WHS SPD PD 5-1-12

Dear Wellmont Health System Employee: MCA Administrators, Inc.
is the third party administrator for your employee benefit plan ("the Plan"). The company was hired to adjudicate your claims for benefits under the Plan. This booklet was prepared to give you a complete explanation of the Plan. The first section of this booklet, entitled Summary Plan Description, provides you with a summary of your benefits; guidelines on how to submit a claim, general plan information, as well as your rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). The second section, the Plan Document, provides you with the specific information governing the Plan such as eligibility, termination, covered benefits, Exclusions, Deductibles, COBRA, coordination of benefits, and definitions. A claims representative is available to answer questions you may have concerning this benefit plan. To contact your claims representative, simply call during the hours of 8:00 a.m. to 5:00 p.m. E.S.T. at 1-800-922-4966 and identify yourself through either your group plan number W301 or Wellmont Health System. The claims representative can discuss your questions concerning the Plan, but cannot give medical advice, pre-authorize any procedure, or guarantee payment. MCA Administrator's job is to review your medical bills, compare them to the coverage in the Plan, and provide this information to Wellmont Health System, who is responsible for funding the Plan. After reading this booklet carefully, we suggest you keep it available for future reference. THE FOLLOWING PAGES, WHICH ARE IDENTIFIED BY THE ACRONYM "SPD" BEFORE THE PAGE NUMBER, ARE INTENDED TO BE THE SUMMARY PLAN DESCRIPTION WHICH MUST BE FURNISHED TO YOU PURSUANT TO SECTION 102 OF THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA).
Original effective date 7/1/1998; restated 7/1/2011
SUMMARY PLAN DESCRIPTION FOR WELLMONT HEALTH SYSTEM EMPLOYEE MEDICAL, DENTAL, AND VISION CARE PLAN
Effective July 1, 1998 Restated July 1, 2011
SUMMARY PLAN DESCRIPTION TABLE OF CONTENTS INTRODUCTION ................................................................................................................. SPD 1 GENERAL PLAN INFORMATION ....................................................................................... SPD 2 ELIGIBILITY ......................................................................................................................... SPD 3 EFFECTIVE DATE ............................................................................................................... SPD 6 CHANGES IN PLAN ENROLLMENT ................................................................................... SPD 8 SPECIAL ENROLLMENT PERIOD...................................................................................... SPD 8 TERMINATION OF COVERAGE ....................................................................................... SPD 10 CHANGE IN BENEFIT ELECTION .................................................................................... SPD 10 LEAVE OF ABSENCE ....................................................................................................... SPD 11 STATEMENT OF ERISA RIGHTS ..................................................................................... SPD 12 SUBMISSION OF CLAIMS ................................................................................................ SPD 13 CLAIM REVIEW AND APPEALS PROCEDURE ............................................................... SPD 13 MEDICAL PLAN SCHEDULE OF BENEFITS.................................................................... SPD 18 PRESCRIPTION DRUG PROGRAM ................................................................................. SPD 26 DENTAL PLAN SCHEDULE OF BENEFITS ..................................................................... SPD 27 VISION PLAN SCHEDULE OF BENEFITS ....................................................................... SPD 28
NOTE: Capitalized terms in the Summary Plan Description are defined terms. Their definitions can be found in the Plan Document, beginning on page 1.
INTRODUCTION Health care services are available through Highlands Wellmont Health Network for eligible Employees and their dependents. The Network provides a way for health care professionals and the Employer to work together to help ensure that the Covered Person receives appropriate health care services. Agreements have been entered into with selected Hospitals, Physicians, and other health care providers to provide care and services economically. This Plan differs substantially from traditional health care protection coverage. Greater responsibility is placed on the Covered Person in making decisions pertaining to his/her health care. It is important the Covered Person knows how the plan works in order to take full advantage of the health care coverage and avoid unnecessary expense. Enhanced benefits are available when using Highlands Wellmont Health Network. In addition, the Plan offers a lower level of benefits through the USA-MCO Network. Because the Participating Providers have agreed to accept reduced fees for their services, the Plan can provide a higher level of benefit. Therefore, when a Covered Person uses a HWHN or USA-MCO provider, the actual cost to the Covered Person is reduced. The Covered Person is responsible for verifying that a provider is participating in the provider organization before receiving health care services. A directory of Participating Providers may be requested by and given to Covered Persons at no cost. The most current list of Participating Providers is available from the Networks via their toll-free telephone numbers and websites. HWHN: USA-MCO: (423) 844-4175 (800) 844-3820 (800) 872-3860 www.HWHN.com www.usamco.com
If a Non-Participating Provider (Non-HWHN or non-USA-MCO) is used, benefits will be provided at a reduced level as stated in the Schedule of Benefits. Benefits provided for covered services performed by a Non-Participating Provider may be considerably less than the amount charged by the provider. Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no coverage at all. Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan, such as coordination of benefits, subrogation, exclusions, timeliness of COBRA elections, utilization review or other cost management requirements, lack of Medical Necessity, lack of timely filing of claims, or lack of coverage. These provisions are explained in summary fashion in this document; additional information is available from the Plan Administrator or Claims Administrator at no extra cost. The Plan will pay benefits only for the expenses incurred while this coverage is in force. No benefits are payable for expenses incurred before coverage began or after coverage terminated, even if the expenses were incurred as a result of an accident, injury, or disease that occurred, began, or existed while coverage was in force. An expense for a service or supply is incurred on the date the service or supply is furnished. The Employer fully intends to maintain this Plan indefinitely. However, it reserves the right to terminate, suspend, discontinue, or amend the Plan at any time and for any reason. Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, deductibles, maximums, exclusions, limitations, definitions, eligibility, and the like. If the Plan is terminated, amended, or benefits are eliminated, the rights of Covered Persons are limited to Eligible Charges incurred before termination, amendment, or elimination. The Plan has a cost sharing mechanism for certain health care services and supplies used by a Covered Person. The Plan is not responsible for the efficiency and integrity of the health care providers delivering such health care services and supplies. The Plan is not liable in any way for the effect of delivery of such health care services and supplies or the results of action taken as a result of a health care service or supply being limited or not covered by the Plan.
SPD 1
GENERAL PLAN INFORMATION TYPE OF ADMINISTRATION The Plan is a self-funded group health Plan and the administration is provided through a Third Party Claims Administrator. The funding for the benefits is derived from the funds of the Employer and contributions made by covered Employees. The Plan is not insured. PLAN NAME Wellmont Health System Employee Medical, Dental, and Vision Care Plan PLAN NUMBER: 501 TAX ID NUMBER: 62-1636465 PLAN EFFECTIVE DATE: 07/01/1998 PLAN YEAR ENDS: 06/30 EMPLOYER, PLAN ADMINISTRATOR, PLAN SPONSOR, and PLAN SUPERVISOR Wellmont Health System 1905 American Way Kingsport, TN 37660 (423) 224-6455 AGENT FOR SERVICE OF LEGAL PROCESS Sr. Vice President of Human Resources Wellmont Health System 1905 American Way Kingsport, TN 37660 CLAIMS ADMINISTRATOR MCA Administrators Manor Oak Two, Suite 605 1910 Cochran Road Pittsburgh, Pennsylvania 15220 (800) 922-4966
SPD 2
ELIGIBILITY EMPLOYEE Hours at Work per Week A Full Time Employee is an Employee working for the Employer on a regularly scheduled work week of .................................................................................................................... 35 to 40 Hours per Week A Part Time Employee is an Employee working for the Employer on a regularly scheduled work week of .................................................................................................................... 24 to 34 Hours per Week Eligibility Date An Employee is eligible for coverage under the Plan on the first day that the Employee meets all of the following requirements: 1. The Employee is working on a regular basis for the Employer either at such Employees customary place of employment or at such other place or places as required by the Employer, and 2. The Employee is working for the Employer on a regular weekly schedule as set forth under Hours at Work per Week. However, an absence of work due to a Health Factor during any period before coverage becomes effective is not considered an absence for purposes of determining the Employees Eligibility Date. Employees who were previously covered by the Plan and lost coverage because they no longer met the eligibility requirements will be eligible for coverage under the Plan again if they subsequently regain Part-Time or Full-Time Employee status. These Employees must enroll for coverage as instructed in the Effective Date section of this document and will be subject to Preexisting conditions as defined in the Plan. RETIRED EMPLOYEES Retired Employees are eligible for coverage provided such Employee qualified for continuation of coverage through a retirement incentive program offered by the Employer. Please contact your Employer to determine eligibility. BOARD MEMBER Wellmont Health System Board Members are eligible for coverage. References to eligibility and coverage of Employees throughout this document are deemed to include Board Members, as applicable. DEPENDENT The following dependents of an Employee, if any, are eligible for coverage: 1. A spouse (if not legally separated). All of the requirements of a legally valid marriage contract must be met in the state of marriage of the Employee and spouse. Evidence of marriage in the form of official documents or notarized statements may be required before coverage can commence. 2. An unmarried dependent Child until such Child's 19th birthday. 1. An unmarried Child age 19 but less than age 23 who is a full-time student at an accredited post-secondary school, college, or university, is not employed on a full-time basis, and is dependent on the Employee for principal support. Full-time student status is defined by the school, college, or university. If the Child does not maintain full-time status or graduates, coverage closes independent of limiting age.
SPD 3
Full-time student coverage continues between semesters/quarters only if the student is enrolled as a full-time student in the next regular semester/quarter. If the student is not enrolled as a full-time student, coverage will be terminated retroactively to the last day of the attended school term. Michelles Law Notification shall mean the extension of coverage to full-time student Dependents at postsecondary educational institutions who experience a Medically Necessary Leave of Absence for Michelles Law, for up to one year, if both of the following conditions are met: a. The Plan receives written certification from the Dependents treating Physician certifying that:
i. The Dependent is suffering from a serious Illness or Injury; and ii.The leave of absence from the postsecondary institution is a Medically
Necessary Leave of Absence for Michelles Law. b. The loss of student status would cause a loss of health coverage under the terms of the Plan without the application of Michelles Law. The one-year period begins with the first day of the Medically Necessary Leave of Absence for Michelles Law and may end before the year ends, if the Dependents coverage under the Plan would terminate for any reason. Dependent Children who were previously covered by the Plan and lost coverage because they exceeded the eligibility age and did not remain in school as a full-time student or who were already over the eligibility age when coverage was first available to the Employee will be eligible for coverage under the Plan if they become full-time students before reaching age 23. 4. A Child age 19 and older who is covered under the Plan on the day prior to the day the Child's coverage under the Plan would have terminated due to the Child's age and who is Totally Disabled, mentally or physically unable to earn a living, unmarried, and dependent on the Employee for principal support. Proof of such disability must be submitted to the Employer within 31 days of the date the Child's coverage would have terminated due to age. Periodic proof that the dependent Child continues to be incapable of self-support will be required. The Plan Administrator reserves the right to have such dependent examined by a Physician of the Plan Administrator's choice, at the Plan's expense, to determine the existence of such incapacity. 5. A Child who is an alternate recipient under a qualified medical child support order in accordance with the provisions of ERISA. A participant of this Plan may obtain, without charge, a copy of the procedures governing qualified medical child support order (QMCSO) determinations from the Plan Administrator. 6. If a covered Employee is the Legal Guardian of an unmarried Child or Children, these Children may be enrolled in this Plan as covered dependents. Grandchildren are not covered unless legal guardianship exists. To maintain coverage under the Plan beyond age 19, the Employee must furnish due proof to the Employer that the Child remains unmarried and that the Child continues to be primarily dependent upon the Employee for support and maintenance and meets the requirements of 3, 4, or 5 above. At any time, the Plan may require proof that a spouse or a child qualifies or continues to qualify as an eligible dependent under this Plan. The term Child means an unmarried natural child, adopted child, child legally Placed with the employee for adoption, stepchild, or Foster Child. A stepchild or Foster Child must be living in the employee's home in a parent-child relationship and be chiefly dependent on the Employee for support.
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A Foster Child is: a. a child the Employee is raising as his own (i.e., the Employee has assumed a legal obligation for the child); b. a child who lives in the Employee's home; c. a child who is unmarried, under the Plans limiting age, chiefly dependent on the Employee for support; and d. a child for whom the Employee has taken full parental responsibility and control. A Foster Child is not: a. a child temporarily living in the Employee's home; b. a child placed with the Employee by a social service agency which retains control of the child; c. a child whose natural parent is in a position to exercise or share parental responsibility and control; or d. a child who is eligible for medical coverage, other than coverage available through the foster parents. A Child may not be covered as a dependent if the Child is eligible for coverage under this Plan as an Employee. If a person covered under this Plan changes status from Employee to dependent or dependent to Employee, and the person is covered continuously under this Plan before, during and after the change in status, credit will be given for deductibles and all amounts applied to benefit maximums. Any person on active duty in any military service is not eligible for coverage as a dependent under this Plan.
SPD 5
ENROLLMENT and EFFECTIVE DATE This Plan now requires all members to supply specific identification elements for coordination of benefits purposes. Such information includes, but is not limited to: Social Security numbers, date of birth, etc. for ALL members. Claims received for members who have not provided the Plan Administrator this information will be pended (or possibly denied based on Department of Labor claim regulations) until receipt of such information. EMPLOYEE An Employee's coverage will become effective only if the Employee makes written request for coverage on a form approved by the Employer and agrees in writing to make any required contributions. For Employees who meet these requirements, coverage will become effective as follows: 1. An Employee who makes a written request for coverage within 60 days after his or her Eligibility Date will be covered on the first day of the first calendar month coincident with or following the Employees Eligibility Date. This also applies to Employees who lost and subsequently regained eligibility under the Plan. 2. Employees who make written request for coverage after the end of a 60-day period which began on the date they became eligible, or who are requesting reinstatement after voluntarily electing to terminate their benefits will become covered only on one of the following dates: a. July 1 following an annual enrollment period during which the Employee makes written request for coverage. b. The date the Employee loses group medical coverage under the plan of another employer group as described under Special Enrollment Period or as a result of a Change in Status provided the Employee makes written request for coverage under this Plan within 60 days of the Change in Status or loss of other coverage. c. The date the Employee returns to work, if the Employees coverage was terminated for non-payment of Employee contributions while the Employee was on a leave of absence protected by the Family and Medical Leave Act of 1993, or on a leave of absence protected by the Uniformed Services Employment and Reemployment Rights Act of 1994, and the Employee returns to employment within the time period required to preserve the Employees rights under those Acts. 3. If an Employee fails to enroll when the Employee is first eligible for coverage, the Employee will be deemed to have declined coverage. 4. Unless the Employer receives a written request for any change to coverage (e.g. cancellation, deletion of dependent) during subsequent enrollment periods, the Employee will be deemed to have elected to continue coverage the same as the coverage in effect immediately prior to the enrollment period.
SPD 6
DEPENDENT Coverage will become effective for an Employee's dependents only if the Employee is covered and makes written request for dependent's coverage on a form approved by the Employer and also agrees in writing to make any required contributions. Dependents cannot be covered for any benefit unless the Employee is covered for such benefit. For Employees who meet these requirements, coverage for their dependents will become effective as follows: 1. An Employee who makes written request for dependent coverage within 60 days after the Employees Eligibility Date will have coverage effective for such dependents on the Employees Eligibility Date. 2. For dependents acquired after the Employee's effective date, coverage will become effective on the date of a Change in Status (or as specified in the Special Enrollment section of this document, as applicable) provided written request for coverage is made within 60 days following the date the dependent first becomes an eligible dependent and the change qualifies as a Change in Status or a Special Enrollment event. If dependent coverage is in effect at the time of acquisition of a new eligible dependent, coverage for such new dependent will be automatic & will be effective on the date the dependent is first eligible (i.e. date of birth, marriage, adoption, etc.). Notification of the new dependent must be provided to the Employer by completing and submitting the Employers enrollment form within 60 days following the date the new dependent is acquired. 3. Employees who enroll for dependent coverage after the end of a 60 day period beginning on the date such dependents first became eligible; or who are requesting reinstatement after voluntarily electing to terminate benefits for such dependents while continuing to have dependents that were eligible under the Plan will become covered only on one of the following dates: a. July 1 following an annual enrollment period during which the Employee makes written request for dependent coverage. b. The date the dependent loses group medical coverage under the plan of another employer group as described under Special Enrollment Period or as a result of a Change in Status provided the dependent is enrolled for coverage under this Plan within 60 days of the Change in Status or loss of other coverage. c. The date the Employee returns to work, if the dependents coverage was terminated for non-payment of Employee contributions while the Employee was on a leave of absence protected by the Family and Medical Leave Act of 1993, or on a leave of absence protected by the Uniformed Services Employment and Reemployment Rights Act of 1994, and the Employee returns to employment within the time period required to preserve the Employees rights under those Acts.
SPD 7
CHANGES IN PLAN ENROLLMENT This Plan allows Employees to pay their contributions for health care coverage on a pre-tax basis. A portion of the Employees compensation is deducted from their paycheck before their taxes are calculated. In this way, Employees pay for their health care coverage with pre-tax dollars and pay less in taxes. For this reason, covered Employees are generally not permitted to make a change in the Plan coverage options they elected at the initial enrollment period for a Plan Year until the next annual open enrollment period. See the section of this document entitled Changes in Benefit Elections. However, covered Employees may change their level of coverage under certain circumstances permitted by the Employer and Internal Revenue Service regulations and rulings. The Plan Administrator may use discretion in determining whether a change in status or other event permitting an election change has occurred. If a covered Employee experiences a change in status or other change affecting coverage and wishes to change his or her level of coverage, he or she must submit an enrollment application to the Plan Administrator within 60 days after the change. The change in coverage must be consistent with the change in status. The Plan Administrator reserves the right to require the Employee to submit proof of any change of status or other event at the Employees expense. Coverage will become effective on the first day of the first calendar month following the date the Plan Administrator approves the completed application (except as otherwise required by law) provided that the Employee has met all eligibility requirements of the Plan. Examples of a change in status include: 1. Acquisition of a newly eligible dependent by marriage, birth, adoption, court appointed guardianship of a Child, Placement for adoption, custody. 2. Loss of a dependent through death, divorce, legal separation, ineligibility, changes in custody. 3. A spouse losing or gaining employment. 2. A change in a spouses employment status affecting the spouses eligibility for coverage under the plan. Examples of other events that may permit a change in enrollment are a significant curtailment of a spouses coverage or a significant change in the cost of coverage. SPECIAL ENROLLMENT PERIOD If an Employee elects on the application form provided at initial enrollment to decline coverage under the Employers plan for either the Employee, the Employees eligible dependents, or both, because of other health coverage, the Employee may in the future be able to enroll for coverage in this Plan for the Employee and eligible dependents, provided written request for coverage is made within 60 days after the other health coverage ends due to loss of eligibility (including divorce, legal separation, cessation of dependent status, death, termination of employment, reduction in hours, meeting or exceeding the Plans Overall Maximum Benefit Amount, or the Plan ceasing to provide benefits to a class of similarly-situated individuals), exhaustion of COBRA (this includes meeting or exceeding the Plans Overall Maximum Benefit Amount), or due to cessation of Employer contributions. Coverage will be effective on the day after the other coverage ends. NOTE: For termination of coverage as a result of reaching the Plans Overall Maximum Benefit Amount, the 60-day enrollment period begins on the date a claim is denied due to the Overall Benefit limit (this does not apply to exhaustion of COBRA coverage; in these situations, the 60day special enrollment period begins on the date the claim meeting or exceeding the Overall Maximum Benefit is incurred).
SPD 8
If the Employee or dependent lost the other coverage as a result of the individual's failure to pay premiums or required contributions or for cause (such as making a fraudulent claim), that individual does not have a Special Enrollment right. If the Employee acquires a new dependent as a result of marriage, birth, adoption, or Placement for adoption, the Employee may be able to cover the Employee and eligible dependents, provided the written request for coverage is submitted to the Employer within 60 days after the marriage, birth, adoption, or Placement for adoption. Coverage will become effective in the case of a marriage, birth, adoption, or Placement for adoption on the date of marriage, birth, adoption, or Placement for adoption respectively, provided the written request for enrollment is received within 60 days of the date of marriage, birth, adoption, or Placement for adoption. Additional Special Enrollment Rights Employees and Dependents who are eligible but not enrolled are entitled to enroll under the following circumstances: 1. The Employee's or Dependent's Medicaid or State Child Health Insurance Plan (i.e. CHIP) coverage has terminated as a result of loss of eligibility and the Employee requests coverage under the Plan within 60 days after such termination; or 2. The Employee or Dependent become eligible for a premium assistance subsidy under Medicaid or a State Child Health Insurance Plan (i.e. CHIP), and the Employee requests coverage under the Plan within 60 days after such eligibility is determined.
SPD 9
TERMINATION OF COVERAGE When coverage under this Plan stops, Covered Persons will receive a certificate that will show the period of coverage under this Plan. Please contact the Plan Administrator for further details. EMPLOYEE An Employee's coverage will terminate on the first to occur of the following: 1. the last day of the month in which the Employee worked in a benefit eligible position for the Employer. 2. for any specific benefit, the date the Plan stops offering that benefit, or the date the Employee is no longer eligible for that benefit. 3. the date that the Plan itself terminates. 4. the last day of the period for which contributions are made if the required contribution is not made, when due. 5. June 30th of the Plan Year in which the Employee elects to terminate coverage during an annual enrollment period designated by the Employer. 6. the date on which the Employee elects to terminate coverage, provided such election is made within 60 days of the date the Employee experiences a qualifying Change in Status. DEPENDENT Dependents coverage will terminate on the first to occur of the following: 1. the date the Employee's coverage under the Plan terminates. 2. the last day in which the dependent ceases to be an eligible dependent. 3. the date of termination of all dependents' benefits under the Plan. 4. the last day of the period for which contributions are made to the cost of dependent coverage, if the required contribution is not made, when due. 5. the date the dependent enters active duty with any branch of the military. 6. for a covered dependent of a covered Employee who elects to terminate dependent coverage during an annual enrollment period, June 30th of the Plan Year in which such enrollment period occurs. 7. the date on which the covered Employee elects to terminate dependent coverage, provided such election is made within 60 days of the date the Employee experiences a qualifying Change in Status. CHANGE IN BENEFIT ELECTION Benefit decisions made during the Plans annual enrollment period will become effective July 1st and remain in effect until June 30th of the following year except as set forth in the section of this document entitled Changes in Plan Enrollment. During the Plans annual enrollment period, Employees will be given the opportunity to elect different plan options, or change coverage levels (i.e. adding or dropping dependent coverage).
SPD 10
LEAVE OF ABSENCE FOR ILLNESS OR INJURY A person may continue to be a covered Employee for benefits under the Plan if the person ceases work as a result of an approved leave of absence or as a result of Illness or Injury. Coverage may be continued by the Employer at the Employer's option, with the Employee paying the full cost of the coverage during the leave of absence or Illness or Injury, as defined by the Employer. Benefits will run concurrent with FMLA. Family and Medical Leave Act Coverage may be continued during an approved leave of absence in accordance with the federal Family and Medical Leave Act, subject to payment of any required contribution. Contact the personnel department for details. If Plan coverage terminates during the FMLA leave, coverage will be reinstated for the Employee and his or her covered dependents if the Employee returns to work in accordance with the terms of the FMLA leave. Coverage will be reinstated only if the person(s) had coverage under this Plan when the FMLA leave started, and will be reinstated to the same extent that it was in force when that coverage terminated. Employees on Military Leave Employees going into or returning from military service may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act under the following circumstances. These rights apply only to Employees and their dependents covered under the Plan before leaving for military service. (1) The maximum period of coverage of a person under such an election shall be the lesser of: (a) (b) (2) The 24 month period beginning on the date on which the person's absence begins; or The day after the date on which the person was required to apply for or return to a position or employment and fails to do so.
A person who elects to continue health plan coverage may be required to pay up to 102% of the full contribution under the Plan, except a person on active duty for 30 days or less cannot be required to pay more than the Employee's share, if any, for the coverage. An exclusion may not be imposed in connection with the reinstatement of coverage upon reemployment if one would not have been imposed had coverage not been terminated because of service. However, exclusion may be imposed for coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of uniformed service.
(3)
SPD 11
STATEMENT OF ERISA RIGHTS Covered Persons are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA specifies that all Plan participants shall be entitled to:

Examine, without charge, at the Plan Administrator's office, all Plan documents and copies of all documents governing the Plan, including a copy of the latest annual report (form 5500 series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies. Continue health care coverage for a Plan participant, spouse, or other dependents if there is a loss of coverage under the Plan as a result of a qualifying event. Employees or dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing COBRA continuation coverage rights. Reduction or elimination of exclusionary periods of coverage for pre-existing conditions (if applicable) under this group health Plan, if an Employee or dependent has Creditable Coverage from another plan. The Employee or dependent should be provided a certificate of Creditable Coverage, free of charge, from the group health plan or health insurance issuer when coverage is lost under the plan, when a person becomes entitled to elect COBRA continuation coverage, when COBRA continuation coverage ceases, if a person requests it before losing coverage, or if a person requests it up to 24 months after losing coverage. Without evidence of Creditable Coverage, a Plan participant may be subject to a pre-existing conditions exclusion (if applicable) for 12 months (18 months for Late Enrollees) after the Enrollment Date of coverage.
If a Plan participant's claim for a benefit is denied or ignored, in whole or in part, the participant has a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps a Plan participant can take to enforce the above rights. For instance, if a Plan participant requests a copy of Plan documents or the latest annual report from the Plan and does not receive them within 30 days, he or she may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and to pay the Plan participant up to $110 a day until he or she receives the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If the Plan participant has a claim for benefits that is denied or ignored, in whole or in part, the participant may file suit in state or federal court. In addition, if a Plan participant disagrees with the Plan's decision or lack thereof concerning the qualified status of a medical child support order, he or she may file suit in federal court. In addition to creating rights for Plan participants, ERISA imposes obligations upon the individuals who are responsible for the operation of the Plan. The individuals who operate the Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of the Plan participants and their beneficiaries. No one, including the Employer or any other person, may fire a Plan participant or otherwise discriminate against a Plan participant in any way to prevent the Plan participant from obtaining benefits under the Plan or from exercising his or her rights under ERISA. If it should happen that the Plan fiduciaries misuse the Plan's money, or if a Plan participant is discriminated against for asserting his or her rights, he or she may seek assistance from the
SPD 12
U.S. Department of Labor, or may file suit in a federal court. The court will decide who should pay court costs and legal fees. If the Plan participant is successful, the court may order the person sued to pay these costs and fees. If the Plan participant loses, the court may order him or her to pay these costs and fees, for example, if it finds the claim or suit to be frivolous. If the Plan participant has any questions about the Plan, he or she should contact the Plan Administrator. If the Plan participant has any questions about this statement or his or her rights under ERISA or the Health Insurance Portability and Accountability Act (HIPAA), that Plan participant should contact either the nearest area office of the Employee Benefits Security Administration, U.S. Department of Labor listed in the telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, at 200 Constitution Avenue, N.W., Washington, DC 20210. SUBMISSION OF CLAIMS If a Covered Person claims benefits, the claim must be submitted to the Claims Administrator within 365 days following the date charges for medical services were incurred. A charge is incurred on the date that the service or supply is performed or furnished. Claims filed later than that date may be declined or reduced. Evidence that the claim was submitted in the required time period must also be submitted within 365 days of the date charges for the service was incurred. See the section on Instructions for Filing a Claim for more information. The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, the claim will be denied and more information will be requested from the claimant. The claimant may then appeal the claim decision according to the procedure described in the Claims Procedure section below (under Appeals). CLAIM REVIEW AND APPEALS PROCEDURE Benefits are based on the Plan's provisions at the time the charges were incurred. Following is a description of how the Plan processes Claims for benefits. A Claim is defined as any request for a Plan benefit, made by a claimant or by a representative of a claimant, which complies with the Plan's reasonable procedure for making benefit Claims. The times listed are maximum times only. A period of time begins at the time the Claim is filed. Decisions will be made within a reasonable period of time appropriate to the circumstances. "Days" means calendar days. There are different kinds of Claims and each one has a specific timetable for approval, payment, request for further information, or denial of the Claim. If you have any questions regarding this procedure, please contact the Claims Administrator or the Plan Administrator. The definitions of the types of Claims are: Urgent Care Claim A Claim involving Urgent Care is any Claim for medical care or treatment where using the timetable for a non-urgent care determination could seriously jeopardize the life or health of the claimant; or the ability of the claimant to regain maximum function; or in the opinion of the attending or consulting Physician, would subject the claimant to severe pain that could not be adequately managed without the care or treatment that is the subject of the Claim. A Physician with knowledge of the claimant's medical condition may determine if a Claim is one involving Urgent Care. If there is no such Physician, an individual acting on behalf of the Plan applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine may make the determination.
SPD 13
In the case of a Claim involving Urgent Care, the following timetable applies: Notification to claimant of benefit determination 72 hours
Insufficient information on the Claim, or failure to follow the Plan's procedure for filing a Claim: Notification to claimant, orally or in writing Response by claimant, orally or in writing Benefit determination, orally or in writing 24 hours 48 hours 48 hours after the earlier of the receipt of information of the end of the claimants response period.
Ongoing courses of treatment, notification of: Reduction or termination before the end of treatment Determination as to extending course of treatment Review of adverse benefit determination 72 hours
24 hours
72 hours
If there is an adverse benefit determination on a Claim involving Urgent Care, a request for an expedited appeal may be submitted orally or in writing by the claimant. All necessary information, including the Plan's benefit determination on review, may be transmitted between the Plan and the claimant by telephone, facsimile, or other similarly expeditious method. Pre-Service Claim A Pre-Service Claim means any Claim for a benefit under this Plan where the Plan conditions receipt of the benefit, in whole or in part, on approval in advance of obtaining medical care. These are, for example, Claims subject to prior authorization. Please see the Prior authorization/Certification section of this booklet for further information about Pre-Service Claims. In the case of a Pre-Service Claim, the following timetable applies: Notification to claimant of benefit determination Extension due to matters beyond the control of the Plan Insufficient information on the Claim: Notification of Response by claimant Notification, orally or in writing, of failure to follow the Plan's procedures for filing a Claim 15 days 45 days 5 days 15 days 15 days
SPD 14
Ongoing courses of treatment: Reduction or termination before the end of the treatment Request to extend course of treatment Review of adverse benefit determination Post-Service Claim A Post-Service Claim means any Claim for a Plan benefit that is not a Claim involving Urgent Care or a Pre-Service Claim; in other words, a Claim that is a request for payment under the Plan for covered medical services already received by the claimant. In the case of a Post-Service Claim, the following timetable applies: Notification to claimant of benefit determination Extension due to matters beyond the control of the Plan Insufficient information on the Claim: Notification of Response by claimant Review of adverse benefit determination Notice to claimant of adverse benefit determinations Except with Urgent Care Claims, when the notification may be orally followed by written or electronic notification within three days of the oral notification, the Plan Administrator shall provide written or electronic notification of any adverse benefit determination. The notice will state, in a manner calculated to be understood by the claimant: (1) (2) (3) The specific reason or reasons for the adverse determination. Reference to the specific Plan provisions on which the determination was based. A description of any additional material or information necessary for the claimant to perfect the Claim and an explanation of why such material or information is necessary. A description of the Plan's review procedures and the time limits applicable to such procedures. This will include a statement of the claimant's right to bring a civil action under section 502 of ERISA following an adverse benefit determination on review. A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Claim. If the adverse benefit determination was based on an internal rule, guideline, protocol, or other similar criterion, the specific rule, guideline, protocol, or criterion will be provided free of charge. If this is not practical, a statement will be included
SPD 15
15 days
15 days 30 days
30 days 15 days
15 days 45 days 60 days
(4)
(5)
(6)
that such a rule, guideline, protocol, or criterion was relied upon in making the adverse benefit determination and a copy will be provided free of charge to the claimant upon request. (7) If the adverse benefit determination is based on the Medical Necessity or Experimental or Investigational treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant's medical circumstances, will be provided. If this is not practical, a statement will be included that such explanation will be provided free of charge, upon request.
Appeals When a claimant receives an adverse benefit determination, the claimant has 180 days following receipt of the notification in which to appeal the decision. A claimant may submit written comments, documents, records, and other information relating to the Claim. If the claimant so requests, he or she will be provided, free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Claim. The period of time within which a benefit determination on review is required to be made shall begin at the time an appeal is filed in accordance with the procedures of the Plan. This timing is without regard to whether all the necessary information accompanies the filing. A document, record, or other information shall be considered relevant to a Claim if it: (1) (2) was relied upon in making the benefit determination; was submitted, considered, or generated in the course of making the benefit determination, without regard to whether it was relied upon in making the benefit determination; demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify that benefit determinations are made in accordance with Plan documents and Plan provisions have been applied consistently with respect to all claimants; or constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit.
(3)
(4)
The review shall take into account all comments, documents, records, and other information submitted by the claimant relating to the Claim, without regard to whether such information was submitted or considered in the initial benefit determination. The review will not afford deference to the initial adverse benefit determination and will be conducted by a fiduciary of the Plan who is neither the individual who made the adverse determination nor a subordinate of that individual. If the determination was based on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is Experimental, Investigational, or not Medically Necessary or appropriate, the fiduciary shall consult with a health care professional who was not involved in the original benefit determination. This health care professional will have appropriate training and experience in the field of medicine involved in the medical judgment. Additionally, medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the initial determination will be identified. If the decision on review affirms the initial denial of the claim, the claimant will be furnished with a notice of adverse benefit determination on review setting forth: the specific reason(s) for the decision on review, the specific Plan provision(s) on which the decision is based,
SPD 16
a statement of the claimants right to review (on request and at no charge) relevant documents and other information, if an internal rule, guideline, protocol, or other similar criterion is relied on in making the decision on review, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request, an explanation of the scientific or clinical judgment for the determination if the adverse benefit determination is based on the Medical Necessity or Experimental or Investigational treatment or similar exclusion or limit, or a statement that such explanation will be provided free of charge, upon request, and a statement of the claimants right to bring suit under ERISA 502(a).
Any suit for benefits must be brought within one year after the date the Plan Administrator (or his or her designee) has made a final denial (or deemed denial) of the claim. Notwithstanding any other provision herein, any suit for benefits must be brought within two years after the date the service or treatment was rendered.
SPD 17
MEDICAL PLAN SCHEDULE OF BENEFITS Following is a summary of benefits under the Plan. This summary is subject to all other provisions, conditions, limitations, and exclusions of the Plan Document. IMPORTANT Benefits are only payable under this Plan for expenses which are Eligible Charges (defined in the Eligible Charges section of this document) arising from Medically Necessary treatment of an Illness or Injury and which are defined further in this Plan Document. All maximum benefits whether expressed as overall, yearly or otherwise, refer to the maximum benefits payable for the period specified only for Eligible Charges incurred while the Covered Person is covered under this Plan. COMPREHENSIVE MEDICAL EXPENSE BENEFIT HWHN Network USA-MCO Network NonNetwork
Annual Dollar Limit on Essential Health $2,000,000 $1,500,000 $1,000,000 Benefits The Annual Dollar Limit on Essential Benefits is integrated for all three Network Levels. Amounts applied toward one Networks Annual Dollar Limit on Essential Benefits will also be applied to the other two Networks Annual Dollar Limit on Essential Health Benefits. For all three Network levels combined, the Annual Dollar Limit on Essential Health Benefits for any one Covered Person is $2,000,000. Plan Year Deductible $2,000 $1,000 $500 Per Covered Person Basic Option $4,000 $2,000 $1,000 Per Family (aggregate) Basic Option Per Covered Person Standard Option Per Family (aggregate) Standard Option Per Covered Person High Option Per Family (aggregate) High Option $250 $500 $100 $200 $500 $1,000 $300 $600 $1,000 $2,000 $1,000 $2,000
Amounts applied to the deductible for charges from HWHN Network Providers will be used to satisfy the deductible for charges from USA-MCO Network Providers and vice versa. However, amounts applied to the deductible for charges from Non-Network Providers will not count toward satisfaction of the HWHN or USA-MCO deductibles. Any deductible, co-pay for NonWellmont Hopsitals in Northeast TN and Southwest VA will not count towards the Out-ofPocket.
SPD 18
HWHN Network Maximum Out-of-Pocket Expense per Plan

year due to Eligible Charges (except cost containment penalties) excluding any deductibles and copayments Per Covered Person Basic Option Per Family per Plan year (aggregate) Basic Option Per Covered Person Standard Option Per Family per Plan year (aggregate) Standard Option Per Covered Person High Option Per Family per Plan year (aggregate) High Option
USA-MCO Network
NonNetwork
$3,000 $6,000
$6,000 $12,000
$10,000 N/A
$2,000 $4,000
$4,000 $8,000
$8,000 N/A
$1,500 $3,000
$3,000 $6,000
$8,000 N/A
Amounts applied to the Maximum Out-Of-Pocket Expense for charges from HWHN Network Providers will be used to satisfy the Maximum Out-of-Pocket Expense for charges from USAMCO Network Providers and vice versa. However, amounts applied to the Maximum Outof-Pocket Expense for charges from NonNetwork Providers will not count toward the HWHN or USA-MCO Maximum Out-of-Pocket Expense. Emergency Room Facility Charges Non-medical Emergency
100% after $75 co-pay Deductible waived 100% after $75 co-pay Deductible waived
50% after $75 co-pay and Deductible 100% after $75 co-pay Deductible waived
Emergency Room Facility Charges Medical Emergency
Emergency Room Physician Charges Coinsurance and deductible are waived if use of the Emergency Room is due to a Medical Emergency or if the patient is admitted to the Hospital from the Emergency Room. Ambulance Air (prior authorization required for non-Life Threatening Air transports) Ambulance - Land
100% after deductible
100%, Deductible waived 100%, Deductible waived
SPD 19
HWHN Network Physician Office Visit Charge Only

Does not include diagnostic x-ray and laboratory services, injections, and other covered services provided and billed by the Physician
USA-MCO Network 100% after Copayment, Deductible waived $35 $45
Non-Network 50% after deductible
COPAYMENT: Primary care physician Specialist Outpatient Non-Preventive Diagnostic X-ray, Testing, and Laboratory Services Technical/Professional Fees when billed in conjunction with an Office Visit Basic & Standard Options
100% after Copayment, Deductible waived $25 $35
n/a n/a
80% Deductible waived 90% Deductible waived 100% after deductible
High Option Outpatient Surgeon Fee when surgery is performed in the Physicians Office Outpatient Non-Preventive Diagnostic X-ray, Testing, and Laboratory Services Physician Fee Basic & Standard Options
60% after deductible 60% after deductible
80% Deductible waived 90% Deductible waived
High Option Outpatient Non-Preventive Diagnostic X-ray, Testing, and Laboratory Services Facility Fee Basic & Standard Options
High Option All Physicians that refer members for Outpatient Non-Preventive Diagnostic X-ray, Testing, and Laboratory Services Facility Fee Basic & Standard Options
High Option
SPD 20
HWHN Network Outpatient Surgeon Fee when surgery is performed in other than a Physicians office $75 co-pay, then 100% Deductible waived
USA-MCO Network $100 co-pay, then 60% after deductible
Outpatient Surgical Facility

(Other than a Physicians office)
Wellmont Facility or Endoscopy Center of Bristol or Kingsport Endoscopy Corporation Wellmont Hawkins County Memorial Hospital Bristol Surgery Center Holston Valley Ambulatory Surgery Center Sapling Grove Surgery Center Renaissance Surgery Center
$100 co-pay, then 100% Deductible waived
N/A
N/A
Anesthesia - Outpatient Associated with a procedure performed in the above listed facilities Non-Wellmont Outpatient Surgical Facility
100% Deductible waived $600 co-pay, then 100% after deductible 100% after deductible
N/A
N/A
$650 co-pay, then 60% after deductible 60% after deductible
Anesthesia - Outpatient Associated with a procedure performed at a Non-Wellmont Facility Inpatient Hospital Basic & Standard Options
80% deductible waived 90% deductible waived
High Option
Note: Effective 5/15/2011 Non-Wellmont hospitals in Northeast TN and Southwest VA will be paid at 30% regardless if they are a USA/MCO hospital and will not accumulate towards the out-of-pocket. Hospital Room & Board Allowance Semi-Private .................................. Up to Hospital's Most Common Semi-Private Room Rate Intensive Care .........................................................................Up to Hospital's Actual Charge *Private .......................................... Up to Hospital's Most Common Semi-Private Room Rate *In the event the Hospital has only Private Room accommodations and does not, therefore have a Most Common Semi-Private Rate, the Hospital's Most Common Private Room Rate will be considered an eligible expense. Second Surgical Opinion 100% after $35 co-pay 60% after $40 co-pay 50% after deductible
SPD 21
HWHN Network Physician Fees In-Hospital Expenses (Includes surgery) Anesthesia - Inpatient Basic & Standard Options High Option Pregnancy/Maternity (Physician Fees only) 80% after deductible 90% after deductible 100% after deductible 100% after deductible
USA-MCO Network 60% after deductible 60% after deductible 60% after deductible 60% after deductible
Non-Network 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Physical Therapy, Speech Therapy and Occupational Therapy (prior authorization required) Combined Network and Non-Network Plan Year Maximum: 60 outpatient treatment days per disability combined benefit maximums. To receive the highest level of benefits a Wellmont-owned facility (billing tax ID #s: 62-1636465, 51-0603966, or 62-1816368) must be utilized. Physical Therapy (prior authorization required) Basic & Standard Options High Option Speech Therapy (prior authorization required) Basic & Standard Options High Option Occupational Therapy (prior authorization required) Basic & Standard Options High Option Dialysis Basic & Standard Options High Option Wig after Chemotherapy One wig per lifetime Basic & Standard Options High Option Subject to the HWHN deductible, then 100% Subject to the HWHN deductible, then 100% 80% after deductible 90% after deductible 60% after deductible 60% after deductible 50% after deductible 50% after deductible 80% after deductible 90% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 80% after deductible 90% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 80% after deductible 90% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible
SPD 22
HWHN Network Medical and Nutritional Therapy Orthotics (prior authorization required) Diabetic Shoes and inserts (prior authorization required) Prosthetics (prior authorization required) Diabetes Educational Training Contraceptive Management Office Visit 100% after deductible 100% after deductible 100% after deductible 100% after deductible
Injections, Implants, Intrauterine Device, Diaphragm Over the Counter Contraceptives Please Note: Birth control pills and patches are covered under the pharmacy benefit plan. Chiropractic Treatment Copayment per visit Maximum payable per Covered Person per Plan Year.....................$500 Temporomandibular Joint Dysfunction (TMJ) Surgical & Non-surgical Overall Maximum Benefit.. $2,500 Infertility Treatment Diagnosis or Treatment Durable Medical Equipment (prior authorization required for charges over $500.00) CPAP and BiPAP Masks Limited to 1 every 6 months Mental or Nervous Disorders/Substance Abuse Inpatient Physician/Provider Inpatient Hospital Basic & Standard Options
100% after 60% after Not deductible deductible Covered If part of wellness visit, payable under Routine Physical Examination Physician Fee. If separate from wellness visit, payable as Physician Office Visit. 50% after 60% after 100% after deductible deductible deductible Not Covered Not Covered Not Covered
$25 co-pay, then 100% Deductible waived 100% after deductible Not Covered 100% after deductible 100% after deductible
100% after deductible 80% deductible waived 90% deductible
60% after deductible 60% after Deductible 60% after deductible
50% after deductible 50% after Deductible 50% after decuctible
High Option
SPD 23
HWHN Network waived
USA-MCO Network
Non-Network
Outpatient Physician/Provider(Specialist)
50% after 100% after 100% after Deductible $45 $35 copayment; copayment; deductible deductible waived waived 60% after $75 50% after $75 100% after Hospital Emergency Room Services Copayment copayment; $75 (Non-emergency) and deductible copayment; Deductible waived deductible waived 100% after 100% after Intensive Outpatient Program 50% after $100 copay; $100 copay; Copay is per program deductible Deductible Deductible waived waived Residential Treatment/Partial Day Programs will be excluded under the Plan. The following will be excluded; providers/facilities: Social workers and day/night psychiatric facilities. If a member chooses, they may access 5 free visits per issue thru the Horizon Behavioral Service Employee Assistance Program by calling Horizon at 1-800955-6422. Chemotherapy/Radiation Basic & Standard Options High Option Cardiac & Pulmonary Rehab Basic & Standard Options 80% after deductible 90% after deductible 80% after deductible 90% after deductible 60% after deductible 60% after deductible 60% after deductible 60% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible
High Option CyberKnife (prior authorization required-only available at a WHS facility) Basic & Standard Options High Option CTA (only available at a WHS facility or HWHN provider) Basic & Standard Options High Option Skilled Nursing Facility Basic & Standard Options
SPD 24
N/A N/A
N/A N/A
80% after deductible 90% after deductible 80% after
N/A N/A 60% after
N/A N/A 50% after
HWHN Network deductible High Option Maximum visits USA-MCO/Non-Network combined per Plan Year Hospice Care Home Health Care (prior authorization required) All other COVERED expenses not specifically listed in the Schedule of Benefits Basic & Standard Options High Option Preventive Services Covered Services on the HWHN recommended schedule 90% after deductible N/A 100% after deductible 100% after deductible 80% after deductible 90% after deductible 100% Deductible waived
USA-MCO Network deductible 60% after deductible 60 visits 60% after deductible 60% after deductible 60% after deductible 60% after deductible 60% Deductible waived
Non-Network deductible 50% after deductible 60 visits 50% after deductible 50% after deductible 50% after deductible 50% after deductible
All other covered routine services not listed on the recommended HWHN schedule Basic & Standard Options High Option
80% after deductible 90% Deductible waived
Note: the HWHN Schedule includes all of the items listed on the US Preventive Task Force Guide to Clinical Preventive Services COST CONTAINMENT PROVISIONS Admission Certification (Applicable to All Providers) Admission Certification is required for HWHN, USA-MCO Network, & Non-Network Providers. Failure to obtain certification will result in a $500.00 non-compliance penalty. Day Prior Admissions Admission prior authorization is required. This provision does not apply to emergency admissions. Emergency Admissions, including admissions required as a result of complications from an outpatient procedure Certification is required within 24 hours of the patients admittance or by the end of the next business day. Durable Medical Equipment If DME equipment is required on a weekend, prior authorization is required by the end of the next business day.
SPD 25
PRESCRIPTION DRUG PROGRAM Catalyst RX Customer Service: (877) 464-0085 www.catalystrx.com Covered Prescription Drug Copayment Generic Formulary Brand Name Non-Formulary Brand Name WHS Pharmacies Catalyst Retail Catalyst Mail Order (90-Day Supply) $30.00 $87.50 $125.00 NonContracted Pharmacies Not Covered Not Covered Not Covered
$12.00 $35.00 $50.00
$12.00 $35.00 $50.00
This Plan contains a pharmacy prescription drug benefit. Benefits under this portion of the Plan are provided instead of benefits otherwise available under the Comprehensive Medical Expense Benefits provision of this Plan. There is a Copayment required for each new or refill prescription. Any Copayment required under this program will not apply to the Plan's plan year deductible or the maximum out-ofpocket expense. Claims submitted to the Plan for prescription drugs which can be obtained by use of the drug card will not be paid under the Comprehensive Medical Expense Benefits provision of this Plan. YOU MAY OBTAIN FURTHER DETAILS FREE OF CHARGE FROM CATALYST RX INCLUDING A LISTING OF ELIGIBLE DRUGS OR THOSE THAT MAY BE EXCLUDED.
SPD 26
DENTAL PLAN SCHEDULE OF BENEFITS
Following is a summary of benefits under the Plan. This summary is subject to all other provisions, conditions, limitations, and exclusions of the Plan Document. IMPORTANT Benefits are only payable under this Plan for expenses that are Eligible Charges arising from Dental treatment which is defined further in this Plan Document. All maximum benefits whether expressed as overall, yearly or otherwise, refer to the maximum benefits payable for the period specified only for Eligible Charges incurred while the Covered Person is covered under this Plan. DENTAL EXPENSE BENEFIT Benefits are payable for Covered Dental Expenses incurred, as described below, but not to exceed the Plan's Maximum Benefit. Plan Year Deductible Per Covered Person Per Family (aggregate) Class A - Diagnostic, Preventive, and Palliative (Deductible waived) Class B - Extractions, Endodontics, Periodontal, Oral Surgery, Restorative Class C - Prosthodontic Class D - Orthodontic Overall Maximum Orthodontic Benefit Maximum Benefit per Plan Year (Class A, B and C combined) Plan A $50 $150 Plan B $25 $75
100%
100%
80% 50% No Benefits Payable N/A $1,000
80% 50% 50% $1,000 $1,500
Note: Employees who elect Plan B may not change this election until they have completed two Plan Years with coverage under this Plan. Employees who decline dental coverage when first eligible must enroll in Plan A at the next annual enrollment period and remain in Plan A for one Plan Year before being eligible for coverage under Plan B.
SPD 27
VISION PLAN SCHEDULE OF BENEFITS
Following is a summary of benefits under the Plan. This summary is subject to all other provisions, conditions, limitations, and exclusions of the Plan Document. IMPORTANT Benefits are only payable under this Plan for expenses that are Eligible Charges (defined in the Eligible Charges section of this document) arising from vision treatment which is defined further in this Plan Document. All maximum benefits whether expressed as overall, yearly, or otherwise, refer to the maximum benefits payable for the period specified only for Eligible Charges incurred while the Covered Person is covered under this Plan. VISION CARE BENEFITS Maximum Annual Benefit Per Person ......................................................................................................... $270 Employee plus One Dependent ......................................................................... $540 Per Family (aggregate) ...................................................................................... $800 NOTE: Each person in a family is limited to a maximum annual benefit of $270, and the family unit is limited to a maximum annual benefit of $800. Similarly, if an individual has Employee plus One Dependent coverage, the Employee and Dependent each are limited to a maximum annual benefit of $270. Examination............................................................................................................ 100% Maximum payable per Plan Year ........................................................................ $48 Frames .................................................................................................................... 100% Maximum payable per Plan Year ........................................................................ $96 Lenses for Eyeglasses .......................................................................................... 100% Maximum payable per Plan Year ........................................................................ $96 Contact Lenses ...................................................................................................... 100% Soft Maximum payable per Plan Year .................................................................... $80 Hard Maximum payable per Plan Year .................................................................. $120 Note: Disposable contact lenses are covered up to the amount allowed for soft contact lenses. Prescription sunglasses are covered as regular prescription glasses.
SPD 28
THE PRECEDING PAGES OF THIS BOOKLET ARE THE SUMMARY PLAN DESCRIPTION (SPD). It is given to all eligible Employees and eligible Dependents. It is only a summary of the Plan. All Plan benefits, terms and conditions are governed and controlled by the Plan Document. The Plan Document can be found on the following pages of this booklet. Should there be any conflict(s) between the language, terms, and/or conditions of the Benefit Description and the Plan Document, the Plan Document will control and govern. The Plan Administrator shall have discretionary authority to interpret the terms and conditions of the foregoing Summary Plan Document and the Plan.
SPD 29
HEALTH AND WELFARE PLAN DOCUMENT FOR WELLMONT HEALTH SYSTEM EMPLOYEE MEDICAL, DENTAL, AND VISION CARE PLAN
Effective July 1, 1998 Restated July 1, 2011
PLAN DOCUMENT TABLE OF CONTENTS
DEFINED TERMS ......................................................................................................................... 1 ELIGIBILITY ................................................................................................................................ 10 ENROLLMENT and EFFECTIVE DATE ..................................................................................... 12 CHANGES IN PLAN ENROLLMENT .......................................................................................... 14 SPECIAL ENROLLMENT PERIOD............................................................................................. 14 TERMINATION OF COVERAGE ................................................................................................ 16 CHANGE IN BENEFIT ELECTION ............................................................................................. 16 LEAVE OF ABSENCE ................................................................................................................ 17 COBRA CONTINUATION OF COVERAGE ................................................................................ 21 MEDICAL PLAN BENEFITS ....................................................................................................... 29 ELIGIBLE CHARGES ................................................................................................................. 39 COST CONTAINMENT PROVISIONS ....................................................................................... 43 PRIOR AUTHORIZATION .......................................................................................................... 44 MEDICAL CASE MANAGEMENT............................................................................................... 49 CATASTROPHIC CASE MANAGEMENT .................................................................................. 49 MEDICAL EXCLUSIONS AND LIMITATIONS ............................................................................ 50 PRESCRIPTION DRUG PROGRAM .......................................................................................... 55 DENTAL PLAN BENEFITS ......................................................................................................... 56 DENTAL EXCLUSIONS AND LIMITATIONS .............................................................................. 59 VISION PLAN BENEFITS ........................................................................................................... 61 VISION LIMITATIONS AND EXCLUSIONS ................................................................................ 62 COORDINATION OF BENEFITS................................................................................................ 64 PRIMARY COVERAGE FOR EMPLOYEES UNDER MEDICARE ............................................. 67 SUBROGATION ......................................................................................................................... 67 PRIVACY AND SECURITY OF MEDICAL INFORMATION........................................................ 68 GENETIC INFORMATION NONDISCRIMINATION ACT ........................................................... 71 GENERAL PLAN PROVISIONS ................................................................................................. 72 CLAIM REVIEW AND APPEALS PROCEDURE ........................................................................ 73 GENERAL PLAN INFORMATION .............................................................................................. 78
DEFINITIONS Accidental Bodily Injury or Injury means Injury resulting directly and independently of all other causes from an accident of external, violent means which requires treatment by a Physician. Active Employee is an Employee who is on the regular payroll of the Employer and who has begun to perform the duties of his or her job. Alcohol or Substance Abuse means conditions caused by consumption of alcohol, physical dependency on drugs or other substances (including those medically prescribed) as certified by a Physician that result in harm to either physical health or personal or social functioning. Drug or Substance dependency does not include dependence on tobacco or ordinary drinks containing caffeine or other like substances. Eligible charges for the treatment of alcoholism or substance dependence will include charges made by a licensed Hospital or any other public or private facility or portion thereof licensed to provide alcoholism or substance dependence treatment and rehabilitation services. Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery, has a staff of Physicians, has continuous Physician and nursing care by registered nurses (RNs) and does not provide for overnight stays. Birthing Center means a legally licensed, public or private establishment for the performance of prenatal care, delivery and post-partum care, with an organized medical staff. Charges for its services must be made. The Birthing Center must be under the direction of a Physician specializing in obstetrics and gynecology. A Physician must be present at all births and during the immediate postpartum period. Nursing services, under the direction of a registered graduate, or professional nurse (R.N.), must be provided in the recovery room. Medical records for each patient must be kept. The Birthing Center must have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop complications or require pre- or post-delivery confinement. Board Members means Wellmont Health System Board Members are eligible for coverage. References to eligibility and coverage of Employees throughout this document are deemed to include Board Members, as applicable. Brand Name means a trade name medication. COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. Copayment or Co-pay is that portion of Eligible Charges which is payable by the Covered Person. Course of Treatment means a planned program of one or more services or supplies rendered by one or more Dentists or Physicians, for the treatment of a covered dental condition diagnosed by the attending Dentist or Physician as a result of an oral examination. The Course of Treatment begins on the date the Dentist or Physician first renders a service or supply to correct or treat such covered diagnosed condition. Covered Person means an Employee or any eligible dependents of an Employee who have become covered under the Plan. Creditable Coverage is coverage as defined under the Health Insurance Portability and Accountability Act of 1996 as then constituted or later amended. Creditable Coverage includes most health coverage, such as coverage under a group health plan (including COBRA continuation coverage), HMO membership, an individual health insurance policy, Medicaid or Medicare, a State health benefits risk pool, a public health plan (including plans established or maintained by a foreign country), or the State Childrens Health Insurance Program. Creditable Coverage does not include coverage consisting solely of dental or vision benefits. Custodial Care is care (including room and board needed to provide that care) that is given principally for personal hygiene or for assistance in daily activities and can, according to generally accepted medical standards, be performed by persons who have no medical training. Examples of Custodial
1
Care are help in walking and getting out of bed; assistance in bathing, dressing, feeding; or supervision over medication which could normally be self-administered. Dental Care means care or treatment of the teeth or gums. Dentist means a person duly licensed to practice dentistry by the governmental authorities having jurisdiction over the licensing and practice of dentistry in the locality where the service is rendered. Dependent means: 1. A spouse (if not legally separated). All of the requirements of a legally valid marriage contract must be met in the state of marriage of the Employee and spouse. Evidence of marriage in the form of official documents or notarized statements may be required before coverage can commence. 2. An unmarried dependent Child until such Child's 19th birthday. 3. An unmarried Child age 19 but less than age 23 who is a full-time student at an accredited postsecondary school, college, or university, is not employed on a full-time basis, and is dependent on the Employee for principal support. Full-time student status is defined by the school, college, or university. If the Child does not maintain full-time status or graduates, coverage closes independent of limiting age. Full-time student coverage continues between semesters/quarters only if the student is enrolled as a full-time student in the next regular semester/quarter. If the student is not enrolled as a full-time student, coverage will be terminated retroactively to the last day of the attended school term. Dependent Children who were previously covered by the Plan and lost coverage because they exceeded the eligibility age and did not remain in school as a full-time student or who were already over the eligibility age when coverage was first available to the Employee will be eligible for coverage under the Plan if they become full-time students before reaching age 23. 4. A Child age 19 and older who is covered under the Plan on the day prior to the day the Child's coverage under the Plan would have terminated due to the Child's age and who is Totally Disabled, mentally or physically unable to earn a living, unmarried, and dependent on the Employee for principal support. Proof of such disability must be submitted to the Employer within 31 days of the date the Child's coverage would have terminated due to age. Periodic proof that the dependent Child continues to be incapable of self-support will be required. The Plan Administrator reserves the right to have such dependent examined by a Physician of the Plan Administrator's choice, at the Plan's expense, to determine the existence of such incapacity. 5. A Child who is an alternate recipient under a qualified medical child support order in accordance with the provisions of ERISA. A participant of this Plan may obtain, without charge, a copy of the procedures governing qualified medical child support order (QMCSO) determinations from the Plan Administrator. 6. If a covered Employee is the Legal Guardian of an unmarried Child or Children, these Children may be enrolled in this Plan as covered dependents To maintain coverage under the Plan beyond age 19, the Employee must furnish due proof to the Employer that the Child remains unmarried and that the Child continues to be primarily dependent upon the Employee for support and maintenance and meets the requirements of 3, 4, or 5 above. At any time, the Plan may require proof that a spouse or a child qualifies or continues to qualify as an eligible dependent under this Plan. The term Child means an unmarried natural child, adopted child, child legally Placed with the employee for adoption, stepchild, or Foster Child. A stepchild or Foster Child must be living in the employee's home in a parent-child relationship and be chiefly dependent on the Employee for support.
A Foster Child is: a. a child the Employee is raising as his own (i.e., the Employee has assumed a legal obligation for the child); b. a child who lives in the Employee's home; c. a child who is unmarried, under the Plans limiting age, chiefly dependent on the Employee for support; and d. a child for whom the Employee has taken full parental responsibility and control. A Foster Child is not: a. a child temporarily living in the Employee's home; b. a child placed with the Employee by a social service agency which retains control of the child; c. a child whose natural parent is in a position to exercise or share parental responsibility and control; or d. a child who is eligible for medical coverage, other than coverage available through the foster parents. A Child may not be covered as a dependent if the Child is eligible for coverage under this Plan as an Employee. If a person covered under this Plan changes status from Employee to dependent or dependent to Employee, and the person is covered continuously under this Plan before, during and after the change in status, credit will be given for deductibles and all amounts applied to benefit maximums. Any person on active duty in any military service is not eligible for coverage as a dependent under this Plan. Durable Medical Equipment means equipment which (a) can withstand repeated use, (b) is primarily and customarily used to serve a medical purpose, (c) generally is not useful to a person in the absence of an Illness or Injury and (d) is appropriate for use in the home. Examples include hospital beds, wheelchairs, oxygen equipment, walkers, and bedside commodes. Employee means a person who is on the regular payroll of the Employer as either a Full Time Employee or a Part Time Employee, regularly scheduled to work for the Employer in an Employee/Employer relationship, and who has begun to perform the duties of his or her job with the Employer. The following persons are not eligible for coverage under this Plan: (1) employees who are nonresident aliens who receive no earned income from the Employer / Plan Sponsor which constitutes income from sources within the United States, (2) employees who are self-employed individuals as defined in section 401(c) of the Internal Revenue Code (including sole proprietors and partners in a partnership), and (3) employees who own (or are considered to own within the meaning of section 318 of the Internal Revenue Code) more than 2 percent of the outstanding stock of an S corporation or stock possessing more than 2 percent of the total combined voting power of all stock of such corporation, (4) leased employees as defined in Internal Revenue Code section 414(n), and (5) individuals classified by the Employer as temporary employees or seasonal employees. Employer is Wellmont Health System. Enrollment Date means the first day the person becomes covered under the Plan. ERISA is the Employee Retirement Income Security Act of 1974, as amended. Experimental or Investigational is the use of any treatment, procedure, facility, equipment, drugs, devices, or supplies not yet recognized by the Plan as acceptable medical practice as determined within the sole discretion of the Benefit Committee. This term will also apply if the services or supplies require federal or other governmental agency approval and that approval was not granted at the time the services were received. Services or supplies which are educational or Experimental in nature include: A. Services, care, procedures, treatment protocols, or technologies which: 1. Are not widely accepted throughout the geographic area by Physician providers practicing in the
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geographic area as being safe, effective, and appropriate for the Injury, or Sickness, or condition; 2. Are in the research or Investigational state; 3. Are conducted as part of a research protocol; 4. Have not been proved by statistically significant randomized clinical trials to establish increased survival or improvement in the quality of life over other conventional therapies; and B. Supplies, drugs, tests, or technologies, which are: 1. Not widely accepted throughout the geographic area by Physician providers practicing in the geographic area as being safe, effective, and appropriate for the Injury or Sickness, or condition; or 2. The Food and Drug Administration has not approved for general use; 3. For research or Investigational use; or 4. Approved for a specific medical condition by the Food and Drug Administration, but are applied to another condition.
Formulary means a list of prescription medications compiled by the third party payor of safe, effective therapeutic drugs specifically covered by this Plan. Full Time Employee is an Employee working for the Employer on a regularly scheduled workweek of 35 to 40 hours per week. Generic drug means a Prescription Drug that has the equivalency of the brand name drug with the same use and metabolic disintegration. This Plan will consider as a Generic drug any Food and Drug Administration approved generic pharmaceutical dispensed according to the professional standards of a licensed pharmacist and clearly designated by the pharmacist as being generic. Genetic Information means information about genes, gene products and inherited characteristics that may derive from an individual or a family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct analysis of genes or chromosomes. Health Factor means, in relation to an individual, any of the following health status-related factors: (i) health status; (ii) Medical Condition; (iii) claims experience; (iv) receipt of health care; (v) medical history; (vi) Genetic Information; (vii) evidence of insurability (including conditions arising out of domestic violence); or (viii) disability. Home Health Care Agency means: 1. 2. 3. a Hospital which holds a valid operating certificate pursuant to the state public health law authorizing the Hospital to provide home health care services. a non-profit or a public home health care service or agency possessing a valid certificate of approval issued to such state public health law, or a Home Health Care Agency which is federally certified.
Home Health Care Plan must meet these tests: it must be a formal written plan made by the patient's attending Physician which is reviewed at least every 30 days; it must state the diagnosis; and it must specify the type and extent of Home Health Care required for the treatment of the patient. Hospice Care means palliative and supportive care provided to a terminally ill person by or under arrangement with a Hospice Care Agency in accordance with a Hospice Care Program. Hospice Care Agency is an agency which meets all of the following criteria: 1. has Hospice Care available 24 hours a day; 2. is licensed or certified as a Hospice by the appropriate licensing authority in the jurisdiction where it is located; 3. establishes policies governing provisions of Hospice Care; 4. assesses the patient's medical & social needs; 5. develops a Hospice Care Program to meet those needs;
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6. provides an ongoing quality assurance program which includes reviews by Physicians, other than those who own or direct the Agency; 7. permits all area medical personnel to utilize its services for their patients; 8. keeps medical records on each patient; 9. utilizes volunteers trained in providing services for non-medical needs; 10. has a full-time administrator; 11. has personnel which include at least (a) one Physician, (b) one registered nurse, (c) one certified master level social worker employed by the agency, and (d) one pastoral or other counselor. Hospice Care Program means a written plan of Hospice Care which is established and reviewed periodically by the Covered Person's attending Physician or the Hospice Care Agency's Medical Director along with appropriate personnel of the Hospice Care Agency. The program is designed to provide palliative and supportive care to terminally ill persons and supportive care to their families; and will include assessment of the person's medical and social needs and a description of the care to be given to meet those needs. Hospice Facility means a facility, or distinct part of one, which: 1. 2. 3. 4. 5. provides mainly inpatient Hospice Care to terminally ill persons; and makes a charge to its patients; and meets licensing or certification standards as set forth by the jurisdiction where it is located; and maintains medical records on each patient; and provides an ongoing quality assurance program which includes reviews by Physicians, other than those who own or direct the facility; and 6. is run by a staff of Physicians of which at least one such Physician is on call at all times; and 7. provides 24 hour nursing services under the direction of a registered nurse; and 8. has a full-time administrator. Hospital is an institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense and which fully meets these tests: it is accredited as a Hospital by the Joint Commission on Accreditation of Healthcare Organizations or the American Osteopathic Association Healthcare Facilities Accreditation Program; it is approved by Medicare as a Hospital; it maintains diagnostic and therapeutic facilities on the premises for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of Physicians; it continuously provides on the premises 24-hour-a-day nursing services by or under the supervision of registered nurses (RNs); and it is operated continuously with organized facilities for operative surgery on the premises. The definition of "Hospital" shall be expanded to include the following: A facility operating legally as a psychiatric Hospital or residential treatment facility for mental health and licensed as such by the state in which the facility operates. A facility operating primarily for the treatment of Substance Abuse if it meets these tests: maintains permanent and full-time facilities for bed care and full-time confinement of at least 15 resident patients; has a Physician in regular attendance; continuously provides 24-hour a day nursing service by a registered nurse (R.N.); has a full-time psychiatrist or psychologist on the staff; and is primarily engaged in providing diagnostic and therapeutic services and facilities for treatment of Substance Abuse.
Illness means a disorder or disease of the body. All Illnesses which are due to the same cause or causes will be deemed to be one Illness. Intensive Care Unit is defined as a separate, clearly designated service area which is maintained within a Hospital solely for the care and treatment of patients who are critically ill. It has: facilities for special nursing care not available in regular rooms and wards of the Hospital; special life saving equipment which is immediately available at all times; at least two beds for the accommodation of the
critically ill; and at least one registered nurse (R.N.) in continuous and constant attendance 24 hours a day. Injury (See "Accidental Bodily Injury") Late Enrollee is defined as a person who enrolls in the Plan other than either on the earliest date on which coverage can become effective under the terms of the Plan or during a Special Enrollment Period. Legal Guardian means a person recognized by a court of law as having the duty of taking care of the person and managing the property and rights of a minor child. Lifetime is a word that appears in this Plan in reference to benefit maximums and limitations. Lifetime is understood to mean while covered under this Plan. Under no circumstances does Lifetime mean during the lifetime of the Covered Person. Medical Care Facility means a Hospital, a facility that treats one or more specific ailments, or any type of Skilled Nursing Facility. Medical Condition means any condition, whether physical or mental, including, but not limited to, any condition resulting from illness, Injury (whether or not the Injury is accidental), pregnancy, or congenital malformation. However, Genetic Information is not a Medical Condition. Medical Emergency is the sudden and unexpected onset of a Sickness or Injury with severe symptoms requiring medical (as opposed to surgical) care. To be a Medical Emergency, the Sickness or Injury, as finally diagnosed or as indicated by its symptoms must be one which would normally require immediate medical care, such as, but not limited to, acute appendicitis, asthmatic attack, kidney stone attack, stroke, poisoning (including overdoses), or convulsions. In order to determine whether a Medical Emergency exists, the following requirements will be applied: a. Severe symptoms must occur and the symptoms must be sufficiently severe to cause a person to seek immediate medical aid regardless of the hour of the day or night; b. Severe symptoms must occur suddenly and unexpectedly. A chronic condition in which moderately acute symptoms have existed over a period of time would not qualify for Medical Emergency consideration. However, if symptoms suddenly become severe enough to require immediate medical aid, it may at that point, so qualify; c. Immediate care is secured - a Medical Emergency would not be considered to exist if medical care is not secured immediately after the appearance of symptoms. A telephone call to a Physician does not meet this requirement if deferred beyond forty-eight (48) hours after the appearance of symptoms; and d. The Sickness or Injury as finally diagnosed or is indicated by its symptoms and the degree of severity of the Sickness or Injury is such that immediate medical care would normally be required. Medically Necessary or Medical Necessity means services or supplies provided by a Hospital, Physician, or other qualified provider, if they are: 1. required for the diagnosis and/or treatment of the particular condition, disease, Injury, or Illness; and 2. consistent with the symptom or diagnosis and treatment of the condition, disease, Injury, or Illness; and 3. commonly and usually noted throughout the medical field as proper to treat the diagnosed condition, disease, Injury, or Illness; and 4. the most fitting supply or level of service which can safely be given to the Covered Person. When assessing the Medical Necessity of inpatient care, medical symptoms or conditions must require that the proposed services or supplies cannot safely be delivered at an alternate level of care. A diagnosis, treatment, service or supply with respect to a condition, disease, Injury or Illness is not Medically Necessary if made, prescribed, or delivered solely for the convenience of the patient or provider. The fact that a Physician has performed or prescribed a procedure or treatment does not mean that it is Medically Necessary. The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically
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Necessary. Medically Necessary Leave of Absence for Michelles Law shall mean a leave of absence by a fulltime student Dependent in a postsecondary educational institution that:
1. 2. 3.
Commences while such Dependent is suffering from a Illness or Injury; Is Medically Necessary; and Causes such Dependent to lose student status at a postsecondary educational institution for purposes of coverage under the terms of the Plan.
Medicare is the Health Insurance for the Aged and Disabled program under Title XVIII of the Social Security Act, as amended. Mental Disorder means any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of International Classification of Diseases, published by the U.S. Department of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. Michelles Law shall mean H.R. 2851 Morbid Obesity is a diagnosed condition in which the body weight exceeds the medically recommended weight by either 100 pounds or is twice the medically recommended weight for a person of the same height, age and mobility as the Covered Person. Non-Participating Provider means a provider who does not hold a Participating Provider agreement with the provider organization contracted by the Employer. Occupational Illness is one which arises out of or in the course of any work for pay or profit or in any way results from an Illness which does. If, in the discretion of the Plan Administrator, satisfactory proof is furnished that an individual covered under a Worker's Compensation Law (or other law of similar purpose), is not covered for a particular Illness under such law, that Illness shall not be considered an Occupational Illness. Occupational Injury is one which arises out of or in the course of any work for pay or profit or in any way results from an Injury which does. Orthotics/orthosis are devices added to the body to stabilize or immobilize a body part, prevent deformity, protect against injury, or assist with function. Orthotic devices range from arm slings, corset and finger splints, shoe inserts, and diabetic shoes. Outpatient Care and/or Services is treatment including services, supplies and pharmaceuticals provided and used under the direction of a Physician in a Physician's office, laboratory, radiology facility, infusion center, Ambulatory Surgical Center, other ancillary center, the patient's home, or a Hospital if the patient is not admitted as a registered bed patient. Participating Provider means a designated institution, Physician or other provider who holds a Participating Provider agreement with the provider organization contracted by the Employer. Part Time Employee is an Employee working for the Employer on a regularly scheduled work week of 24 to 34 hours per week. Pharmacy means a licensed establishment where covered Prescription Drugs are filled and dispensed by a pharmacist licensed under the laws of the state where he or she practices. Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Licensed Professional Counselor, Licensed Professional Physical Therapist, Master of Social Work (M.S.W.), Midwife, Occupational Therapist, Physiotherapist, Psychiatrist, Psychologist (Ph.D.), Speech Language Pathologist and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his or her license.
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Placed or Placement in connection with any placement for adoption of a Child with the covered Employee, means the assumption and retention by such Employee of a legal obligation for total or partial support of such Child in anticipation of adoption of such Child. The Child must be available for adoption and the legal process must have commenced. The Child's placement with the Employee terminates upon termination of such legal obligation. The phrase "Child placed with a covered Employee in anticipation of adoption" refers to a Child whom the Employee intends to adopt, whether or not the adoption has become final, who has not attained the age of 18 as of the date of such placement for adoption. Plan means the Employee Medical, Dental, and Vision Care Plan for Employees of Wellmont Health System that is described in this document. Plan Year is the 12-month period beginning July 1st of each year. Primary Care Physician is a Physician whose practice largely entails providing primary care services to individuals and their families. This includes General Practitioners, Family Practitioners, General Internists, Obstetrician/Gynecologists, and Pediatricians. Pre-Existing Condition means a condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the person's Enrollment Date under this Plan (e.g. the six month look back period for an Enrollment Date of August 15 is February 15 through August 14). Genetic Information is not a condition. Treatment includes receiving services and supplies, consultations, diagnostic tests or prescribed medicines. In order to be taken into account, the medical advice, diagnosis, care or treatment must have been recommended by, or received from, a Physician. The Pre-Existing Condition does not apply to Pregnancy, to a newborn child who is covered under any Creditable Coverage within 31 days of birth, or to a child who is adopted or placed for adoption before attaining age 18 and who, as of the last day of the 31-day period beginning on the date of the adoption or placement for adoption, is covered under any Creditable Coverage. A Pre-Existing Condition exclusion may apply to coverage before the date of the adoption or placement for adoption. The prohibition on Pre-Existing Condition exclusion for newborn, adopted, or pre-adopted children does not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any Creditable Coverage. Pregnancy is childbirth and conditions associated with Pregnancy, including complications. Prescription Drug means any of the following: a Food and Drug Administration-approved drug or medicine which, under federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without prescription"; injectable insulin; hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed Physician. Such drug must be Medically Necessary in the treatment of a Sickness or Injury. Prosthesis is a replacement of a missing body part by an artificial substitute, such as an artificial extremity or an artificial organ or part, including arms, hands, joints, heart valves, or teeth, or a device to augment performance of a natural function, such as a hearing aid. Retired Employees are eligible for coverage provided such Employee qualified for continuation of coverage through a retirement incentive program offered by the Employer. Please contact your Employer to determine eligibility. Semi-Private Room and Board means the charges made by a Hospital for the cost of room, meals, and services (such as general nursing services) provided to all inpatients on a routine basis in a room designed to accommodate two or more bed patients. Service Area means a specific area in which services of Participating Providers are available under this Plan, as outlined with the Participating Provider organization contracted by the Employer. Sickness is an Illness, disease or Pregnancy. Skeletal Adjustments means care connected with the detection, including X-rays or correction by
8
manual or mechanical means of structural imbalance, distortion, or subluxation where such care is for purposes of removing nerve interference and its effects, where interference is the result of or related to distortion, misalignment, or subluxation of or in the spinal column. Skilled Nursing Facility means an institution, or a distinct part of an institution, which meets all of the following: 1. Has a transfer agreement with at least one Hospital; 2. Chiefly provides 24-hour skilled nursing care and rehabilitation services under the full-time supervision of a Physician or registered nurse; for the treatment of injured, disabled, or sick persons; 3. has policies which are developed and reviewed by a group of professionals, which includes at least one Physician; 4. requires that a Physician supervise the health care of each patient; 5. employs at least one registered nurse full-time; 6. is legally licensed by the state of location; 7. maintains clinical records for all patients; 8. is not chiefly a place for the aged, alcoholics, drug addicts, the mentally ill or retarded, or a place for custodial care. Specialist is a Physician or other health professional who concentrates on medical activities in a particular specialty of medicine, based on advanced education, training and qualifications. Substance Abuse is regular excessive compulsive drinking of alcohol and/or physical habitual dependence on drugs. This does not include dependence on tobacco and ordinary caffeine-containing drinks. Temporomandibular Joint (TMJ) syndrome is the treatment of jaw joint disorders including conditions of structures linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the temporomandibular joint. Care and treatment shall include, but are not limited to orthodontics, crowns, inlays, physical therapy and any appliance that is attached to or rests on the teeth. Totally Disabled and Total Disability means: 1. with respect to a covered Employee or spouse, the inability as a result of Illness or Injury to engage in any and all of the usual duties of one's occupation; and 2. with respect to a dependent Child, the dependent Child's inability as a result of Illness or Injury to perform the normal duties or activities of a healthy person of the same age and sex. Usual and Customary Charge is a charge which is not higher than the usual charge made by the provider of the care or supply and does not exceed the usual charge made by most providers of like service in the same area. This test will consider the nature and severity of the condition being treated. It will also consider medical complications or unusual circumstances that require more time, skill or experience. The Plan will reimburse the actual charge billed if it is less than the Usual and Customary Charge. The Plan Administrator has the discretionary authority to decide whether a charge is Usual and Customary.
ELIGIBILITY EMPLOYEE Hours at Work per Week A Full Time Employee is an Employee working for the Employer on a regularly scheduled workweek of 35 to 40 Hours per Week A Part Time Employee is an Employee working for the Employer on a regularly scheduled workweek of 24 to 34 Hours per Week Eligibility Date An Employee is eligible for coverage under the Plan on the first day that the Employee meets all of the following requirements: 1. The Employee is working on a regular basis for the Employer either at such Employees customary place of employment or at such other place or places as required by the Employer, and 2. The Employee is working for the Employer on a regular weekly schedule as set forth under Hours At Work Per Week. However, an absence of work due to a Health Factor during any period before coverage becomes effective is not considered an absence for purposes of determining the Employees Eligibility Date. Employees who were previously covered by the Plan and lost coverage because they no longer met the eligibility requirements will be eligible for coverage under the Plan again if they subsequently regain Part-Time or Full-Time Employee status. These Employees must enroll for coverage as instructed in the Effective Date section of this document and will be subject to Pre-existing conditions as defined in the Plan. RETIRED EMPLOYEES Retired Employees are eligible for coverage provided such Employee qualified for continuation of coverage through a retirement incentive program offered by the Employer. Please contact your Employer to determine eligibility. BOARD MEMBER Wellmont Health System Board Members are eligible for coverage. References to eligibility and coverage of Employees throughout this document are deemed to include Board Members, as applicable. DEPENDENT The following dependents of an Employee, if any, are eligible for coverage: 1. A spouse (if not legally separated). All of the requirements of a legally valid marriage contract must be met in the state of marriage of the Employee and spouse. Evidence of marriage in the form of official documents or notarized statements may be required before coverage can commence. 2. An unmarried dependent Child until such Child's 19th birthday. 3. An unmarried Child age 19 but less than age 23 who is a full-time student at an accredited postsecondary school, college, or university, is not employed on a full-time basis, and is dependent on the Employee for principal support. Full-time student status is defined by the school, college, or university. If the Child does not maintain full-time status or graduates, coverage closes independent of limiting age. Full-time student coverage continues between semesters/quarters only if the student is enrolled as a full-time student in the next regular semester/quarter. If the student is not enrolled as a full-time student, coverage will be terminated retroactively to the last day of the attended school term. Michelles Law Notification shall mean the extension of coverage to full-time student Dependents
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at postsecondary educational institutions who experience a Medically Necessary Leave of Absence for Michelles Law, for up to one year, if both of the following conditions are met: a. The Plan receives written certification from the Dependents treating Physician certifying that: The Dependent is suffering from a serious Illness or Injury; and The leave of absence from the postsecondary institution is a Medically Necessary Leave of Absence for Michelles Law. b. The loss of student status would cause a loss of health coverage under the terms of the Plan without the application of Michelles Law. The one-year period begins with the first day of the Medically Necessary Leave of Absence for Michelles Law and may end before the year ends, if the Dependents coverage under the Plan would terminate for any reason.
Dependent Children who were previously covered by the Plan and lost coverage because they exceeded the eligibility age and did not remain in school as a full-time student or who were already over the eligibility age when coverage was first available to the Employee will be eligible for coverage under the Plan if they become full-time students before reaching age 23. 4. A Child age 19 and older who is covered under the Plan on the day prior to the day the Child's coverage under the Plan would have terminated due to the Child's age and who is Totally Disabled, mentally or physically unable to earn a living, unmarried, and dependent on the Employee for principal support. Proof of such disability must be submitted to the Employer within 31 days of the date the Child's coverage would have terminated due to age. Periodic proof that the dependent Child continues to be incapable of self-support will be required. The Plan Administrator reserves the right to have such dependent examined by a Physician of the Plan Administrator's choice, at the Plan's expense, to determine the existence of such incapacity. 5. A Child who is an alternate recipient under a qualified medical child support order in accordance with the provisions of ERISA. A participant of this Plan may obtain, without charge, a copy of the procedures governing qualified medical child support order (QMCSO) determinations from the Plan Administrator. 6. If a covered Employee is the Legal Guardian of an unmarried Child or Children, these Children may be enrolled in this Plan as covered dependents To maintain coverage under the Plan beyond age 19, the Employee must furnish due proof to the Employer that the Child remains unmarried and that the Child continues to be primarily dependent upon the Employee for support and maintenance and meets the requirements of 3, 4, 5 or 6 above. At any time, the Plan may require proof that a spouse or a child qualifies or continues to qualify as an eligible dependent under this Plan. The term Child means an unmarried natural child, adopted child, child legally Placed with the employee for adoption, stepchild, or Foster Child. A stepchild or Foster Child must be living in the employee's home in a parent-child relationship and be chiefly dependent on the Employee for support. A Foster Child is: a. a child the Employee is raising as his own (i.e., the Employee has assumed a legal obligation for the child); b. a child who lives in the Employee's home; c. a child who is unmarried, under the Plans limiting age, chiefly dependent on the Employee for support; and d. a child for whom the Employee has taken full parental responsibility and control. A Foster Child is not:
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a. a child temporarily living in the Employee's home; b. a child placed with the Employee by a social service agency which retains control of the child; c. a child whose natural parent is in a position to exercise or share parental responsibility and control; or d. a child who is eligible for medical coverage, other than coverage available through the foster parents. A Child may not be covered as a dependent if the Child is eligible for coverage under this Plan as an Employee. If a person covered under this Plan changes status from Employee to dependent or dependent to Employee, and the person is covered continuously under this Plan before, during and after the change in status, credit will be given for deductibles and all amounts applied to benefit maximums. Any person on active duty in any military service is not eligible for coverage as a dependent under this Plan. ENROLLMENT and EFFECTIVE DATE This Plan now requires all members to supply specific identification elements for coordination of benefits purposes. Such information includes, but is not limited to: Social Security numbers, date of birth, etc. for ALL members. Claims received for members who have not provided the Plan Administrator this information will be pended (or possibly denied based on Department of Labor claim regulations) until receipt of such information. EMPLOYEE An Employee's coverage will become effective only if the Employee makes written request for coverage on a form approved by the Employer and agrees in writing to make any required contributions. For Employees who meet these requirements, coverage will become effective as follows: 1. An Employee who makes a written request for coverage within 60 days after his or her Eligibility Date will be covered on the first day of the first calendar month coincident with or following the Employees Eligibility Date. This also applies to Employees who lost and subsequently regained eligibility under the Plan. 2. Employees who make written request for coverage after the end of a 60-day period which began on the date they became eligible, or who are requesting reinstatement after voluntarily electing to terminate their benefits will become covered only on one of the following dates: a. July 1 following an annual enrollment period during which the Employee makes written request for coverage. b. The date the Employee loses group medical coverage under the plan of another employer group as described under Special Enrollment Period or as a result of a Change in Status provided the Employee makes written request for coverage under this Plan within 60 days of the Change in Status or loss of other coverage. c. The date the Employee returns to work, if the Employees coverage was terminated for nonpayment of Employee contributions while the Employee was on a leave of absence protected by the Family and Medical Leave Act of 1993, or on a leave of absence protected by the Uniformed Services Employment and Reemployment Rights Act of 1994, and the Employee returns to employment within the time period required to preserve the Employees rights under those Acts. 3. If an Employee fails to enroll when the Employee is first eligible for coverage, the Employee will be
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deemed to have declined coverage. 4. Unless the Employer receives a written request for any change to coverage (e.g. cancellation, deletion of dependent) during subsequent enrollment periods, the Employee will be deemed to have elected to continue coverage the same as the coverage in effect immediately prior to the enrollment period. DEPENDENT Coverage will become effective for an Employee's dependents only if the Employee is covered and makes written request for dependent's coverage on a form approved by the Employer and also agrees in writing to make any required contributions. Dependents cannot be covered for any benefit unless the Employee is covered for such benefit. For Employees who meet these requirements, coverage for their dependents will become effective as follows: 1. An Employee who makes written request for dependent coverage within 60 days after the Employees Eligibility Date will have coverage effective for such dependents on the Employees Eligibility Date. 2. For dependents acquired after the Employee's effective date, coverage will become effective on the date of a Change in Status (or as specified in the Special Enrollment section of this document, as applicable) provided written request for coverage is made within 60 days following the date the dependent first becomes an eligible dependent and the change qualifies as a Change in Status or a Special Enrollment event. If dependent coverage is in effect at the time of acquisition of a new eligible dependent, coverage for such new dependent will be automatic & will be effective on the date the dependent is first eligible (i.e. date of birth, marriage, adoption, etc.). Notification of the new dependent must be provided to the Employer by completing and submitting the Employers enrollment form within 60 days following the date the new dependent is acquired. 3. Employees who enroll for dependent coverage after the end of a 60 day period beginning on the date such dependents first became eligible; or who are requesting reinstatement after voluntarily electing to terminate benefits for such dependents while continuing to have dependents that were eligible under the Plan will become covered only on one of the following dates: a. July 1 following an annual enrollment period during which the Employee makes written request for dependent coverage. c. The date the dependent loses group medical coverage under the plan of another employer group as described under Special Enrollment Period or as a result of a Change in Status provided the dependent is enrolled for coverage under this Plan within 60 days of the Change in Status or loss of other coverage. c. The date the Employee returns to work, if the dependents coverage was terminated for nonpayment of Employee contributions while the Employee was on a leave of absence protected by the Family and Medical Leave Act of 1993, or on a leave of absence protected by the Uniformed Services Employment and Reemployment Rights Act of 1994, and the Employee returns to employment within the time period required to preserve the Employees rights under those Acts.
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CHANGES IN PLAN ENROLLMENT This Plan allows Employees to pay their contributions for health care coverage on a pre-tax basis. A portion of the Employees compensation is deducted from their paycheck before their taxes are calculated. In this way, Employees pay for their health care coverage with pre-tax dollars and pay less in taxes. For this reason, covered Employees are generally not permitted to make a change in the Plan coverage options they elected at the initial enrollment period for a Plan Year until the next annual open enrollment period. See the section of this document entitled Changes in Benefit Elections. However, covered Employees may change their level of coverage under certain circumstances permitted by the Employer and Internal Revenue Service regulations and rulings. The Plan Administrator may use discretion in determining whether a change in status or other event permitting an election change has occurred. If a covered Employee experiences a change in status or other change affecting coverage and wishes to change his or her level of coverage, he or she must submit an enrollment application to the Plan Administrator within 60 days after the change. The change in coverage must be consistent with the change in status. The Plan Administrator reserves the right to require the Employee to submit proof of any change of status or other event at the Employees expense. Coverage will become effective on the first day of the first calendar month following the date the Plan Administrator approves the completed application (except as otherwise required by law) provided that the Employee has met all eligibility requirements of the Plan. Examples of a change in status include: 1. Acquisition of a newly eligible dependent by marriage, birth, adoption, court appointed guardianship of a Child, Placement for adoption, custody. 2. Loss of a dependent through death, divorce, legal separation, ineligibility, changes in custody. 3. A spouse losing or gaining employment. 4. A change in a spouses employment status affecting the spouses eligibility for coverage under the plan. Examples of other events that may permit a change in enrollment are a significant curtailment of a spouses coverage or a significant change in the cost of coverage. SPECIAL ENROLLMENT PERIOD If an Employee elects on the application form provided at initial enrollment to decline coverage under the Employers plan for either the Employee, the Employees eligible dependents, or both, because of other health coverage, the Employee may in the future be able to enroll for coverage in this Plan for the Employee and eligible dependents, provided written request for coverage is made within 60 days after the other health coverage ends due to loss of eligibility (including divorce, legal separation, cessation of dependent status, death, termination of employment, reduction in hours, meeting or exceeding the Plans Overall Maximum Benefit Amount, or the Plan ceasing to provide benefits to a class of similarlysituated individuals), exhaustion of COBRA (this includes meeting or exceeding the Plans Overall Maximum Benefit Amount), or due to cessation of Employer contributions. Coverage will be effective on the day after the other coverage ends. NOTE: For termination of coverage as a result of reaching the Plans Overall Maximum Benefit Amount, the 60-day enrollment period begins on the date a claim is denied due to the Overall Benefit limit (this does not apply to exhaustion of COBRA coverage; in these situations, the 60-day special enrollment period begins on the date the claim meeting or exceeding the Overall Maximum Benefit is incurred).
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If the Employee or dependent lost the other coverage as a result of the individual's failure to pay premiums or required contributions or for cause (such as making a fraudulent claim), that individual does not have a Special Enrollment right. If the Employee acquires a new dependent as a result of marriage, birth, adoption, or Placement for adoption, the Employee may be able to cover the Employee and eligible dependents, provided the written request for coverage is submitted to the Employer within 60 days after the marriage, birth, adoption, or Placement for adoption. Coverage will become effective in the case of a marriage, birth, adoption, or Placement for adoption on the date of marriage, birth, adoption, or Placement for adoption respectively, provided the written request for enrollment is received within 60 days of the date of marriage, birth, adoption, or Placement for adoption. Additional Special Enrollment Rights Employees and Dependents who are eligible but not enrolled are entitled to enroll under the following circumstances: 3. The Employee's or Dependent's Medicaid or State Child Health Insurance Plan (i.e. CHIP) coverage has terminated as a result of loss of eligibility and the Employee requests coverage under the Plan within 60 days after such termination; or 4. The Employee or Dependent become eligible for a premium assistance subsidy under Medicaid or a State Child Health Insurance Plan (i.e. CHIP), and the Employee requests coverage under the Plan within 60 days after such eligibility is determined.
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TERMINATION OF COVERAGE When coverage under this Plan stops, Covered Persons will receive a certificate that will show the period of coverage under this Plan. Please contact the Plan Administrator for further details. EMPLOYEE An Employee's coverage will terminate on the first to occur of the following: 1. the last day of the month in which the Employee worked in a benefit eligible position for the Employer. 2. for any specific benefit, the date the Plan stops offering that benefit, or the date the Employee is no longer eligible for that benefit. 3. the date that the Plan itself terminates. 4. the last day of the period for which contributions are made if the required contribution is not made, when due. 5. July 1st of the Plan Year in which the Employee elects to terminate coverage during an annual enrollment period designated by the Employer. 6. the date on which the Employee elects to terminate coverage, provided such election is made within 60 days of the date the Employee experiences a qualifying Change in Status. DEPENDENT Dependents coverage will terminate on the first to occur of the following: 1. the date the Employee's coverage under the Plan terminates. 2. the last day in which the dependent ceases to be an eligible dependent. 3. the date of termination of all dependents' benefits under the Plan. 4. the last day of the period for which contributions are made to the cost of dependent coverage, if the required contribution is not made, when due. 5. the date the dependent enters active duty with any branch of the military. 6. for a covered dependent of a covered Employee who elects to terminate dependent coverage during an annual enrollment period, July 1st of the Plan Year in which such enrollment period occurs. 7. the date on which the covered Employee elects to terminate dependent coverage, provided such election is made within 60 days of the date the Employee experiences a qualifying Change in Status. CHANGE IN BENEFIT ELECTION Benefit decisions made during the Plans annual enrollment period will become effective July 1st and remain in effect until June 30th of the following year except as set forth in the section of this document entitled Changes in Plan Enrollment. During the Plans annual enrollment period, Employees will be given the opportunity to elect different plan options, or change coverage levels (i.e. adding or dropping dependent coverage).
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LEAVE OF ABSENCE OR ILLNESS OR INJURY A person may continue to be a covered Employee for benefits under the Plan if the person ceases work as a result of an approved leave of absence or as a result of Illness or Injury. Coverage may be continued by the Employer at the Employer's option, with the Employee paying the full cost of the coverage during the leave of absence or Illness or Injury, as defined by the Employer. Benefits will run concurrent with FMLA. Family and Medical Leave Act (FMLA) Qualifying Circumstances for FMLA Leave Coverage under FMLA Leave is limited to a total of 12 workweeks during any 12-month period that follows: 1. The birth of, and to care for, a Son or Daughter; 2. The placement of a Child with the Employee for adoption or foster care; 3. The Employees taking leave to care for his or her Spouse, Son or Daughter, or Parent who has a Serious Health Condition; or 4. The Employees taking leave due to a Serious Health Condition which makes him or her unable to perform the functions of his or her position. 5. A Qualifying Exigency arising out of the fact that a Spouse, Son or Daughter, Parent, or Next of Kin of the Employee has been called to active duty in the Armed Forces in support of a contingency operation (i.e. a war or similar combat operation). Coverage under FMLA Leave is limited to a total of 26 workweeks during any 12-month period that follows a Serious Illness or Injury of a service member when the Employee is that service members Spouse, Son or Daughter, Parent, or Next of Kin. This leave may be paid (accrued vacation time, personal leave or family or sick leave, as applicable) or unpaid. The Participating Employer has the right to require that all paid leave be used prior to providing any unpaid leave. An Employee must continue to pay his or her portion of the Plan contribution, if any, during the FMLA Leave. Payment must be made within 30 days of the due date established by the Plan Administrator. If payment is not received, coverage will terminate on the last date for which the contribution was received in a timely manner. Notice Requirements An Employee must provide at least 30 days' notice to his or her Participating Employer prior to beginning any leave under FMLA. If the nature of the leave does not permit such notice, the Employee must provide notice of the leave as soon as possible. The Participating Employer has the right to require medical certification to support the Employees request for leave due to a Serious Health Condition for the Employee or his or her eligible family members. Length of Leave During any one 12-month period, the maximum amount of FMLA Leave may not exceed 12 workweeks for most FMLA related situations. The maximum periods for an Employee who is the primary care giver of a service member with a Serious Illness or Injury that was Incurred in the line of active duty may take up to 26 weeks of FMLA Leave in a single 12-month period to care for that service member. The Participating Employer may use any of four methods for determining this 12-month period. If the Employee and his or her Spouse are both employed by the Participating Employer, FMLA Leave may be limited to a combined period of 12 workweeks, for both Spouses, when FMLA Leave is due to: 1. The birth or placement for adoption or foster care of a Child; or 2. The need to care for a Parent who has a Serious Health Condition.
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Termination of FMLA Leave Coverage may end before the maximum 12-week (or 26-week) period under the following circumstances: 1. When the Employee informs his or her Participating Employer of his or her intent not to return from leave; 2. When the employment relationship would have terminated but for the leave (such as during a reduction in force); 3. When the Employee fails to return from the leave; or 4. If any required Plan contribution is not paid within 30 days of its due date. If an Employee does not return to work when coverage under FMLA Leave ends, he will be eligible for COBRA continuation of coverage at that time. Recovery of Plan contributions The Participating Employer has the right to recover the portion of the Plan contributions it paid to maintain coverage under the Plan during an unpaid FMLA Leave if the Employee does not return to work at the end of the leave. This right will not apply if failure to return is due to the continuation, recurrence or onset of a Serious Health Condition that entitles the Employee to FMLA Leave (in which case the Participating Employer may require medical certification) or other circumstances beyond the Employees control. Reinstatement of Coverage The law requires that coverage be reinstated upon the Employees return to work following an FMLA Leave whether or not the Employee maintained coverage under the Plan during the FMLA Leave. On reinstatement, all provisions and limits of the Plan will apply as they would have applied if FMLA Leave had not been taken. The Service Waiting Period and the Pre-existing Condition limitation will be credited as if the Employee had been continually covered under the Plan. Definitions (For this provision only, the following terms are defined as stated.) Next of Kin shall mean the nearest blood relative to the service member. Parent shall mean the Employees biological parent or someone who has acted as his parent in place of his biological parent when he was a Son or Daughter. Qualifying Exigency shall mean: 1. Short-notice deployment. a. To address any issue that arises from the fact that a covered military member is notified seven or less calendar days prior to the date of deployment of an impending call or order to active duty in support of a contingency operation; and b. Leave taken for this purpose can be used for a period of seven calendar days beginning on the date a covered military member is notified of an impending call or order to active duty in support of a contingency operation; 2. Military events and related activities.
a. To attend any official ceremony, program, or event sponsored by the military that is related to
the active duty or call to active duty status of a covered military member; and
b. To attend family support or assistance programs and informational briefings sponsored or
promoted by the military, military service organizations, or the American Red Cross that are related to the active duty or call to active duty status of a covered military member; 3. Childcare and school activities.
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a. To arrange for alternative childcare when the active duty or call to active duty status of a
covered military member necessitates a change in the existing childcare arrangement for a biological, adopted, or foster Child, a stepchild, or a legal ward of a covered military member, or a Child for whom a covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence; b. To provide childcare on an urgent, immediate need basis (but not on a routine, regular, or everyday basis) when the need to provide such care arises from the active duty or call to active duty status of a covered military member for a biological, adopted, or foster Child, a stepchild, or a legal ward of a covered military member, or a Child for whom a covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence; c. To enroll in or transfer to a new school or daycare facility, a biological, adopted, or foster Child, a stepchild, or a legal ward of the covered military member, or a Child for whom the covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence, when enrollment or transfer is necessitated by the active duty or call to active duty status of a covered military member; and d. To attend meetings with staff at a school or a daycare facility, such as meetings with school officials regarding disciplinary measures, parent-teacher conferences, or meetings with school counselors, for a biological, adopted, or foster Child, a stepchild, or a legal ward of the covered military member, or a Child for whom the covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence, when such meetings are necessary due to circumstances arising from the active duty or call to active duty status of a covered military member; 4. Financial and legal arrangements.
a. To make or update financial or legal arrangements to address the covered military members
absence while on active duty or call to active duty status, such as preparing and executing financial and healthcare powers of attorney, transferring bank account signature authority, enrolling in the Defense Enrollment Eligibility Reporting System (DEERS), obtaining military identification cards, or preparing or updating a will or living trust; and b. To act as the covered military members representative before a federal, state, or local agency for purposes of obtaining, arranging, or appealing military service benefits while the covered military member is on active duty or call to active duty status, and for a period of 90 days following the termination of the covered military members active duty status; 5. Counseling. To attend counseling provided by someone other than a health care provider for oneself, for the covered military member, or for the biological, adopted, or foster Child, a stepchild, or a legal ward of the covered military member, or a Child for whom the covered military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA Leave is to commence, provided that the need for counseling arises from the active duty or call to active duty status of a covered military member; 6. Rest and recuperation. To spend time with a covered military member who is on short-term, temporary, rest and recuperation leave during the period of deployment. Eligible Employees may take up to five days of leave for each instance of rest and recuperation;
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7. Post-deployment activities.
a. To attend arrival ceremonies, reintegration briefings and events, and any other official
ceremony or program sponsored by the military for a period of 90 days following the termination of the covered military members active duty status; and b. To address issues that arise from the death of a covered military member while on active duty status, such as meeting and recovering the body of the covered military member and making funeral arrangements; and 8. Additional activities. To address other events which arise out of the covered military members active duty or call to active duty status provided that the Participating Employer and Employee agree that such leave shall qualify as an exigency, and agree to both the timing and duration of such leave. Serious Health Condition shall mean an Illness, Injury, impairment, or physical or mental condition that involves:
1. Inpatient care in a Hospital, hospice, or residential medical facility; or 2. Continuing treatment by a health care provider (a doctor of medicine or osteopathy who is
authorized to practice medicine or Surgery, as appropriate, by the state in which the doctor practices, or any other person determined by the Secretary of Labor to be capable of providing health care services). Serious Illness or Injury shall mean an Illness or Injury Incurred in the line of duty that may render the service member medically unfit to perform his or her military duties. Son or Daughter shall mean the Employees biological child, adopted child, stepchild, foster child, a child placed in his legal custody, or a child for which he or she is acting as the parent in place of the childs natural blood related parent. The child must be: 1. Under the age of 18; or 2. Over the age of 18, but incapable of self-care due to a mental or physical disability. Spouse shall mean an Employees husband or wife. NOTE: For complete information regarding FMLA rights, contact the personnel department. Employees on Military Leave Employees going into or returning from military service may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act under the following circumstances. These rights apply only to Employees and their dependents covered under the Plan before leaving for military service. (1) The maximum period of coverage of a person under such an election shall be the lesser of: (a) (b) (2) The 24 month period beginning on the date on which the person's absence begins; or The day after the date on which the person was required to apply for or return to a position or employment and fails to do so.
A person who elects to continue health plan coverage may be required to pay up to 102% of the full contribution under the Plan, except a person on active duty for 30 days or less cannot be required to pay more than the Employee's share, if any, for the coverage. An exclusion may not be imposed in connection with the reinstatement of coverage upon reemployment if one would not have been imposed had coverage not been terminated
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(3)
because of service. However, exclusion may be imposed for coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of uniformed service. COBRA CONTINUATION OF COVERAGE Under federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), certain Employees and their families covered under the Plan will be entitled to the opportunity to elect a temporary extension of health coverage (called "COBRA continuation coverage") where coverage under the Plan would otherwise end. This notice is intended to inform Plan Participants and beneficiaries, in summary fashion, of their rights and obligations under the continuation coverage provisions of COBRA, as amended and reflected in final and proposed regulations published by the Department of the Treasury. This notice is intended to reflect the law and does not grant or take away any rights under the law. The Plan Administrator is Wellmont Health System, 130 West Ravine, Kingsport, TN 37662, (423) 224 6455. COBRA continuation coverage for the Plan is administered by MCA Administrators, Inc., Manor Oak Two, Suite 605, 1910 Cochran Road, Pittsburgh, PA 15220, (800) 922-4966. Complete instructions on COBRA, as well as election forms and other information, will be provided by the Plan Administrator to Plan Participants who become Qualified Beneficiaries under COBRA. What is COBRA continuation coverage? COBRA continuation coverage is the temporary extension of group health plan coverage that must be offered to certain Plan Participants and their eligible family members (called "Qualified Beneficiaries") at group rates for up to a statutory-mandated maximum period of time or until they become ineligible for COBRA continuation coverage, whichever occurs first. The right to COBRA continuation coverage is triggered by the occurrence of one of certain events that result in the loss of coverage under the terms of the Plan (the "Qualifying Event"). The coverage must be identical to the Plan coverage that the Qualified Beneficiary had immediately before the Qualifying Event, or if the coverage has been changed, the coverage must be identical to the coverage provided to similarly situated active employees who have not experienced a Qualifying Event (in other words, similarly situated non-COBRA beneficiaries). Who can become a Qualified Beneficiary? In general, a Qualified Beneficiary can be: (1) Any individual who, on the day before a Qualifying Event, is covered under a Plan by virtue of being on that day either a covered Employee, the Spouse of a covered Employee, or a Dependent child of a covered Employee. If, however, an individual is denied or not offered coverage under the Plan under circumstances in which the denial or failure to offer constitutes a violation of applicable law, then the individual will be considered to have had the Plan coverage and will be considered a Qualified Beneficiary if that individual experiences a Qualifying Event. Any child who is born to or placed for adoption with a covered Employee during a period of COBRA continuation coverage, and any individual who is covered by the Plan as an alternate recipient under a qualified medical support order. The Employee must enroll the child in the Plan by submitting an Enrollment Form (available from the COBRA or Plan Administrator) to the COBRA Administrator within sixty days after the birth or adoption. If, however, an individual is denied or not offered coverage under the Plan under circumstances in which the denial or failure to offer constitutes a violation of applicable law, then the individual will be considered to have had the Plan coverage and will be considered a Qualified Beneficiary if that individual experiences a Qualifying Event. A covered Employee who retired on or before the date of substantial elimination of Plan coverage which is the result of a bankruptcy proceeding under Title 11 of the U.S. Code with respect to the Employer, as is the Spouse, surviving Spouse or Dependent child of such a
(2)
(3)
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covered Employee if, on the day before the bankruptcy Qualifying Event, the Spouse, surviving Spouse or Dependent child was a beneficiary under the Plan. An individual is not a Qualified Beneficiary if the individual's status as a covered Employee is attributable to a period in which the individual was a nonresident alien who received from the individual's Employer no earned income that constituted income from sources within the United States. If, on account of the preceding reason, an individual is not a Qualified Beneficiary, then a Spouse or Dependent child of the individual will also not be considered a Qualified Beneficiary by virtue of the relationship to the individual. A domestic partner is not a Qualified Beneficiary. Each Qualified Beneficiary (including a child who is born to or placed for adoption with a covered Employee during a period of COBRA continuation coverage) must be offered the opportunity to make an independent election to receive COBRA continuation coverage. What is a Qualifying Event? A Qualifying Event is any of the following if the Plan provided that the Plan participant would lose coverage (i.e., cease to be covered under the same terms and conditions as in effect immediately before the Qualifying Event) in the absence of COBRA continuation coverage: (1) (2) (3) (4) (5) (6) The death of a covered Employee. The termination (other than by reason of the Employee's gross misconduct), or reduction of hours, of a covered Employee's employment. The divorce or legal separation of a covered Employee from the Employee's Spouse. A covered Employee's enrollment in any part of the Medicare program. A Dependent child's ceasing to satisfy the Plan's requirements for a Dependent child (for example, attainment of the maximum age for dependency under the Plan). A proceeding in bankruptcy under Title 11 of the U.S. Code with respect to an Employer from whose employment a covered Employee retired at any time.
If the Qualifying Event causes the covered Employee, or the covered Spouse or a Dependent child of the covered Employee, to cease to be covered under the Plan under the same terms and conditions as in effect immediately before the Qualifying Event (or in the case of the bankruptcy of the Employer, any substantial elimination of coverage under the Plan occurring within 12 months before or after the date the bankruptcy proceeding commences), the persons losing such coverage become Qualified Beneficiaries under COBRA if all the other conditions of the COBRA are also met. For example, any increase in contribution that must be paid by a covered Employee, or the Spouse, or a Dependent child of the covered Employee, for coverage under the Plan that results from the occurrence of one of the events listed above is a loss of coverage. The taking of leave under the Family and Medical Leave Act of 1993 ("FMLA") does not constitute a Qualifying Event. A Qualifying Event will occur, however, if an Employee does not return to employment at the end of the FMLA leave and all other COBRA continuation coverage conditions are present. If a Qualifying Event occurs, it occurs on the last day of FMLA leave and the applicable maximum coverage period is measured from this date (unless coverage is lost at a later date and the Plan provides for the extension of the required periods, in which case the maximum coverage date is measured from the date when the coverage is lost.) Note that the covered Employee and family members will be entitled to COBRA continuation coverage even if they failed to pay the employee portion of premiums for coverage under the Plan during the FMLA leave. What is the procedure for obtaining COBRA continuation coverage? The Plan has conditioned the availability of COBRA continuation coverage upon the timely election of such coverage. An election is timely if it is made during the election period.
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What is the election period and how long must it last? The election period is the time period within which the Qualified Beneficiary can elect COBRA continuation coverage under the Plan. The election period must begin not later than the date the Qualified Beneficiary would lose coverage on account of the Qualifying Event and must not end before the date that is 60 days after the later of the date the Qualified Beneficiary would lose coverage on account of the Qualifying Event or the date notice is provided to the Qualified Beneficiary of her or his right to elect COBRA continuation coverage. Note: If a covered employee who has been terminated or experienced a reduction of hours qualifies for a trade readjustment allowance or alternative trade adjustment assistance under a federal law called the Trade Act of 2002, and the employee and his or her covered dependents have not elected COBRA coverage within the normal election period, a second opportunity to elect COBRA coverage will be made available for themselves and certain family members, but only within a limited period of 60 days or less and only during the six months immediately after their group health plan coverage ended. Any person who qualifies or thinks that he and/or his family members may qualify for assistance under this special provision should contact the Plan Administrator for further information. Is a covered Employee or Qualified Beneficiary responsible for informing the Plan Administrator of the occurrence of a Qualifying Event? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator or its designee has been timely notified that a Qualifying Event has occurred. The employer (if the employer is not the Plan Administrator) will notify the Plan Administrator of the Qualifying Event within 30 days following the date coverage ends when the Qualifying Event is: (1) the end of employment or reduction of hours of employment, (2) death of the employee, (3) commencement of a proceeding in bankruptcy with respect to the employer, or (4) enrollment of the employee in any part of Medicare. IMPORTANT: For the other Qualifying Events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child), the Qualified Beneficiary must notify the Plan Administrator or its designee in writing within 60 days after the later of the date the Qualifying Event occurs or the date the Qualified Beneficiary would lose coverage on account of the Qualifying Event, using the procedures specified below. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator or its designee during the 60-day notice period, any spouse or dependent child who loses coverage will not be offered the option to elect continuation coverage. Special COBRA Premium Assistance Opportunity The Federal Government through the passage of the American Recovery and Reinvestment Act of 2009 has made a special COBRA opportunity available for certain Assistance Eligible Individuals. (As of this writing, COBRA Premium Assistance expired May 31, 2010. The Federal Government could pass additional extensions and the following could apply.) Reduced COBRA Premium For a period of time as determined by current law, an Assistance Eligible Individual is treated as having paid any premium required for COBRA continuation coverage under the Plan if the individual pays 35% of the premium. Thus, if the Assistance Eligible Individual pays 35% of the premium, the Plan will treat the individual as having paid the full premium required for COBRA continuation coverage, and the individual is entitled to a subsidy for 65% of the premium.
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Termination of Eligibility for Premium Assistance The Assistance Eligible Individuals eligibility for the subsidy terminates with the first month beginning on or after the earlier of: 1. The date which the subsidy provision expires; 2. The end of the maximum required period of continuation coverage for the qualified beneficiary under the Codes COBRA rules or the relevant State or Federal law (or regulation); or 3. The date that the Assistance Eligible Individual becomes eligible for Medicare benefits under Title XVIII of the Social Security Act or health coverage under another group health plan (including, for example, a group health plan maintained by the new employer of the individual or a plan maintained by the employer of the individuals spouse). However, eligibility for coverage under another group health plan does not terminate eligibility for the subsidy if the other group health plan provides only dental, vision, counseling, or referral services (or a combination of the foregoing), is a health flexible spending account or health reimbursement arrangement, or is coverage for treatment that is furnished in an on-site medical facility maintained by the employer and that consists primarily of first-aid services, prevention and wellness care, or similar care (or a combination of such care). If a Qualified Beneficiary paying a reduced premium for COBRA continuation coverage under this provision becomes eligible for coverage under another group health plan or Medicare, then the Qualified Beneficiary is required to notify the Plan in writing. This notification must be provided to the Plan in the time and manner as is specified by the Secretary of Labor. If an Assistance Eligible Individual fails to provide this notification at the required time and in the required manner, and as a result the individuals COBRA continuation coverage continues to be subsidized after the termination of the individuals eligibility for such subsidy, a penalty will be imposed by the Department of Labor that is equal to 110% of the subsidy provided after termination of eligibility. NOTICE PROCEDURES: Any notice that you provide must be in writing. Oral notice, including notice by telephone, is not acceptable. You must mail, fax or hand-deliver your notice to the person, department or firm listed below, at the following address: Human Resources Department Wellmont Health System 130 West Ravine Kingsport, TN 37662 If mailed, your notice must be postmarked no later than the last day of the required notice period. Any notice you provide must state: the name of the plan or plans under which you lost or are losing coverage, the name and address of the employee covered under the plan, the name(s) and address(es) and Plan identification numbers of the Qualified Beneficiary(ies), and the Qualifying Event and the date it happened. If the Qualifying Event is a divorce or legal separation, your notice must include a copy of the divorce decree or the legal separation agreement. Be aware that there are other notice requirements in other contexts, for example, in order to qualify for a disability extension.
Once the Plan Administrator or its designee receives timely notice that a Qualifying Event has
24
occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each Qualified Beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage for their spouses, and parents may elect COBRA continuation coverage on behalf of their children. For each Qualified Beneficiary who elects COBRA continuation coverage, COBRA continuation coverage will begin on the date that plan coverage would otherwise have been lost. If the qualified beneficiaries do not elect continuation coverage within the 60-day election period described above, the right to elect continuation coverage will be lost. Is a waiver before the end of the election period effective to end a Qualified Beneficiary's election rights? If, during the election period, a Qualified Beneficiary waives COBRA continuation coverage, the waiver can be revoked at any time before the end of the election period. Revocation of the waiver is an election of COBRA continuation coverage. However, if a waiver is later revoked, coverage need not be provided retroactively (that is, from the date of the loss of coverage until the waiver is revoked). Waivers and revocations of waivers are considered made on the date they are sent to the Plan Administrator or its designee, as applicable. When may a Qualified Beneficiary's COBRA continuation coverage be terminated? During the election period, a Qualified Beneficiary may waive COBRA continuation coverage. Except for an interruption of coverage in connection with a waiver, COBRA continuation coverage that has been elected for a Qualified Beneficiary must extend for at least the period beginning on the day after the date coverage is lost due to a Qualifying Event and ending not before the earliest of the following dates: (1) (2) (3) (4) The last day of the applicable maximum coverage period. The first day for which Timely Payment is not made to the Plan with respect to the Qualified Beneficiary. The date upon which the Employer ceases to provide any group health plan (including a successor plan) to any employee. The date, after the date of the election, that the Qualified Beneficiary first becomes covered under any other Plan that does not contain any exclusion or limitation with respect to any pre-existing condition, other than such an exclusion or limitation that does not apply to, or is satisfied by, the Qualified Beneficiary. The date, after the date of the election, which the Qualified Beneficiary first enrolls in the Medicare program (either part A or part B, whichever occurs earlier). In the case of a Qualified Beneficiary entitled to a disability extension, the later of: (a) (i) 29 months after the date coverage is lost due to the Qualifying Event, or (ii) the first day of the month that is more than 30 days after the date of a final determination under Title II or XVI of the Social Security Act that the disabled Qualified Beneficiary whose disability resulted in the Qualified Beneficiary's entitlement to the disability extension is no longer disabled, whichever is earlier; or the end of the maximum coverage period that applies to the Qualified Beneficiary without regard to the disability extension.
(5) (6)
(b)
The Qualified Beneficiary must notify the COBRA Administrator in writing within 30 days after the Qualified Beneficiary becomes covered by another group health plan or entitled to Medicare. The Qualified Beneficiary must also notify the COBRA Administrator in writing within 30 days after the date of the final determination by the Social Security Administration that the Qualified Beneficiary is no longer disabled. This written notice must include the names and Plan identification numbers of the Qualified Beneficiaries and the date on which the other coverage (or Medicare) became effective, or the date of the non-disability determination (as applicable). The Plan can terminate for cause the coverage of a Qualified Beneficiary on the same basis that the
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Plan terminates for cause the coverage of similarly situated non-COBRA beneficiaries, for example, for the submission of a fraudulent claim. In the case of an individual who is not a Qualified Beneficiary and who is receiving coverage under the Plan solely because of the individual's relationship to a Qualified Beneficiary, if the Plan's obligation to make COBRA continuation coverage available to the Qualified Beneficiary ceases, the Plan is not obligated to make coverage available to the individual who is not a Qualified Beneficiary. What are the maximum coverage periods for COBRA continuation coverage? The maximum coverage periods are based on the type of the Qualifying Event and the status of the Qualified Beneficiary, as shown below. (1) In the case of a Qualifying Event that is a termination of employment or reduction of hours of employment, the maximum coverage period ends 18 months after the date coverage is lost due to a Qualifying Event if there is not a disability extension and 29 months after the date coverage is lost due to a Qualifying Event if there is a disability extension. In the case of a covered Employee's enrollment in the Medicare program before experiencing a Qualifying Event that is a termination of employment or reduction of hours of employment, the maximum coverage period for Qualified Beneficiaries other than the covered Employee ends on the later of: (a) (b) 36 months after the date the covered Employee becomes enrolled in the Medicare program; or 18 months (or 29 months, if there is a disability extension) after the date of the covered Employee's loss of coverage due to termination of employment or reduction of hours of employment.
(2)
(3)
In the case of a bankruptcy Qualifying Event, the maximum coverage period for a Qualified Beneficiary who is the covered retiree ends on the date of the retiree's death. The maximum coverage period for a Qualified Beneficiary who is the covered Spouse, surviving Spouse or Dependent child of the retiree ends on the earlier of the Qualified Beneficiary's death or 36 months after the death of the retiree. In the case of a Qualified Beneficiary who is a child born to or placed for adoption with a covered Employee during a period of COBRA continuation coverage, the maximum coverage period is the maximum coverage period applicable to the Qualifying Event giving rise to the period of COBRA continuation coverage during which the child was born or placed for adoption. In the case of any other Qualifying Event than that described above, the maximum coverage period ends 36 months after the date coverage is lost due to the Qualifying Event.
(4)
(5)
Under what circumstances can the maximum coverage period be expanded? If a Qualifying Event that gives rise to an 18-month or 29-month maximum coverage period is followed, within that 18or 29-month period, by a second Qualifying Event that gives rise to a 36-months maximum coverage period, the original period is expanded to 36 months, but only for individuals who are Qualified Beneficiaries at the time of both Qualifying Events. Also, these events can be a second Qualifying Event only if they would have caused the Qualified Beneficiary to lose coverage under the Plan if the first Qualifying Event had not occurred. For example, in most cases a former employees entitlement to Medicare will not extend the 18-month COBRA continuation coverage period for the employees spouse and dependents. This is because if the employee had not terminated employment or reduced working hours (i.e., if the first qualifying event had not occurred), entitlement to Medicare would not result in a loss of family coverage under the Plan. By contrast, the divorce of the employee and spouse after the first qualifying event generally will extend the COBRA continuation coverage period for the spouse. If the employee had not terminated employment or reduced working hours (i.e., if the first qualifying event had not occurred), the divorce would result in a loss of coverage for the spouse.
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In no circumstance can the COBRA maximum coverage period be expanded to more than 36 months after the date coverage is lost due to the first Qualifying Event. The Qualified Beneficiary must send written notice of the second Qualifying Event to the COBRA Administrator within 60 days after the later of the date of the Qualifying Event or the date coverage would be lost due to the Qualifying Event. This written notice must include the names and Plan identification numbers of the Qualified Beneficiaries, the type of Qualifying Event, and the date on which the Qualifying Event occurred. How does a Qualified Beneficiary become entitled to a disability extension? A disability extension will be granted if an individual (whether or not the covered Employee) who is a Qualified Beneficiary in connection with the Qualifying Event that is a termination or reduction of hours of a covered Employee's employment, is determined under Title II or XVI of the Social Security Act to have been disabled at any time before the 60th day of COBRA continuation coverage. To qualify for the disability extension, the Qualified Beneficiary must also provide the COBRA Administrator with written notice of the disability determination (including a copy of the determination) on a date that is both within 60 days after the later of the date of the determination or the date coverage is lost due to the Qualifying Event, and before the end of the original 18-month maximum coverage. Does the Plan require payment for COBRA continuation coverage? For any period of COBRA continuation coverage under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. Qualified beneficiaries will pay up to 102% of the applicable premium and up to 150% of the applicable premium for any expanded period of COBRA continuation coverage covering a disabled Qualified Beneficiary due to a disability extension. The Plan will terminate a Qualified Beneficiary's COBRA continuation coverage as of the first day of any period for which timely payment is not made. Must the Plan allow payment for COBRA continuation coverage to be made in monthly installments? Yes. The Plan is also permitted to allow for payment at other intervals. What is Timely Payment for payment for COBRA continuation coverage? Timely Payment means a payment made no later than 30 days after the first day of the coverage period. Payment that is made to the Plan by a later date is also considered Timely Payment if either under the terms of the Plan, covered employees or Qualified Beneficiaries are allowed until that later date to pay for their coverage for the period or under the terms of an arrangement between the Employer and the entity that provides Plan benefits on the Employer's behalf, the Employer is allowed until that later date to pay for coverage of similarly situated non-COBRA beneficiaries for the period. Notwithstanding the above paragraph, the Plan does not require payment for any period of COBRA continuation coverage for a Qualified Beneficiary earlier than 45 days after the date on which the election of COBRA continuation coverage is made for that Qualified Beneficiary. Payment is considered made on the date on which it is postmarked to the Plan. If Timely Payment is made to the Plan in an amount that is not significantly less than the amount the Plan requires to be paid for a period of coverage, then the amount paid will be deemed to satisfy the Plan's requirement for the amount to be paid, unless the Plan notifies the Qualified Beneficiary of the amount of the deficiency and grants a reasonable period of time for payment of the deficiency to be made. A "reasonable period of time" is 30 days after the notice is provided. A shortfall in a Timely Payment is not significant if it is no greater than the lesser of $50 or 10% of the required amount. Must a qualified beneficiary be given the right to enroll in a conversion health plan at the end of the maximum coverage period for COBRA continuation coverage? If a Qualified Beneficiary's COBRA continuation coverage under a group health plan ends as a result of the expiration of the applicable maximum coverage period, the Plan will, during the 180-day period that ends on that expiration date, provide the Qualified Beneficiary with the option of enrolling under a conversion health plan if such an option is otherwise generally available to similarly situated non-COBRA beneficiaries
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under the Plan. If such a conversion option is not otherwise generally available, it need not be made available to Qualified Beneficiaries. IF YOU HAVE QUESTIONS If you have questions about your COBRA continuation coverage, you should contact the COBRA Administrator or you may contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website at www.dol.gov/ebsa. KEEP YOUR PLAN ADMINISTRATOR INFORMED OF ADDRESS CHANGES In order to protect your family's rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator or COBRA Administrator. NON-OCCUPATIONAL COVERAGE The accident and health coverage provided under this Plan is non-occupational and any reference to Illness or Injury in the following benefit sections means only non-Occupational Illness or Injury.
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MEDICAL PLAN SCHEDULE OF BENEFITS Following is a summary of benefits under the Plan. This summary is subject to all other provisions, conditions, limitations, and exclusions of the Plan Document. IMPORTANT Benefits are only payable under this Plan for expenses which are Eligible Charges (defined in the Eligible Charges section of this document) arising from Medically Necessary treatment of an Illness or Injury and which are defined further in this Plan Document. All maximum benefits whether expressed as overall, yearly or otherwise, refer to the maximum benefits payable for the period specified only for Eligible Charges incurred while the Covered Person is covered under this Plan. COMPREHENSIVE MEDICAL EXPENSE BENEFIT HWHN Network USA-MCO Network NonNetwork
Annual Dollar Limit on Essential Health $2,000,000 $1,500,000 $1,000,000 Benefits The Annual Dollar Limit on Essential Benefits is integrated for all three Network Levels. Amounts applied toward one Networks Annual Dollar Limit on Essential Benefits will also be applied to the other two Networks Annual Dollar Limit on Essential Health Benefits. For all three Network levels combined, the Annual Dollar Limit on Essential Health Benefits for any one Covered Person is $2,000,000. Plan Year Deductible $2,000 $1,000 $500 Per Covered Person Basic Option $4,000 $2,000 $1,000 Per Family (aggregate) Basic Option Per Covered Person Standard Option Per Family (aggregate) Standard Option Per Covered Person High Option Per Family (aggregate) High Option $250 $500 $100 $200 $500 $1,000 $300 $600 $1,000 $2,000 $1,000 $2,000
Amounts applied to the deductible for charges from HWHN Network Providers will be used to satisfy the deductible for charges from USA-MCO Network Providers and vice versa. However, amounts applied to the deductible for charges from Non-Network Providers will not count toward satisfaction of the HWHN or USA-MCO deductibles. Any deductible, co-pay for NonWellmont Hopsitals in Northeast TN and Southwest VA will not count towards the Out-ofPocket.
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HWHN Network Maximum Out-of-Pocket Expense per Plan

year due to Eligible Charges (except cost containment penalties) excluding any deductibles and copayments Per Covered Person Basic Option Per Family per Plan year (aggregate) Basic Option Per Covered Person Standard Option Per Family per Plan year (aggregate) Standard Option Per Covered Person High Option Per Family per Plan year (aggregate) High Option
USA-MCO Network
NonNetwork
$3,000 $6,000
$6,000 $12,000
$10,000 N/A
$2,000 $4,000
$4,000 $8,000
$8,000 N/A
$1,500 $3,000
$3,000 $6,000
$8,000 N/A
Amounts applied to the Maximum Out-Of-Pocket Expense for charges from HWHN Network Providers will be used to satisfy the Maximum Out-of-Pocket Expense for charges from USAMCO Network Providers and vice versa. However, amounts applied to the Maximum Outof-Pocket Expense for charges from NonNetwork Providers will not count toward the HWHN or USA-MCO Maximum Out-of-Pocket Expense. Emergency Room Facility Charges Non-medical Emergency
50% after $75 co-pay and Deductible 100% after $75 co-pay Deductible waived
Emergency Room Facility Charges Medical Emergency
Emergency Room Physician Charges Coinsurance and deductible are waived if use of the Emergency Room is due to a Medical Emergency or if the patient is admitted to the Hospital from the Emergency Room. Ambulance Air (prior authorization required for non-Life Threatening Air transports) Ambulance - Land
100%, Deductible waived 100%, Deductible waived
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HWHN Network Physician Office Visit Charge Only

Does not include diagnostic x-ray and laboratory services, injections, and other covered services provided and billed by the Physician
USA-MCO Network 100% after Copayment, Deductible waived $35 $45
COPAYMENT: Primary care physician Specialist Outpatient Non-Preventive Diagnostic X-ray, Testing, and Laboratory Services Technical/Professional Fees when billed in conjunction with an Office Visit Basic & Standard Options
100% after Copayment, Deductible waived $25 $35
n/a n/a
80% Deductible waived 90% Deductible waived 100% after deductible
High Option Outpatient Surgeon Fee when surgery is performed in the Physicians Office Outpatient Non-Preventive Diagnostic X-ray, Testing, and Laboratory Services Physician Fee Basic & Standard Options
80% Deductible waived 90% Deductible waived
High Option Outpatient Non-Preventive Diagnostic X-ray, Testing, and Laboratory Services Facility Fee Basic & Standard Options
High Option All Physicians that refer members for Outpatient Non-Preventive Diagnostic X-ray, Testing, and Laboratory Services Facility Fee Basic & Standard Options
High Option
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HWHN Network Outpatient Surgeon Fee when surgery is performed in other than a Physicians office $75 co-pay, then 100% Deductible waived
USA-MCO Network $100 co-pay, then 60% after deductible
Outpatient Surgical Facility

Wellmont Facility or Endoscopy Center of Bristol or Kingsport Endoscopy Corporation Wellmont Hawkins County Memorial Hospital Bristol Surgery Center Holston Valley Ambulatory Surgery Center Sapling Grove Surgery Center Renaissance Surgery Center
$100 co-pay, then 100% Deductible waived
N/A
N/A
Anesthesia - Outpatient Associated with a procedure performed in the above listed facilities Non-Wellmont Outpatient Surgical Facility
100% Deductible waived $600 co-pay, then 100% after deductible 100% after deductible
N/A
N/A
$650 co-pay, then 60% after deductible 60% after deductible
Anesthesia - Outpatient Associated with a procedure performed at a Non-Wellmont Facility Inpatient Hospital Basic & Standard Options
80% deductible waived 90% deductible waived
High Option
Note: Effective 5/15/2011 Non-Wellmont hospitals in Northeast TN and Southwest VA will be paid at 30% regardless if they are a USA/MCO hospital and will not accumulate towards the out-of-pocket. Hospital Room & Board Allowance Semi-Private .................................. Up to Hospital's Most Common Semi-Private Room Rate Intensive Care .........................................................................Up to Hospital's Actual Charge *Private .......................................... Up to Hospital's Most Common Semi-Private Room Rate *In the event the Hospital has only Private Room accommodations and does not, therefore have a Most Common Semi-Private Rate, the Hospital's Most Common Private Room Rate will be considered an eligible expense. Second Surgical Opinion 100% after $35 co-pay 60% after $40 co-pay 50% after deductible
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HWHN Network Physician Fees In-Hospital Expenses (Includes surgery) Anesthesia - Inpatient Basic & Standard Options High Option Pregnancy/Maternity (Physician Fees only) 80% after deductible 90% after deductible 100% after deductible 100% after deductible
Physical Therapy, Speech Therapy and Occupational Therapy (prior authorization required) Combined Network and Non-Network Plan Year Maximum: 60 outpatient treatment days per disability combined benefit maximums. To receive the highest level of benefits a Wellmont-owned facility (billing tax ID #s: 62-1636465, 51-0603966, or 62-1816368) must be utilized. Physical Therapy (prior authorization required) Basic & Standard Options High Option Speech Therapy (prior authorization required) Basic & Standard Options High Option Occupational Therapy (prior authorization required) Basic & Standard Options High Option Dialysis Basic & Standard Options High Option Wig after Chemotherapy One wig per lifetime Basic & Standard Options High Option Subject to the HWHN deductible, then 100% Subject to the HWHN deductible, then 100% 80% after deductible 90% after deductible 60% after deductible 60% after deductible 50% after deductible 50% after deductible 80% after deductible 90% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 80% after deductible 90% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 80% after deductible 90% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible
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HWHN Network Medical and Nutritional Therapy Orthotics (prior authorization required) Diabetic Shoes and inserts (prior authorization required) Prosthetics (prior authorization required) Diabetes Educational Training Contraceptive Management Office Visit 100% after deductible 100% after deductible 100% after deductible 100% after deductible
Injections, Implants, Intrauterine Device, Diaphragm Over the Counter Contraceptives Please Note: Birth control pills and patches are covered under the pharmacy benefit plan. Chiropractic Treatment Copayment per visit Maximum payable per Covered Person per Plan Year.....................$500 Temporomandibular Joint Dysfunction (TMJ) Surgical & Non-surgical Overall Maximum Benefit.. $2,500 Infertility Treatment Diagnosis or Treatment Durable Medical Equipment (prior authorization required for charges over $500.00) CPAP and BiPAP Masks Limited to 1 every 6 months Mental or Nervous Disorders/Substance Abuse Inpatient Physician/Provider Inpatient Hospital Basic & Standard Options
100% after 60% after Not deductible deductible Covered If part of wellness visit, payable under Routine Physical Examination Physician Fee. If separate from wellness visit, payable as Physician Office Visit. 50% after 60% after 100% after deductible deductible deductible Not Covered Not Covered Not Covered
100% after deductible 80% deductible waived 90% deductible
60% after deductible 60% after deductible 60% after deductible
50% after deductible 50% after Deductible 50% after deductible
High Option
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HWHN Network waived
USA-MCO Network
Non-Network
Outpatient Physician/Provider(Specialist)
50% after 100% after 100% after Deductible $45 $35 copayment; copayment; deductible deductible waived waived 60% after $75 50% after $75 100% after Hospital Emergency Room Services Copayment copayment; $75 (Non-emergency) and deductible copayment; Deductible waived deductible waived 100% after 100% after Intensive Outpatient Program 50% after $100 copay; $100 copay; Copay is per program deductible Deductible Deductible waived waived Residential Treatment/Partial Day Programs will be excluded under the Plan. The following will be excluded; providers/facilities: Social workers and day/night psychiatric facilities. If a member chooses, they may access 5 free visits per issue thru the Horizon Behavioral Service Employee Assistance Program by calling Horizon at 1-800955-6422. Chemotherapy/Radiation Basic & Standard Options High Option Cardiac & Pulmonary Rehab Basic & Standard Options 80% after deductible 90% after deductible 80% after deductible 90% after deductible 60% after deductible 60% after deductible 60% after deductible 60% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible
High Option CyberKnife (prior authorization required-only available at a WHS facility) Basic & Standard Options High Option CTA (only available at a WHS facility or HWHN provider) Basic & Standard Options High Option Skilled Nursing Facility Basic & Standard Options
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N/A N/A
N/A N/A
80% after deductible 90% after deductible 80% after
N/A N/A 60% after
N/A N/A 50% after
HWHN Network deductible High Option Maximum visits USA-MCO/Non-Network combined per Plan Year Hospice Care Home Health Care (prior authorization required) All other COVERED expenses not specifically listed in the Schedule of Benefits Basic & Standard Options High Option Preventive Services Covered Services on the HWHN recommended schedule 90% after deductible N/A 100% after deductible 100% after deductible 80% after deductible 90% after deductible 100% Deductible waived
USA-MCO Network deductible 60% after deductible 60 visits 60% after deductible 60% after deductible 60% after deductible 60% after deductible 60% Deductible waived
Non-Network deductible 50% after deductible 60 visits 50% after deductible 50% after deductible 50% after deductible 50% after deductible
All other covered routine services not listed on the recommended HWHN schedule Basic & Standard Options High Option
80% after deductible 90% Deductible waived
Note: the HWHN Schedule includes all of the items listed on the US Preventive Task Force Guide to Clinical Preventive Services COST CONTAINMENT PROVISIONS Admission Certification (Applicable to All Providers) Admission Certification is required for HWHN, USA-MCO Network, & Non-Network Providers. Failure to obtain certification will result in a $500.00 non-compliance penalty. Day Prior Admissions Admission prior authorization is required. This provision does not apply to emergency admissions. Emergency Admissions, including admissions required as a result of complications from an outpatient procedure Certification is required within 24 hours of the patients admittance or by the end of the next business day. Durable Medical Equipment If DME equipment is required on a weekend, prior authorization is required by the end of the next business day.
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COMPREHENSIVE MEDICAL EXPENSE BENEFIT PLAN YEAR DEDUCTIBLE The deductible is stated in the Schedule of Benefits for the Medical Plan. This amount of each Covered Person's Eligible Charges must be satisfied each Plan Year before benefits become payable under the Plan. It is important to note that certain payments, such as office visit copayments, do not apply towards satisfying the Plan Year Deductible. After the deductible has been satisfied, the Plan will pay the benefits as set forth in the Schedule of Benefits for the rest of the Plan Year. The Employee will have to pay the balance for each Covered Person. No more than the total amount per family unit as stated in the Schedule of Benefits is required to be paid toward satisfying the Plan Year Deductible in a given Plan Year. After that, the deductible for each Covered Person in that family will be considered as having been satisfied for that Plan Year. EMERGENCY ROOM COPAYMENT A Covered Person must pay the Copayment as stated in the Schedule of Benefits each time outpatient treatment is received in a Hospital emergency room. The Copayment and Deductible will be waived if treatment received is due to acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual, or with respect to a pregnant woman, the health of the woman or unborn child, in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. Examples include such conditions as heart attacks, cardiovascular accidents, poisonings, loss of consciousness or respiration, convulsions, or other such acute medical conditions for which treatment could not be reasonably sought from a Physician's office, clinic, or other free standing facility. The Copayment will also be waived if the patient is admitted to the Hospital immediately following the emergency room treatment. HWHN OR USA-MCO PHYSICIAN SERVICES Covered charges for a HWHN or USA-MCO Physician office visit will be subject to the Copayment stated in the Schedule of Benefits. Only one Copayment per office visit will be applied to the Physicians charge for the office visit. Any injections, diagnostic x-rays, laboratory procedures, and other covered services performed in the Physicians office and billed by the Physician during that visit will be paid as stated in the Schedule of Benefits. Other covered services rendered outside the Physicians office will be payable as stated in the Schedule of Benefits. When covered services are rendered in a HWHN or USA-MCO Hospital by an anesthesiologist, radiologist or pathologist who is not a HWHN or USA-MCO Provider, the benefit percentage will be that stated in the Schedule of Benefits for Network Providers. MEDICAL EMERGENCY SERVICES (Outpatient treatment only) When a Covered Person receives treatment or services as a result of a Medical Emergency, eligible outpatient expenses will be paid on the basis of a HWHN provider, whether or not such services were performed by a HWHN provider. However, the allowable charge will be determined based on the Usual and Customary Charge for the service or supply. The Covered Person is responsible for amounts exceeding the Usual and Customary Charge. Inpatient treatment or services must be precertified. NON-HWHN PROVIDERS
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Any service or supply received from a Non-HWHN Provider will be paid according to the provisions stated in the Schedule of Benefits unless the Plan Administrator approves the documented service or care. Any service or supply received from a Non-HWHN Provider as the direct result of a referral authorized by HWHN Case Care will be reimbursed consistent with the HWHN level of benefits in the Schedule of Benefits. However, the allowable charge will be determined based on the Usual and Customary Charge for the service or supply. The Covered Person is responsible for amounts exceeding the Usual and Customary Charge. MAXIMUM OUT-OF-POCKET EXPENSE The maximum out-of-pocket expense for Eligible Charges in any Plan Year for a Covered Person will be the amount listed in the Schedule of Benefits. The maximum out-of-pocket expense is the dollar amount of eligible charges that (after Plan benefits have been paid) are the Covered Person's responsibility. The HWHN and USA-MCO Provider maximum can be satisfied by a combination of HWHN and Participating Provider's Eligible Charges. However, the Non-Network maximum must be satisfied independently. Charges in excess of the out-of-pocket amount (except as stated below) will be paid at 100% for the remainder of the Plan Year. Expenses incurred for treatment, services, or purchases which are not Eligible Charges, plan deductibles, Eligible Charges which exceed any plan maximums or exceed the Usual and Customary Charge, prescription drug Copayments, or Mental and Nervous, Alcohol, Drug and Substance Abuse expenses will NOT go toward satisfying the Maximum Out-of-Pocket Expense nor will such charges ever be paid at 100% under the Plan. No more than the total amount per family unit as stated in the Schedule of Benefits is required to be paid in a given Plan Year. After that, the Maximum Out-of-Pocket Expense for each Covered Person in that family will be considered as having been satisfied for that Plan Year. OVERALL MAXIMUM BENEFIT The Plan's Overall Maximum Benefits are stated in the Schedule of Benefits and consists of Plan payments for all Eligible Charges incurred by a Covered Person during that person's eligibility, while under this plan. However the HWHN and USA-MCO Overall Maximums are satisfied by a combination of HWHN, USA-MCO, and Non-Network Provider's payments with the overall maximum being $2,000,000. PRE-EXISTING CONDITIONS NOTE: The length of the Pre-Existing Conditions Limitation may be reduced or eliminated if an eligible person has Creditable Coverage from another health plan. However, coverage before a 63-day period during all of which an individual had no Creditable Coverage cannot be used to reduce the length of a Pre-Existing Conditions Limitation. An eligible person may request a certificate of Creditable Coverage from his or her prior plan within 24 months after losing coverage and the Employer will assist any eligible person in obtaining a certificate of Creditable Coverage from a prior plan. A Covered Person will be provided a certificate of Creditable Coverage if he or she requests one either before losing coverage or within 24 months of coverage ceasing. If, after Creditable Coverage has been taken into account, there will still be a PreExisting Conditions Limitation imposed on an individual, that individual will be so notified.
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Eligible Charges incurred by a Covered Person for Pre-Existing Conditions are not payable unless incurred 12 consecutive months after the person's Enrollment Date. This time may be offset if the person has Creditable Coverage from his or her previous plan. However, coverage before a 63-day period during all of which an individual had no Creditable Coverage cannot be used to reduce the length of a Pre-Existing Conditions Limitation. A Pre-Existing Condition is a condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the person's Enrollment Date under this Plan. Genetic Information is not a condition. Treatment includes receiving services and supplies, consultations, diagnostic tests, or prescribed medicines. In order to be taken into account, the medical advice, diagnosis, care, or treatment must have been recommended by, or received from, a Physician. The Pre-Existing Condition does not apply to pregnancy, to a newborn child who is covered under any Creditable Coverage within 30 days after birth, or to a child who is adopted or placed for adoption before attaining age 18 and who is covered under any Creditable Coverage within 30 days after adoption or placement for adoption. A Pre-Existing Condition exclusion may apply to coverage before the date of the adoption or placement for adoption. The prohibition on Pre-Existing Condition exclusion for newborn, adopted, or pre-adopted children does not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any Creditable Coverage. ELIGIBLE CHARGES Charges for the Medically Necessary care of a covered Illness or Injury. Such charges will be covered if incurred by a Covered Person while under the care of a legally qualified Physician and while covered under the Plan's Comprehensive Medical Expense Benefit. Not all charges are covered. (See Medical Exclusions and Limitations). A Covered Person should contact the Plan Administrator to obtain additional information, free of charge, about Plan coverage of a specific benefit, particular drug, treatment, test, or any other aspect of Plan benefits or requirements. The following are Eligible Charges: 1. Room and board and routine nursing services for each day of confinement in a Hospital, including a Birthing Center up to the amounts specified in the Schedule of Benefits. 2. Medical services and supplies furnished by a Hospital. 3. Anesthetics and their administration. 4. Physician's fees for medical or surgical treatment. 5. Services of a registered nurse (RN), a licensed practical nurse (LPN), Nurse Practitioner (NP), or a licensed physiotherapist if recommended by a Physician. 6. Diagnostic X-ray examination, other than dental. 7. Radiation therapy and chemotherapy. 8. Diagnostic, laboratory, microscopic tests, and other diagnostic services. 9. Air and ground ambulance will be covered in cases of Medical Emergency from the place where the Injury or Illness occurred to the nearest Hospital which has equipment to furnish special treatment required for such Illness or Injury. Transportation by commercial airline is not covered. Transportation by ambulance in other situations may be covered with prior authorization. 10. Medical supplies ordered in writing by a Physician as follows:
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a. Drugs and medicines which require a written prescription by a Physician and are consumed or administered in the Physicians office or while an inpatient in a Hospital or other health care facility. Outpatient prescription drugs are payable under the Prescription Drug Program section of this Plan; b. Unreplaced blood and other fluids to be injected into the circulatory system; c. Casts, splints, trusses, braces (except dental braces), crutches, and surgical dressings; d. Initial prosthetic appliance needed to replace all or part of an absent or malfunctioning body part; however, the replacement of such item is not a covered expense unless due to pathological or physiologic changes, normal growth, or unintentional damage due to an accident; e. The lesser of the purchase price or the rental cost of Durable Medical Equipment including wheel chair, Hospital bed, and equipment for the treatment of respiratory paralysis. This also includes charges for repair of the equipment if the repair allows continued use of the equipment for a reasonable length of time. Replacement of the equipment is allowed if the initial equipment is no longer serviceable, the need is still deemed to be Medically Necessary, or a replacement is needed because of a change in the patients condition or physical change such as growth. Durable Medical Equipment also includes diabetic supplies such as blood glucose test strips, urine glucose test strips, lancets, insulin pump needles, glucose monitors, and lancet devices. Charges for maintenance services as well as supplies needed to use or maintain the equipment on an ongoing basis, such as belts, bulbs, filters, etc., are not considered an eligible expense. The purchase or rental of Durable Medical Equipment, which exceeds $500 in cost, must receive prior authorization. Refer to the section entitled Prior authorization/Certification for further details. f. CPAP & Bi-PAP Masks are limited to one in any six month period. If the purchase price exceeds $500, prior authorization must be received. Refer to the section entitled Prior authorization/Certification for further details.
g. Oxygen and rental of equipment for administration of oxygen; h. A wig following chemotherapy or radiation treatment, limited to one. i. j. Breast prosthesis and bra following mastectomy. Replacement is limited to one breast prosthesis every two Plan Years and two bras every Plan Year. Orthotic devices. The initial purchase, fitting, and repair of orthotic appliances such as braces, splints, or other appliances required for support for an injured or deformed part of the body as a result of a disabling congenital condition or an Injury or Sickness. This Plan does cover Orthotics for the foot, i.e., custom-molded shoe inserts that are used to support and reposition the heel, arch, muscles, ligaments, tendons, and/or bones in the feet, and Orthotics used to treat plantar fasciitis.
11. Charges for or in connection with dental treatment but only to the extent that the dental work is made necessary by Accidental Injury to sound natural teeth. As to dental work which is covered, a duly licensed dentist is considered to be a Physician. However, Facility or Anesthesia charges made in connection with any Case Care approved Dental services will be covered. 12. Charges for pregnancy, childbirth, or related medical conditions. The Hospital stay following a vaginal delivery generally will not be less than 48 hours for the mother (if a Covered Person) and the newborn child (if a Covered Person). A Hospital stay in connection with childbirth following a cesarean section generally may not be limited to less than 96 hours for the mother (if a Covered Person) and the newborn child (if a Covered Person). Federal law generally does not prohibit the mothers or newborns attending
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provider, after consultation with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In addition, the Plan may not, under federal law, require that a Physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 (or 96) hours. However, the Plan requires the attending Physician, the patient, the patients family member, or the medical care facility to notify HWHN Case Care of the estimated delivery date as soon as reasonably possible and within 24 hours after the admission. Obstetric hospitalizations that exceed the 48 (for vaginal delivery) or 96 (for cesarean section delivery) hour time periods and any services that are not associated with the delivery must receive prior authorization as set forth in this document. NOTE: When the delivery occurs outside a Hospital, the Hospital length of stay begins at the time the mother or newborn is admitted as a Hospital inpatient in connection with childbirth. The attending provider will determine whether the admission is in connection with childbirth. 13. Charges for reproductive sterilization procedures (however, sterilization reversal procedures are not covered) but only for the Employee or the spouse of the Employee. 14. Charges for cosmetic or reconstructive procedures and any related services or supplies, which alter appearance and/or improve normal bodily function as follows: a. Due to and within two years of an Accidental Injury. b. Repair following surgery performed due to an Illness (excluding correction of cosmetic abnormalities resulting from significant weight loss, whether due to obesity surgery or other weight loss programs). c. Due to a congenital anomaly affecting the bodily function of a child. A group health plan generally must, under federal law, make certain benefits available to a Covered Person who has undergone a mastectomy. This Plan complies with federal law by providing mastectomy patients benefits in connection with such mastectomy for: a. b. c. reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; breast prosthesis (includes implants, and external prosthesis (replacement is covered once every two Plan Years), and holding bra (replacement is covered twice every Plan Year); and treatment of physical complications resulting from the mastectomy, including lymphedemas.
d.
Benefits for these items generally are comparable to those provided under this Plan for similar types of medical services and supplies. The extent to which any of these items is appropriate following a mastectomy is a matter to be determined by consultation between the attending Physician and the patient. This Plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. 15. Chiropractic services as stated in the Schedule of Benefits including but not limited to treatment of Skeletal Adjustments. 16. Charges for total enteral and parenteral nutrition. 17. Hospital and Physician's charges for the routine care of a newborn infant, including circumcision, during the mother's initial confinement. Dependent coverage must be in force at the time of birth of the infant or added within 60 days following birth. Eligible Charges will be covered under the Childs coverage.
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18. Temporomandibular Joint (TMJ) Disorder Eligible charges for treatment or service for temporomandibular joint disorder or TMJ pain syndrome will be paid at the percentage and up to the limits stated in the Schedule of Benefits. Treatment is limited to diagnostic procedures, and surgical procedures to correct jaw joint problems, craniomandibular disorder or other conditions of the joints linking the jawbone and skull, including the complex of muscles, nerves and other tissues related to that joint. It does not include dental appliances, dental fixed or removable bridgework or dentures, inlays, onlays, crowns, implants, or equilibrations. 19. Surgical removal of impacted wisdom teeth. 20. Expenses incurred for the initial testing to determine the cause and diagnosis of sleep disorders. Subsequent treatment is limited to only those charges for outpatient treatment of acute insomnia disorders (but not chronic insomnia), and charges for inpatient and outpatient treatment of life threatening sleep disorders. 21. Allergy injections. 22. Speech therapy for a residual speech impairment resulting from stroke, accidental Injury, or surgery to the head or neck. Congenital and developmentally delayed psychosocial speech delay or dysfunction, including stuttering, is also covered; however, if therapy is required because of a congenital anomaly, the Covered Person must have had corrective surgery, if appropriate, before the therapy. Expenses related to special educational needs are not covered. Speech Therapy in the treatment of autism, behavior problems, ADHD, conceptual handicap or mental retardation is not considered an eligible expense. As used in this section, Speech Therapist means an audiologist who possesses a masters or doctorate degree in audiology and speech pathology from an accredited university, a certificate of clinical competence in audiology from the American Speech and Hearing Association, and a license from the state in which he or she practices (where required). 23. Occupational therapy. 24. Rehabilitative therapy. 25. Cardiac rehabilitation as deemed Medically Necessary provided services are rendered (a) under the supervision of a Physician; (b) in connection with a myocardial infarction, coronary occlusion, or coronary bypass surgery; (c) initiated within 12 weeks after other treatment for the medical condition ends; and (d) in a Medical Care Facility as defined by this Plan. 26. Charges for infertility, diagnostic testing and treatment up to the limits specified in the Schedule of Benefits. Benefits are provided for extraction of eggs/sperm for Covered Persons. Implantation of fertilized eggs/sperm will be covered only when the recipient is a Covered Person under the Plan. 27. Charges for office visit and audiological testing for the diagnosis of hearing loss. 28. Counseling services related to eating disorders provided under the mental/nervous benefits. 29. Organ transplants deemed Medically Necessary, as defined, subject to prior approval by Case Care. The surgery must be performed by a transplant center approved by the Plan. The donor, the donor recipient and the transplant surgery must meet the medical selection criteria of the Plan, and prevailing medical standards. Transplants are reviewed with regard to Medical Necessity, Case Care recommendations, and Physician documentation. Surgical or medical care related to Experimental transplants, animal organ transplants, and artificial organ or mechanical organ transplants are not considered eligible. If the recipient is a Covered Person, but the donor is not, both donor and recipient
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expenses are covered, but the donor charges will be considered covered only to the extent not covered by the donor's plan. If the donor is a Covered Person but the recipient is not, the donor charges will not be considered covered expenses. If both recipient and donor are Covered Persons, covered expenses incurred by each will be treated separately for each person. Benefits for such charges, services, and supplies are not provided under this provision if benefits are provided under another group Plan or any other group or individual contract or any arrangement of coverage for individuals in a group (whether an insured or uninsured basis), including any prepayment coverage. 30. Charges for medical Nutrition Therapy Services provided by a Physician or upon referral by a Physician to a licensed and/or registered dietitian or nutritionist. In order for these services to be covered, the service must be ordered and certified Medically Necessary by a Physician: (a) upon diagnosis of a covered medical condition, (b) because of a significant change in the Covered Persons symptoms or condition which necessitates changes in the Covered Persons self-management, or (c) re-education or refresher training. 31. Charges for routine preventive services. Refer to the HWHN Recommended Pediatric Preventive Services Schedule and the HWHN Recommended Adult Preventive Services Schedule for a listing of recommended services. These schedules are printed in the Flexible Benefits Program Enrollment Workbook. Preventive services performed that are not on the HWHN recommended schedule (with the exception of all related services that a member has with the diagnosis of family history) are subject to a reduction in benefits as stated in the Schedule of Benefits. 32. Charges for diabetic counseling services as follows: Outpatient self management training and medical nutrition counseling provided by a Physician, or upon referral by a Physician to a licensed registered nurse, licensed dietitian, licensed pharmacist, or other licensed professional who has expertise in diabetes management as determined by the Plan Administrator. In order for professional services to be covered, the services must be certified by a Physician to be Medically Necessary to prevent an immediate negative impact on the health of the covered person: (a) upon diagnosis of diabetes, or (b) because of a significant change in the covered persons symptoms or condition which necessitates changes in the covered persons selfmanagement. Services rendered by a Non-Network Provider will not be covered. COST CONTAINMENT PROVISIONS SECOND SURGICAL OPINION When an elective non-emergency surgical procedure is recommended, the Covered Person may obtain a second opinion. The second opinion and any related tests obtained from the Physician of the Covered Person's choice will be paid as shown in the Schedule of Benefits of the Usual and Customary charge as determined by the Plan Administrator. The second opinion does not have to agree with the first opinion. The Covered Person may also obtain a third opinion and it will be covered the same as the second opinion. The Physician giving the second or third opinion(s) must not practice in the same office with the Physician(s) who gave the previous opinion(s). All surgical opinions must be rendered by a Physician specializing in the appropriate field.
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MULTIPLE SURGICAL EXPENSES If two or more operations or procedures are performed at the same time the total amount payable for such operations or procedures will be paid at the percentages indicated in the Schedule of Benefits of the Usual and Customary charges, as defined, for the first and 50% of Usual and Customary charges for the second and subsequent procedures; and SURGICAL ASSISTANCE SERVICES For Medically Necessary service of one Physician who actively assists the operating surgeon when a covered Surgery is performed in a Hospital or an Outpatient Surgical Facility, and when such surgical assistance service is not available by an intern, resident or house Physician, the Plan will provide benefits equal to 50% percent of the allowance for the Surgery, not to exceed the Physicians actual charges. PRE-ADMISSION TESTING Physician's charges and any tests performed on an inpatient basis will be reimbursed at the rate indicated in the Schedule of Benefits for all other Eligible Charges if Medically Necessary X-ray and laboratory tests are done in connection with and within 72 hours before admission to the Hospital for scheduled surgery. The requirement that admission occur within 7 days of the tests will be waived if the admission is cancelled due to test results or if the surgery is performed on an outpatient basis. PRIOR AUTHORIZATION The Covered Person will be responsible to notify his/her Physician of this prior authorization program, by showing the Physician his/her identification card. The attending Physician or his/her designee is responsible for obtaining prior authorization as required by the Plan. Prior authorization may be completed by calling HWHN Case Care at (423) 844-4166 or 1-800-8443730. Case Care hours of operation are Monday through Friday, from 8:00 a.m. until 4:30 p.m., except for legal holidays. Confidential voice mail is available for submitting prior authorization requests after office hours. The request for prior authorization may also be submitted by facsimile at (423) 793-0006. HWHN Providers The Covered Person will not be at risk for failure of the attending Physician to adhere to this prior authorization/certification Policy. Non-HWHN Providers (USA-MCO and Non-Network Providers) Failure of the attending Physician to complete prior authorization of healthcare services in nonemergent situations where Medically Necessary services could have been rendered by an HWHN Provider, as prescribed by this plan will exclude the Covered Person from the increased benefit as defined in the Schedule of Benefits. The penalty for failure to precertify inpatient admissions will apply only to the hospital facility charge for the inpatient stay.
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The following procedures/services will require prior authorization with HWHN Case Care: Failure to obtain prior authorization will result in a $500.00 non-compliance penalty. If no prior authorization is obtained, the claim will be denied with the following comment: Medical Necessity has not been established due to Prior Authorization not being obtained; please contact Case Care. Note: The penalty of $500.00 for non-compliance will apply per claim. If a retro review is obtained and the services are deemed to be medically necessary by Case Care, the penalty will still apply up to the authorization date. Ambulance air (in the case of a Medical Emergency, certification is required within 24 hours of the patients arrival at the treating facility or by the end of the next business day) Any procedure for which a procedure code does not exist Anesthesia for dental procedures at an outpatient surgery center Botox injections Breast Reduction Cyber Knife procedure (Note: If precertified, the service is covered only if performed in a WHS facility) Diabetic Shoes and inserts Durable Medical Equipment in excess of $500 Home Health Care Hysterectomy All Infertility Services Inpatient Admissions OB Care Occupational Therapy Organ Transplant P.E.T. Scans Physical Therapy Prosthetics Removal of excess skin as a direct result of the treatment of morbid obesity or as a result of a gastric bypass procedure Rhinoplasty Speech Therapy Weight Reduction Surgery (including gastric bypass and banding procedures)
Prior authorization procedures: (This procedure is to be applied to the above procedures or services when defined as non-urgent or routine in nature.) Prior authorization Procedures: 1. The attending Physician when applicable contacts HWHN Case Care by phone or facsimile preferably five days prior to a scheduled procedure/service, and not less than 48 hours or two business days prior to a scheduled non-urgent or routine procedure/service. The following information is needed to process a prior authorization: a. Patients name and age b. Patients address c. Covered Persons name d. Covered Persons ID number e. Claim Administrators name f. Consulted Physicians name if applicable g. Patient diagnosis and history (including results of previous treatments and/or tests)
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2.
h. Date and location (facility) where the procedure/service will occur i. Patient status during the procedure/service, i.e. Inpatient or Outpatient. Notification of Elective In-Patient Admissions: The attending Physician is responsible to notify HWHN Case Care of all elective (non-urgent & routine) procedures, treatments, and care requiring in-patient hospitalization. The Case Care office should receive notification of elective in-patient admissions as soon as scheduled. Failure of the provider to notify Case Care of an elective inpatient admission will result in a $500 noncompliance penalty. Certification of Emergency In-Patient Admissions The attending Physician or his/her designee is responsible to notify HWHN Case Care of the patients admission to an acute care facility, within 24 hours of the patients arrival or by the end of the next business day. Continued In-Patient Stay Reviews for Emergency Admissions 1. Based on the number of days certified by Case Care, the attending Physician will be responsible to provide additional clinical data to support the approval of additional days. Failure to request additional days or obtain certification could result in a delay of payment, a reduction of benefits, and/or possible administrative sanctions for the attending Physician. If certification criteria continue to be met, Case Care will continue to assign approval to the in-patient days. The patients medical treatment and recovery will be continuously monitored to assist in determining the need to remain in the Hospital. When medically feasible, while ensuring patient safety and maintaining the same level of quality in services, alternate cost effective levels of care will be suggested by Case Care to the attending Physician. When certification of on-going services is in progress and Case Care identifies a lack of criteria to complete certification, the attending Physician and Facility, as appropriate, will be notified.
2. 3.
4.
Maternity Review The attending Physician is responsible to notify HWHN Case Care of a pregnancy once the expected date of confinement has been determined. In addition, the attending Physician or the Covered Person when applicable is responsible to notify HWHN Case Care of the admission for delivery within 24 hours of the admission. On-going certification of in-patient days that exceed the 48 (for vaginal delivery) or 96 (for cesarean section delivery) hour time periods permitted by law will be processed in the same manner as described above in the Continued In-Patient Stay Review.
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Retroactive Review 1. HWHN will allow the attending Physician to submit retroactive reviews. 2. Requests may be received telephonically, by facsimile, or by mail within 60 days of the completion of services. 3. The attending Physician must have the following information in order for Case Care to verify eligibility and begin the retroactive review process. a. Patients name, age and address b. Covered Persons name and ID number c. Claims Administrators name d. Attending Physicians name e. Consulted Physicians name, if applicable f. Medical Condition, treatment, or procedure being reviewed. g. Date of treatment, from beginning to end h Supporting information from the medical record i. A verbal or written statement from the attending Physician indicating medical rationale for procedure/services to be provided. OUTPATIENT SURGERY All facility charges related to the outpatient surgery, rendered on the day of surgery will be paid as shown in the Schedule of Benefits, at Usual and Customary Charge. HOSPICE CARE Hospice Care services are covered for palliative and supportive care furnished to a terminally ill Covered Person under a Hospice Care Program. Palliative and supportive care means care and support aimed mainly at lessening or controlling pain or symptoms and makes no attempt to cure the Covered Persons terminal Illness. The Covered Person's attending Physician must certify that the Covered Person is terminally ill and suffering from a condition which results in a life expectancy of six months or less. Such person will be eligible for up to six months of Hospice Care in a Hospice Facility or by a Hospice Care Agency. Benefits will be paid as shown in the Schedule of Benefits. Hospice services include: 1. 2. 3. 4. 5. 6. 7. skilled nursing services by or under the direction of a Registered Nurse (R.N.). medical social services. psychological and dietary counseling. services of a Physician. physical, speech, or occupational therapy when rendered by a licensed therapist. part-time home health aide services which consist of caring for terminally ill persons. inpatient care in a facility when needed for pain control and acute and chronic symptom management. 8. drugs and medicines under the direction of a Physician for palliative care and the administration of such drugs. 9. medical supplies and equipment. If the Covered Person lives more than 6 months, the attending Physician must again certify in writing that the Covered Person is still terminally ill and as to the life expectancy. Extension of coverage under this section must be approved by HWHN. If, at any time, the terminally ill patient is deemed no longer terminally ill and thus does not qualify for Hospice benefits, the Covered Person will be eligible for other home care services if skilled care is required. HOME HEALTH CARE Home Health Care expenses will be paid as stated in the Schedule of Benefits. A Home Health
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Care Plan is a program for continued care and treatment of the Covered Person which is established and approved in writing by such Covered Person's attending Physician and is in place of or begins following termination of a Hospital confinement as a resident inpatient and is for the same or related condition for which the person was or would have been hospitalized. The attending Physician must certify that the proper treatment of the disease or injury would require admission to or continued confinement as a resident in-patient in a Hospital in the absence of the services and supplies provided as part of the Home Health Care Plan. Eligible Charges for Home Health Care benefit: 1. Nutritional counseling provided by or under the supervision of a registered dietitian; 2. Part-time or intermittent nursing care by a Registered Graduate Nurse or, if the services of a Registered Graduate Nurse are not available, by a Licensed Practical Nurse; 3. Physical, occupational, respiratory, or speech therapy; and 4. Medical supplies, drugs and medications prescribed by a Physician, and laboratory services provided by or on behalf of a Hospital, if such supplies and services would be covered under the Plan if the Covered Person was Hospital confined. 5. Each visit by a home health nurse of up to four (4) consecutive hours in a twenty-four (24) hour period shall be considered as one (1) Home Health Care visit. The Home Health Care benefit shall not cover: 1. Services rendered in any period during which the Covered Person is not under the continuing care of a Physician. 2. Services of a person who ordinarily resides in the Covered Persons home or is a member of the family of the patient/Covered Person. 3. Transportation services. 4. Custodial Care. 5. Care for a Child or family member while caretaker is ill. SKILLED NURSING FACILITY The Plan will pay for eligible expenses for confinement in a Skilled Nursing Facility as shown in the Schedule of Benefits when the confinement is in place of or begins following a Covered Person's discharge from a Hospital confinement for a covered condition and is for treatment of the same condition that caused or would have resulted in the Hospital confinement. A Physician must actually visit in the physical presence of the Covered Person at least once each 30 days. Eligible expenses are limited to room and board charges and ancillary charges, not including any charges for professional services ordered by a Physician and furnished by the facility for Inpatient care. The term "Skilled Nursing Facility" does not include a rest home or a place for the care of the aged, alcoholics, or drug addicts.
MEDICAL CASE MANAGEMENT The Plan Administrator may approve the payment of benefits for services not included as an Eligible Charge or may approve the payment of Eligible Charges at a higher benefit level than described in this plan. Such additional benefits will be paid only when the Plan Administrator, in
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its sole discretion, determines that such services are Medically Necessary and cost effective and when the Covered Person and the Covered Person's attending Physician concur with the treatment plan which includes such services. In making its determination, the Plan Administrator may seek the recommendations of an independent medical review organization or independent Physicians. Such recommendations will not, however, be binding upon the Plan Administrator. Approval of additional benefits in one or more instances will not obligate the Plan Administrator to provide such additional benefits in other instances. This provision does not constitute a waiver of the Plan Administrator's right to adhere to the provisions, conditions, and limitations of this Plan. CATASTROPHIC CASE MANAGEMENT The following case types have been selected to evaluate the appropriateness of case management services: In-Patient Hospital stays greater than 6 days Hospital bills greater than $50,000 Spinal Cord Injury Severe burns Cancer Premature births Organ transplants Chronic renal failure
HWHN Case Care will provide the following services to patients meeting the above criteria. 1. 2. Screen all admissions in an effort to make early identification of cases that meet requirements for case management services. Conduct telephonic assessments and evaluations of cases, which will include an explanation of Case Cares responsibilities to the Physician, patient, and/or responsible caregivers, regarding the delivery of case management services. Continue on-going evaluations of the patients care to insure the patient receives care in the most appropriate, cost-effective setting. Contact the attending Physician and consultants to discuss plan of treatment, patient care goals, and alternatives of care as medically appropriate. Negotiate fees on Out-of-Network services, and communicate these negotiated rates to the Claims Administrator. Provide monthly/quarterly reports to Wellmont Plan Administrators as requested, demonstrating savings as a result of case management services provided.
3. 4. 5. 6.
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MEDICAL EXCLUSIONS AND LIMITATIONS No benefits will be payable under the Plan for the following: 1. Charges incurred while the Covered Person was not under the direct care of a Physician. 2. Charges for housekeeping, custodial, or domiciliary care. 3. Charges that exceed the Usual and Customary Charge for the services performed or supplies furnished or that exceed any maximum benefit stated in this Plan document. 4. Charges that would not have been made to the patient had the patient not been covered by this Plan. The fact that a person is covered under this Plan will not create the obligation to pay where such obligation would not otherwise have existed. 5. Charges resulting from an Illness or Injury which arises out of or in the course of employment for occupation for wage or profit, or for which the Covered Person is entitled to benefits under any Worker's Compensation, employer's liability or occupational disease law, or any such similar law. 6. Charges incurred for cosmetic or reconstructive surgery or complications of cosmetic or reconstructive surgery unless specifically set forth under Eligible Charges. 7. Charges for hearing aids, implants, routine hearing testing, or services necessary due to degenerative hearing loss not specifically caused by Sickness, congenital defect, or trauma. 8. Visual acuity testing, visual correction other than cataract removal, by any means, including radial keratotomy and other surgeries, exercise, eyeglasses, contact lenses, or orthoptic training. (See Vision Plan) 9. Charges for, or in connection with dental treatment except to the extent specifically set forth under Eligible Charges. 10. Charges for services of a provider who usually resides in the same household with the Covered Person, or is related by blood, marriage, or legal adoption to the Covered Person or the spouse of the Covered Person. 11. Charges due to voluntary or elective abortions, except for charges incurred when: a. the life of the mother would be medically endangered if the fetus were carried to term; or b. medical complications have arisen from an abortion. 12. Charges incurred as a result of a weekend Hospital admission, charges incurred on any such weekend day(s), except for emergency confinement, unless surgery is scheduled on that day, or the following day. 13. Charges for or in connection with Experimental or Investigational treatment or any treatment not recognized as generally accepted medical practice by the medical profession in the United States on the date the service or supply is rendered or received. 14. Charges incurred as a result of participating in a riot or civil disturbance, or while committing or attempting to commit an assault or felony. 15. Charges for, or in connection with, the care or treatment of any Injury or Sickness due to war or any act of war; "war" includes armed aggression resisted by the armed forces of any country, combination of countries, or international organization, whether or not war is declared. 16. Charges for premarital examinations.
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17. Charges for treatment of obesity whether or not it is, in any case, a part of the treatment plan for another Sickness, including but not limited to, diet control, diet or food supplements, exercise or weight loss programs, medications, therapy, or enrollment in a health, athletic, or similar club. If approved as Medically Necessary by Case Care, charges for weight reduction surgery such as gastric bypass surgery or laparoscopic banding procedures will be payable at the percentages specified in the Schedule of Benefits and will be subject to an Overall Maximum Benefit of $40,000. MEDICAL APPROPRIATENESS CRITERIA Bariatric surgery, for the treatment of morbidly obese individuals 18 years or older, is medically appropriate if all the following criteria are met: 1. The individual has a diagnosis of Morbid Obesity that has persisted for at least five (5) years, and is defined as either: o More than 45 kg (100 pounds) over the ideal weight or at least twice the ideal weight. The ideal body weight can be determined from the Metropolitan Life Height and Weight table; or o Body Mass Index is greater than 40 kg/m2; or o BMI is greater than or equal to 35 kg/m2 in conjunction with any of the following obesity-related co-morbidities that will reduce the individual's life expectancy: Coronary artery disease; or Type 2 diabetes mellitus; or Obstructive sleep apnea; or Three or more of the following cardiac risk factors: Hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic); or High density lipoprotein (HDL) less than 40mg/dL; or Low density lipoprotein (LDL) greater than 100 mg/dL; or Impaired glucose tolerance (2-hour blood glucose greater than 140 mg/dL on an oral glucose tolerance test); or Family history of early cardiovascular disease in first degree relative (myocardial infarction at fifty years of age or younger in a male relative or at sixty-five years of age or younger in a female relative); and 2. There must be documentation of medical evaluations with a history of medical / dietary therapy failures (e.g., low calorie diet, increased physical activity, and behavioral reinforcement). The provider must submit the following: o Evidence that the attempt at conservative management was within two (2) years prior to the planned surgery. An attending physician, who is managing the care and weight loss of the individual, recommends the bariatric surgery and documents the failure of conservative management. This physician must be someone other than the operating surgeon and his / her associates. o Documentation of the individual's willingness to comply with both the pre and postoperative treatment plans recommended by a licensed mental health provider. 18. Charges for music, visual, or remedial reading therapy or treatment for learning disability therapy. 19. Charges for treatment of sexual dysfunctions or inadequacies. 20. Charges that are not considered Medically Necessary.
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21. Charges submitted from a Physician not meeting the definition of a Physician. 22. Charges for educational therapy. 23. Treatment of corns, calluses, or toenails unless at least part of the nail root or matrix is removed or services are Medically Necessary in treatment of metabolic or peripheral vascular disease. 24. Charges for treatment or surgery to change gender. 25. Charges for treatment or surgery to improve or restore sexual function; including but not limited to charges for penile prosthesis. 26. Charges for hypnosis, acupuncture, and biofeedback. 27. Charges for physical or psychological therapy where art, play, music, dance, drama, reading, nutrition, home economics, recreational activities, or other similar activity is the method of treatment. 28. Charges for military service-related Injuries or Illness (past or present) furnished by a Hospital or facility operated by any foreign government agency or the United States Government or any authorized agency of the United States Government or furnished at the expense of such government or agency. 29. Charges for reversal of sterilization. 30. Charges for nonprescription, non-legend medicines, vitamins, nutrients, food supplements, and specialty infant formula even if prescribed or administered by a Physician. 31. Charges incurred for or related to transplant or implant of a human organ or tissue for a) artificial or mechanical implants or transplants, or non-human organ transplants; b) any services or supplies which are considered Experimental or investigative in nature; c) donor expenses for meals and lodging; d) expenses eligible to be repaid under a private or public research fund, other group health plan, or expenses covered by another organization (the patient is required to apply for any other benefits for which he or she may be eligible); e) payment to an organ donor or organ donor's family as compensation for an organ or for the written consent needed to obtain an organ. 32. Charges to the extent of coverage required by, or available through, any federal, state, municipal, or other governmental body or agency, except for medical assistance under a state Plan for medical assistance approved under title XIX of the Social Security Act (Medicaid). 33. Charges incurred for Mental and Nervous Disorders, Alcohol, Drug, and Substance Abuse except for the initial visit to determine the diagnosis provided an internist or Primary Care Physician provides such visit. These services may be available through the Employee Assistance Program. This program is coordinated by Horizon Behavioral Services. Please contact Horizon at 1-800-955-6422 for further details. 34. Charges for a licensed midwife not working under the direct supervision of a Physician. 35. Charges for services and supplies that constitute personal comfort or beautification items, including television or telephone use. 36. With respect to diagnostic testing: a. Tests performed more frequently than is necessary according to the diagnosis and accepted medical practice; b. Genetic testing unless family history necessitates; c. Duplicate testing by different Physicians unless required for a second opinion; and 37. Smoking cessation and any related services including but not limited to Nicorettes, patches
52
(Nicoderm/Habitrol, etc.). 38. Charges for any period of Hospital confinement prior to the day before scheduled surgery, except for charges incurred when: a. a documented hazardous medical condition exists; or b. when confinement is no earlier than 8:00 PM on the day before a Coronary Artery Bypass Graft (CABG) Pathway is to be performed. 39. Services received or supplies purchased outside the United States or Canada, unless the Employee or a dependent is a resident of the United States or Canada and the charges are incurred while traveling on business or for pleasure. 40. Charges that are not specified in this Plan as covered charges. 41. Any loss due to an intentionally self-inflicted Injury, while sane or insane. This exclusion does not apply if the Injury resulted from an act of domestic violence or a Medical Condition. 42. Care, services or treatment required as a result of complications from a treatment not covered under the Plan are not covered. Complications from a non-covered abortion are covered. 43. Exercise programs for treatment of any condition, except for Physician-supervised cardiac rehabilitation, occupational, or physical therapy covered by this Plan. 44. Care and treatment for hair loss including wigs (except as otherwise provided), hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician. 45. Professional services billed by a Physician or nurse who is an employee of a Hospital or Skilled Nursing Facility and paid by the Hospital or facility for the service. 46. Charges for services received as a result of Injury or Sickness caused by or contributed to by engaging in an illegal act or occupation; by committing or attempting to commit any crime, criminal act, assault or other felonious behavior; or by participating in a riot or public disturbance. This exclusion does not apply if the Injury resulted from an act of domestic violence or a Medical Condition. 47. Services, supplies, care or treatment to a Covered Person for Injury or Sickness resulting from that Covered Person's voluntary taking of or being under the influence of any controlled substance, drug, hallucinogen or narcotic not administered on the advice of a Physician. Expenses will be covered for Injured Covered Persons other than the person using controlled substances and expenses will be covered for substance abuse treatment as specified in this Plan. This exclusion does not apply if the Injury resulted from an act of domestic violence or a Medical Condition. 48. Care, treatment, or supplies for which a charge was incurred before a person was covered under this Plan or after coverage ceased under this Plan. 49. Charges for travel or accommodations, whether or not recommended by a Physician, except for ambulance charges as defined as a covered expense or as otherwise specified as covered in this Plan. 50. Maintenance care, which consists of services and supplies furnished mainly to maintain rather than improve a level of physical or mental function or to provide a protected environment free from exposure that can worsen the Covered Persons physical or mental condition. 51. Residential Treatment/Partial Day Programs will be excluded under the Plan. The following will be excluded: providers/facilities: Social workers and day/night psychiatric facilities.
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The Plan is not in lieu of, and does not affect, any requirement for coverage by any Worker's Compensation Law.
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PRESCRIPTION DRUG PROGRAM Catalyst RX Customer Service: (877) 464-0085 www.catalystrx.com Covered Prescription Drug Copayment Generic Formulary Brand Name Non-Formulary Brand Name WHS Pharmacies Catalyst Retail Catalyst Mail Order (90-Day Supply) $30.00 $87.50 $125.00 NonContracted Pharmacies Not Covered Not Covered Not Covered
$12.00 $35.00 $50.00
$12.00 $35.00 $50.00
This Plan contains a pharmacy prescription drug benefit. Benefits under this portion of the Plan are provided instead of benefits otherwise available under the Comprehensive Medical Expense Benefits provision of this Plan. There is a Copayment required for each new or refill prescription. Any Copayment required under this program will not apply to the Plan's plan year deductible or the maximum out-ofpocket expense. Claims submitted to the Plan for prescription drugs which can be obtained by use of the drug card will not be paid under the Comprehensive Medical Expense Benefits provision of this Plan. YOU MAY OBTAIN FURTHER DETAILS FREE OF CHARGE FROM CATALYST RX INCLUDING A LISTING OF ELIGIBLE DRUGS OR THOSE THAT MAY BE EXCLUDED.
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DENTAL PLAN SCHEDULE OF BENEFITS Following is a summary of benefits under the Plan. This summary is subject to all other provisions, conditions, limitations, and exclusions of the Plan Document. IMPORTANT Benefits are only payable under this Plan for expenses that are Eligible Charges arising from Dental treatment which is defined further in this Plan Document. All maximum benefits whether expressed as overall, yearly or otherwise, refer to the maximum benefits payable for the period specified only for Eligible Charges incurred while the Covered Person is covered under this Plan. DENTAL EXPENSE BENEFIT Benefits are payable for Covered Dental Expenses incurred, as described below, but not to exceed the Plan's Maximum Benefit. Plan Year Deductible Per Covered Person Per Family (aggregate) Class A - Diagnostic, Preventive, and Palliative (Deductible waived) Class B - Extractions, Endodontics, Periodontal, Oral Surgery, Restorative Class C - Prosthodontic Class D - Orthodontic Overall Maximum Orthodontic Benefit Maximum Benefit per Plan Year (Class A, B and C combined) Plan A $50 $150 Plan B $25 $75
100%
100%
80% 50%
80% 50%
No Benefits Payable 50% $1,000 $1,000 $1,500
Note: Employees who elect Plan B may not change this election until they have completed two Plan Years with coverage under this Plan. Further, Employees who declined dental coverage when first eligible must enroll in Plan A at the next annual enrollment period and remain in Plan A for one Plan Year before being eligible for coverage under Plan B. COMPREHENSIVE DENTAL EXPENSE BENEFIT PLAN YEAR DEDUCTIBLE The deductible is stated in the Schedule of Benefits for the Dental Plan. This maximum amount of each Covered Person's Eligible Charges must be satisfied each plan year before benefits become payable under the Plan. After the deductible has been satisfied, the Plan will pay the percentage indicated in the Schedule of Benefits for the rest of the Plan Year. The Employee will have to pay the balance for each Covered Person.
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BENEFITS PAYABLE When a Covered Person incurs Covered Dental Expenses in excess of the deductible amount for Dental Care while covered under the Plan, the Employee will become entitled to dental benefits for Covered Dental Expenses incurred. In no event will benefits payable to or on behalf of any Covered Person exceed the Maximum Benefit. MAXIMUM BENEFIT The amount of the Maximum Benefit is shown in the Dental Expense Benefit portion of the Schedule of Benefits. It applies separately to Covered Dental Expenses incurred by each person covered for dental benefits. COVERED DENTAL EXPENSES The term Covered Dental Expenses refers to the items of dental expense for which dental benefits may be payable. Covered Dental Expenses are charges for the following services and supplies, which are Medically Necessary, to the extent that the charges do not exceed the usual charge of the Dentist or Physician and the Usual and Customary Charges generally made in the same locality under similar conditions. Charges shall be considered as having been incurred as of the date on which the service or supply for which the charge is made was rendered or obtained. ELIGIBLE CHARGES Class A - Diagnostic, Preventive, Palliative l. Routine oral examinations and prophylaxis (scaling and cleaning of teeth), but not more than one during any 6 month period. 2. Topical application of fluoride for dependent Children under 14 years of age, but not more than one during any 6 month period. 3. Space maintainers that replace prematurely lost teeth for dependent Children under 14 years of age, including adjustments during the first six months following installation. 4. Palliative treatment if no other services are rendered during the visit. 5. Dental x-rays, including full mouth x-rays, but not more than once in any period of 36 consecutive months; supplementary bitewing x-rays, but not more than one during any 6 month period; and such other dental x-rays required in connection with the diagnosis of a specific covered condition which requires treatment. 6. Sealants for covered dependent Children under 14 years of age. Class B - Extractions, Endodontics, Periodontal, Oral Surgery, Restorative 1. Extractions. Please note that if the Covered Person also has coverage under the Employers Medical Plan, the removal of impacted wisdom teeth is covered under the Medical Plan and not under the Dental Plan. For individuals covered under only the Dental Plan, benefits are available for the removal of impacted wisdom teeth as indicated in the Dental Plan Schedule of Benefits for Class B dental expenses. 2. Oral Surgery. Please note that if the Covered Person also has coverage under the Employers Medical Plan, the removal of impacted wisdom teeth is covered under the Medical Plan and not under the Dental Plan. For individuals covered under only the Dental Plan, benefits are available for the removal of impacted wisdom teeth as indicated in the Dental Plan Schedule of Benefits for Class B dental expenses. 3. Amalgam, silicate, acrylic, synthetic porcelain and composite filling restoration to restore
57
diseased or fractured teeth. 4. General and local anesthesia when Medically Necessary and administered in connection with oral or dental surgery. 5. Treatment of periodontal or other diseases of the tissues of the mouth. 6. Endodontic treatment, including root canal therapy. 7. Injection of antibiotic drugs by the attending Dentist or Physician. 8. Repair or recementing of crowns, inlays, onlays, bridgework or dentures, or relining or rebasing of dentures more than 6 months after the installation of an initial or replacement denture, but not more than one relining or rebasing in any period of 24 consecutive months. 9. Provision splinting. Class C - Prosthodontic 1. Initial installation of fixed bridgework (including inlays and crowns as abutments). 2. Initial installation of partial or full removable dentures (to include any adjustments during the 6 month period following installation) 3. Replacement of an existing partial or full removable denture or fixed bridgework by a new denture or by new bridgework, or the addition of teeth to an existing partial removable denture or to bridgework, but only if satisfactory evidence is presented that: a. The existing denture or bridgework was installed at least 5 years prior to its replacement and the existing denture or bridgework cannot be made serviceable; or b. The existing denture is an immediate temporary denture which cannot be made permanent and replacement by a permanent denture takes place within 12 months from the date of initial installation of the immediate temporary denture. 4. Inlays, onlays, gold fillings, or crown restorations to restore diseased or fractured teeth. Class D - Orthodontic (Applicable to Plan B only) Course of Orthodontic Treatment is that period which: 1. Begins when the first orthodontic appliance is installed; and 2. Ends when the last appliance is taken off, or maximum benefits have been exhausted. Benefits will be considered for dental expense charges incurred for any one Course of Orthodontic Treatment (including any orthodontic diagnosis, evaluation, and pre-orthodontic treatment). Dental expense charges for orthodontics shall be considered at the percentage stated in the Schedule of Benefits of the Usual and Customary Charge for "1" plus "2" below where: 1. is an initial amount of 1/4 of the total Covered Dental Expenses for the Course of Orthodontic Treatment to be considered for an initial Dentist's fee incurred for diagnosis, evaluation, pre-orthodontic treatment, and the insertion of orthodontic appliances, not to exceed the Dentist's actual charge, if less; and 2. is a monthly maximum amount equal to the difference between the initial amount (defined above) and the total dental charges for such Course of Orthodontic Treatment divided by the number of months in the projected period of treatment specified in the written treatment plan for orthodontic treatment. In no event shall Covered Dental Expenses for orthodontic treatment exceed the maximum orthodontic benefit shown in the Schedule of Benefits.
58
DENTAL EXCLUSIONS AND LIMITATIONS Benefits will not be payable under the Plan for: 1. Services other than those specifically shown as Covered Dental Expenses. 2. Charges for treatment by other than a Dentist or Physician, except that scaling or cleaning of teeth and topical application of fluoride may be performed by a licensed dental hygienist if the treatment is rendered under the supervision and guidance of and billed for by the Dentist. 3. Charges for veneers or similar properties of crowns and pontics placed on or replacing teeth, other than the twelve upper and lower anterior teeth. 4. Charges for prosthetic devices (including bridges and crowns) and the fitting thereof which are finally installed or delivered to the covered Employee or his dependent after termination of coverage even if they were ordered while the family member was covered for dental expense benefits. 5. Charges for the replacement of a lost, missing, or stolen prosthetic device. 6. Charges for failure to keep a scheduled visit with the Dentist or Physician. 7. Charges for any service or supply which is not Medically Necessary, or which are not recommended or approved by the attending Dentist or Physician. 8. Charges for services or supplies which do not meet accepted standards of dental practice, including charges for services or supplies which are Experimental in nature. 9. Charges for services or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared. 10. Charges for any duplicate prosthetic device or any other duplicate appliance. 11. Charges for the completion of any insurance forms. 12. Charges for a plaque control program. 13. Charges for implantology (implants). 14. Charges for services or supplies that are partially or wholly cosmetic in nature or directed toward a cosmetic end, including charges for personalization or characterization of dentures. 15. Charges resulting from an illness or injury which arises out of or in the course of employment for occupation for wage or profit, or for which the Covered Person is entitled to benefits under any Worker's Compensation, employer's liability or occupational disease law, or any such similar law. 16. Services or supplies for which no charge is made that a Covered Person is required to pay. 17. Services received or supplies purchased outside the United States or Canada, unless the Employee or a dependent is a resident of the United States or Canada and the charges are incurred while traveling on business or for pleasure. 18. Charges for appliances, restorations, and procedures to alter vertical dimension or restore occlusion. 19. Charges for any dental services if benefits or services for all or any part of the expenses for such services are provided under the group employee benefit or prepayment plans providing hospital, surgical, and medical services or benefits. 20. Charges for orthodontic diagnostic procedures and treatment under Plan A.
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21. Charges for replacement or repair of an orthodontic appliance. 22. Charges for oral hygiene and dietary instruction. 23. Charges for services received by an Employee or dependent that are performed by a member of the immediate family of the Employee or of the spouse. PROOF OF CLAIM The Plan Administrator reserves the right at its discretion to accept, or to require verification of, any alleged fact or assertion pertaining to any claim for Covered Dental Expenses. As part of the basis for determining benefits payable, the Plan may require submission of x-rays and other appropriate diagnostic and evaluative materials. When these materials are unavailable, and to the extent that verification of Covered Dental Expenses cannot reasonably be made by the Supervisor based on the information available, benefits for the course of treatment may be for a lesser amount than that which otherwise would have been payable.
60
VISION PLAN SCHEDULE OF BENEFITS Following is a summary of benefits under the Plan. This summary is subject to all other provisions, conditions, limitations, and exclusions of the Plan Document. IMPORTANT Benefits are only payable under this Plan for expenses that are Eligible Charges (defined in the Eligible Charges section of this document) arising from vision treatment which is defined further in this Plan Document. All maximum benefits whether expressed as overall, yearly, or otherwise, refer to the maximum benefits payable for the period specified only for Eligible Charges incurred while the Covered Person is covered under this Plan. VISION CARE BENEFITS Maximum Annual Benefit Per Person ......................................................................................................... $270 Employee Plus One Dependent......................................................................... $540 Per Family (aggregate) ...................................................................................... $800 NOTE: Each person in a family is limited to a maximum annual benefit of $270, and the family unit is limited to a maximum annual benefit of $800. Similarly, if an individual has Employee Plus One Dependent coverage, the Employee and Dependent each are limited to a maximum annual benefit of $270. Examination............................................................................................................ 100% Maximum payable per Plan Year ........................................................................ $48 Frames .................................................................................................................... 100% Maximum payable per Plan Year ........................................................................ $96 Lenses for Eyeglasses .......................................................................................... 100% Maximum payable per Plan Year ........................................................................ $96 Contact Lenses ...................................................................................................... 100% Soft Maximum payable per Plan Year .................................................................... $80 Hard Maximum payable per Plan Year .................................................................. $120 Note: Disposable contact lenses are covered up to the amount allowed for soft contact lenses. Prescription sunglasses are covered as regular prescription glasses. COMPREHENSIVE VISION EXPENSE BENEFIT Covered vision expenses for services rendered by a duly licensed Ophthalmologist or Optometrist acting within the scope of his or her license, including vision examinations, lenses, frames, and other services will be payable up to the reasonable expense incurred, but not to exceed the maximum benefits as shown in the Schedule of Benefits. All vision care benefits must be rendered on a prescription basis by an Optometrist or an Ophthalmologist.
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Eligible Charges 1. Case History. 2. Binocular measure. 3. Visual Acuity, near and far. 4. External examination, including biomicroscopy or other magnified evaluation of the anterior chamber. 5. Objective and subjective examination, distance and near. 6. Ophthalmoscopic examination. 7. Summary and findings. 8. Recommendations. Post-Refractive Services consist of, but are not limited to the following: 1. Ordering lenses and frames. 2. Cost of materials. 3. Verification of completed prescription. 4. Adjustment of the completed glasses. 5. Subsequent servicing (refitting, realigning, readjusting, tightening, and polishing of lenses). The date of service is: 1. For vision examinations, the date of the examination. 2. For lenses or frames, the date they are ordered by the Covered Person. VISION LIMITATIONS AND EXCLUSIONS 1. Charges incurred in connection with the care or treatment of any vision disorder contracted or Injury sustained which resulted from war, declared or undeclared, or any act of war. 2. Charge for non-prescription eyewear. 3. Chares for services and supplies which are not Medically Necessary for treatment of the vision disorder or are not recommended and approved by the attending eye care provider or charges to the extent they are unreasonable. 4. Charges resulting from an Illness or Injury which arises out of or in the course of employment for occupation for wage or profit, or for which the covered person is entitled to benefits under any Worker's Compensation, employer's liability or occupational disease law, or any such similar law. 5. Charges that would not have been made to the patient had the patient not been covered by this Plan. The fact that a person is covered under this Plan will not create the obligation to pay where such obligation would not otherwise have existed. 6. Charges not consistent with the diagnosis. 7. Services or supplies rendered or furnished prior to the Covered Persons effective date or after the Covered Persons termination date. 8. Services provided by the US or state agencies; however, charges incurred in a Veterans Administration Hospital for non-military related vision disorders will be considered Eligible Expenses.
62
9. Charges for cosmetic reasons. 10. Services or supplies not listed as Eligible Expenses. 11. Any interest charges applicable to services for which payment may have been made by the Plan. 12. The cost of any insurance premiums indemnifying the Covered Person against losses for lenses or frames. 13. Special procedures, such as orthoptics or vision training, and special supplies such as nonprescription sunglasses and subnormal vision aids. 14. Anti-reflective coating or charges for tinting and charges for prescribed sunglasses or lightsensitive glasses in excess of treatment which would be a covered expense for prescribed non-tinting glasses. 15. Eye examinations required by an employer as a condition of employment. 16. Surgical or medical treatment of eye disease (Ex. Cataract surgery or treatment of glaucoma). 17. Drugs or medications. 18. Charges for or in connection with Experimental or Investigational treatment or any treatment not recognized as generally accepted medical practice by the medical profession in the United States on the date the service or supply is rendered or received. Charges that exceed the Usual and Customary Charge for the services performed or supplies furnished. Charges for services of a provider who usually resides in the same household with the Covered Person; or is related by blood, marriage, or legal adoption to the Covered Person or the spouse of the Covered Person. Charges incurred as a result of participating in a riot or civil disturbance, or while committing or attempting to commit an assault or felony. Charges for military service-related injuries or illness (past or present) furnished by a hospital or facility operated by any foreign government agency or the United States government or any authorized agency of the United States government or furnished at the expense of such government or agency. Charges to the extent of coverage required by, or available through, any federal, state, municipal, or other governmental body or agency, except for medical assistance under a state Plan for medical assistance approved under title XIX of the Social Security Act (Medicaid).
19. Visual correction by radial keratotomy and other surgeries. 20. 21.
22. 23.
24.
25. Services received or supplies purchased outside the United States or Canada, unless the Employee or a dependent is a resident of the United States or Canada and the charges are incurred while traveling on business or for pleasure.
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COORDINATION OF BENEFITS Coordination of the benefit plans. Coordination of benefits sets out rules for the order of payment of Covered Charges when two or more plans -- including Medicare -- are paying. When a Covered Person is covered by this Plan and another plan, or the Covered Person's Spouse is covered by this Plan and by another plan or the couple's Covered children are covered under two or more plans, the plans will coordinate benefits when a claim is received. The plan that pays first according to the rules will pay as if there were no other plan involved. The secondary and subsequent plans will pay the balance up to each one's plan formula minus whatever the primary plan paid. This is called non-duplication of benefits. The total reimbursement will never be more than the amount that would have been paid if the secondary plan had been the primary plan -- 50% or 80% or 100% -- whatever it may be. The balance due, if any, is the responsibility of the Covered Person. If a husband and wife both work for the Employer, benefits will not be coordinated between husband and wife or for an eligible Dependent. Benefit plan. This provision will coordinate the medical benefits of a benefit plan. The term benefit plan means this Plan or any one of the following plans: (1) (2) (3) (4) (5) (6) Group or group-type plans, including franchise or blanket benefit plans. Blue Cross and Blue Shield group plans. Group practice and other group prepayment plans. Federal government plans or programs. This includes Medicare. Other plans required or provided by law. This does not include Medicaid or any benefit plan like it that, by its terms, does not allow coordination. No Fault Auto Insurance, by whatever name it is called, when not prohibited by law.
Allowable Charge. For a charge to be allowable it must be a Usual and Reasonable Charge and at least part of it must be covered under this Plan. In the case of HMO (Health Maintenance Organization) or other in-network only plans: This Plan will not consider any charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also, when an HMO or network plan is primary and the Covered Person does not use an HMO or network provider, this Plan will not consider as an Allowable Charge any charge that would have been covered by the HMO or network plan had the Covered Person used the services of an HMO or network provider. In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will be the Allowable Charge. Automobile limitations. When medical payments are available under vehicle insurance, the Plan shall pay excess benefits only, without reimbursement for vehicle plan deductibles. This Plan shall always be considered the secondary carrier regardless of the individual's election under PIP (personal injury protection) coverage with the auto carrier.
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Benefit plan payment order. When two or more plans provide benefits for the same Allowable Charge, benefit payment will follow these rules: (1) (2) Plans that do not have a coordination provision, or one like it, will pay first. Plans with such a provision will be considered after those without one. Plans with a coordination provision will pay their benefits up to the Allowable Charge: (a) The benefits of the plan which covers the person directly (that is, as an employee, member or subscriber) ("Plan A") are determined before those of the plan which covers the person as a dependent ("Plan B"). The benefits of a benefit plan which covers a person as an Employee who is neither laid off or retired are determined before those of a benefit plan which covers that person as a laid-off or Retired Employee. The benefits of a benefit plan which covers a person as a Dependent of an Employee who is neither laid off nor retired are determined before those of a benefit plan which covers a person as a Dependent of a laid off or Retired Employee. If the other benefit plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule does not apply. The benefits of a benefit plan which covers a person as an Employee who is neither laid off nor retired or a Dependent of an Employee who is neither laid off nor retired are determined before those of a plan which covers the person as a COBRA beneficiary. When a child is covered as a Dependent and the parents are not separated or divorced, these rules will apply: (i) The benefits of the benefit plan of the parent whose birthday falls earlier in a year are determined before those of the benefit plan of the parent whose birthday falls later in that year; If both parents have the same birthday, the benefits of the benefit plan which has covered the parent for the longer time are determined before those of the benefit plan which covers the other parent.
(b)
(c)
(d)
(ii)
(e)
When a child's parents are divorced or legally separated, these rules will apply: (i) This rule applies when the parent with custody of the child has not remarried. The benefit plan of the parent with custody will be considered before the benefit plan of the parent without custody. This rule applies when the parent with custody of the child has remarried. The benefit plan of the parent with custody will be considered first. The benefit plan of the stepparent that covers the child as a Dependent will be considered next. The benefit plan of the parent without custody will be considered last. This rule will be in place of items (i) and (ii) above when it applies. A court decree may state which parent is financially responsible for medical and dental benefits of the child. In this case, the benefit plan of that parent will be considered before other plans that cover the child as a Dependent. If the specific terms of the court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans
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(ii)
(iii)
(iv)
covering the child shall follow the order of benefit determination rules outlined above when a child is covered as a Dependent and the parents are not separated or divorced. (v) (f) For parents who were never married to each other, the rules apply as set out above as long as paternity has been established.
If there is still a conflict after these rules have been applied, the benefit plan which has covered the patient for the longer time will be considered first. When there is a conflict in coordination of benefit rules, the Plan will never pay more than 50% of Allowable Charges when paying secondary.
(3)
Medicare will pay primary, secondary or last to the extent stated in federal law. When Medicare is to be the primary payer, this Plan will base its payment upon benefits that would have been paid by Medicare under Parts A, B and D, regardless of whether or not the person was enrolled under any of these parts. If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will pay first and this Plan will pay second.
(4)
Claims determination period. Benefits will be coordinated on a Calendar Year basis. This is called the claims determination period. Right to receive or release necessary information. To make this provision work, this Plan may give or obtain needed information from another insurer or any other organization or person. This information may be given or obtained without the consent of or notice to any other person. A Covered Person will give this Plan the information it asks for about other plans and their payment of Allowable Charges. Facility of payment. This Plan may repay other plans for benefits paid that the Plan Administrator determines it should have paid. That repayment will count as a valid payment under this Plan. Right of recovery. This Plan may pay benefits that should be paid by another benefit plan. In this case this Plan may recover the amount paid from the other benefit plan or the Covered Person. That repayment will count as a valid payment under the other benefit plan. Further, this Plan may pay benefits that are later found to be greater than the Allowable Charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid. Exception to Medicaid. In accordance with ERISA, the Plan shall not take into consideration the fact that an individual is eligible for or is provided medical assistance through Medicaid when enrolling an individual in the Plan or making a determination about the payments for benefits received by a Covered Person under the Plan.
66
PRIMARY COVERAGE FOR EMPLOYEES UNDER MEDICARE Notwithstanding any other provision to the contrary, the benefits under this Plan will be determined and paid before the benefits under Medicare, for each Employee who: 1. 2. 3. 4. is age 65 or over; and is a covered Employee under this Plan; and is not a retired Employee of the Employer or an affiliate or subsidiary; and has not taken the option of rejecting primary coverage under this Plan or under the Employer's prior plan in favor of Medicare.
The benefits under the Plan will be determined and paid before the benefits under Medicare for the spouse of an Employee who meets all of the requirements set forth immediately above, if such spouse is age 65 or over and is covered as a dependent under this Plan. The period of extended primary coverage for Employees under this provision shall begin with the first day of the month in which the employee attains age 65, unless terminated as of an earlier date. In addition to any other provision for the termination of coverage under this Plan Document, coverage will terminate under this provision as to any Employee who is age 65 or over and chooses to reject primary coverage under this Plan in favor of Medicare ("Election"). The effective date of termination will be: 1. the date of the "Election" if the Employee is then covered under Medicare, or 2. the date Medicare coverage for such Employee becomes effective following such "Election". Coverage under this Plan provision will terminate as to the spouse of any such Employee on the date coverage terminates for the Employee. SUBROGATION In the event a Covered Person sustains an Injury or Illness for which a third party is or may be legally responsible, this Plan is subrogated to the Covered Person's rights against such third party to the full extent of payments made under the Plan for the Covered Person's medical expenses. The Plan has the right of first reimbursement from any recovery received by the Covered Person. This means that if the action of another cause a Covered Person to become ill or injured and the Plan pays all or part of that Covered Person's medical bills, the Plan has the right to recover its payments directly from the person responsible. Further, the Plan has the right to recover its payment from any payments made directly to the Covered Person by or on behalf of the responsible party. The Plan may sue the responsible party to recover the payments under the Plan for the Covered Person. If the Covered Person sues the responsible person or receives any recovery by way of judgment, settlement, or otherwise, the Plan still has the right to recover the money. The Plan, moreover, is entitled to recover the money from insurance payments available to the Covered Person under coverages such as uninsured or underinsured motorists provisions of automobile insurance policies. If, prior to the payment of Plan benefits, the Covered Person recovers any amount from any of the above sources, Plan benefits to or on behalf of the Covered Person may be reduced by the amount of such recovery. The Plan shall have no obligation whatsoever to pay medical or dental benefits to a Covered
67
Person if a Covered Person refuses to cooperate with the Plan's reimbursement and subrogation rights or refuses to execute and deliver such papers as the Plan may require in furtherance of its reimbursement and subrogation rights. Further, in the event the Covered Person is a minor, the Plan shall have no obligation to pay any medical or dental benefits incurred on account of Injury or Sickness caused by a responsible third party until after the Covered Person or his authorized legal representative obtains valid court recognition and approval of the Plan's 100%, first dollar reimbursement and subrogation rights on all recoveries, as well as approval for the execution of any papers necessary for the enforcement thereof, as described herein. In all cases, the Plan's right of recovery shall be a first priority right to any recovery received by the Covered Person even if such recovery (a) is not specifically identified as relating to medical expenses or (b) is not sufficient to cover the total losses claimed by the Covered Person. Without a specific agreement to the contrary, the Plan shall not be responsible for any legal fees or costs incurred in connection with any recovery from the responsible party by the Covered Person. PRIVACY AND SECURITY OF MEDICAL INFORMATION Effective April 14, 2003, this Plan will comply with the requirements of 164.504(f) of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 C.F.R. parts 160 through 164 (the regulations are referred to herein as the HIPAA Privacy Rule, and 164.504(f) is referred to as the 504 provisions). This section establishes the extent to which the Plan Sponsor will receive, use, and/or disclose Protected Health Information. In addition, this Plan will comply with the HIPAA Security Standards (Subpart C of Part 164 in 45 C.F.R.) as of April 21, 2005. I. Plans Designation of Person/Entity to Act on its Behalf
The Plan has determined that it is a group health plan within the meaning of the HIPAA Privacy Rule and Security Standards, and the Plan designates the Director of Human Resources of Wellmont Health System to take all actions required to be taken by the Plan in connection with the HIPAA Privacy Rule and Security Standards (e.g., entering into business associate contracts; accepting certification from the Plan Sponsor). II. Definitions
All terms defined in the HIPAA Privacy Rule and Security Standards, shall have the meaning set forth therein. The following additional definitions apply to the provisions set forth in this Amendment. A. B. Plan means the Wellmont Health System Employee Medical Care Plan. Plan Documents mean the Plans governing documents and instruments (i.e., the documents under which the Plan was established and is maintained), including but not limited to the Wellmont Health System Employee Medical Care Plans Group Health Plan Document and Summary Plan Description. Plan Sponsor means plan sponsor as defined at section 3(16)(B) of ERISA, 29 U.S.C. 1002(16)(B). The Plan Sponsor is Wellmont Health System.
C.
68
III.
The Plans Disclosure of Protected Health Information to the Plan Sponsor Required Certification of Compliance by the Plan Sponsor A. Except as provided below with respect to the Plans disclosure of summary health information, the Plan will (a) disclose Protected Health Information to the Plan Sponsor or (b) provide for or permit the disclosure of Protected Health Information to the Plan Sponsor by a health insurance issuer or HMO with respect to the Plan, only if the Plan has received a certification (signed on behalf of the Plan Sponsor) that: 1. the Plan Documents have been amended to establish the permitted and required uses and disclosures of such information by the Plan Sponsor, consistent with the 504 provisions; 2. the Plan Documents have been amended to incorporate the Plan provisions set forth in this Amendment; and 3. the Plan Sponsor agrees to comply with the Plan provisions as modified by this Amendment.
IV.
Permitted disclosure of individuals Protected Health Information to the Plan Sponsor A. The Plan (and any business associate acting on behalf of the Plan), or any health insurance issuer or HMO servicing the Plan will disclose individuals Protected Health Information to the Plan Sponsor only to permit the Plan Sponsor to carry out plan administration functions. Such disclosure will be consistent with the provisions of this Amendment. All disclosures of the Protected Health Information of the Plans individuals by the Plans business associate, health insurance issuer, or HMO to the Plan Sponsor will comply with the restrictions and requirements set forth in this Amendment and in the 504 provisions. The Plan (and any business associate acting on behalf of the Plan), may not, and may not permit a health insurance issuer or HMO, to disclose individuals Protected Health Information to the Plan Sponsor for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor. The Plan Sponsor will not use or further disclose individuals Protected Health Information other than as described in the Plan Documents and permitted by the 504 provisions. In addition, as part of the Security Standards effective 4/21/06, the Plan Sponsor must implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic Protected Health Information that it creates, receives, maintains, or transmits on behalf of the Plan. The Plan Sponsor will ensure that any agent(s), including a subcontractor, to whom it provides individuals Protected Health Information received from the Plan (or from the Plans health insurance issuer or HMO), agrees to the same restrictions and conditions that apply to the Plan Sponsor with respect to such Protected Health Information. As part of the Security Standards, the Plan Sponsor must also ensure that any agent or subcontractor receiving Protected Health Information from the Plan Sponsor agrees to implement reasonable and appropriate security measures to protect the information. The Plan Sponsor will not use or disclose individuals Protected Health Information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.
69
B.
C.
D.
E.
F.
G.
The Plan Sponsor will report to the Plan any use or disclosure of Protected Health Information that is inconsistent with the uses or disclosures provided for in the Plan Documents (as amended) and in the 504 provisions, of which the Plan Sponsor becomes aware. Upon the effective date of the Security Standards, the Plan Sponsor must report to the Plan any security incident of which it becomes aware. The Plan Sponsor will make the Protected health Information of the individual who is the subject of the Protected Health Information available to such individual I accordance with 45 C.F.R. 164.524. The Plan Sponsor will make the individuals Protected Health Information available for amendment and incorporate any amendments to individuals Protected Health Information in accordance with 45 C.F.R. 164.526. The Plan Sponsor will make and maintain an accounting so that it can make available those disclosures of individuals Protected Health Information that it must account for in accordance with 45 C.F.R. 164.528. The Plan Sponsor will make its internal practices, books, and records relating to the use and disclosure of individuals Protected Health Information received from the Plan available to the U.S. Department of Health and Human Services for purposes of determining compliance by the Plan with the HIPAA Privacy Rule. The Plan Sponsor will, if feasible, return or destroy all individuals Protected Health Information received from the Plan (or a health insurance issuer or HMO with respect to the Plan) that the Plan Sponsor still maintains in any form after such information is no longer needed for the purpose for which the use or disclosure was made. Additionally, the Plan Sponsor will not retain copies of such Protected Health Information after such information is no longer needed for the purpose for which the use or disclosure was made. If, however, such return or destruction is not feasible, the Plan Sponsor will limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible. The Plan Sponsor will ensure that the required adequate separation, described in paragraph VII below, is established and maintained. Upon the effective date of the Security Standards, the Plan Sponsor will also ensure that the separation is supported by reasonable and appropriate security measures.
V.
Disclosure of individuals Protected Health Information Disclosure by the Plan Sponsor A.
B.
C.
D.
E.
F.
VI.
Disclosures of Summary Health Information and Enrollment and Disenrollment Information to the Plan Sponsor A. The Plan, or a health insurance issuer or HMO with respect to the Plan, may disclose summary health information to the Plan Sponsor without the need to amend the Plan Documents as provided for in the 504 provisions, if the Plan Sponsor requests the summary health information for the purpose of: 1. Obtaining premium bids from health plans for providing health insurance coverage under the Plan; or 2. B. Modifying, amending, or terminating the Plan. The Plan, or a health insurance issuer or HMO with respect to the Plan, may disclose enrollment and disenrollment information to the Plan Sponsor without the need to amend the Plan Documents as provided for in the 504 provisions.
70
VII.
Required Separation between the Plan and the Plan Sponsor A. In accordance with the 504 provisions, this section describes the employees or classes of employees or workforce members under the control of the Plan Sponsor who may be given access to individuals Protected Health Information received from the Plan or from a health insurance issuer or HMO servicing the Plan. 1. President of Wellmont Health System. 2. Human Resources Director and Human Resources staff of Wellmont Health System, who are responsible for assistance with the administration of employee health benefits. B. This list reflects the employees, classes of employees, or other workforce members of the Plan Sponsor who receive individuals Protected Health Information relating to payment under, health care operations of, or other matters pertaining to plan administration functions that the Plan Sponsor provides for the Plan. These individuals will have access to individuals Protected Health Information solely to perform these identified functions, and they will be subject to disciplinary action and/or sanctions (including termination of employment or affiliation with the Plan Sponsor) for any use or disclosure of individuals Protected Health Information in violation of, or noncompliance with, the provisions of this Amendment. The Plan Sponsor will promptly report any such breach, violation, or noncompliance to the Plan and will cooperate with the Plan to correct the violation or noncompliance, to impose appropriate disciplinary action and/or sanctions, and to mitigate any deleterious effect of the violation or noncompliance.
C.
GENETIC INFORMATION NONDISCRIMINATION ACT (GINA)
The Genetic Information Nondiscrimination Act of 2008 (Public law No. 110-233) prohibits group health plans, issuers of individual health care policies and employers from discriminating on the basis of genetic information. The term "genetic information" means, with respect to any individual, information about (i) such individual's genetic tests, (ii) the genetic tests of family members of such individual, and (iii) the manifestation of a disease or disorder in family members of such individual. The term "genetic information" includes participation in clinical research involving genetic services. Genetic tests would include analysis of human DNA, RNA, chromosomes, proteins, or metabolites that detect genotypes, mutations, or chromosomal changes. Therefore this Plan will not discriminate in any manner with its Plan Members on the basis of such genetic information GENERAL PLAN PROVISIONS
71
SUBMISSION OF CLAIMS If a Covered Person claims benefits, the claim must be submitted to the Claims Administrator within 365 days following the date charges for medical services were incurred. A charge is incurred on the date that the service or supply is performed or furnished. Claims filed later than that date may be declined or reduced. Evidence that the claim was submitted in the required time period must also be submitted within 365 days of the date charges for the service was incurred. See the section on Instructions for Filing a Claim for more information. The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, the claim will be denied and more information will be requested from the claimant. The claimant may then appeal the claim decision according to the procedure described in the Claims Procedure section below (under Appeals). PAYMENT OF CLAIM All benefits are payable to the covered Employee. If such benefits are not paid as of the date the covered Employee dies, or if the covered Employee is a minor, or in the Plan Supervisors judgment, is not capable of giving a legally binding receipt for payment of any benefit, the Plan Supervisor at its option, may pay the benefit to: 1. any person appearing to the Plan Supervisor to be entitled to the payment by reason of having incurred funeral or other expense for the last Illness or death of the covered Employee; or 2. one or more of the following relatives of the covered Employee: spouse, parent(s), children, brother(s) or sister(s). Any payments made in this manner will discharge the Plan Supervisor of its duty to the extent of such payments. The Plan Supervisor will not be liable as to the application of such payment. If a covered Employee submits due proof of claim and so requests, the Plan Supervisor will pay on an interim basis any accrued daily Hospital benefits according to the terms and conditions of this Plan during any period for which the Employee is covered by the Plan. When the Plan Supervisor receives due proof, it will pay the balance as of the end of that period. The Plan Supervisor has the right to allocate: 1. the Comprehensive Medical, Dental, or Vision Expense Benefit deductible amount, if any, to any Eligible Charges; and 2. the benefits to any assignee. Such actions will be binding on the Covered Persons and the assignees. Any benefits or portion thereof provided by the Plan for Hospital, nursing, medical, or surgical services may, at the Plan Supervisor's option, be paid directly to the Hospital or person rendering such services, but it is not required that the services be rendered by a particular Hospital or person. EXAMINATION The Plan Supervisor will have the right at its own expense to have a Physician examine the person of any Employee or dependent whose Illness or Injury is the basis of a claim under the Plan. Such examinations will be performed as often as the Plan Supervisor may reasonably require while a claim is pending. The Plan Supervisor will have the right and opportunity to have a Physician make an autopsy where not prohibited by law.
72
CLAIM REVIEW AND APPEALS PROCEDURE Benefits are based on the Plan's provisions at the time the charges were incurred. Following is a description of how the Plan processes Claims for benefits. A Claim is defined as any request for a Plan benefit, made by a claimant or by a representative of a claimant, which complies with the Plan's reasonable procedure for making benefit Claims. The times listed are maximum times only. A period of time begins at the time the Claim is filed. Decisions will be made within a reasonable period of time appropriate to the circumstances. "Days" means calendar days. There are different kinds of Claims and each one has a specific timetable for approval, payment, request for further information, or denial of the Claim. If you have any questions regarding this procedure, please contact the Claims Administrator or the Plan Administrator. The definitions of the types of Claims are: Urgent Care Claim A Claim involving Urgent Care is any Claim for medical care or treatment where using the timetable for a non-urgent care determination could seriously jeopardize the life or health of the claimant; or the ability of the claimant to regain maximum function; or in the opinion of the attending or consulting Physician, would subject the claimant to severe pain that could not be adequately managed without the care or treatment that is the subject of the Claim. A Physician with knowledge of the claimant's medical condition may determine if a Claim is one involving Urgent Care. If there is no such Physician, an individual acting on behalf of the Plan applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine may make the determination. In the case of a Claim involving Urgent Care, the following timetable applies: Notification to claimant of benefit determination 72 hours
Insufficient information on the Claim, or failure to follow the Plan's procedure for filing a Claim: Notification to claimant, orally or in writing Response by claimant, orally or in writing Benefit determination, orally or in writing 24 hours 48 hours 48 hours after the earlier of the receipt of information of the end of the claimants response period.
Ongoing courses of treatment, notification of: Reduction or termination before the end of treatment Determination as to extending course of treatment Review of adverse benefit determination 72 hours 24 hours 72 hours
If there is an adverse benefit determination on a Claim involving Urgent Care, a request for an
73
expedited appeal may be submitted orally or in writing by the claimant. All necessary information, including the Plan's benefit determination on review, may be transmitted between the Plan and the claimant by telephone, facsimile, or other similarly expeditious method. Pre-Service Claim A Pre-Service Claim means any Claim for a benefit under this Plan where the Plan conditions receipt of the benefit, in whole or in part, on approval in advance of obtaining medical care. These are, for example, Claims subject to prior authorization. Please see the Prior authorization section of this booklet for further information about Pre-Service Claims. In the case of a Pre-Service Claim, the following timetable applies: Notification to claimant of benefit determination Extension due to matters beyond the control of the Plan Insufficient information on the Claim: Notification of Response by claimant Notification, orally or in writing, of failure to follow the Plan's procedures for filing a Claim Ongoing courses of treatment: Reduction or termination before the end of the treatment Request to extend course of treatment Review of adverse benefit determination Post-Service Claim A Post-Service Claim means any Claim for a Plan benefit that is not a Claim involving Urgent Care or a Pre-Service Claim; in other words, a Claim that is a request for payment under the Plan for covered medical services already received by the claimant. In the case of a Post-Service Claim, the following timetable applies: Notification to claimant of benefit determination Extension due to matters beyond the control of the Plan 30 days 15 days 15 days 15 days 45 days 5 days 15 days 15 days
15 days 30 days
74
Insufficient information on the Claim: Notification of Response by claimant Review of adverse benefit determination Notice to claimant of adverse benefit determinations Except with Urgent Care Claims, when the notification may be orally followed by written or electronic notification within three days of the oral notification, the Plan Administrator shall provide written or electronic notification of any adverse benefit determination. The notice will state, in a manner calculated to be understood by the claimant: (1) (2) (3) The specific reason or reasons for the adverse determination. Reference to the specific Plan provisions on which the determination was based. A description of any additional material or information necessary for the claimant to perfect the Claim and an explanation of why such material or information is necessary. A description of the Plan's review procedures and the time limits applicable to such procedures. This will include a statement of the claimant's right to bring a civil action under section 502 of ERISA following an adverse benefit determination on review. A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Claim. If the adverse benefit determination was based on an internal rule, guideline, protocol, or other similar criterion, the specific rule, guideline, protocol, or criterion will be provided free of charge. If this is not practical, a statement will be included that such a rule, guideline, protocol, or criterion was relied upon in making the adverse benefit determination and a copy will be provided free of charge to the claimant upon request. If the adverse benefit determination is based on the Medical Necessity or Experimental or Investigational treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant's medical circumstances, will be provided. If this is not practical, a statement will be included that such explanation will be provided free of charge, upon request. 15 days 45 days 60 days
(4)
(5)
(6)
(7)
Appeals When a claimant receives an adverse benefit determination, the claimant has 180 days following receipt of the notification in which to appeal the decision. A claimant may submit written comments, documents, records, and other information relating to the Claim. If the claimant so requests, he or she will be provided, free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Claim. The period of time within which a benefit determination on review is required to be made shall begin at the time an appeal is filed in accordance with the procedures of the Plan. This timing is without regard to whether all the necessary information accompanies the filing.
75
A document, record, or other information shall be considered relevant to a Claim if it: (1) (2) was relied upon in making the benefit determination; was submitted, considered, or generated in the course of making the benefit determination, without regard to whether it was relied upon in making the benefit determination; demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify that benefit determinations are made in accordance with Plan documents and Plan provisions have been applied consistently with respect to all claimants; or constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit.
(3)
(4)
The review shall take into account all comments, documents, records, and other information submitted by the claimant relating to the Claim, without regard to whether such information was submitted or considered in the initial benefit determination. The review will not afford deference to the initial adverse benefit determination and will be conducted by a fiduciary of the Plan who is neither the individual who made the adverse determination nor a subordinate of that individual. If the determination was based on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is Experimental, Investigational, or not Medically Necessary or appropriate, the fiduciary shall consult with a health care professional who was not involved in the original benefit determination. This health care professional will have appropriate training and experience in the field of medicine involved in the medical judgment. Additionally, medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the initial determination will be identified. If the decision on review affirms the initial denial of the claim, the claimant will be furnished with a notice of adverse benefit determination on review setting forth: the specific reason(s) for the decision on review, the specific Plan provision(s) on which the decision is based, a statement of the claimants right to review (on request and at no charge) relevant documents and other information, if an internal rule, guideline, protocol, or other similar criterion is relied on in making the decision on review, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request, an explanation of the scientific or clinical judgment for the determination if the adverse benefit determination is based on the Medical Necessity or Experimental or Investigational treatment or similar exclusion or limit, or a statement that such explanation will be provided free of charge, upon request, and a statement of the claimants right to bring suit under ERISA 502(a).
Any suit for benefits must be brought within one year after the date the Plan Administrator (or his or her designee) has made a final denial (or deemed denial) of the claim. Notwithstanding any other provision herein, any suit for benefits must be brought within two years after the date the service or treatment was rendered.
76
CLERICAL ERROR Clerical errors or delays in record keeping will not invalidate coverage that would have been in force had the error or delay not been made. If the error or delay would affect contributions, an equitable adjustment will be made. PLAN AMENDMENT OR TERMINATION The Board of Directors reserves the right to terminate this Plan at any time and in any manner. The Vice President of Human Resources reserves the right to amend this Plan at any time and in any manner. Each of the above may delegate the authority to any officer(s) of the Company. Any actions by the Board of Directors or Vice President of Human Resources shall be evidenced by a valid resolution. Any action by an officer(s) shall be evidenced by the signature of the officer on the amendment. The amendment shall be attached to this Plan and considered a part hereof. DISCRETIONARY AUTHORITY The Plan Administrator has the discretionary authority to determine eligibility for coverage or benefits or to construe uncertain terms, and also reserves the right to change contributions, at any time and for any reason. There is neither vesting in benefits, nor a vested right to benefits. The Plan Administrator will make such rules as may be necessary for the administration of the Plan, supply any omissions and reconcile any inconsistencies, make equitable adjustment for any mistakes or errors, and decide at its discretion, all questions arising in interpretation of the Plan, all of which shall be conclusive and binding on all parties. INSTRUCTIONS FOR FILING A CLAIM All claims should be filed according to the addresses shown on the Employee identification card. The attending Physician's statement must be completed by the Physician, or his/her itemized bill, with diagnosis, must be attached. The Physician will generally show his/her charge on the claim form. For the Hospital or other medical charges which do not appear on the claim form, the Covered Person should submit the actual bills, and keep copies for his or her records. Prescriptions Use your Prescription Drug Card and pay the applicable benefit percentages. The pharmacist will bill the Plan Administrator for the balance. Mental and Nervous Disorders, Alcohol, Drug, and Substance Abuse DO NOT submit claims for Mental and Nervous Disorders, Alcohol, Drug, and Substance abuse expenses to the Claims Administrator. These claims will not be accepted or processed by the Claims Administrator. Charges incurred for Mental and Nervous Disorders, Alcohol, Drug, and Substance Abuse may be available through the Employee Assistance Program. This program is coordinated by Horizon Behavioral Services. Please contact Horizon at 1-800-955-6422 for further details.
IMPORTANT - THE NAME OF THE EMPLOYER AND THE COVERED PERSONS FULL NAME AND SOCIAL SECURITY NUMBER MUST BE SHOWN ON ALL BILLS, FORMS, AND CORRESPONDENCE.
This is a summary only. For further details consult the Human Resources Department.
77
GENERAL PLAN INFORMATION TYPE OF ADMINISTRATION The Plan is a self-funded group health Plan and the administration is provided through a Third Party Claims Administrator. The funding for the benefits is derived from the funds of the Employer and contributions made by covered Employees. The Plan is not insured. PLAN NAME Wellmont Health System Employee Medical, Dental, and Vision Care Plan PLAN NUMBER: 501 TAX ID NUMBER: 62-1636465 PLAN EFFECTIVE DATE: 07/01/1998 PLAN YEAR ENDS: 06/30 EMPLOYER, PLAN ADMINISTRATOR, PLAN SPONSOR, and PLAN SUPERVISOR Wellmont Health System 1905 American Way Kingsport, TN 37660 (423) 224-6455 AGENT FOR SERVICE OF LEGAL PROCESS Vice President of Human Resources Wellmont Health System 1905 American Way Kingsport, TN 37660 CLAIMS ADMINISTRATOR MCA Administrators Manor Oak Two, Suite 605 1910 Cochran Road Pittsburgh, Pennsylvania 15220 (800) 922-4966
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BY THIS AGREEMENT, Wellmont Health System Employee Health Plan is hereby adopted as shown. IN WITNESS WHEREOF, this instrument is executed for Wellmont Health System on or as of the day and year first below written.
By _________________________________ Wellmont Health System Date _______________________________
Witness ____________________________ Date _______________________________

WHS SPD PD 5-1-12

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WHS SPD PD 5-1-12

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Dear Wellmont Health System Employee: MCA Administrators, Inc.

Original effective date 7/1/1998; restated 7/1/2011

Effective July 1, 1998 Restated July 1, 2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

15 days 45 days 60 days

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

Original effective date 7/1/1998; restated 7/1/2011

HWHN Network Maximum Out-of-Pocket Expense per Plan

Emergency Room Facility Charges Medical Emergency

100% after deductible

60% after deductible

50% after deductible

100%, Deductible waived 100%, Deductible waived

Original effective date 7/1/1998; restated 7/1/2011

HWHN Network Physician Office Visit Charge Only

USA-MCO Network 100% after Copayment, Deductible waived $35 $45

Non-Network 50% after deductible

100% after Copayment, Deductible waived $25 $35

80% Deductible waived 90% Deductible waived 100% after deductible

60% after deductible

50% after deductible

60% after deductible 60% after deductible

50% after deductible 50% after deductible

80% Deductible waived 90% Deductible waived

60% after deductible

50% after deductible

60% after deductible

50% after deductible

80% after deductible 90% after deductible

60% after deductible 60% after deductible

50% after deductible 50% after deductible

80% after deductible 90% after deductible

60% after deductible 60% after deductible

50% after deductible 50% after deductible

Original effective date 7/1/1998; restated 7/1/2011

USA-MCO Network $100 co-pay, then 60% after deductible

Non-Network 50% after deductible

Outpatient Surgical Facility

$100 co-pay, then 100% Deductible waived

$650 co-pay, then 60% after deductible 60% after deductible

50% after deductible

50% after deductible

80% deductible waived 90% deductible waived

60% after deductible

50% after deductible