Download basic plan summary - McAllen Independent School District

MASTER PLAN DOCUMENT AND
PLAN DESCRIPTION OF
McALLEN INDEPENDENT SCHOOL DISTRICT
EMPLOYEE BENEFIT PLAN
Effective October 1, 2005
I.
SUMMARY OF MEDICAL BENEFITS.......................................................................................... 1
SUMMARY OF LIMITING FACTORS ..................................................................................................... 1
SCHEDULE OF BENEFITS .................................................................................................................... 3
DESCRIPTION OF NETWORK PROVIDER MEDICAL COVERAGE ......................................................... 20
MAXIMUM MEDICAL BENEFITS ...................................................................................................... 20
MEDICAL COSTS ............................................................................................................................. 21
1.
Benefit Percentages................................................................................................................... 21
2.
Copayments ............................................................................................................................... 21
3.
Deductible ................................................................................................................................. 21
4.
Out-of-Pocket Maximums.......................................................................................................... 22
5.
Automatic Restoration............................................................................................................... 22
F.
DESCRIPTION OF MEDICAL BENEFITS.............................................................................................. 22
1.
Abortion..................................................................................................................................... 22
2.
Allergy Injections and Surveys .................................................................................................. 22
3.
Ambulance Service .................................................................................................................... 22
4.
Ambulatory Surgical Center...................................................................................................... 22
5.
Birthing Centers ........................................................................................................................ 23
6.
Chemical Dependency (Substance Abuse) ................................................................................ 23
7.
Chemotherapy ........................................................................................................................... 23
8.
Chiropractic Treatment............................................................................................................. 23
9.
Dental Care for Accidental Injury............................................................................................. 24
10. Diagnostic Services ................................................................................................................... 24
11. Emergency Room Treatment ..................................................................................................... 24
12. Home Health Care Services ...................................................................................................... 24
13. Hospice Care Expenses ............................................................................................................. 24
14. Hospital Confinement................................................................................................................ 25
15. Hospital Outpatient Treatment.................................................................................................. 26
16. Infertility Testing ....................................................................................................................... 26
17. Medical Supplies/Durable Medical Equipment......................................................................... 26
18. Mental Health............................................................................................................................ 27
19. Newborn Care Expenses ........................................................................................................... 27
20. Nutritional Counseling .............................................................................................................. 28
21. Oral Surgery.............................................................................................................................. 28
22. Organ Transplants .................................................................................................................... 28
23. Physical/Occupational Therapy ................................................................................................ 29
24. Physician Services..................................................................................................................... 29
25. Preadmission Testing ................................................................................................................ 29
26. Pregnancy ................................................................................................................................. 29
27. Prescription Drugs.................................................................................................................... 30
28. Preventive Care......................................................................................................................... 31
29. Radiation Therapy..................................................................................................................... 31
30. Rehabilitation Facility............................................................................................................... 32
31. Skilled Nursing Facility............................................................................................................. 32
32. Speech Therapy ......................................................................................................................... 32
33. Sterilization ............................................................................................................................... 32
34. Surgery ...................................................................................................................................... 32
35. Temporomandibular Joint Dysfunction..................................................................................... 33
G. EXCLUSIONS FROM MEDICAL COVERAGE ....................................................................................... 34
H. DESCRIPTION OF ALTERNATE PLAN BENEFITS ................................................................................ 40
1.
Cancer Treatment...................................................................................................................... 40
2.
Hospital Expenses ..................................................................................................................... 41
3.
Prescription Drugs.................................................................................................................... 42
4.
Routine and Preventive Care .................................................................................................... 42
A.
B.
C.
D.
E.
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I.
J.
1.
2.
K.
L.
M.
1.
2.
3.
4.
N.
II.
EXCLUSIONS FROM ALTERNATE PLAN COVERAGE ......................................................................... 42
DENTAL COVERAGE COSTS............................................................................................................. 44
Benefit Percentages................................................................................................................... 44
Dental Deductible ..................................................................................................................... 44
EXTENDED DENTAL BENEFITS ........................................................................................................ 44
ALTERNATIVE DENTAL PROCEDURES ............................................................................................. 44
SUMMARY OF DENTAL BENEFITS .................................................................................................... 45
Covered Preventive Services ..................................................................................................... 45
Covered Basic Services ............................................................................................................. 45
Covered Major Services ............................................................................................................ 47
Covered Orthodontia Services .................................................................................................. 47
EXCLUSIONS FROM DENTAL COVERAGE......................................................................................... 48
CARE MANAGEMENT.................................................................................................................. 51
A.
B.
C.
D.
PREAUTHORIZATION FOR HOSPITAL CONFINEMENT ....................................................................... 51
DURABLE MEDICAL EQUIPMENT PREAUTHORIZATION ................................................................... 51
EMPLOYEE ASSISTANCE PROGRAM (EAP)...................................................................................... 52
MEDICAL CASE MANAGEMENT ....................................................................................................... 52
III. ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATES..................................................... 54
A.
1.
2.
B.
1.
2.
3.
4.
C.
1.
2.
3.
IV.
EXTENSIONS OF COVERAGE .................................................................................................... 60
FMLA QUALIFIED LEAVE OF ABSENCE .......................................................................................... 60
TOTAL DISABILITY EXTENSION OF COVERAGE ............................................................................... 60
PERSONAL OR MEDICAL LEAVE OF ABSENCE EXTENSION OF COVERAGE ....................................... 60
COBRA CONTINUATION COVERAGE .............................................................................................. 60
A.
B.
C.
D.
V.
ELIGIBILITY .................................................................................................................................... 54
Employee ................................................................................................................................... 54
Dependents ................................................................................................................................ 54
ENROLLMENT AND EFFECTIVE DATES ............................................................................................ 55
New Hire Enrollment................................................................................................................. 56
Late Enrollment......................................................................................................................... 56
Dual Option Transfer ................................................................................................................ 56
Special Enrollment .................................................................................................................... 57
PREEXISTING CONDITIONS .............................................................................................................. 57
Definition................................................................................................................................... 57
Limitation on or Exclusion from Coverage ............................................................................... 58
Creditable Coverage ................................................................................................................. 58
TERMINATION AND REINSTATEMENT OF COVERAGE................................................... 63
A.
B.
C.
VI.
TERMINATION OF EMPLOYEE COVERAGE........................................................................................ 63
TERMINATION OF DEPENDENT COVERAGE ...................................................................................... 63
REINSTATEMENT OF PARTICIPANT’S COVERAGE............................................................................. 64
1.
COBRA Participants ................................................................................................................. 64
2.
Reinstatement of Coverage Following a Military Leave........................................................... 64
3.
Reinstatement of Coverage After Voluntary Termination of Employment ................................ 64
CLAIMS ............................................................................................................................................ 65
A.
B.
1.
2.
3.
4.
5.
FILING ............................................................................................................................................. 65
APPEALING ..................................................................................................................................... 65
Explanation of Denial ............................................................................................................... 65
Request for Review .................................................................................................................... 66
Providing Additional Information ............................................................................................. 66
Decision on Review ................................................................................................................... 66
Explanation of Decision on Review........................................................................................... 66
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6.
VII.
Limitation .................................................................................................................................. 67
COORDINATION OF BENEFITS/THIRD PARTY LIABILITY ......................................... 68
A.
B.
C.
D.
E.
ALLOWABLE EXPENSE .................................................................................................................... 68
APPLICATION OF COORDINATION OF BENEFITS ............................................................................... 68
COORDINATION OF BENEFITS WITH MEDICARE ............................................................................... 70
RIGHT TO RECEIVE MEDICAL INFORMATION NECESSARY TO DETERMINE BENEFIT ....................... 71
SUMMARY AND PROTECTED HEALTH INFORMATION ...................................................................... 72
1.
Disclosure of Summary Health Information ............................................................................. 72
2.
Disclosure of Protected Health Information (PHI)................................................................... 72
3.
Limitations of PHI Access and Compliance.............................................................................. 73
F.
SUBROGATION/RIGHT OF REIMBURSEMENT .................................................................................... 73
VIII.
PLAN ADMINISTRATION ....................................................................................................... 76
A.
B.
C.
PLAN ADMINISTRATOR ................................................................................................................... 76
CLAIMS ADMINISTRATOR ............................................................................................................... 77
PARTICIPANT .................................................................................................................................. 78
IX.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
GENERAL PROVISIONS............................................................................................................... 79
LEGAL COMPLIANCE/CONFORMITY ................................................................................................ 79
EFFECT OF PRIOR COVERAGE.......................................................................................................... 79
SEVERABILITY ................................................................................................................................ 79
STATUS OF EMPLOYMENT RELATIONS ............................................................................................ 79
HEADINGS ....................................................................................................................................... 79
WORD USAGE ................................................................................................................................. 79
TITLES FOR REFERENCE .................................................................................................................. 80
CLERICAL ERROR ............................................................................................................................ 80
MISSTATEMENTS ............................................................................................................................. 80
REFUND OF OVERPAYMENTS .......................................................................................................... 80
X.
DEFINITIONS .................................................................................................................................. 81
XI.
IDENTIFICATION OF PLAN........................................................................................................ 89
iii
NOTICE OF ELECTION TO BE EXEMPTED FROM CERTAIN
REQUIREMENTS OF THE HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT OF 1996
In general, Federal Law imposes the following requirements on group health plans:
•
•
•
•
•
•
Limitations on Preexisting exclusion periods
Special enrollment periods for individuals (and Dependents) losing other coverage
Standards relating to benefits for mother and newborns
Parity in the application of certain limits to mental health benefits
Breast cancer surgery and reconstruction
Limitation on the requirement of evidence of health status as a condition for
enrollment
However, Federal law gives the sponsor of a non-Federal governmental plan the right to
exempt the plan, in whole or in part, from the above requirements. McAllen Independent
School District has elected to exempt the McAllen Independent School District
Employee Benefit Plan in part. Consequently, the Plan may limit benefits and restrict
enrollment without regard to the Federal requirements that would otherwise apply.
McAllen Independent School District, as sponsor of a non-Federal governmental plan,
has elected to exempt the McAllen Independent School District Employee Benefit Plan
accordingly.
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I.
SUMMARY OF MEDICAL BENEFITS
A.
Summary of Limiting Factors
This document serves as the Master Plan Document and as the Summary Plan
Description for this Plan. This document describes the conditions under which this Plan
will pay for medical care. There may be circumstances when a Participant and his
medical provider determine that medical care which is not covered by this Plan is
appropriate. All decisions regarding medical care are up to a Participant and his medical
provider.
Several factors affect the Participant’s receipt of the benefits described in the Schedule of
Benefits which follows. The Participant must be properly enrolled and have coverage
that is effective and which is not limited by a Preexisting Condition or other exclusions.
The Participant’s benefits are subject to coverage limits, claims limitations, satisfaction
of Participant costs, and coordination of benefits provisions. Benefits are listed and
described first, subject to the limitations described in detail in subsequent sections.
Services are as specified; exclusions are examples only.
Special Notice of the existence of a Preexisting Condition exclusion is given below:
PREEXISTING CONDITION EXCLUSION RULES
This Plan imposes a Preexisting Condition exclusion. That means that if a Participant
has a medical condition before coming to this Plan, the Participant might have to wait a
certain period of time before the Plan will provide coverage for that condition. This
exclusion applies only to conditions for which medical advice, diagnosis, care or
treatment was recommended or received within the 6-month period prior to the
Participant’s Enrollment Date. Generally, this 6-month period ends the day before
coverage becomes effective. However, if the Participant was in a Waiting Period for
coverage, the 6-month period ends on the day before the Waiting Period begins. The
Preexisting Condition exclusion does not apply to pregnancy nor to a child who is
enrolled in the Plan or who has other creditable coverage within 30 days of birth,
adoption or placement for adoption.
This exclusion may last up to 12 months from the first day of coverage or, if the
Participant was in a Waiting Period, from the first day of the Waiting Period. However,
the Participant can reduce the length of this exclusion period by the number of days of his
prior “creditable coverage”. Most prior health coverage is creditable coverage and can
be used to reduce the Preexisting Condition exclusion if the Participant has not
experienced a break in coverage of at least 63 days. To reduce the 12-month exclusion
period by the Participant’s creditable coverage, the Participant should give the Plan a
copy of any certificates of creditable coverage (HIPAA Certificates) he has. If the
Participant does not have a Certificate but does have prior health coverage, the Plan will
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help him obtain one from his prior plan or issuer. There are also other ways that the
Participant can show that he has creditable coverage. The Participant should contact the
Plan if he needs help demonstrating creditable coverage.
All questions about the Preexisting Condition exclusion and creditable coverage should
be directed to the Claims Administrator.
2
B.
Schedule of Benefits
BASIC PLAN
MEDICAL BENEFITS
MAXIMUMS
Lifetime Benefit
$1,000,000
Treatment of Mental Disorders
Inpatient
30 days per Calendar Year
Outpatient Psychotherapy
25 visits per Calendar Year
Skilled Nursing Facility
$10,000 per Calendar Year
Hospice
$20,000 per Calendar Year
Home Health Care (all professional visits)
$30,000 per Calendar Year
Chiropractic Treatment
$500 per Calendar Year
Occupational Therapy
$2,000 per Calendar Year
Routine Hearing Exam
1 per Calendar Year
Routine Eye Examination
1 per Calendar Year
Routine Physical Exam
1 per Calendar Year
Orthognathic Services
(available to individuals up to age 23)
$5,000 Lifetime
Treatment of Temporomandibular Joint
Syndrome
$750 Lifetime
CALENDAR YEAR DEDUCTIBLE
Network
Non-Network
Note: The Calendar Year deductible applies to all services unless otherwise specified.
Individual
$500
$500
Family (cumulative)
$1,500
$1,500
$0
$500 (per admission)
HOSPITAL CONFINEMENT
DEDUCTIBLE
3
BASIC PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Office Visit Charge
$30 copay per visit,
100% (1)
50%*
Prescriptions Dispensed in
Physician’s Office
50%* (2)
50%*
All Other Office Expenses
70%*
(1)
50%*
Independent Laboratory and Diagnostic
Testing Expenses
100% (1)
50%*
Independent X-ray Expenses
$30 copay per visit,
70%* (1)
50%*
MRI’s, PET and CAT Scans
(facility and professional fees,
all places of service)
$30 copay per visit,
70%* (1)
50%*
Second or Third Surgical Opinion
$30 copay per visit,
100% (1)
50%*
Inpatient Hospital Expenses
70%*
50%*
Outpatient Hospital Expenses
70%*
50%*
Ambulance Service
70%* (1)
70%* (1) (3)
Orthognathic Services
70%*
50%*
Physician Office/Clinic Expenses
(1) Calendar Year deductible waived.
(2) The non-Network deductible and out-of-pocket maximum will apply.
(3) The Network out-of-pocket maximum will apply.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
4
BASIC PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Immunizations/Flu Shots
100% (1)
50%*
Routine Hearing and Vision Exam
70%* (1)
50%*
Office Visit, All Other Services(4)
$30 copay per visit,
100% (1)
50%*
Immunizations/Flu Shots
100% (1)
50%*
Office Visit, All Other Services(4)
$30 copay per visit,
100% (1)
50%*
70%*
50%*
Facility Expenses
$75 copay per visit,
70%* (1)
$75 copay per visit,
70%* (1)
Physician Expenses
70%* (1)
50%* (1)
Facility Expenses
$75 copay per visit,
70%*
$75 copay per visit,
50%*
Physician Expenses
70%*
50%*
Preventive Care Services – Adult
Preventive Care Services – Child
Therapy Services
(occupational, physical and speech)
Emergency Room Services
(copay waived if admitted)
•
•
Emergency Use
Non-Emergency Use
(1) Calendar Year deductible waived.
(4) Please refer to Section F. for additional limitations that may apply.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
5
BASIC PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Urgent Care Expenses
70%*
50%*
Skilled Nursing Facility
70%* (1)
50%* (1)
Hospice
70%* (1)
50%* (1)
Home Health Care
70%* (1)
50%* (1)
Inpatient
70%*
Not Covered (5)
Outpatient (including psychotherapy)
70%*
Not Covered (5)
Inpatient
70%*
50%*
Outpatient (including psychotherapy)
70%*
50%*
Office Visit
$30 copay per visit,
100% (1) (6)
50%*
All Other Services
$30 copay per visit,
70%* (1) (6)
50%*
Durable Medical Equipment/Supplies
70%*
50%*
All Other Covered Expenses
70%*
50%*
Treatment of Mental Disorders
Treatment of Chemical Dependency
Chiropractic Treatment
(1) Calendar Year deductible waived.
(5) Coverage is not available for treatment received from non-Network providers, except
in the case of a Medical Emergency.
(6) The copay applies to all services rendered. Only one copay will be applied per visit.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
6
BASIC PLAN (Continued)
OUT-OF-POCKET MAXIMUM (excluding Calendar Year deductible)
Network
Non-Network
Individual
$3,500
$7,000
Family (cumulative)
$10,500
$21,000
PRESCRIPTION DRUG BENEFITS
• Retail Benefit
(Limited to a 30-day supply per prescription or refill)
$5 copay for generic
$25 copay for brand name
$45 copay for non-formulary
• Mail Order Benefit
(Limited to a 90-day supply per prescription or refill)
$7.50 copay for generic
$37.50 copay for brand name
$67.50 copay for non-formulary
7
HIGH PLAN
MEDICAL BENEFITS
MAXIMUMS
Lifetime Benefit
$1,000,000
Treatment of Mental Disorders
Inpatient
30 days per Calendar Year
Outpatient Psychotherapy
25 visits per Calendar Year
Skilled Nursing Facility
$10,000 per Calendar Year
Hospice
$20,000 per Calendar Year
Home Health Care (all professional visits)
$30,000 per Calendar Year
Chiropractic Treatment
$500 per Calendar Year
Occupational Therapy
$2,000 per Calendar Year
Routine Hearing Exam
1 per Calendar Year
Routine Eye Examination
1 per Calendar Year
Routine Physical Exam
1 per Calendar Year
Orthognathic Services
(available to individuals up to age 23)
$5,000 Lifetime
Treatment of Temporomandibular Joint
Syndrome
$750 Lifetime
Podiatric Supplies and Non-Surgical Treatment
of the Feet
$250 per Calendar Year
CALENDAR YEAR DEDUCTIBLE
Network
Non-Network
Note: The Calendar Year deductible applies to all services unless otherwise specified.
Individual
$300
$300
Family (cumulative)
$900
$900
$0
$250 (per admission)
HOSPITAL CONFINEMENT
DEDUCTIBLE
8
HIGH PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Office Visit Charge
$20 copay per visit,
100% (1)
60%*
Prescriptions Dispensed in
Physician’s Office
60%* (2)
60%*
All Other Office Expenses
80%*
(1)
60%*
Independent Laboratory and Diagnostic
Testing Expenses
100% (1)
60%*
Independent X-ray Expenses
$20 copay per visit,
80%* (1)
60%*
MRI’s, PET and CAT Scans
(facility and professional fees,
all places of service)
$20 copay per visit,
80%* (1)
60%*
Second or Third Surgical Opinion
$20 copay per visit,
100% (1)
60%*
Inpatient Hospital Expenses
80%*
60%*
Outpatient Hospital Expenses
80%*
60%*
Ambulance Service
80%* (1)
80%* (1) (3)
Orthognathic Services
80%*
60%*
Physician Office/Clinic Expenses
(1) Calendar Year deductible waived.
(2) The non-Network deductible and out-of-pocket maximum will apply.
(3) The Network out-of-pocket maximum will apply.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
9
HIGH PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Immunizations/Flu Shots
100% (1)
60%*
Routine Hearing and Vision Exam
80%* (1)
60%*
Office Visit, All Other Services(4)
$20 copay per visit,
100% (1)
60%*
Immunizations/Flu Shots
100% (1)
60%*
Office Visit, All Other Services(4)
$20 copay per visit,
100% (1)
60%*
80%*
60%*
Facility Expenses
$50 copay per visit,
80%* (1)
$50 copay per visit,
80%* (1)
Physician Expenses
80%* (1)
60%* (1)
Facility Expenses
$50 copay per visit,
80%*
$50 copay per visit,
60%*
Physician Expenses
80%*
60%*
Preventive Care Services – Adult
Preventive Care Services – Child
Therapy Services
(occupational, physical and speech)
Emergency Room Services
(copay waived if admitted)
•
•
Emergency Use
Non-Emergency Use
(1) Calendar Year deductible waived.
(4) Please refer to Section F. for additional limitations that may apply.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
10
HIGH PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Urgent Care Expenses
80%*
60%*
Skilled Nursing Facility
80%* (1)
60%* (1)
Hospice
80%* (1)
60%* (1)
Home Health Care
80%* (1)
60%* (1)
Inpatient
80%*
60%*
Outpatient (including psychotherapy)
80%*
60%*
Inpatient
80%*
60%*
Outpatient (including psychotherapy)
80%*
60%*
Office Visit
$20 copay per visit,
100% (1) (5)
60%*
All Other Services
$20 copay per visit,
80%* (1) (5)
60%*
Durable Medical Equipment/Supplies
80%*
60%*
All Other Covered Expenses
80%*
60%*
Treatment of Mental Disorders
Treatment of Chemical Dependency
Chiropractic Treatment
(1) Calendar Year deductible waived.
(5) The copay applies to all services rendered. Only one copay will be applied per visit.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
11
HIGH PLAN (Continued)
OUT-OF-POCKET MAXIMUM (excluding Calendar Year deductible)
Network
Non-Network
Individual
$2,500
$5,000
Family (cumulative)
$7,500
$15,000
PRESCRIPTION DRUG BENEFITS
• Retail Benefit
(Limited to a 30-day supply per prescription or refill)
$5 copay for generic
$20 copay for brand name
$35 copay for non-formulary
• Mail Order Benefit
(Limited to a 90-day supply per prescription or refill)
$7.50 copay for generic
$30 copay for brand name
$52.50 copay for non-formulary
12
STATE PLAN
MEDICAL BENEFITS
MAXIMUMS
Lifetime Benefit
Network Providers
Unlimited
Non-Network Providers
$1,000,000
Note: Both Network and non-Network expenses will be applied to the non-Network
Lifetime Benefit listed above.
Treatment of Mental Disorders (1)
Inpatient
30 days per Calendar Year
Outpatient Psychotherapy
30 visits per Calendar Year
Inpatient Treatment of Chemical Dependency
2 series of treatments per Lifetime
Skilled Nursing Facility
$10,000 per Calendar Year combined
for both Network and non-Network
providers, non-Network is limited to
$7,000 per Calendar Year
Hospice
$20,000 per Calendar Year combined
for both Network and non-Network
providers, non-Network is limited to
$14,000 per Calendar Year
Home Health Care (all professional visits)
$10,000 per Calendar Year combined
for both Network and non-Network
providers, non-Network is limited to
$7,000 per Calendar Year
Chiropractic Treatment
$1,500 per Calendar Year
Routine Hearing Exam
1 per Calendar Year
Hearing Aid
$1,000 per 36 months
Routine Eye Examination
1 per Calendar Year
Routine Physical Exam or Gynecological Exam
1 each per Calendar Year
(1) Please refer to the Important Note on page 17 for information regarding benefits for
the treatment of Mental Disorders and Serious Mental Disorders.
13
STATE PLAN (Continued)
CALENDAR YEAR DEDUCTIBLE
Network
Non-Network
Note: The Calendar Year deductible applies to all services unless otherwise specified.
Individual
$0
$500
Family (cumulative)
$0
$1,500
Network
Non-Network
PCP copay –
$20 copay per visit,
65%*
BENEFIT PERCENTAGES
Physician Office/Clinic Expenses
Office Visit Charge
Specialist –
$30 copay per visit,
then 100%
Diagnostic X-ray/Lab, Therapeutic
and Allergy Injections
100% (2)
65%*
All Other Office Expenses
85%*
65%*
Independent Diagnostic Testing, X-ray
and Laboratory Expenses
85%*
65%*
MRI’s, PET and CAT Scans
85%*
65%*
Second or Third Surgical Opinion
PCP copay –
$20 copay per visit,
65%*
Specialist –
$30 copay per visit,
then 100%
Inpatient Hospital Expenses
85%*
65%*
(2) If an office visit charge is not incurred with these services, expenses will be
considered at 85%, subject to the out-of-pocket maximum.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
14
STATE PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Outpatient Hospital Expenses
85%*
65%*
Ambulance Service
85%*
85%*
Routine Hearing Exam
$30 copay per visit,
then 100% (2) (3)
65%*
Office Visit, All Other Services
PCP copay –
$20 copay per visit,
65%* (3)
Preventive Care Services – Adult
Specialist –
$30 copay per visit,
then 100% (2) (3)
Preventive Care Services – Child
PCP copay –
$20 copay per visit,
65%* (3)
Specialist –
$30 copay per visit,
then 100% (2) (3)
Therapy Services
(occupational, physical and speech)
85%*
65%*
Facility Expenses
$50 copay per visit,
85%*
65%*
Physician Expenses
85%*
65%*
Emergency Room Services
(copay waived if admitted)
(2) If an office visit charge is not incurred with these services, expenses will be
considered at 85%, subject to the out-of-pocket maximum.
(3) Please refer to Section F. for additional limitations that may apply.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
15
STATE PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Urgent Care Expenses
85%*
65%*
Skilled Nursing Facility
85%*
65%*
Hospice
85%*
65%*
Home Health Care
85%*
65%*
Inpatient
85%*
65%*
Outpatient (including psychotherapy)
85%*
65%*
Treatment of Mental Disorders (1)
(maximum allowable
of $60 per visit)
Treatment of Chemical Dependency
Inpatient
85%*
65%*
Outpatient Psychotherapy, or
Physician Office Visit charge
PCP copay –
$20 copay per visit,
65%*
Specialist –
$30 copay per visit,
then 100%
All Other Outpatient Expenses
85%*
65%*
Office Visit
$30 copay per visit,
100%*
65%*
All Other Services
85%*
65%*
Chiropractic Treatment
(1) Please refer to the Important Note on page 17 for information regarding benefits for
the treatment of Mental Disorders and Serious Mental Disorders.
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
16
STATE PLAN (Continued)
BENEFIT PERCENTAGES
Network
Non-Network
Durable Medical Equipment/Supplies
85%*
65%*
All Other Covered Expenses
85%*
65%*
*To the out-of-pocket maximum, benefits thereafter will be payable at 100% for the
remainder of that Calendar Year.
OUT-OF-POCKET MAXIMUM (excluding Calendar Year deductible)
Individual
Network
Non-Network
$1,000
$3,000
IMPORTANT NOTE:
The following Serious Mental Disorder diagnoses will be paid as stated in the Schedule
of Benefits and will not be subject to the maximums or benefit levels indicated for the
treatment of Mental Disorders.
•
•
•
•
•
Schizophrenia
Paranoid and other Psychotic Disorders
Bipolar Disorders (mixed, manic and depressive)
Major Depressive Disorders (single episode or recurrent)
Schizo-Affective Disorders (bipolar or depressive)
PRESCRIPTION DRUG BENEFITS
• Retail Benefit
(Limited to a 30-day supply per prescription or refill)
$10 copay for generic
$25 copay for brand name
$40 copay for non-formulary
•
Mail Order Benefit
$20 copay for generic
$50 copay for brand name
$80 copay for non-formulary
17
ALTERNATE PLAN
BENEFITS
MAXIMUMS
Lifetime Benefit
Unlimited
Hospital Expenses
Inpatient Services
100%;
Per day benefit - $250
Outpatient Surgical Services
100%;
$100 per procedure maximum
Outpatient Cancer Treatment
100%;
$100 per day maximum
Routine and Preventive Care Services
100%;
$200 per Calendar Year
Prescription Drugs
100%;
$500 per Calendar Year
IMPORTANT NOTES:
The Alternate Plan offers limited benefits to covered Employees and may be elected
instead of the Basic, High or State Plans. Dependents are not eligible for benefits under
the Alternate Plan. However, Employees who elect the Alternate Plan may enroll their
Dependents in the Dental Plan. Specified benefits are considered “cash” benefits and are
not subject to the following Plan provisions: Deductible, Benefit Percentage, Maximum
Out-of-Pocket, Care Management, Preexisting Conditions, Subrogation and Coordination
of Benefits. All other Plan provisions, including Employee Eligibility and Termination
of Coverage provisions will apply to the Employee covered under the Alternate Plan.
Benefits will not be payable for expenses incurred in connection with treatment received
for Mental Disorders and/or Chemical Dependency.
18
DENTAL PLAN
BENEFIT
MAXIMUM
Dental
$2,000 per Calendar Year
Orthodontia
$1,000 Lifetime
DEDUCTIBLE
Individual
$75 per Calendar Year
Family (cumulative)
$225 per Calendar Year
BENEFIT PERCENTAGES
Preventive Services
80% (deductible waived)
Basic Services
80%
Major Services
50%
Orthodontia Services
50% (deductible waived)
19
C.
Description of Network Provider Medical Coverage
Network providers are Hospitals, Physicians or other providers who have agreed to
provide health care services to plan Participants at negotiated rates. Network provider
lists will be furnished automatically and without charge to Employees. As specified in
this article, Network provider benefits are generally higher than non-Network provider
benefits. Network provider benefits will be payable to non-Network providers under the
following circumstances:
Network Provider benefits will be payable to non-Network Providers under the following
circumstances:
•
Professional services rendered from an emergency room Physician, radiologist,
anesthesiologist, or pathologist if such services are rendered in a Network facility.
•
Treatment of a Medical Emergency.
•
Services unavailable by a Network provider within a 50 mile radius from the
individual’s residence.
•
Specialized care – no Network facility equipped to provide services.
D.
Maximum Medical Benefits
Subject to the exclusions, conditions, and limitations stated in this document, the Plan
will pay benefits to or on behalf of a Participant for covered medical expenses described
in this article up to the maximum amounts specified in the Schedule of Benefits.
The Plan will pay benefits for the Reasonable and Customary Charges for services and
supplies which are ordered by a Physician. However, Reasonable and Customary
limitations will not apply to Network PPO repriced claims. Services must be furnished
by an eligible provider and must be Medically Necessary.
The obligation of this Plan shall be fully satisfied by the payment of allowable expenses
in accordance with the Schedule of Benefits. Benefits will be paid for the reimbursement
of medical expenses incurred by the Participant if all provisions mentioned in this
document are satisfied. All payments made under this Plan for allowable charges will be
limited to Reasonable and Customary or the applicable Network repriced amount.
20
E.
Medical Costs
1.
BENEFIT PERCENTAGES
After satisfaction of any applicable deductible, the Plan will provide the level of payment
indicated in the Schedule of Benefits. The Participant is responsible for the remaining
percentage.
2.
COPAYMENTS
A Participant may be assessed a per-service charge for Physician office visits, emergency
room visits, prescriptions, and other services according to the Schedule of Benefits.
3.
DEDUCTIBLE
a)
Level
BASIC PLAN
• Network Providers*
Per Participant per Calendar Year:
Per Family per Calendar Year:
•
$500
$1,500 (cumulative)
Non-Network Providers*
Per Participant per Calendar Year:
Per Family per Calendar Year:
Per Hospital Confinement
$500
$1,500 (cumulative)
$500
HIGH PLAN
• Network Providers*
Per Participant per Calendar Year:
Per Family per Calendar Year:
•
$300
$900 (cumulative)
Non-Network Providers*
Per Participant per Calendar Year:
Per Family per Calendar Year:
Per Hospital Confinement
$300
$900 (cumulative)
$250
STATE PLAN
• Network Providers
Per Participant per Calendar Year:
Per Family per Calendar Year:
•
$0
$0
Non-Network Providers
Per Participant per Calendar Year:
Per Family per Calendar Year:
$500
$1,500 (cumulative)
*Note: Amounts applied to the Calendar Year deductible for Network providers will
also apply to the Calendar Year deductible for non-Network providers, and vice versa.
21
b)
Applicability
Carryover:
Each Calendar Year, a new deductible must be satisfied. Any charges
incurred by an individual during the last three months of a year and applied toward such
individual’s deductible for that year will be applied also toward such individual’s
deductible for the next year.
4.
OUT-OF-POCKET MAXIMUMS
The maximum amount a Participant must pay (not including deductibles) toward eligible
expenses. Penalties do not apply to the out-of-pocket maximum, nor do amounts over the
Reasonable and Customary limitation, nor any per-visit or prescription drug copayments.
Note: Amounts applied to the out-of-pocket maximum for Network providers will also
apply to the out-of-pocket maximum for non-Network providers, and vice versa
5.
AUTOMATIC RESTORATION
A Participant in this Plan as of January 1st shall have restored to the Participant’s
Lifetime maximum an amount up to $1,000 representing usage during the previous Plan
Year.
F.
Description of Medical Benefits
The following description of covered services is applicable to the Basic, High and State
Plans only.
1.
ABORTION
Induced termination of a pregnancy for an Employee or spouse, by any acceptable means
only when Medically Necessary to preserve the life of the mother.
2.
ALLERGY INJECTIONS AND SURVEYS
3.
AMBULANCE SERVICE
Professional ambulance service to the Hospital. In the event that a Sickness or Injury
requires specialized emergency treatment not available at a local Hospital, transportation
for such treatment is covered when ordered by a Physician. The transportation within the
United States and Canada must be by regularly scheduled airlines or railroad or by air
ambulance. The covered transportation is only from the city or town where the disability
occurred to the nearest Hospital qualified to render special treatment.
4.
AMBULATORY SURGICAL CENTER
Facility charges for procedures performed in an Ambulatory Surgical Center and
associated services and supplies.
22
5.
BIRTHING CENTERS
Expenses for facility charges and associated services and supplies for procedures
performed in a Birthing Center will be considered under the Inpatient Hospital Benefits
of this Plan.
6.
CHEMICAL DEPENDENCY (SUBSTANCE ABUSE)
Benefits will be payable up to the maximum amount indicated in the Schedule of
Benefits for the following:
a)
Inpatient
Semiprivate room accommodations and Medically Necessary services and supplies
furnished by the Hospital or facility for diagnosis or treatment of Chemical Dependency.
b)
Outpatient
Medical Expenses for Outpatient treatment of Chemical Dependency including the
following:
•
•
Medically Necessary services and supplies provided by a Hospital or other
duly licensed facility on an Outpatient basis.
Physician office visits or Physician visits on an Outpatient basis at a Hospital
or other licensed facility.
7.
CHEMOTHERAPY
A regimen comprised of a single agent or a combination of anti-cancer agents clinically
recognized for treatment of a specific type of cancer, including modifications and
combinations appropriate to the history of the cancer or according to protocol specifying
the combination of drugs, doses, and schedules for administration of the drugs.
Drug Requirements
•
•
•
Use that is included as an indication on the drug’s label as approved by the
FDA or
Use of an FDA-approved drug for an off-label purpose that is medically
accepted for an anti-cancer therapeutic regimen as evidenced by major drug
compendia, medical literature, and/or accepted standards of medical practice.
Use of drugs to treat toxicities or side effects of the cancer treatment regimen
when the drug is administered in relation to chemotherapy, including off-label
uses supported by medical literature.
8.
CHIROPRACTIC TREATMENT
Diagnostic evaluations, and subject to the maximum amount indicated in the Schedule of
Benefits, treatments by manipulation and other modalities.
23
9.
DENTAL CARE FOR ACCIDENTAL INJURY
Treatment of Accidental Injuries to the jaw, mouth, or sound natural tooth (a tooth which
is free of decay but may be restored by fillings, has a live root, and does not have a cap or
crown).
10.
DIAGNOSTIC SERVICES
Services performed for the express purpose of determining the cause of definite
symptoms experienced by the patient, not in connection with routine physical
examinations except as specified in this Plan Document. Covered expenses include:
•
•
•
Pathology
Radiology
Physician’s Interpretation.
11.
EMERGENCY ROOM TREATMENT
Benefits will be payable as specified in the Schedule of Benefits for the following:
a)
Life-Threatening/Sudden & Serious Illness
Immediate care required for a life-threatening Medical Emergency or Accidental bodily
Injury which untreated could result in death or serious bodily impairment.
b)
Non-Emergency Use
Care received for Sickness or Injury which does not qualify as life-threatening.
12.
HOME HEALTH CARE SERVICES
Benefits will be payable up to the maximum amount specified in the Schedule of Benefits
for the following:
a)
Services
Part-time or intermittent nursing care provided or supervised by a Registered Nurse
(R.N.) to the limit provided for Nursing Care; part-time or intermittent home health aide
services, primarily for the patient’s medical care; physical, occupational, speech, or
respiratory therapy by a licensed qualified therapist; nutrition counseling provided by or
under the supervision of a registered dietician; or medical supplies, laboratory services,
drugs, and medications prescribed by a Physician.
b)
Requirements
Services must be provided in the patient’s home under a written plan of the patient’s
attending Physician’s stating the diagnosis, certifying that the Home Health Care is in
lieu of Hospital Confinement, and further specifying the type and extent of treatment.
13.
HOSPICE CARE EXPENSES
Benefits will be payable up to the maximum amount specified in the Schedule of Benefits
for the following:
24
•
•
•
a)
Services
Hospice room and board while the terminally ill person (diagnosed by the
attending Physician as having six months or less to live) is an inpatient in a
Hospice;
Outpatient and other customary Hospice services provided by a Hospice or
Hospice team; and
Counseling services provided by a member of the Hospice team.
b)
Requirements
These services and supplies are eligible only if the Hospice operates as an integral part of
a Hospice Care Agency and the Hospice team includes at least a doctor and a registered
graduate nurse. Each service or supply must be:
•
•
•
•
14.
Provided under a Hospice Care Agency program that meets standards set by
the Plan. If such a program is required by federal or state law to be licensed,
certified, or registered, it must meet that requirement;
Provided while the terminally ill person is in a Hospice Care Program; and
Ordered by the doctor directing the Hospice Care Program.
Counseling services for the Family unit must be ordered and received under
the Hospice Care Program; on the day before death the terminally ill person
must have been in a Hospice Care Program, a member of the Family unit, a
covered Participant; and charges must be incurred within six months after the
death.
HOSPITAL CONFINEMENT
a)
Room and Board
Semi-private room accommodations, including general nursing services. Room charges
made by a Hospital having only private rooms will be paid as if the room were a semiprivate room. Expenses for special care units, including general nursing services.
Special care units include intensive care units, cardiac care units, respiratory care units,
step down units, emergency care facilities, and other units considered by the Plan to be
special care units.
If a private room is Medically Necessary for isolation purposes, the private room charge
will be considered as semiprivate.
b)
Hospital Services and Supplies
Benefits will be payable for Medically Necessary services and supplies furnished during
a covered Hospital Confinement, including, but not limited to, the following:
•
•
•
•
Meals and special diets
Operating and recovery rooms
Drugs and medicines required during a period of confinement
Oxygen and the use of equipment for its administration
25
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Laboratory and pathological tissue examinations
Dressings and casts
Thyroid function studies
Blood transfusion services
X-ray and other radiological examinations
Electrocardiograms
Electroencephalograms
Physical therapy
Inhalation therapy
Use of heart-lung equipment
Kidney dialysis services
Anesthesia services
Use of anesthesia equipment
Radioactive materials and radiation therapy
Diagnostic services
15.
HOSPITAL OUTPATIENT TREATMENT
Services rendered in an Outpatient department of a Hospital, including, but not limited to,
the following:
•
•
•
•
•
•
•
•
•
Allergy testing
Chemotherapy
Dialysis
Emergency Room Services
Laboratory Tests and X-rays
Pre-Admission Testing
Radiation Therapy
Respiratory Therapy
Surgical Services
16.
INFERTILITY TESTING
Diagnostic procedures and related expenses (including X-ray and laboratory
examinations) performed solely to determine the cause of infertility.
17.
MEDICAL SUPPLIES/DURABLE MEDICAL EQUIPMENT
Coverage includes, but is not limited to, the following:
•
•
Rental or initial purchase (whichever is less expensive, subject to approval by
the Plan) of Durable Medical Equipment, including, but not limited to,
respiration equipment, hospital beds, and wheelchairs. Replacement of
Durable Medical Equipment when Medically Necessary due to a
physiological change to the patient, due to normal wear and tear of an item or
the existing equipment is damaged and cannot be made serviceable.
Blood and blood plasma (unless replaced by or for the patient).
26
•
•
•
•
Artificial limbs, eyes, and larynx (including fitting); heart pacemaker, surgical
dressings; cast; splints; trusses; braces; crutches.
Oxygen, and lenses following cataract surgery.
Basic and High Plans – Initial hearing aid needed for loss of hearing due to
surgery, illness, or injury.
State Plan – Hearing aids, including evaluation and testing, limited to the
maximum amount stated in the Schedule of Benefits.
18.
MENTAL HEALTH
Benefits will be payable up to the maximum amount specified in the Schedule of Benefits
for the following:
a)
Inpatient
Semiprivate room accommodations and Medically Necessary services and supplies
furnished by the Hospital or facility for diagnosis or treatment of Mental Disorders.
b)
Outpatient
Medical Expenses for Outpatient treatment of Mental Disorders including the following:
•
•
•
Medically Necessary services and supplies provided by a Hospital or other
duly licensed facility on an Outpatient basis, including laboratory testing.
Physician office visits or Physician visits on an Outpatient basis at a Hospital
or other licensed facility.
Outpatient shock therapy.
Note: Covered expenses incurred as a result of or in connection with diagnosis or
treatment of a learning disability, learning impairment or behavioral problem(s) by any
name called, whether or not associated with manifest mental disorders or other
disturbances, will be processed under and subject to the limited Mental Nervous
conditions, benefits and limitations as shown elsewhere in this Plan.
19.
NEWBORN CARE EXPENSES
Payment for covered expenses incurred by a well newborn child for Hospital services
only, during the Hospital confinement immediately following birth, will be made on the
same basis as for any other Sickness. Covered expenses for a newborn child incurred for
Hospital services while the mother is confined for delivery will be added to covered
expenses of the mother to determine allowable benefits payable (one deductible, one
copayment). These benefits will be available provided the Employee has properly
enrolled his Dependent for Dependent benefits and Dependent coverage is in force.
When a newborn incurs charges as a result of Sickness, Injury or congenital abnormality,
payment for covered expenses incurred for Hospital and Physician services during
Hospital confinement immediately following birth will be made on the same basis as for
any other Sickness provided the Employee has properly enrolled his Dependent for
Dependent benefits and Dependent coverage is in force.
27
20.
NUTRITIONAL COUNSELING
Nutritional counseling rendered by a licensed nutritionist (if licensing is required by the
state) or registered dietician. Benefits will be limited to diabetes and post cardiac
surgery.
21.
ORAL SURGERY
Benefits are limited to the following procedures:
•
•
•
•
22.
Excision of tumors or cysts from the mouth
Treatment of fractures of facial bones
External incision and drainage of cellulitis
Incision of accessory sinuses, salivary glands or ducts
ORGAN TRANSPLANTS
a)
Services
Covered expenses related to non-experimental human organ transplants which are
Medically Necessary. Covered procedures include, but are not limited to:
•
•
•
•
•
•
•
•
Bone Marrow
Cornea
Heart
Heart/lung
Kidney
Liver
Lung
Pancreas
The Plan will also cover any other types of human organ transplants that become
accepted as non-experimental procedures, as determined by the Plan Administrator.
Covered charges include acquisition cost and drugs, even if not otherwise covered under
this Plan.
Covered transplant-related expenses incurred by a living donor. Subject to coordination
with any other medical benefits covering the donor and subject to the Participant’s
maximum benefits payable under this Plan.
b)
Requirements
Transplants: Any human solid organ or bone marrow/stem cell transplant provided that:
1) The condition is life-threatening; and
2) Such transplant for that condition follows a written protocol that has been
reviewed and approved by an institutional review board, federal agency or
other such organization recognized by medical specialists who have
appropriate expertise; and
3) The patient is a suitable candidate for the transplant approved by the Plan.
28
23.
PHYSICAL/OCCUPATIONAL THERAPY
Medically Necessary services, as certified by a Physician, rendered by a certified or
licensed physical therapist or registered occupational therapist. Therapy rendered by a
licensed therapist to restore the loss or impairment of motor functions resulting from
illness, disease or Injury. Coverage ends once maximum medical recovery has been
achieved and further treatment is primarily for maintenance purposes. Only therapy
designed to restore motor functions needed for activities of daily living (such as walking,
eating, dressing, etc.) is covered.
Benefits for occupational therapy services will be subject to the maximums indicated in
the Schedule of Benefits for the Basic and High Plans.
24.
PHYSICIAN SERVICES
a)
Hospital Inpatient
Inpatient Services and Medically Necessary consultations by a Physician to a Hospital
inpatient.
b)
Physician Home/Office Visits
Services and supplies provided by a Physician in a professional office or in the home of
the Participant when Medically Necessary.
c)
Other
Reasonable and necessary services of a Physician. Covered services include, but are not
limited to, the following:
•
•
•
•
•
•
•
•
•
•
•
•
25.
Allergy Injections
Allergy Testing
Cardiac Rehabilitation
Chemotherapy
Dermatology Testing
Dialysis
Emergency Room Services
Infusion Therapy
Injections
Interpretation of Diagnostic Tests
Radiation Therapy
Respiratory Therapy
PREADMISSION TESTING
26.
PREGNANCY
This Plan shall not restrict benefits for any Hospital length of stay in connection with
childbirth for the mother or newborn child to less than 48 hours following a normal
vaginal delivery, or less than 96 hours following a cesarean section. This Plan shall not
29
require that a provider obtain authorization from the Plan or the insurance issuer for
prescribing a length of stay not in excess of the above periods, and nothing is to prevent
the mother’s or newborn’s attending health care provider and the mother from agreeing to
an earlier discharge. Notwithstanding the above, compliance with this Plan’s policy of
precertification for maternity care management shall be required.
Regular Plan benefits (as specified in the applicable sections of this document) are
payable for expenses incurred by the Employee or spouse.
Services required for the normal management of pregnancy, including any condition
usually associated with the management of a difficult pregnancy but not considered a
complication of pregnancy. Antepartum and postpartum care of the mother is included.
Services required for the treatment of complication of pregnancy, including any physical
effect directly caused by pregnancy but considered to be an effect of a normal pregnancy,
conditions related to ectopic pregnancy or conditions requiring cesarean section.
Care for Miscarriage.
27.
PRESCRIPTION DRUGS
Prescription benefits are provided outside the medical/surgical benefits of the Plan and
therefore are not subject to the Plan maximum.
a)
Retail Benefit
In addition to the benefits provided by this Plan, the Employer has selected a Prescription
Benefit Manager to provide benefits for prescription drugs.
If a Participant incurs expenses for prescription drugs, the prescription drug plan will pay
100% after application of the appropriate per prescription copay.
If a prescription is filled at a participating pharmacy the Participant will have to pay only
the copay amount. The pharmacy will submit the claim to the prescription drug plan,
which will reimburse the pharmacy.
For Participants in the Basic and High Plans, if a prescription is filled at a nonparticipating pharmacy, benefits will not be available.
For Participants in the State Plan, if a prescription is filled at a non-participating
pharmacy the Participant must pay the entire cost of the prescription. For reimbursement,
a prescription drug claim form must be completed by the Participant, then submitted by
the Participant to the prescription drug plan for processing. Reimbursement for the
discounted cost of the prescription minus the copay will be made to the Participant.
30
b)
Mail Order Benefit
In addition to the benefits provided by this Plan, the Employer has selected a Prescription
Benefit Manager to provide benefits for mail order prescription drugs.
This program is particularly beneficial for those individuals who take medication over an
extended period of time (maintenance medication). Maintenance medication is usually
associated with the treatment of such illnesses as anemia, arthritis, diabetes, emotional
distress, epilepsy, heart disorders, high blood pressure, thyroid or adrenal conditions,
ulcers, etc.
If a Participant incurs expenses for prescription drugs, the prescription drug plan will pay
100% of the cost of the prescription minus the per prescription copay.
28.
PREVENTIVE CARE
a)
Adult
Routine physical examinations, hearing exams, vision exams, immunizations, flu shots
and diagnostic tests performed as part of the examination. Benefits will be subject to the
maximums indicated in the Schedule of Benefits, and include but are not limited to the
following:
•
•
•
•
•
•
Pap test
Prostate testing
Mammograms – limited to once per Calendar Year
Fecal occult testing - limited to once per Calendar Year for Participants age
50 and older;
Colonoscopies – limited to once per 10 consecutive years for Participants age
50 and over;
Sigmoidoscopies
Note: For Participants in the Basic and High Plan, expenses are covered for individuals
over age 18. For participants in the State Plan, expenses are covered for individuals
over age 2.
b)
Child
Physician expenses incurred for well child checkups for Dependent children up to age
18* for Participants of the Basic or High Plan, and up to age 2* for Participants in the
State Plan. Expenses will be payable for the office visit, vision exams, immunizations,
flu shots and any related diagnostic tests.
*For Dependent children over the limiting age specified above, benefits for routine
services will be payable under the Adult Preventive Care Benefits.
29.
RADIATION THERAPY
Radiation therapy by X-ray, radon, radium and radioactive isotopes.
31
30.
REHABILITATION FACILITY
Facility charges for rehabilitation treatment performed in a Rehabilitation Facility and
associated services and supplies.
31.
SKILLED NURSING FACILITY
Benefits will be payable up to the maximum amount indicated in the Schedule of
Benefits for the following:
a)
Services
Services and supplies (other than personal items and professional services) provided
while the patient is under continuous medical care and requires 24-hour nursing care, and
room and board up to the facility’s semi-private room rate.
b)
Requirements
Confinement must be ordered by the Physician as Medically Necessary for convalescence
from the illness or Injury that caused the Hospital Confinement.
The attending Physician completes a treatment plan which includes a diagnosis, the
proposed course of treatment and the projected date of discharge from the facility.
32.
SPEECH THERAPY
Therapy rendered by a certified speech therapist/pathologist on the recommendation and
evaluation of a Physician to restore already established speech loss due to an illness or
Injury or to correct an impairment due to congenital defect for which corrective surgery
has been performed.
33.
STERILIZATION
Procedures to bring about, but not reverse, sterilization, regardless of Medical Necessity.
34.
SURGERY
a)
Surgeon
Charges for multiple surgical procedures will be a covered expense subject to the
following provisions:
•
If bilateral or multiple surgical procedures are performed by one surgeon,
benefits will be determined based on the Reasonable and Customary Charge
that is allowed for the primary procedures. Then a portion of the Reasonable
and Customary Charge will be allowed for each additional procedure
performed through the same incision; as well as for each additional procedure
performed through a separate incision. Any procedure that would be an
integral part of the primary procedure or is unrelated to the diagnosis will be
considered “incidental” and no benefits will be provided for such procedures.
32
•
If multiple unrelated surgical procedures are performed by two or more
surgeons on separate operative fields, benefits will be based on the
Reasonable and Customary Charge for each surgeon’s primary procedure. If
two or more surgeons perform a procedure that is normally performed by one
surgeon, benefits for all surgeons will not exceed the Reasonable and
Customary percentage allowed for that procedure; and
•
If an assistant surgeon is required, the assistant surgeon’s covered charge will
not exceed 25% of the surgeon’s Reasonable and Customary allowance.
b)
Anesthesiologist
Services of a qualified anesthesiologist (not the services of an operating surgeon or a
surgical assistant) in administering regional or general anesthesia in connection with a
covered surgical service. Usual related care rendered in connection with the
administration of anesthesia is covered.
c)
Cosmetic Surgery
Required Coverage for Reconstructive Surgery Following Mastectomies: This Plan shall
provide, in a case of a Participant who is receiving benefits in connection with a
mastectomy and who elects breast reconstruction with such mastectomy, coverage for:
•
•
•
reconstruction of the breast on which the mastectomy has been performed;
surgery and reconstruction of the other breast to produce a symmetrical
appearance; and
prostheses and physical complications for all stages of mastectomy, including
lymphedemas;
in a manner determined in consultation with the attending Physician and the patient.
Such coverage may be subject to annual deductibles and benefit percentage provisions as
may be deemed appropriate and as are consistent with those established for other benefits
under the Plan.
d)
Dental Surgery
Dental services for the treatment of a fractured jaw or an Injury to sound natural teeth.
Benefits are payable for the services of a Physician, Dentist or dental surgeon, provided
the services are rendered for treatment of an Accidental Injury and are received within 12
months from the date of the Injury.
35.
TEMPOROMANDIBULAR JOINT DYSFUNCTION
Subject to any applicable maximum indicated in the Schedule of Benefits, covered
services and supplies recognized as effective and appropriate by the medical or dental
profession as necessary to treat TMJ, myofacial pain dysfunction syndromes and other
associated disorders.
33
G.
Exclusions From Medical Coverage
The following exclusions apply to this Plan except that if any exclusion is contrary to any
law to which this Plan is subject, the provision is hereby automatically changed to meet
the law’s minimum requirement.
Abortion, except as specified.
Acupuncture Services.
Biofeedback.
Charges which are not Medically Necessary.
Chelation Therapy. Charges for chelation therapy.
Chiropractic. Charges for professional chiropractic services in connection with
diagnosis, care and/or treatment of any Sickness or Injury; except, this exclusion does not
apply to such charges which result in benefit payments not exceeding a total of $500 per
Participant per Calendar Year (Basic and High Plans) or $1,500 per Participant per
Calendar Year (State Plan).
Circumcision. Routine circumcision for newborns.
Contraceptives. Charges incurred for or in connection with contraceptives or
medications used for contraceptive purposes, including but not limited to, the Norplant
Birth Control System and /or charges for Depo Provera injections for the purpose of birth
control.
Cosmetic or Reconstructive Surgery. Cosmetic or reconstructive surgery unless the
surgery is necessary for (a) repair or alleviation of damage resulting from an Accident;
(b) because of infection or Sickness; or (c) because of congenital disease,
developmental condition or anomaly of a covered Dependent child which has resulted in
a functional defect. A treatment will be considered cosmetic for either of the following
reasons: (a) its primary purpose is to beautify or (b) there is no documentation of a
clinically significant impairment, meaning decrease in function or change in physiology
due to illness, Injury or congenital abnormality. The term “cosmetic services” includes
those services which are described in IRS Code Section 213(d)(9).
Court Order. Charges for services that are provided due to a court order.
Custodial Care. Charges for custodial care, domiciliary care, rest cures, services that
are primarily educational in nature (except as specified), or any maintenance-type care
which is not reasonably expected to improve the patient’s condition (except Hospice Care
as specified).
34
Dental Treatment. Charges incurred for or in connection with treatment on or to the
teeth, malocclusion, the nerves or roots of the teeth, gingival tissue or alveolar process;
except, benefits will be payable for charges incurred:
•
For treatment required because of Accidental bodily Injury to sound natural teeth
sustained while covered. Such expenses must be incurred within 12 months of the
date of the Accident. This exception shall not in any event be deemed to include
charges for treatment for the repair or replacement of a denture.
•
For excision of non-dental related neoplasms , including benign tumors and cysts and
all malignant and pre-malignant lesions and growths.
•
For incision and drainage of facial cellulitis.
•
For surgical procedures involving salivary glands and ducts and non-dental related
procedures of the accessory sinuses.
•
For Hospital and associated professional fees (other than the surgeon and assistant
surgeon) in connection with a dental procedure which must be performed at a
Hospital due to documented Medical Necessity.
Drugs requiring a written prescription (except those taken or administered in whole or
in part during confinement in a licensed facility or those administered in a Physician’s
office) are not covered by this Plan. They are provided under a separate plan provided by
the Employer through the prescription drug vendor chosen by the Employer.
Educational or vocational testing or training. Services for educational or vocational
testing or training, except as specified and diabetic training.
Environmental. Charges for equipment for environmental control or general household
use such as air filters or food liquidizers.
Exercise programs. Exercise programs for treatment of any condition, except for
Physician-supervised cardiac rehabilitation, occupational or physical therapy covered by
this Plan.
Experimental or Investigative. For the purposes of determining eligible expenses under
the Plan, a treatment (other than off label drug use) will be considered to be experimental
or investigational if:
•
The treatment is governed by the US Food and Drug Administration (FDA) and the
FDA has not approved the treatment for the particular condition at the time the
treatment is provided; or
35
•
The treatment is subject to ongoing phase I, II, or III clinical trials as defined by the
National Institute of Health, National Cancer Institute, or FDA; or
•
There is documentation in published US peer-reviewed medical literature that states
that further research, studies, or clinical trials are necessary to determine safety,
toxicity or efficacy of the treatment.
Any expenses for experimental or investigational treatment, or any Hospital confinement
or treatment that results from the experimental or investigational treatment will be
excluded from coverage by the Plan.
Eye care. Glasses, contact lenses, or eye examinations and/or treatment of refractive
error for the correction of vision or fitting of glasses, except as specified. This exclusion
includes charges for surgical procedures to correct refractive errors (to improve
nearsightedness, farsightedness and/or astigmatism), including but not limited to, Radial
Keratotomy, Keratoplasty or Lasik procedures.
Felony participation. Charges for a Sickness or Injury sustained during the
commission, or attempted commission, of an assault or felony; or Injuries sustained while
engaging in an illegal occupation.
Foot care. Charges for orthotics, orthopedic shoes or other supportive devices or
appliances for the feet, or charges in connection with consultations, diagnosis, and/or
treatment for weak, strained, flat, unstable or unbalanced feet, metatarsalgia, fascitis or
bunions, corns, calluses, or toenails; except this exclusion does not apply if services are
needed in treatment of a metabolic or peripheral-vascular disease or in connection with
an open cutting operation and/or the removal of nail or nail root(s). In addition, under the
High Plan, this exclusion does not apply to charges for supplies and/or non-surgical
treatment of the feet which results in benefit payments not exceeding a total of $250 per
Participant per Calendar Year.
Foreign Travel. Charges incurred outside the United States if the Participant traveled to
such a location for the sole purpose of obtaining medical services, drugs or supplies.
However, this exclusion shall not apply to the following:
•
•
Charges for Medically Necessary treatment due to a Medical Emergency (as defined
in this Plan); or
Charges for services at a Hospital registered with the American Hospital Association
provided all requirements of the Plan for mandatory Preauthorization for Hospital
Confinement are completed.
Functional Therapy. Charges made for functional therapy for learning or vocational
disabilities or for speech, hearing and/or occupational therapy, unless specifically
covered under another provision of this Plan.
36
Government coverage. Charges for services or supplies provided by the Veterans
Administration or in any Hospital or institution owned, operated, or maintained by the
United States Government for a service-related Sickness or Injury.
Hair loss. Care and treatment for hair loss including wigs, cranial prostheses, hair
transplants or any drug that promises hair growth, whether or not prescribed by a
Physician.
Hearing Aids and Exams. Charges for services or supplies in connection with hearing
aids or exams for their fitting, except as specified.
Hospital Care. Charges for Hospital care and services if it is determined after the
receipt of a claim that:
•
The Injury or Sickness did not require (i) constant direction and supervision of a
Physician, (ii) constant availability of licensed nursing personnel, (iii) immediate
availability of diagnostic and therapeutic facilities and equipment found only in the
Hospital setting;
•
The primary cause of the confinement was for rest cure or custodial care consisting of
daily routine personal maintenance, administration of medication on schedule,
preparation of diet and assistance with ambulation.
Hospital Employees. 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.
Hospitalization. Charges for hospitalization when such confinement occurs primarily
for physiotherapy, hydrotherapy, convalescent or rest cures, or any routine physical
examinations or tests not connected with the actual Sickness or Injury.
Infertility Treatment. Any infertility treatment, testing or any procedure for which the
purpose is to enhance the possibility of reproduction, except as specified.
Marriage Counseling.
No charge. Care or treatment for which there would not have been a charge if no
coverage had been in force.
Non-emergency Hospital Admissions. Care and treatment billed by a Hospital for nonMedical Emergency admissions on a Friday or a Saturday. This does not apply if surgery
is performed within 24 hours of admission.
No Obligation to Pay. Charges incurred for which the Plan has no legal obligation to
pay.
37
No Physician Recommendation.
Care, treatment, services or supplies not
recommended and approved by a Physician; or treatment, services or supplies when the
Participant is not under the regular care of a Physician. Regular care means ongoing
medical supervision or treatment which is appropriate care for the Injury or Sickness.
Obesity. Care and treatment relating to weight loss or dietary control, including the care
and treatment of obesity whether or not it is, in any case a part of the treatment plan for
another Sickness.
Occupational. Care and treatment of an Injury or Sickness that is occupational—that is,
arises from work for wage or profit including self-employment regardless of the
availability of Workers’ Compensation coverage.
Orthognathic Surgery. Charges for orthognathic surgery (to correct congenital or
developmental maxillofacial skeletal deformities of the mandible or maxilla); except, this
exclusion does not apply to Participants enrolled in the State Plan or for covered
Dependents under age 23 who seek initial treatment and/or counseling (Basic and High
Plans). For Participants enrolled in the Basic and High Plans, such charges shall be
considered and processed subject to the Plan’s normal deductible and coinsurance and
shall track toward a Lifetime maximum benefits of $5,000 for orthognathic services.
Orthoptics/Vision Therapy.
Personal Comfort Items. Personal comfort items or other equipment, such as, but not
limited to, air conditioners, air-purification units, humidifiers, electric heating units,
orthopedic mattresses, blood pressure instruments, scales, elastic bandages or stockings,
nonprescription drugs and medicines, and first-aid supplies and nonhospital adjustable
beds.
Physician Visits. Charges made by a doctor for phone calls or interviews when the
Physician does not see the patient for treatment. This also includes charges for failure to
keep a scheduled visit or charges for completion of a claim form.
Pregnancy of Dependent Child.
Private Duty Nursing.
Psychiatric or Professional Services. Charges for professional services on an outpatient
basis in connection with Chemical Dependency, mental illness, functional Mental
Disorders or Mental Disorders of any type or cause or for psychiatric or psychoanalytic
care for any reason, unless such services are rendered by a Physician as defined in this
Plan.
Reasonable and Customary. The part of an expense for care and treatment of an Injury
or Sickness that is in excess of the Reasonable and Customary Charge.
38
Relationships. Professional services performed by a person who ordinarily resides in the
Participant’s home or is related to the Participant as a spouse, parent, child, brother or
sister, whether the relationship is by blood or exists in law.
Replacement Braces. Replacement of braces of the leg, arm, back, neck or artificial
arms or legs, unless there is sufficient change in the Participant’s physical condition to
make the original device no longer functional or the age of the brace makes it no longer
functional.
Routine. Charges incurred for routine medical examinations or routine health check-ups,
routine newborn or well-baby care, immunizations not necessary for the treatment of an
Injury or Sickness (except as specifically stated as a covered expenses elsewhere in the
Plan).
Self-inflicted Injury. Any loss due to an intentionally self-inflicted Injury, while sane or
insane.
Services Before or After Coverage. 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.
Sex Changes. Care, services or treatment for non-congenital transsexualism, gender
dysphoria or sexual reassignment or change. This exclusion includes medications,
implants, hormone therapy, surgery, medical or psychiatric treatment.
Smoking Cessation. Care and treatment for smoking cessation programs, including
smoking deterrent patches, unless Medically Necessary due to a severe active lung Illness
such as emphysema or asthma.
Speech Therapy for remedial or educational purposes or for initial development of
natural speech. This would apply to children who have not established a natural speech
pattern for reasons that do not relate to a congenital defect. In these cases, speech
therapy would be considered educational in nature and not eligible for coverage. Speech
therapy would not meet coverage criteria for the following conditions: chronic voice
strain, congenital deafness, delayed speech, developmental or learning disorders,
environmental or cultural speech habits, hoarseness, infantile articulation, lisping, mental
retardation, resonance, stuttering, and voice defects of pitch, loudness, and quality.
Sterilization Reversal.
Temporomandibular Joint Dysfunction. Charges for diagnosis and/or medical or
surgical treatment of temporomandibular joint disorder or dysfunction, by any name
called; except, this exclusion does not apply to Participants enrolled in the State Plan or
to such charges which result in benefit payments not exceeding a total of $750 per
Participant per Calendar Year (Basic and High Plans).
39
Travel or Accommodations. Charges for travel or accommodations, whether or not
recommended by a Physician, except for ambulance charges as defined as a covered
expense.
Vitamins.
Charges for vitamins, minerals, non-prescription food and/or food
supplements and non-prescription dietary drugs.
War. Any loss that is due to a declared or undeclared act of war.
H.
Description of Alternate Plan Benefits
The following description of covered services is applicable to the Alternate Plan only.
For Employees enrolled in the Alternate Plan, benefits will be payable as stated in the
Schedule of Benefits for services as specified in this provision only.
1.
CANCER TREATMENT
Benefits will be payable for cancer treatment received in a Physician’s office, Outpatient
Hospital or Cancer Treatment Facility as follows:
a)
Chemotherapy
A regimen comprised of a single agent or a combination of anti-cancer agents clinically
recognized for treatment of a specific type of cancer, including modifications and
combinations appropriate to the history of the cancer or according to protocol specifying
the combination of drugs, doses, and schedules for administration of the drugs.
Drug Requirements
•
•
•
Use that is included as an indication on the drug’s label as approved by the
FDA or
Use of an FDA-approved drug for an off-label purpose that is medically
accepted for an anti-cancer therapeutic regimen as evidenced by major drug
compendia, medical literature, and/or accepted standards of medical practice.
Use of drugs to treat toxicities or side effects of the cancer treatment regimen
when the drug is administered in relation to chemotherapy, including off-label
uses supported by medical literature.
b)
Radiation Therapy
Radiation therapy by X-ray, radon, radium and radioactive isotopes.
40
2.
HOSPITAL EXPENSES
a)
Inpatient Services
If a Participant is confined in a Hospital for a period for which a room and board charge
is made, for treatment of a non-occupational Injury or Sickness, the Plan will pay
according to the Schedule of Benefits for the following:
•
Charges billed by the Hospital for room and board and other services which
are required for the purpose of treatment during such confinement;
•
Professional fees for radiology and/or pathology services rendered on an
inpatient basis in connection with such confinement;
•
Physician services for administration of anesthesia;
•
Inpatient Hospital Physician visits; and
•
Birthing Centers expenses, on the same basis as Hospital services.
b)
Outpatient Surgical Expenses
If a Participant undergoes a covered surgical operation, the Plan will pay up to the
maximum amount specified in the Schedule of Benefits for the following:
•
Facility charges and associated services and supplies for procedures
performed in an Outpatient Hospital, Ambulatory Surgical Center, Outpatient
Surgical Center or Cancer Treatment Center.
•
Professional fees for radiology and/or pathology services rendered on an
outpatient basis in connection with the performance of such surgical services;
•
Physician services for administration of anesthesia;
•
The fee charged by the Physician for performing the operation.
Charges for multiple surgical procedures will be a covered expense subject to the
following provisions:
•
If bilateral or multiple surgical procedures are performed by one surgeon,
benefits will be determined based on the Reasonable and Customary Charge
that is allowed for the primary procedures. Then, a portion of the Reasonable
and Customary Charge will be allowed for each additional procedure
performed through the same incision; as well as for each additional procedure
performed through a separate incision. Any procedure that would be an
integral part of the primary procedure or is unrelated to the diagnosis will be
considered “incidental” and no benefits will be provided for such procedures.
41
•
If multiple, unrelated, surgical procedures are performed by two or more
surgeons on separate operative fields, benefits will be based on the
Reasonable and Customary Charge for each surgeon’s primary procedure. If
two or more surgeons perform a procedure that is normally performed by one
surgeon, benefits for all surgeons will not exceed the Reasonable and
Customary percentage allowed for that procedure.
•
If an assistant surgeon is required, the assistant surgeon’s covered charge will
not exceed 25% of the surgeon’s Reasonable and Customary allowance.
3.
PRESCRIPTION DRUGS
Drugs requiring a written prescription are eligible for benefits as stated in the Schedule of
Benefits.
Vitamins, dietary drugs, contraceptives (with the exception of oral
contraceptives), food and/or food supplements will not be covered with or without a
prescription.
4.
ROUTINE AND PREVENTIVE CARE
Benefits will be payable, up to the maximum specified in the Schedule of Benefits, for
the following services:
• Office visit and diagnostic/laboratory tests performed as part of the
examination;
• Routine vision and hearing exams;
•
Mammograms, limited to one per Calendar Year for Participants age 35 and
older; and
•
Prostate testing (PSA), limited to once per Calendar Year for Participants age
40 and older.
I.
Exclusions From Alternate Plan Coverage
The following exclusions apply to this Plan except that if any exclusion is contrary to any
law to which this Plan is subject, the provision is hereby automatically changed to meet
the law’s minimum requirement.
Charges which are not Medically Necessary.
Cosmetic or Reconstructive Surgery. Cosmetic or reconstructive surgery unless the
surgery is necessary for (a) repair or alleviation of damage resulting from an Accident;
(b) because of infection or Sickness; or (c) because of congenital disease,
developmental condition or anomaly of a covered Dependent child which has resulted in
a functional defect. A treatment will be considered cosmetic for either of the following
reasons: (a) its primary purpose is to beautify or (b) there is no documentation of a
42
clinically significant impairment, meaning decrease in function or change in physiology
due to illness, Injury or congenital abnormality. The term “cosmetic services” includes
those services which are described in IRS Code Section 213(d)(9).
Court Order. Charges for services that are provided due to a court order.
Experimental or Investigative. For the purposes of determining eligible expenses under
the Plan, a treatment (other than off label drug use) will be considered to be experimental
or investigational if:
•
The treatment is governed by the US Food and Drug Administration (FDA) and the
FDA has not approved the treatment for the particular condition at the time the
treatment is provided; or
•
The treatment is subject to ongoing phase I, II, or III clinical trials as defined by the
National Institute of Health, National Cancer Institute, or FDA; or
•
There is documentation in published US peer-reviewed medical literature that states
that further research, studies, or clinical trials are necessary to determine safety,
toxicity or efficacy of the treatment.
Any expenses for experimental or investigational treatment, or any Hospital confinement
or treatment that results from the experimental or investigational treatment will be
excluded from coverage by the Plan.
Felony participation. Charges for a Sickness or Injury sustained during the
commission, or attempted commission, of an assault or felony; or Injuries sustained while
engaging in an illegal occupation.
Government coverage. Charges for services or supplies provided by the Veterans
Administration or in any Hospital or institution owned, operated, or maintained by the
United States Government for a service-related Sickness or Injury.
No charge. Care or treatment for which there would not have been a charge if no
coverage had been in force.
No Obligation to Pay. Charges incurred for which the Plan has no legal obligation to
pay.
Not Specified as Covered. Any expense which is not specifically listed in the Schedule
of Benefits.
Occupational. Care and treatment of an Injury or Sickness that is occupational—that is,
arises from work for wage or profit including self-employment.
43
Self-inflicted Injury. Any loss due to an intentionally self-inflicted Injury, while sane or
insane.
Services Before or After Coverage. 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.
War. Any loss that is due to a declared or undeclared act of war.
J.
Dental Coverage Costs
1.
BENEFIT PERCENTAGES
If a Participant receives any necessary Dental services or treatment specified in this
Section, the Plan, subject to all the provisions of this Plan Document will pay:
80% of Reasonable and Customary expenses for covered Preventive Services.
50% of Reasonable and Customary expenses for covered Orthodontia Services.
After the deductible, 80% of Reasonable and Customary expenses for covered Basic
Services, and 50% of Reasonable and Customary expenses for covered Major Services.
2.
DENTAL DEDUCTIBLE
The Dental deductible amount for each Calendar Year with respect to each Participant is
the deductible amount in the Schedule of Benefits.
The Dental deductible does not apply to Preventive or Orthodontia Services.
If in any Calendar Year Family members shall have incurred sufficient Covered
Expenses to satisfy the deductible specified, the deductible shall be deemed to be
satisfied for all covered Family members for the remainder of that Calendar Year.
K.
Extended Dental Benefits
Dentures or bridges—If a final impression for a denture has been taken, or tooth for a
bridge has been prepared, before coverage ceases, then charges for the construction
and/or insertion of such denture or bridge will be considered as eligible expenses only to
the extent that such construction or insertion procedures are performed within 30 days
after termination of coverage.
L.
Alternative Dental Procedures
If two or more alternate procedures, services, or courses of treatment may satisfactorily
correct a dental condition, the least expensive procedure will be considered for payment.
Such determination will be made by the Claims Administrator based upon professionally
endorsed standards of dental care.
44
M.
Summary of Dental Benefits
Covered Dental Expenses include Reasonable and Customary necessary expenses
incurred for the services and supplies listed below:
1.
COVERED PREVENTIVE SERVICES
Initial or periodic oral examinations, but not more than twice per Calendar Year.
Prophylaxis, including cleaning, routine scaling and polishing, but not more than twice
per Calendar Year.
Full mouth or panorex X-rays, but not more than once per 36 months.
Bitewing X-rays, but not more than twice per Calendar Year.
Fluoride treatments for Participants up to age 19, but not more than twice per Calendar
Year.
Other dental X-rays as deemed necessary.
2.
COVERED BASIC SERVICES
Consultations.
Space maintainers for Participants up to age 19.
Palliative emergency treatment and emergency oral examinations.
Fillings (amalgam, sedative, composite, plastic and acrylic).
Extractions (simple, erupted and impacted).
Endodontics (root canal therapy).
Repair of dentures.
Repair of crowns, inlays and/or bridges.
Recementation of crowns/bridges.
Denture adjustments.
Denture relining, limited to once every 36 months.
Pin retention.
45
Biopsies of oral tissue.
Pulp caps.
Pulp vitality tests.
Home visits by a Physician when Medically Necessary in order to render a covered
Dental Service.
Oral surgery.
Apicoectomy.
Hemisection.
General anesthesia administered in connection with a covered dental service only if
administered by an individual licensed to administer general anesthesia.
Intravenous sedation.
Nitrous oxide.
Injection of antibiotic drugs.
Periodontics:
Occlusal equilibration, when no restoration is involved.
Gingivectomy and gingivoplasty.
Gingival curettage.
Scaling and root planing.
Osseous surgery (osteoplasty and ostectomy), including flap entry and closure.
Surgical periodontic examination.
Mucogingivoplastic surgery.
Management of acute periodontal infection and oral lesions.
Perio-prophylaxis.
46
3.
COVERED MAJOR SERVICES
No benefits for Major Services are available for the first 12 months of coverage.
Inlays, onlays and crowns, either restorative or as part of a bridge, including precision
attachments for dentures.
Gold restoration.
Post and cores.
Initial dentures, full and partial, and bridges, fixed and removable as follows:
1. Dentures to replace one or more natural teeth extracted while covered under
these benefits.
2. Bridgework to replace one or more natural teeth extracted while covered
under these benefits (including inlays and crowns to form abutments).
Replacement of or addition of teeth to an existing removable denture (full or partial) or
fixed bridgework as follows:
1. Replacement or addition of teeth is made necessary by the extraction of
natural teeth which occurred while covered under this Plan;
2. Replacement is necessary when an immediate temporary denture was inserted
shortly following extraction of teeth and cannot be economically modified to
the final shape required;
3. The existing denture or bridgework was installed at least five years prior to its
replacement and the existing denture or bridgework cannot be made
serviceable.
4.
COVERED ORTHODONTIA SERVICES
No benefits for Orthodontia Services are available for the first 12 months of coverage.
Orthodontia benefits are available to Participants who are under 19 years of age.
Installations of orthodontic appliances and all orthodontic treatments concerned with the
reduction or elimination of an existing malocclusion and conditions resulting from that
malocclusion through correction of abnormally positioned teeth.
Diagnostic services, including examination, study models, radiographs and all other
diagnostic aids used to determine orthodontic needs only once in any five (5) year period,
commencing with the date of the initial visit.
Active orthodontic treatment for thirty-six consecutive months or less.
treatment for eighteen consecutive months or less.
47
Retention
N.
Exclusions From Dental Coverage
The following exclusions apply to this Plan except that if any exclusion is contrary to any
law to which this Plan is subject, the provision is hereby automatically changed to meet
the law’s minimum requirement.
Appliance Replacement. Appliance replacement performed less than five years after a
placement or replacement, except as specified.
Broken Appointments. Charges for failure to keep a scheduled visit or charges for
completion of a claim form.
Cosmetic Dentistry. Dental care which is provided solely for the purpose of improving
appearance, when form and function of the teeth are satisfactory and no pathological
condition exists.
Denture Adjustments. Denture adjustments during the first six months following
denture placement performed by the same or associated Physician who provided or
repaired the appliance.
Education or Training.
Employer Sponsored Services. Services or supplies received from a dental or medical
department maintained by or on behalf of an employer, a mutual benefit association,
labor union, trustees, or similar person or group.
Experimental or Investigational. Any treatment unless it is both (1) generally
accepted by the dental community in the United States, meaning that the clinical efficacy
(including the anticipation of use outweighing harm) of the treatment has been
documented in credible published dental literature which demonstrates that the results of
the treatment have been measured for a five-year period or other period generally
regarded as valid. (2) The treatment, as compared to accepted alternative treatments for
that condition, can reasonably be expected to: (a) result in similar or improved survival,
health or function, or (b) alleviate symptoms of or stabilize the condition.
Felony participation. Charges for a Sickness or Injury sustained during the
commission, or attempted commission, of an assault or felony; or Injuries sustained while
engaging in an illegal occupation.
Government Coverage. Any treatment or service which is compensated for or furnished
by the local, state or federal government (except where required by law).
Harmful Habit Appliances.
48
Lost or Stolen Bridges or Dentures. Charges for replacement of bridges or dentures
lost, misplaced or stolen.
Medical Treatment. Services, supplies, or treatment covered under the Medical Plan.
No Charge. Care or treatment for which there would not have been a charge if no
coverage had been in force.
No Obligation to Pay. Charges incurred for which the Plan has no legal obligation to
pay.
No Physician Recommendation.
Care, treatment, services or supplies not
recommended and approved by a Physician; or treatment, services or supplies when the
Participant is not under the regular care of a Physician. Regular care means ongoing
dental supervision or treatment which is appropriate care for the Injury or Sickness.
Not Necessary Service or Supply. Services or supplies which are not necessary.
Occlusal Adjustments.
Occupational. Care and treatment of an Injury or Sickness that is occupational—that is,
arises from work for wage or profit including self-employment regardless of the
availability of Workers’ Compensation coverage.
Personal Comfort Items. Personal hygiene, comfort or convenience items.
Personalized Services. Personalizing dental service by added restorations to artificial
teeth, implant dentures, use of magnets, or similar procedures.
Reasonable and Customary. The part of an expense for care and treatment of an Injury
or Sickness that is in excess of the Reasonable and Customary Charge.
Relationships. Professional services performed by a person who ordinarily resides in the
Participant’s home or is related to the Participant as a spouse, parent, child, brother or
sister, whether the relationship is by blood or exists in law.
Replacement of Crowns. Replacement of defective or lost crown until five years have
elapsed from the date of insertion.
Replacement of Dentures or Bridges. Replacement at any time of dentures or bridges
which can be made serviceable.
Replacement of Orthodontia Appliances. Replacement and/or repair of any appliance
used during the course of orthodontia treatment.
Sealants.
49
Self-inflicted Injury. Any loss due to an intentionally self-inflicted Injury, while sane or
insane.
Services Before Coverage. Charges incurred for dental services which were ordered or
started before coverage began, including but not limited to the installation, manufacture
or filling of dental restorations (fillings, inlays, crowns, bridgework and dentures) and
orthodontic appliances.
Splinting. Splinting for periodontal purposes and/or other appliances or restorations
whose primary purpose is to stabilize periodontally involved teeth.
Sport Appliances. Expenses related to services or supplies of the type normally
intended for sport or home use.
Subsequent Orthodontia Treatment. Orthodontia treatment rendered within five years
after the completion of a course of orthodontia treatment.
Temporary Crowns.
Temporomandibular Joint Dysfunction Syndrome. Treatment of Temporomandibular
Joint Dysfunction Syndrome (including all myofacial pain syndromes and other
associated disorders).
Tooth Implants.
Vertical Dimensions. Appliances or restorations necessary to increase vertical
dimensions and/or restore the occlusion.
War. Any loss that is due to a declared or undeclared act of war.
50
II.
CARE MANAGEMENT
A.
Preauthorization For Hospital Confinement
If a Participant requires Hospital confinement for an Injury or Sickness, Hospital
admission authorization and length of stay approval must be obtained from the Care
Management Organization prior to a nonemergency admission. In the event of an
emergency admission, authorization must be obtained within 48 hours or as soon as
reasonably possible given the facts and circumstances of the emergency admission.
Refer to the Plan identification card for the telephone number to call for Precertification
Review.
Full benefits for Hospital charges will be paid only for approved admissions and
confinement days.
Benefits for covered charges for Medically Necessary Hospital confinement which would
normally be payable will be reduced by $500 if admission and length of stay approval is
not obtained as specified above.
If confinement extends beyond the approved length of stay, additional days must be
authorized by the Care Management Organization. The same requirements and reduction
penalties will apply to the additional days.
Charges for any part of a Hospital confinement not deemed to be Medically Necessary by
the Care Management Organization will be excluded.
The Care Management Organization does not verify, authorize or guarantee payment of
benefits. The Care Management Organization’s authorization means only necessity of
treatment. It is not a certification of benefits.
B.
Durable Medical Equipment Preauthorization
If a Participant requires Durable Medical Equipment and the rental/purchase price is
greater than $500, prior approval must be obtained from the Care Management
Organization. Refer to the Plan identification card for the telephone number to call for
Preauthorization Review.
Preauthorization must be received before Durable Medical Equipment is rented or
purchased. Benefits for Medically Necessary expenses which would normally be payable
will be reduced by $500 if prior approval is not obtained as specified above.
The Medical Care Management Organization does not verify, authorize or guarantee
payment of benefits. The Medical Care Management Organization’s authorization means
only necessity of treatment. It is not a certification of benefits.
51
C.
Employee Assistance Program (EAP)
The Employee Assistance Program (EAP) is a confidential case management program
which reviews treatment for Mental Disorders and/or Chemical Dependency cases. The
EAP program includes early evaluation and introduction of alternatives to acute Hospital
care. The objective of the EAP is to help the patient get the best available treatment in
the most appropriate setting at the maximum level of benefits.
Any care for Mental Disorder or Chemical Dependency conditions, including both
inpatient and outpatient services, must be approved by the EAP vendor prior to the start
of any testing or treatment. The program will certify necessary treatment. Failure to use
the EAP to pre-certify Mental Disorder or Chemical Dependency healthcare will result in
the following penalty: The claims will be denied and no benefits will be available. If a
patient utilizes the EAP, benefits will be payable as stated in the Schedule of Benefits for
either Network or non-Network* providers.
The EAP should be notified prior to any proposed treatment for Mental Disorders and/or
Chemical Dependency by calling the telephone number listed on the Plan identification
card for certification. In the event of an emergency Hospital admission, the EAP should
be notified as soon as reasonably possible given the facts and circumstances of the
emergency admission.
The EAP does not verify, authorize or guarantee payment of benefits. Authorization by
the EAP means only necessity of treatment. It is not a guarantee of benefits.
*Note: For Participants in the Basic Plan, coverage is not available for treatment
received for Mental Disorders from non-Network providers, except in the case of a
Medical Emergency.
D.
Medical Case Management
Medical Case Management is a cost management program administered to provide a
timely, coordinated referral to alternative care facilities to a Participant who suffers a
catastrophic Sickness or Injury while covered under this Plan.
The following are examples of diagnoses that might constitute a catastrophic Sickness or
Injury:
Neonatal High Risk Infant
Cerebral Vascular Accident (CVA)
Multiple Sclerosis
Amyotrophic Lateral Sclerosis (ALS)
Leukemia
Major Head Trauma and Brain Injury Secondary to Illness
Spinal Cord Injuries
52
Amputations
Multiple Fractures
Severe Burns
AIDS
Transplants
Any claim expected to exceed $25,000
When the case manager is notified of one of the above diagnoses (or any other diagnosis
for which Medical Case Management might be appropriate), the case manager will
consult with the attending Physician to develop a written plan of treatment outlining all
medical services and supplies to be utilized, as well as the most appropriate treatment
setting. The treatment plan may be modified intermittently as the Participant’s condition
changes, with the mutual agreement of the case manager, the patient, and the attending
Physician.
All services and supplies authorized by the treatment plan will be considered covered
expenses, whether or not they are otherwise covered under the Plan. The benefit level for
alternative treatment settings may be the same as the Hospital benefit level, in the
absence of the Medical Case Management program. For all other services and supplies,
the benefit level will be the same as the benefit for outpatient medical treatment, in the
absence of the program.
Any deviation from the treatment plan without the case manager’s prior approval will
negate the treatment plan, and all charges will be subject to the regular provisions of this
Plan.
53
III.
ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATES
A.
Eligibility
The following are eligible:
1.
EMPLOYEE
An active full-time Employee who is directly employed in the regular business of and
compensated for services by the Employer and regularly works 20 or more hours per
week.
A retired Employee who retired prior to October 1, 1989 and who was covered under the
Plan immediately prior to retirement and has been continuously covered since. Retirees
are not eligible for the Alternate Plan.
2.
DEPENDENTS
A Participant cannot be covered simultaneously as an Employee and a Dependent.
a)
Spouse
The Employee’s spouse who is not legally divorced from the Employee or whose
marriage to the Employee has not been otherwise legally terminated.
b)
Children
An Employee’s unmarried child from birth until the date he attains age 25, provided the
child is principally dependent on the Employee for his support and maintenance. (Proof
may be required.)
An Employee’s unmarried child who is already covered under the Plan and who is 25
years of age or older and who, from the date his coverage would otherwise terminate
under the Plan, is both (a) incapable of self-sustaining employment by reason of mental
retardation or physical handicap and (b) principally dependent (named as an exemption
on the Employee’s most current Federal Income Tax Return) upon the Employee for
support and maintenance. (Proof may be required.)
The Employer will have the right to require due proof of the continuation of the mental
retardation and/or physical handicap and will have the right and opportunity to examine
the child whenever the Employer may reasonably require it during such continuation.
After two years have elapsed from the date the child attained the limiting age, only one
examination will be required per year.
54
A “Child” is:
•
An Employee’s natural born child or legally adopted child, provided the child
is principally dependent on the Employee for his support and maintenance.
(Proof may be required.) An adopted child shall be considered a “child” from
the moment the child is placed in the custody of the parents for adoption; or
•
An Employee’s stepchild who resides in the Employee’s household in a
regular parent-child relationship and is principally dependent (named as an
exemption on the Employee’s most current Federal Income Tax Return) on
the Employee for support and maintenance (Proof may be required); or
•
An Employee’s Foster Child who resides in the Employee’s household in a
regular parent-child relationship and qualifies as an exemption under the
Internal Revenue Code. (Proof may be required.); or
•
Any child for whom the Employee has been granted legal guardianship by a
court of law, provided that the child resides in the Employee’s household in a
regular parent-child relationship and qualifies as an exemption under the
Internal Revenue Code. (Proof may be required.); or
•
Any child for whom the Employee is required to provide health care coverage
under a Qualified Medical Child Support Order. Participants have the right to
obtain applicable determination procedures free of charge from the Plan
Administrator.
If both parents of a child are covered for benefits, either but not both may cover the child
as a Dependent.
B.
Enrollment and Effective Dates
When an Employee enrolls his Dependents and authorizes any required contributions for
Dependent benefits, Dependent benefits will become effective as follows:
•
If an Employee has eligible Dependents on the effective date of his coverage
and he has enrolled and authorized contributions for Dependent benefits on or
prior to the Employee’s effective date, then coverage for those Dependents
will be effective on the date the Employee’s coverage begins.
•
If an Employee does not have eligible Dependents on the effective date of his
coverage and later acquires his first eligible Dependent(s), and if he enrolls
and authorizes any required contributions for Dependent benefits within 30
days of the date of acquisition, then coverage for the Dependent(s) will be
effective on the date of acquisition.
55
If the Employee is already enrolled for Dependent benefits, any newly acquired
Dependents, including newborns, must be enrolled within 30 days of acquisition.
Coverage will be effective on the date of acquisition.
Benefits will not become effective for the Dependents of an Employee unless the
Employee is covered, or simultaneously becomes covered, for benefits. Under no
circumstances will coverage for an Employee’s Dependents occur prior to coverage for
the Employee.
1.
NEW HIRE ENROLLMENT
An Employee hired on or after the effective date of this Plan becomes eligible for
benefits on the date of employment.
Coverage for benefits becomes effective on the date the Employee is eligible for
coverage provided the Employee has enrolled and authorized any required contributions
within 30 days of the date eligible.
Each Employee becomes eligible to cover his Dependents for benefits on the later of the
following dates:
•
•
the date he is eligible for benefits, if he then has a Dependent (spouse and/or
child);
the date he acquires his first eligible Dependent through marriage, birth,
adoption, or placement for adoption.
2.
LATE ENROLLMENT
If the Employee does not enroll himself and/or his Dependents within 30 days of the date
eligible, the Employee and/or his Dependents may apply for coverage during the annual
open enrollment period, which is held as determined by the Employer. Coverage will be
effective on the subsequent January 1st. The Preexisting Condition limitation will apply.
The Employee and/or his Dependents may also enroll at any time throughout the year by
completing an enrollment form, however the Employee and/or his Dependents will not be
covered until medical evidence of good health, obtained at the Employee’s expense, is
submitted and approved. Coverage will be effective on the first of the month following
the date the application is approved. The Preexisting Condition limitation will apply.
3.
DUAL OPTION TRANSFER
Each Employee who is a member of any other plan sponsored by the Employer will have
the opportunity to transfer coverage from one Plan to another Plan during the annual
enrollment period, which is held as determined by the Employer. Coverage under the
elected Plan will become effective subsequent January 1st. The Preexisting Condition
limitation will not apply to the extent that it was previously satisfied.
56
4.
SPECIAL ENROLLMENT
If an Employee experiences a loss of other health coverage, including COBRA
Continuation Coverage, the existence of which was the reason for declining coverage
under this Plan when first eligible to enroll, then the Employee may enroll for coverage
within 30 days of the loss of such coverage. Loss of coverage means that COBRA
Continuation Coverage has been exhausted or that coverage which was not under a
COBRA Continuation provision has been terminated as a result of loss of eligibility for
the coverage or termination of employer contributions towards such coverage. Coverage
will be effective on the date of the occurrence. The Preexisting Condition limitation will
apply.
If an Employee declined coverage for his Dependents under this Plan when first eligible
to enroll because his Dependents had other health coverage, including COBRA
Continuation Coverage, and they experience a loss of the other health coverage as
described above, the Employee may enroll for Dependent benefits within 30 days of the
occurrence. Coverage will be effective on the date of the occurrence. The Preexisting
Condition limitation will apply.
If an Employee acquires a Dependent through marriage, he may enroll for coverage
within 30 days of the marriage. Coverage will be effective on the date of the marriage.
The Preexisting Condition limitation will apply.
If an Employee acquires a Dependent through birth, adoption or placement for adoption,
the Employee may enroll for coverage within 30 days of the birth, adoption or placement
for adoption. Coverage will be effective on the date of the acquisition. The Preexisting
Condition limitation will not apply to the child but will apply to any other individual not
previously covered by this Plan.
C.
Preexisting Conditions
1.
DEFINITION
The term Preexisting Condition means a condition (except pregnancy) for which medical
advice, diagnosis, care or treatment was recommended or received within the 6 month
period ending on the Participant’s Enrollment Date. For these purposes, 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.
*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.
57
2.
LIMITATION ON OR EXCLUSION FROM COVERAGE
Payment will be nonexistent for covered medical expenses incurred in connection with a
Preexisting Condition until twelve consecutive months from the Participant’s Enrollment
Date.
The Preexisting Condition limitation does not apply to pregnancy, or to a newborn child,
an adopted child under age 18, or a child under 18 who has been placed for adoption, if
that child becomes covered under this Plan or had any other Creditable Coverage within
31 days of birth, adoption or placement for adoption.
This exception to the Preexisting Condition limitation for a newborn or adopted child or
one placed for adoption does not apply if there has been a break in coverage of 63 days or
more.
3.
CREDITABLE COVERAGE
a)
Acceptance of Certificates
Any Preexisting Condition limitation period is reduced by the period of other Creditable
Coverage unless there has been a lapse in coverage of 63 days or more, termed a Break in
Coverage. Waiting periods and HMO affiliation periods are not considered a lapse in
coverage. Days of Creditable Coverage that occur before a Break in Coverage shall not
be counted by the Plan in reducing the Preexisting Condition limitation.
Creditable Coverage includes coverage under most individual and group health insurance
plans (including Medicare, Medicaid, governmental and church plans) whether or not a
fully insured plan or a self-insured plan. Creditable coverage does not include liability,
dental, vision, specified diseases and/or other supplemental type plans which are defined
as excepted benefits by HIPAA.
To reduce a Preexisting Condition limitation period by creditable coverage, proof of prior
creditable coverage must be submitted. A Participant may request a Certificate of
Coverage from his prior plan. The Employer will assist any Participant in obtaining a
Certificate of Coverage from a prior plan.
Within a reasonable time following the receipt of a Certificate of Creditable Coverage or
other evidence of Creditable Coverage, the Plan shall make a determination regarding the
length, if any, of the Preexisting Condition limitation that shall apply to the Participant
and provide notice to the Participant of said determination. The Plan shall have the right
to reconsider and modify its initial determination if it is later determined that the claimed
Creditable Coverage did not exist.
The Plan shall determine the total days of creditable coverage for each Participant by
counting all the days during which the Participant had one or more types of Creditable
Coverage. This determination will be made regardless of the specific benefits included in
the coverage.
58
If, after creditable coverage has been taken into account, there will be a Preexisting
Condition limitation imposed on a Participant, that Participant will be notified.
b)
Provision of Certificates
The Plan shall issue a Certificate of Creditable Coverage, automatically and without
charge, under the following circumstances:
1. For an individual who is a Qualified Beneficiary entitled to elect COBRA coverage,
the Certificate of Creditable Coverage shall be issued with the COBRA notice sent
after the Qualifying Event.
2. For an individual who loses coverage under the Plan, but is not entitled to COBRA
coverage, the Certificate of Creditable Coverage shall be issued as soon as reasonably
possible after coverage ceases.
3. For an individual who is a Qualified Beneficiary and has elected COBRA coverage,
the Certificate of Creditable Coverage shall be issued within a reasonable time after
the cessation of COBRA coverage or, if applicable, after the expiration of any grace
period for the payment of COBRA premiums.
The Plan shall also issue a Certificate of Creditable Coverage at any time within twentyfour (24) months after coverage ceases, provided that the Plan receives a written request
for the Certificate of Creditable Coverage by the former Plan Participant (or by another
person authorized by the former Plan Participant).
The Certificate of Creditable Coverage shall be in the form required by HIPAA.
Also upon written request, the Plan shall provide a copy of the Plan Document and other
information as outlined in the model form established by HIPAA to provide additional
information on categories of benefits for plans that use the Alternative Method of
counting Creditable Coverage. The Plan shall charge the requesting entity or individual a
fee to cover the reasonable cost of providing this information.
59
IV.
EXTENSIONS OF COVERAGE
A.
FMLA Qualified Leave of Absence
If a Covered Employee takes a qualified leave of absence as recognized by the Family
Medical Leave Act of 1993 or similar state law, coverage for the Employee and any
covered Eligible Dependents may be continued for the duration of the qualified leave up
to twelve weeks under the Family Medical Leave Act. The Employee will be responsible
for making any required contributions to the Plan.
B.
Total Disability Extension of Coverage
If a Covered Employee becomes totally disabled, coverage for the Employee and any
covered Eligible Dependents may be continued until terminated by the Employer. This
extension of coverage will run concurrently with the Family Medical Leave Act of 1993
extension of coverage. The Employee will be responsible for making any required
contributions to the Plan.
C.
Personal or Medical Leave of Absence Extension of
Coverage
If a Covered Employee takes an approved personal or medical leave of absence, (other
than FMLA), coverage for the Employee and any covered Eligible Dependents may be
continued until terminated by the Employer. The Employee will be responsible for
making any required contributions to the Plan.
D.
COBRA Continuation Coverage
Federal Legislation known as the Consolidated Omnibus Budget Reconciliation Act of
1985 as amended (COBRA) requires that an Employee and/or Dependent may elect to
continue coverage up to the length of time specified below after the occurrence of any of
the following events which would normally result in termination of coverage under the
Plan, provided they pay the full cost of Plan coverage, not to exceed 102% of the total
cost (Employer and Employee) or 150% of the total cost during the 11-month extension
for disability.
Each Qualified Beneficiary, including the Employee, spouse or any Dependent covered
under the regular Plan, may make an independent election for Continuation Coverage.
Coverage may be continued up to 18 months for an Employee and/or Dependent in the
qualifying event of the termination of employment (other than by reason of gross
misconduct) or the reduction of hours of an Employee. Continuation coverage may be
extended from 18 months to 36 months for Dependent(s) who are qualified beneficiaries
60
if during the 18-month period a second qualifying event occurs, such as the Employee
dies, enrolls in Medicare, or divorces or legally separates from his spouse. This
extension may also apply upon the loss of Dependent status by a Dependent child, but
only if the event would have caused the spouse or Dependent child to lose coverage
under the plan had the first qualifying event not occurred.
Continuation coverage may extend from 18 months to 29 months for an Employee and/or
Dependent who is or becomes totally disabled (as determined by the Social Security
Administration under Title 2 or Title 16) at any time during the first 60 days of COBRA
continuation coverage, provided that such Employee and/or Dependent has given notice
of the disability within 60 days of the Social Security determination and requested the
extended continuation period before the end of the first 18 months. If during the
continuation coverage the qualified beneficiary is later determined by the SSA to be no
longer disabled, the individual must inform the Plan of this redetermination within 30
days of the date it is made.
Coverage may be continued for up to 36 months for a Dependent in the qualifying event
of:
(a)
(b)
(c)
(d)
The death of the Employee;
The divorce or legal separation of the Employee from his spouse;
The Employee’s becoming entitled to Medicare, and as a result the loss of
eligibility for coverage under the Plan by him and his Dependents;
The loss of Dependent status by a Dependent child under the terms of this
Plan.
Coverage will be continued only for those Employees and/or Dependents who were
covered under the Plan on the day immediately preceding termination. However, if a
child is born or placed for adoption with the Participant during the period of COBRA
continuation coverage, such child is entitled to receive COBRA continuation coverage
with independent COBRA rights.
Coverage will not be continued beyond the earliest of the following dates:
(a)
(b)
(c)
The date ending the period for which any required contribution has been
paid;
The date the Employee and/or Dependent first become entitled to
Medicare, or first becomes covered under another group health plan
without being subject to that plan’s preexisting limitations;
The date the Employer ceases to provide any group health plan.
Sometimes, filing a proceeding in bankruptcy under Title 11 of the United States Code
can be a qualifying event. If a proceeding in bankruptcy is filed with respect to McAllen
Independent School District, and that bankruptcy results in the loss of coverage of any
retired Employee covered under the Plan, the retired Employee is a qualified beneficiary
with respect to the bankruptcy. The retired Employee’s spouse, surviving spouse, and
61
Dependent children will also be qualified beneficiaries if bankruptcy results in the loss of
their coverage under the Plan.
If any provision of this section is contrary to the Consolidated Omnibus Reconciliation
Act of 1985 (as amended), the provision is changed to comply with the law.
Note: All Plan Participants must notify the Plan in writing within sixty (60) days of
(a)
(b)
(c)
(d)
(e)
(f)
Divorce or legal separation
Covered Dependent child ceasing to qualify as a Dependent
Acceptance of Medicare or coverage under another employer’s group
health plan (whether or not as an Employee), if that plan does not limit
coverage for Preexisting Conditions.
Second qualifying event
Qualified Beneficiary’s disability or cessation of disability
Death of the Employee
Written notice must be provided to the Claims Administrator or the designated COBRA
Claims Administrator, if applicable. The notice must include the name of the Employee
with identification number, Plan Name and Number, date and type of the qualifying event
and name(s) of the applicable Dependent(s).
FAILURE TO NOTIFY THE PLAN IN A TIMELY MANNER WILL RESULT IN
LOSS OF ELIGIBILITY FOR COBRA CONTINUATION COVERAGE.
62
V.
TERMINATION AND REINSTATEMENT OF COVERAGE
A.
Termination of Employee Coverage
The coverage of any Employee covered under this Plan Document will cease on the
earliest of the following dates except as provided under Continuation of Benefits (if
applicable):
•
•
•
•
•
•
•
The date this Plan Document terminates.
The date ending the period for which any required contributions have been
paid.
The date he is no longer eligible for coverage under this Plan Document.
The date he begins active duty in the Armed Forces of any country for longer
than two weeks.
The date of death.
The date his employment terminates.
The date he elects in writing that termination of coverage occurs.
This Plan will provide a Certificate of Creditable Coverage after the Employee’s
coverage terminates under the Plan. (See Preexisting Condition Limitation section.)
B.
Termination of Dependent Coverage
Coverage with respect to each Dependent covered under this Plan Document will cease
on the earliest of the following dates:
•
•
•
•
•
The date benefits cease for the Employee.
The date such individual ceases to be a Dependent as defined in this Plan
Document.
The date the Dependent begins active duty in the Armed Forces of any
country for longer than two weeks.
The date for which written election of termination is received.
The date ending the period for which any required contributions have been
paid.
The Plan will provide a Certificate of Creditable Coverage after the Dependent’s
coverage terminates under the Plan.
63
C.
Reinstatement of Participant’s Coverage
1.
COBRA PARTICIPANTS
A Qualified Beneficiary who has elected COBRA continuation coverage will be
considered to have had no lapse of coverage, provided the coverage is in effect on the
day before the Employee returns to eligible employment.
2.
REINSTATEMENT OF COVERAGE FOLLOWING A MILITARY LEAVE
Upon return from a military leave of absence, provided the Employee qualifies under the
Veteran’s Reemployment Rights Statute and provided that an enrollment form is
submitted, coverage for the Employee and Eligible Dependents will be reinstated on the
return-to-work date. Under these conditions, the Employee and any Eligible Dependents
will not be subject to the Waiting Period or Preexisting Condition exclusion. Any
deductible or out-of-pocket maximum satisfied prior to the leave of absence will be
credited if reinstatement takes place during the same Calendar Year in which the
expenses were incurred.
REINSTATEMENT OF COVERAGE AFTER VOLUNTARY TERMINATION OF
EMPLOYMENT
If an Employee terminates his employment with the Plan Sponsor and is subsequently
rehired by the Plan Sponsor, the Employee will be treated as a newly hired Employee.
3.
64
VI.
CLAIMS
A.
Filing
Written notice of a claim must be given as soon as reasonably possible after the
occurrence or commencement of any loss covered by this Plan.
The Plan, upon receipt of a written notice of a claim, will furnish to the Participant forms
for filing proof of loss. If such forms are not furnished within 15 days after notice is
given, the Participant will be considered to have complied with the requirement of the
Plan with respect to proof of loss and written proof covering the occurrence, the
character, and the extent of the loss for which the claim is made.
In order to promptly process claims and to avoid errors in processing that could be
caused by delays in filing, written proof of loss should be furnished to the Plan within 90
days following the date of loss. Failure to furnish written proof within 90 days of loss
will not invalidate or reduce any claim if it was not reasonably possible to give proof
within such time, provided that such proof is furnished as soon as reasonably possible.
Except for the circumstance of legal incapacity of the claimant, proof must be furnished
no later than 90 days from the date an expense was incurred (if Coordination of Benefits
is involved, 90 days from the date the claim was processed by the primary carrier) or the
claim will be barred.
The Plan shall process a claim in accordance with its reasonable claims procedures,
providing a written explanation of its claim decision within 30 days of receipt of a claim.
The Plan has a right to secure independent medical advice and to require such other
evidence as it deems necessary to decide the claim. The Plan may determine that an
extension is necessary for reasons beyond the control of the Plan. If an extension is
necessary, the Plan shall provide written notice to this effect before the expiration of the
initial 30-day period. If the reason for taking the extension is the failure of the claimant
to provide information necessary to decide the claim, the Plan will notify the claimant of
this fact and will render a decision within 15 days of the date on which the claimant’s
response is received by the Plan.
B.
Appealing
1.
EXPLANATION OF DENIAL
The written explanation of a claim denial shall set forth, in a manner calculated to be
understood by the Participant, the following information:
•
The reason(s) for denial.
•
If the claim is denied because the Plan needs more information to make a decision, a
description of any additional information necessary for the Participant to perfect the
claim and explanation of why such information is necessary.
65
•
A statement that the claim and its denial shall be reviewed upon submission of a
written report.
•
A statement that the Participant, the Participant’s attorney or other duly authorized
representative shall have, as part of the review procedure, a reasonable opportunity to
examine pertinent Plan documents and records and to submit written comments on
issues.
•
A statement that failure to submit a written request for review within 180 days after
the receipt of the written explanation of the claim denial shall make the Plan’s
decision final.
2.
REQUEST FOR REVIEW
In order to appeal to the Plan for review of a denied claim, a Participant must provide an
appeal or request for review in writing to the Plan within 180 days after the claim is
denied. A claim and its denial shall be reviewed if a written request for review is filed
within 180 days after receipt of the written explanation of the claim denial by the
Participant. The Plan will decide an appeal in accordance with its reasonable claims
procedures. A Participant who does not appeal on time and in writing will lose the right
to file a suit in state or federal court by failing to exhaust internal administrative appeal
rights if, as is generally the case, they are prerequisite to such a suit; in that event, the
initial decision shall be the final decision of the Plan.
3.
PROVIDING ADDITIONAL INFORMATION
As part of the review procedure, the Participant or the Participant’s duly authorized
representative shall have a reasonable opportunity to examine pertinent Plan documents
and records and to submit written comments on the issues.
4.
DECISION ON REVIEW
The Plan shall review the information and comments submitted by the Participant or the
Participant’s duly authorized representative. The Plan shall furnish the Participant with a
written explanation of the decision on review within 60 days following receipt of the
written request for review.
5.
EXPLANATION OF DECISION ON REVIEW
The written explanation of the decision on review shall set forth, in a manner calculated
to be understood by the claimant, the following information:
•
The specific reason(s) for the decision, including a response to the information and
comments, if any, submitted by the claimant and his duly authorized representative.
•
Specific reference to pertinent Plan provisions and records, if any, on which the
decision is based.
66
6.
LIMITATION
• No action at law or in equity can be brought to recover on this Plan before exhausting
the appeals procedure described above.
•
No action at law or in equity can be brought to recover after the expiration of two
years after the time when written proof of loss is required to be furnished to the Plan.
67
VII. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY
A.
Allowable Expense
Allowable Expense means any Medically Necessary, Reasonable and Customary item of
expense which is covered at least in part under one or more of the plans covering the
person for whom a claim is made. If a plan provides benefits in the form of services
rather than cash payments, the reasonable cash value of each service rendered will be
considered an Allowable Expense and a benefit paid.
B.
Application of Coordination of Benefits
The benefits of another plan will be ignored in determining the benefits of this Plan if the
rules establishing the order of benefit determination stated below require that this Plan
determine its benefits before the other plan.
The benefits of a plan which does not contain a Coordination of Benefits provision
always shall be determined before the benefits of the plan which does contain a
Coordination of Benefits provision.
The plan that covers the person directly rather than as a Dependent, for example, as an
Employee, member, subscriber, or retiree (Plan A) is primary, and the plan that covers
the person as a Dependent (Plan B) is secondary.
Coverage through a Health Maintenance Organization (HMO) is primary for a Dependent
Participant in this Plan who is also an HMO participant.
When the Participant is denied benefits by a Managed Care Organization, including an
HMO, for voluntary treatment by a provider that does not participate in the Managed
Care Organization, the Participant will receive benefits under this Plan at a level that is
secondary to the benefits the Managed Care Organization would have provided had the
Participant utilized a participating and/or network provider.
However, if the person covered directly is a Medicare beneficiary, and if Medicare is
secondary to Plan B and if Medicare is primary to Plan A (for example, if the person is a
retiree), then Plan B will pay before Plan A.
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If a child is covered under more than one plan, the primary plan is the plan of the parent
whose birthday is earlier in the year if:
a) the parents are married;
b) the parents are not legally separated (whether or not they have ever
been married); or
c) a court decree awards joint custody without specifying that one parent
has the responsibility to provide health care coverage.
If both parents have the same birthday, the plan that has covered either of the parents
longer is primary.
If the specific terms of a court decree state that one of the parents is responsible for the
child’s health care expenses or health care coverage and the plan of that parent has actual
knowledge of those terms, that plan is primary. If the parent with financial responsibility
has no coverage for the child’s health care services or expenses, but that parent’s spouse
does, the spouse’s plan is primary. This subparagraph shall not apply with respect to any
claim determination period during which benefits are paid or provided before the entity
has actual knowledge.
If the parents are not married or are legally separated (whether or not they ever were
married) or are divorced, and there is no court decree allocating responsibility for the
child’s health care services or expenses, the order of benefit determination among the
plans of the parents and parents’ spouses (if any) is:
a)
b)
c)
d)
the plan of the custodial parent;
the plan of the spouse of the custodial parent;
the plan of the noncustodial parent;
the plan of the spouse of the noncustodial parent.
The following rules apply unless the other plan does not have the same rule and as a
result the plans do not agree on the order of benefits:
The plan that covers a person as an Employee who is either laid off or retired (or as that
Employee’s Dependent) is primary and a plan that covers a person as a Dependent of an
inactive spouse is secondary. Coverage provided an individual as a retired worker and as
a Dependent of that individual’s spouse as an active worker will be determined as
previously stated above.
If a person whose coverage is provided under a right of continuation pursuant to federal
or state law is also covered under another plan, the plan covering the person as an
Employee, member, subscriber, or retiree (or as that person’s Dependent) is primary and
the continuation coverage is secondary.
69
If the preceding rules do not determine the order of benefits, the primary plan is the one
that covered the person for the longer period of time, measured from the person’s first
date of coverage. If that date is not readily available for a group plan, the date the person
first became a member of the group shall be used as the date from which to determine the
length of time the person’s coverage under the present plan has been in force. To
determine the length of time a person has been covered under a plan, two plans shall be
treated as one if:
a) the covered person was eligible under the second within 24 hours after
the first ended; and
b) the start of a new plan does not include a change in the amount or
scope of a plan’s benefits or a change in the entity that pays, provides
or administers the plan’s benefits, or a change from one type of plan to
another (single- to multi-employer, for example).
If none of the preceding rules determines the primary plan, the Allowable Expenses shall
be shared equally by the two plans.
C.
Coordination of Benefits with Medicare
Medicare is the program of medical care benefits provided under Title XVIII of the
Social Security Act of 1965 as amended.
Individuals who have earned the required number of quarters for Social Security benefits
within the specified timeframe are eligible for Medicare Part A at no cost. Ineligible
individuals age 65 and over may purchase Medicare Part A by making application and
paying the full cost. Participation in Medicare Part B is available to all individuals who
pay the full cost of coverage. A new voluntary prescription drug benefit (Part D) to the
Medicare program is available to “Part D individuals,” which Medicare defines as
individuals who have coverage under Medicare Part A or Part B and who live in the
service area of a Part D plan. IF A PARTICIPANT IN THIS PLAN ENROLLS IN
MEDICARE PART D, ANY PRESCRIPTION BENEFIT UNDER THIS PLAN
TERMINATES AS OF THE DATE ENROLLMENT IN PART D IS EFFECTIVE.
Federal legislation requires that active Employees age 65 and over be given the option to
elect either the Employer’s plan or Medicare as primary coverage. If the affected
Employee elects this Plan as his primary coverage, the regular benefits of this Plan will
apply. If an Employee elects Medicare as his primary coverage, no benefits will be
available under this Plan.
Federal legislation also requires that an active Employee’s spouse who is age 65 or over
be given the option to elect the Employer’s plan or Medicare as his primary coverage. If
the affected spouse elects the benefits of this Plan as his primary coverage, the regular
benefits of this Plan will apply. If the spouse elects Medicare as his primary coverage, no
benefits will be available under this Plan.
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The Plan is the primary payor and Medicare is the secondary payor for services that
would have been covered by Medicare in each of the following situations:
an Employee or Dependent spouse of an Employee covered under this Plan
because of current employment who is entitled to Medicare benefits because of
his age;
an Employee or Dependent covered under this Plan as a result of current
employment who is entitled to Medicare benefits because of total disability;
an Employee or Dependent who is entitled to Medicare because of end stage renal
disease until the end of the Medicare secondary coordination period.
Benefits for Participants who are eligible for Medicare benefits will be paid according to
the Health Care Financing Administration rules and regulations coordinating Medicare
with group health plans. This Plan will pay secondary in all instances allowed by HCFA
and the Medicare Secondary Payer provisions of the Social Security Act except that it
will not supplement Medicare Part D. Enrollment in prescription drug coverage in
connection with this Plan will terminate on the effective date of the Participant’s
enrollment in Medicare Part D.
When Medicare is the primary payor and an Employee or Dependent entitled to Medicare
incurs Hospital, surgical or other charges covered under Medicare and other charges
which are not covered under Medicare, this Plan’s benefits will cover charges incurred to
the extent that they are not covered under Medicare. All of the Coordination of Benefits
provisions will apply, including the provision that states that a Managed Care Participant
will receive benefits under this Plan at a level that is secondary to the benefits of the
Managed Care Option (for example, Medicare Plus Choice) would have provided had the
Participant utilized a participating and/or network provider. Furthermore, this Plan shall
not provide coverage for costs that may be counted towards meeting a Participant’s
Medicare Savings Account Policy deductible.
Medicare will pay primary, secondary or last to the extent stated in federal law. When
Medicare is the primary payer, this Plan will base its payment upon benefits that would
have been paid by Medicare under Parts A and B regardless of whether or not the person
was enrolled in both of these parts. Enrollment in Part D is voluntary.
D.
Right To Receive Medical Information Necessary To
Determine Benefit
By accepting coverage under this Plan, the Participant agrees to supply information about
medical conditions and records or other coverage he and his spouse or Dependent(s) have
when this Plan asks for it. If this Plan makes a payment and later finds out that it should
not have been primary, the Participant must return the excess amount paid to this Plan.
All private health information will be kept confidential and will be used on a need only
basis.
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E.
Summary and Protected Health Information
1.
DISCLOSURE OF SUMMARY HEALTH INFORMATION
This Plan shall disclose to the Plan Sponsor summary health information (information
that does not and could not be used to identify an individual) if the Plan Sponsor requests
such information for the purpose of:
•
•
obtaining premium bids from health plans for providing health insurance coverage
under this Plan; or
modifying, amending, or terminating this Plan.
2.
DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)
The Plan will disclose PHI (information that identifies or could identify an individual) to
the Plan Sponsor only in accordance with HIPAA Privacy laws. The Plan will use PHI to
the extent and in accordance with the uses and disclosures permitted by the Health
Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the Plan
will use and disclose PHI for purposes related to health care treatment, payment for
health care, and health care operations.
The Plan Sponsor hereby acknowledges and agrees to the following provisions in this
document:
a. Not to use or further disclose PHI other than as permitted or required by the plan
document or as required by law; and to ensure that the separation between the Plan
and Plan Sponsor required under the privacy rules is supported by reasonable and
appropriate security measures;
b. To ensure that any agents, including a subcontractor, to whom the Plan Sponsor
provides PHI received from the Plan agree to the same restrictions and conditions that
apply to the Plan Sponsor with respect to such PHI; and to implement administrative,
physical and technical safeguards that reasonably and appropriately protect the
confidentiality, integrity and availability of the electronic PHI that it creates, receives,
maintains or transmits on behalf of the Plan;
c. Not to use or disclose PHI for employment-related actions and decisions or in
connection with any other benefit or employee benefit plan of the Plan Sponsor
unless authorized by an individual;
d. To report to the Plan any security incident or any PHI use or disclosure that it
becomes aware is inconsistent with the uses or disclosures for which provision is
made;
e. To make available protected health information in accordance with 45 CFR
§164.524;
72
f. To make available protected health information for amendment and incorporate any
amendments to protected health information in accordance with 45 CFR §164.526;
g. To make available the information required to provide an accounting of disclosures in
accordance with 45 CFR §164.528;
h. To make its internal practices, books, and records relating to the use and disclosure of
PHI received from the Plan available to the Department of Health and Human
Services upon request;
i. If feasible, to return or destroy all PHI received from the Plan that the Employer
maintains in any form and retain no copies of such information when no longer
needed for the purpose for which disclosure was made, except that, if such return or
destruction is not feasible, the Employer will limit further its uses and disclosures of
the PHI to those purposes that make the return or destruction of the information
infeasible; and
j. To ensure that adequate separation between the Plan and the Employer, as required
by 45 CFR §164.504(f), is established and maintained.
3.
LIMITATIONS OF PHI ACCESS AND COMPLIANCE
Access to PHI information may be given only to the Plan Sponsor and staff of the Plan
Sponsor who receive protected health information relating to payment under, health care
operations of, or other matters pertaining to the Plan in the ordinary course of business in
carrying out Plan administration functions that the Plan Sponsor performs for the Plan.
The access and use of PHI by the Plan Sponsor and staff described above is limited to
purposes of the administration functions that the Plan Sponsor performs for the Plan. If
the Plan Sponsor and said staff do not comply with this Plan document, the Plan Sponsor
shall provide a mechanism for resolving issues of noncompliance, including disciplinary
sanctions.
F.
Subrogation/Right of Reimbursement
Expenses which result from an Injury or Sickness due to the act of a third party are not
covered by this Plan. These expenses are excluded, but if the Plan chooses to advance
expenses, the Plan will have a first priority lien against any amounts received by the
Participant from any source, regardless of whether the Participant is made whole by the
settlement or judgment. The Participant agrees to cooperate with the Plan and to take no
action to prejudice the Plan’s full recovery.
If a Participant files a claim under this Plan for medical and/or dental expenses incurred
as a result of an Injury or Sickness due to the act of a third party, the Plan Administrator
shall have the right to enforce either the Subrogation or the Right of Reimbursement
provision below.
73
The Participant must execute any subrogation/right of reimbursement agreement required
by the Plan Administrator prior to receipt of any benefits payable under this Plan.
Neither the Subrogation nor the Right of Reimbursement provisions and/or agreement
may be modified by the Participant unless specifically authorized in writing by the Plan
Administrator.
The Participant must furnish the Plan Administrator any and all information that the Plan
Administrator may reasonably require to protect the Plan’s right of subrogation and/or
reimbursement, and shall do nothing to prejudice that right.
•
a)
Subrogation
Recovery will be from any source making payment to the full extent of payments
made by the Plan, regardless of whether or not the Participant has been made whole
or fully compensated for his/her illness/Injury.
•
The Plan Administrator will be subrogated to any legal claim the Participant may
have and is entitled to assert a lien against the third party.
•
Notice of a lien is sufficient to establish the Plan’s lien against the third party.
•
Any recovery by the Plan Administrator will be limited to the amount of any
payments made under the Plan for medical expenses resulting from the negligent or
intentional act and the cost of prosecuting the claim including attorneys’ fees and
collection fees. The Plan will not be responsible for the fees or costs of attorneys
retained by the Participant, and that same shall not be deducted from the Plan’s
recovery, unless the Plan agrees to such an arrangement in writing.
For purposes of this provision, subrogation means the Plan Administrator has the right to
act in place of the Participant to make a lawful claim or demand against the third party.
CONFLICTING STATUTES: Although the Plan Administrator may choose to enforce
either the Subrogation or Right of Reimbursement provision, if the Subrogation provision
conflicts with the laws of the State or the governing jurisdiction, and the application of
such laws to the Plan is not preempted by the Employee Retirement Income Security Act
of 1974 (ERISA), then the Subrogation provision shall not be enforced, and the Right of
Reimbursement provision will apply.
•
b)
Right of Reimbursement
The Participant will reimburse this Plan from any money received from the
Participant’s insurer, a third party, or the third party’s insurer; first party coverage,
including Um/UIM, MedPay/PIP.
•
Reimbursement will be up to the amount of benefits paid by this Plan;
74
•
The Plan will not be responsible for the fees or costs of attorneys retained by the
Participant and that same shall not be deducted from the Plan’s recovery unless the
Plan agrees to such an arrangement in writing.
The reimbursement agreement will be binding upon the Participant whether the payment
received from the third party or its insurer results from:
•
•
•
•
A legal judgment or
An arbitration award or
A compromise settlement or
Any other arrangement.
The reimbursement agreement will be binding on any recovery made by the Participant,
even if the settlement does not include medical expenses.
It is not necessary that the medical expenses be itemized in the third party payment or
that the third party and/or its insurer admit liability.
Also the Employer is under no obligation to recover such reimbursement on behalf of the
Participant.
75
VIII. PLAN ADMINISTRATION
A.
Plan Administrator
Any duly authorized officer of the Plan Administrator may exercise any authority or
responsibility allocated or reserved to the Plan Administrator under this Plan.
The Plan Administrator shall have the right to hire all persons providing services to the
Plan and to appoint a Claims Administrator to receive, initially review, and process
claims for benefits.
The Plan Administrator shall have the authority and responsibility to call and attend the
meetings at which this Plan’s funding policy and method are reestablished and reviewed.
The Plan Administrator shall have the discretionary authority and responsibility to
construe and interpret terms of this Plan; to make factual determinations, including all
questions of eligibility; to establish the policies, interpretations, practices, and procedures
of this Plan; to adopt and implement procedures, including Care Management, in its sole
discretion; to decide whether care or treatment is Medically Necessary and whether a
charge meets Reasonable and Customary criteria; and to render final decisions on review
of claims as described in this Plan Document. All interpretations under the Plan, and all
determinations of fact made in good faith by the Plan Administrator will be final and
binding on the Participants and beneficiaries and all other interested parties.
Furthermore, the Plan Administrator shall have the right to determine the amount,
manner, and time of payment of any benefits under this Plan and to change contribution
rates for Participants at any time and from time to time.
The Plan Administrator has a duty to maintain records and to file reports required by law.
This duty shall include complying with applicable reporting or disclosure requirements.
The Plan Administrator shall forward applications to the Claims Administrator and notify
the Claims Administrator in writing of changes with respect to Participants and other
facts necessary for determining Plan coverages and for processing claims for Plan
benefits.
The Plan Administrator or any duly authorized representative of the Plan Administrator
will have the right to examine any claim for benefits under this Plan, whether assigned or
unassigned. The Plan Administrator will, at the Plan’s expense, have the right to have
the person whose Sickness or Injury is the basis for a claim examined as often as
reasonably required during the time a claim is pending under the Plan. The Plan
Administrator will not discriminate in treatment of individuals in similar situations, and
the Claims Administrator is not obligated to inquire into the circumstances.
76
For purposes of determining the applicability of the coordination of benefits and
subrogation provisions of this Plan or any provision with a similar purpose that is in
another plan and for purposes of implementing those provisions, the Plan Administrator
or Claims Administrator may release necessary information to, or obtain necessary
information from, any other organization or individual.
The Plan Administrator shall have the unlimited right to amend this Plan in any and all
respects at any time, and from time to time, without prior notice to any Participant or
Eligible Dependent. Any such amendment shall be adopted by formal action by the
officer(s) and/or other designated representative(s) authorized to act for or on behalf of
the District in this capacity and shall become effective as of the date specified during
such adoption proceedings. Any such amendment shall be binding upon all Participants
(including those Participants on continuation coverage). However, the responsibilities of
the named fiduciaries and their delegates shall not be increased or changed by
amendment without their written consent.
An amendment to the Plan may be retroactively effective but shall not adversely affect
the rights of a Participant under this Plan for covered medical expenses provided after the
effective date of the amendment but before the amendment is adopted.
The Plan shall furnish a summary of a material reduction in covered services or benefits
to Participants within 60 days after the change has been adopted by the Plan.
Notwithstanding that the Plan is established with the intention that it be maintained
indefinitely, the Plan Administrator reserves the unlimited right to terminate or merge the
Plan at any time without prior written notice to any Participant. Such termination shall
be adopted by formal action by the officer(s) and/or other designated representative(s)
authorized to act on behalf of the District in this capacity. The date of the merger or
termination will be the date specified during such adoption proceedings. Termination of
the Plan shall apply to all Participants (including those on continuation coverage).
Additionally, the Plan Administrator reserves the right to determine from time to time the
level of contribution required from Participants for Plan coverage.
The Plan Administrator shall perform all other responsibilities allocated to the Plan
Administrator in the instrument appointing the Plan Administrator.
B.
Claims Administrator
The Claims Administrator shall have the authority and responsibility to administer the
Plan’s claims procedures, to process claims for benefits in accordance with Plan
provisions, and to file claims with the insurance companies, if any, who issue stop loss
insurance policies to the Plan.
77
The Plan Administrator must furnish the Claims Administrator all information the Claims
Administrator reasonably requires as to matters pertaining to this Plan. All material
which may have a bearing on coverage or contributions will be open for inspection by the
Claims Administrator at all reasonable times during the continuance of this Plan and until
the final determination of all rights and obligations under this Plan.
C.
Participant
As a Participant in this Plan, the Employee is entitled to certain rights.
Participants shall be entitled to:
All Plan
1. Examine, without charge, at the Plan Administrator’s office, all Plan
documents, including insurance contracts, collective bargaining agreements,
and copies of documents, such as detailed annual reports and Plan
descriptions.
2. 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.)
If you have any questions about this statement or about your rights under HIPAA, you
should contact the nearest office of the Employee Benefits Security Administration, U.S.
Department of Labor, listed in your telephone directory or the Division of Technical
Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department
of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also
obtain certain publications about your rights and responsibilities under HIPAA by calling
the publications hotline of the Employee Benefits Security Administration.
The Participants in this Plan have the sole right to select their own providers of health
care. The Plan will not choose a provider for any Participant, or have any liability for
any acts, omissions, or conduct of any provider. The Plan’s only obligation is to make
payments according to the terms of this Plan Document. The payments that the Plan
makes are not an attempt to fix the value of any services or supplies provided to a
Participant.
A Participant will have the right to assign the payment of any benefits for which he is
eligible under this Plan to any eligible provider of services. If a provider makes a
representation to the Claims Administrator that a person covered under this Plan has
made an assignment of benefit payments to the provider, the Claims Administrator will
make payment to the provider based on that representation.
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IX.
GENERAL PROVISIONS
A.
Legal Compliance/Conformity
This Plan shall be interpreted, construed, and administered in accordance with applicable
state or local laws of the Employer’s principal place of business to the extent such laws
are not preempted by federal law. If any provision of the Plan Document or Employer’s
Plan is contrary to any law to which it is subject, the provision is hereby automatically
changed to meet the law’s minimum requirement.
B.
Effect of Prior Coverage
Coverage for any Participant under this Plan Document replaces any prior coverage in
effect for that Participant provided by the Employer under any immediately prior plan
document or policy.
C.
Severability
In the event that any provision of this Plan shall be held to be illegal or invalid for any
reason by a court of competent jurisdiction, such illegality or invalidity shall not affect
the remaining provisions of the Plan and the Plan shall be construed and enforced as if
such illegal or invalid provision had never been contained in the Plan.
D.
Status of Employment Relations
The adoption and maintenance of this Plan shall not be deemed to constitute a contract
between the Employer and the Employees or to be consideration for, or an inducement or
condition of, the employment of an Employee. Nothing in this Plan shall be deemed to
affect the right of the Employer to discipline or discharge any Employee at any time or
the right of the Employee to terminate his employment at any time. Nor shall anything in
this Plan be deemed to give the Employer the right to require any Employee to remain in
its employ or give the right to any Employee to be retained in the employ of the
Employer.
E.
Headings
Headings are for reference and not for interpretation or construction.
F.
Word Usage
Whenever words are used in this document in the singular or masculine form, they shall
where appropriate be construed so as to include the plural, feminine, or neuter form.
79
G.
Titles for Reference
The titles used within this document are for reference purposes only. In the event of a
discrepancy between a title and the content of a section, the content of a section shall
control.
H.
Clerical Error
No clerical errors made by the Employer, Plan Administrator, or the Claims
Administrator in keeping records pertaining to this coverage or delays in making entries
in such records will invalidate coverage otherwise validly in force or continue coverage
otherwise validly terminated. Upon discovery of any error, an equitable adjustment of
any benefits paid will be made.
I.
Misstatements
If any relevant fact as to an individual to whom the coverage relates is found to have
been misstated, an equitable adjustment of contributions will be made. If the
misstatement affects the existence or amount of coverage, the true facts will be used in
determining whether coverage is in force under this Plan and its amount.
J.
Refund of Overpayments
If the Plan pays benefits for expenses incurred on account of a Covered Participant, that
Covered Participant, or any other person or organization that was paid, must provide a
refund to the Plan if either of the following apply:
•
All or some of the expenses were not paid by the Covered Participant or did not
legally have to be paid by the Covered Participant.
•
All or some of the payment the Plan made exceeded the benefits under the Plan.
The refund shall equal the amount the Plan made in excess of the amount it should have
paid under the terms of the Plan. If the refund is due from another person or
organization, the Covered Participant agrees to help the Plan obtain the refund when
requested.
If the Covered Participant, or any other person or organization that was paid, does not
promptly refund the full amount, the Plan may reduce the amount of any future benefits
that are payable under the Plan. The reductions will equal the amount of the required
refund. The Plan may have other rights in addition to the right to reduce future benefits.
80
X.
DEFINITIONS
Accident and Accidental means an unforeseen or unexplained sudden occurrence by
chance, without intent or volition.
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 (R.N.s) and does not provide for overnight stays.
Birthing Center means any freestanding or Hospital-based facility which provides an “at
home” atmosphere for the delivery of babies. This facility must be licensed and operated
in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the
facility is located.
The Birthing Center must provide facilities for obstetrical delivery and short-term
recovery after delivery; provide care under the full-time supervision of a Physician and
either a Registered Nurse (R.N.) or a Licensed Nurse-midwife; and 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.
Calendar Year means a twelve-month period beginning on the first day of January and
ending on the last day of the following December.
Chemical Dependency is the condition caused by regular excessive compulsive drinking
of alcohol and/or physical habitual dependence on drugs that results in a chronic disorder
affecting physical health and/or personal or social functioning. This does not include
dependence on tobacco and ordinary caffeine-containing drinks.
Claims Administrator means American Administrative Group, Inc.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as
amended.
Cosmetic Dentistry means dentally unnecessary procedures.
Covered Charge means any expense that is eligible for benefits and not otherwise
excluded under this Plan.
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 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.
81
Dental Service means a professional dental service which is included in the list of dental
services under Covered Dental Expenses and is rendered by a Dentist in the necessary
treatment of Accidental Injury, dental disease or defect.
Dentist is a person who is properly trained and licensed to practice dentistry and who is
practicing within the scope of such license.
Durable Medical Equipment means equipment that (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.
Eligible Dependent means an individual who meets the requirements for such status as
stated in the eligibility section of this document.
Eligible Employee means a person who is an active, regular Employee of the Employer,
regularly scheduled to work sufficient hours for the Employer in an Employer/Employee
relationship, as specified in the Eligibility section of this Plan. The term also means a
retiree as stated in the Eligibility section of this Plan Document.
Employer is McAllen Independent School District.
Enrollment Date is the first day of coverage or, if there is a Waiting Period, the first day
of the Waiting Period.
Family means an Employee and his Dependents. Under any benefit section, a “covered
Family member,” as of any given time, is a Family member for whom coverage is then in
force under the section.
Foster Child means an unmarried child under the limiting age shown in the Dependent
Eligibility Section of this Plan for whom an Employee has assumed a legal obligation.
All of the following conditions must be met: the child is being raised as the Employee’s;
the child depends on the Employee for primary support; the child lives in the home of the
Employee; and the Employee may legally claim the child as a federal income tax
deduction.
A Foster Child is not a child temporarily living in the Employee’s home; one placed in
the Employee’s home by a social service agency which retains control of the child; or
whose natural parent(s) may exercise or share parental responsibility and control.
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 generical pharmaceutical
dispensed according to the professional standards of a licensed pharmacist and clearly
designated by the pharmacist as being generic.
82
Home Health Care Agency is an organization the main function of which is to provide
Home Health Care services and supplies and which is federally certified as a Home
Health Care Agency and licensed by the state in which it is located, if licensing is
required.
Hospice Care Agency is an organization the main function of which is to provide
Hospice Care services and supplies and which is licensed by the state in which it is
located, if licensing is required.
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; 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
Registered Nurses (R.N.s); 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 Rehabilitation Facility for rehabilitative care.
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 Chemical Dependency 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 Chemical Dependency.
Hospital Confinement. Any confinement in a Hospital for which a charge is made for
room and board.
Hospital Confinement Deductible. The deductible amount to be paid by the Participant
for each inpatient Hospital confinement incurred by a Participant is the deductible
amount shown in the Schedule of Benefits.
Injury means an Accidental physical Injury to the body caused by unexpected external
means.
Intensive Care Unit is defined as a separate, clearly designated service area that is
maintained within a Hospital solely for the care and treatment of patients who are
critically ill. This also includes what is referred to as a “coronary care unit” or an “acute
care unit.” It has facilities for special nursing care not available in regular rooms and
83
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 per day.
Late Enrollee means a Plan Participant who enrolls under the Plan other than during the
first 30-day period in which the individual is eligible to enroll under 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.
Licensed Practical Nurse or Licensed Vocational Nurse means an individual who is
licensed to perform nursing service by the state in which the person performs such
service and who is performing within the scope of that license.
Lifetime, used in this Plan in the context of benefit maximums and limitations, refers to
the “lifetime” of coverage under this Plan, not to the term of an individual’s life.
Medical Emergency means a sudden onset of a condition with acute symptoms requiring
immediate medical care and includes such conditions as heart attacks, cardiovascular
accidents, poisonings, loss of consciousness or respiration, convulsions or other such
acute medical conditions.
Medically Necessary care and treatment is recommended or approved by a Physician or
Dentist; is consistent with the patient’s condition or accepted standards of good medical
and dental practice; is medically proven to be effective treatment of the condition; is not
performed mainly for the convenience of the patient or provider of medical and dental
services; is not conducted for research purposes; and is the most appropriate level of
services which can be safely provided to the patient.
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.
Morbid Obesity is defined as being 100% or 100 pounds over a Participant’s ideal body
weight.
No-Fault Auto Insurance is the basic reparations provision of a law providing for
payments without determining fault in connection with automobile accidents.
84
Outpatient Care is treatment including services, supplies and medicines provided and
used at a Hospital under the direction of a Physician to a person not admitted as a
registered bed patient; or services rendered in a Physician’s office, laboratory or X-ray
facility, an Ambulatory Surgical Center or the patient’s home.
Participant is a person covered under this Plan or the legal representative or guardian of
a minor or incompetent person covered under this Plan.
Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of
Dental Surgery (D.D.S.), Doctor of Medical Dentistry (D.M.D.), Doctor of Podiatry
(D.P.M.), Doctor of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist,
Certified Nurse Midwife (C.N.M.), Nurse Practitioner (N.P.), Occupational Therapist,
Optometrist (O.D.), Physician Assistant (P.A.), Physiotherapist, Psychiatrist,
Psychologist (Ph.D.), Registered Physical Therapist, Social Workers (S.W., C.S.W.,
M.S.W., L.C.S.W., A.C.S.W.), Advanced Clinical Practitioner (A.C.P.), L.P.C. Licensed
Professional Counselor (L.P.C.), Speech Language Pathologist. In addition, the above
providers must be licensed and regulated by a state or federal agency and must be acting
within the scope of his or her license.
Plan means McAllen Independent School District Employee Benefit Plan, which is a
benefit plan for certain Employees of McAllen Independent School District and is
described in this document.
Plan Year is the twelve-month period beginning on either the effective date of the Plan
or on the day following the end of the first Plan Year which is a short Plan Year.
Preexisting Condition means a condition (except pregnancy) for which medical advice,
diagnosis, care or treatment was recommended or received within the 6 month period
ending on the Participant’s Enrollment Date. 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.
Pregnancy is childbirth and conditions associated with Pregnancy, including
complications.
Prescription Benefit Manager is the prescription drug vendor contracted by the Plan
Administrator to provide benefits for prescription drugs.
Primary Care Provider means a licensed Doctor of Medicine (M.D.) who is a general
or family practitioner, pediatrician, general internist or obstetrician/gynecologist who has
contracted with the Network to render services, supplies and treatment to the Participant
and to assist in managing the care of Participants.
85
Reasonable 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 base Plan benefits on the actual charge billed if it is less than the
Reasonable and Customary Charge.
Reasonable and Customary limitations will not apply to Network PPO repriced claims.
Registered Nurse means a professional person who is licensed to perform nursing
service by the state in which the person performs such service and who is performing
within the scope of that license.
Rehabilitation Facility means an inpatient medical facility that is licensed as a Hospital
or freestanding Rehabilitation Facility, where licensure is required, or it may be CARF
accredited. Physicians and Registered Nurses are on staff and available. This type of
facility provides physical, occupational and speech therapy by licensed therapists and
also have available a program of structured cognitive therapy. Social work and discharge
planning are provided, to include planning for care and equipment needs after discharge.
Sickness is a person’s illness, disease or Pregnancy (including complications).
Skilled Nursing Facility is a facility that fully meets all of these tests:
It is licensed to provide professional nursing services on an inpatient basis to persons
convalescing from Injury or Sickness. The service must be rendered by a Registered
Nurse (R.N.) or by a Licensed Practical Nurse (L.P.N.) under the direction of a
Registered Nurse. Services to help restore patients to self-care in essential daily living
activities must be provided.
Its services are provided for compensation and under the full-time supervision of a
Physician or with Physician services available at all times under an established
agreement.
It provides twenty-four hour per day nursing services by licensed nurses, under the
direction of a full-time Registered Nurse (R.N.).
It has established methods and written procedures for the dispensing and administration
of drugs.
It maintains a complete medical record on each patient.
It has an effective utilization review plan.
86
It is not, other than incidentally, a place for the provision of rest, custodial care, or
education or for care required by reason of age, drug addiction, alcoholism, mental
retardation or mental disorders.
It is approved and licensed by Medicare.
This term also applies to charges incurred in a facility referring to itself as an extended
care facility, convalescent nursing home or any other similar nomenclature.
Specialists mean those practitioners other than a Family Practitioner, General
Practitioner, Internist, Pediatrician or Obstetrician/Gynecologist.
Spinal Manipulation/Chiropractic Care means skeletal adjustments, manipulation or
other treatment in connection with the detection and correction by manual or mechanical
means of structural imbalance or subluxation in the human body. Such treatment is done
by a Physician to remove nerve interference resulting from, or related to, distortion,
misalignment or subluxation of, or in, the vertebral column.
Surgical Procedure shall include but not be limited to one or more of the following
types of medical procedures performed by a Physician:
•
•
•
•
•
•
•
•
•
Incision, excision or electrocauterization and shave biopsy of any part of the body.
Manipulative reduction or treatment of a fracture or dislocation, including application
of a cast or traction.
Laser beam photocoagulation.
Suturing of a wound, surgical debridement and dressing of burns; acne surgery.
Diagnostic and therapeutic endoscopic procedures.
Surgical injection treatments of aspirations.
Cardiac catheterizations and other arterial or venous catheterizations.
Maternity procedures.
Transplantation of organ(s).
Total Disability as it applies to an Employee means the Employee is unable, as a result
of Sickness or Injury, to perform the normal duties of his occupation and is not
performing work of any kind for wage or profit. As it applies to a Dependent, it means
that the Dependent, as a result of Sickness or Injury, is unable to perform the normal
duties appropriate to a person in good health of the same sex and age.
Urgent Care Facility shall mean a facility other than a free clinic providing medical care
and treatment of Sick or Injured persons on an Outpatient basis. In addition, it must meet
all of the following tests:
It is accredited by the Joint Commission on Accreditation of Hospitals or is approved by
the federal government to participate in federal and state programs.
87
It maintains on-premise diagnostic and therapeutic facilities for surgical and medical
diagnosis and treatment by or under the supervision of duly qualified Physicians.
It is operated continuously with organized facilities for operative surgery on the
premises.
It is staffed with continuous Physician services and registered professional nursing
services whenever a patient attends the facility.
It does not provide services or other accommodations for patients to stay overnight.
Waiting Period shall mean any period of time imposed by the Plan between the first day
of employment and the first day of eligibility for coverage under the Plan.
88
XI.
IDENTIFICATION OF PLAN
PLAN: McAllen Independent School District Employee Benefit Plan
PLAN SPONSOR:
McAllen Independent School District
2000 North 23rd Street
McAllen, Texas 78501
PLAN SPONSOR TAX ID NO.: 74-6001658
PLAN NO.: 501
CLAIMS ADMINISTRATOR:
American Administrative Group
PO Box 34297
San Antonio, Texas 78265
1 (800) 221-4582
AMERICAN ADMINISTRATIVE GROUP, INC. CLIENT NO.: 2048700
TYPE OF BENEFITS PROVIDED:
See Schedule of Benefits
TYPE OF PLAN ADMINISTRATION:
Self-Funded Third Party
PLAN ADMINISTRATOR/AGENT FOR
LEGAL PROCESS/NAMED FIDUCIARY:
McAllen Independent School District
2000 North 23rd Street
McAllen, Texas 78501
CONTRIBUTIONS TO PLAN:
Contributions for the Plan are provided partially by contributions of the Plan Sponsor and
partially by contributions of Covered Employees.
FISCAL YEAR END:
September 30th
89
HIGH PLAN SUMMARY
McAllen Independent School District
Plan Effective Date: October 1, 2009
Calendar Year Deductible
Individual
Family
NOTE: Covered expenses applied to the deductible October through December
may be applied to satisfy the individual deductible for the following calendar
year.
Out-of-Pocket Limit
(excludes Calendar Year Deductible)
Individual
Family
NOTE: The plan pays 100% for most covered services after the out-of-pocket
expense is reached.
Maximum (while covered under the plan except as noted below)
NOTE: In-Network and Out-of-Network maximums are combined.
Covered Services
Physician Services
Office Visits/Consultations only
Group #2048700
In-Network
Out-of-Network
$300
$900
$300
$900
$2,500
$7,500
$5,000
$15,000
$1,000,000
$1,000,000
In-Network
(The plan pays the % shown after any
copay and/or the calendar year
deductible)
Out-of-Network
(The plan pays the % shown after
any copay and/or the calendar year
deductible)
60%
Other Physician Services
Maternity Services – includes prenatal, delivery and postnatal physician services
$20 copay each visit, then 100%,
deductible waived
80%, deductible waived
80%
Physician Surgical Services
- Inpatient
- Outpatient
Nonsurgical Services
Routine Physical Exam (age 18 or older) which includes Routine Mammogram
and Prostate Screening
Vision (one exam per calendar year)
Hearing (one exam per calendar year)
80%
80%
80%
$20 copay each visit, then 100%,
deductible waived
80%, deductible waived
80%, deductible waived
60%
60%
60%
60%
60%
Immunization
$20 copay each visit, then 100%,
deductible waived
100%, deductible waived
Hospital Services
Room & Board and Services & Supplies
80%
$250 copay per admission then 60%
after the calendar year deductible
$50 copay each visit, then 80%,
deductible waived
80%, deductible waived
$50 copay each visit, then 80%,
deductible waived
60%, deductible waived
$50 copay each visit, then 80%
80%
80%
80%, deductible waived
$50 copay each visit, then 60%
60%
60%
80%, deductible waived
80%
80%
60%
60%
80%
80%
60%
60%
Routine Preventive Care (through age 17)
Emergency Care
Accident/Medical Emergency Room
Facility (each visit copay waived if admitted to the hospital)
Physician
Non-Emergency Situations
Facility
Physician
Urgent Care Center
Ambulance Services
Mental and Nervous Disorders
Outpatient Visit (up to 25 visits each calendar year)
Inpatient Stay (up to 30 days each calendar year)
Alcohol & Drug Abuse and/or Substance Abuse
Outpatient Visit
Inpatient Stay
60%
60%
60%
60%
60%
Revised 01/22/10
HIGH PLAN SUMMARY
McAllen Independent School District
Plan Effective Date: October 1, 2009
Group #2048700
In-Network
Out-of-Network
$20 copay then 80%, deductible
waived
$20 copay then 80%, deductible
waived
100%, deductible waived
80%
80%
80%
60%
$20 copay each visit, then 100%,
deductible waived
$20 copay each visit, then 80%,
deductible waived
80%, deductible waived
80%, deductible waived
60%
80%, deductible waived
80%, deductible waived
80%
80%
80%
60%, deductible waived
60%, deductible waived
60%
60%
60%
80%
80%
80%, may utilize Medical Specialty
Network or the Mutually Preferred
PPO Network
$500
No
Yes
$2,500
Yes
Yes
80%
60%
60%
60%
Other Covered Services (NOTE: In-Network and Out-of-Network maximums
and limitations are combined.)
High End Radiology (MRIs, PET Scans, CT Scans, etc)
Independent Radiology Center (i.e., x-rays, etc.)
Independent Pathology Center (i.e., labs, etc.)
Outpatient Facility Services
Speech and/or Physical Therapy Services
Occupational Therapy (up to $2,000 maximum per calendar year)
Chiropractic Services (up to $500 maximum per calendar year)
Office visit only
Other chiropractic Services (includes modalities/ manipulations/X-rays)
Skilled Nursing Facility (up to $10,000 maximum each calendar year)
Home Health Care (up to $30,000 maximum each calendar year)
Hospice Care (up to $20,000 maximum per calendar year)
Inpatient
Outpatient
Durable Medical Equipment
Prosthetics
Orthognathic Services (only dependents under age 23) up to a $5,000 plan
maximum
TMJ (Temporomandibular Joint Syndrome) up to a $750 maximum while covered.
Specialty Pharmacy Drugs and Medicines (provided in the office)
Transplant Benefit
Non Pre-Certification Penalty
Admission Copay
Second Surgical opinion required
Maximum Out of Pocket
Travel Expenses allowed
Fees for Waiting List Allowed
Supplies and Non-Surgical Treatment of Feet (up to $250 maximum per calendar
year
60%
60%
60%
60%
60%
60%
60%, deductible waived
60%, deductible waived
$500
250
Yes
$10,000
No
No
60%
Pre-Certification is required for mental health and substance abuse treatment,
inpatient hospitalization and other services listed in Plan document.
Prescription Drugs ( Oral Contraceptives are included)
Retail (up to a 30-day supply)
Generic Drugs
Preferred
Non-Preferred
Plan pays 100% after:
$2.50 copay per prescription
$20.00 copay per prescription
$35.00 copay per prescription
*Mail Order (up to a 90-day supply)
Generic Drugs
Preferred
Non-Preferred
$3.75 copay per prescription
$30.00 copay per prescription
$52.50 copay per prescription
No Benefit
No Benefit
A voluntary generic substitution program applies. A mandatory generic
program is proposed effective 1/1/10.
*90 Day Supply also available at select retail pharmacies. Contact SunRx at
1-800-786-1791 for a pharmacy listing.
PPI (Gastric) & Allergy prescription strength medications will be covered at the
preferred brand co-payment + 50% of the cost of the product. If a member
converts to the Over the Counter Equivalent (OTC), the OTC product will be
covered at 100%. The employee will have $0 co-payment.
This Plan Summary provides a brief description of the features and benefits of the Plan. This summary is not a contract. For complete plan benefits and
exclusions refer to the McAllen Independent School District Employee Benefit Plan Document.
Revised 01/22/10
HIGH PLAN SUMMARY
McAllen Independent School District
Employee Monthly Premiums
Employee Only
Employee & Child
Employee & Spouse
2 Persons MISD Employed & Family
Employee & Family
Group #2048700
Current
$ 88.00
$ 213.00
$407.00
$ 331.00
$ 500.00
Revised 01/22/10
BASIC PLAN SUMMARY
McAllen Independent School District
Plan Effective Date: October 1, 2009
Calendar Year Deductible
•
Individual
•
Family
NOTE: Covered expenses applied to the deductible October through
December may be applied to satisfy the individual deductible for the
following calendar year.
Out-of-Pocket Limit
(excludes Calendar Year Deductible)
•
Individual
•
Family
NOTE: The plan pays 100% for most covered services after the out-ofpocket expense is reached.
Maximum (while covered under the plan except as noted below)
NOTE: In-Network and Out-of-Network maximums are combined.
Covered Services
Physician Services
•
Office Visits/Consultations only
•
Other Physician Services
•
•
•
•
Maternity Services – includes prenatal, delivery and postnatal
physician services
Physician Surgical Services
- Inpatient
- Outpatient
Nonsurgical Services
Routine Physical Exam (age 18 or older) which includes Routine
Mammogram and Prostate Screening
Vision (one exam per calendar year)
Hearing (one exam per calendar year)
Routine Preventive Care (through age 17)
•
Immunization
•
•
•
Hospital Services
•
Room & Board and Services & Supplies
Emergency Care
Accident/Medical Emergency Room
•
Facility (each visit copay waived if admitted to the hospital)
•
Physician
Non-Emergency Situations
•
Facility
•
Physician
•
Urgent Care Center
•
Ambulance Services
Group #2048700
In-Network
Out-of-Network
• $500
• $1,500
• $500
• $1,500
• $3,500
• $10,500
• $7,000
• $21,000
• $1,000,000
• $1,000,000
In-Network
(The plan pays the % shown after
any copay and/or the calendar year
deductible)
Out-of-Network
(The plan pays the % shown after
any copay and/or the calendar year
deductible)
• $30 copay each visit, then 100%,
deductible waived
• 70%, deductible waived
• 50%
• 70%
• 50%
•
•
•
•
•
•
•
•
•
•
•
•
70%
70%
70%
$30 copay each visit, then 100%,
deductible waived
70%, deductible waived
70%, deductible waived
$30 copay each visit, then 100%,
deductible waived
100%, deductible waived
• 50%
50%
50%
50%
50%
• 50%
• 50%
• 50%
• 50%
• 70 %
• $500 copay per admission then
50% after the calendar year
deductible
• $75 copay each visit, then 70%,
deductible waived
• 70% deductible waived
• $75 copay each visit, then 70%,
deductible waived
• 50% deductible waived
•
•
•
•
•
•
•
•
$75 copay each visit, then 70%
70%
70%
70%, deductible waived
$75 copay each visit, then 50%
50%
50%
70%, deductible waived
Revised 01/22/10
BASIC PLAN SUMMARY
McAllen Independent School District
Plan Effective Date: October 1, 2009
Group #2048700
In-Network
Out-of-Network
Mental and Nervous Disorders
•
Outpatient Visit (up to 25 visits each calendar year)
• 70%
•
•
• 70%
•
• 70%
• 50%
• 50%
Inpatient Stay (up to 30 days each calendar year)
Alcohol & Drug Abuse and/or Substance Abuse
•
Outpatient Visit
•
Inpatient Stay
Other Covered Services (NOTE: In-Network and Out-of-Network
maximums and limitations are combined.)
•
High End Radiology (MRIs, PET Scans, CT Scans, etc)
•
Independent Radiology Center (i.e., x-rays, etc.)
•
•
•
•
•
Independent Pathology Center (i.e., labs, etc.)
Outpatient Facility Services
Speech and/or Physical Therapy Services
Occupational Therapy (up to $2,000 maximum per calendar year)
Chiropractic Services (up to $500 maximum per calendar year)
•
Office visit only
•
•
•
•
•
•
•
•
•
•
Other chiropractic Services (includes modalities/
manipulations/X-rays)
Skilled Nursing Facility (up to $10,000 maximum each calendar
year)
Home Health Care (up to $30,000 maximum each calendar year)
Hospice Care (up to $20,000 maximum per calendar year)
•
Inpatient
•
Outpatient
Durable Medical Equipment
Prosthetics
Orthognathic Services (only dependents under age 23) up to a
$5,000 plan maximum
TMJ (Temporomandibular Joint Syndrome) up to a $750
maximum while covered.
Specialty Pharmacy Drugs and Medicines (provided in the office)
Transplant Benefit
• Non Pre-Certification Penalty
• Admission Copay
• Second Surgical opinion required
• Maximum Out of Pocket
• Travel Expenses allowed
• Fees for Waiting List Allowed
• 70%
No Benefit unless determined
to be medical emergency
No Benefit unless determined
to be medical emergency
• $30 copay then 70%, deductible
waived
•
$30 copay then 70%, deductible
waived
•
100%, deductible waived
•
70%
•
70 %
•
70%
• 50%
•
•
•
•
50%
50%
50%
50%
•
•
50%
•
50%
•
$30 copay each visit, then
100%, deductible waived
$30 copay each visit, then 70%,
deductible waived
70%, deductible waived
•
50%, deductible waived
•
70%, deductible waived
•
50%, deductible waived
•
• 50%
• 70 % deductible waived
• 70% deductible waived
•
70%
•
70%
•
70%
•
•
•
•
•
•
70%
• 50%
•
•
70%
70%, may utilize Medical
Specialty Network or the
Mutually Preferred PPO
Network
$500
No
Yes
$3,500
Yes
Yes
• 50%
• 50%
•
•
•
•
•
•
•
•
•
•
•
•
50% deductible waived
50% deductible waived
50%
50%
50%
$500
250
Yes
$14,000
No
No
Pre-Certification is required for mental health and substance abuse
treatment, inpatient hospitalization and other services listed in Plan
document.
Revised 01/22/10
BASIC PLAN SUMMARY
McAllen Independent School District
Plan Effective Date: October 1, 2009
Group #2048700
In-Network
Out-of-Network
Prescription Drugs ( Oral Contraceptives are included)
Retail (up to a 30-day supply)
•
Generic Drugs
•
Preferred
•
Non-Preferred
Plan pays 100% after:
•
$2.50 copay per prescription
•
$25.00 copay per prescription
•
$45.00 copay per prescription
•
No Benefit
*Mail Order (up to a 90-day supply)
•
Generic Drugs
•
Preferred
•
Non-Preferred
•
•
•
•
No Benefit
$3.75 copay per prescription
$37.50 copay per prescription
$67.50 copay per prescription
A voluntary generic substitution program applies. A mandatory
generic program is proposed effective 1/1/10.
*90 Day Supply also available at select retail pharmacies. Contact
SunRx at 1-800-786-1791 for a pharmacy listing.
PPI (Gastric) & Allergy prescription strength medications will be
covered at the preferred brand co-payment + 50% of the cost of the
product. If a member converts to the Over the Counter Equivalent
(OTC), the OTC product will be covered at 100%. The employee will
have $0 co-payment.
This Plan Summary provides a brief description of the features and benefits of the Plan. This summary is not a contract. For complete plan
benefits and exclusions refer to the McAllen Independent School District Employee Benefit Plan Document.
Employee Monthly Premiums
Employee Only
Employee & Child
Employee & Spouse
2 Persons MISD Employed & Family
Employee & Family
Current
$ 25.00
$ 178.00
$ 310.00
$ 181.00
$ 371.00
Revised 01/22/10
STATE PLAN SUMMARY
McAllen Independent School District
Group #2048700
Plan Effective Date: October 1, 2009
Calendar Year Deductible
Individual
Family
Out-of-Pocket Limit
(excludes Calendar Year Deductible)
Individual
Family
NOTE: The plan pays 100% for most covered services after the out-of-pocket
expense is reached.
Maximum (while covered under the plan except as noted below)
NOTE: In-Network and Out-of-Network maximums are combined.
Covered Services
Doctor and Lab Services
Doctor office visits (includes immunizations, injections, diagnostic X-rays and
lab tests when performed during an office visit)
- Primary Care Physician
- Specialist
Immunizations, diagnostic X-rays and lab tests (when no office visit is billed)
Allergy injections (when no office visit is billed)
Office Surgery
Outpatient Surgery
Maternity Care (doctor charges only; see Hospital/Facility Services for inpatient
charges)
Inpatient doctor visits
In-Network
Out-of-Network
$0
$0
$500
$1,500
$1,000
N/A
$3,000
N/A
Unlimited
$1,000,000
In-Network
(The plan pays the % shown after any
copay and/or the calendar year
deductible)
Out-of-Network
(The plan pays the % shown after
any copay and/or the calendar year
deductible)
$20 copay each visit, then 100%
$30 copay each visit, then 100%
85 %
65%
65%
65%
85%
85%
$20 copay for Primary
$30 copay for Specialist
(Copay applies to initial visit, then
delivery charges are paid at 85%)
85%
65%
65%
65%
$20 copay each visit, then 100%
$30 copay each visit, then 100%
65%
65%
$20 copay each visit, then 100%
$30 copay each visit, then 100%
65%
65%
$20 copay each visit, then 100%
$30 copay each visit, then 100%
85%
85%
85%
65%
65%
65%
65%
65%
85%
85%
85%
$50 copay per visit, (waived if
admitted) then 85%
$50 copay per visit, (waived if
admitted) then 85%
65%
65%
65%
65%
65%
Preventive Care
Office visit copay includes all preventive care services billed with an office visit
by a network doctor. Preventive care visits – network or out-of-network – are
limited to one physical exam per plan year for age two and over; one OB/GYN
well-woman exam per plan year; and one routine mammogram per plan year.
Network services billed without an office visit will be paid at 85%.
Office Visit (including lab, X-rays, immunizations)
- Primary Care Physician
- Specialist
Routine Eye Exam (one per plan year)
- Primary Care Physician
- Specialist
Hearing Exams
- Primary Care Physician
- Specialist
Lab and X-ray (without an office visit)
Immunizations (without an office visit)
Routine mammograms (without an office visit)
Hospital/Facility Services
Inpatient hospital (semi-private room and board or intensive care unit)
Other inpatient charges (including surgery)
Outpatient hospital/facilities
Emergency room care within 48 hours of accident or medical emergency
Emergency room care for all other conditions
65%
Revised 01/22/10
STATE PLAN SUMMARY
McAllen Independent School District
Group #2048700
Plan Effective Date: October 1, 2009
Extended Care Services
Skilled Nursing facility ($10,000 plan year maximum; up to $7,000 can be outof-network charges.)
Home Health Care ($10,000 plan year maximum; up to $7,000 can be out-ofnetwork charges.)
Hospice ($20,000 lifetime maximum; up to $14,000 can be out-of-network
charges.)
Other Medical Services
Physical Therapy
- Office visit
- All other services
Chiropractic Care (up to $1,500 maximum per plan year)
- Office visit
- All other services
Home Infusion Therapy
Hearing Aids (up to $1,000 per 36-month period)
Durable Medical Equipment
Prosthetics
Ambulance Services (ground or air)
Mental and Nervous Disorders
Inpatient facility (up to 30 days per plan year)
Inpatient physician charges (up to 30 visits per plan year)
Outpatient/Office visits (up to 30 visits per plan year; out-of-network limited to
$60 allowable per visit)
Chemical Dependency (maximum of two separate series per lifetime)
Inpatient facility
Inpatient physician charges
Outpatient
Office visits
Serious Mental Illness
Inpatient facility
Inpatient physician charges
Outpatient
Office visits
Pre-Certification is required for mental health and substance abuse treatment,
inpatient hospitalization and other services listed in Plan document.
Prescription Drugs
Retail (up to a 30-day supply)
Generic
Preferred
Non-Preferred
In-Network
Out-of-Network
85%
65%
85%
65%
85%
65%
$20 copay for Primary
$30 copay for Specialist
85%
65%
65%
65%
$30 copay for Specialist
85%
85%
85%
85%
85%
85%
65%
65%
65%
85%
65%
65%
85%
85%
85%
85%
65%
65%
65%
85%
85%
85%
$20 copay for Primary
$30 copay for Specialist
65%
65%
65%
65%
85%
85%
85%
$20 copay for Primary
$30 copay for Specialist
65%
65%
65%
65%
$ 5 copay per prescription
$25 copay per prescription
$40 copay per prescription
You will be reimbursed the amount
that would have been charged by a
network pharmacy less the required
copay.
A mandatory generic program is proposed effective 1/1/10.
N/A
Home Delivery Pharmacy Service
$10 copay per prescription
Generic
$50 copay per prescription
Preferred
$80 copay per prescription
Non-Preferred
This Plan Summary provides a brief description of the features and benefits of the Plan. This summary is not a contract. For complete plan benefits and
exclusions refer to the McAllen Independent School District Employee Benefit Plan Document.
Employee Monthly Premiums
Employee Only
Employee & Child
Employee & Spouse
2 Persons MISD Employed & Family
Employee & Family
Current
$ 199.00
$ 458.00
$ 595.00
$ 711.00
$ 886.00
Revised 01/22/10
DENTAL PLAN SUMMARY
McAllen Independent School District
Benefit Waiting Period(s):
All Employees
Class
A
B
C
Orthodontia
Months
None
None
12
12
Other
Providers
Deductible Waived
Calendar Year Deductible
Class A
Classes B & C (combined)
Individual
Family
Orthodontia
Individual
Family
Maximums
Classes A, B & C (Calendar Year Maximum) effective date 1/1/10- $1,000 calendar year maximum.
$75
$225
$0
$0
$1,000
Orthodontia (Lifetime Maximum)
$1,000
Covered Services
(The plan pays the % shown after the Calendar Year Deductible
and any Benefit Waiting Period(s) are satisfied)
Class A – Preventive & Diagnostic
Oral Examinations, including prophylaxis (scaling and cleaning of teeth), but not more than twice (2) per
Calendar Year
Topical application of sodium or stannous fluoride, but not more than twice per Calendar Year, and only for
covered individuals under nineteen (19) years of age
Dental X-rays required in connection with the diagnosis of a specific condition requiring treatment. Dental Xrays not more than one (1) full-mouth X-ray or series in any period of thirty-six (36) consecutive months and not
more than two (2) sets of supplementary bitewing X-rays per Calendar Year
Class B – Basic Services
Tests & Laboratory Examinations
Oral Surgery
Amalgam
Periodontics
Endiodontics
Space Maintainers
Services & Supplies to include:
Emergency pallative treatment
General anesthetics and the administration thereof, including intravenous
Sedation, related to cutting procedures in the oral cavity
Antibiotic drug injection by attending dentist
Class C – Major Services
Inlays, Onlays, gold fillings or Crowns
Bridgework
Dentures
Orthodontics (Child(ren))
Treatment is available to Covered Persons under age 19 only)
Other
Providers
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
50%
50%
50%
50%
Benefits for Orthodontia treatment will be payable in equal monthly amounts during the first twelve (12) months
of orthodontia treatment. Such monthly installments will terminate on the date the Covered Person is no longer
eligible for coverage under the Plan.
This Plan Summary provides a brief description of the features and benefits of the Plan. This summary is not a
contract. For complete plan benefits and exclusions refer to the McAllen Independent School District Employee
Benefit Plan Document.
EMPLOYEE PAYS
EMPLOYEE ONLY
2 PERSONS EMPLOYED-FAMILY
EMPLOYEE & FAMILY
$0.00-Provided by the District
$17.82
$36.00
Revised 01/22/10
MCALLEN INDEPENDENT SCHOOL DISTRICT
2010-2011 Benefit Information
Effective January 1, 2011
Administered by Blue Cross Blue Shield of Texas (BCBSTX)
MONTHLY PREMIUMS
Basic Plan
2009-2010
2010-2011*
High Plan
2009-2010
2010-2011*
State Plan
2009-2010
2010-2011*
Employee Only
$
$
Employee & One Child
$ 178.00
Employee & Spouse
25.00
$
30.00
Alternate Plan
No Changes
Dental Plan
2009-2010
2010-2011*
88.00
$ 106.00
$
199.00
$
239.00
$ 0.00
$ 0.00
No Change
$ 196.00
$ 213.00
$ 234.00
$
458.00
$
504.00
N/A
N/A
N/A
$ 310.00
$ 341.00
$ 407.00
$ 448.00
$
595.00
$ 655.00
N/A
N/A
N/A
2 Persons Employed-Family
$ 181.00
$ 199.00
$ 331.00
$ 364.00
$
711.00
$ 782.00
N/A
$ 17.82
$ 20.00
Employee & Family
$ 371.00
$ 408.00
$ 500.00
$ 550.00
$
886.00
$ 975.00
N/A
$ 36.00
$ 42.00
SUMMARY OF BENEFIT PLAN CHANGES
Basic Plan
High Plan
State Plan
2009-2010
2010-2011
2009-2010
2010-2011
2009-2010
2010-2011
Generic Co-Pay*
$2.50
$7.50
$2.50
$7.50
$5.00
$7.50
Formulary Co-Pay*
$25
No Change
$20
$25
$25
No Change
Non-Formulary Co-Pay*
$45
No Change
$35
$45
$40
$45
90 Day Retail Co-Pay*
1.5X Co-Pay
2X Co-Pay
1.5X Co-Pay
2X Co-Pay
2X Co-Pay
No Change
$75
$100
$50
$75
$50
$75
$500/$1,500
$1,000/$3,000
$300/$900
$500/$1,500
$0/$0
No Change
$3,500/$10,500
$4,000/$12,000
$2,500/$7,500
$3,000/$9,000
$1,000
No Change
Co-Pay, Limits and/or
Coinsurance
$0
Co-Pay, Limits and/or
Coinsurance
$0
Co-Pay, Limits and/or
Coinsurance
$0
Lifetime Limit1
$1,000,000
Unlimited
$1,000,000
Unlimited
Unlimited
No Change
Dependent Eligibility Age1
To Age 25
To Age 26
To Age 25
To Age 26
To Age 25
To Age 26
Emergency Room Co-Pay*
Deductible* (Individual/Family)
Out Of Pocket Maximum* (Individual/Family)
Preventative Services1
*Changes effective January 1, 2011- Deductions effective with the December Payroll for January 1, 2011 effective date.
1Benefit changes effective October 1, 2010
Revised 10/27/101
MCALLEN INDEPENDENT SCHOOL DISTRICT
2011-2012 Benefit Information
Rates Effective October 1, 2011
Administered by Blue Cross Blue Shield of Texas (BCBS)
State Plan*
Basic Plan*
High Plan*
Alternate Plan
2010-2011 2011-2012 2010-2011 2011-2012 2010-2011
2011-2012
No Changes
Employee
Employee
Employee
2 Persons
Employee
Only
& One Child
& Spouse
Employed-Family**
& Family
$
$
$
$
$
30.00
196.00
341.00
199.00
408.00
$
$
$
$
$
52.00
218.00
363.00
221.00
430.00
$
$
$
$
$
106.00
234.00
448.00
364.00
550.00
$
$
$
$
$
128.00
256.00
470.00
386.00
572.00
$
$
$
$
$
239.00
504.00
655.00
782.00
975.00
$
$
$
$
$
261.00
526.00
677.00
804.00
997.00
Dental Plan*
(Employee covered by
another insurance may
select the Alternate Plan.)
Provided by District
Provided by District
N/A
N/A
N/A
N/A
N/A
N/A
$ 20.00
$ 42.00
Benefit Plans and other benefit related information listed below are available on-line at http://mws.mcallenisd.net/benefits/
• Health & Dental Plans
• 403(b) Investments
• Miscellaneous Claim Forms
• Prescription Drug Plan Administrator
• FAQ’s
• Employee Assistance Program
• Staff Contact Information
• Flexible Spending Accounts (Cafeteria Plan)
• Provider Links
• Health Insurance Portability and Accountability (HIPAA)
• Voluntary Insurance Benefits (Cancer, Disability, Legal Services,Term Life and AD&D)
The District, as a sponsor of a self-funded medical plan, must comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Standard. You have a right to
a paper copy of the District's Notice of Privacy Practice. The Notice outlines how health information about you may be used and disclosed as well as your rights regarding this information. A copy
of the Notice is available upon your written request to the Employee Benefits Office. A copy of the Notice is also available online.
The District, as a sponsor of self funded, non-federal governmental health plan has the right to exempt the health plan, in whole, or in part, from certain Health Insurance Portability and
Accountability Act (HIPAA) requirements by notifying the appropriate Medicare and Medicaid Services office in writing. The District has annually elected to exercise its option to exempt the
Employee Health/Dental Benefit Plan. A copy of the Notice is available upon your written request to the Employee Benefits Office.
From time to time, providers will be added to the PPO Plan or may discontinue their participation. Prior to receiving treatment, be sure to ask the providers if they are still participating in the Plan
and that the address you are making your appointment at is participating, and confirm they are taking new patients. Also, facility-based physicians may not be contracted health care providers.
Be sure to ask providers if they are still participating in the PPO Plan, or are taking new patients, prior to receiving treatment.
*Represents the employee portion of the total cost of coverage. The District contributes $347 per employee per month toward the total cost of providing medical and dental benefits ($329 Medical
and $18 Dental per employee per month).
**Represents the family premium when employee & spouse are both MISD employees.