e ppropriaten ss of the review action oaken and the elimination of the prroble"ss) which led to he comp aiintf
The President and Board of Directors Shall likewise review the complaint reports not lose frequently than annually
Allog shall be maintained by the Quality Assurance Coordinator of all written complaints and responses and
shall be retained for a minimum of three (3) years The log shall clarify each complaint by type and shall note
the disposition of and total amount of time required to process each complaint
XV MISCEL_ LA^ N_ EpUg
A Pronouns
Masculine pronouns used In this A r
B
Records and Information g eemant shall include both masculine and feminine genders
1 SANDS TEXAS shall have the right at reasonable times to examine the Group a records Including payroll
records of employers having employes covered through the Group with r
payments under this Agreement aspect to eligibility and monthly
2 Information from medical records of Members and information received from Physicians or Providers or Facilities
me dent to the Physician Patient Provider patient or Facility patient relationship shall be kept confidential The
intimation, except as reasonably necessary in connection with the administration of this Agreement or as
required by law may not be disclosed without the consent of Members
3 For the purposes of administering this Plan (Including without limitation Section XII hereof) SANDS TEXAS
m
ay to the extent legally allowable and without further consent of or notice to any Member release to or Insurance
obtain from
com son, which SANDS TEXAS deems anyo be necessary for such purposely Animation with respect benefits any per
thislPlan shelf furnish to SANDS TEXAS such Information as may be necessary to implementiSSection XII hereofr
4 The Application completed by Subscriber authorizes any Physician Health Professional or Facility to make
such records photographs or information available to SANUS TEXAS as SANUS TEXAS may reasonably re-
quest on behalf of Subscriber or his Dependents
5 Prior to admission as an inpatient for elective hospitalization or for same day surgery the Participating Primary
Care Physician must obtain preadmission certification from SANUS TEXAS
Notices
Any notice under this Agreement may be given by United States Marl postage prepaid addressed as follows
If to SANUS TEXAS
SANUS TEXAS HEALTH PLAN
8600 Freeport Parkway, Suite 3o4o
Irving Texas 75063
If to Group
The latest address provided by the Group in writing to SANUS TEXAS
If to Member
The telephone number of SANUS TEXAS is (214) 82"376 Metro 621 8143
Assignment
The bone its to a Member under this Agreement are personal to the Member and are not assignable or otherwise
in 910
r
The latest address provided by the Member on forms actually delivered to SANUS TEXAS
Telephone
13
r C
t: ;
r oeversollity
The invalidity or nforceability of any term or condition hereof a in
,
of any other ten r provision hereof no way affect the validity or enforceability
G Incorporation by Reference
The Schedule of Benefits, the Schedule herein
of Rates and Premiums, any optional Riders, the Application and any
amendments to any of the foregoing attached hereto form a part of this Agreement as If full Incorporated
Any direct conflict or ambiguity between this Agreement and the Schedule of Benefits and any Rider attached
hereto will be resolved under terms most favorable to the Member y prated
H Entire Agreement
This Agreement the Schedule of Benefits the Schedule of Rates and Premiums Amendments, if any any op
h Riders and Application constitute the entire Agreement between SANDS TEXAS and the Group
I Authority
Any alteration or revision to this Agreement or the attached Schedule of Benefits and Riders must be in writing
and signed by an officer of SANUS TEXAS to be valid No other person has the authority to change this Agree•
ment or to waive any of Its provisions
J Certificates of Coverage
Upon execution of this Agreement SANUS TEXAS will deliver sufficient copies of this Agreement to the Group
for delivery by the Group to each Subscriber Such copies shall serve as a Subscriber s Certificate of Coverage
K List of Providers of Services
Upon execution of this Agreement and from time to time thereafter SANDS TEXAS will provide to the Group for
dissemination to Subscribers a list of Participating Physicians Participatingg Hospitals, Participating Alcohol or
Drug Treatment Facilities and other Providers who have contracted with SANUS TEXAS to provide the services
and benefits covered by this Agreement
L Furnishing Information
Any person claiming or who may claim benefits under this Plan shall facilitate the access of or furnish to SANUS
TEXAS such information as may be necessary to implement this Agreement and SANUS TEXAS may release
or obtain such information as needed to implement the provisions of this Agreement
M Independent Agents
1 The relationship between SANUS TEXAS and Facilities is that of Independent contractors Facilities are not
agents or employees of SANUS TEXAS no is SANUS TEXAS or any employee of SANUS TEXAS an employee
or agent of any Facility Facilities shall maintain the Facility-patient relationship with Members and shall be
the only parties responsible to Members for the services that they provide
2 The relationship between SANUS TEXAS and Physicians and Other Health Professionals is that of Indepen
dent contractors Physicians and Health Professionals are not agents or employees of SANDS TEXAS nor
is SANDS TEXAS or any employee of SANUS TEXAS an em o or Health Pro.
fessional Physicians and Health Professionals shall maintain lthe Physic en-patien orhysician
Patient relationship with Members Grou
Health Professional.
nor
thereof 9 be Neither the liable for any acts or omfisss onerof S NUSITEXAS tits agents ore ployees any Physician any Provider
or any other person or organization with which SAWS EX and neither shall
for the Performance of services under this TEXAS has made or hereafter shall l make arrangements
Agreement
ngements
*4
xA
GSA AB-0987D
14
c r c , n Y b 4
GROUP APPLICATION
To the extent herein defined and limited, this contract provides for comprehensive health
care arranged through SANDS TEXAS HEALTH PLAN, INC (hereinafter referred to as
"SANUS TEXAS"), a prepaid health care program
Issued by
SANUS TEXAS HEALTH PLAN, INC
8800 FREEPORT PARKWAY, SUITE 3040
IRVING, TEXAS 75083
METRO 821.8143 OR (214) 929.0378
A Corporation organized as a Health Maintenance Organization under the Laws of
the State of Texas
This AGREEMENT between
(nereinatter referred to as the "Group") and
SANUSi TEXAS entities the Subscriber and his enrolled Dependents, if any, to receive
the benefits hereinafter set forth for the Contract Year, subject to the terms and condi-
tions of this Agreement and upon payment of stipulated premium
benefits) of verrage M 111 Subscribers and Dependents shall be entitled to receive the Plan 5
Agreement This Agreement consists of the terms of Sections I through XV, all
Attttachments and Schedules to the Agreement, all Applications, all Amendments,
If any, and the following Riders attached hereto
S (DURABLE MEDICAL EQUIP NT a D a)
Group Enrollment Period
The Group Enrollment Period shall be from to
Effective Date
The Effective Date of this Agreement shall be at 12 01 a m on 12/01/89
OSAGA-0087 0
m + S 1 SHNUS TEXAS HEALTH
Schedule of Rates and Premiums
Monthly Premium Rates
Effective From io/Di/a9 to 09/30/90
Subscriber Only
Subscriber + Spouse + Children
( ) 3•Tier
Subscriber Only
Subscriber + t Dependent
Subscriber + Spouse + Children
(x) 4-Tler
Subscriber Only $100.00
Subscriber + Spouse ~o, ac
Subscriber + Child(ren) '~grn7
Subscriber + Spouse + Children 255 42
P 05
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed on
this day of
19,_
SANDS TEXAS HEALTH PLAN, INC
By Executive Director
C t of Den MP- By Authorized Representative
SANDS TEXAS HEALTH PLAN has a maximum Member Copayment limit per calendar year which ap•
pllea to any Copsyments for services covered under the Basic Plan Benefits (excluding Riders)
The Limits are specified In Section VI A(2) of this Agreement
This means that any Copaymente paid by SANUS TEXAS Members for Participating Physician, Provider
or Emergency services covered under the Basic Plan Benefits may be added together to reach the max
imum Member Copayment limits Once reached, no other Copayments are required for the remainder of
the calendar year (except Riders)
OSAGA-0967D 2
i" U 1 5 4 9 SANUS TEXAS HEALTH P.02
e-
GROUP APPLICATION
To the extent herein defined and limited, this contract provides for comprehensive health
care arranged through SANUS TEXAS HEALTH PLAN, INC (hereinafter referred to as
"SANUS TEXAS"), a prepaid health care program
Issued by
SANUS TEXAS HEALTH PLAN, INC
8600 FREEPORT PARKWAY, SUITE 3040
IRVINQ, TEXAS 76063
METRO 621.8143 OR (214) 929.0376
A Corporation organized as a Health Maintenance Organization under the Laws of
the State of Texas
This AGREEMENT between
SANUS TEXAS entitles the Subscriber and his enrolledtDependents, If any, to "Group")
the benefits hereinafter set forth for the Contract Year, subject to the terms and condi-
tions of this Agreement and upon payment of stipulated premium
sage o All SS bscribers and Dependents shall be entitled to receive the
benef 8 of vera
Agreement- This Agreement consists of the terms of Sections I through XV, all
Attachments and Schedules to the Agreement, all Applications, all Amendments,
if any, and the following Riders attached hereto
M (PRESCRIPTION DRUG - 850) A (IN 1TTFNT ME Ar m
5 (DURABLE MEDICAL EQUIPMENT RIDER)
Group Enrollment Period
The Group Enrollment Period shall be from to
Effective Date
The Effective Date of this Agreement shall be at 12 01 a m on TM1/89
QSAGA-M7-)
' L = r - S- S S 0 T H U 1 S. S 0 SANUS TEXAS HEALTH P 03
4
Schedule of Rates and Premiums
Monthly Premium Rates
Effective From _ in/oi /Ae to 09/10/90
Subscriber Only
Subscriber + Spouse + Children _
( ) 3-Tier
Subscriber Only
Subscriber + 1 Dependent
Subscriber + Spouse + Children
(x) 4~ le
Subscriber Only $150.25
Subscriber + Spouse a AS
Subscriber + Child(ren) 219 68
Subscriber + Spouse + Children 402.62
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed on
this day of 19_
SANUS TEXAS HEALTH PLAN, INC
By
Executive Director
Citv Denton
roup
By
Authorized Representative
SANUS TEXAS HEALTH PLAN has a maximum Member Copayment limit per calendar year which ap-
piles to any Copayments for services covered under the Basic Plan Benefits (excluding Riders)
The Limits are specified in Section VI A(2) of this Agreement
This means that any Copayments paid by SANUS TEXAS Members for Participating Physician, Provider
or Emergency ssrvloes covered under the Basic Plan Benefits may be added together to reach the max
imum Member Copsyment limits Once reached, no other Copayments are required for the remainder of
the calendar year (except Riders)
QSAC1*00e7-0 2
DESIGNED ESPECIALLY FOR
City of Denton
THESE MONTHLY PREMIUM RATES ARE GUARANTEED
FOR A PERIOD OF--A2. MONTHS,
IF ACCEPTED FOR AN EFFECTIVE DATE OF-2"1 /a9
CATEGORY MONTHLY RATES
Employee $231 73
Employee + Family 487 08
Option III Retiree Rates
THE SANDS TEXAS
ACCOUNT MMCIMVE- Hr. Yen DiBella
TELEPHONE NUMBER 214/921-8143
BBNBWLEVEL 0 2f A S (FLIli-inured)
DATE. Santember 29 1989
ftm o s-NN (FAR 4
v.
- a .J ~ H r1 t H L I H p+ ~ ~p L
DESIGNED ESPECIALLY FOR
City of Denton
THESE MONTHLY P
REMIUM RATES ARE GUARANTEED
FOR A PERIOD OF. 12
IF ACCEPTED FOR AN EFFECTIVE DATE _ MONTHS
~'T'EGORY MONTHLY
Employee RATES
$171 52
Employee + Family
360.56
option I Retiree Ratee
. • 11F. %MnvV TEXAS HEALTH A N
ACCOUNTEXBDU7M !1r Pen DiBalla
TBLBPHONE NUMBER 214/621-8149
DENIM Lou.
N 5 Full insured)
DAIS ce -
DESIGNED ESPECIALLY FOR
City of Denton
THESE MONTHLY PREMIUM RATES ARE GUARANTEED
FOR A PERIOD OF 12 MONTHS,
IF ACCEPTED FOR AN EFFECTIVE DATE OF 12/01/89
CATEGORY
MONTHLY RATES
1
on
$ 81
23
2
on
162
46
1
on + 1 off
324
90
1
on + 1 off + family
484
66
2
on + family
322
21
THE SANDS TEXAS HEALTH PLAN
ACCOUNT EXECUTIVE Mr Ken DiBella
TELEPHONE NUMBER 2141621-8143
BENEFIT LEVEL Medicare Supplement (Q M A 5)
DATE October 11. 1989
Vam a sr
DESIGNED ESPECIALLY FOR
City of Denton
THESE MONTHLY PREMIUM RATES ARE GUARANTEED
FOR A PERIOD OF 12 MONTHS,
IF ACCEPTED FOR AN EFFECTIVE DATE OF 12/01/89
CATEGORY
1
on
2
on
1
on+1 off
1
on + 1 off + family
2
on + family
MONTHLY RATES
$ 61 89
123 78
247 56
369 27
245 49
THE SANDS TEXAS HEALTH PLAN
ACCOUNT EXECUTIVE Mr Ken DiBella
TELEPHONE NUMBER 214/621-8143
BENEFIT LEVEL Medicare Supplement (M 3 5)
DATE October 11. 1989
SP?
~ SANUSPWS
~ BENEFITS
s ~o'~`"' r~w~onu
At Doer oR Ar a cost ov:
PWAT6 PNYSM"'S 0111101106
All office visits to pertkipeting physicians
(primary care and splBcialist) for diagnosis and
treatmentof IMesaorinJury lab x ray and
other diagnostic procedures $7perwsd Deductible
PMENVA CARE SMWW498
Well babycare onphysician'srecommended
schedule
Routine Immunizations
Periodic health assessments on physicians
recommended schedule NOCHARGE Not covered
Annual well woman examination
Routine vision speech and hearing screening
(through 17 years of age)
IN THE NOSWAL
No limits on your covered hospital days
as preauthorized
All diagnostic services e g lab x ray etc
Drugs, medications and radiotherapy
intensive and Coronary Care Units $275
Medical services per admission' Deductible
(saml-gNate %
All necessary specialist care and consultations plus 20 roan unleu
Use of Operating and Recovery Rooms private room is
~ I~ary~
Anesthesia
Surgery
Special Duty Nursing NO CHARGE' Deductible
(onlywRSn plus 50%
meEkely (benef t limit of
necefeery $2500 per
calendar year)
PRwm CARE ppyS10M OR PREAVII40R12AT)ON IFY SAN BS TEXAS PROVIDERS RECUIRE REFERRAL By YOUR
T SENSM Late s WALL 09 DETERMINED BY TAKING INTO ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANS
Additional Benefits
►URABLE MEDICAL E UIPMENT RIDER
provided at no charge when Medically Necessary, Prescribed by a =arucipa~t
he following will be the SANUS TEXAS Medical Director
nmary Care Physician and approved in advance by
A Initial placement of Durable Medical Equipment such as standard wheelchairs, crutches, walkers,
hospital beds oxygen orthopedic tractions, etc
an
"Durable Medical Equipment means equipment anotiuseful thstandto apepeted rson use in use, is the absence primarily of a
Y is than one person, and
customarily used to serve a medical purpose. g be used by more
sickness or injury is appropriate and used in the home may
doesn t require an individual prescription for construction
The following items are among those excluded, deluxe and motor driven equipment, comfort items,
disposable supplies, exercise equipment. professional instruments. sauna baths, orthopedic shoes, arch
rch items Repair, replacement or maintenance is excluded
, dentures, experimental or resea
supports
B Hearing Aids and Related Testing Physician,
a SANUS TEXAS Participating r,
Diagnosis of hearing deficiencies when ordered bheanng aid device(s) one (1) audiogram pe Year
including audiometry, initial placement of necessary four (4) years if medically necessary
if needed and replacement of the hearing aid device (s) every 4
Additional Benef s
J' PRESCRIPTION DRUGS - $50
Prescription Drugs are covered when prescribed or authorized by a participating Sanus Texas Physician or
participating Sanus Texas Dentist for covered benefits and filled by a participating pharmacy
F Member Cost
Source
NO CHARGE (No Deductible) Mail Order
1 $2•
Generically Equivalent Prescription Drugs
$7' Brand Name Prescription Drugs
• After a $50 calendar year deductible per person, maximum of 3 people per family need to meet this
# deductible
Maximum Dosage 30 day supply or 100 units (whichever is less)
Exclusions Non-prescription, experimental or investigational drugs, blood, blood products, blood or untie
testing devices, appetite suppresants or antismoking aids, uuectibles other than inlecUble
insulin, therapeutic devices or appliances, compounded medications not provided for an FDA
approved indication, contraceptive devices (other than oral contraceptives and diaphragms),
cosmetic medications including topical minoxidil and Retin A, Schedule V controlled
substances including Robitussin, Guaiatussin and terpin hydrate with codeine, allergy sera,
allergy testing materials, and prescriptions available without charge
11
a
11
4
11
11
a
11
SCHEDULE OF BENEFITS
SANUS TEXAS Members are entitled to receive the services and benefits set forth in this Schedule of Benefits which are Medically Necessary and
are provided ordered prescribed or authorized by a Participating Primary Care Physician subject to the limitations exclusions Copayments and deductibles
specified
I Routine Medical and Health Services when covered
Except In the case of a Medical Emergency services are covered only C The Participating Primary Care Physician may make referrals
under the following conditions only to Participating Physicians Participating Hospitals Par
A Each member must select a Participating Primary Care Physician At hul or Dru De ndency Treatment Facilities and
from the directory who will be responsible for the Member s health
needs including coordination of out-of area services and specialist
referrals
B To be covered under the Plan all services must be provided
directed or authorized by the Participating Primary Care Physician
at a Participating Facility When the Member requires care by
' another Physician Hospital Participating Alcohol or Drug
Dependency Treatment Facility or other Health Professional the
Participating Primary Care Physician will make a written referral to
such Physician Hospital Participating Alcohol or Drug Dependency
Treatment Facility or Health Professional The only exception is the
well woman examination provided for in Section 11 B(1)(a) or as
otherwise expressly provided The Plan will not pay for visits to any
Physicians Hospitals Participating Alcohol or Drug Dependency
Treatment Facilities or Health Professionals that have not been
authorized in writing by the Participating Primary Care Physician
and when appropriate approved in advance by SANUS TEXAS
The Participating Primary Care Physician will be responsible for
reviewing coordinating and following up on any specialty or
hospital course of treatment
n Dmiilrina fiAariir•al Ranaflta Health RAnaf is and Coo
A OUTPATIENT SERVICES
1 Office visits for diagnosis and treatment of illness or Injury
a Laboratory services
b Diagnostic and therapeutic radiological services In support of
other covered benefits and services
c Surgical procedures in a Participating Physicians office
(See Section II CHI)
d Administered drugs medications injectibles biologicals
fluids radioactive materials dressings splints caste braces
and crutches The use of splints and braces except in case
of emergency must be approved in advance by SANDS
TEXAS (See Section IV X)
i e Obstetrical care including prenatal and post natal services
2 Short term outpatient rehabilitation (19 physical
therapy) services for acute conditions which are Medically
Necessary recommended by a Participating Primary Care
Physician and approved in advance by SANUS TEXAS The
acute condition must be subject to significant improvement
through short term therapy Short term is defined as up to sixty
(60) consecutive days per medical condition including treatment
received as an inpatient under Section II D(2) The total of out
patient and inpatient rehabilitative services shall not exceed six
ty (60) days per medical condition beginning with the first date
of treatment
3 outpatient or same day inpatient surgery services Including
anesthesia (See Section II C(11)
0 Services rendered in a Member a home
5 Allergy testing (Allergy injections and serum are not covered)
6 When approved in advance by SANDS TEXAS up to twenty
(20) fifty (50) minute office visits per calendar year to a par
ticipating psychiatrist psychologist or mental health professional
for evaluation or crisis intervention mental health services (See
Section IV 0)
Sanue Texas Health Plan Inc
A Health Maintenance Organization
8600 Freeport Parkway Suite 3040
Irving TX 7li0
Metro (214) 821
21-0557
S81445 a•o
ticipating co o g V-
other Participating Health Professionals who have signed par
ticipating provider agreements with SANUS TEXAS The Par
ticipating Primary Care Physician may make referrals to
Non Participating Physicians and Non Participating Hospitals
and Health Professionals when such services cannot be proved
ad by another Participating Provider Such referrals must be in
writing and approved in advance by SANUS TEXAS
Participating Specialist Physicians may make further referrals to
other Physicians Hospitals Participating Alcohol or Drug
Dependency Treatment Facilities and Health Professionals In each
case they must receive the concurrence of the responsible Par
ticipating Primary Care Physician and follow the same referral pro-
cedures set out in paragraphs B and C above
When a Participating Physician determines that a Member requires
admission to a Participating Hospital the physician must obtain
precertdicabon from SANUS TEXAS Length of stay will be carefully
monitored to ensure that required treatment is provided in the most
cost effective manner
$15 per visit
None in laboratory facility
None in radiology facility
(Office visit Copayment applies
if laboratory or radiological services are performed in
Participating Physicians office)
$15 per visa
$100 for each surgery in a hospital outpatient unit day surgery
unit or Ambulatory Surgical Center
$15 for each physician home visit
$25 per testing visit
$15 per visit (all others)
$25 for each 50 minute visit
TEXAS HEALTH PLAN, INC
7 l lcohol and rudrg dependency Is provided na the t treatment
for same basis
and is subject to the same limitations exclusions and
nt must t be peauthorized for by physical Illness SANDS TEXAS and generally 11 caAll ret
me
must be provided by a Participating Facility
8 PREVENTIVE HEALTH SERVICES
1 Periodic health assessments pediatric well baby care and
routine immunizations when deemed Medically Necessary by the
Participating Primary r assessments shall A be determined by the parent
of such he
ticlpating Primary Care Physician immunizations are given and
covered in accordance with accepted medical practice for car
tarn common communicable diseases including diptherla per
tusis measles mumps rubella poliomyelitis and tetanus
a Annual Well Woman Exam Female Members
may elect to have a gynecological and related examination
including Pap smear performed by any SANUS TEXAS Par
ticipating Physician offering such examination
NOTE No Participating Primary Care Physician referral is
needed for this exam However referrals are still required
for other gynecological procedures
b Routine vision speech and hearing screening through 17
years of age to determine the need for correction not to in
clude retraction eye exams testing or fitting for hearing
aids
C FAMILY PLANNING
1 Family planning services on a voluntary basis to include history
physical examination related laboratory tests and medical
supervlsior in accordance with generally accepted medical prac
tics information and counseling on contraception including ad
vice on or prescription for a contraceptive method
2 Infertility services on a voluntary basis Diagnostic testing ser
vices to determine the cause of infertility are covered Artificial
insemination (patients spouses sperm only) is covered All In-
fertility services require precertification from SANUS TEXAS
(See Section IV O)
D INPATIENT SERVICES
Inpatient Hospital Services for Medical Conditions Member is entitl.
ed to receive the Inpatient hospital services set forth in this Sac
tion subject to all definitions terms and conditions in this
Agreement and its attachments Except as otherwise provided in
Section 111 these services will be available only in the Service Area
and only if performed prescribed arranged for directed or
authorized by a Participating Primary Care Physician at a Per
ticipating Facility All non emergency hospitalization must be ap-
proved in advance by SANUS TEXAS
1 Inpatient hospital services are those provided by Participating
Hospitals within the Sam Area Inpatient hospital services for
the specific treatment of illness or injury including but not
limited to semi private room and board special diets when
Medically Necessary use of operating room and related
facilities special care unit and services x ray laboratory and
other diagnostic tests drugs medications biologicals
anesthesia and oxygen services physical therapy radiation
therapy and inhalation therapy and administration of whole
blood or blood products (See Section IV L) Special duty nursing
shall be provided only when Medically Necessary (i a in the
absence of an intensive care unit) when recommended by a
Participating Primary Care Physician and approved In advance
by SANUS TEXAS Private room coverage shall be provided on
ly in cases of medical necessity (i a isolation due to infectious
diseases) The Member may elect private room accommodations
for other than the above stated reason In such cases the
Member is responsible for the direct payment of the difference
to the Hospital
NOTE Members electing to remain to the Hospital beyond
authorized discharge time are responsible for direct payment to
the Hospital SANUS TEXAS is not responsible or financially
liable for such additional payments
2 Rehabilitation Services Short term Inpatient rehabilitation (I e
physical therapy) services at a Participating Facility for acute
conditions which are Medically Necessary recommended by a
Participating Primary Care Physician and approved in advance
by SANUS TEXAS This acute condition must be subject to
significant Improvement through short term therapy Short term
is defined as up to sixty (60) consecutive days per medical con
not be approved outpatient under
Sch serv services shall received
Section which il A(2) includes
$15 per Wait (No C
None
/merit for aftercare maintenance visits)
$15 per visit plus
IUD $25 for insertion or removal
Diaphragm $25 Vasectomy $25
Elective lubal ligation $25
(See Section II A131)
$15 per visit
50% for each artificial insemination service
Medical or Surgical $400 per admission
Obstetrical (Including therapeutic abortions)
Mother $400
Baby $400
$400 per admission
aeM-0BaeD
Inpatient basis unless other acute medical care is to be provld
ad The total of inpatient and outpatient rehabilitative services
shall not exceed sixty (00) r 9cutive days per medical condl
Non beginning with the firs a of treatment
3 Inpatienservices in a Participating Skilled Nursing Facility A
Member shall be able to receive short term Inpatient treatment
at a Por Iclpatlrtg Skilled Nursing Facility when acute care
hospital) cation Is not appropriate is recommended by a Par
ticipatin Physician and approved in advance by SANDS
TEXAS
NOTE killed nursing care is not covered when provided for
conditiorla of senile deterioration Alzhiemer s Disease mental
retardation or mental Illness Private duty nursing services
private room accomodations personal or comfort Items and
other articles not specifically necessary for treatment of illness
or injury pre excluded Short term is defined as up to sixty (50)
consecutive days per medical condition
4 Alcohol and Drug Dependency Necessary inpatient treatment
for Alcohol and Drug Dependency Is provided on the same basis
and subject to the same limitations exclusions and Copaymente
as treatment for physical illness generally All treatment must be
pre•authotized by SANDS TEXAS and all care must be provided
by a Participating Facility
E OTHER SERVICES
1 Home Health Care Services Home health care services are
available only in the Service Area when provided by a SANDS
TEXAS p rticipating home health care agency and are
specificall limited to short term intermittent skilled visits Such
services ust be Medically Necessary recommended by a Par
Ncipaling Ikrimary Care Physician and approved in advance by
SANUS TEXAS Short term is defined a$ up to sixty (50) con
secutive days per medical condition beginning on the date
when the first such visit occurs
2 Emergency Services
a Hospital Emergency Room
b Out Patient Emergency Care Center or physician offices
operating alter hours or as emergency centers
c Emergency ambulance service
I Ambulances Services Medically Necessary ambulance service to
the nearest medical facility capable of providing Emergency
Care or Medically Necessary non-emergency ambulance service
when authorized in advance by SANUS TEXAS
Prosthetic Devices Internal prosthetic devices (except organ
transplant devices) are covered Initial external standard pro.
sthetic medical appliances and limbs are coveretl when due to
an acute illness or injury Internal prosthetic items covered are
permanent eida and supports for defective part of the body such
as the Star Edwards mitel valve the internal pacemaker and
minor device Such as screw nails sutures and wire mesh Ex
ternal prost silo appliances covered are artificial arms legs
eyes or per anent lenses stove or below knee or elbow pro•
stheses ext. met cardiac pacemaker and terminal devices such
as hand or ook All other prosthetic medical appliances in
cluding aemo described in Section IV are excluded In ques.
tions of medical necessity a second opinlon may be requested
by the Plan and is binding See Section IV AA
Administration of Blood and Blood Products
L
by a imited Dental Related Services Services which are authorized
licensed nparrticipat participating dentista(D D S or D M and ) and which are
either treatment of a fractured or dislocated jaw or to repair
damage to natural teeth resulting from nomoccupatlonal ac
cidental injury provided such Injury occurred and services are
d i
Provided that the Member seeks treatment within hereunder further
and thirty (30) days
of such accidental Injury Removal of cysts of the mouth are
covered unless they are directly related to the teeth and their
supporting structures
Services
IN GENERAL
1 Emergency Core services must be secured by the Member im
medtatety afte the onset of the medical condition or ae soon
thereafter ae I; possible but not later then twelve (12) hours
alter the first Appearance of symptoms of illness or forty eight
$25 per day
$400 per admission
$15 per visit
$40 Copayment for each visit (Charge waived if admission
occurs at the time of emergency room visit)
$25 Copayment for each visit
None
None
None
None
None
(48) hours after an accident
Heart attacks cardiovascular accidents poisoning loss of con
sctousness or respiration convulsions severe bleeding and
broken bones are examples of true Medical Emergencies
3
r-
III Emergency and Urgent Servias Continued,
2 Emergency and urgent services are subject to SANUS TEXAS
retrospective review for determination of whether an acute condition
or incident requiring immediate emergency or urgent care existed If
SANUS TEXAS determines that no need for emergency or urgent
care existed the Member will be responsible for payment of all
charges incurred for such care subject to the Member Complaint
Resolution Procedure
B WITHIN THE SERVICE AREA
Inside the Service Arse the Member or someone acting on behalf
of the Member is expected to contact the Participating Primary Care
Physician for advice If it is not reasonably possible to contact the
Participating Primary Care Physician at the time (such as that of a
life threatening emergency) the Member or someone acting on
behalf of the Member shall notify SANUS TEXAS within forty-eight
(48) hours of the emergency or it not possible within forty-eight (48)
hours as soon as it is reasonably possible Upon receipt of notifica
lion SANUS TEXAS will coordinate the transfer of the patient to the
care of the Participating Primary Care Physician when medically pru
dent to do so
Coverage for treatment for Medical Emergencies within the Service
Area by non participating providers is limited to the care required
before the Member can without medically harmful or injurious con
sequences be treated by a Participating Physician or Participating
Hospital
C OUTSIDE THE SERVICE AREA
Services are available while outside the Service Area provided that
such Services are of an emergency or urgent nature and cannot be
postponed until the Member Is able to return to the Service Area to
obtain treatment through a Participating Physician All continuing or
follow up treatment shall be provided only within the Service Area
subject to all the provisions of this Agreement
To constitute a covered out of area service SANUS TEXAS must
make the following determinations
1 onset of the acute illness or injury must have been sudden and units
petted
2 the Member must not have been able to return to the Service Area
to receive treatment from the Participating Primary Care Physician
3 the treatment must have been Medically Necessary
SANUS TEXAS shall pay the Subscriber or arrange to pay the Non
Participating Hospital(s) or Non Participating Physician(s) directly
The payment shall be at the prevailing rate subject to any required
Coperyments Covered services include ambulance transportation
provided it is Medically Necessary and appropriate
At the time of the emergency the Member or someone acting on
behalf of the Member shall make every reasonable effort to notify
SANUS TEXAS (and to obtain advice from the Participating Primary
Care Physician) If it is not reasonable possible to notify SANUS
TEXAS at that time the Member or someone acting on behalf of
the Member shall notify SANUS TEXAS within forty-eight (48) hours
or if not possible as soon as it is reasonably possible Upon
notification SANUS TEXAS will coordinate the transfer of the patient
to the care of the Participating Primary Care Physician within the
Service Area when medically prudent to do so
IV Limitations and Exclusions from Coverage
The following services and supplies and the cost thereof are excluded from
coverage under this Agreement unless specifically included by a supplemental
rider
A Private room accommodations and special duty nursing except as
provided in Section II D(1) or unlimited hospital care except when
deemed by SANUS TEXAS to be appropriate for an acute level of
inpatient care
a Services rendered by a Participating Specialist Physician or other
Provider in non-emergency settings without referral by Member s
Participating Primary Care Physician except for annual well woman
examinations (see Section II BlIJjaJ)
C Any service given without a prior written referral from the Member s
Participating Primary Care Physician except as otherwise permitted
in Sections 1 II or III of this Schedule of Benefits
D Treatment or evaluations required by third persons including but not
limited to those for school employment flight clearance summer
camp insurance or court ordered
E To the extent the Member does not comply with the SANUS TEXAS
procedures for obtaining services SANUS TEXAS shall not pay for
services and benefits for military service connected disabilities which
are provided to the Member in governmental or military service con
netted fatalities which the Member chooses to use
F Care which a Member receives from or through the United States
Government or any of its corporations agencies or bureaus or from
or through any Stale County City or any political subdivision
thereof unless a charge is customarily made and services were pro•
vided in accordance with the provisions of Sections It A II E
G Cosmetic or surgical procedures are excluded except reconstructive
surgery necessary to repair a functional disorder as a result of
disease injury or congenital defect Such exclusions include but are
not limited to surgical excision or reformation of any sagging skin
on any part of the body including but not limited to the eyelids
face neck abdomen arms jogs or buttocks any services perform
ad in connection with the enlargement reduction implantation or
change in appearance of a portion of the body including but not
limited to the breasts face laps jaw chin nose ears or genitals
hair transplantation chemical face peels or abrasion of the skin
electrolysis dipflitation or any other surgical or non surgical pro.
cedures which are primarily for cosmetic purposes SANUS TEXAS
reserves the right to secure a second opinion by a physician of its
own choosing with respect to any case involving cosmetic or
reconstructive surgery
H Dental services and dental prostheses including dentures are ex
eluded except as covered in Section II E(6) Maxillary and man
lobular osteotomies including any treatment for temporomandibular
joint syndrome are excluded Hospitalization anesthesiology or other
services relating to dental work are excluded
I Custodial respite or Domiciliary Care
aeMABe&D
J Services and appliances for the correction of vision deficiencies in
ctudmg but not limited to special procedures such as orthophcs
invasion training or radial keratotomy
K Personal comfort and convenience items or services including but
not limited to care kits provided on admission to a hospital k s
and telephones
L Whole blood or blood components (blood replacement fees)
M Surgery or other procedures or services for obesity including but
not limited to gastric intestinal bypass surgery
N Sex change surgery including medical or psychological counseling
and hormonal therapy in preparation or subsequent to any such
surgery
O Reversal of voluntary sterilization gamete mtra fallopian transfer
any fees relating to donor sperm pergonal (menotropins) or related
drug therapy surrogate parenting fees and In Vitro Fertilization
P Acupuncture naturopathy and hypnotherapy
0 Inpatient mental health Treatment for mental retardation mental
deficiency or other forms of senile deterioration such as
Alzhoemer a Disease
R Heart transplants bone marrow transplants (except autogemc) and
all other organ transplants (except cornea kidney liver [for biliary
attesae only)) All donor expenses are excluded
S Any procedure or treatment that is deemed by the Plan to be ex
penmental
T Care for conditions that Federal state or local law requires to be
treated in a public fatality or while in the custody of legal
authorities
U Services payable under worker a compensation black lung benefits
or a government program to the extent that such services are fully
covered under worker s compensation or similar laws
V Routine toot care such as hygienic care treatment for flat feel
removal of toms or calluses and onhotics Corrective orthopedic
shoes arch supports orthotics custom fitted braces or splints
W All durable medical equipment
X Outpatient patient purchased consumables or disposable supplies in
eluding but not limited to sheaths bags elastic garments syringes
needles blood or urine testing supplies ostomy bags home testing
kits vitamins dietary supplements special food items non rigid ap•
pliances and supplies
Y Occupational and educational testing and therapy
Z Long term rehabilitation therapy Long term means treatment in ex
case of sixty (80) consecutive calendar days per illness or event
AA Replacement repair or routine periodic maintenance of prosthetic
devices Penile prostheses are excluded
B 8 Speech and hearing therapy including hearing aids
CC Outpatient prescription drugs and hospital discharge or take home
drugs
4 110111 71880
CITY OF DENTON RETIREES
I 92UHW-LU HEALTH ELM
NAME
BIRTHDATE
SM
COVERAGE
Buell, Dorothy
12-20-26
Female
Single
Fritz, George
05-15-21
Male
Single
Hale, Walker
04-23-21
Male
Spouse
Magana, Jose
10-15-24
Male
Spouse
Mendoza, Clarita
08-13-30
Female
Single
Ponce, Bruno
10-06-13
Male
Single
Steele, James
03-15-18
Male
Spouse
Jones, Jean (COBRA)
09-06-23
Female
Single
II CITY PLAN
Allred, Clifton
05-18-13
Male
Spouse
Arnett, Charles
04-13-25
Male
Spouse
Castleberry, Carl
09-11-09
Male
Spouse
Johns, Crain
08-16-14
Male
Spouse
Vinson, Taylor
05-05-29
Male
Spouse
retirsan
092780
SANUS TEXAS HEALTH PLAN, INC
8600 Freeport Parkway, Suite 3040
Irving, Texas 75063
(214) 929-0376 or Metro (214) 621-8143
AMENDMENT TO
GROUP MEMBERSHIP SERVICE AGREEMENT/
CERTIFICATE OF COVERAGE
In accordance with Section VIII B(2) of the Group Membership Service Agreement/
Certificate of Coverage between SANDS TEXAS and the Group, the Agreement 1s
hereby amended to reflect the changes indicated below All other terms and
conditions of the Agreement are unchanged
A Section II C is amended by adding the following paragraph before Section
II C(1)
For the purposes of this Section, the following words and phrases
shall have the following meaning
a "Confined in a Hospital or Other Medical Institution" means
that a person is a patient and/or undergoing medical care or
treatment in a hospital, nursing home, or other medical institution
b "Confined at Home" means that a person is undergoing medical
care or treatment in his home and/or has a condition, due to
an illness, injury or congenital deformity, which restricts
the patient's ability to leave his home without the aid of a
supporting device, or monitoring equipment, or without the aid
of another person
B The first sentence of Section II C(1) is amended to read as follows
1 On Date Subscriber Becomes Covered An Eligible Dependent for whom
the Subscriber has applied for membership in the Plan by submitting
an application in accordance with Sections II A and II B shall become
covered under the Plan as a Dependent on the effective date, provided
that any Dependent Confined at Home or Confined in a Hospital or Other
Medical Institution on the day that person would otherwise become covered
will become covered on the first day such dependent is not confined
C Section II C(2)(a) is amended to read as follows
a A newly acquired Eligible Dependent other than a newborn child,
and an Eligible Dependent who first meets the eligibility requirements
of Section II A other than during a Group Enrollment Period and
has an Application submitted on his behalf within thirty-one (31)
days of meeting such requirements shall be covered as of the first
day on which he meets such requirements, provided that any Dependent
Confined at Home or Confined in a Hospital or Other Medical Institution
on the day that person would otherwise become covered will become
covered on the first day such Dependent is not confined
Amendment to
Group Membership Service Agreement/
Certificate of Coverage
Page Two
D Section III B(1) is amended by adding the following to the end of the paragraph
1 In the event no such notice is given, and this Agreement continues for
another Contract Year, the premiums will not exceed 1227 of the previous
Contract Year's premiums
E Section VIII B(2) is amended by adding the following to the end of the paragraph
2 The reason for having the language in this Agreement is to permit Sanus
Texas to change premium rates (1) on the Anniversary Date of the Plan,
(2) if there are benefit changes mandated by state or federal law, and
(3) if a group requests a change in benefits during the plan year Unless
one of these events occurs, Sanus Texas will not increase Group's premiums
F Section II is amended by adding paragraph J which shall read as follows
1 Sanus Texas agrees to provide coverage under this Plan for each of the
Group's retirees who is covered by an Alternative Health Benefits Plan
on the date immediately preceding the Effective Date of this Agreement
2 Sanus agrees to provide coverage to former employees and dependents
who have exercised their rights under the COBRA "Act" for periods as
specified under the "Act" and at the premiums specified by the "Act"
G Section III is amended by adding paragraph F which shall read as follows
At the end of the contract period, or upon termination of this Agreement
as specified, Sanus Texas agrees to provide the City with an unlabeled,
1600 BPI computer tape of all claims data on employees and dependents
by social security number, if permitted by law
CITY OF DENTON, TEXAS
RAY S EP ENS, MAYOR
SANU TEXAS HEALTH PLAN, INC
EXECUTIVE DIRECTOR
A Additional Benef s
if DURABLE MEDICAL EQUIPMENT RIDER
41 The following will be provided at no charge when Medically Necessary, prescribed by a Participating
Primary Care Physician and approved in advance by the SANUS TEXAS Medical Director
IA
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Initial placement of Durable Medical Equipment such as standard wheelchairs, crutches, walkers,
hospital beds oxygen, orthopedic tractions, etc
"Durable Medical Equipment means equipment which can withstand repeated use, is primarily and
customarily used to serve a medical purpose, generally is not useful to a person in the absence of a
sickness or injury is appropriate and used in the home may be used by more than one person, and
doesn t require an individual prescription for construction
The following items are among those excluded, deluxe and motor driven equipment, comfort items
disposable supplies, exercise equipment, professional instruments, sauna baths, orthopedic shoes, arch
supports, dentures, experimental or research items Repair, replacement or maintenance is excluded
B Hearing Aids and Related Testing
Diagnosis of hearing deficiencies when ordered by a SANUS TEXAS Participating Physician
including audiometry, initial placement of necessary hearing aid devtce(s) one (1) audtogram per year
if needed, and replacement of the hearing aid device(s) every four (4) years if medically necessary
11
11
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L.__J
14
Additional Benefitb
INPATIENT MENTAL HEALTH
Members shall be entitled to additional mental health care benefits for evaluation, crisis
intervention, treatment or any combination thereof for acute conditions when such
evaluation, crisis intervention or treatment is recommended by a Sanus Texas
Participating Primary Care Physician, approved in advance by the Sanus Texas
Medical Director and precertified by Sanus Texas
A The total benefit is limited to any combination of the following, not to exceed thirty
(30) treatment days per calendar year
I As an inpatient in an authorized Sanus Texas participating psychiatric facility,
one (1) inpatient day equals one (1) treatment day, or
2 As a daycare patient in an authorized Sanus Texas participating psychiatric
facility, one (1) daycare equals one-half (1/2) treatment day, or
3 As an inpatient in an authorized Sanus Texas particpating crisis stabilization
unit or an authonzed Sanus Texas participating residential treatment center for
' children and adolescents, one (1) inpatient day equals one-half (1/2) treatment
day Benefits in these facilities are available only for acute conditions which
would otherwise necessitate confinement in an authorized Sanus Texas
participating psychiatnc facility
B Limitations and Exclusions
' 1 Mental health services for the following diagnosed conditions are excluded
Chronic psychosis, Alzheimer's Disease, intractable personality disorders,
mental retardation, psychiatric therapy on court order or as a condition of parole
or probation, and chronic organic brain syndrome
2 The benefits described in the Rider are available when (a) the Member does not
refuse to accept recommended procedures or treatment, and (b) they are
provided in an authorized Sanus Texas participating psychiatric hospital,
psychiatric facility, cnsis stabilization unit or residential treatment center for
children and adolescents and by a Participating Provider, and (c) the
Member continues to meet the Sanus Texas criteria for continued benefits under
this Rider
C Copayment 50%
Additional Bene" Ys
PRESCRIPTION DRUGS - $50
Prescription Drugs are covered when prescribed or authorized by a participating Sanus Texas Physician or
]participating Sanus Texas Dentist for covered benefits and filled by a participating pharmacy
Member Cost Source
NO CHARGE (No Deductible) Mail Order
$2* Generically Equivalent Prescription Drugs
$7• Brand Name Prescription Drugs
' After a $50 calendar year deductible per person, maximum of 3 people per family need to meet this
deductible
Maximum Dosage 30 day supply or 100 units (whichever is less)
Exclusions Non-prescription, experimental or investigational drugs, blood, blood products, blood or unne
testing devices, appetite suppresants or antismoking aids, irgectibles other than irgectible
insulin, therapeutic devices or appliances, compounded medications not provided for an FDA
approved indication, contraceptive devices (other than oral contraceptives and diaphragms),
cosmetic medications including topical minoxidil and Retin A, Schedule V controlled
substances including Robitussin, Gueiatussm and terpm hydrate with codeine, allergy sera,
allergy testing materials, and prescriptions available without charge
LI
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BENEFITS
SANW M" MO COVU AOEt PCOTNO111111111111
I Advance approval of Banes Taw required (Precsroleatim)
z Does not cover Wally mental retardation mental health cadincna or Alzheimahi Diseases
a Must notn Bence Axes or Primary Care Physician within p hours alter onset of emergency
" The out of•podaet maximum does not include comments for Prescription drugs inpatient memel health and
Omer Addltfonal Benaete which may be Included es a rider option
The total of outpatient and inpatient Physical therapy services may not exceed tip consecut" days par
medical oontlllbn
SANW TEXAS HMO COVERAGE OEMWIAL LNIRATIONS A DICLWIOW
Unless otherwise covered as an AddepW BwwM
B.nwAxes does not cover tmabnantaevaWobwemqubadbytdrd-psroons miRery, service convected dbeGNtln.
I
rare received hum or thromph the Mdeel or 1AW governawnt a airy subdivision #WW any beetrnwnt fortenlpomVMWIN •
dibular joint (TW) syndnwne cuffWal napite or domlrklery ore services and at>Plianass for the cowed n of view
deMdancae eyeglasses personal comfort and conwrtlerae Mans whole blood or blood oonporwes surgery, cor char
prooedures or services for obesity sex cwW surgery or related oxpenses reversed of voluntary taefibstion less
related to doff apsm a eoropets parmtlrp pwbo fertiszslbn WOUINAUM naWmPadry or hyp l*WW Inpesere
mental health beaanam for nw W retardation mental detdenay or other brow of eerie deterioration AWatrws
Disease holdInneplerda expedmemal procedures cero for canh 101 MquhedlobstreatedwepAlleledNywakers
compensation roalM fact owe oonaolive ontma o sc n Aron supports ortatwa custom lewd braces or spaft
dunce meditsl eghYpnwh4 otlpesert paoleeed cerwwneblss or d epos" supplies occupational and edueetialsl
repaln or malmerence of praawtle drAoss, speech and how" OWWA hear"
and slangy awn ArE iryscaro.
s outpatient prescription drugs
Spatial grassed" also apply to privets mom mmmmodatio s special dory rseaMhg services given wham Prior,
antler Marl ccsmetfa surgery, dental services andrW Insemination servlcee bee marrow and organ transplant.
epBMe and brscee prosthetic ftvk= W mehablkabon therapy
Except In on ct srrargsncy, as hospitalizetlon end erageny must be approved In advance by Banes Ante
Benue Texas UOW to Pnovde for aarvkse will be linked In an tent of major d",W epidemic sun not. or other
dmamsleoces beyond He owed
THE FOLLOWING ARE NOT COVERED BY SANW TEXAS NMOt
osure oophyl" Wicets Wmrede Gum Ran or Mass Allergy lint.
nlase W ex
0
~
V
1
p
McPOMa
p
Iet
110 (u
800
SANYS T WM NMO EJJOMWM
A be eMpfale to anroa in Sanw Axes HMO each Poem (last roalde in ant Berea Are Service AM mod RIM as
other 00" gMa4
REASON{ IPOR MO MATKN/ OF SANW TOE" HMO COVERAGE POR NJBtCANgw
Ccvnage may be terminated by Banes Texas because of dslaut in payments or ocpyamente subscriber is no taupe,
eligible or deceased fraud or misrepresentation mwoondpc detrknemM to ask plan operations talks, to establish e
setetaatory physids"MIGIA releUOmhlp rah" to accept casement or misuse of the Sinus Axes 10 sad
NEW YORK L!E MAJOR MEDICAL COVERAM OEIIERAL LWTATIOMS S EXCLUMM
Has" &"ask= under the Major Medical batu s are KMW to Prior rowsw by CoMed our Major Medical Rselew
Agency Failure a leWW thle review can ream In your MNng an eddbWW U00 out-of-pocket cost far hoWtAi
tonanemetl
1
Barents we provlees under a Drop Major Medical Pokey Weed by New York Lko to the Trustee of The beaus
Industry Tat an form GRP Serfs aro far coveerod expenses which kvade only usual or prevailing charges far
N
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Th
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ew
or
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o
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necessary medical me for an Injury s sbunies s mental disorder or a plegnsecye
cover OWWWWW Injury or sickness dwo" for pre furnishes by a government agency war congla" services
rougne physical examine,
of
infoMft
pnwided by relatives, tnuumsm
~
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WWO Injury of this bath
covered @X0W chWW for s
rs Dents!
ti inswntze
ca
Charges far view care we covered only for treatoent of socdem or IlIness Special Imitations also apply to cosmetic
surgery, MWknsm of jaw ON d W(ders and body dWertice Overseas business trawl limited to charges In first nc days
ol trip Compels detase of to benaete. kwhdlrp at becall ma wxms and e"Esti ns are oorlslred in are Ceroteeta
Booklet which all be Weed to you
This broNwe is for I is, oft only For a ascent! and ixedr MtlMrwnt M she berwab evesebw to you canlplaed preadese.
W the conpanyb &WORN stabs, ar Wit PMeMne ds WWNM for a copy of to SAKS TE M Scbdse of Benefits and
Grow MembeWap Service AgannnNCxalkaw of Coverage. or as SANDS TEAS
kxm ♦ Gana (11,18) 13 P084006
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SANUSPWS
BENEFITS
AT
PRESCRIPTION DRUGS
See Additional Cove
BenefltS4 Benue
SANUS NEWYORKUFE
BENEFIT
HMO MAJOR MEDICAL
OVERVIEW
BENEFITS BENEFITS
Annual Deductible
(par calendar year)
None
$400
per individual"
Coinsurance None 80%/20%
(azGpl orcop ants on all covered
listed above) expa=
(except as %icated above)
Not covered Deductible
plus 20%
(up to $500 In
covered expenses)
Lifetime Maximum Benefit
Unlimited
Unlimited
(except SW 000 for Mental Heaah)
Outofpocket $650 perindividual •
maximum $1300 per family oftWo4 $5000
(percelendaryear) $1500perfamilXof per individual
three or more plus deductible"
MAO BENEFITS FOR SERVICES BY PARTICIPATING SANDS PROVIDERS REQUIRE REFERRAL By YOUR PRIMARY
CARE PHYSICIAN OR PREAUTH)RIZATION BY SANIIS TEXAS
t BENEFIT LIMITS WILL BE DETERMINED BY TAKING IWO ACCOUNT BENEFITS RECEIVED UNDER BO1H PLANS
FAMILY LIMIT IS THREE TIMES INDIVIDUAL AMOUNT
~ SANUSPWS
~ BENEFITS
f
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PHYSICAL THERAPY
HOO
a uu
w
Mr A COST OR ~r rwsr t~rl
Outpatient services
$7 per visit's Deductible
plus 200/6
Inpatient services
$275 Deductible
's
per admission
plus 20%
ALLERGY
Testing
$25 per vies Deductible
plus 20%
All other visits
$7 per visit Deductible
(serum and plus 20%
Injection not
covered)
FAMILY PLANNING
Voluntary Family Planning Services
$7 per visit
IUD
$25 oopayment
Diaphragm
$25 copayment
Vasectomy
$25copayment Not
(plusapplicaw covered
eurperycopayment)
Elective tuba) ligation
$25copayment
~
wrwry
ymeno
INFERTILITY SERVICES
Diagnostic Testing Services $7 per visit'
Artificial Insemination Services 50% copayment' covereodt
d (Spouro's Sperm)
4
d HMO BENEFIT$ FOR SERVICES BY PARTICIPATING SANDS TEXAS PROVIDERS REQUIRE REFERRAL BY YOUR
PRIMARY CARE PHYSICIAN OR PREAIITHORIZATION BY SANDS TEXAS
tBENEFIT LIMITS WILL BE DETERMINED BY TAKING INTO ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANS
14*11 Paew.e
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SANUSP
wm=m~avk
BENWITS
SENEFITS AND SERVICES YOU CAN CHOOSE EITHER
MENTAL HEALTH
AT A owr or1
a w
In Your Physicians Private Office
Up to 20 sessions of short term
evaluation and crisis intervention per
calendar year
$25 per visa'
Deductible
minuiss
plus 50%
(W so =5
bene01 limn
In the Hospital
Per vied)
• As an inpatient up to thirty (30) days per
calendar year
50% copaymersl
Deductible
plus 50%
'WITH sao
000 LIFETIME BENEFIT UNIT
FOR MENTAL HEALTH
ALCOHOL A DRUG
DEPENDENCY REHABILITATION
Outpatient visits
Inpatient services
CARE IN YOUR HOME
Home health care services
Home physician visits
$7pervlas'
Deductible
plus 20%
$275
(yeu
per admission'
Os
lordruaabUns
servlcss in an
ennsl
e
arrorFrostl non-teed
venrrlenl lXDgyarn)
rem)
$7pervlsal
Deductible
lm
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on
plus 20°/0.
e
ca
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Inlermlaers
(UP to 100 visa
skilled vlseal
Per 12 morlMe)
$7 per visit
Deductible
plus 20%
HMO BENEFITS FOR SERVICES BY PARTICIPATING SANUS TEXAS PROVIDERS REOUIRE REFERRAL BY YOUR
PRIMARY CARE PHYSIOWI OR PREAUTHORWTION By SANUS TEXAS
1SENEFIT LIMITS WILL BE DETERMINED BY TAKING INTO ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANS
SMUSPUJS
BENEFITS
suRGERr e~}a!, aI; 6 t
All medically necessary procedures
Physician's office $7pervish' Deductible
plus 20%
Outpatient Hospital $50persurgery' Deductible
plus 20%
EXTENDED CARE IN A
SKILL= NURSING FACILITY
$25/day'R Deductible
(up W eo plus 20%
data (net 0o1+Ied after
medial
I~day4p
in Wit
hospuszotion)
MATERNITY CARE
In Your Physician's Private Offke
Pre-natal and post natal visits $7 per visit SERVICES
In the Hospital FOR
MOTHER
All physician services for mother t Deductible
Mother's hospital services { per admission' Plus 20%
SERVICES
Newborn nursery services $275 NEWBORFOR
N
Physician services for newborn peradmission' Deductible
plus 20%
out
'UP 10
well baby an)
AMID UMIQM3MIT CARE (24 hours a day, 7 d
In case of accident or sudden and serious illness
• Hospital Emergency Room
• Emergency/Urgent Care Facility
a
$40 per visits
(NO CHAR
AddMUeA Deductible
to Bw now") plus 20%
$20 per visits
HMO BENEFITS FOR SERVICES BY PARTICIPATING 9ANUS TEXAS PROVIDERS REQUIRE REFERRAL BY YOUR
PRIMARY CARE PHYSICW! OR PREAUrNORiZATION BY SANUS TEXAS
t BENEFIT LIMITS WILL BE OETE IMIMID BY IMM 5110 ACCOUNT BENEFITS RECEIVED UNDER BOTH PLANE
0.1010 CAD (Ila" P094006
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